December 2012 Oncology Fellows

Volume 4 • Issue 4, December 2012

f e l lo w s

Canine Caring

A therapy dog for cancer patients

The ABCs of IRBs: A Brief Overview Achieving Career Success in Academic Oncology BIO0001466501

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Table of Contents

Volume 4 • Issue 4, December 2012

President Peter Ciszewski pciszewski@onclive.com

Editorial & Production Senior Vice President, Clinical and Scientific Affairs Jeff D. Prescott, PharmD, RPh 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 Vice President, Sales & Marketing Lisa Greene lgreene@onclive.com Director of Sales Scott Harwood sharwood@onclive.com

2 Canine Caring:

A therapy dog for cancer patients

By Brendan Curley, DO, MPH Oncology fellow Brendan Curley, DO, MPH and his therapy dog Princess Danger Curley positively impact the lives of patients and their families, sometimes more than expected.

Digital Media Vice President, Digital Media Jung Kim

Feature

Director,Digital Content Sean Johnson

8 The ABCs of IRBs: A Brief Overview

By Nancy Fell Hill, MPH Understanding the Institutional Review Board (IRB) and its process for review and approval of research proposals.

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 Executive Vice President/Executive Director of Education Judy V. Lum, MPA Vice President, Group Creative Director Jeff Brown

Departments A Word From Your Fellows 14 Bone Marrow Biopsy Simulation Training for Fellows

By Cyrus Khan, MD and Ghulam Rehman Mohyuddin Institutions are beginning to develop a model program that teaches fellows correct procedural techniques for performing a bone marrow aspirate and biopsy.

16 How do I keep up with the literature?

By Amer M. Zeidan Strategies and resources to keep fellows current on the stream of published literature while balancing their clinical duties and research activities.

Transitions 18 Achieving Career Success in Academic Oncology: What to know when deciding on a career in academia

By Mohammed Almubarak, MD, and Jame Abraham, MD, FACP Practical advice for oncologists contemplating a career in academia.

The Online Oncologist 22 Mobile Medicine Apps for the health care professional.

23 By the Numbers 24 Conference Center

Office Center at Princeton Meadows Bldg. 300 • Plainsboro, NJ 08536 (609) 716-7777

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.

Feature

Canine Caring

A therapy dog for cancer patients

By Brendan Curley, DO, MPH

2 | December 2012

Brendan Curley, DO, MPH, with Princess Danger Curley

I

wear 2 hats in the hospital.

First, I am a hematology/ oncology fellow. In this role, I am responsible for seeing consults, primary patients, and patients in clinic. There are hundreds of other heme/onc fellows around the country, all doing the same things that I do.

My second hat is my more unusual one; I am also a registered therapy dog handler.

During my residency, one of our rotations was in a community hospital away from the inner city university where I did most of my training. At this community hospital, I was first introduced to therapy dogs. At the time, I had no experience with therapy

dogs and really didn’t know anything about them. These dogs are normal house pets that do extraordinary things. To work as a therapy dog, the animals must be older than 1 year and have exceptional manners and behavior. Their job is simple: to provide joy and smiles. One day, a therapy dog may have an entire nursing unit doting over him; the next may be spent with a very sick patient and her family. Another day, a therapy dog and his handler provided answers to questions about “How is this dog here”…questions from me, a resident near the end of a 30-hour shift.

I have always had a dog in my life.

While I was growing up, my family had

many different kinds of dogs in our home: Golden Retrievers, Irish Setters, Newfoundlands, and Chow Chows.

Once I was in college, then medical school, I had little time to raise and care for a puppy. That didn’t stop me from dreaming, though. I knew that an English bulldog would soon be my pet. I also knew that I could not raise one alone. I was lucky that my future wife Anjaly fell in love with bulldogs as well. Our engagement consisted of her receiving a beautiful diamond, and her present to me was my first dog of my own, an English bulldog puppy we named Princess Danger Curley.

Princess Danger was never intended to be a therapy dog. She came into December 2012 | 3

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our home as a pet, a goofball who immediately stole our hearts. The funny thing is that she not only stole our hearts, but that of anyone who met her. She would roll on her back and kiss faces, and was a sweetheart to everyone she met. She left us no choice in the matter—she was clearly born to be a therapy dog! Waiting until she was a year old seemed like overkill, since she was ready at 8 months.

Within a month of her first birthday, we scheduled her session to become certified. After 3 sessions, we had our own certified therapy dog.

We didn’t start small. We applied for her to be one of HUP’s Pups at the Hospital of the University of Pennsylvania (HUP). Her certification and vaccine reports were a start, but were not enough for HUP. She underwent a full veterinary examination and passed with flying colors. Her next test was with a veterinary behavioral psychologist, the final test prior to her entering the hospital. We were not surprised that she did not disappoint.

She had her ID card picture taken the very next day. She was now a hospital therapy dog with patients to see.

The first day we took her to the hospital, my nerves were on edge.

I was entering not as a doctor, not as a patient, but as a handler. My sole responsibility was to make sure

that my dog was well behaved and appropriate. Her first assignment was the Surgical Intensive Care Unit (SICU) where the head of the therapy dog program walked us through the unit. She gave her love to the nurses’ station and proceeded to see patients.

She did this for months, approximately once a week. Her visits lasted between 90 minutes and 2 hours (which is standard for therapy dog visits).

