Dec 19, 2012
Mentorship programs encourage medical students to enter the field:
The oncology profession stands at a crossroads. According to an ASCO-commissioned study, over the next eight years the United States will face an estimated shortage of up to 4,080 oncologists, a daunting prediction for a country in which cancer is the second leading cause of death. Despite these bleak numbers, exposure to oncology is underrepresented in U.S. medical schools—this includes medical oncology, radiation oncology, and surgical oncology. From a lack of oncologists on the United States Medical Licensing Examinations (USMLE) test-writing committee to few oncology rotation opportunities, a career in oncology often isn’t on a medical student’s radar.
However, ASCO members can take actions to ensure that oncology is noticed, and in doing so, cushion the impending blow. For example, members can encourage students to sign up for a free ASCO membership. In 2011, ASCO introduced the Student/Non-Oncology Resident membership category. These members pay no annual dues, receive significant discounts on both ASCO journals, and can attend the ASCO Annual Meeting at a reduced rate. For a full list of student member benefits and eligibility, visit benefits.asco.org/student.
Also, members should consider taking on a shadow medical student. Recently, two 2011 Doris Duke Clinical Research Fellowship recipients spent time shadowing oncologists, and their experiences deeply affected their medical careers. Virginia Alldredge, a medical student at Tulane University, worked with patients with melanoma alongside ASCO member Frances A. Collichio, MD, of the University of North Carolina, Chapel Hill (UNC). Trevor Royce, a UNC medical student, studied radiation oncology alongside ASCO member Ronald C. Chen, MD, MPH, an Assistant Professor in the Radiation Oncology Department of the UNC Lineberger Comprehensive Cancer Center.
To better understand how early exposure to oncology can influence student career choices, ASCO Connection spoke with Dr. Collichio. Also featured are articles written exclusively for ASCO Connection by Ms. Alldredge and Mr. Royce.
The Rewards of Training Medical Students
An interview with Frances A. Collichio, MD, Professor of Medicine and Associate Fellowship Director, the University of North Carolina, Chapel HillWhen Dr. Collichio was asked by UNC colleague Nancy Thomas, MD, PhD, to take on a shadow medical student the spring of 2011, she considered saying “no.”
“At the time, I thought I couldn’t handle more work,” Dr. Collichio said. “The first bit of training anyone slows the trainer down. There’s time needed outside the clinic setting to go over what the clinic will be like. You need to be careful that these students aren’t overwhelmed by the sadness of the profession.”
| From left to right: Dr. Collichio, Virginia Alldredge, and Trevor Royce |
“I was immediately impressed by this young lady who came to my office and just was a Godsend,” Dr. Collichio said. She was so impressed that after the first two shadowing sessions she sent out Ms. Alldredge on her own. “Over time, these patients became her patients,” Dr. Collichio said. “She just has a tremendous bedside manner and this youth that sparkles, and here we are taking care of patients at the very end of their lives. She’s such a charming young woman.”
After having such a positive experience with Ms. Alldredge, Dr. Collichio hopes that she has a medical student in her clinic from now on—a proposition that couldn’t come at a better time for the profession.
“Challenges exist with how oncology is taught in medical schools,” said Dr. Collichio. “Most curricula are composed of system-based modules with oncology interspersed in each. This interferes with learning comprehensive cancer care, leaving graduating physicians without sufficient knowledge or skills, especially for screening and survivorship. Nearly all physicians will treat patients with cancer at some point during their careers. Additionally, involving students in outpatient care of patients with cancer may get students more interested in oncology as a career choice.
“Although cancer questions are part of the USMLE Steps 1-3, results are reported as part of larger categories,” she continued. “Thus, programs and medical students receive no specific feedback on their performance regarding cancer. What we measure we tend to improve. Cancer needs to part of these high-stake exams driving curricula and learning.”
Understanding Disease from a Patient Perspective
Tulane University medical student Virginia Alldredge describes the need for further exposure to oncology.
