By Jonathan Berry, MD, and Aakash Desai, MBBS, MPH
Becoming a physician in the U.S. medical system is a marathon in which trainees must continuously look ahead. This starts with rigorous pre-med expectations for undergraduate students that continue as medical students prepare for their desired residencies. Just as trainees settle into this role and begin to become accustomed, the time comes to look forward to the next step, specialty fellowship or a job search. With all this constant gazing forward, it should be no surprise that trainees are used to partially living in the future. This was certainly true for us as we envisioned finally becoming hematologists/oncologists, the goal for which we had been striving since medical school.
The pandemic that has swept across the world, touching all aspects of society. Although we have learned much more about preventing transmission, risk factors of the disease, and treatment options, there are many unknowns still. As trainees, the pandemic has radically transformed the fellowship experience from what we had envisioned across the three pillars of modern medicine (and also the three shields of Mayo Clinic): education, research, and patient care.
Mourning the Death of Expectations
Fellowship is the capstone of the structured educational experience for aspiring hematologists/oncologists. While we absolutely continue to learn throughout our careers, this is the final position where we find ourselves in a direct apprenticeship model with structured and protected time for didactic experiences. We fondly remember the days when we had the chance to sit in on fellows' lectures as residents. We remember seeing the first-year fellows—with nervous yet excited visages—as they sat around "the table," tacitly reserved for them as they engaged face-to-face with experts across the medical center. After matching at our dream fellowships, we anticipated our moment would come, but alas, COVID-19!
The reality we entered in July is a bit different. Instead of taking our places around "the table,” we look at our co-fellow's faces in the now-iconic "Hollywood Squares" gallery of Zoom. The same world-class teachers are present and graciously give of their time and knowledge to teach us their craft, but we cannot deny that experience changes when it is mediated via data streams. The teaching is still superb and we still learn, but something is lost when it takes place in a sort of video conference no-man's-land, with some participants at home, others alone in their offices. This is a far cry from the hallowed dark-paneled room with its whiteboards, where we envisioned discussions over morning coffee and pastries.
The taint of COVID-19 reaches not only to formal didactics but also to the informal teaching in the clinics. One of the oncology clinics’ crowning stars is the multidisciplinary space where new or established patients are seen synchronously by medical, surgical, and radiation oncologists. In these spaces, experiences fly between participants as we assess patients from our perspectives and share our knowledge. Unfortunately, as we have attempted to maximize safety for our patients and staff, institutions have had to make difficult choices about who is onsite versus virtual. In many instances, this has led to a decrease in multidisciplinary clinics, taking away opportunities for the team-based approach that often drives us to the field.
The physicality which provides such a spark to education is equally vital to making research connections and identifying mentors. Its absence also chips apart our prefigured fellowship experience. In those moments before and after lectures, space and time exist for fellows to get to know faculty, discuss personal scholarly interests, and make connections. Many of these crucial mentorship relationships form not due to a structured approach but from chance encounters. These same interactions simply do not occur in a virtual lecture scenario. Everyone waits quietly for the lecture to begin, muted (or hopefully so!), often with video off until it starts, and upon its conclusion, we all disperse our separate ways. This displacement of spontaneity may have compromised potential connections that we otherwise might have made.
Most trainees who choose a career in hematology/oncology come with a desire for deep physician-patient relationships that form amidst life-changing diagnoses. We remember watching the joy of a physician as one of their patients completed chemotherapy, and the comfort of a squeeze of the hand or the empathy of a hug after sharing that another patient's disease had worsened. Much of the relationship involves being in the same room over many appointments, walking alongside patients through pain and suffering. Much of that compassion is expressed through physical touch or a soft smile—which we now hide behind our masks.
We entered the field finding this paradigm radically shifted. In the best-case scenario, we find ourselves in the same room with patients, separated by 6 feet, wearing masks, thereby eliminating the all-important ability to read facial cues and stripped of the ability to share compassion through physical touch. At worst, we find ourselves physically separated from our patients, attempting to build such a relationship over video or phone. Whether physical or spatial, a barrier is always between us.
Thriving in the New Normal
There is no denying that there is much to mourn for the fellowship experience that we expected. We suspect if we polled all the hematology-oncology fellows, most would prefer to go back to the picture they had in their mind, rather than the experience we are having now. And yet, there are some silver linings within the constraints of the COVID-19 pandemic—aspects of the changes that have occurred that we can cling to, celebrate, and through which we can thrive.
With the core didactic fellowship education moving to virtual meetings, we have gained great flexibility in attendance for both instructors and trainees. Previously, most lectures would be attended primarily by first-year fellows, with the assigned instructor and perhaps a core member or two of the fellowship leadership. Now that attendance requires merely an internet connection, significantly more of the upper-year fellows attend conferences, where they have the chance to consolidate information and see previous topics again, and many more faculty members attend as well. Faculty may have great insights on a topic that the assigned instructor may not have, and commonly great learning experiences emerge from such conversations. Furthermore, a wide variety of consultants can now provide their perspectives and experiences. This is not even limited to faculty at our institutions; due to the ease of joining, the barrier of participation to bring in alumni of our institution who are now across the country has been drastically lowered, to our benefit. Another welcome change has been virtual tumor boards, which have made it easier to pop in from clinic to attend different tumor group meetings without hustling from the opposite end of the building. Lastly, the availability of online recordings makes it easier for trainees to curate their learning based on their practice patterns and current assignments.
