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.