Volume 4 • Issue 3, September 2012
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Conference Success: How to get the most out of attending a major oncology meeting
Clinical Ethics 101: Practical Ethical Principles for Oncology Fellows Lessons on Patient Care Learned at Home This edition is supported by
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Table of Contents
Volume 4 • Issue 3, September 2012
Project Director Donna Bonura Project Manager Jaclyn Pallotti Editor Elizabeth McDonald Assistant Editor Jeanne Linke Quality Assurance Editor David Allikas Art Director Ray Pelesko
Sales & Marketing President Peter Ciszewski pciszewski@onclive.com Executive Vice President, Sales Jack Lepping jlepping@onclive.com Vice President, Sales & Marketing Lisa Greene lgreene@onclive.com Vice President, Integrated Special Projects Group David Lepping dlepping@mdmag.com Directors of Sales Scott Harwood sharwood@onclive.com Erik Lohrmann elohrmann@onclive.com
2
Conference Success:
How to get the most out of attending a major oncology meeting By Elizabeth A. Guancial, MD This author offers valuable tips to help you make the most of the time and money you spend to attend an oncology conference.
Senior National Accounts Manager Mike Hennessy, Jr mjhennessy@onclive.com National Accounts Managers Robert Goldsmith rgoldsmith@onclive.com Corrie Payson cpayson@onclive.com Sales & Marketing Coordinator Megan O’Connell
Digital Media
Features 8 Clinical Ethics 101: Practical Ethical Principles for Oncology Fellows
14 Lessons on Patient Care Learned at Home
Liza-Marie Johnson, MD, MPH, MSB Are you prepared for the ethical issues you will face throughout your career? This article helps with some essential principles.
Ross Perko, MD This fellow shares the insights he’s gained from his wife, a pediatric oncology nurse, and how they help in the care he provides.
Vice President, Digital Media Jung Kim
Operations & Finance Group Director, Circulation and Production John Burke jburke@mdng.com Director of Operations Thomas J. Kanzler Controller Jonathan Fisher, CPA Assistant Controller Leah Babitz, CPA
Corporate Chairman/Chief Executive Officer/President Mike Hennessy Chief Operating Officer Tighe Blazier Chief Financial Officer Neil Glasser, CPA/CFE
Departments A Word From Your Fellows 17 Don’t Quit
Transitions 21 Why Did I Become an Oncologist?
By Brendan Curley, DO, MPH The first year of residency gives a new understanding of advice from the voice of experience.
By Amer M. Zeidan, MD This author shares patient experiences that have taught him how much an oncologist offers, beyond chemotherapy.
19 Different Faces of a Career in Oncology By Sean Truong, MD His vivid emotional experiences have shaped the author’s career choice.
Apps for the health care professional.
23 By the Numbers
Executive Vice President/Executive Director of Education Judy V. Lum, MPA
24 Conference Center
Vice President, Group Creative Director Jeff Brown
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The Online Oncologist 22 Mobile Medicine
Interested in contributing to Oncology Fellows? If you’d like to submit an article for consideration in an upcoming issue, please e-mail Donna Bonura at dbonura@clinicalcomm.com.
Cover Story
Conference Success: How to get the most out of attending a major oncology meeting By Elizabeth A. Guancial, MD
2 | September 2012
magine navigating through a crowd of 25,000 oncology professionals in the largest conference center in the United States. In this environment, it is easy for even the most seasoned oncologist to feel overwhelmed. Plenary sessions, exhibit halls, late-breaking abstracts, and poster discussions…where to begin? For first-time attendees of a large medical conference, excitement and enthusiasm can quickly fade to exhaustion and attention deficit when confronted with such a staggering number of choices. A significant commitment of time, energy, and money is required to attend a large oncology conference. Furthermore, we are becoming aware of the potentially negative environmental impact of such meetings. Therefore, it is essential to create a plan to ensure that the medical conference you attend is a worthwhile experience, rather than a waste of resources.
Why do we attend medical conferences? Education and social interaction are often cited as the primary reasons to attend a major medical conference. From large sessions devoted to the latest ground-breaking advances to smaller lectures specifically designed to review the current standard of care, conferences aim to educate attendees. In addition, these meetings provide opportunities to contribute to the dissemination of information by presenting your own original work to a group of peers
who provide immediate feedback. Conferences that bring together thousands of oncology professionals create the ideal environment for reconnecting with former colleagues and networking with fellows from other training programs, future collaborators, and competitors. For an oncology fellow who will soon join the ranks of practicing oncologists, this is also the place to meet future employers.
Worth the price? Some have begun to question whether the educational and social opportunities provided by such meetings justify the expense. Critics raise concern over the environmental impact of thousands of tons of carbon emissions from air travel to meetings.1 Professional time and the level of expertise of an oncologist are also limited resources and may be better spent outside of an airport. While meeting abstracts may be peer-reviewed, the process is not as rigorous as for full-length publication. Furthermore, 35% of abstracts that describe the results of randomized clinical trials are never published in full.2 Thus, the potential for harm exists due to incomplete information. Finally, while disclosure of conflicts of interest for speakers is now mandated, some question the objectiveness of a scientific program organized by leaders in a field for whom such conflicts exist.3 Alternatives to large medical conferences include digital meetings with online webinars, educational podcasts, and
September 2012 | 3
Cover Story
digital review of poster presentations. Given the vast array of social networking tools, some question whether in-person communication remains necessary. However, until the sponsors and funders of major oncology conferences decide otherwise, these meetings will likely continue in a recognizable format for the foreseeable future. Therefore, it is important to develop a strategy to ensure that you get the most for your time, energy, and money when attending large oncology meetings.
