Amy Jones, MD, details the socioeconomic challenges with patients coming into the Dallas County clinics and how oncology fellows become equipped to address them.
Amy Jones, MD, was on the inpatient service at Parkland Health in Dallas, Texas, while helping treat a young mother with an aggressive lymphoma. While it was time to discontinue therapy and move her to hospice care, and the patient agreed, she wasn’t ready to have that end-of-life conversation without her clinic fellow in the room.
“It was pretty rewarding as a program director, and as a teacher, to be able to have this fellow come in, lead this really important conversation, and have the patient completely trust the medical team, because that fellow was there,” said Jones, assistant professor of hematology oncology in the Department of Internal Medicine, and the director of the Division of Hematology Oncology Fellowship Program at UT Southwestern Medical Center.
This situation is one of many that Jones has witnessed her fellows experience. Along those lines, she’s seen them attack patients’ socioeconomic and language barriers head on. Dallas County has become more diverse in recent years, with approximately 80% of the population projected to comprise Black and Hispanic residents by 2050.1
On the healthcare front, data show that more than 43% of individuals and 38% of families in Dallas County live below 2 times the federal poverty level.2 Additionally, the uninsured rate is 3.5 times higher for Hispanic residents, and nearly 2 times higher for Black residents compared with White residents.3
The fellowship program comprises multiple sites for hematology oncology fellows to practice at in Dallas County: Harold C. Simmons Comprehensive Cancer Center, Parkland Health and Hospital System, William P. Clements Jr. University Hospital, and Dallas VA Medical Center.
“They get a lot of experience in different practice areas so that they can figure out what they like, but also be able to manage patients in all different types of situations,” she added.
In an interview with Oncology Fellows, Jones details the socioeconomic challenges with patients coming into the Dallas County clinics and how oncology fellows become equipped to address them. She also provides advice for current fellows and lessons she learned during her own fellowship.
Jones: It is a fellowship that is undergoing tremendous growth, and evolution, just like our institution and our division in general. I applied to fellowship not excessively long ago, but it was a fellowship with about 12 fellows, [and it was] very clinical—not a lot of research. There were about 30 faculty or so at that time. Our division, in the past decade, has gone to pushing 80 faculty; we’re now going to have 24 fellows a year.
Our fellows have an excellent mix of clinical training and research training. One of the really cool things about our fellowship is that we have 3 very diverse clinical sites that our fellows spend time in.
Some of the barriers are different based on what site we see patients at. We see patients at the university, which comprises Harold C. Simmons Comprehensive Cancer Center, a National Comprehensive Cancer Network–designated comprehensive cancer center, as well as Clements University Hospital, which is associated with the university. We see patients at Parkland Health and Hospital System, which is the safety net hospital system for Dallas County and is one of the oldest and most well-established county hospital systems in the country. Then, we also see patients at the Dallas VA [Medical Center], which is the second largest VA health care system in the country.
Each of those sites is very diverse, but in different mixes and ways. For example, I practice at Parkland, where 95% [of the patients are] socioeconomically disadvantaged, so over half of the patients don’t have insurance, and for the rest of them, most of them are on Medicare or Medicaid. Then, that 85% of that population [comprises] underrepresented minorities, with the majority of patients not having English as their first language. That’s probably the most challenging patient population, just because most patients are coming in with cancers who maybe have not had treatment, or are at the time where the patients didn’t have screening because they didn’t have any access to healthcare—whether that was an insurance or citizenship barrier.
Patients who don’t speak English is another barrier for care. While we have excellent translation services, it can be hard because sometimes patients are coming in with a language that doesn’t rank among the 200 different translation offerings that we have. Then, of course, there are a lot of socioeconomic things that we have to take into account both, in making treatment decisions, but then also in terms of resource allocation.
There are a lot of barriers there at the cancer center; we’re still seeing a very diverse patient population. One of the things that we struggle with at our cancer center— it is both a struggle, but also a strength— is that we want to enroll a lot of patients on clinical trials. There’s a lot of history, especially in the African American population, of distrust about clinical trials and the healthcare system in general.
