By Aqsa Mumtaz, MD, Gliceida Galarza, MD, Houssein Safa, MD, Humaira Sarfraz, MD, Saurabh Zanwar, MD, Muhammad Salman Faisal, MD, Fernando Diaz, MD, Pamela Contreras-Chavez, MD, Ghulam R. Mohyuddin, MD, and Karun Neupane, MD

To address the common questions that aspiring fellows and current fellows have about hematology/oncology fellowship, HemOncFellows’ Network (@HemOncFellows) organized two Twitter Space sessions on March 10 and 20, 2024.  In the article that follows, session participants, organizers, and members of the HemOncFellows’ Network recap the discussion and share practical advice that you can use in preparing for your fellowship. The content in this article has been modified to some extent from the original discussion to ensure its suitability for publication.

A note on roles and authorship: The session was hosted by Dr. Karun Neupane (KN). The speaker panel included Dr. Gliceida Galarza (GG), Dr. Houssein Safa (HS), Dr. Humaira Sarfraz (HuS), Dr. Saurabh Zanwar (SZ), Dr. Muhammad Salman Faisal (MSF), Dr. Fernando Diaz (FD), Dr. Pamela Contreras-Chavez (PC), and Dr. Ghulam R. Mohyuddin (GRM). Dr. Aqsa Mumtaz helped to write this article based on the Twitter discussion. The article was approved by all the authors. The discussion sessions and this article were coordinated and supervised by Dr. Neupane.

KN: Can you please start by sharing your thoughts on learning research and clinical knowledge/skills in fellowship in general?

GG: The structure of your fellowship determines your experience. In the first year, we focus mainly on inpatient rotations over outpatient ones. To cope, I relied on resources like The Fellow on Call (@TheFellowOnCall) and Two Onc Docs (@TwoOncDocs) podcasts, which offered invaluable insights and helped me develop a solid framework for each day. Despite the long hours, typically ranging from 12 to 14 daily, and being on call for 10 days plus two weekends each month, the experience was incredibly rewarding. Every question I encountered was not only a challenge but also an opportunity to learn and grow, thanks to the fantastic support from my colleagues and attendings at the University of Utah.

HS: My experience differed slightly. Our program follows a two-plus-one system, alternating between two months of inpatient rotations and one month of outpatient. The first year was busy, reminiscent of intern year but in a good way. Coming from a background in internal medicine, adjusting to the unique mindset required in hem/onc was indeed a challenge. However, as time went on, I found myself getting more comfortable with the system.

SZ: Before starting fellowship, many of us share similar concerns and anxieties. In fellowship, we focus on becoming skilled clinicians and advancing our careers in science. Career goals vary, with some aiming for community oncology, academia, or industry. Despite initial anxieties, it's important to remember that everyone feels nervous about starting clinical responsibilities. Learning is ongoing, and staying updated with literature enhances clinical practice.

HuS: Understanding that you don't need to know everything from the start is crucial. Knowing how to acquire the necessary knowledge is key. For instance, utilizing resources like the NCCN guidelines is essential. Dr. Rami Komrokji, one of my mentors and an MDS expert, advised that in your first year, the goal should be learning how to clinically approach a particular malignancy or a hematology case and then building upon that in your subsequent years. Familiarizing oneself with hematology/oncology terminology is a slow gradual process, unlike starting an internal medicine residency, where knowledge is primarily based on medical school. It's normal to feel overwhelmed initially, but it's all part of the learning curve.

KN: Imposter syndrome is a big part of residency and fellowship training. How did you manage imposter syndrome during your training?

GG: Like every trainee, imposter syndrome has been a challenge for me, but it lessened as I progressed through my first year. Finding my rhythm and approach to handling questions and situations boosted my confidence. Although moments of doubt still arose, I learned to trust my foundational knowledge and accept that I belonged where I was.

HS: Imposter syndrome hit me hard initially, especially coming from a background in internal medicine. Embracing the learning process and the support of colleagues and mentors helped me realize it's okay not to have all the answers immediately. Recognizing that learning is ongoing and that doubt is universal eased my struggle with imposter syndrome.

