Vol. 3, Issue 3 Digital Edition of Oncology Fellow Advisor

ONCOLOGYFellow

Vol. 3, Issue 3

S UPPORT & INFORMATION FOR THE NEXT GENERATION OF ONCOLOGY PRACTITIONERS

o oncologyfellowadvisor.com

Career Paths

Fellowship Training

A DAY IN THE LIFE

We highlight the work of fellowship director Timothy Gilligan, MD. 4 FELLOWSHIP TRAINING

Experts discuss what to expect in 6 the first year of fellowship.

FELLOWSHIP TRAINING

Communication skills are crucial for oncology fellows.

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advisor

Mentor Memos

Survey Says

Physician Finance

Top-Tier Centers Share Tips

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ospitals in the United States are anxious to be included in the annual US News and World Report’s list of top hospitals. To make the 2011 to 2012 cut, cancer centers had to treat at least 254 inpatients with highlevel expertise in 2007, 2008, and 2009.1 The following are the top 10 cancer centers in US News and World Report, in ascending order of quality: University of Texas MD Anderson Cancer Center, Memorial Sloan-Kettering Cancer Center (MSKCC), Johns Hopkins (JH), Mayo Clinic, Dana Farber Cancer Institute/Brigham & Women’s Cancer Center, University of Washington Cancer Center in Seattle, Massachusetts General Hospital, UCSF Medical Center, Cleveland Clinic, and Ronald Reagan UCLA Medical Center.1 Oncology Fellow Advisor spoke with Daniel Spratt, radiation oncology trainee at Memorial Sloan-Kettering (No. 2 on the

see, Top-Tier page 5

Master Work–Life Balance

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raining to be an oncologist can be rough. In the face of long hours, sleep deprivation, and patient suffering, young oncologists may sacrifice hobbies, interests, and even relationships. Many fellows find comfort in reminding themselves that better days are ahead but experts say that they may be setting themselves up for disappointment.

Oncologists who cope by looking to the future may miss opportunities in the present to shape their career to meet their needs.1 “Putting aside one’s personal needs or personal wellness can eventually come back in a negative

or unhealthy way that can lead to burnout,” said Charles M. Balch, MD, FACS, professor of surgery in the Division of Surgical Oncology at University of Texas Southwestern Medical School in Dallas, Texas. “A successful medical career at the expense of personal wellbeing is not at all successful.”

One in 3 oncologists will experience significant career burnout— described as emotional exhaustion, depersonalization, and a sense of low personal accomplishment that leads to decreased effectiveness at work.2 Some of its more tragic consequences see, Work–Life page 2

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CAREER PATH

Oncology Fellow Advisor • Vol. 3, Issue 3

Work–Life continued from page 1

accomplished? Seeking out mentors who have achieved some sense of balance in their career also may be a great help, Dr. Balch added.

Just as importantly, oncologists should protect their personal well-being and find ways to renew themselves, said Dr. Lyckholm, who is Page Professor of Bioethics and Humanities and fellowship program director in the Division of Hematology/Oncology and Palliative Care at Virginia Commonwealth University School of Medicine in Richmond, Virginia. “Some days will be really hard and you need to find ways to absorb the grief ... whether it is physical activity, writing, talking, praying. Find ways to take small breaks during the day—just 5 minutes to do something pleasant 3 or 4 times a day, read a joke, email a friend, take a short walk, and have a soda or ice cream or something delicious from time to time. Find a space where you work that you can go to. For me, there is a floor of the hospital that has a quiet corridor with windows and a place to sit. It is my sacred space.”

Outside of work, oncologists also must nurture their personal life to prevent burnout (Table 2).2-4 “I heard a great piece of advice once,” Dr. Lyckholm said. “When you

include broken relationships, substance abuse, and suicide. “Work–home balance is a common denominator of burnout and depression and having a proactive plan for personal wellness is essential if one is to prevent burnout and depression or to mitigate its consequences when it happens,” Dr. Balch said.