Therefore, there’s a lot of patient education, outreach to communities and churches to say, “Actually, we want to take care of whoever is in our community.” Our most recent numbers showed that a little over onethird of patients enrolled on our clinical trials to the cancer center were underrepresented minorities, which is phenomenal, considering how a lot of papers you read note that 5% 10% [of patients enrolled included underrepresented minorities]. We are getting more than one-third, but it’s still a challenge.
Then the VA, of course, has its own barriers and own difficulties. Again, it is a very diverse population. There are a lot of patients who are coming from rural areas to the Dallas VA to get their cancer care, so there are a lot of transportation issues, and then just a lot of patients have not had good oncologic screening and workup because access to care may be more challenging.
The first thing is having fellows feel comfortable being able to communicate at patients’ health literacy levels. Incoming oncology fellows are eager to get the lingo right and start talking like an oncologist. But sometimes, we have to unlearn that to be able to reach our patients where they are. Being able to explain to patients, their treatment decisions and the plan, in a way they can understand is super important.
Just to give you an example, at Parkland, all of our written materials have to be on an eighth grade reading level or less for English and a fourth grade reading level or less for Spanish, which can be really challenging when you’re trying to write any printed publications. We’re lucky at Parkland in that we have a lot of support from social work, behavioral health, psychology, palliative care, physical therapy, and nutrition—a lot of things that maybe patients wouldn’t have that at other safety net institutions.
One of the things I always tell my fellows is that, as an oncologist, your job is to care for the patient, but you don’t have to do all of it yourself. It’s a lot of learning how to use the resources that we have. Learning when it’s right to ask your nurse or your nurse navigator, or the social worker, or the nutritionist or whoever it is, to help you out with an issue. We are lucky at Parkland that we have an extensive pharmacy staff that helps us get a lot of our medicines approved through patient assistance programs. It’s very rare that I am unable to give a medical therapy to a patient that I want to.
However, we do run into a lot of issues, sometimes with things like nuclear medicine intervention, or we can’t do things like stem cell transplant. We are treating some of these patients with an acute leukemia, who, outside of a safety net hospital, would go to transplant, but that’s just not an option if they’re not a citizen. You have to be a little bit creative. In some ways, for fellows, it’s good because it helps you really understand the decisions you’re making medically, and be able to interpret data for the patient in front of you, which can be challenging, but it’s a good skill to learn.
Especially starting oncology fellowship, but anytime you’re practicing as an oncologist, there’s a lot of emotional burden that we take on dealing with death and dying every day. Then when you add on that next layer of, “My patient came to me, and they don’t have food. Now, what do I do about that?” Or, they’re the only breadwinner and they are a family of 6, and they can’t come to chemotherapy because that means they’re going to have to miss a day of work and then they can’t pay their rent. That’s stressful, and that’s a lot of burden—you’re learning how to emotionally manage that burden and spread it out. I think it’s really important for being able to plan for longevity of careers in a very emotionally laden subspecialty.
We don’t have any requirement, and definitely the vast majority of our fellows do not speak the primary second language of Spanish; we have some that do. As a Spanish speaker, it does make clinic a lot easier, because I don’t have to dial in an interpreter or have one come in, but it’s not impossible. It does require additional skill sets to clinic management, because using an interpreter takes more time.
You have to figure out how to do that effectively, but it also requires another level of being able to communicate clearly to an interpreter, and then trust that that’s happening to the patient. It does add complexity to clinic. Maybe I’m biased, but I think it there is a huge reward to being able to serve a community that may not be able to see an oncologist in any other situation.
So many of our patients have gone to many different places and been told “no.” Then, they come to one of our UT Southwestern clinics, or at Parkland or the Dallas VA, and they’re so thankful to see an oncologist. It can be rewarding, because our fellows do get to be the primary oncologists for a lot of these patients. You’re getting to make the clinical and medical decisions, but also, you’re forming long-lasting relationships with patients, which is really important in training.