Patients laughed, cried, and told me about their dogs. Danger smiled, rolled around, and loved every moment of the scratching and attention she received.

She was a rock star at HUP, but we were both leaving to a new city and job at West Virginia University (WVU).

I started my hematology/oncology fellowship at WVU and immediately loved what I was doing. Oncology was truly my calling, and each day that

She left us no choice in the matter—she was clearly born to be a therapy dog!

4 | December 2012

passed showed me that I had made the right decision. Therapy dogs were conspicuously absent at WVU and Princess Danger was the perfect dog to fill that role. She started as a visitor, and soon turned herself into a regular at the cancer center. She first won over the nurses, followed by the staff and patients. She makes both outpatient and inpatient visits at the clinic and hospital, and some of her best work is with those receiving chemotherapy.

Chemotherapy visits are typically outpatient (but can sometimes be inpatient) and can last many hours over months, even weeks. These patients love seeing her, as her visit is a bright spot during their time at the cancer center or in the hospital.

She has made countless people laugh, smile, and some cry, but there is one experience that I will never forget.

Princess was making her rounds on the oncology floor as usual, when a nurse asked if she could come see a dying patient. He had a very aggressive form of leukemia that he had fought valiantly, but he had lost the battle. He was on comfort measures, being given only medications to make his last days of life as comfortable as possible. He was much younger than his sunken eyes showed, as I was able to tell by his young wife and high-school-aged daughter. They were obviously having such a tough time with his imminent death. I thought about how hard it must be for him and his wife. They had spent 18 years raising their daughter,

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and now he was dying as she was about to become an adult, and her mom would be left alone.

Princess entered the room with her normal amount of energy. The patient could barely move, and each breath caused him pain. His daughter and wife were at his bedside, and the true therapy began. My 40-pound love bug hopped in their laps and cuddled up like she hadn’t done before. She knew they needed it, and they truly latched onto her. We stayed for almost 2 hours. They talked about their loved one, but were mainly distracted by Princess Danger.

She showered them with love and affection, and moved them both to tears.

I knew she truly made a difference, but I didn’t yet know how much she had done to change their lives.

I started taking care of the unfortunate gentlemen as a patient the next day, caring for him and his family. His wife never left his side. His

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daughter was gone for the day, but I didn’t ask where she was. I can’t really imagine the level of emotion she was going through, losing her father at only 18. The next day I was in the physician workroom when a nurse asked me urgently to come to the unit. Usually this means that someone is gravely ill and needs immediate attention. That day, that was not why I was called. In the hallway, I found a bouncing, happy, 12-week-old English bulldog puppy, freshly picked out by the patient’s daughter the day she was not in the hospital. She was so happy to have her own little bundle of love, and that puppy picked up the staff’s morale that day. I spoke with the patient’s wife; she couldn’t say no to a puppy at that point. She told me that the dog was helping them get through the hardest days of their lives.

The patient died the day after the puppy joined their family. He passed

2:53 PM

peacefully, surrounded by his family. I was at his bedside and let them know that he had died, and their emotions came pouring out. The family left that day broken, their husband and father taken from them prematurely and unfairly. Cancer is not a fair disease, especially when it relentlessly attacks the young and innocent. We did everything we could to save his life, and in the end we could not succeed.

However, Princess Danger had changed their lives forever. I am sure that when they look in the eyes of their dog, they will not only see their lost loved one, but will always remember the day my therapy dog changed their lives. ■

Brendan Curley, DO, MPH, is a hematology/oncology fellow at the West Virginia University School of Medicine, Mary Babb Randolph Cancer Center, Morgantown, WV.

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Feature

The ABCs of IRBs: A Brief Overview

By Nancy Fell Hill, MPH

8 | December 2012

At some point in their careers, most oncologists will need to submit a research proposal to their hospital’s Institutional Review Board (IRB). Too many physicians view the IRB process as an additional bureaucratic burden in their already overloaded daily schedules. In reality, these boards serve an extremely important purpose: protecting human subjects who choose to participate in research.

Since most medical schools do not provide information regarding IRBs in their curriculum, many oncology fellows may not have a basic understanding of IRBs or what they do. This article provides a brief overview of IRBs and outlines pertinent resources for fellows who conduct or may contribute to human research studies.

An Abbreviated History The mandate for IRBs in the United States is a result of notorious human experiments performed over the last century. The horrific Nazi experiments during World War II involved physicians overseeing research on: the effects of drinking sea water; human experiments with spreading diseases such as hepatitis, typhus, and malaria; cold immersion studies; and, human sterilization experiments. Sadly, irresponsible studies were carried out in the United States as well, including the Willowbrook Hepatitis Studies, Milgram Studies of Obedience, and the Tuskegee Syphilis Study.

In short, these types of research prompted the current US system of protection in human subject research.

The ethical standards for the conduct of human subject research are codified in several federal regulations, including 45CFR46 and 21 CFR Parts 50 & 56. The IRB serves an integral part in the system of protection by upholding these standards.

The Role of the IRB The IRB has the authority to approve, require modifications to, or disapprove a research activity. Each IRB is composed of at least 5 members from various disciplines, at least one of whom is a non-scientist. Some institutions have multiple IRBs, depending on the number of research proposals to be reviewed.