Strategies to get the most out of a major oncology meeting 1. Be organized: Create a plan to avoid missing important deadlines or events. • As an oncology fellow, meet with your clinical or research mentor to discuss what conferences are best suited to your interests. This is the perfect time in your training to attend a variety of meetings to get a sense of how they differ with respect to target population, purpose of the meeting, and general atmosphere. For example, mega-meetings such as the annual American Society of Clinical Oncology (ASCO) or American Association for Cancer Research (AACR) provide venues for groundbreaking clinical or translational research across the spectrum of oncology, while meetings like the San Antonio Breast Cancer Symposium are disease-specific. National
• •
•
• •
Comprehensive Cancer Network (NCCN) conferences discuss updates to clinical guidelines developed by this organization, and meetings for patient advocacy organizations may focus on survivorship issues, ways to improve screening, or increasing clinical trial participation for specific diseases. Once you have decided what to attend, create a calendar of important dates, including abstract submission and registration deadlines. Prior to arriving at the conference, spend time reviewing the schedule of events and speakers. Check on the meeting website close to the conference date for latebreaking abstracts or newly added sessions that you may want to attend. Again, talk to your mentor about events he or she thinks will be particularly valuable. Prioritize sessions that you want to attend while you are at the conference, such as plenary sessions or controversial topics where the speakers will field questions from the audience. Most meetings record sessions and make them available online for viewing after the meeting; therefore, educational talks can be watched at home or at work where they may be more high-yield because of less distraction. Take advantage of online planning tools provided by the sponsoring organization to customize your conference itinerary. If possible, try to stay close to the convention center because this will reduce commuting time and allow you to go back to your hotel room during the day for a break.
It is important to develop a strategy to ensure that you get the most for your time, energy, and money when attending large oncology meetings.
4 | September 2012
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Cover Story
3. S ave money: Travel awards and sharing expenses can result in substantial savings. • If submitting an abstract, review the sponsoring organizations’ website for travel or merit awards offered to fellows to help defer costs. • Register and book your flight early, as fares typically increase closer to the date of the meeting. Airport shuttles to hotels are often cheaper than cabs and have less environmental impact. • Share a hotel room with co-fellows or former colleagues. Check the prices of nearby hotels not affiliated with the conference as they may be less expensive. Or consider a condo rental instead of a hotel; these usually accommodate more people and include a kitchen, which can substantially reduce costs in many areas.
2. Participate: Get involved by seeking out opportunities to meet new people. • Scan the conference schedule for the names of speakers or chairs of individual sessions in your area of interest whom you may want to meet. Do not be afraid to introduce yourself after sessions or in the hallway or to ask your mentor to provide the introduction at a poster session. Many established researchers or clinicians welcome the opportunity to meet fellows. • Some conferences have prominent figures lead smaller, “meeting highlights” sessions specifically for fellows. These venues provide excellent opportunities to meet such people one-on-one to ask for their thoughts on controversies in the field or career advice. • Review abstracts before the meeting and plan to attend poster sessions where you can speak with the authors and develop your own project ideas. • Better yet, submit your own abstract—you may be selected for an oral presentation or a poster, both of which are great learning experiences. • Visit the exhibit hall where physician recruiters provide information about jobs and different practice environments. Patient advocacy organizations will often have booths featuring educational resources for both physicians and patients. Pharmaceutical companies and device manufacturers will also have exhibits of their latest products. • Reconnect with former colleagues by contacting them before the meeting and schedule plans to meet up. 6 | September 2012
Despite concerns that major oncology conferences may become obsolete in the digital age, they present an excellent opportunity for fellows to become engaged in the field by contributing their own work, meeting colleagues, and learning from established researchers and clinicians. Organization prior to the meeting can ensure that the conference is both an educational and social success.
References 1. G reen M. Are international medical conferences an outdated luxury the planet can’t afford? yes. BMJ. 2008;336(7659):1466. 2. S cherer RW, Langenberg P, von Elm E. Full publication of results initially presented in abstracts. Cochrane Database Syst Rev. 2007;(2):MR000005. 3. I oannidis JP. Are medical conferences useful? and for whom? JAMA. 2012;307(12):1257-1258.
Elizabeth A. Guancial, MD, is a third-year hematology/ oncology fellow in the Dana-Farber/Partners CancerCare Hematology/Oncology Fellowship Program in Boston, MA.
Interested in contributing to Oncology Fellows? If you’d like to submit an article for consideration in an upcoming issue, please e-mail Donna Bonura at dbonura@clinicalcomm.com.
Bringing the Oncology Community Together
OncLive.com features full, exclusive online access to all the articles in each issue of Oncology Fellows. For the latest on the issues and concerns facing oncology and hematology Fellows, go to OncLive.com and click on “Publications� for free, unlimited access to Oncology Fellows.
Feature
Clinical Ethics 101:
Practical Ethical Principles for Oncology Fellows Liza-Marie Johnson, MD, MPH, MSB
8 | September 2012
Education in medical ethics is required in medical school and residency programs, yet there is so much variability in the timing and delivery of this education and many house staff report inadequacies and gaps in their ethical training. Although physicians traditionally think of ethics during times of crises when a difficult case results in moral distress, it is actually important to consider ethical issues as part of our daily responsibilities as a physician. This is true whether we are engaging in research or direct patient care. Numerous studies have shown that physicians who are knowledgeable about ethical issues are more likely to recognize ethical dilemmas in clinical practice and feel more confident addressing these issues. Rather than using a tragic case to teach ethics, I will provide a few key principles that are essential for clinical practice.
Fiduciary Responsibility A special relationship exists between patient and physician that extends beyond ordinary professional obligations. The relationship with a physician is different from most other professional relationships, since a physician is provided information on confidential lifestyle choices, is allowed to examine our body, and may perform invasive procedures. This relationship is based on presumptions of confidentiality, safety, and loyalty. Fiduciary responsibility is the ethical obligation of a physician to honor a patient’s trust and act in ways that honor the patient’s interests above the competing interests presented by the demand of families, the institution, or even our own lives. It includes the obligation to promote the best interests of the patient (beneficence) while minimizing any potential harm (non-maleficence). For example, your patient is anxiously waiting for you to deliver the results of her disease evaluation, but the news is not good and her son has already demanded that you not disclose any negative information to his mother.
