Congratulations! You have successfully made it into fellowship after years of hard work during medical school and residency. You are now a first-year oncology fellow and you are excited about this new career phase. But you are also a little nervous and that is completely understandable.
You have spent about two-thirds of your residency training within the hospital with an emphasis on inpatient therapies. After all, the goal is to graduate someone who is comfortable with the bread and butter of general internal medicine, from CHF to COPD to pneumonia and DKA. You have rotated through a general outpatient clinic and are familiar with managing diabetes and hypertension. Maybe you rotated electively through a few oncology clinics in preparation. However, your oncology exposure has likely been limited to inpatient oncology wards, which offer a skewed and limited representation of what you will encounter during your fellowship.
Outpatient oncology clinics can be daunting for a new fellow and the learning curve is steep. Often, people will remark that the first year of fellowship is even tougher than intern year. Furthermore, the culture of fellowship training is drastically different from residency. In contrast to the close supervision provided to medical interns, first-year fellows are often expected to jump right in. You may find yourself as the designated “oncology expert” while carrying the on-call pager during your first few months of training! Other providers will often talk to you in an alphabet soup of chemotherapy acronyms that sound foreign and overwhelming.
However, you are a board-eligible/-certified internist now. You already have the basic foundations of patient care. Remember: a history and a physical exam are just that—with some relevant nuances from an oncologic perspective. So, take a deep breath; you got this!
Here are a few tips to help you tackle the oncology clinics as an early first-year fellow.
- Ask about the expectations and objectives of each clinic.
The expectations and responsibilities will vary according to the type of clinic at which you rotate. If your program is affiliated with a Veterans Affairs (VA) medical center, you may have a longitudinal continuity clinic of your own. In this clinic, you are usually the primary oncologist who directly manages a patient panel under an attending’s supervision. This structure is like your longitudinal clinic during residency and the expectations are similar. In contrast, attending-run clinics may be more subspecialized in nature, especially if you are at an academic institution. You will rotate through each for a fixed period.
It is helpful to discuss with your attendings, in brief, what your expected role is. It also never hurts to get the inside scoop from a senior fellow about an attending’s personal preferences and pet peeves!
- Do your homework.
Do not show up to clinic unprepared. The care of a patient with cancer is often complex, with a significant amount of diagnostic and treatment history to review. Make sure to look over patient charts the day before your clinic. Jot down specific questions you want to ask and areas you want to read more about. If your attending expects you to see new patients, make sure you have reviewed the history carefully and have devised a draft treatment plan to discuss.
- You will need to adjust to the pace and workflow of the outpatient setting.
As someone who primarily worked in the inpatient setting as a hospitalist after I graduated from my internal medicine residency program, I was surprised at the fast pace of the outpatient clinics. I felt that I had the time to reflect on my inpatient encounters and revisit the patient in their hospital room throughout the day to elicit more history or follow up on a physical exam. In contrast, outpatient encounters are a fixed duration of 15 to 30 minutes in which you need to collect and convey the required information. It is important to realize that you may not cover everything you need to discuss in one encounter and that less urgent issues will need to be deferred to future appointments.
- Your patients are your teachers.
Like many areas in medicine, oncology is a field that you cannot learn through reading alone. Often, you will only retain information by correlating it to patient-related discussions. Furthermore, our field heavily focuses on physician-patient communication, delivery of bad news, and end-of-life discussions—none of which can be learned solely from reading a book. Oncology is a practice, and much of your education from this point forward will come from real-world experience.
- You will learn something from each patient, but you cannot possibly know everything about every patient.
Similar to your previous training, you will collect nuggets of medical knowledge and, over time, assimilate them into an understanding of the bigger picture. You cannot learn everything about metastatic triple-negative breast cancer from one patient. You will need multiple encounters with multiple patients to understand the scope. As you go through your patient encounters, write down teaching pearls from your attending. Keep a note of things you need to look up and landmark trials to review.
- Utilize technology to your benefit.
Having a list of handy apps and resources on your phone can be a lifesaver during a busy clinic. UpToDate will help you with a distilled summary on the go and provide a quick answer to a clinical question. You can quickly look up trials and chemotherapy regimens on Hemonc.org. NCCN guidelines are undoubtedly an essential resource, but could require a more careful review before or after clinic. For a more in-depth review and structured studying, you will find a wealth of resources through ASCO eLearning, including tumor boards, presentations, and a comprehensive self-assessment book. Your fellowship program may even have a subscription for fellows to access the educational material.
- “Don't let the perfect be the enemy of the good"—especially when it comes to your paperwork.
One of my mentors taught me this aphorism during my residency training. Medicine attracts type A personalities and often our desire for perfection can decrease our efficiency and hinder our learning. You do not need to spend 2 weeks writing the world’s most perfect notes. My goal is always to have clinic notes completed in 24 to 48 hours, so that I am not falling behind and wasting my limited time in the evenings and weekends catching up on documentation. This is a good habit that will serve you well during training and after graduation.
- Finally, be realistic about how much to take on and practice self-compassion and self-care.
You will be juggling clinical duties, a rigorous call schedule, didactics, and research. Be selective about which projects to take on and do not neglect your social life and family commitments. Regularly schedule time for self-care. Do not forget to pause occasionally and enjoy what you are doing! Savor your accomplishments so far and enjoy the privilege of serving patients in the capacity of an oncologist, forging a unique physician-patient relationship where you can make a big difference in someone’s life when they are at their most vulnerable.
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