Trainees have sat in this hot seat at the front of the room for decades. It's not really warm, of course. This is where the fellow sits who is asked to review the findings, come up with a differential diagnosis, and devise a plan for the case in question.
Trainees have sat in this hot seat at the front of the room for decades. It’s not really warm, of course. This is where the fellow sits who is asked to review the findings, come up with a differential diagnosis, and devise a plan for the case in question. A peripheral smear appears on the big screen and John, a first-year fellow, starts to tell us what he sees. He points out red cells, then platelets, then white cells. We ask him the history and physical. John then develops a differential diagnosis, makes the diagnosis, and discusses the treatment plan. Twenty to 30 minutes later, we’re on to a second case and another fellow takes John’s place. At then end of the hour, we’ve reviewed 3 cases and we’re all a little wiser. Now it’s time to see the patients.
Is There a Typical Day?
After the conference at 7:30, the rest of the day generally goes as follows, more or less:
8:30 am — Office hours
12:00 pm — Oncology conference with fellows and attendings
1:00 pm — Desk time
3:30 pm — Sign-out conference with the hematologic malignancies and stem cell transplantation team
But is there a typical day for a fellowship director? Not really. The days are crammed full of activities and responsibilities that vary based on the time of the year and the clinical responsibilities for the day. There are often changes in the schedules due to new issues that come up. Flexibility is very important. Half the time, I have clinical responsibilities. These may be inpatient or outpatient activities, and may or may not include the fellows or other trainees.
Following our conference on this particular Friday morning, I start to see outpatients with hematologic malignancies. As part of her training, Amy, one of the fellows, is doing an outpatient hematologic malignancies block and is working with me. Together with Lisa, one of a team of great nurse practitioners, we divide up the schedule and start to see our patients in the outpatient offices. Most of the patients with follow-up visits are doing well. Together with Amy and Lisa, I make plans to restage lymphoma in 2 patients, evaluate anemia and a monoclonal protein in another, sign a consent for salvage chemotherapy for another, do some long-term follow-up for a few more, and end the morning with a new patient who would like to discuss options for an allogeneic stem cell transplant for relapsed acute myeloid leukemia. It’s been a busy morning, but we got through it without any emergencies or admissions and finish with just enough time to get to our noon conference.
Our noon conference focuses on solid tumor didactics. Fellows and attendings are present, along with a student and that the fellows’ didactic conferences are up to par, so I try to attend as many as possible. Most program directors would agree that keeping tabs on the quality of the lectures and the attendance by faculty and fellows is best done if you or the associate program director regularly attend.
On a good day, the afternoon will include time spent at my desk. This time is valuable (and difficult to protect) and usually includes some fellowship-related activities. My program coordinator has a folder of e-mails about elective requests and vacation coverage for the fellows, off-campus conferences a fellow would like to attend, research plans that need to be reviewed, and other papers that need signatures. Fellows’ schedules need to be revised. Online and paper evaluations must be reviewed to ensure all fellows are progressing in the right direction. Goals and objectives are updated. Process-improvement projects and plans for research projects must be reviewed and approved. I frequently visit the Web sites of the Accreditation Council for Graduate Medical Education (ACGME), American Board of Internal Medicine (ABIM), and Electronic Residency Application Service (ERAS). The ACGME page is particularly useful right now, as I prepare for a site visit. The ABIM site is visited more frequently as annual reports become due. This year, with the change in the schedule for fellowship matches, I probably won’t need to visit ERAS for awhile, but once that starts up in the fall, I’ll be reviewing applications for what will seem like weeks.
Halfway through the afternoon there’s a page. An issue has come up. Today, one of the fellows has to leave early because her 6 year old got sick at school. We call the backup fellow, arrange a quick sign-out, and 30 minutes later everything is under control. On another day, the afternoon call will be one of the fellows who needs clarification about a policy. A week later, one of the faculty members pages me with concerns about one of the fellow’s ability to manage a rapidly growing service. Sometimes, it’s a simple call to clarify the rotation or call schedule. Whether a big problem or a small one, however, everything else gets put on hold to deal with the current crisis.
Then there are meetings; these range from individual discussions with 1 fellow to full-blown conferences that include all of the fellows. There are also semiannual reviews with individual fellows, fellowship committee meetings, and meetings with faculty to review and revise rotations.
The afternoon draws to a close and it’s time to go home. But then an hour later my beeper goes off. When I call back Maria (a third-year fellow), she says, “Sorry to bother you, but I thought you should know….” So even though I’m home, I still have to deal with this next problem, clarifying how we deal with growing services at a time when service caps on the internal medicine services are changing the landscape for all of us.
A Good Fit
Five years ago, 6 months after my second child was born, my division chief walked into my office and said “We need a new fellowship program director. Motherhood seems to agree with you—I bet this would be a good fit.” We laughed, but he wasn’t completely wrong. My fellows are a family. Although no longer children, they need guidance and mentoring as they go through the training program. They need support and someone who will be available as an advocate. Being a program director is a full-time job. As program directors for fellowship programs in hematology and medical oncology, we are teachers, administrators, and counselors—not to mention physician role models. At times we are mentors and at times disciplinarians. We are advocates for our fellows; we liaise between the fellows and the faculty and administration. The most rewarding aspects of the job come from the fellows themselves. As I watch them become confident and mature hematologists and oncologists, ready to go out into practice, I commend them on their progress and share a sense of accomplishment.