According to 45CFR46.111, in order to approve a research proposal the IRB must determine that each of the following requirements is satisfied: • Risks to subjects are minimized: o By using procedures that are consistent with sound research design and do not unnecessarily expose subjects to risk. o Whenever appropriate, by using procedures already being performed on subjects for diagnostic or treatment purposes.

• Risks to subjects are reasonable in relation to anticipated benefits, if any, to subjects and the importance of the knowledge that may reasonably be expected to result. In evaluating risks and benefits, the IRB considers only those risks and benefits that may result from the research (as distinguished from risks and benefits of therapies subjects would receive even if not participating in the research).

• Selection of subjects is equitable.

In making this assessment the IRB takes into account the purposes of the research and the setting in which the research will be conducted.

• Informed consent will be sought from each prospective subject or the subject’s legally authorized representative.

December 2012 | 9

Feature • Informed consent will be appropriately documented, typically with a signed consent form.

Types of IRB Review

• When appropriate, the research plan makes adequate provision for monitoring the data collected to ensure the safety of subjects.

• Full Board Review This type of review is conducted for studies that entail greater than minimal risk to subjects. It is carried out by a fully convened IRB committee. According to federal regulation, minimal risk means that “The probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.” [45CFR26.102(f)]

• When appropriate, there are adequate provisions to protect the privacy of subjects and to maintain the confidentiality of data.

• When some or all of the subjects are likely to be vulnerable to coercion or undue influence, additional safeguards are included in the study.

Is This Project Human Research?

This is a question often asked by clinicians and investigators. At times there is an affirmative and straightforward answer, such as in the case of drug trials designed to determine the effectiveness of a new pharmaceutical formulation in treating a certain illness.

But at other times, the answer is not as immediately apparent.

The federal regulations define research as “a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.”[45CFR46.102(d)] A human subject is defined as “a living individual about whom an investigator (whether professional or student) conducting research obtains data through intervention or interaction with the individual, or identifiable private information.” [45CFR46.102(f)] There are a lot of grey areas here.

If you have any questions regarding whether a project you are planning to implement is considered human research, you should address them to your local IRB office. They will likely require some written documentation from you to consider the question. The details vary by site, but you may be asked to submit a written protocol and/ or an application; this varies by site.

10 | December 2012

There are 3 types of IRB review categories:

• Expedited Review This type of review is for studies that involve minimal risk to subjects. The review is performed by the IRB chair or an experienced designee. One example is a project that collects biological specimens for research purposes via noninvasive means (such as hair and nail clippings in a non-disfiguring manner).

The Department of Health and Human Services (DHHS) Office for Human Research Protections (OHRP) has a list of activities that fall under the category of minimal risk. Please note that use of the term “expedited” does not necessarily translate into a speedier review by the IRB. • Exempt Review Regulations specify several research activities that are considered exempt from review (45CFR46.101b). An example would be a minimal risk survey that cannot be linked to subjects through any form of identifiers.

Due to the potential for conflict of interest, it is important to note that someone other than the investigator must make the determination of whether or not a study meets the criteria for exemption. Typically, this determination should be made by an IRB member. Contact your IRB office

to determine the local procedures for exemption in your institution.

In assessing the type of review your research project may require, a useful tool to have on hand is a group of decision charts published by the DHHS. This will guide you through a list of questions to determine which review category is appropriate for your particular study (see sidebar for resources). Also, communicating with the IRB office to confirm that you are completing the correct forms for submission can save you time later.

Documents Needed for IRB Review Typically, IRBs include a list of documents required for review submissions on their website. The documents may vary according to the type of research involved. The website will also have a template consent form containing standard language.

Examples of documents that may be required to be submitted with each new full-board review submission include an IRB application, detailed study protocol, subject consent form, data collection tools, grant/contract application, Investigator Brochure, recruitment advertisements, subject questionnaires, and Financial Interest Disclosure forms.

In addition, funding and accreditation agencies have adopted policies that mandate human research protection education for all study personnel.

Many institutions utilize the Collaborative Institutional Training Initiative (CITI) course for this purpose. This contains various training modules and a certificate is issued upon successful completion of the course. Most IRBs will not issue final approval of a project until they have verified that all study personnel have completed this training.

The Full Board IRB Review Process For full IRB review, the board will need all of the required documentation to assess that the study meets

Online Resources for Human Research Studies

US Department of Health and Human Services: Human Subject Regulations Decision Charts http://tinyurl.com/8rren7b

US Food and Drug Administration: Science & Research: Running Clinical Trials http://tinyurl.com/y995a4r

US Department of Health and Human Services: Office for Human Research Protections www.hhs.gov/ohrp/

National Institutes of Health: Bioethics Resources on the Web http://tinyurl.com/8jjxljf

the federal criteria for approval. Many IRBs operate on a primary reviewer system whereby 1 or more IRB members are assigned a protocol based on the member’s education, background, and expertise. If no member has the appropriate expertise, an outside consultant is usually called upon. Some IRBs invite the investigator to the convened meeting to present their new protocols and answer any questions that might arise.

Much of the committee’s discussion is typically focused on weighing the risks involved with the study versus the potential for benefit to subjects.

Risks include not only physical risks but also psychological and social risks.

Recommended changes to the consent form are also discussed. If significant concerns are raised by the IRB, the protocol may be tabled or disapproved.

During the meeting, the IRB will determine the length of approval. This is based on the risks associated with the study and cannot exceed 1 year. The IRB may shorten the approval period for higher- risk protocols.

