Understanding Your New Role as a Hematology/Oncology Fellow

First and foremost, congratulations! You have finally made it to the last stage in your training, a training that will have spanned over a decade by the time you are ready to treat patients independently as a hematologist and/or oncologist.

When I started fellowship, I felt like a brand-new intern, frantically reading the National Comprehensive Cancer Network guidelines and reading the How I Treat series on the American Society of Hematology website. I questioned every recommendation I gave and made sure that the bottom of my note always read “Recommendations are preliminary until cosigned by an attending.” Over the past 3 years, I have realized that my relationship with patients, colleagues, and medicine as a whole fundamentally changed after starting fellowship, and as that relationship evolved, so did the responsibilities and expectations. Here are some of the things I wish I had known when I started fellowship!

No. 1 The Relationship Between a Patient and Their Oncologist Is Unique and Special

A cancer diagnosis is life-changing in every way for patients. Symptoms of the disease can be overwhelming. Travel plans have to be tailored to accommodate treatment schedules, and activities must be timed around the adverse effects (AEs) of treatment. Even seemingly minor symptoms such as foot swelling after a day out or back pain after moving furniture prompts the insidious, lingering question of “Is this my cancer getting worse?” Care teams must navigate these difficult scenarios with their patients over the course of their disease and treatment, especially as their cancer progresses.

When you are on consults or starting in clinic and meeting patients for the first time, it is important to understand that context. Understand that as a hematology/ oncology fellow, you are representing the team that has gotten to know this patient on a deep, personal level throughout one of the greatest challenges this patient and their family have faced, sometimes over many years. Here are some strategies that I have found to be helpful in establishing a therapeutic relationship:

• Always review the patient’s chart before seeing them. Generally, I believe knowing what they have, when they were diagnosed, what treatment they are currently on, and what their last imaging showed is a good start. Knowing why they are here today also allows you to ask specific, relevant questions.
• Reassure them that you will update and speak directly to their primary hematologist/oncologist (if you’re inpatient) or that the attending will join you shortly (if you’re in clinic). Many patients are accustomed to a certain routine in clinic, and when a new physician walks into the room, it can throw them off.
• Sometimes, checking in with the advanced practice provider or physician before seeing the patient can be helpful — some patients want granular details on their imaging or pathology and others just want your interpretation. Checking in with the providers who have cared for this patient will help you provide the most personalized care for the patient.

No. 2 Your Priority as a Fellow Is to Provide a Thoughtful Heme/Onc Perspective

During the first several months of fellowship I struggled with taking on my new role as a heme/onc consultant and felt drawn to managing the medicine aspects of a patient’s care, which is where I felt the most helpful. I also tried hard to be extra friendly and readily available on EPIC chat, hoping that I could make up for lack of experience with accessibility. If you find yourself doing this, remember: you are involved in this patient’s care specifically to evaluate a question in the context of their known hematologic or oncologic condition(s), or to provide guidance for further hematologic and oncologic work-up.

During fellowship, you tend to have fewer messages and calls than during residency, and I strongly encourage you to use that time and space to read, research, and reach out to experts at your institution and other places, and consolidate the data and perspectives into coherent and concise recommendations. Not only does this maximize your own learning, it is the best way to help the primary team and the patient. Growing into this new role is challenging and uncomfortable but always remember you are not alone!

No. 3 Listen, Truly Listen, to the Patient Experience

One of the most important things I have heard comes from patient advocate Jill Feldman, whom I met at the EGFR Resisters Research Summit in 2024. She mentioned how actually having grade 2 diarrhea (4-6 stools above baseline daily), which is generally considered to be a manageable toxicity in the context of oncology clinical trials, could very well keep any of us from coming to work.

Although toxicities have an objective grading system with the [Common Terminology Criteria for Adverse Events version] 5.0, the subjective severity and significance of any toxicity cannot be accurately captured by anything or anyone besides the patient. I recently had a conversation about treatment options with a patient about a new diagnosis of metastatic colorectal cancer. The patient worked as a long-distance trucker and emphasized that gastrointestinal toxicities would significantly affect his ability to work. Conversely, I had the same conversation with a different patient who taught at a dance studio, who emphasized that neuropathy needed to be kept to a minimum. These discussions prior to initiating treatment are essential to good patient care and must be revisited regularly as patients’ lives and their diseases change.

Although I sincerely hope that one day chemotherapy will be a thing of the past, and our understanding of the cancer genomics and ability to harness the immune system allows for truly personalized cancer therapy, chemotherapies remain the backbone of many treatment regimens, and understanding how the expected AEs will affect your patient personally is paramount to your relationship with them as a hematologist/oncologist.

In Conclusion

Hematology and oncology are rapidly growing and evolving disciplines, but what remains constant is the special relationship you share with your patients and their families. As you embark on this new journey as a member of our community, remember the significance of your role in patient care, reflect on the effect of your words and recommendations, and use both scientific literature and the patient experience to guide your management. Remember that you are not alone, lean on the support of your mentors, and reach out to others to discuss challenging cases and research collaborations. Your journey has just begun!