By Ramy Sedhom, MD
My colleagues and I have previously written our case for the benefits of dual training in medical oncology and palliative care. Thankfully, the opportunity for integrated training is finally here. Through an innovative partnership with Accreditation Council for Graduate Medical Education (ACGME) and the Medical Oncology Board, and under the leadership of Dr. Jamie H. Von Roenn, ASCO’s vice president of Education, Science and Professional Development, four programs will begin to combine medical oncology, hematology, and hospice and palliative medicine into a single fellowship program. Trainees will be able to accomplish training in less time than would be required for sequential training in each area.
The proposed program allows integrated programs of medical oncology and hospice and palliative medicine to be completed in 24 months (all clinical training) and a combined training in hematology, medical oncology, and hospice and palliative medicine to be completed in 36 months with a minimum 30 months of clinical training. Because of the request for double counting rotations (i.e., counting them for both palliative care and medical oncology), there is time for research initiatives by the fellows.
Currently 485 oncologists (of 15,163 total, or about 3.2%) are also certified in palliative care. It is hoped this combined competency-based training model may see this number grow in the future. Many trainees considering a career in medical oncology (or hematology/oncology) may not know what career trajectories look like or what the return on investment might be from expertise in palliative medicine. So, I reached out to several superstars in the field for perspective.
First, I asked Dr. Deepa Rangachari, director of Hematology/Oncology Graduate Medical Education and of the Hematology/Oncology Fellowship Program at Harvard Beth Israel Deaconess Medical Center, to comment on why it was important for her to offer this pathway for future trainees.
“I am elated to collaborate with oncology and palliative care colleagues and to offer this innovative combined fellowship training pathway in oncology and hospice and palliative medicine to our trainees. As a medical oncologist and educator, I am cognizant on a daily basis of the indelible value of truly comprehensive cancer care. This is defined both by rigorous interdisciplinary collaboration as well as individual provider expertise in addressing the well-being of the whole individual under our care. By wedding rigorous training in oncology and hospice and palliative medicine, we will mentor a new generation of exceptionally trained cancer physicians and thought leaders who will leverage these skills to transform the practice, advance the science, and elevate the well-being of individual patients with cancer and society at large.”
The Icahn School of Medicine at Mount Sinai Medical Center, Fox Chase Cancer Center with Temple Health, The Ohio State University, and the University of Pittsburgh will be the first to offer integrated training starting with the upcoming 2023 fellowship match cycle. Three additional programs (Harvard Beth Israel Deaconess, Indiana University, and Oregon Health & Science University) will offer combined training in the following year. Dr. Jessica Bauman, chief of the Division of Head and Neck Oncology and director of the Hematology/Oncology Fellowship Training Program at Fox Chase, shared her view on why integrated, as opposed to sequential, training is important for those considering a career in palliative care and cancer:
“Dual training in hematology-oncology and palliative care offers a unique skillset. For hematologists-oncologists, expertise in a palliative care skillset including symptom management, communication, psychosocial care, and end-of-life care is paramount to taking exceptional care of patients throughout the trajectory of their illness. However, palliative care education is often inadequate within hematology-oncology education. Combining both fellowships into one allows for trainees to be acquiring both skillsets such that their oncology care is enhanced with additional training in palliative care as well as vice versa where their palliative care training is enhanced with improved understanding of disease pathobiology and treatment options.”
During my time as an oncology trainee, I was always enamored by colleagues who put the patient experience at the core of their work. This is hallmarked by the careers of Dr. Cardinale Smith and Dr. Thomas LeBlanc.
Dr. Smith is a thoracic oncologist and palliative care physician who holds many leadership positions, including chief quality officer for oncology, director of the Supportive Oncology Program, and associate director for community outreach and engagement at The Tisch Cancer Institute at Mount Sinai. She shared:
“Specialty palliative care training combined with my oncology training sparked my clinical and research interests in serious illness communication and is a core component of quality initiatives that I lead.”
Dr. LeBlanc is a medical oncologist, palliative care physician, and patient experience researcher who serves as the chief patient experience and safety officer for the Duke Cancer Institute and founding director of the Duke Cancer Patient Experience Research Program. I asked him how his career trajectory may have been different without specialty training in palliative care:
“Having additional training in palliative medicine has made an enormous difference in my career. My work aims to integrate palliative care into more standard cancer care processes, and being dual-trained has ensured that I have the necessary knowledge and credibility in both the oncology and palliative medicine communities to effectively collaborate with key stakeholders from both groups. Dual-training has also opened up a number of funding opportunities that otherwise would not have been available to me as a single-boarded oncologist. Lastly, the additional and unique skills gained through palliative medicine training have proved invaluable in my clinical practice, especially regarding communication and complex symptom management.”
I see this in how Dr. LeBlanc engages on Twitter, where is he is often an advocate for unmet patient needs. Perhaps the most influential voice in this space is none other than Dr. Eduardo Bruera, the 2022 recipient of ASCO’s Walther Cancer Foundation Supportive Oncology Award. Dr. Bruera is the F.T. McGraw Chair in the Treatment of Cancer at The University of Texas MD Anderson Cancer Center; he established and chaired the institution’s Department of Palliative, Rehabilitation, and Integrative Medicine. Dr. Bruera has been interested in the development of palliative care clinical and research programs internationally, particularly in low- and middle-income countries, where he helped in the establishment of numerous palliative care programs in the Latin American region, India, and different areas of Europe. He has trained hundreds of physicians, nurses, and other health care professionals in the different aspects of the clinical delivery of palliative care and has received several national and international awards.
