As a practicing pediatric oncologist at an academic institute, every morning begins with optimism and a quest to win the day.
As a practicing pediatric oncologist at an academic institute, every morning begins with optimism and a quest to win the day. As I walk into my office, I see my nurse flagging me down to sign a bunch of papers including procedure orders, chemotherapy orders, and home-health laboratory test orders. I get a hot cup of coffee and take time to catch up on emails, communications from consultants, referrals, and patient reports. Next, I review the children admitted through the inpatient service and their blood test results from overnight. Often, this is also the ideal time to review updates on new clinical developments in oncology, or to read up and educate myself on clinical dilemmas and ongoing research. This helps to prepare me for my resident education on clinical bedside rounds.
Children admitted to our facility, a pediatric specialty service, are cared for by resident staff at night, in consultation with practicing oncologists. In the morning, I attend the inpatient service bedside rounds and discuss the children’s care with the resident staff. Academicians at most institutions have teaching responsibilities that may occasionally include additional lectures for residents or medical students. Investing time in teaching the residents often rewards me with fewer tortuous night calls, since the residents are usually better prepared to handle anticipated complications as a result.
Pediatric oncology is a stimulating field with a multitude of research opportunities and discoveries every day. The prognosis in several childhood cancers has improved tremendously thanks to novel drug therapies, drug delivery systems, and protocol-driven treatments that have helped standardize therapy across the U.S. and improve results. It is intellectually stimulating to discuss ideas and diagnoses with other consulting services or experienced colleagues in my field across the country. Doing so enhances the quality of care I provide and helps broaden my perspective and differential on a given case. Be prepared to be humbled, however, as discussing clinical experiences with other physicians makes you vigilant and allows for fewer errors. Also, while consulting services can add to the quality of care you provide, remember to advocate for your patients and keep possible diagnoses in perspective before heading down the path of ordering multiple tests or scans.
For example, I once saw a 6-year-old girl with Cushing’s syndrome and a hepatic mass suspected to be hepatoblastoma. The mass showed calcification on scans and her alpha-fetoprotein level was normal. The child had severe hypertension consequent to paraneoplastic syndrome, preventing us from taking her to surgery. We insisted on a biopsy before proceeding with any chemotherapy, although the majority of the consultants were convinced it was a hepatoblastoma. Ultimately, when the mass was excised, it was a rare “nested stromal tumor” of the liver.
Following up on your patients when they are admitted to another service, such as surgery or intensive care, helps you stay abreast of events and changes in their status. Being familiar with a child’s long-term medical illness also helps protect him or her when you advocate for their care. It is key to follow up on the children and their several tests as the day progresses, as each update has the potential to alter treatment plans that were made earlier in the day based on certain assumptions.
I head to the hospital in-service as I begin the day. My resident team, pharmacist, and nurse practitioner are waiting and ready. We spend the morning seeing and discussing our inpatients. A simple case of scheduled chemotherapy, a sick child with fever and neutropenia, or a more involved case of a newly diagnosed child with acute leukemia or a new solid tumor keeps us engaged. The morning passes in a flash as we manage each issue and care plan. Some of the most enjoyable moments involve the exchange of knowledge between myself, residents, pharmacists, nursing staff, child life services, and social services because it helps me render comprehensive care for my patients. Unfortunately, not every day is a breeze. We have challenging days where we spend considerable time discussing and resolving more complicated issues such as end-of-life care, palliative therapy, pain control, and optimal quality of life for our less fortunate children with terminal disease.
Communicating with parents and children is a skill. It is also a predominant part of my job description and of my professional day. Training in how to communicate bad news and discuss end-of-life care or options such as pain relief, hospice care, and resuscitation choices with parents is often initiated during fellowship and fully mastered in practice when you are responsible for the care of each child whom you manage. Prudency is in realizing that each situation is unique, showing true empathy to the needs of children and parents, and being prepared to listen. As much as you would like to be outlining plans, taking the time to listen to the concern of a child or parent can help get you through difficult situations. Remember to include the children in decisions and discussions.
Next, I head to the outpatient clinic and infusion center. The aura is lighter and less somber. Scheduled outpatient chemotherapy follow-up, outpatient procedures like spinal tap with instillation of medications, bone marrow procedures, postchemotherapy follow-up, and health surveillance for our cancer survivors fill the afternoon. Seeing a cancer survivor cheerfully return to the clinic with tales of school or summer vacation, or witnessing young teens recount their camp experience or academic success brings true satisfaction. Those days, I succeed in my quest to win the day.
I end the day with some more paperwork, including billing for services rendered. Coding and billing is an integral part of practicing medicine. Detailed and time-intensive care planning is often accompanied by paperwork, and an efficient team of personnel including nurse, patient liaison, social worker, and home-health services is an invaluable asset. I check back on issues pending for the day and make sure my hospital patients are well cared for before I head home for the night. While every day is not a winning day as an academic oncologist, optimism can provide hope for winning every day!
This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.