Additionally, in a world where physical lectures cannot occur, the value of asynchronous learning and the use of new media platforms has been increasingly recognized. Despite a notable presence of medical educators on Twitter before the COVID-19 pandemic, digital education opportunities via Twitter are increasingly being identified. Our institutions have begun utilizing Twitter for spaced repetition and consolidation of topics taught during lectures as well as for providing information for fellowship applicants (you can find these on Twitter @MayoHemOnc and @BIDMC_HOFellows). Other institutions have used this format to start a recurring online journal club (@HOJournalClub), incorporating faculty and trainees from institutions across the U.S. and worldwide.
Along a similar line, attending scientific meetings has never been easier now that most of them this year went virtual! In the past, our programs supported fellowship trainees in attending conferences when possible, but often limited the number due to travel time, clinical duties, and funding. Now that the major meetings are online and, to a large extent, free of charge to trainees, we have a much-expanded ability to participate in these massive international learning experiences.
While spontaneous in-person interactions may be limited, the digitalization of so much of our work has, in some ways, lowered the barrier for cross-institutional collaborations. While laboratory-based research’s physicality lends itself to best be performed by faculty and trainees in the same location, much clinical, educational, and quality research can be just as easily conducted remotely. Such collaborations were always possible, but perhaps we are more aware of them. We look forward to mentorship and collaboration to emerge between faculty, trainees, and peers who connect through interactions in virtual conferences and via the digital communities of new media.
Ironically, the sheer restrictions secondary to the COVID-19 pandemic have also perhaps made potential local mentors easier to meet. With conferences going virtual and work-related travel on hold, some of our most esteemed faculty—who usually would often be quite busy with travel—have much more time freed on their schedules and more availability to meet with potential mentees.
Regarding patient care, the necessary restrictions and requirements for safety when interacting in person are vital, yet do result in unfortunate barriers—both physical and emotional—between physicians and their patients. There is no substitute for face-to-face patient care; however, there are silver linings to be found in our work with telehealth. We have learned that, contrary to guidelines and standard practice, not all patients with cancer need to be seen in person as frequently as we had previously thought. Telehealth was initially the only option allowed for non-urgent follow-up, and we learned as a system that, for some patients, it might work better than an in-person visit.
As we both practice in quaternary academic referral centers, we know many patients whose commute to seek care can be more than 2 hours in each direction. Some patients who are several years out from definitive cancer treatment would much rather have labs and imaging performed locally and conduct a surveillance visit via telehealth. With a continued emphasis on patient-centered care, having this flexibility allows us to—quite literally—meet our patients where they are and provide necessary follow-up while limiting burden and enabling them to have more full lives. Furthermore, with telehealth, it is much more convenient for caregivers and loved ones to join visits, even if they live elsewhere or have difficulty traveling.
There are additional and wide-ranging benefits to telehealth, as we are discovering. We have experienced the joys of meeting patients' pets and extended family, which brightens our days. We can see our patients in their living situation, which gives us a much better understanding of the milieu in which they spend the majority of their time, far from the sterile walls of the hospital, clinic, or infusion center.
Throughout this, one thing certainly has not changed. Hematology/oncology remains a fascinating and immensely rewarding field, and we count ourselves extremely lucky to have the opportunity to learn and develop our practice within it. We also are incredibly fortunate to have such a phenomenal group of co-fellows as we strive together to capitalize on the benefits and work past the frustrations of the unexpected nature of our first year of fellowship. Our co-fellows are the ones who keep us going, day in and day out.
Although we might not have had the chance to share experiences outside of the hospital as we would have liked, with no concerts or plays to attend, and no opportunities to gather at a local restaurant over appetizers or a meal, we have still each formed a close-knit crew with our co-fellows. Going through this medical training experience together in such a bizarre and atypical time has, if anything, actually brought us closer. We laugh together over the oddities of the days and weeks and mourn together in the ways this year is so different from what we had expected.
There are many ways in which we wish things were different, and we are hopeful that many of those things will return in the years to come. However, there are undoubtedly positives to this experience. We hope that those will continue to be incorporated into fellowship even when we move back from the "new normal" to something approaching simply "normal.”
We remain truly grateful for the opportunity to train in this wonderful field, to our patients for putting their trust in us, and to our respective program leaders who are working tirelessly to squeeze every possible drop of lemonade out of the lemons that the COVID-19 pandemic has handed to us.
Acknowledgment: Both authors are incredibly grateful for their support systems and co-fellows at their respective institutions and would like to acknowledge and thank their first-year co-fellows for their support. At Beth Israel Deaconess Medical Center: Dr. Michail Alevizakos, Dr. Matt Chase, Dr. Jim Doolin, Dr. Justine Ryu, and Dr. Emily Stern Gatof. At Mayo Clinic Rochester: Dr. Nadine Abdallah, Dr. Allison Bock, Dr. Matthew Braithwate, Dr. Grace Choong, Dr. Brett Grieb, Dr. Akeem Lewis, Dr. Patrick McGarrah, Dr. Sri Harsha Tella, and Dr. Colt Williams.
Dr. Berry is a first-year hematology-oncology fellow at Beth Israel Deaconess Medical Center. His professional interests include medical education, focusing on the intersection between hematology/oncology and general medicine, the role of new media in medical education, and innovations to improve cancer care quality. Follow him on Twitter @JLBerryMD. Disclosure.
Dr. Desai is a first-year hematology-oncology fellow at Mayo Clinic, Rochester. He holds a master’s degree in public health from the University of Texas Health Science Center in Houston and a certification in Health Professions Education from University of Connecticut. He also serves as a secretary for the Minnesota State Medical Association Resident and Fellow Section. His professional interests include evidence base in oncology, clinical trials, drug development, cancer care quality and healthcare delivery. He is one of the founding members of the grassroots consortium focusing on COVID19 in cancer patients now known as the COVID19 and Cancer Consortium (CCC19, @COVID19nCCC). Follow him on Twitter @ADesaiMD. Disclosure.