At the conclusion of the discussion, an IRB member makes a motion, it is seconded by another member, and then all members vote for or against approval or may abstain from voting.

Members with a conflict of interest are required to leave the meeting room during the discussion and cannot participate in the vote.

IRB Approval Timeline Oncology fellows need to be aware that once an application is submitted to the IRB it may take up to a month to be reviewed, although the time frame depends on the particular institution.

Ask your local IRB for its average turn around time. This may vary according to review category and deadlines for submission. Since projects cannot be initiated until IRB approval is received, it is imperative to take this interval into consideration when developing a timeline for the implementation of any given research project.

Another issue to consider in scheduling planning is that project approval will likely not be granted outright.

Upon review, the IRB may determine that certain changes are required in order to obtain approval. These could include recommended changes to the protocol, consent document, data collection sheet, etc. The investigator will need to respond to the IRB’s suggested revisions in writing and resubmit the materials for review by the IRB.

Conclusion It is the responsibility of the investigator to maintain IRB approval at all times. This means that continuing reviews must be submitted in a timely manner to avoid a lapse in approval.

All study amendments must be submitted for approval prior to their implementation. Protocol deviations or violations and adverse reactions must be reported.

It is important for oncology fellows to communicate with their local IRB office. The IRB staff can review materials (such as study protocols, consent forms, etc) prior to the formal submission to the full IRB committee and can provide answers to many questions. This can save investigators valuable time and avoid aggravation in the long run.

Breaches in compliance can lead not only to bad headlines in newspapers, but also a suspension of all federally funded research at the institution. The ultimate responsibility for the protection of human subjects in research rests with the investigator and is congruent with the declaration in the Hippocratic Oath to “Do no harm.”

The primary mission of the IRB is to protect human subjects. But it is important to note that in so doing, they can serve as a resource and can also protect investigators who are conducting the studies.

Nancy Fell Hill, MPH, is a New Jersey– based research administrator and freelance author. She has more than 10 years of experience working with IRBs in both a hospital setting and a large university.

December 2012 | 11

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A Word from Your Fellows

Bone Marrow Biopsy Simulation Training for Fellows

By Cyrus Khan, MD, and Ghulam Rehman Mohyuddin

A

bone marrow aspirate and biopsy is the single most common procedure that hematologists and oncologists carry out day in and day out throughout their career. Therefore, it is also the most common procedure that fellows in hematology/oncology training programs have to learn and then perform during their training. It is very important for fellows to become proficient and confident in doing this procedure independently and safely. In order to achieve this level of competence, they must learn not only the necessary steps but also master the correct technique.

Typically, in most training programs, new fellows learn how to do a bone marrow biopsy from either their senior fellows or attending physicians. They will usually observe a few procedures first and then learn to carry them out on patients under supervision. This training process is often unstructured, and there is no way to monitor the fellow’s progress or proficiency.

Moreover, different fellows and attending physicians have different procedural techniques and skills, as well as teaching ability. This combination leads to a haphazard method of learning for the new fellows in training.

At our institution, we recognized this deficiency and devised a plan to address it. We have recently developed a 14 | December 2012

program for new fellows that allows them to learn the correct indications, contraindications, and technique for doing a bone marrow aspirate and biopsy. They can then demonstrate their learning by simulating it on a mannequin or patient actor. In order to help others who may want to set up a similar program, we will describe how we structured it.

Program Setup The first step is to identify a space where the program will be run. At our institution, and at many academic centers, a simulation center is available. Such centers provide examination rooms, conference rooms, audiovisual equipment, medical instruments, monitors, and mannequins.

The next step is scheduling. It is important to arrange a suitable time when all of the new fellows will be free for 3 hours for the training program. Cross-coverage must be arranged if needed.

To run the program, you need to have the following equipment available: a bone marrow biopsy kit, an examination room, an anatomical model of the pelvis, and audiovisual equipment. We also employed the services of a patient actor for demonstration purposes.

Table. The evaluation criteria for observation of new fellows performing bone marrow biopsy procedures Patient Care ‘Time Out’ performed Anatomic landmarks identified Aseptic technique maintained Adequate local anesthesia used Appropriate technique Medical Knowledge Understands indications Understands what specimens are needed, ie, cytogenetics, flocytometry Communication/Interpersonal skills Explains the indication for the procedure Explains what the patient will experience Explains the potential risks; consent properly obtained Uses clear, understandable terms Professionalism Accepts instruction and suggestions Respects patient privacy and dignity Uses respectful language

Conclusion

Courteous to nursing and allied health staff

Feedback from the participating fellows and attending physicians has been very encouraging. The fellows now have greater self-confidence when carrying out their first bone marrow biopsy and their learning curve is much steeper. We plan to offer this program to incoming fellows every year. We strongly believe that this program will streamline the process of fellows learning this essential procedure. The more detailed training offered in this program helps fellows become skilled at performing a bone marrow biopsy, and these abilities are practiced and reinforced further during their live-patient encounters.

Practice-Based Learning Reviews final results of the test Systems-Based Practice Understands logistics of setting up a bone marrow biopsy Understands logistics of specimen handling, transportation to lab

Training Process About 2 weeks prior to the session, all of the fellows were sent a link to an online video that is available on the website of the New England Journal of Medicine1 that demonstrates how to do a bone marrow biopsy. They were also sent a copy of the article “How to do the perfect bone marrow biopsy.”2 On the day of the training session, they were given a PowerPoint presentation on the didactics of a bone marrow biopsy to reinforce specific relevant points, including indications, contraindications, possible complications, etc. They were also shown the anatomical landmarks on a pelvic model. They were then guided through a review of all of the requisition forms they would need to fill out when doing an actual biopsy and how to correctly complete them.