You are anxious about giving the bad news, not sure how to handle the son’s requests, and your co-fellows have invited you to lunch off campus that would allow you to avoid this difficult encounter a little longer. The principle of fiduciary responsibility reminds you it is your duty to honor the interests of your patient over the competing issues in this encounter. It would be your duty to see the patient before lunch and disclose to her son when he made his request that it is your professional obligation to honor his mother’s wishes to receive her test results. A small minority of patients will prefer “not to know,” but this can be easily clarified by asking patients their preference for delivery of important medical information in advance of testing. When there is an overbearing family member, it is helpful to ask this question of patients when they are alone. Knowing you might have to deliver bad news after a disease evaluation, it is often helpful to set a time frame to return results to the patient and ask them to consider inviting family to help them process the information. September 2012 | 9
Feature Decision Making & Consent for Treatment The ethical principles of autonomy and respect for persons recognize an individual’s right to self-determination and allow patients to agree to or refuse a medical treatment. We often do not question a patient’s decision-making skills unless they are clearly very confused or refuse a recommended medical therapy. Patients who lack the global ability to make decisions may be labeled “incompetent” by the courts, but this is a legal decision and physicians do not make competency decisions. As a physician, it is important to assess your patients’ decision-making capacity (DMC), whether it is in discussions of a medical intervention or prior to consent for research. DMC is the task-specific ability to make an individual medical decision, does not require a consult from a psychiatrist, and can be assessed by any physician. In order to have decisional capacity,
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the patient must be able to understand the diagnosis, prognosis, and treatment alternatives, as well as the risks and benefits of each. It is not enough that the patient can simply repeat the factual information. DMC requires that a patient be able to appreciate how it applies to the situation and express how the decision falls within his or her life plan and value system. Patients may have DMC for one medical decision, but lack DMC for another decision. DMC can fluctuate over time and attempts should be made to maximize a patient’s ability to understand and appreciate a treatment decision. For example, time discussions to coincide with the patient’s “best” time, and minimize the effects of other interventions (drugs, dialysis) and environmental distractions (noise, television). The patient’s family, friends, and primary physicians can provide valuable insight into the patient’s capacity (“he’s not acting like
2:53 PM
himself”) and may help facilitate communication with the patient. Assessing DMC balances 2 risks: failing to respect a patient’s right to self-determination versus failing to protect well-being and best interests if a patient lacks decisional capacity. Consultation from psychiatry or the ethicist can be useful in cases that are unclear or when conflicts exist over the capacity assessment. Decisions that are riskier and more complex (enrollment in a phase I or II clinical trial) require the patient to have more DMC to make the decision at hand than do more simple medical decisions. It is often morally distressing to accept patients who seem to be making the so-called “wrong choice,” however this is not automatically a reason to override patient autonomy. Fiduciary responsibility reminds us of our obligation not to abandon patients who make “poor” or “wrong” decisions. In patients who make unorthodox
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requests, have religious refusals of care, or are making the wrong choice, the assessment of DMC provides an opportunity for communication and discussion with the patient. Careful listening with open-ended questioning to clarify unclear points in the patient’s decision making may resolve a misunderstanding or reveal common ground to negotiate a mutually agreeable treatment plan. Often involvement of pastoral care (institutional or from the patient’s primary community) can be helpful in fostering communication surrounding religious issues in care decisions. One exception to religious freedoms involves religious refusals related to pediatric patients. In Prince v Williams, the US Supreme Court stated, “Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretions when they can make that choice for themselves.” The fiduciary responsibility is to protect the interests of the child; however, attempting to override parental decision making is not appropriate when the prognosis is grave even with accepted treatment or if the treatment being refused is not of clear benefit or efficacy.
Surrogate Decision Making and Advance Care Planning If the patient is found to lack capacity then a surrogate/proxy decision maker (SDM) should be appointed to make decisions on behalf of the patient. The role of the SDM is to make decisions consistent with the patient’s previously expressed wishes (at time of capacity) if these wishes are known. When the patient’s wishes are unknown, the SDM should make decisions in the patient’s best interests based upon what they believe that patient would have wanted. As a physician, your fiduciary responsibility remains with your patient, and it is important to also evaluate the DMC of the SDM. It may be necessary to hold a family or team
meeting or request an ethics consultation if the SDM makes choices that are known to be contrary to the patient’s wishes. In any patient with a chronic illness, such as cancer, it is impossible to predict events that may result in the future loss of capacity; for example your patient could develop neutropenic sepsis and be intubated in the ICU. Therefore, it is important to ask patients early in the care course who they would like to make decisions on their behalf in the event they are unable to do so. Although there are default SDM precedents based upon local legal jurisdictions, patients with capacity can appoint whomever they wish to act as their health care proxy. Documenting this information in the medical record, per institutional guidelines, allows clinicians to identify the appropriate SDM, which is particularly helpful when there are disagreements among potential surrogates (example: a conflict among adult children over a decision involving their parent). Proxy decision-making discussions are excellent opportunities to begin clarifying patient preferences surrounding life-sustaining treatments. Using open-ended questions it is possible to ask the patient if they have previously had discussions with the designated surrogate about end-of-life issues and ask the patient to tell you more about the discussion. You can ask the patient what they would want the surrogate to consider in the event he or she was having difficulties making a decision. When appropriate, offer to facilitate a discussion between the patient and surrogate about the responsibilities of a surrogate and the types of decisions that proxies might be asked to make on behalf of a patient. It is important to document the patient’s goals and wishes in the medical record and these conversations can often lead to the completion of a formal advance directive when the patient is ready. Even when the patient is not ready
to complete an advance directive, documentation of his or her goals and preferences surrounding lifesustaining treatments can be helpful in future decision making.