When I met Jim in the summer of 2011, he was a patient with stage IV melanoma and stable disease, and I was a medical student starting a year of studying and researching melanoma [with Frances Collichio, MD, of the University of North Carolina, Chapel Hill, School of Medicine]. He was wheelchair-bound with myotonic dystrophy, yet animated and welcoming. Jim was always accompanied by his father and close friend. The whole room greeted Jim’s oncologist with a hug at the beginning of each appointment, and soon I was greeted the same way.
When Jim’s tumors were no longer stable, Vemurafenib had recently gained U.S. Food and Drug Administration approval. The patient and his family viewed this drug as a miracle. The treatment caused fatigue, arthralgia, and a scaly rash—but shrunk a large gastrointestinal metastasis that had caused pain, halted new tumors, and bought him time. Jim needed time because he had goals. He needed to sit in the coaches’ box for a Clemson football game and take a long parkway drive to see the vibrant autumn leaves. During appointments in late summer and early fall, we’d talk about side effects, cancer symptoms, and Jim’s next adventure.
We knew his cancer would likely acquire resistance to targeted therapy but hoped that time was far off. As winter approached, Jim’s pain and fatigue increased. He was still welcoming when we entered the clinic room, although less energetic. Labs showed his hemoglobin had dropped dramatically. A large abdominal metastasis had consumed the wall of his descending colon and was causing a slow gastrointestinal bleed. We discussed hospice, but Jim still had items on his bucket list. He received bimonthly blood transfusions to replace what he was losing, and life went on.
Jim’s friend had a tradition of baking homemade holiday cookies for Jim’s doctors, and this year he had a tin with my name on it. I wasn’t a rotating medical student standing on the sidelines for a few days, but rather an integral team member taking care of his friend. In January, Jim seemed weak and tired. His tumors were growing in spite of the BRAF inhibitor, causing significant pain. Still, he had places to go and people to see. After visiting out-of-state friends, Jim developed an altered mental status, and an MRI showed too many tumors in his brain. He was ready to stop fighting, and his dad and friend were ready to let him go.
In medical school, I learned melanoma was difficult to treat with an increasing incidence and high mortality rate, and I was motivated to take a year out and study this cancer. During the year, I watched melanoma take life away from people like Jim. I’ve watched others ride out clinical trials and new treatments, hoping researchers are on the cusp of something great. It was only by taking a year out from the normal progression of medical school that I was able to know patients longitudinally, understand a disease, and see the multidisciplinary management of patients with cancer.
I knew “my” patients and their families by their first names, and they allowed me to participate in each clinic visit. I saw them before the oncologist, helped with the assessments and plans, and made decisions that were important to management. The setting of continuity provided invaluable understanding to disease process, treatment selection, and psychosocial aspects of patient care. It was as if my career had fast-forwarded. One patient even thought I was her hematology oncology fellow, until I told her otherwise.
During the clinical years of medical school, exposure to oncology and care of patients with cancer is disjointed. As medical students, we may follow an inpatient with cancer during internal medicine, scrub into a surgery, or see many patients for one visit in an outpatient setting. We never really understand how the disease is affecting the patient’s daily life. This is unfortunate, because regardless of the field of medicine we enter, we will care for patients living with cancer. When a conversation is sensitive, we are often asked to wait outside the room. We memorize diagnostic markers, tumor staging, and treatment side effects but only see fragments of patient care and rarely feel like a valuable member of cancer care team. In the setting of a research fellowship, an attending oncologist allowed me to become part of her team and encouraged me to learn about cancer by understanding how it affected the patients.
Solidifying One’s Career Path through Mentorship
UNC medical student Trevor Royce describes how a mentorship put him on a path toward an oncology career.
