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The New Medical Oncology/Palliative Medicine Fellowship Track
I was drawn to medical oncology because it combines science and humanism. I am witness to my patients’ most vulnerable, challenging, and genuine moments. That said, the most lasting memories I have from internship involve the fear, shock, and failure that I felt as I cared for ill or dying oncology inpatients. I decided that if I was to become a medical oncologist and be entrusted to care for patients with a life-threatening illness, it was my responsibility to be as well trained as possible in physical symptom management, communication, and nonphysical distress. I would follow them from diagnosis to either cure or death and never abandon them. Training in palliative medicine as well as medical oncology felt like honoring the saying: “To cure sometimes, to relieve often, to comfort always.” I am just finishing up a 2-year medical oncology fellowship after completing a hospice and palliative medicine fellowship and will be starting as an attending in both GI oncology and palliative medicine this summer. This dual training is becoming a much more frequent occurrence with medical oncologists,1 and some oncology training programs across the country have integrated medical oncology/palliative medicine into a 3-year ACGME-accredited fellowship similar to hematology/oncology. This article aims to recount my experience in this dual training, including the challenges I faced and the benefits I reaped. Hopefully, this will help better inform oncology fellows regarding whether or not this training suits them. Benefits I will never forget visiting a hospice patient as a palliative medicine fellow and talking with his wife. She felt their oncologist was wonderful, knowledgeable, and connected with them, but he had abandoned them since hospice enrollment. He didn’t call and was no longer involved in decision making. And believe me, there were decisions to be made. Should they continue tube feeds? What were the benefits and risks? What should they do about his secretions that were severely impacting his quality of life? When and how should they tell other family members? Most likely the oncologist “abandoned” his patient because he just didn’t know or have experience in caring for patients while they were dying. Just as I can advise the right chemotherapy regimen for treating metastatic cancer, I can also assure symptoms are managed right up until death or assure a patient is sedated if all other conventional methods fail.This continuity of care is vital to helping patients transition as their cancer progresses. I have known them for months to years and have learned and elicited their values and goals throughout their course of cancer. They trust me because I know them intimately, what they have been through, and have fought beside them during their battle with cancer. Therefore, when I tell them we have come to a point where their life would be “better” (based on their own definition) without further chemotherapy, they believe me. They can accept their fate and begin to find other sources of hope to sustain them for the time they have left.As oncologists, we gather to discuss challenging clinical quandaries in conferences, but we do not discuss how emotionally draining it is to care for certain patients or families and grieve their loss. In hospice and palliative care, emotional coping and strategizing is a crucial piece of the multidisciplinary meeting time with chaplains, social workers, psychologists, nurses, and physicians. Oncologists are prone to burnout2 and having the experience of a true multidisciplinary support network in cancer care and learning emotional resilience3, such as that learned in hospice and palliative medicine, can help improve job satisfaction and prevent this burnout. Solid malignancy services can be heavily burdened with patients who have suffered complications from chemotherapy or their cancer. A palliative medicine training can assure that I can always make an impact on the patient’s care and on the residents’ and fellows’ education whether I am titrating medications to relieve refractory nausea or pain, navigating tricky goals of care issues with challenging families or young patients, or helping coworkers and residents grieve their dying patients. Lastly, improved end-of-life care, including decreased spending and better symptom management, are hot button topics. In an era when research money is tight and innovation is valued, having insight into strategies that could reduce aggressive care at the end of life while respecting patients’ values and goals could allow for a successful, independently funded research niche. Challenges