After this review, all the fellows were taken to an examination room to observe the entire process of a bone marrow biopsy demonstrated on the patient actor. The actual procedure was not performed on the actor, but the process was simulated from taking consent all the way through to making slides and sending off the specimens in the correct containers.

Alternatively, if an anatomy lab is available, the procedure can be performed on a cadaver. Each fellow then demonstrated how he/she would carry out the procedure. Teaching faculty and senior fellows observed these demonstrations and provided critiques. They also demonstrated their ability in making slides, using fake blood. Specific attention was paid to the communication aspects of the demonstration, especially ensuring that correct consent was obtained, the indications and complications of the procedure were explained, and that adequate anesthetic and pain control was offered.

This simulation lesson must be followed up with reinforcement of the procedures taught in this program during livepatient encounters. We have developed an evaluation form that is used by an attending physician or a senior fellow to evaluate the junior fellows on their performance when they perform a bone marrow biopsy on their first 5 patients. This is an invaluable tool in helping to streamline the process of feedback and helps the fellows hone their skills further. The specific areas on which each fellow is graded are shown in the Table. In these areas, each fellow is graded on a 5-point scale from “superior performance,” “good,” “fair,” “sub-standard,” to “unable to grade because of lack of observation.”

References 1. Malempati S, Joshi S, Lai S, et al. Videos in clinical medicine: bone marrow aspiration and biopsy. N Engl J Med. 2009;361(15): e28.

2. Khan C, Moffa C. How to do the perfect bone marrow biopsy. Onc Fellows. 2011;3(3):12-16.

When this article was written, Cyrus Khan, MD, was chief fellow in the hematology/oncology fellowship program at the West Penn Allegheny Health System in Pittsburgh, Pennsylvania. He is now a member of the faculty in the Division of Stem Cell Transplantation and Cellular Therapy at the same institution. Ghulam Rehman Mohyuddin is a final-year medical student at the Aga Khan University, Karachi, Pakistan, who has completed a clinical elective in hematology/oncology at the same institution.

December 2012 | 15

A Word from Your Fellows

How do I keep up with the literature?

By Amer M. Zeidan

A

s an oncology fellow pursuing an academic career, one of the major challenges I face is the arduous process of multi-tasking and time management to balance my clinical duties and my research activities. In addition to taking care of my clinic patients and conducting several clinical research studies, I have had to find an efficient way to keep up with the developments reported in the literature.

Through current literature, I learn about many practicechanging clinical trials, novel insights into the pathogenesis and molecular mechanisms underlying various malignancies including newly identified potential therapeutic targets, and many newly approved drugs and therapeutic approaches to different types of malignancies and hematologic disorders.

The sheer volume of clinical studies, case reports, and review articles available in print journals and online creates a daunting mountain to face.

One of the most successful senior investigators at my institution always told fellows that we should follow the “hour-glass” model of knowledge and skill acquisition in 16 | December 2012

order to succeed in the academic world. According to this model, at the beginning of your fellowship you should focus on understanding general principles and acquiring a wealth of actionable knowledge in general oncology and hematology. This knowledge is needed for safe and efficient care of patients. Then, in the latter parts of fellowship and during the junior faculty years, the focus should shift to becoming the “world expert” in a particular area of research interest through detailed and comprehensive reading and learning.

In the later phases of an academic career, after becoming an established investigator in a specific area of interest, the focus can be broadened again to encompass other possible areas of interest.

I have tried to follow this model during my fellowship training. As a result, during my second and third years of fellowship (the narrow neck of the “sand-glass”), I have devoted the vast majority of my time to expanding my knowledge in the micro-details in my area of expertise and the focus of my future academic career: pathogenesis and management of myelodysplastic syndromes (MDS) and acute myeloid leuke-

mia (AML). Achieving this goal successfully required that I dedicate a lot of time to keep up with the countless new research papers in these areas while conducting my own clinical research. The natural result of this shift to a narrow focus during the latter parts of my fellowship was that I have had little time to keep up with the rapidly expanding literature in other areas of oncology and hematology disciplines.

It is important to me to keep updated on general hematology and oncology developments for a number of reasons.

First, this information helps me to appropriately treat my clinic patients, who present with a variety of malignancies and hematologic diseases. Also, since I have pursued dual certification in both hematology and oncology, I need to be prepared to take the boards. Last but not least, I have a relentless desire to be aware of all the new exciting developments in the fields of oncology and hematology. Senior fellows interested in academic careers share this challenge: How to tackle the never-ending stream of published literature. In attempting to maintain a balance, I have found several strategies and resources to be quite useful.

First, since it is virtually impossible to read every medical journal on regular basis to keep up with new oncology and hematology research, a reasonable alternative for me was to focus on the leading MDS and AML journals. I also read at least one of the clinical journals that regularly tracks and summarizes the major papers and developments in the field.