Resolving Ethical Dilemmas Ethical conflicts in clinical care often arise from breakdowns in communication or divergence of goals among individuals caring for or related to a patient. It is said that good ethics begins with good facts; therefore, the first step in resolving a dilemma is to have accurate information from the individuals in conflict. Interdisciplinary team meetings or family care conferences can often resolve perceived conflicts by facilitating communication among the stakeholders involved in patient care. Goal-setting discussions allow patients to discuss their wishes and values, which can help you uphold your fiduciary responsibility to the patient when decisions arise with the potential for moral distress. Your hospital ethics committee (HEC) is a valuable educational resource and should not be perceived as the “ethics police.” Take time to identify the members of your HEC and utilize them as a resource “curbside” when you need help thinking through a difficult case. This simple communication may resolve your dilemma or, when the case is particularly challenging, may lead to a formal consultation. Finally, the first step in resolving an ethical dilemma is recognizing the dilemma itself. Sharpen your abilities to recognize ethical dilemmas by attending ethics rounds and educational sessions whenever possible.
Liza-Marie Johnson MD, MPH, MSB is a clinical fellow in pediatric hematology/ oncology, the Vice-Chair of the Institutional Ethics Committee, and a member of the Institutional Review Board at St. Jude Children’s Research Hospital in Memphis, TN. September 2012 | 11
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Feature
Lessons on Patient Care Learned at Home Ross Perko, MD
14 | September 2012
I am a second-year pediatric oncology fellow at St. Jude Children’s Research Hospital in Memphis, Tennessee. So, I am far from an experienced care provider. I have been married to my wife, Rachel, a pediatric oncology nurse, for about 3 years. So I am also far from an experienced husband. But in this time, I have gained a new perspective from what she has taught me involving patient care and doctors’ interactions with nurses. This has also made me aware of the ways I can enhance the care I give pediatric oncology patients, as a fellow and in the future as an oncologist. I think some of these insights may help other fellows as well.
I
met my wife when I was a pediatric intern and it was far from a scene in a medical television series. Rather, I was post call in mid-December trying to finish my progress notes, leave the hospital, and complete my Christmas shopping. Due to the high number of respiratory infections on our service, I was short on rest and would likely have been a hazard to others and myself on icy Minnesota roads if I had driven to the mall. She offered to give me a ride that evening and while driving and shopping, we soon realized we had much more in common than caring for children. We held similar interests in music, sports, and shared a love for running. One of our earliest dates (her idea) was a nationally televised college basketball game and takeout Chinese food; and it could not have been better! A first-year oncology fellow is a newly minted, board-certified pediatric physician, capable of starting or joining a practice. For many, only days before beginning a fellowship, they might have been overseeing a complex pediatric inpatient service. Then the gears suddenly change and they are submerged again, in new patients, new diseases, new faculty, mid-level providers, nurses, and cafeteria food. As a fellow, the expectation is to know the most about every patient and then some. At times,
the process of gaining this information takes place outside of the patient room, leaving less time for the interactions that we who care for children crave. Deeper relationships with patients and their families can get lost in learning how to correctly enter and then retrieve information from the computer medical record. Rachel has pointed out to me many times that doctors are not always the best communicators. Shocking, I know. Thankfully, with computer order entry in most hospitals, far less time is spent interpreting handwriting now. Prior to meeting Rachel, I didn’t understand the difference between TID and Q8H and I don’t think I am alone when I admit I have no idea what volume of heparin is used to lock a central line. However, I also discovered that many nurses are unaware of the level of activity a resident or fellow is responsible for while they are on call, or with the current duty hour system. In a profession in which 2 individuals work so critically together to ensure the health and safety of a shared patient, much of each other’s job is surprisingly poorly understood. Learning more about the other’s job not only improves the workplace, but also elevates the care we can all provide to our patients. I had never heard of, or even thought of, “flushing” prior to meeting Rachel, September 2012 | 15
Feature but it is especially prevalent among teenage patients. I had assumed that what was recorded in the patient chart was the absolute truth. “Flushing” is when a patient forgets to tell their nurse when they void and the event is not recorded, which gives the appearance that the patient is fluid positive. For a resident or fellow, this can lead to unnecessary diuretic use and fluid mismanagement, especially when cross covering numerous patients overnight. To the patient, this might seem like a trivial thing that nurses ask them; however, it leads to improved decision making of the primary team when the correct information is understood. I used to think doctors were the only ones with stressful jobs (trust me, that thought lasted only a few days). I never fully understood how busy a single patient could keep a nurse until I learned the steps that occur after a medication order has been entered. For the medication to have its proper effect, it might need a premed, a fluid bolus, specific urinalysis parameters prior to and during administration, and/or spe-
cific monitoring at 15-minute intervals. These steps have one thing in common: they all require a nurse to be present in the patient’s room. Despite what I used to think, patients tell doctors and nurses different things. I believe that patients trust all of their caregivers and I am not trying to imply that patients make up stories, but certain levels of trust develop differently over time. With the current state of fellow education being spent less at the bedside and more at the computer desk, how our limited time in the presence of our patients is used is critical in building patient trust and habits for future practice as an attending. A patient, for instance, might disclose a personal matter or report vague symptoms not yet reported, just as the nurse is getting ready to start an IV medication. To a patient, doctors can sometimes appear to be on a tight time schedule popping in for a quick check-in, while a nurse can seem more devoted with their time just by being present in the room so much more often. Many times, when a busy fellow is in a patient room, it is
Despite what I used to think, patients tell doctors and nurses different things. I believe that patients trust all of their caregivers and I am not trying to imply that patients make up stories, but certain levels of trust develop differently over time.