For young oncologists, the first step in avoiding burnout is to choose a fulfilling career track—private practice, clinician-educator, translational scientist, or basic scientist—and prepare to manage the stress specific to each (Table 1).2 Each track offers varying clinic duties, intellectual rewards, and potential stressors. Academia presents unique stressors related to balancing research, getting published, and maintaining grant funding. However, private practice, with its heavy clinic schedule and patient exposure, can take a substantial toll on oncologists, and they need to be especially vigilant in protecting their health. Dr. Balch recently published research that found subspecialty surgeons in private practice were more likely to burn out than “A successful medical career those in academia.3 at the expense of personal In another recent paper, Laurel J. well-being is not at Lyckholm, MD, and her colleagues suggested oncologists identify profesall successful.” sional goals to help them choose their —Charles M. career track and shape it along the way to focus on what is most rewarding to Balch, MD them about that track.2 Oncologists may be able to offset potential burnout by making choices in their career based on the answers to these questions2: Why did I choose to become a physician? Why did I choose to become an oncologist? What do I like most about my job? What motivates me professionally? By the end of my career, what 3 things do I hope to have

Table 1. Work–Life Questions To Ponder

Table 2. Tips To Achieve Work–Life Balance

Why did I choose to become a physician?

Choose a career track that fulfills you (private practice, clinicianeducator, translational scientist, or basic scientist).

Why did I choose to become an oncologist?

Be vigilant in protecting your health.

What do I like most about my job?

Identify professional goals.

What motivates me professionally?

Eat well, exercise, and get enough sleep.

By the end of my career, what 3 things do I hope to have accomplished?

Based on references 2-4 and conversations with Charles M. Balch, MD, and Laurel J. Lyckholm, MD.

Based on reference 2.

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Vol.3, Issue 3

CAREER PATH

• Oncology Fellow Advisor

are at work with your patient, be entirely there with them.

No wife, no husband, no kids—just the patient and [his or her] family. And when you walk in the door at night, you must leave them [patients] behind and be present for your family and friends.” Going on vacation also is a must, she added.

Eating well, exercising, getting enough sleep, and spending time with family and friends may be advice given by all oncologists and taken by only a few.4 Delegating at work and home can afford you time to include these healthy habits. “If you are spending too many hours at work, think about cutting back and spending money on hiring another registered nurse, nurse practitioner, etc.,” Dr. Lyckholm said. “The money will not be as important as the time. Organize your work around your family, not vice-versa.” At home, hiring household help for laundry, cleaning, and cooking could be worth the time freed up.4 Additionally, living near parents or relatives and finding quality child care can be very helpful for oncologists with growing families.4 In the end, neglecting life at home for career or trying to “do it all” is an unsustainable path. Balance is not easy to find but pursuing it is a worthwhile goal for both physicians and their patients.1-3 “We can’t always control our workplace environment and there is going to be stress,” Dr. Balch said. “It’s a matter of whether we adapt to it in a healthy or an unhealthy way.”

Editorial Board Karin Hahn, MD Associate Program Director, The University of Texas MD Anderson Hematology/Oncology Fellowship Chief of Medical Oncology Associate Professor Lyndon B. Johnson General Hospital Houston, Texas Jamal Rahaman, MD Fellowship Director Division of Gynecologic Oncology Associate Clinical Professor of Obstetrics, Gynecology, and Reproductive Science Mount Sinai School of Medicine New York, New York Andrew D. Seidman, MD Attending Physician, Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center Professor of Medicine Weill Cornell Medical College New York, New York

Marc Stewart, MD Program Director, Hematology/Oncology Fellowship University of Washington/Fred Hutchinson Cancer Research Center Medical Director, Seattle Cancer Care Alliance Professor of Medicine, University of Washington Seattle, Washington

References 1. Shanafelt TD. Finding meaning, balance, and personal satisfaction in the practice of oncology. J Support Oncol.

2005;3(2):157-164.

2. Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24(24):4020-4026.

3. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings.

Ann Surg. 2011;254(4):558-568.

4. Chittenden EH, Ritchie CS. Work-life balancing: challenges and strategies. J Palliat Med. 2011;14(7):870-874.

Copyright © 2011

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MENTOR MEMOS

Oncology Fellow Advisor • Vol. 3, Issue 3

ogram director Fellowship pr ittee member Ethics comm

A Day in the Life of Timothy Gilligan, n, MD

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ncology Fellow Advisor presents our Day in the Life series. In each segment, we interview a prominent thought leader about how he or she got into the field of oncology and his or her typical workday.

