By Shannon Ugarte, MD
A visiting away elective is a resident’s designated time to visit another academic program to foster the growth of medical knowledge through patient care from the perspective of another health care system and educational experience. The time dedicated to make this dream happen is grueling.
First is the application packet, which includes completing and obtaining numerous documents, requires an acceptance from the designated division, graduate medical education approval, and additional processing, which can take at least 30 days. You then have to set up your own housing accommodation and transportation during the expected rotation dates; in some programs, these arrangements might be made for you, but that is rare.
A week or 2 before the rotation start date, the department/division sends a welcome email, identifying the tentative rotation schedule, reporting time, appropriate reading, and other pertinent rotation information (including EHR and badge access instructions). If you aren’t familiar with the EHR, you may participate in an EHR orientation on day 1 instead of jumping right into the rotation—one less half-day or day to immerse yourself into your new acting role.
As the COVID-19 era began in the U.S. in March 2020, almost all visiting away electives for medical students and residents were “cancelled until further notice.” This unknown, dark cloud slowly enveloped the world, destroyed all strategically thought-out plans, and disrupted the natural ebbs and flows of society, including the medical world. All of those extra minutes or hours spent over the past several months, on top of an already 80+ hour/week resident schedule, to acquire the away elective may have vanished without a trace.
Multifactorial Effects of Cancellation
For starters, medical education became restricted indefinitely, pending normalization of the medical world. As a result, our perspective as doctors-in-training may be from the experience of one or two hospital systems, from like-minded faculty, with residents who are taught methodically and algorithmically to think alike, and under the constraints of, the doctors and limited specialties available at our respective home programs. The opportunity to develop highly specialized analytical skills, experience the administering of a promising oncologic therapy, or observe the newest infrared technologies may be limited to those residents training at large academic sites; the sharing of knowledge and clinical skills among specialists and residents have become hindered due to social distancing.
Other learning opportunities built into the resident’s schedule are being affected similarly. Traditional morning reports and noon conferences may be an afterthought. Twice-daily, 1-hour, dedicated learning slots may now be occurring only three to four times a week over Zoom, with more than 50% of the teaching gone. Some conferences are locked to latecomers after 5 minutes into a lecture, to prevent Zoom bombers. Foundational or outside reading is not encouraged or addressed. Getting home early to continue social distancing is emphasized, second to medically or surgically treating patients for the day.
Away electives offer the opportunity for a program director and faculty to gain a new perspective of the resident, in addition to what’s on your application, including your curriculum vitae and personal statement. These face-to-face interactions can make or break your chances of being offered an interview and/or spot for a fellowship in that specific program. Though the hours may be long, authentic enthusiasm and the ability to shine make an impact. Your performance during an away rotation can either boost or considerably damage a program’s impression of you.
Do your oncologic vision, your values, and your interests align with those of your away program? Are the career and research possibilities offered adequate to mentor and grow your envisioned identity? Can you thrive and learn in this environment? Does your personality mesh or clash with those on the team? Do you want to work with the ancillary staff and administrators to create cohesive plans and changes for the future? Are you happy here? Does this program feel “right?” All of these questions help to solidify or dissipate your desire to pursue this program as one of the top choices during fellowship application season.
If your away elective experience screams to you, “Yes, I want to be here” or “I can’t imagine going anywhere else to train for my career,” then this experience would be a great opportunity to obtain a strong letter of recommendation from a faculty member of the away program who grew to know your moral foundation and observed you clinically. Based on anecdotal evidence, the letter of recommendation should be from a well-published faculty member of the program or someone with clout. Receiving such a letter, or “certificate of approval,” will significantly boost your application and chances of being interviewed at your top oncology fellowship choices.
A Similar but Different Educational Experience: As I was among the last visiting residents allowed to continue training at an away program during the COVID-19 era, the experience, though exhilarating and unique, is getting downplayed by the current circumstances with remarks such as, “You’re not getting the true experience.... The teaching isn’t the same.... Everything is cancelled.” Rounds are via Zoom, while each person on the team (the oncology attending, fellow, co-residents, RN, RN manager, pharmacist, and social worker) works remotely from a separate workstation on different floors or even buildings of the hospital.
What once used to be 2 to 5 hours of discussion and learning with a census of up to 20 patients has transitioned to speed rounds with minimal to no teaching, without reasoning and explaining why one management strategy is being chosen over another, with a census that is reduced by at least 30% to efficiently work through a patient’s plan toward a quicker disposition. Engaging in thorough discussions, deep conversation, “playing devil’s advocate,” or theorizing as to what etiology caused a patient’s current presentation seem to be absent since the start of the COVID-19 pandemic. The main goal is now shifted to avoid stumbling through technology and being infected with COVID-19. Education is nearly abandoned.
Creatively Resurrecting the Purpose of Training
I have continued to make educational strides toward growth by employing several different subtle, though well-known, techniques we used just 3 months prior to the COVID-19 pandemic. During rounds, while moving systemically through my assessment and plan, I continue to include teaching points and/or evidence-based medicine to support my medical decision, i.e., to start a medication or administer a transfusion. If I’m holding back on continuing immunotherapy to treat a patient’s refractory malignancy, I share my reasoning about being concerned that immunotherapy may be causing an immune-related adverse effect, and wanting to work up the acute kidney injury with renal biopsy, consider corticosteroids, and/or hold off or discontinue the immune checkpoint inhibitor based on European Society for Medical Oncology guidelines or other evidence-based practice.