all business with concrete discussions about pain, rashes, and stool consistency. With young children, comfort level is often correlated to the time spent with that provider. My 6-year-old patient hasn’t read my CV and her trust in me is based on the foundation that I know who Elmo is, not because of any medical journal publications I may have submitted. This realization has made me focus more on being fully engaged with my patients and their families when I am with them. This means that I try to limit outside distractions, do my best to be on time, and, when I am late, explain why I am running behind. Over time, I believe this builds trust and lets my patients and their families know that I am dedicated to them as a provider. Many times as trainees, especially newer fellows, it is easy to feel threatened when an experienced nurse raises a question, or worse yet, corrects an error. Questions can seem like another opportunity to highlight a fellow’s gap in knowledge rather than become opportunities to learn more. For me, I used to think that a nurse would look down on me when I said, “I don’t know.” I have learned that this is not true. Nurses don’t equate an “I don’t know” answer with ability, but rather honesty, especially when the fellow later returns with the answer. My personal perspective of patient care has changed since I met Rachel and other great nurses like her. Many of these things I’ve learned from being married to a nurse are similar to any lasting relationship: strong communication, understanding of the other’s situation, and honesty. The learning continues, beyond patient care. One of the more recent lessons Rachel taught me is that regular laundry detergent should never be used in a high-efficiency washing machine, unless you plan to mop your floors later that night.
Ross Perko, MD is a second-year pediatric oncology fellow at St. Jude Children’s Research Hospital in Memphis, TN. 16 | September 2012
A Word from Your Fellows
Don’t Quit By Brendan Curley, DO, MPH
Mukherjee photo by Deborah Feingold
“D
on’t quit.” These are words of wisdom passed attend conference, rinse, wash, and repeat. There are days down from one oncologist to one in training. when things are different; a transfer to the intensive care Two months into my fellowship, I had the unit, a difficult family talk is all par for the course. Things opportunity to listen to Dr Siddhartha Mukherjee, Pulitzer change when you become an oncology fellow, though. It is Prize—winning author of “The Emperor of All difficult to label them as good or bad, but perMaladies,” speak at my home institution. This haps it’s best summarized that the unexpected was his simple answer to a very complex quesis now a routine. The average day as an oncoltion: I had asked him what advice he had for ogy fellow is best described as riding a rollera first-year fellow. The message behind that coaster in the dark, without sound. There is no simple statement speaks volumes abut how clicking in anticipation of the big fall, no ledge difficult and taxing an oncology fellowship can in front of you to warn of the impending drop be. It is amazing that after 4 years of medical lurking ahead. school, 3 years of internal medicine residency, As the consult fellow, when the pager goes off, and countless interviews that quitting would anything can be waiting at the other end of the even be an option. We work so hard to become phone. If it’s a benign hematologic issue, a throma fellow, to become an oncologist, but when we bocytopenic patient is intellectually stimulating Dr Siddhartha Mukherjee get there, sometimes we wonder what we got and patients rarely fear seeing the hematologist. ourselves into. However, when the oncologist comes into the As an internal medicine resident, you essentially have an room, the intensity and attention are heightened. Patients truly idea of what your day will entail when you wake up. You arlisten to every word, hanging on what is being said. You don’t rive for work, see your patients, go to morning report, round, notice this on day 1, nor does it take until the end of your fellow
September 2012 | 17
A Word from Your Fellows
ship; but at some point it clicks in your head. This is the worst day of this patient’s life, and I am playing an integral role in it. Cancer is now a stigma that they carry, a survivor is something they long to become. Words that had different meanings to patients become routine; cycles, palliation, neutropenia are all terms that oncology patients understand but were likely foreign to them prior to their diagnosis. We introduce this metamorphosis to them, changing their vocabulary and views on their mortality. We are there for the worst day of their life, more times than not. It is difficult, it is draining, and it can become very emotional. Remember to lend a shoulder to cry on, a hand to touch, and silence to let them absorb the news. Our patients are human, and we are strangers entering their lives, seeing them at their height of emotional vulnerability. Show them that you are human and that you care. Unless we have been through the diagnosis ourselves, we can never truly understand,
Our patients are human, and we are strangers entering their lives, seeing them at their height of emotional vulnerability. only empathize. There will be days when you will sit in your car for an extra moment, or sink further into the couch than normal. A long stare at a PET scan will not change that progression, will not make the tumor marker go down. Silently asking yourself why you are doing this is normal (I hope!) and something that we all experience. It lets you know that you are human, that bad days for you are not nearly as bad as they are for the patients who are receiving that news. The other side of that coin is why we are able to continue with this job and don’t flee to a specialty with less stress or leave medicine altogether. The good news, the post chemotherapy visit with a patient can be amazing. We all love to show a clean PET scan, or a negative tumor marker. I have observed my attending physicians and notice myself linger in the room with these patients, soaking it in. We walk with a spring in our step into their room, excited to deliver that good news. Tears flow, smiles break out, and what follows is rarely a hard discussion. We all exhale, and breathe easier, whether we notice it or not. The follow-up patients who are no longer receiving chemotherapy are terribly nervous when coming to the 18 | September 2012
cancer center. Oncology center emesis has been described prior to our modern-day anti-emetics; stress-induced hypertension is now routinely seen as patients fear the devil they know making a return with a vengeance. Oncologists rarely speak of their failures, of the early stage patient in which things went terribly. We instead remember the exceptions, the miracles, and the patients that prove the textbooks and us wrong. As oncologists, we have to be optimistic, as our treatments are not 100% effective for all patients. That is why our ultimate goal while training should be to further the field, to make advances in treatment options and therapeutic decisions. The National Comprehensive Cancer Network (NCCN) states that the best treatment for a patient is a clinical trial, and that is something we should all think about for every patient we evaluate. Clinical trials offer advancements in the field and are the reason why we have the therapeutic choices available today. Without oncologists screening appropriately and patients choosing the unknown for their future, the field will become stagnant. It is our responsibility as fellows to start thinking this way early in our careers so not only will our patients have better outcomes, but also the oncology fellows that we will someday train will have more options and better choices than we do today. This is an essay written at the end of the first year of an oncology fellowship that was filled with ward months seeing leukemia, lymphoma, solid malignancies, and multiple hematologic abnormalities. In the future, I may look back at this essay and see myself as naïve, truly optimistic, and not yet weathered and jaded from years of success and failure. What I have learned can be summarized here, as many of us do while looking at consults or books, by skipping to the end. Remember: don’t quit! There are good days and bad days for us, but no matter how high the high or low the low, the patient is the one with the disease. Screen and enroll patients in clinical trials, as research brought us the treatment choices we have today. Dr Michael Craig, one of my mentors in fellowship, left a note near the fellows’ microscope. I have stared at acute leukemia through those eyepieces, and made therapeutic decisions and diagnoses that changed people’s lives. The note encompasses what we do, what we represent as oncologists. It reads: “Cancer sucks. What can you do? Call me with questions.”