In this issue, we interview Timothy Gilligan, MD, program director of the Cleveland Clinic’s Hematology-Oncology Fellowship, director of the Late Effects Clinic, and a member of the Cleveland Clinic’s Ethics Committee and Graduate Medical Education Committee in Cleveland, Ohio. We are honored to include a renowned fellowship director in this series.

If you would like to nominate someone to be interviewed for our Day in the Life series, please send your nomination via email to oncologyfellowadvisor@mcmahonmed.com.

With several generations of physicians adorning the branches of his family tree, it’s not terribly surprising that Timothy Gilligan, MD, aspired to join their ranks and keep the medical tradition alive into the fourth generation. “I think it was in my genes,” Dr. Gilligan said. “I was exposed to medicine at a very early age. My brother, dad, grandfather, great grandfather—all doctors.”

That he wanted to follow in their footsteps was always clear, but Dr. Gilligan had not always wanted to be an oncologist; he had originally set his sights on being an intensive care physician. A 4-month stint during residency at Brigham and Women’s Hospital in Boston, Massachusetts, with its intensive exposure to cancer care, sent Dr. Gilligan down a different path. “During those months I would stay late at the hospital. After the medical work was done I wanted to talk to [the patients], learn more about what they were going through.” He was moved by the compassion he felt for patients going through a difficult and frightening time, and by the tight bonds he would form with patients in need of care. “Also, when you’re looking at potential death or the fear of death, a lot of the nonsense that you deal with people in other situations drops away; people don’t want to waste their time at that point,” he said.

Dr. Gilligan finds that his experience is not uncommon in people who choose oncology as their medical specialty.

“People find it very meaningful, the kinds of relationships and conversations they have,” he said. “If you can get over the fact that there are a lot of sad stories and focus on the fact that these are people who really need good doctors, it’s a very engaging line of work to be in.”

As compelling as oncology is, it never ceases to be challenging, especially to those just beginning to learn the different angles and facets of care and to tackle learning the vast quantity of information they will need to know.

“It is harder than most fellows expect. Our patients are very complicated. They have the emotional stress of the diagnosis, and those with advanced disease have a lot of

Clinic director

medical complications. You need to be a good internist, and to get really comfortable with all the complications of cancer medicine,” Dr. Gilligan said. “But if you put in the work and learn how to do this very well, it’s really rewarding to achieve a high level of confidence.”

Oncology is a field rife with published data. There is a lot to learn, memorize, and integrate into clinical care. “There was a time when people thought that anyone starting fellowship should read textbook X in their field, but I don’t think that’s very helpful to fellows. Patients never fit the textbook very well and it’s hard to retain information that way—especially when you don’t have an exam at the end of the month.” A more effective approach may be to see a lot of patients in different clinical scenarios, and to supplement that exposure with reading to enhance retention.

“We’re coming to understand that the more active learning is—patient-based and problem-based—the more people retain the information,” Dr. Gilligan said.

No 2 days look alike for Dr. Gilligan, who teaches at the medical school and advises a dozen medical students, has 2 full clinic days each week, and serves as deputy editor of the Cleveland Clinic Journal of Medicine, reviewing articles and developing continuing medical education.“I feel like I wear 5 different hats,” he said. Right now he is working on improving quality of care—specifically the quality of communication between oncologists and patients. “We’ve been working with fellows for a while, but now we’re starting it with staff and faculty physicians at the Cleveland Clinic.”

Looking toward the future, Dr. Gilligan imagines the details will change, but that the overall structure will remain the same. Although he’s been running a fellowship program for 5 years now, he is not eager to give it up. “I like working with the fellows. It’s hard to think that there’s anything more important than training the next generation of physicians,” he said. “The challenge for us is to make it easier for them, not in terms of less work, but in helping them clarify what they need to work on in order to succeed: How do you identify a good mentor? How do you learn everything you need to know to be a good doctor?”