One such resource is the “Oncology and Hematology Journal Watch,” which summarizes key hematology and oncology research papers from more than 250 medical journals and offers clinical commentary from experts in the field. The American Society of Clinical Oncology (ASCO) produces “ASCO News,” which also presents many updates in oncology research. In addition, I always try to read two of the leading journals in the field, Blood and Journal of Clinical Oncology (JCO), as well as the oncology/hematology articles in the New England Journal of Medicine (NEJM). Recent review articles can also be very helpful in keeping updated in a particular area without devoting as much time as it takes to read every new clinical research article. Each of the major journals in oncology and hematology publishes serial reviews of current hot topics in the field. For example, for benign and malignant hematology, I find the “How I treat” review articles in Blood to be good reviews of the current status of the literature on that particular subject.

Second, in addition to reading journals, another helpful resource that I frequently use are the audio updates that can be downloaded in mp3 format and so I can listen to them on my iPod while working out or while driving back and forth to work.

For example, the oncologic educational activities produced by Research To Practice are distributed by mail to subscribers or can be downloaded from the website. These educational materials include audio interviews with experts in the field, casebased panel discussions, studies of patterns of care, and other programs that are delivered in an easy to follow format.

Online Resources • American Society of Clinical Oncology (ASCO) Meetings http://tinyurl.com/963mnwm • ASCO News http://tinyurl.com/9hxz8yx • American Society of Hematology (ASH) Meetings http://tinyurl.com/9oq9s7e • Blood http://tinyurl.com/2tvpmv • Journal of Clinical Oncology http://jco.ascopubs.org • The New England Journal of Medicine www.nejm.org • Oncology and Hematology Journal Watch http://tinyurl.com/9bg9tet • OncLive www.OncLive.com • Research To Practice www.researchtopractice.com

Third, in addition to attending some of the major national and international meetings in AML and MDS that are important for my research interest, I also try to attend one of the smaller regional meetings that summarizes the most important presentations in the international meetings of oncology and hematology. For example, both ASCO and the American Society of Hematology (ASH) organizes several condensed regional “highlights” meetings in different cities throughout the year to print the information to a wider audience of oncologists and hematologists who might not have the chance to attend the main meetings. Some of these highlights of ASH and ASCO meetings are being conducted internationally as well. Many institutions, societies, and agencies also conduct their own “board-review” courses or conferences in specific areas of oncology, hematology, clinical pharmacology, targeted therapies, immunologic mechanisms, and other disciplines.

These approaches have been most useful to me in keeping current in the oncology and hematology disciplines that are out of the scope of my focused research interest. But I’m sure other fellows have developed other useful strategies. I welcome any suggestions of other approaches to this important challenge that faces most senior fellows in oncology or hematology preparing for academic careers.

Amer M. Zeidan, MD is a clinical hematology/oncology fellow at the Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital in Baltimore, MD. Email: Azeidan1@jhmi.edu.

December 2012 | 17

transitions

Achieving Career Success in Academic Oncology

What to know when deciding on a career in academia

By Mohammed Almubarak, MD, and Jame Abraham, MD, FACP

18 | December 2012

The field of oncology has undergone a significant transformation in the last few years. In this era of individualized medicine, we are learning new ways to tailor treatment based on the molecular pathways of the tumor. There has never been a more exciting time to be in the field of oncology, especially in academic oncology. In addition to the ability to develop a disease-focused clinical career, an academic oncologist can build a research, educational, or administrative career (as, for example, a cancer center medical director or a department section chief). Academic oncologists have a critical role as opinion leaders and shape the future of cancer care by research and training future oncologists, residents, and medical students.

Applying for an academic job

Tenure versus non-tenure tracks

If you are planning to pursue an academic career, make sure you have a mentor who can guide you through the application, interview, and selection processes. Generally speaking, there are usually many academic oncology practices in universities and cancer centers that actively search for young talent to build their department or join their established staff. A fellow should start looking for an academic job opportunity before the end of the second year of fellowship or during the early part of third year. A good place to start is with advertisements in major oncology journals or postings at national meetings such as the American Society of Clinical Oncology or the American Society of Hematology Symposium.

Preparing an adequate curriculum vitae (CV) is probably the most important step in the job application process. The CV should include the following information in a clear and organized manner: contact information, academic background and training history, research experience, grants and publications, awards, and voluntary work experience. Emphasizing teaching or mentoring experience and research skills (while avoiding falsifying information) will make a candidate more desirable for an academic job. A candidate should also identify mentors who know him or her well, and who are willing to write letters of recommendation or serve as references if needed.

It is important to understand the different aspects of a tenure vs non-tenure academic oncology track, including the academic ranks and specific requirements for each. A proper understanding of the responsibilities associated with a specific academic position, as well as the culture and expectations of the cancer center and department, is crucial for the candidate’s success in that environment.

Usually, a candidate who has recently completed fellowship is accepted as an assistant professor or, in some cases, as a tutor or clinical instructor. In general, the candidate is offered a position in either tenure track or non-tenure track. In the past, tenure track meant guaranteed, permanent job appointment and benefits. The definition, however, varies from one institution to another. It is very important to find out if you are interviewing for a position in the tenure or non-tenure track and what the specific requirements are for each track. The type of appointment and the requirements needed to achieve tenure status should be made clear in the offer letter.

A key factor to advancing the academic ladder is identifying a mentor who shares common clinical and research interests. On average, an assistant professor is usually eligible to be promoted to an associate professor rank after 5 to 7 years. Each institution will have its own criteria for promotion, and new faculty should familiarize themselves with them. The promotion process involves a thorough review of performance in various aspects of the particular track you are in. It is important to maintain a high level of academic, research, and clinical productivity.

