Surgical Oncology Is More Than Just Surgery

After 15 years as a surgeon, Jeffrey M. Farma, MD, says he's still learning how to treat patients with cancer. As fellowship director of the Complex General Surgical Oncology (CGSO) Fellowship at Fox Chase Cancer Center, he expects his trainees to be prepared to do the same.

Farma earned his MD at Temple University’s Lewis Katz School of Medicine in Philadelphia, Pennsylvania, before completing surgical fellowships at the National Cancer Institute (NCI) in Bethesda, Maryland, and Moffitt Cancer Center in Tampa, Florida. He returned to his native Philadelphia in 2009 when he joined the Department of Surgical Oncology at Fox Chase. He also serves as chair of the program directors’ committee for the Society of Surgical Oncology.

A surgical fellowship is different from other oncology programs because instead of focusing on a single tumor type, the surgeon has to learn about all of them. Farma said that an oncological surgeon may eventually specialize in a particular disease site, but surgeons must come out of fellowship with a broad knowledge of many types of disease and many areas of the body.

“My job is to make them into cancer doctors, not just surgeons and not just oncologists, but to really have a full understanding of treating all aspects of the patient with cancer,” he said. “That’s my ultimate goal.”

Farma talked with Oncology Fellows about the most important thing he learned as a fellow, how fellows can manage their finances, and the skills a fellow must develop during fellowship.

What was the most important thing you learned during your fellowships?

Working at the NCI is just, in itself, an amazing experience, especially being exposed to people like Steven A. Rosenberg, MD, PhD, chief of surgery at the NCI [Rosenberg is a 2013 Giants of Cancer Care^® award winner], and researchers who have a pure perspective on cancer. I think the most rewarding part of my experience at the NCI, was that patients were traveling in from all over the world to be treated at the National Institutes of Health.

There had been a lot of times I [had] been told that a patient had no other options—that there was nothing else we could do. Sometimes that was the case, but at the NCI, I learned there was always something else. There’s always another option. There’s always something positive or something on the horizon or some ability to give hope to patients.

At Moffitt Cancer Center, I was exposed to talented academic surgical oncologists who were able to perform really important research, be involved in national guidelines and cooperative group trials, and run clinical trials, while also working as high-volume cancer surgeons. It really taught me, both in and out of the operating room, how to best treat patients with cancer, how to evaluate them, and how to follow them afterward. I learned how to not only be a part of a multidisciplinary team, but to also lead multidisciplinary teams, which I currently do.

What do you tell your trainees about managing their money?

I always advise the residents I work with, number one, you have to have the long-game strategy in play. I trained for 9 years after medical school to do what I do. If you were an economist or a financial planner, that’s not the best strategy. That puts you 9 years behind a lot of your peers who went into other industries. But more important, you have to do something you’re exceedingly passionate about. We have jobs that are time demanding and emotionally demanding, so you have to love what you do.

That said, I did finish my fellowship in debt and I’m still paying off my medical school loans. You do have to consider all these things. Some fellowships might allow you to do some extra work on the side, which I did during my fellowship to make a little extra money. I definitely wouldn’t choose a fellowship because of that, but I think that there are a lot of fellowships that have some leniency to allow for moonlighting. And then, eventually, you start working and things gradually improve.

Are there skills that fellows, especially surgical fellows, must develop?

They have to learn when to operate, but more importantly, when not to operate. That’s a very, very important skill to learn. They need to learn how to effectively stage and initially evaluate patients for cancer. Then after surgery, they have to learn how to follow the patients. We generally see all the patients for surveillance for years to come.

They need to know how run and manage a clinic and how to run teams–leadership, surveillance, and survivorship. They also need to know the palliative side of surgical oncology, how best to lead and manage difficult conversations. These are all aspects that I think are really important in the 2-year fellowship.

It’s definitely not just cutting. Our surgical oncology fellowship is exceedingly competitive. A large majority of the applicants now have multiple research publications. They’ve worked in the clinic and taken dedicated time off to do research. Many of them have advanced degrees, including MBAs, MPHs, and PhDs. We really are getting the cream of the crop. So another thing I say to all the applicants is, I can make them slightly better surgeons and show them some tips and tricks, but we need to concentrate on cancer care. Being a surgeon is a continuum. You don’t just finish. I’m still learning and becoming a better surgeon every day. But we are, more importantly, teaching them how to think about cancer, which is the most important thing for me.

What do you enjoy about working with fellows?

I’m heavily involved in education be it through medical students, physician assistant students, residents, and our fellows, who are really near and dear to my heart and training. There is nothing that makes my job more rewarding than seeing the success of others, seeing them progress in their career, and doing great things. Fox Chase was among the first surgical oncology programs in the country, and now we have networks of physicians who are practicing throughout the world who have been trained here and improving cancer care for patients in their communities. That’s really rewarding.