The field of oncology seems to be increasing in popularity, Dr. Gilligan said, and he thinks this has to do partly with the allure of the science and research, and partly because oncology holds more promise and optimism than ever before.

Dr. Gilligan also has noticed that the caliber of oncology fellows appears to be rising as the field becomes more intriguing, and as role models emerge whom younger doctors emulate. “It’s an encouraging thing for a program director to see good candidates apply,” he said.

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Vol. 3, Issue 3 • Oncology Fellow Advisor

FELLOWSHIP TRAINING

Top-Tier

have nothing else to offer them in hopes of a cure. Fortunately, MSKCC has resources to help patients and families in other ways, as well as to provide physicians a wealth of continued from page 1 resources to find solutions for them,” Dr. Spratt said.

For Dr. Rasheed, the challenge of training is the intensity list) and Zeshaan Rasheed, MD, PhD, medical oncologist of the first year due to a combination of patients’ needs who trained at Johns Hopkins (No. 3 on the list) about the and how sick they are. “Treating cancer is emotionally advantages and challenges of their experiences. exhausting and physically depleting due to the nature of MSKCC is a large institution in New York City with sevthe illness and the long hours we work,” he noted. eral smaller regional centers. JH is in Baltimore, Maryland, To be accepted as a trainee at a top-tier institution, Dr. and also has some regional centers. Inpatient admissions Spratt said, “You need to demonstrate that you are dedare 24,346 per year at MSKCC and 2,300 per year at JH.2,3 icated to being a future leader in oncology research.

Average length of stay for patients is 5.9 and 8.9 days,3 This will be looked at in depth by using measures such respectively. Radiation treatments and implants number as your dedication and success 59,223 at MSKCC,2 whereas radioin research, and common clinisurgery numbers 230 at JH.3 The “Make yourself distinct by being cal parameters, such as honor total number of employees at society memberships, grades, MSKCC is 11,474 and 1,000 oncol- involved in lab and clinical research and board scores. Most people ogy employees work at JH.2, 3 on topics that are at the forefront who become fellows at a top According to Dr. Spratt, who is of medicine—for example, novel institution already have pubcurrently training at MSKCC, he is lished research and presented “surrounded by excellence, inno- therapeutic targets, biomarkers, public nationally.” vation, inspiration, and opportu- health policy, and health disparities.”

Dr. Rasheed agreed that nity, all with the focus of finding a —Zeshaan Rasheed, MD, PhD in addition to the standard cure for cancer.” MSKCC focuses requirements of board scores only on treating cancer, which and recommendations, it is key “to make yourself distinct affects the caliber of physicians, fellows, and residents. The by being involved in lab and clinical research on topics best people from around the world come to train at MSKCC that are at the forefront of medicine—for example, novel and having top colleagues to work with is a privilege, he therapeutic targets, biomarkers, public health policy, and noted. “The level of detail is unparalleled,” he added. health disparities.”

“For example, to our radiologists, a vertebral metastaOnce accepted into a top-tier training program, the sis is not just listed as a bone metastasis, but is described trainee should maximize his or her experience by taking in remarkable detail as to the degree of epidural disease, advantage of the multitude of resources, including the spinal cord compression, neural foramina involvement, endless opportunities for collaboration with leaders in the and subtleties that aid in choosing an optimal radiological field of oncology, Dr. Spratt advised. “Expand your reptherapy. The multidisciplinary approach provides collaborertoire. If your main interest has been clinical, then learn ative innovative care,” he said. about basic science.”

Dr. Rasheed said that there are 2 main benefits of trainAccording to Dr. Rasheed, the biggest challenge is geting at JH. The first is that year 1 is devoted entirely to clinting funding for research. Once training is complete, stayical training and treating patients with a wide variety of ing at an academic center involves accepting less money malignancies. “The fellows are the primary caretakers of than in private practice. “My advice is to stay focused on their patients, and the attending physicians oversee the your research and be patient. Practicing clinical medicine cases. This is unique and doesn’t happen at most other is gratifying at the end of the day, whereas doing research institutions.” The second benefit is that years 2 and 3 are does not always have immediate payback.” focused on research, with clinical care accounting for about 20% of each week. “JH strives to create physician References scientists. Many other training programs outside the top 1. U.S. News and World Report. U.S. News Best Hospitals: tier have much less focus on research,” he noted.