The job interview process Institutions that have great interest in a candidate will send an invitation for a job interview. This is an opportunity for the candidate to make a lasting impression and also take a closer look at the work environment. To prepare for the interview, the candidate should inquire about interviewees—including other cancer specialists such as radiation oncologists and surgical oncologists—and their clinical interests. This information can be used to emphasize potential areas of collaboration in the future.

In general, the candidate is expected to give a presentation related to his or her work and research interest. It’s vital to tailor the depth of the presentation based on the audience’s clinical interest and background. For example, if your audience is predominantly clinicians, try to focus on the translational or clinical aspects of your research as opposed to basic science. The interview is also an opportunity to highlight individual strengths such as involvement with investigator-initiated clinical trials and prior publication.

Types of academic appointments In general, there are 3 types of academic appointments in oncology: clinical track, scientist track, and clinician scientist track.

Clinical track: Academic oncologists in a clinical track spend most of their working hours (up to 90%) in direct patient care–related activities. This can involve an assigned number of outpatient clinics per week (sometimes up to 4 days of clinic), along with hospital setting or inpatient coverage. The remainder of the time is dedicated to teaching and some research. Since this is a primarily patient care–focused track, the research expectation is limited. However, the faculty member is strongly encouraged to enroll patients in clinical trials and participate December 2012 | 19

Feature in national cooperative oncology group– or industry-sponsored studies. A clinician track oncologist is rarely expected to write an investigator-initiated trial due to their limited time.

Keys to Success in Academic Oncology

Scientist track: In this track, the emphasis is primarily on

• Thoroughly understand the expectations and goals of your track.

research (bench or translational). These oncologists can have up to 90% protected time for research, with less emphasis on patient care and teaching responsibilities. In general, academic oncologists in this setting are guaranteed lab space and initial funding to buy supplies and cover other overhead costs for the first 1 to 2 years. In addition, other ancillary services (eg, animal facilities and tissue banking) and access to other collaborative facilities (eg, clinical trial research units and statisticians) is provided. Academic oncologists are expected to eventually bring extramural support for research and mentor fellows with research interest. The patient care responsibility is usually minimal, consisting of 1 or 2 half-day clinics per week.

• Identify a mentor who is familiar with your career goals and who is willing to help you.

• Focus is essential for academic success; concentrate on your strengths and focus on your goals.

• Always try to be a good team player and treat others with respect.

• Take care of your patients, yourself, your family.

• Remember to keep a positive outlook and have fun!

Clinician scientist track: Clinician scientists are usually translational investigators. They are the bridge between clinicians and basic scientists or oncologist in the scientist track. Clinician scientists are expected to write investigator-initiated trials and be principal investigator for national cooperative oncology group or industry-sponsored trials. Clinician scientists are also expected to acquire financial support through clinical trials or extramural funding. Usually, clinician scientists are in the clinic 2 or 3 days per week, with the rest of their time dedicated to research and clinical trial activities.

“ On average, an assistant professor is usually eligible to be promoted to an associate professor rank after 5 to 7 years.

Each institution will have its own criteria for promotion, and new faculty should familiarize themselves with them.”

20 | December 2012

Financial compensation in academia The financial compensation for an academic oncologist is significantly less than for an oncologist in a private practice.

The starting salary for an academic oncologist is $160,000 to $200,000, compared with $175,000 to $300,000 for an oncologist in private practice. However, the financial risk in academia is less since academic oncologists work within the structure of university hospitals where the costs and profits are spread over multiple departments. Academic oncologists can choose to supplement their salary through research grants or by giving lectures at pharmaceutical-sponsored conferences.

Academic oncologists are not isolated from real-world medicalfinancial concerns; they will need to learn about the “ins and outs” of medical billing including, for example, assigning the correct Current Procedural Terminology code for Medicare patients.

Familiarity with reimbursement measures such as Relative Value Units (RVUs) is essential since they are also used as a productivity indicator (ie, many practices set RVU goals based on the number of years in practice and assigned academic track).

All in all, finding your niche in academia and tailoring your career to suit your personal strengths and interests is instrumental.

As Confucius said, “If you enjoy what you do, you will never work another day in your life.” ■

Mohammed Almubarak, MD, is assistant professor of medicine in the hematology/oncology section of Mary Babb Randolph Cancer Center in Morgantown, West Virginia.

Jame Abraham, MD, FACP, is Bonnie Wells Wilson Distinguished Professor and Eminent Scholar; co-leader of the Breast Cancer Program; chief of the hematology/oncology section; and medical director of the Mary Babb Randolph Cancer Center at West Virginia University in Morgantown.

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ONLINEONCOLOGIST

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M o b ile M e d icine: A pps fo r t he H ea lth ca re P rof e s s iona l

DrawMD Price: Free Platforms: iPad The DrawMD app was originally developed by surgical oncologists and is now available for a number of specialties.

The app provides detailed anatomic drawings to help doctors explain conditions and procedures to their patients. Users can add freehand drawings or stamps to illustrate patients’ specific findings or planned surgical procedures.