Brendan Curley, DO, MPH is a hematology/oncology fellow at the West Virginia University School of Medicine, Mary Babb Randolph Cancer Center, Morgantown, WV.
Different Faces of a Career in Oncology By Sean Truong, MD
A
t various stages of our lives, most of us experience situations or events that help us to mature and may lead to decisions that affect our futures. Two such events in my life forged my career choice as a communitybased oncologist. The first was my family’s circumstances at the beginning of my life, and the second was the end of my father’s life. Like many others my age from Vietnam, the conditions of my homeland forced me to experience life-changing events when I was very young. Yes, I am one of those who were labeled “The Boat People,” a product of a war-torn country. My family escaped from the oppression of the Vietnamese communist regime and sought refuge on a small Indonesian island with the hope of reaching our destination in America after our
fourth and final attempt. During our refuge in Indonesia, we had almost nothing, not even a full stomach before going to bed. The only thing that kept us going was our hearts full of hope, which were continually challenged by the shortage of food, shelter, and medical care. A small medical facility staffed by a single physician was unable to keep up with the increasing demand for health care. Friends and strangers alike were stricken with various diseases that ended their journey there. Our parents kept us going with their inspired words and prayers and constant hope of a better tomorrow. This painful experience gave me a direction early in life. Although I was only 4 years old, I developed a deep respect for the physician who cared for the refugees on that small Indonesian island, especially for helping my mother narrowly September 2012 | 19
A Word from Your Fellows
escape the plague of malaria. It nourished within me the hope that one day I would be granted the privilege to step into his shoes. My aspiration to become an oncologist budded during my father’s struggle against nasopharyngeal cancer. As the youngest in a family of 5 children while all my siblings were either away at college or living far away, I inherited the task of accompanying my father on his physician visits. I distinctly remember being overwhelmed by his diagnoses and treatment plan and other physician consultations. The one common thread was that we could always rely on his community oncologist to coordinate his care with a patient-centered approach. Despite treatment, his health steadily declined. I felt helpless as I watched my father’s health spiral downward. I was torn between honoring my father’s wish to stop treatment and continuing with therapy that might offer a hope of remission. It was so difficult to convince my father to continue treatment when he already knew that at his stage of disease treatment was futile. He was ready to accept his fate before I was. I’d always trusted my father’s judgment, since he was not one to give up without a fight. He had a well-honed will to live despite life-threatening conditions. He had served 22 years of active military duty in a swift boat patrol unit. For this, his name was placed on the “wanted” list of the Vietnamese communist government. My father succumbed to his illness on Easter Sunday. He struggled to attend the prayer service that morning against the advice of my mother. Even in his last remaining hours, he consoled us with his last breath, “Be strong. Don’t cry. I will be in a far better place than I am now.” The only comfort we had through that ordeal was that we had that same oncologist guiding his care from the beginning to the end. During my first year of hematology/oncology fellowship, I was strongly considering academic medicine as a career choice. The 3 things I enjoy most in medicine are patient care, teaching residents and students, and participating in clinical trials to advance the field of oncology. Of all 3, I’ve realized that the most rewarding to me is taking care of my patients and guiding them throughout their illness. During my first year of fellowship, I slowly realized that some circumstances in academic oncology interrupt that
I’d always trusted my father’s judgment, since he was not one to give up without a fight. 20 | September 2012
continuity of care and long-term patient-oncologist relationships. In the in-patient service, the faculty can change frequently and there may not be consistent care, which could delay certain planned procedures, therapy, and discharge planning. The patients in the hospital hardly see their treating oncologist; the bond and level of trust with the covering physician is nonexistent. With the lack of an ongoing patient-physician relationship, I believe there is less accountability as well, which can make patient advocacy inherently more difficult. The patients themselves feel lost in the “system.” For instance, when a patient needs a procedure completed, a port placed, or a diagnostic colonoscopy, these could be delayed due to a scheduling issue. Physician consultation referrals can also be very difficult. The resident or fellow on the other services sometimes begrudgingly accepts the consult, which can create a lot of tension in a short period of communication. In our hospital system, certain oncology patients have an automatic consult by the palliative care team, or are referred for a consult by another service admitting them. Unfortunately, in some cases, this has resulted in the palliative care service making recommendations without consulting the patient’s oncologist. In some cases, “system” has made the oncologist a bystander while these decisions are being made, minimizing our role as a patient advocate. As I complete my second year in fellowship, I have chosen a career in a private practice in a community-based setting. My primary goal is to deliver effective oncology care, and in private practice, I will have control of my patient’s continuity of care. In this unique community practice, I will have residents and students rotating through oncology and I will be able to fulfill my interests as an educator and mentor. Finally, this group practice also participates in active clinical trials and has more than 100 trials available. So I will be able to enroll my patients in trials to advance the field and also to offer therapy to patients who no longer have any conventional therapy available. In accepting a position in this unique practice, I hope to be able to offer my patients the highest level of care combined with compassion. I want them to be informed and to be able to individualize their care around their needs and preferences. I am reminded of my father and I know the life I’ve chosen does not come in a perfect package. Whether an oncologist comes home at the end of the day seeing the cup as half full or half empty depends on his ability to balance the risks and benefits of medicine, whether in academia or private practice. As an oncologist, I learned that the art of medicine is as important as the science. An oncologist utilizes the science of medicine to save lives and the art of medicine to help improve the quality of life.