SZ: It's something that never really goes away throughout your career. You'll often find yourself working alongside individuals who are much more knowledgeable in the field that you are just entering. An approach to addressing this is acknowledging that it's impossible to know everything. Moreover, different types of impostor syndrome manifest at various stages. As you progress into the third and fourth years, you may encounter more research-based challenges and experiences. However, everyone is on their unique trajectory, and that's what truly matters. There's no need to be too hard on yourself. This perspective has helped me cope, and as you encounter more challenges and learn more, your confidence will naturally grow.

HuS: I also don't see impostor syndrome as entirely negative. It's more about feeling unsure, which can prompt self-improvement. If we feel like we don't know enough, it motivates us to read more, seek advice from colleagues, or consult with attending physicians. Ultimately, this leads to continuous learning and better patient care. While many perceive impostor syndrome as a weakness, I see it as a strength. It pushes us to strive for more and improve ourselves. We've all experienced different forms of impostor syndrome at various points, but I believe it can be empowering as long as we use it as a catalyst for growth.

KN: Research has become increasingly essential in fellowship applications and throughout the fellowship itself. What advice do you have for gaining exposure to research, especially for those who haven't yet decided on a specific research pathway?

SZ: Research has become integral to fellowship applications. While crucial for fellowship applications, it's vital to assess your long-term interests. Personally, my passion for multiple myeloma and plasma cell dyscrasias influenced my decision to choose Mayo Rochester for fellowship due to its conducive research environment. Regardless of whether it's clinical, translational, or basic science research, selecting a center with appropriate resources and expertise in your area of interest is key. Lack of experience shouldn't deter you; everyone starts somewhere. Focus on understanding disease biology rather than specific technologies, as the latter can become outdated. When pursuing research, consider how each project contributes to your overall academic story and potential job prospects. Publications matter, but building a coherent narrative around your research is equally crucial.

HuS: Absolutely. It's normal not to have a clear research focus at the beginning of the fellowship. Your interests will evolve, so exploring different avenues initially is acceptable. For instance, I began with breast cancer but eventually found my passion in immunotherapy and melanoma research, integrating it with my clinical interest in breast cancer. If research is part of your fellowship journey, carving out your trajectory and leveraging various support teams, such as biostatistics and trial coordinators, is essential. However, it's unrealistic to be an expert in everything, so prioritize your time wisely, especially if research is significant for your fellowship.

SZ: If you haven't secured a mentor yet, now is the time to actively seek one out. Meeting with various researchers allows you to find someone whose vision aligns with yours, as they will play a significant role in shaping your research endeavors. Remember, it's okay to outgrow mentors; sometimes, you need to move on to continue growing in your research career. Ideally, you should have at least one senior mentor for a broader perspective and a mid-career mentor for day-to-day guidance. Don't hesitate to ask questions, even if they seem trivial, and consider seeking external advisory mentorship for additional insights beyond your institution's confines.

KN: When entering a fellowship, many of us are faced with the decision between clinical research and lab research. How do you recommend approaching this decision?

HuS: When it comes to choosing your pathway, immersing yourself in both options is essential to truly understand what resonates with you. For those without lab experience, getting involved in lab projects, attending meetings, and talking to researchers can provide valuable insights. Similarly, exploring clinical trial participation or shadowing clinicians can help gauge interest in clinical research. Finding mentors is also crucial, and institutions may offer internship programs or structured mentorship initiatives. Additionally, identifying mentors with a track record of successful mentorship, particularly in your area of interest, is important. Starting with an initial mentor and adjusting as needed ensures alignment with your academic and research goals.

SZ: Absolutely. While lab experience may be limited for some, clinical expertise is immensely valuable in research settings. Clinicians bring a unique perspective and important questions to the lab and their skills can be complementary to what PhDs can accomplish. Remember that you don't need to be a lab expert to contribute meaningfully. Focus on thinking like a scientist, identifying relevant biological questions, and collaborating effectively. Avoid getting too caught up in learning specific techniques; instead, prioritize understanding biology and leveraging your clinical insights to drive translational research forward. You are an invaluable member of the research team, bringing essential clinical perspectives to the table.

KN: What qualities do you look for in a mentor, and how do you suggest fellows find good mentors during their training?