It is difficult to put concisely how amazing Dr. Bruera is and how much he has contributed to the field, and to patient care. So, I would instead encourage you to read about him for yourself. He shared his thoughts on what he thought were the major gaps in clinical cancer care and how he envisioned dual-training in palliative care can help our field:
“Internal medicine and medical oncology training provide physicians with optimal preparation to face all aspects of cancer and other comorbidities. Unfortunately, the vast majority of the training does not focus on the person who is ill. When we are not well trained on the management of physical, psychosocial, and spiritual suffering of our patients and their family caregivers, and how to communicate and build rapport, the daily practice of cancer medicine becomes burdensome, and the likelihood of burnout increases. Dual training prepares future oncologists to lead in person-centered cancer medicine, and it opens large fields of education and research that are currently ignored by cancer medicine.”
Perhaps most meaningful, at least to me, are the words of Dr. Michael Fisch. Dr. Fisch is the national medical director of medical oncology programs and genetics for AIM Specialty Health. His faculty career at MD Anderson began in the Department of Palliative Care and Rehabilitation in 1999. He then led the MD Anderson Community Clinical Oncology Program (CCOP) Research Base and subsequently served as the founding chair of the Department of General Oncology. Currently, he is a co-chair of the SWOG Symptom Control and Quality of Life Committee and a member of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). From 2007 to 2014, he co-chaired the NCI Symptom Management and Quality of Life Committee. He also served as chair of the Eastern Cooperative Oncology Group and the American College of Radiology Imaging Network (ECOG-ACRIN) Symptom Science and Treatment Toxicity Committee, the SWOG Social Media Working Group, and the first ASCO Palliative Care in Oncology Symposium.
He has served as a mentor to me and to many, with his genuine Southern hospitality. He shared his thoughts on how living in both worlds of medical oncology and palliative care influenced his perspective and vision throughout his career:
“The fact that I have grown personally and professionally as the domains of palliative care were learned is a feature of the order of events in my career and does not imply that those with only oncology training do not also grow and learn in many of the same ways, and in other valuable and distinct ways.
“Before adding palliative care to my oncology perspective, my mind was in a ‘bench-to-bedside and back’ frame, focused on eliminating or at least controlling cancer. Patients were certainly in my focus, but medicine, science, professionalism, and my own priorities could distract me, and the patient and family sometimes drifted into my blind spot.
“After, in the onco/palliative world, I live in a ‘bedside-to-bench and back to bedside’ world, more consistently focused on the patient and family even while still keenly interested in medicine, science, and professionalism, etc. I negotiate rather than impute the goals of care. My thinking is informed by conceptual models of the person, the nature of suffering, and the principles of palliative care. In my former role as chair of the Department of General Oncology at MD Anderson Cancer Center, I was able to promote the principles of palliative care across our different clinical, educational, and research programs. Likewise, these same principles are being applied and promoted at individual and population health levels in my current role as senior national medical director for oncology and genetics at AIM.”
Not convinced? Maybe it is best to close with the words of my (awesome) boss, Dr. Lynn Schuchter, chief of the Division of Hematology-Oncology at the Abramson Cancer Center at the University of Pennsylvania, director of the Tara Miller Melanoma Center, and professor of hematology-oncology at the Perelman School of Medicine at the University of Pennsylvania, and ASCO’S president for the 2023-2024 term. Many may not know of her decision to pursue mid-career certification in palliative medicine, through an innovative pilot at the University of Pennsylvania. She said:
“As a medical oncologist caring for patients with melanoma for over 30 years, long before we had the effective therapies for melanoma we have today, I was already a relative expert in providing palliative care and hospice care for my patients. Nonetheless, I decided to complete a palliative care and hospice fellowship about 6 years ago. Completing the palliative care fellowship not only enhanced my own skills but also provided me with the additional credential and credibility to implement many new programs in the division which focused especially on helping providers improve their own ability to have effective, compassionate, and earlier goals-of-care conversations. One of the challenges in oncology is that of over-treatment and over-testing, particularly at the end of life. We know that patients who have conversations with their clinicians about their values, goals, and wishes are more likely to receive the care they want. This is hard work. Having more oncologists who are dual-trained could be a transformational step for our field. I think many oncology fellows are going to pursue such training—this is an exciting and valuable opportunity for our trainees.”
Dr. Sedhom is a medical oncologist and palliative care physician with Penn Medicine. He is an Innovation Faculty member at the Penn Center for Cancer Care Innovation focused on supportive care and cancer care delivery. He is group Leader of the ASCO Trainee & Early Career Advisory Group, a member of the Use of Opioids During Cancer Treatment Expert Panel, and co-leader of the ASCO Palliative Care Community of Practice. Follow him on Twitter @ramsedhom. Disclosure.