If I haven’t had a chance to read up on a patient’s diagnosis prior to rounds, I will add in my history and physical examination or progress notes to engage in rounds, such as, “I think the patient’s syncope may be due to the profuse diarrhea causing orthostatic hypotension leading to syncope. MEK inhibitors used to treatment metastatic melanoma have a more than 40% risk of causing vomiting or diarrhea; dose reduction is essential to prevent recurrent side effects based on the pharmacologic instructions.”
I’ve also researched questions that may have been brought up during rounds and emailed evidence-based articles with brief summaries to the team later that day to close the loop on any loose-ended questions. These opportunities allow me to elaborate on my thought process and provide systematic value to my decisions for the attending to read before attesting my note.
Forming a bond and “dancing in sync with one another [your fellow or attending] without stepping on each other’s toes,” as my mentor attending advises, is the ideal formulation to a dynamic partnership. Becoming acquainted on the superficial level, then advancing to deeper levels of character and clinical knowledge, while sharing the intricate pieces of yourself that are professionally feasible—your joys, virtues, passions, future planned accomplishments—shape a comprehensive impression for your attending. However, this has not been as fluid as it sounds while social distancing and interacting only through Zoom and email. This is where using technology as a catalyst to show your adaptability is important.
Lessons Learned During Televisits: At the beginning of my rotation, I reached out to numerous recommended, friendly, technology-savvy attendings offering to see their patients with them via online sources such as PolyCom, Doximity, FaceTime, or Zoom. Although the majority of the replies included apologies that COVID-19 was inhibiting a steady clinic schedule or an inability to incorporate residents/fellows into the televisit, one attending was happy to have me join in on his Tuesday and Thursday outpatient genitourinary oncology clinic visits.
For 4 weeks, I pre-rounded on all of his patients on the day prior to our televisit, read up on their cancer diagnosis/management, clinical trial, and/or looked up any lingering questions. On the day of the visit, we sometimes encountered some minute issues at the start. Internet connections were shaky, microphones were muted, buttons were difficult to navigate, technology naivety led to improvising with an alternative televisit method, but in the end, I saw every single patient scheduled for the day. I’d then call my attending’s office phone, present the patient’s case, and discuss the assessment and plan.
To engage in conversation and make an effort to learn from each patient case, I asked questions to keep the attending on the call for as long as appropriate, mindful of the need to be respectful to the other patients waiting to be seen for the day. “How do supersaturating testosterone receptors lead to receptor sensitivity? Why is our PSA threshold 2 ng/mL as opposed to the other patient whose PSA threshold was 20 ng/mL? Did we include bicalutamide for 1 month along with leuprolide to inhibit the PSA surge that is seen with LHRH antagonists? Based on the clinical trial protocol, despite a fluctuating though overall down-trending PSA level, and improving symptoms, can we continue the trial, and what’s the threshold to safely continue the patient on the study?”
After our phone call, we would hang up and both join the video visit along with the patient to discuss the finalized plan. Although this looks like a lot of back and forth with multimodal communication, we successfully improvised with this new method of attending-trainee education, without losing out on the key piece to my education.
As for kindly enquiring whether that attending would be able to provide a strong letter of recommendation for my fellowship application next year, since I’ll be doing a chief year, well, that also had to happen via phone call. Despite the informality of my request, to my surprise, the attending had already offered to help me in any way possible earlier in the week over the phone. He observed that I was able to easily relate and recognize a number of patients who had difficulty understanding their cancer, possible complications, or treatment options through the nuance of video visits. I also was able to address an anxious and angry man’s feelings of inadequacy due to permanent incontinence complicated by erectile dysfunction from his prostatectomy, and to help him get to the heart of his metastatic prostate cancer treatment options. Finally, I eased the fears and hesitations of another man to transition him from intermittent to continuous androgen-deprivation therapy based on his most recent PSA levels.
To put it simply, I sat silently while actively listening to those men, and sometimes women, share their thoughts without interruption. Then, with patience, and language geared toward the patient’s level of understanding, I empathized, listened, and offered answers to their questions with constant closed-loop communication. The most powerful part of our clinical practice is the art of speaking and listening to patients whether the interaction is face-to-face or via televisit.
Forging through this clinic experience allowed me to build relationships and connections I did not think were possible given the circumstances. However, I found success is a conscious choice. No road to growth will ever be straight and smooth without its trials. We will all be confronted with changes and obstacles; how we adapt to these unforeseen events determines our success.
Learning Is All About Adaptability
In our field of practice, the ability to learn is also about the ability to adapt, to think analytically while looking at the big picture, and to practice the art and science of medicine to personalize care for each individual patient. We are hopeful creative individuals, offering altruistic perspectives and therapies when human suffering threatens life.
So, about 4 months into the COVID-19 pandemic hitting the United States, why are we physicians and thought leaders still crippled by this untouchable assailant? We should be using our resilient, persevering natures and unique abilities to heal others during this time. It is our fundamental responsibility to reintegrate education into our medical training facilities, foster interpersonal relations, and promote adaptation into a newfound normal lifestyle. We must combat stagnation and we must work to cultivate the next generation of oncologists into our communities to sustain our call to widespread healing.
Dr. Ugarte is currently a postgraduate student and future chief resident in the Department of Medicine at Highland Hospital, Alameda Health System, Oakland, California.
Originally published in The ASCO Post; republished with permission.