GG: For me, finding a mentor wasn't just about clinical expertise or research prowess; it was about finding someone whose values and aspirations resonated with mine. I observed different attendings throughout my first year, assessing not just their medical practice but also their approach to life outside medicine. About 6 to 8 months into fellowship, I approached those whose qualities I admired, expressing my desire to learn from them further. It's a personal decision, shaped by what matters most to you.

HS: Absolutely, mentorship goes beyond professional guidance. A mentor should be someone who sees your potential and guides you based on their experiences. Dr. Suzanne Koven’s article in the New England Journal of Medicine beautifully encapsulates this idea, emphasizing that a mentor is someone with more imagination about your potential than you have yourself. Look for someone who understands your goals and challenges and is willing to offer personalized advice. It's also worth noting that mentors can be found among your peers or seniors within your fellowship—they offer unique perspectives and support through shared experiences.

KN: As a fellow, when should you make a decision on which particular subspecialty within hematology-oncology you want to pursue, whether it's for research or clinical practice?

GG: Identifying mentors within the subspecialties I want to pursue has been crucial, providing insights into both the field and potential career paths. By the latter part of your first year, it's important to start honing in on your interests. The last 3 to 4 months of the year can serve as a critical period for self-reflection and planning your subsequent years in fellowship.

HS: While some fellows enter with a clear direction, having already engaged in research or specific areas of interest, others, like myself, are still exploring. The first year offers an opportunity to absorb as much as possible. Seek diverse perspectives from fellows and attendings, and don't limit yourself to a single mentor. Gathering insights from multiple sources can better align with your aspirations. It's okay not to have all the answers by the end of your first year. Embrace the journey, remain open-minded, and trust that clarity will come with time and exposure.

HuS: Honestly, I'm not sure if there's a magic number or a specific time point for this. Rotating through all the clinics during your first year, and being exposed to all of the major groups in oncology or hematology, is important for a fair assessment. By the end of the first year, you should have a good idea. Identifying this earlier, especially if you want to go into academics, allows you to focus your research interests in that direction. But I'm not sure if there's a specific timeframe for this.

SZ: I agree. I've known people who knew exactly what subtype of melanoma they wanted to study in their first year of med school, and I know consultants who changed career tracks after completing a fellowship and even after a few years on staff. It's customizable. Ideally, within the first year, you should have an inkling of where you're headed because, by year two, grant applications are rolling in. Planning is important, and it's a good idea to have at least a rough idea of what you want to get into before joining the fellowship. For example, I ruled out the subspecialties I knew I would be miserable in before ruling in what I really wanted. It's important to consider that your career path might impact your lifestyle. For example, transplant physicians often have a busier schedule. Sometimes, the kind of research you've been doing also dictates the career you end up pursuing.

MSF: I just want to add that when I applied for residency, I had no research experience whatsoever, yet I am currently in a decent position. It's remarkable to think how this scenario has changed over the years. However, it's okay if you choose to spend more time in clinics during the fellowship instead of dedicating 18 months to research. It's essential to know what you're getting into, and if you don't enjoy research, that's perfectly fine. Instead, focus on being proactive, writing papers, and building connections, especially if you're interested in community oncology. These experiences can serve as the foundation for your papers and pave the way for further opportunities.

KN: This question is from the audience. For someone deeply interested in community oncology rather than academia, with limited interest in research, where should they focus their efforts, and how much emphasis do university programs typically place on research for fellows not inclined towards it?

SZ: Community oncology is both challenging and rewarding, requiring alignment with your career goals. While academic programs often prioritize research, it's essential to prioritize your interests. No one should feel compelled to pursue research if it doesn't align with their aspirations. Although accrediting bodies may stipulate minimal research requirements, emphasis can primarily be on clinical training and practice. Community oncology presents unique challenges, including staying abreast of rapidly evolving data and treatments. Exposure to community practices is vital for understanding the field's realities. Two primary paths exist within community oncology: physician-owned practices and hospital-based practices, each with distinct dynamics like administrative responsibilities and partnership structures. When considering a career in community oncology, explore these aspects to find a practice that aligns with your preferences and goals. Seek practices specializing in areas matching your interests and well-being.

KN: How can we be efficient during the fellowship while balancing training, clinical updates, research, and life in general?