Cancer. http://health.usnews.com/best-hospitals/rankings/ Both doctors agreed that the major challenge is dealcancer. Accessed October 19, 2011. ing with patients who often are very sick and helping with 2. Memorial Sloan-Kettering Cancer Center. 2010 Annual Report. Statistical Profile. http://www.mskcc.org/annualretheir physical, psychological, and at times, even their finanport/2010/pdfs/MSK_AR2010_stats.pdf. Accessed October cial dilemmas. “Often these are patients who have failed 19, 2011. routine treatment and are enrolled in a variety of clinical 3. Johns Hopkins Medicine. Facts about The Sidney Kimmel trials of investigational therapies. However, these methods Comprehensive Cancer Center at Johns Hopkins. http:// don’t always provide the cure we hoped for. It is challengwww.hopkinsmedicine.org/kimmel_cancer_center/our_center/facts_figures.html. Accessed October 19, 2011. ing to treat people who have failed nearly all options and Oncology Fellow Advisor ® is brought to you as a professional courtesy. This content is selected and controlled by McMahon Publishing and is funded by Lilly USA.

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FELLOWSHIP TRAINING

Oncology Fellow Advisor • Vol. 3, Issue 3

Spotlight on First-Year Fellows

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very year, come July 1, first-year hematology/oncology fellows embark on their last phase of training. Although their backgrounds and career goals may differ widely, all of them will face the daunting learning curve and emotional demands inherent in caring for people with cancer.1 Possibly the biggest challenge to first-year fellows in hematology/oncology is the sheer breadth and depth of knowledge they need to acquire, explained Ann LaCasce, MD, director of the Dana-Farber Cancer Institute (DFCI)/ Partners Cancer Care fellowship in hematology and oncology. “With the explosion of molecular techniques and identifying targets, there is an enormous amount of information to assimilate,” she said.

The DFCI/Partners Cancer Care hematology/oncology fellowship has fellows care for patients as their own instead of following an attending’s patients. “I think the most powerful way to learn about a disease is to take care of a patient with that disease, reading about what relates to their pathophysiology, treatments, and complications.”

The fellowship program also has a number of conferences directed at fellows, from introductory seminars to diseasespecific conferences. “I think you learn a lot when you present a patient to colleagues or to a group of attendings,” Dr. LaCasce said.

Kerry Lynn Massman, MD, a first-year fellow in that program, understood early on that learning what she needed to know would take a lot of self-discipline, as well as patience. “The major challenge initially was coping with my lack of knowledge,” she said. “I went from being a competent, confident senior resident, to suddenly finding myself in disease centers where I didn’t know the third line of chemotherapy. Sometimes I didn’t even know the first line.”

Dr. Massman finds some comfort in looking at upper-level fellows and trusting that knowledge will come to her as it did to them. But she also has taken a practical, systematic approach to furthering her understanding of cancer and caring for patients who have the disease. “I’ve been trying to focus on one cancer a week,” she said. “I’ll read in depth on the prognosis, the staging, the treatment, all the new therapies, and reformat that information into a teaching sheet so that I can refer back to it in the future.”

Dr. LaCasce recommends that fellows tap individual attendings for recommendations on the best literature sources for a particular situation, and that they take the lead in interacting with patients under their care. “Try to be the person conveying information to that patient,” she said.

In addition to acquiring vast amounts of knowledge, first-year fellows also must learn to cope with the emotional burden of taking care of patients who may not survive. “You form tight relationships with patients who have been diagnosed with life-threatening conditions,” Dr. LaCasce said. “Trying to navigate families and communicate

about prognosis and transitioning care from aggressive treatment to palliative care is extremely challenging.”

These tasks are difficult even for senior physicians, and can be especially daunting for those just starting as a patient’s primary caregiver. Dr. LaCasce recommends speaking and sharing with other fellows and attendings.

“Talk to the people you’ve shared those patients with.

When somebody dies, or something terrible happens, you really need to stop and talk to people and process it a bit instead of ignoring it and moving on,” she said.

