There and Back…

One of my teachers in medical school was fond of saying, “Internal medicine isn’t sexy.” Hematology/ oncology is no exception to this rule. Certainly, it is not as glamorous as cardiology or as hands-on as gastroenterology. More often than not, practicing hematology/oncology lacks the instant gratification and immediate results associated with rapid intubations and acute resuscitation. Rare is the mad dash to the emergency department, and even rarer is a patient who thanks an oncologist an hour after receiving treatment. Regardless of these realities, there’s a reason I’ve chosen to work in hematology/oncology: it encompasses what I enjoy most about medicine. In this field, we face a wealth of diagnostic dilemmas, therapeutic challenges, and unique interpersonal relationships.

While this is all true, my circuitous path to a Heme/Onc fellowship was drawn out. In medical school and in residency, I was fortunate (and unfortunate) enough to find every field intriguing. This made the decision of which subspecialty to pursue an especially difficult one. In the end, I narrowed it down to cardiology with an emphasis on congestive heart failure or hematology/oncology. To be fair, CHF is the oncology of cardiology, which makes the 2 fields more similar than one would think. By the time I finally decided on Heme/Onc, I was a third-year resident. This late choice all but guaranteed that I would spend at least 1 year in transition as the ubiquitous hospitalist. In fact, I spent 4 years as a hospitalist at a large academic institution on the East Coast while my wife finished her own residency.

As hospitalists around the nation can attest, the transition from resident on June 30 to a attending on July 1 was quite intimidating. I was suddenly working without the builtin safety nets of a training program and the sage advice of a supervising attending physician. I found myself carefully scrutinizing and second-guessing medical decisions that previously had been completely routine and mundane. Patient disposition was no longer my ultimate goal. Instead, I was focused on the supreme goal of avoiding an embarrassing “bounce-back.” My discharge summary became a surrogate performance evaluation that all other medical providers had access to and could pass judgment on. I was acutely aware of (and frightened by) the fact that I was solely responsible for the care a patient received. I quickly discovered what it truly meant to take responsibility for a patient’s care.

In time, I grew more comfortable with my new role as an attending and eventually found my own rhythm. Rounds went smoothly and efficiently because I no longer had to preround or present my patients to another physician. I had the freedom to determine treatment plans and adjust those plans as needed without double-checking with or getting approval from a supervisor. Consults were called and studies were ordered because I wanted them…and I actually understood the questions I was asking. I moved from clinical instructor, to physician unit director, to general medicine ward attending complete with my own entourage of eager medical students and hard-working house staff. It was profoundly gratifying to teach medical students the basic principles of medicine, work through complex medical issues with residents, and provide helpful recommendations to colleagues as a consultant. But, to be honest, it was the flexible work schedule and the generous financial incentives that are unique to a career in hospitalist medicine that I sometimes appreciated the most.

Although at times it seemed like a dream job, there were obvious downsides to being on the front line at a busy tertiary care center in a large metropolitan city. “Continuity of care” could often be an unwanted experience, depending on the patient population in question. The perpetual sense of urgency and pressure from the hospital administration to evaluate and discharge a large number of patients quickly led a number of my colleagues to burn out. Our department alone averaged a yearly turnover of at least 30% in a group that grew from 14 to 24 full-time employees by the time I left. While I enjoyed a great number of things about being a hospitalist, I found myself continually drawn to cases that involved a hematologic disorder or a new diagnosis of malignancy. Once my wife’s training program was complete, I applied for and was accepted for a heme/onc fellowship in the Pacific Northwest.

Now, as I near the end of my first year of my heme/onc fellowship, I still field the same questions from future heme/ onc hopefuls as I did from interviewers during my fellowship application process. “Do you feel that your years as a hospitalist were beneficial or a detriment?” “Was the adjustment difficult?” In the interest of full disclosure, I usually start by answering the latter question and admit that leaving a 2-week on/off schedule and a 6-figure salary was disheartening. But that change was actually easily overcome. Most people who ask me these questions assume that the transition from attending to house staff is a difficult prospect, since it involves a loss of both stature and autonomy. In truth, the transition was quite effortless because I came into my heme/onc fellowship with the utter certainty that I knew absolutely nothing, and I relished the opportunity to unabashedly ask the “dumb questions.” While hematology/oncology is not without its own intrinsic frustrations and challenges, it has been an undeniably exciting and fulfilling experience to be able to address medical issues in which I am truly interested and invested.

Aside from the realization that medical students I have trained are now my co-fellows and that my former co-residents are now established attendings in their own subspecialties, I truly believe that my years as a hospitalist were well spent. The confidence to make decisions and act on them comes more easily to me now. Years of admitting multiple patients and rounding on a large panel of acutely ill people have helped me to streamline my approach. This allows me to be more efficient when triaging and evaluating consults on a busy service. Numerous interactions with difficult patients have taught me the importance of simply listening and have helped me to refine interpersonal skills. This is especially important in a field in which patient communication is absolutely essential. Dedicating time for medical student and house-staff teaching rounds has ingrained in me the importance of recognizing that a good consultant provides education as well as recommendations.

Having been on the other end of this interaction as a requesting provider, I have particularly come to appreciate the value of being a courteous and gracious consultant in an academic center where everyone is overworked and overwhelmed. Admittedly, I forget that last lesson at times, but as with all of the other lessons I continue to learn, it remains a work in progress.

Perhaps this is the most important lesson I’ve learned throughout my training journey to date: I am still a work in progress. We all tell bright-eyed medical students, petrified interns, and weary residents that “physicians are lifelong learners.” That’s how we justify the many years of higher education, the long hours of residency and fellowship, and the endless pursuit of CME credits to maintain “board-eligible” status. That is why we challenge ourselves to stay abreast of recent advances, fastidiously address our knowledge deficits, and battle complacency in our careers and in the care of our patients. The truth of the matter is this…that 1 statement is simultaneously a cliché, a humble reminder, and a source of perpetual encouragement. Taking it 1 step further, I try to remind myself every day that, no matter where my career takes me, I will always be a trainee