GG: Efficiency during fellowship is essential, and it's something I'm still exploring. Initially, focusing on grasping the basics is crucial, given the ever-changing nature of hem/onc. Building a strong foundation will be paramount for career progression. It's important to remember that efficiency is highly individualized, so finding what works best for you is key.

HS: Absolutely, finding efficiency in fellowship is vital. Drawing from our experiences in residency can provide valuable insights. Residency training is notoriously challenging, but fellowship presents its own set of obstacles. Applying the principles that worked for you in residency can serve as a solid foundation. Establishing a supportive community and environment is essential. Learning to prioritize tasks and recognizing when to decline opportunities can help manage the workload effectively. Remember, it's okay to say no if it doesn't align with your current capacity. Adjusting and revisiting opportunities later can be beneficial. Overall, maintaining a balance and having support systems in place is crucial for navigating fellowship efficiently.

PC: I want to stress that it's common for trainees, like myself, to be hard on themselves. It's important to have research experience, but it's not necessary. For example, I'm in a community fellowship program heading toward academia, a path I hadn't considered before. It's okay not to have a clear direction at the beginning of your fellowship. Many of us felt unsure initially, but it's a process of discovery. Finding balance comes with time and exposure. After about 6 months, you'll start to form an idea of your career direction, but there's no strict timeline. Everyone's preferences vary. Attending conferences is crucial. Networking and learning from others' experiences are invaluable for career growth. Even small conferences offer valuable insights and connections. Some prioritize research over clinical work, while others, like myself, focus more on clinical practice. It's about finding what suits you best. Currently, I'm focusing on benign hematology while also interested in lymphoma. Whether you're inclined towards research or patient care, both are equally important. Salman and I share the belief that being a good clinician is as crucial as being a good researcher. That's the essence of my experience and perspective.

KN: This question is from the audience. Should we aim to take the oncology boards during our second year and the hematology boards in our third year? Is that the typical timeline?

MSF: You cannot take a board exam in your second year. You become eligible to apply for one board during your second year, but the exam itself usually happens around October or November of your third year. So, unfortunately, you can't tackle both boards while you're still in fellowship. However, you can certainly aim to take one board, and if your program permits, it's advisable to do so in your third year.

KN: How have you managed your finances during the fellowship? Any tips or strategies?

MSF: Many residency or fellowship programs provide access to financial advisors or counselors, often offering the first consultation for free. It's a valuable resource that many overlook. Utilizing these services can offer professional guidance beyond what we discuss among colleagues or on podcasts. Although life as a trainee can be financially challenging, things tend to work out eventually. If your program offers financial counseling, don't hesitate to reach out for expert advice. It can greatly assist in managing your finances during training.

KN: Dr. Mohyuddin, as an attending, do you have any advice for the fellows in general to do well in fellowship?                 

MM: Well, I'm not sure if I have much wisdom to add beyond what has already been shared. I've heard many insightful points. Transitioning into fellowship can indeed feel overwhelming, especially when faced with a new specialty like hematology-oncology. It's important to recognize that you don't need to become an expert in every type of cancer right away. Instead, focus on developing a framework for processing oncology information and providing effective patient care. Additionally, there's no one-size-fits-all approach to fellowship. While research is valuable, it's not mandatory for everyone. It's perfectly acceptable to prioritize clinical work if that aligns better with your interests and goals. Remember, forcing yourself into research that you're not passionate about can lead to burnout.

When considering research, choosing the right mentor is crucial. Look for someone with a track record of completing projects and whose research aligns with your interests. Finally, don't hesitate to say no to tasks or projects that don't align with your priorities. As you progress in your career, it's important to make decisions that serve your well-being and professional growth.

KN: Dr. Diaz, as a geri/onc fellow at the University of North Carolina, do you have any specific advice for fellows about the combined programs?

FD:  It's great to have these conversations because finding space to discuss these experiences within your program can be challenging. I learned about geriatric oncology during my fellowship, which offers a pathway to integrate geriatrics into hematology-oncology through clinical training, research, and mentorship. What really drew me into the field were my concerns regarding how little we know of our older patients and how we assess their performance status to determine treatment eligibility.  So, I opted for an extra year in geriatric oncology. Combining fellowships, like geriatric hematology-oncology, has its pros and cons. I believe it is a wise investment in one’s education while for others, it may mean sacrificing a year of attending salary. Moving for an extra year can add financial strain, especially with a family. Despite student loans and relocation challenges, I prioritized my passion. Sacrifices often come with academia, but it's about getting the necessary training to excel in your field. Niche fields like geriatric oncology offer tight-knit communities and deeper connections with colleagues.