It’s good for our fellows that they get to spend a little under half of clinical time over at the university too, because they are in very much a tertiary referral center, a comprehensive cancer center environment where they’re being exposed to the latest interventions, the most exciting clinical trials, and they’re seeing that with attendings in their clinics and managing those patients. Then, being able to take that back to more of a community, safety net hospital setting is great because the patients there benefit from the knowledge that you learn over at Simmons.
However, it can also be frustrating when you have an amazing clinical trial open that you would love to enroll this patient on, and you can’t because the funder doesn’t want to open an additional clinical site. It really makes our fellows acutely aware of the healthcare disparities in our country, and how some people are going to get the top of the line, best care— they’re going get the thing that just was published in the New England Journal of Medicine. Other patients may never see that because of financial issues, citizenship issues, insurance, whatever it is. I hope that we are training fellows that are attuned to those disparities and are able to try to mitigate those and whatever clinical practice they take in the future, whether that’s in academics, community, industry, or in any other setting.
Number one is clinical competence; we want our fellows to be clinically excellent and be able to make complex medical decisions on their own. We do have the luxury with multiple sites that we’re able to have varying levels of autonomy at those sites. Fellows really feel like, by the end of the 3 years, they’re able to independently manage whatever oncologic disorder comes through the door. That is super important.
Second for me is I want to develop fellows who have exceptional emotional intelligence, both so they can interact with patients, but also so that, as we’ve mentioned, they’re able to be resilient and manage the emotional burdens that they will have throughout their career.
The other thing, too, is just to have fellows that are open to inquiry and kind of investigation with wherever their path leads, whether that’s going to be in the lab, whether that’s going to be working on healthcare disparities and helping to level the playing field throughout our country, or that the fellows that are going to be opening these clinical trials. I want our fellows to have these tools, to be able to answer the questions that they want to answer in their career.
I was lucky to do my fellowship at The University of Texas MD Anderson Cancer Center, which the majority of our time was at this huge multinational cancer center. However, 1 day a week, I was in a very similar setting to Parkland at the county hospital in Houston, with my own patient panel. I think I am biased, but I thought that was an incredible learning experience as a fellow to juxtapose those 2 environments.
Something I learned was: don’t settle for maybe the easiest path for patients—whether that is a patient who you don’t think can pay for something or there’s some issue, you can think creatively around that. Or, perhaps there is a patient who maybe everyone else has told that there are no other options, and they’re coming to your major cancer center. There probably is a trial; there is something you can think about with your colleagues to figure out for them.
As a program director, one of the things I’m learning more and more is just the diversity of clinical thought and learning styles of fellows, and trying to figure out how to best support that to make every fellow be successful in the path that they want to take. One of the things I really want to do is make sure that I’m nurturing our physician scientists, our clinician educators, our clinical investigators, our educators, and our community physicians, so that we can have excellent cancer care, no matter what setting a patient’s going to show up to.
Through my training, I always felt very inadequate as far as, “I just can’t keep up with the learning. I can’t keep up with the knowledge.” That’s true, you can’t, there’s no way you’re going to be able to memorize all of these new drugs, all the approvals for every single disease. The best advice I got from a mentor, which I’ve taken to heart, is try to learn something new for every patient you see.
Maybe you read 1 paper per patient, or you really nail 1 statistic for that disease with that patient. We will remember it better if you can attach it to a patient, but then also, it’s not super overwhelming; I don’t have to go home and read every single paper that came out in the Journal of Clinical Oncology. This week, I can focus on, “I have a new patient with colon cancer. I’m going to learn. What should I do for their new left-sided KRAS wild-type disease?
The thing I always tell residents who are applying to fellowship and just fellows in general is that fellowships are really varied. It’s very different from an internal medicine residency, where you’re going to have a relatively similar experience, no matter where you go. Figuring out what you want out of fellowship will help you decide where you should be. If you want a certain environment, make sure that you’re getting that when you’re applying.
Amy Jones, MD, is an assistant professor in the Department of Internal medicine and program director of the Hematology Oncology Fellowship Program at the UT Southwestern Medical Center.