Sean Truong, MD is chief fellow in the Department of Hematology/ Oncology at West Virginia University Hospitals in Morgantown, WV.
transitions
Why Did I Become an Oncologist? By Amer M. Zeidan, MD
What a Candy Bar and Chatting About Skydiving Can Do t has already been 12 years now, but the memory is still as vivid as if it just happened yesterday. I met 8-year-old Abdo as my first assigned patient in my first clinical rotation as a medical student in Jordan. He was lying in a hospital bed with refractory metastatic Ewing’s sarcoma that rendered him blind, bed-ridden with massive ascites and craniomegaly. Abdo had failed all conventional therapy and was kept in the hospital for palliative care due to a social situation that prevented his family from taking him home. He used to ask me every day: “When will I be able to see and play with my friends again?” I never figured out the right thing to say. I used to tell him that we needed to get him stronger first. His mother would listen to our conversation with silent tears running down her cheeks. I always wondered how you can tell an 8-year-old kid that he was dying and that all we could do was to make it as painless as possible. But I also had a newbie medical student’s unconfessed illogical hope that one day I would come to his room and find him miraculously cured. He used to wait eagerly for me to come to his room, as I found out he loved Snickers bars and would bring one with me each time I visited him. One day I came to his room with his favorite candy bar in hand, but his bed was empty. The cold truth struck me, the miracle had not happened and Abdo had died the night before. That night I realized that curing cancer would be my life calling. Twelve years passed quickly, and I joined the hematology/ oncology fellowship program at Johns Hopkins in Baltimore. Approximately 8 pm in a cold winter night, I was finally getting ready to go home after another long, exhausting day in the busy leukemia ward. Just as I was about to leave, I was paged by a nurse saying that one of the leukemia patients was crying, and the nurse wondered whether I would talk to the patient or whether she should call the on-call doctor. I was surprised because the patient had been always very cheerful and upspirited during the 3 weeks I knew her in the ward. She was a 21-year-old college student on an experimental protocol for acute myeloid leukemia that was refractory to 3 different induction regimens. I always admired her bravery, as she smiled and joked with us all the time, despite being very well aware of her dismal prognosis. I went to check on her and found her in tears. Being
confined in the hospital for such a long period in an isolation room, missing being out with her friends in New York City, and the reality of her disease had all caught up with her. I sat down and we began chatting. I only remember a few of the things we talked about, including her leukemia, the TV show “Friends,” skydiving, and many other things. By the time I left her room at about 11 pm, she was back in her cheerful mood; and I do not think I’d ever felt more energized or refreshed in my life. Soon after that night, she was discharged to undergo a stem-cell transplant in her home city. Two months later, her father called to thank those who took care of his daughter and to inform us that she had passed away peacefully from complications of her disease. Many oncology fellows encounter such heartbreaking situations on a regular basis. Despite all the defensive mechanisms we develop subconsciously to prevent ourselves from getting too emotionally involved in these situations, they do not seem to get any easier. I’m sure we’re all asked the common questions, by friends and relatives and from colleagues in other subspecialties: “How can you deal with dying patients on a daily basis without feeling defeated? Don’t you worry that you have failed them by not being able to offer them anything?” Now I know the answer to these questions. I do not need to be giving chemotherapy, experimental agents, and painkillers all the time to be a good oncologist. It turns out that simple things, such as a candy bar and chatting about skydiving, can go a long way to help my patients feel better. As my young patient with leukemia said in the card she sent me before she died: “It was so reassuring for me to know that someone was genuinely concerned with seeing me through this, and giving me the strength to keep going. Someone that would always support me on my good days, and respond to my concerns on my bad days.” Now I really know why it is so gratifying to be an oncologist. Not only because we get to help cure many patients, but also because we are so fortunate to have the ability to help ease the journey of those who are not cured. Amer Zeidan, MD is a clinical hematology/oncology fellow at the Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital in Baltimore, MD. September 2012 | 21
The Online Oncologist ™ M o b ile M e d icine: A pps fo r t he Hea lth ca re P rof e s s iona l
Calculate by QxMD Price: Free Platforms: iPhone, iPad, BlackBerry, and Android This updated clinical support app includes more than 150 calculators and tools for a wide range of medical specialties, including oncology and hematology. It offers point-of-care tools as well as references and integration with PubMed for literature sources. Some specific features help users to determine the prognosis for lymphoma and myeloma, calculate dose for chemotherapy based on body surface area, and help stage lung cancer, renal cell carcinoma, and head and neck cancers. http://bit.ly/hpkIyj
22 | September 2012
MicroMedex Drug Information Price: Free Platforms: iPhone, iPod touch, iPad, and Android This app provides a wealth of drug reference information at your fingertips. Including more than 4500 search terms, the data are available for generic and trade name products, and include black box warnings, adult and pediatric dosages, indications and contraindications, precautions, adverse events, and more. The Toxicology and Clinical Teaching sections are also of value. http://bit.ly/Liohrv