Developed by Visible Health, the app also offers the ability to import backgrounds and to e-mail or save sketches for later reference. www.drawmd.com

22 | December 2012

MedSpeak Price: Lite versions are Free; full versions $9.99 Platforms: iPhone, iPod, and iPad The MedSpeak app is available in both Mandarin and Cantonese versions.

Designed to increase patient communication, the apps provide written and audio translations of more than 3300 common medical phrases. These phrases are designed to help obtain patient history and perform a complete physical examination.

The free Lite versions offer sample content to help users determine if the full version would be useful. www.qxmd.com/apps/ medspeak

Medscape Price: Free Platforms: iPod Touch, iPhone, iPad, Android, BlackBerry, and Kindle Fire From WebMD, the Medscape app offers a variety of resources for physicians. Medscape medical news can be filtered by specialty and can be e-mailed or posted to Facebook for sharing. Medical reference resources include prescribing and safety information on more than 8000 prescription and over-the-counter medications, as well as supplements. The Diseases & Conditions resources include more than 4000 articles by medical experts and more than 600 videos demonstrating medical procedures, step by step. The iPhone version also includes medical calculators. www.medscape.com/ public/mobileapp

Electronic Preventive Services Selector (ePSS) Price: Free Platforms: iPod Touch, iPhone, iPad, Android, BlackBerry, Palm, and Windows mobile The Agency for Healthcare Research and Quality, part of the US Department of Health and Human Services, has entered the mobile app market.

The ePSS app offers searchable access to US Preventive Services Task Force (USPSTF) recommendations for clinical preventative services for your patients. Users can save searches for frequently needed information and can e-mail or print pertinent articles or patient-specific recommendations. epss.ahrq.gov

CellAtlas Price: Free Platforms: iPhone, iPod Touch, Android CellAtlas is the mobile access point to the CellaVision Blood Cell Morphology Guide.

Expert faculty present lectures and relevant images in the following areas: Hematopoiesis, Normal Findings in Peripheral Blood, Other Findings in Peripheral Blood, and Erythrocytes.

Several images of each cell type are included for visual reference.

In addition, the app includes a CellQuiz of image matching quiz to select the correct images for each cell type as well as links to relevant videos. www.cellavision.com/ cellatlas

By the Numbers The graph below illustrates the 2012 estimates of new cases of cancer, by cancer type and sex. The total number of new cases of cancer in males is projected to be 848,170, and 790,740 in females. These data do not include cases of basal or squamous cell skin cancer and in situ carcinoma except urinary bladder. The largest combined cause of new cases of cancer for both genders is cancer of the lung and bronchus, accounting for a total of 226,160 (13.7%) new cases of cancer.

Leading New Cancer Cases, 2012 estimates

1,638,910 Male -- All sites 848,170 241,740

Prostate Lung & bronchus

116,470

Colon & rectum

73,420

Urinary bladder

55,600

Melanoma of the skin

44,250

Kidney & renal pelvis

40,250

Non-Hodgkin lymphoma

38,160

Oral cavity & pharynx

28,540

Leukemia

26,830

Pancreas

22,090 O

50,000

100,000

150,000

200,000

250,000

Female -- All sites 790,740 226,870

Breast Lung & bronchus

109,690

Colon & rectum

70,040

Uterine corpus

47,130

Thyroid

43,210

Melanoma of the skin

32,000

Non-Hodgkin lymphoma

31,970

Kidney & renal pelvis

24,520

Ovary

22,280

Pancreas

21,830 O

50,000

100,000

150,000

200,000

250,000

Source: American Cancer Society. Cancer Facts & Figures 2012. Atlanta, GA: 2012; 10.

Available online at the American Cancer Society website http://tinyurl.com/8kylgc7.

December 2012 | 23

Conference Center 2012-2013 Oncology & Hematology Meetings November 30–December 1

Hematologic Issues in Cancer Care Dallas, TX http://tinyurl.com/8rt5oox December 4–8

35th Annual San Antonio Breast Cancer Symposium San Antonio, TX http://www.sabcs.org/ December 8–11

54th American Society of Hematology Annual Meeting and Exposition Atlanta, GA http://tinyurl.com/d447zr8 January 16–18

Pediatric Oncology Centers of Excellence Philadelphia, PA http://tinyurl.com/8sspmu8 January 18–19 November 15–18

November 28–December 2

Society for Neuro-Oncology 17th Annual Scientific Meeting & Education Day of the Society for Neuro-Oncology

Global Conference on Perioperative Medicine: Care of the Elderly & the Cancer Patient

Washington, DC http://tinyurl.com/932gw6h

Houston, TX http://bit.ly/MUAZxm November 30–December 1

November 15–16

Thoracic Oncology for the Oncologist Scottsdale, AZ http://mayocl.in/PcDDSB November 18–20

17th Annual Perspectives in Thoracic Oncology New York, NY http://bit.ly/Qhl9n7

American Society of Clinical Oncology Quality Care Symposium San Diego, CA http://tinyurl.com/9togz7e

Advances in Thyroid Cancer Diagnosis and Therapy Phoenix, AZ http://tinyurl.com/9dohhmf January 19

9th Annual Clinical Breakthroughs & Challenges in Hematologic Malignancies Lake Buena Vista, FL http://tinyurl.com/9caeqb3 February 15-17

International Congress on Hematologic Malignancies New York, NY http://tinyurl.com/awpyrpl March 7-10

Miami Breast Cancer Conference Miami, FL http://tinyurl.com/amnukaq

24 | December 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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