Traditionally, third-year medical students are trained in the core components of clinical medicine. This generally consists of rotations in internal medicine, family medicine, surgery, pediatrics, neurology, psychiatry, and obstetrics and gynecology. Various specialty rotations are incorporated within the basic clerkships while others are offered as electives during the fourth and final year of school. Exposure to subspecialties, such as oncology, varies not only between medical schools, but also between rotation assignments within a medical school. A medical student could graduate without ever rotating on a cancer-specific service.
Yet, an oft-quoted statistic among cancer patient advocates is that women have a one in three lifetime risk of developing cancer and men have a one in two lifetime risk of developing cancer.1 In addition, cancer is a close second as the leading cause of death in our country.2 Clinicians can be guaranteed their patients will have personal experiences with cancer. By extension, medical students are certain to encounter cancer as professionals.
Moreover, oncology faces a looming crisis. A shortage of 2,550-4,080 oncologists is predicted by 2020.3,4 The pool of oncology fellows comes from the internal medicine residency programs. For the past several years, the United States has not been able to fill their internal medicine positions with graduates from United States medical schools.5 Graduate medical education needs to make internal medicine attractive to students but the curriculum often falls short.6 Increasing exposure to oncology, particularly with opportunities to participate in research with the mentorship of a practicing oncologist, may pique the interest of students to enter the field of oncology.
For example, I became aware of an interest in oncology during a summer of research working on a cancer registry fairly early in medical school. It was through design and persistence that 10 weeks of my third year’s 48 weeks were devoted to cancer-specific clerkships: medical oncology, surgical oncology, and a two-week elective in radiation oncology. Early exposure to radiation oncology was made possible only by postponing one of the required core clerkships until my fourth year. In fact, some of my graduating classmates are unable to differentiate radiation oncology from diagnostic radiology. Like medical oncology, and perhaps even more so, most students graduate from medical school without exposure to radiation oncology. The diffidence in appreciating the role of radiation oncologists was a motivating factor for me to take a leave of absence from medical school and complete a year-long research fellowship.
The field of oncology is rapidly changing on account of research. Therefore it is imperative that individuals who have aspirations to become oncologists possess an understanding of the research process. This year-long fellowship was invaluable and allowed me to experience perspectives of oncology otherwise unobtainable as a medical student, from working with the Surveillance Epidemiology and End Results database, a nation-wide database composed of hundreds of thousands of patients, to attending daily morning conferences and treatment planning sessions. I was able to observe national policy changes based on scientific evidence, such as guidelines for prostate cancer screening, in real time.
In addition, the fellowship offered the opportunity to critically appraise that research and discuss the revisions with experts in the field. Perhaps most importantly, this year allowed the opportunity for dedicated mentorship and tutelage in oncology. Because of my persistence in getting oncology-related clerkships in the third year of medical school and a year out of school for the fellowship, I am certain of pursuing a career in oncology. Perhaps the curriculum should facilitate this and make it easier for students to find the joys in this field. For example, while a full year of oncology-related research may not be feasible for every student, more students may consider a career in an oncology-related field if dedicated time for research was incorporated into the curriculum, all under the guidance of dedicated mentorship. Fostering relationships with faculty can provide sound career advice and solidify one’s decision to pursue oncology; it certainly did for me.
1. Hayat MJ, Howlader N, Reichman ME, et al. Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) Program. Oncologist. 2007;12:20-37. PMID: 17227898.
2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10-29. PMID: 2223778.
3. Erikson C, Salsberg E, Forte G, et al. Future supply and demand for oncologists : challenges to assuring access to oncology services. J Oncol Pract. 2007;3:79-86. PMID: 20859376.
4. Erikson C, Schulman S, Kosty M, et al. Oncology Workforce: Results of the ASCO 2007 Program Directors Survey. J Oncol Pract. 2009;5:62-65. PMID: 20856721.
5. National Resident Matching Program, Results and Data: 2011 Main Residency Match, National Resident Matching Program. Washington, DC, 2011
6. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300:1154-1164. PMID: 18780844.