Along with the challenges, the first year of a hematology/ oncology fellowship includes important milestones. “You learn how to write chemotherapy orders, how to explain to patients what they are going to be treated with, what the goals of care are, and to talk about the toxicities of chemotherapy without completely unnerving patients,” Dr. La Casce said. Fellows also learn in their first year how to discuss a disease and prognosis with a patient, and how to approach an end-of-life discussion.

Some milestones, however, are cause for celebration. For Dr. Massman, an important first was the day a patient of hers completed chemotherapy and radiation. The patient had a complicated medical history and difficult-to-manage side effects, and had several hospital admissions and visits to the infusion center. “It brought me a lot of joy to have that treatment course finished,” she said. “She had a highly curable cancer, so she should live many cancer-free years.”

Another important first for Dr. Massman was surviving her first overnight call. “I feel much more comfortable now, having figured out my way around the hospital, and how to orchestrate acute issues in a new environment,” she said.

Dr. Massman’s overall goal in her first year is to learn how to take good clinical care of patients by deepening her clinical knowledge and developing a procedural skill set. “We have to learn a whole different set of skills outside of residency and be comfortable with both,” she said. At the same time, she is using this first year to reflect on her course and picture herself achieving a successful career in academic medicine. To aid her in this endeavor, she is turning to mentors. “Mentorship is really rich in this institution,” she said, noting that she has set up reminders in Outlook to meet with someone every month. “I’m trying to get a sense of what my career might be, look into the future, all in this first year of trying to figure out the clinical side of oncology.”

Stay tuned for “Spotlight on Second-Year Fellows” in the next issue of Oncology Fellow Advisor.

Reference 1. Kircher S, Feliciano J, Ahmed S. A year-by-year look at a fellowship program. http://www.onclive.com/publications/oncologyfellows/2010/August-2010/A-Year-by-Year-Look-at-a-Fellowship-Program. Accessed October 21, 2011.

Oncology Fellow Advisor ® is brought to you as a professional courtesy. This content is selected and controlled by McMahon Publishing and is funded by Lilly USA.

Vol. 3, Issue 3 • Oncology Fellow Advisor

FELLOWSHIP TRAINING

Communication Skills Crucial for Oncologists

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When a course of treatment ends successfully, patients ny doctor who sees patients should be able to commay experience anxiety as they move away from the municate with them effectively and sensitively, howintensive support of a cancer care team and onto surviever, good communication skills may be of particular vorship. If treatment fails, there needs to be a discussion importance for oncologists, who need to be able to disabout what that failure means to the cuss complex disease states and course of the patient’s disease, and complicated treatment options, and about the possibility of trying a diffrequently have to deliver distress“People are hanging on ferent type of chemotherapy. Ending news.1,2 every word you say.

I’ve of-life issues also may arise at this “Starting out in the field, you realpoint. learned from my training, ize early on how crucial every con“Through the whole trajectory of versation you have is,” said Lanie K. from additional coursework, illness there is a sequence of diffiFrancis, MD, hematologist/oncoloand even more so just being cult, often awkward, often emotiongist at the UPMC Cancer Centers ally charged conversations,” Dr. Back in practice the past 4 years, at UPMC Mercy Hospital, and clinexplained. ical assistant professor, departhow carefully you have to Despite the importance of good ment of medicine, at the University choose your words.” communication skills, many oncoloof Pittsburgh School of Medicine — gists never receive specific training in Pittsburgh, Pennsylvania. “PeoLanie K. Francis, MD in this area.2 Accredited fellowship ple are hanging on every word you say. I’ve learned from my training, programs now are required to profrom additional coursework, and vide some sort of communication even more so just being in practice training, but that can vary from onethe past 4 years, how carefully you on-one coaching, which can be quite have to choose your words.”1 effective, to a didactic lecture, which can be informative but may not have Good communication skills are the power to influence change. critical at every point of the oncol“Knowing the right first, second, ogist–patient relationship, from the and third line of chemotherapy for initial visit to the last.2 “The first visit a particular cancer is something is often very complicated [and it that you can get from lectures, but may] involve bad or serious news. communication is a skill you need to Often, patients with cancer have practice,” Dr. Back said. not gotten a sense of the full extent In order to augment the commuof their disease before they see the nication skills training offered by oncologist,” said Anthony Back, MD, their fellowship program, fellows professor, Department of Medicine, can help themselves to identify their Division of Oncology, University of own strengths and weaknesses and Washington Fred Hutchinson CanTable 3. Tips To Improve to improve in the areas where they cer Research Center in Seattle, Communication Skills need further training (Table 3).