Cancer.net Price: Free Platforms: iPhone, iPad, and Android Unlike most apps covered on this page, this app is not for healthcare professionals, but for your patients. Developed with leading oncologists, it provides patients with reliable cancer information from the American Society of Clinical Oncology. Patients may find this tool especially valuable during the emotional turbulence of cancer diagnosis and treatment. It offers guides to 120 cancer types, a tool to track questions for the oncologist, and the ability to track prescriptions, symptoms, and side effects. http://bit.ly/sQQqI8
InPractice Oncology Price: Free Platforms: iPhone, iPad, and Android The InPractice apps offer mobile access to the InPractice textbooks as well as a drug database. This resource also offers PubMed abstracts for easy reference to published literature, information on clinical trials from ClinicalTrials.gov, and links to patient management guidelines. http://bit.ly/qYzh0n
Journal of Clinical Oncology Price: Free Platforms: iPhone, iPod touch, iPad The Journal of Clinical Oncology, the journal of the American Society of Clinical Oncology, is now available on Apple iOS devices. The app provides access to the 6 most recent issues, in text and PDF formats, access to early release articles, and allows users to track article reading and e-mail or archive articles. Current personal or institutional subscribers to JCO can view the content at no charge, even when “off campus” on a registered device. Non-subscribers can access full-text articles for 90 days. http://bit.ly/MUYeHL
By the Numbers This bar chart compares the cost of cancer care in 2010 with projected costs for 2020. These data are for male and female adults over the age of 65 years across all types of cancer. The costs are shown in 2010 dollars for all phases of cancer care: initial care, continuing care, and last care. These projections are based on cancer incidence constant with the 2003–2005 rate, survival constant at the 2005 rate, and 0% increase in
medical costs. Even with the conservative assumptions for incidence, survival, and medical costs, the costs of cancer care are projected to increase from 29.3% for initial care, to 39.2% for last care, to 44.8% for continuing care. The growth and aging of the United States population accounts for the cost increases even without increases in cancer incidence or overall costs of medical care.
Projected Cost of Cancer Care by Phase of Care in Men and Woman over age 65 2010 2020 40,000
Cost ($) per Year (in millions)
$35,870
$29,545
30,000 $25,579
20,000
$24,779 $21,227
$19,776
44.8% 10,000
29.3%
Increase
39.2%
Continuing
Last
Increase
Increase
0 Initial
Phases of Care
Source: US National Institutes of Health, National Cancer Institute. Cancer Prevalence and Cost of Care Projections. Available online at http://costprojections.cancer.gov. Accessed July 20, 2012.
September 2012 | 23
Conference Center 2012 Oncology & Hematology Meetings October 1–4
27th Annual Critical Issues in Tumor Microenvironment, Angiogenesis & Metastasis Cambridge, MA http://bit.ly/QxmS6O
October 25–27
Lymphoma & Myeloma 2012: An International Congress on Hematologic Malignancies New York, NY http://bit.ly/MDK3tP
October 4–7
14th Annual Lynn Sage Breast Cancer Symposium Chicago, IL http://bit.ly/OuhfQH October 6–8
Annual Ethics and Compliance in Oncology Research Conference Houston, TX http://bit.ly/a7m4lt October 12–13
2012 American Society of Hematology State-of-the-Art Symposium Los Angeles, CA http://bit.ly/p8NjqH October 18–20
Medical Oncology & Hematology 2012: Clinical & Scientific Approaches That Enhance Patient Outcomes Houston, TX http://bit.ly/a7m4lt
October 26–27
November 15–16
New Therapeutics in Oncology: The Road to Personalized Medicine
Thoracic Oncology for the Oncologist
Los Angeles, CA http://bit.ly/OWH1NF
Scottsdale, AZ http://mayocl.in/PcDDSB
October 28–31
November 18–20
54th ASTRO Annual Meeting: Advancing Patient Care Through Innovation
17th Annual Perspectives in Thoracic Oncology
Boston, MA http://bit.ly/AA9fog
New York, NY http://bit.ly/Qhl9n7 November 28–December 2
2nd International Conference on Cancer and the Heart
Global Conference on Perioperative Medicine: Care of the Elderly & the Cancer Patient
Houston, TX http://bit.ly/a7m4lt
Houston, TX http://bit.ly/MUAZxm
November 9–10
November 9–11
Synergy 2012: A Multidisciplinary Approach to Interventional Oncology Miami Beach, FL http://bit.ly/NIlsTM
24 | September 2012
Call for Papers We welcome submissions to Oncology Fellows, a publication that speaks directly to the issues that matter most to hematology/oncology fellows at all stages of training. Oncology Fellows aims to provide timely and practical information that is geared toward fellows from a professional and lifestyle standpoint— from opportunities that await them after the conclusion of their fellowship training, to information on what their colleagues and peers are doing and thinking right now. Oncology Fellows features articles written by practicing physicians, clinical instructors, researchers, and current fellows who share their knowledge, advice, and insights on a range of issues. We invite current fellows and oncology professionals to submit articles on a variety of topics, including, but not limited to: • Lifestyle and general interest articles pertaining to fellows at all stages of training. • A Word From Your Fellows: articles written by current fellows describing their thoughts and opinions on various topics. • Transitions: articles written by oncology professionals that provide career-related insight and advice to fellows on life post-training. • A Day in the Life: articles describing a typical workday for a fellow or an oncology professional post-training.
The list above is not comprehensive, and suggestions for future topics are welcome. Please note that we have the ability to edit and proofread submitted articles, and all manuscripts will be sent to the author for final approval prior to publication. If you are interested in contributing an article to Oncology Fellows, or would like more information, please e-mail Donna Bonura at dbonura@clinicalcomm.com.
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