Preparing for the Unexpected: What You're Not Told During Orientation

Moshe Ornstein, MD
Published: Thursday, Sep 10, 2015
Moshe Ornstein, MD,
MA

Moshe Ornstein, MD, MA

Dear Incoming Oncology Fellow,

Congratulations! It took at least 4 years of college, 4 years of medical school, and 3 years of internal medicine residency to reach this point. But you’re finally here. There are no more agonizing personal statements to write, ERAS tokens to obtain, or “Why do you want to be an oncologist?” questions to answer. That’s the good news. As you begin your first year of oncology fellowship, I want to share with you a few things I’ve learned since standing in your shoes just 12 months ago.

Oncology Fellowship Is Not a Continuation of Residency

During your first year of fellowship, you will confront challenges different from those encountered by your colleagues who have pursued specialty training in other fields such as cardiology, critical care, and gastroenterology. In most residency programs, the majority of inpatient rotations surround the traditional medical fields of general medicine, gastrointestinal medicine, intensive care, and cardiology. Inpatient oncology rotations are far less common, thus limiting your exposure to the acute medical complications faced by cancer patients. Moreover, even if you were to rotate on the inpatient oncology service, it would not be an accurate reflection of what you will experience as an oncology fellow, because the majority of oncology care takes place in the outpatient setting.

Your learning curve will be far steeper than those of your colleagues in other specialties, who gained substantial exposure to the core medical issues in their fields during their residency. Whereas words like heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension roll seamlessly off the tongue of any resident, tongue twisters like blinatumomab and palbociclib do not. You’ll quickly learn that while residency may have prepared you for the acute management of a patient’s prerenal kidney injury, it did not necessarily provide you with the foundation for facing the day-to-day issues and challenges of cancer patients and their medical providers.

There’s another more subtle difference between the world of oncology and other medical fields. Think back (if you are brave enough) to your intensive care unit rotations, or time on the cardiology service. There was so much emphasis on preload, afterload, systemic vascular resistance, pressure, and flow. In other words, the emphasis was on physiology: “Why is the heart failing, why is there blood in the stool, and why are the urine casts granular?” In oncology, the focus is shifted to the pathology of disease: “What is the driver mutation of the cancer, what is the cellularity or dysplasia in the bone marrow, and what is the primary origin of the patient’s cancer?”

However, more important than the fundamental difference between pathology and physiology is the critical distinction between taking care of a patient’s medical condition and taking care of the patient. In residency, you were trained to resolve a patient’s COPD exacerbation, diurese fluid-filled lungs, and control rapid atrial fibrillation. In simple terms, your job was to identify the problem, fix it, and move on. During oncology fellowship, you will be expected to empathize with your patient’s struggle with cancer, understand how a mother’s chemotherapy schedule is interfering with her ability to care for her children, and recognize a patient’s right to choose between quantity and quality of life. The objective is not necessarily to distinguish which drug to use and when, but rather to also understand the emotional and psychological impact of the disease and its therapy.


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