I categorized my interests into different areas like health care disparities in Latinos and geriatric oncology to maintain balance and fulfillment. My advice is to follow your passions, prioritize your well-being, and explore areas that fulfill you.

KN: Could you share the best or most fulfilling experience you've had during fellowship so far, as well as any challenges you've faced? Also, do you have any other general advice for incoming fellows?

GG: Overall, I've found fellowship to be a really rewarding experience. Whether it's clinical work, research, or just life in general, there's been a lot to enjoy. Sure, it's been the toughest stretch of my training yet, but strangely, also the most enjoyable. For me, the biggest hurdle has probably been dealing with the emotional toll of caring for patients with cancer. However, being in a supportive environment has made all the difference, and I've found that having hobbies outside of medicine has been crucial for maintaining a good work-life balance.

HuS: It's crucial to remember that we, as fellows and hematologists, have lives outside of medicine. Whether we're parents, friends, or have other interests, prioritizing our mental and physical well-being is vital. Personally, the fellowship was a beautiful time for me. I was part of a large academic program with culturally diverse colleagues and had the privilege to work with leaders in various fields. The opportunity to collaborate with experts in clinical trials and novel approaches was incredibly gratifying. As for challenges, I view them as learning experiences. When faced with difficulties, I believe in addressing them constructively and using them as opportunities for personal growth.

SZ: Our foremost duty as physicians is to care for our patients, which brings unparalleled satisfaction. I've been fortunate to be part of an amazing fellowship class that offers support and valuable insights. It's essential to prioritize your happiness and not just follow the crowd. Saying no to certain commitments is a skill worth learning to prevent burnout and ensure you focus on what truly matters to you.

MSF: Cancer is bad. There will be times when you feel drained and low. It's important to have a support system in place for those moments—friends, mentors, anyone you can lean on. This field isn't all sunshine and rainbows; there will be tough days. But reaching out for support when you need it can make all the difference.

Dr. Mumtaz is a second-year internal medicine resident at Montefiore St. Luke’s Cornwall Hospital and will be applying for a hematology oncology fellowship in 2024. Follow her on Twitter @Aqsamumtazmd. Disclosure.

Dr. Galarza is a second-year hematology/oncology fellow at the University of Utah. Follow her on Twitter @GliceidaGalarza. Disclosure.

Dr. Safa is a first-year hematology/oncology fellow at Baylor College of Medicine. Follow him on Twitter @hsafaMD. Disclosure.

Dr. Sarfraz is a third-year chief hematology/oncology fellow at Moffitt Cancer Center. Follow her on Twitter @HumairaSarfraz2. Disclosure.

Dr. Zanwar is a third-year hematology/oncology fellow at Mayo Clinic Rochester. Follow him on Twitter @ZanwarSaurabh. Disclosure.

Dr. Faisal is a third-year hematology-oncology fellow at Roswell Park Comprehensive Cancer Center and a co-host of @HemOncFellows Network. Follow him on Twitter @msalmanfaisal. Disclosure.

Dr. Diaz is a geriatric/oncology fellow at University of North Carolina and chair of the ASCO Trainee and Early Career Advisory Group. Follow him on Twitter @FernandoDiazMD1. Disclosure.

Dr. Contreras-Chavez is a third-year hematology-oncology fellow at St. Elizabeth's Medical Center. Follow her on Twitter @PamChMD. Disclosure.

Dr. Mohyuddin is an oncologist at the University of Utah and a co-host of @HemOncFellows Network. Follow him on Twitter @ManniMD1. Disclosure.

Dr. Neupane is a third-year internal medicine resident at Albert Einstein College of Medicine/Jacobi Medical Center and a co-host of @HemOncFellows Network. He will be starting his hematology/oncology fellowship at Moffitt Cancer Center in July 2024. Follow him on Twitter @KarunNeupaneMD. Disclosure.