Washington.

One approach is to identify a good The first patient visit also usually Identify a good communicator and observe communicator and ask how he or entails discussing the pros and cons (take notes!). she prepares for difficult conversaof different treatment options and a tions with patients. “Good commudiscussion of how a course of action Listen instead of talk. nicators don’t just go in and wing it,” will be decided on. In subsequent Dr. Back said. “They will have given it visits, there comes a conversaAssess what the patient understands and what a lot of thought and have very spetion about the patient’s prognosis. knowledge he/she seeks. cific strategies.”

According to Dr. Back, this conFellows also can learn by payversation might include patient Obtain overall expectations of the patient and family members. ing close attention to a good comquestions such as, “What do the municator; it helps to take notes. “A statistics mean to me?” “How is my lot of doctors don’t remember what family going to handle this?” “How Based on conversations with Anthony Back, MD, and Lanie K. Francis, MD. do I talk about it with my friends?” see, Communication page 8 Oncology Fellow Advisor ® is brought to you as a professional courtesy. This content is selected and controlled by McMahon Publishing and is funded by Lilly USA.

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ONCOLOGYFellow S UPPORT & INFORMATION FOR THE NEXT GENERATION OF ONCOLOGY PRACTITIONERS

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Oncology Fellow Advisor • Vol. 3, Issue3

Communication continued from page 7

happened in a patient conversation because they are not used to paying attention at that level,” Dr. Back said. Doctors often gloss over the patient’s response to something the physician said. “The key to becoming better at this is to look at the relationship between what you said and how they [the patients] responded.”

Along with observing others, fellows can ask someone to observe their interactions with a patient and then provide some critical feedback. Fellows who work in a cancer center or clinic should consider asking a nurse or social worker to observe them during a patient visit, but they should keep their request limited. “Ask for specific feedback, for example, 1 or 2 points on how you talk about prognosis,” Dr. Back suggested. “The feedback you want is: What did I do well? What should I change? Is there something I can work on? Someone can give you that feedback in less than 5 minutes, and it’s very useful if you get it from someone you trust.”

Finally, more written resources have appeared as the importance of communication skills has gained recognition. “There are a lot of papers in the medical literature that describe specific strategies that can give you an idea of how to deal with a particular problem,” Dr. Back said.

As Dr. Francis transitioned from fellowship to attending, she found herself reaching for strategies that she had learned that can help oncologists move forward with

patients when they’ve reached a stumbling block in a difficult conversation. These strategies include, for example, listening instead of talking, assessing what the patient understands and wants to know, and trying to get a sense of the overall expectations of the patient and his or her family members.

“Ask them what they know so far about their diagnosis. Listen to how and what they are ready to hear before beginning the conversation,” Dr. Francis said. “I’ve found it very useful to take a step back, take a deep breath, focus inward, look the patient in the eye, and think about how I would feel in their shoes. Put yourself in that place and then proceed with caution.”

As with all skills, communication gets better with practice. “But you have to remind yourself every time you walk into the room that what you say has such an impact on your patients,” Dr. Francis said. In sum, think before you speak.

Oncology fellows interested in learning more about communication skills can read Dr. Back’s book entitled, “Managing Communications With Seriously Ill Patients: Balancing Honesty With Empathy and Hope.”

References 1. Francis L. Learning to listen: a fellow’s experience. J Clin Onc 2006;24(19):3209-3210.

2. Back A, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards, KA. Teaching communication skills to oncology fellows. J Clin Onc. 2003;21(12):2433-2436.

Oncology Fellow Advisor ® is brought to you as a professional courtesy. This content is selected and controlled by McMahon Publishing and is funded by Lilly USA.