Ramy Sedhom, MD, looks back on his first year of oncology fellowship and shares advice for first-year fellows and trainees.
Ramy Sedhom, MD
The other day I had the chance to reflect on my first year of oncology fellowship. Looking back, there is a craziness to it all that is hard to explain unless you experience it. I want to share reflections from what seemed like a typical day, with some advice for first-year fellows and trainees.
Alarm at 5 am. Get dressed. Grab breakfast on the go. Chug a triple-shot espresso.
I am one of the first cars in the hospital parking lot and one of the last out. I wonder if and when things will get easier. I make up in hours what I surely lack in experience. Chemotherapeutics, genomics, and controversies on Twitter over P values. Too much to learn each day. I’m thankful podcasts exist to consolidate my learning.
I take the stairs up to the fellow room. This is the peak of my exercise routine. I sign into the medical record to review patient charts. My colleague asks why I look so tired. I don’t answer. Doesn’t he know why? The fatigue, physical and emotional, adds up.
Training to be an oncologist has made me, at times, an absent friend and a preoccupied husband. I tell myself it is worth it. We all have friends who suffered from cancer. There is meaning in this profession.
There are 19 patients today who are admitted with a variety of solid tumors. All of their ailments make my complaints seem trivial. Their loved ones sleep on couches, and the patients who can sleep barely get any rest because we constantly interrupt them with blood pressure checks.
I start my rounds, and each visit begins with the typical, “How are you doing today?” The question often seems rhetorical. Most of our patients don’t like to complain, and we never have enough time to really engage anyway. We triage through who can go home, who has an impending emergency, and who needs more investigation.
Two cups of coffee later, the nurses remind me it’s time for discharge rounds with social work. We discuss the diagnosis, prognosis, and discharge plans for each patient. We evade talks of hospice, even though it is often on our minds. Maybe we will discuss it during the next admission.
I lose track of time, and now I’m 20 minutes late to noon lecture. Food brings my co-fellows together. It’s the 1 hour of protected education. I am to learn about new advances for metastatic kidney cancer. It is during this hour when our fellowship group text flashes with puns and complaints. I send a few memes. I survey the room for smirks. Eventually, it’ll all be immunotherapy. I think that was the conclusion of the lecture. I promise myself that I'll re-review the PowerPoint slides in a few weeks once I’m on my elective.
It’s time to run the list with the residents. We have many consults to call and outpatient oncologists to touch base with. I begin my first email:
Dear Doctor: Your patient is unfortunately admitted with new-onset ascites. Her scans suggest disease progression. We have shared the bad news. We hope to tie in a few things before discharge to prep for your next visit with her and her family. Let us know if there is anything else you’d like us to coordinate while she is admitted. social work and palliative care have been by to see her. Thank you.
I wonder how many of these emails it took before bad news became routine for me. At some distant time, the suffering of both patient and family was palpable. I can’t remember when that feeling went away.
I start revisiting the patients with whom we did not have a chance to truly engage. The next hour will be the only time in my day where I am not discussing medicine. Following the advice of a mentor, I primarily engage with patients about their grandchildren, favorite movies, places to travel, and the glory of ice cream. I wish the residents had the time to join; instead, they are plagued with progress notes.
I wonder how my wife is doing. She’s at home and a few weeks pregnant with our first child. We haven’t had a chance yet to visit family and share the good news.
I send her a text. She has been waiting to hear from me and sends a warm note back. She asks if I’ll make it home in time for dinner. I check with the charge nurse who confirms no beds for admissions today. I text back, “I think so.”
I walk back to the call room and prepare for the handful of patients I will be seeing in clinic tomorrow. I then realize I forgot about Ms Jones, the new patient admitted last night. She is 85, lives alone, and lacks resources. All her children live on the West Coast. Her performance status is poor. She was too sick to discuss her condition in depth on rounds this morning, so I promised to come back later.
I pull a chair into her room to start our second visit and try to follow the script I’ve been taught. “Good afternoon, Ms Jones. I wanted to check in and see how you’re feeling. I know we didn’t get a chance to talk this morning. I’m all yours for the next few minutes before I have to circle back and check in with the team.”
Selfishly, I am trying to keep this brief, hoping to finally be home for dinner.
“Doctor,” she starts with a smile, “I may be an old lonely lady, but I know how this works. All of the faces this morning suggested this was going to be my last visit to the hospital. I don’t need to be here. Let someone else have this bed. I’ve lived a good life.”
When did I get so cold?
Years ago, at my medical school graduation, I received a reward for humanism. My classmates voted me as the person they’d like to care for their ailing loved ones. Is this who they expected me to be?
Today, I’ve fielded numerous consults. I learned the second- and third-line therapies for what was once a lethal cancer with few options. I supervised and taught our amazing residents. I shared research plans with my mentor. I prepared for journal club. I gave advice to my favorite social worker about where to eat in Italy. Yet I blew off the few minutes that truly mattered.
Later that day, after signing out, I returned to see Ms Jones. She was still smiling, and it seemed as if she knew I’d return. She was ready to speak and I to listen.
After nearly a year, the experiences with patients are what truly matter in oncology training. We all want to learn how to treat, but it is more important to teach yourself to care. First-line treatment may change over time, but what remains constant is this: Patients are our greatest teachers. They want to live normal lives. And they put their trust us—even when we are not deserving.
This article was written by Ramy Sedhom, MD, a Hemotology/Oncology Fellow at Johns Hopkins University School of Medicine.