Volume 4 â€˘ Issue 2, June 2012
f e l lo w s
Finding Time A Day in the Life of an Academic Oncologist Balancing Clinical Education with Scientific Research Medical Writing Basics: CringeWorthy Errors and How to Avoid Them The Art of Analogies in the Clinic
This edition is supported by
FREE, personal websites for cancer patients, survivors, and their caregivers. www.MyLifeLine.org Get started with just a few clicks!
MyLifeLine has been an absolute blessing for me and my family. It’s a great way to keep so many people that want to know how I am in the process.
– Kimberly, 31 years old Inﬁltrating Ductal Carcinoma Grade 2
you for “ Thank providing this
incredible resource. It has really helped us immensely!
– Benny, diagnosed age 52 Squamous cell carcinoma
fello w s
www.onclive.com Editorial & Production Vice President, Clinical and Scientific Affairs Jeff D. Prescott, PharmD, RPh
Table of Contents
Volume 4 • Issue 2, June 2012
Project Director Donna Bonura Project Manager Jaclyn Pallotti Assistant Editor Jeanne Linke Quality Assurance Editor David Allikas Art Director Ray Pelesko
Sales & Marketing President Peter Ciszewski email@example.com Executive Vice President, Sales Jack Lepping firstname.lastname@example.org Vice President, Sales & Marketing Lisa Greene email@example.com Vice President, Integrated Special Projects Group David Lepping firstname.lastname@example.org Directors of Sales Scott Harwood email@example.com Erik Lohrmann firstname.lastname@example.org
A Day in the Life of an Academic Oncologist
By Sam J. Lubner, MD In describing a “typical” day, this academic oncologist explains how he works to balance the many demands of dual clinical and research responsibilities.
Senior National Accounts Manager Mike Hennessy, Jr email@example.com National Accounts Managers Robert Goldsmith firstname.lastname@example.org Corrie Payson email@example.com Sales & Marketing Coordinator Megan O’Connell
Digital Media Vice President, Digital Media Jung Kim
Features 8 Medical Writing Basics: Cringe-Worthy Errors and How to Avoid Them
14 Time Management: Balancing Clinical Education With Scientific Research
By Laura Bruck Paying attention to details and avoiding these errors can help to increase your chances of being published.
By Hatim Husain, MD Effective time management and organization skills are essential in growing in your clinical and research career.
Operations & Finance Director of Circulation John Burke firstname.lastname@example.org Director of Operations Thomas J. Kanzler Controller Jonathan Fisher, CPA Assistant Controller Leah Babitz, CPA
Corporate Chairman/Chief Executive Officer/President Mike Hennessy Chief Operating Officer Tighe Blazier Chief Financial Officer Neil Glasser, CPA/CFE Vice President, Executive Director of Education Judy V. Lum, MPA
Departments A Word From Your Fellows 17 The Art of Analogies in the Clinic By Jaideep Shenoi, MD Analogies can be useful tools to help explain clinical information in a way that patients and their families can more easily understand.
19 There and Back… By Ted Huang, MD This author shares his insights after working as a hospitalist on his way to a hematology/oncology fellowship.
Vice President, Group Creative Director Jeff Brown
Office Center at Princeton Meadows Bldg. 300 • Plainsboro, NJ 08536 (609) 716-7777
Interested in contributing to Oncology Fellows? If you’d like to submit an article for consideration in an upcoming issue, please e-mail Donna Bonura at email@example.com.
The Online Oncologist 22 Mobile Medicine
Apps for the health care professional.
23 By the Numbers 24 Conference Center
Finding Time A Day in the Life of an Academic Oncologist By Sam J. Lubner, MD
We all have to balance competing demands on our time. But as an academic oncologist, I have to keep a foot in 2 worlds, research and clinical, while still keeping my balance.
orking as a medical oncologist in an academic setting challenges doctors to have a foot in 2 worlds: the first world revolves around scientific advancement, and the second around patient care. Each realm has inherent opportunities, rewards, and difficulties that we encounter every day. In this brief snapshot of my experiences, I will try to describe a day that illustrates the balance between these worlds, which is essential to achieve a balanced career in academic oncology. Of course, each academic medical center has its own culture, demands, and spectrum of job types. Some academic physicians have a much more lab-based research practice; others focus on a strictly clinical research practice. My description reflects my own experiences in what might be a typical workday for a clinical trial researcher in gastrointestinal oncology. Each week, I spend 2 days with an entirely clinical schedule. On these days, I see patients in the clinic and administer chemotherapy. I also have at least 1 day each week for entirely academic work. On this academic day, I dedicate my time to research protocols; student, resident, and fellow mentorship; and administrative duties. On other days, I have a mixed schedule with both clinical and research responsibilities. In this article, I will describe a typical Tuesday, which is the best example of a mixed clinical and academic day on my schedule.
June 2012 | 3
Tuesday 7–8 am Multidisciplinary colon conference Our GI oncology group works closely with a variety of other disciplines, and we are lucky to have collaborators in surgery, radiation oncology, gastroenterology, and radiology who share a common vision for patient care and research. We meet weekly to review challenging cases at a colorectal surgical conference. Since this conference is run by our surgical colleagues, we have an early start (but coffee is readily available)! The surgeons review new patient consults and challenging cases. Representatives from each of the participating disciplines have an opportunity to weigh in with their expertise and feedback. This conference is not only a place to collect fascinating cases, it is also a chance to learn the styles and personalities of the other physicians from other departments. Outside of this in-person conference, I may only interact with them over the phone. During conference, we also discuss open research trials, update the group on how shared patients are doing, or vet ideas about possible proposals for new research studies. Getting a “buy-in” for study participation from the providers who have the first contact with patients (in GI, that is usually the gastroenterologists and surgeons) will lead to more fruitful studies and faster subject accrual.
8 am–1 pm Hepatobiliary-pancreas clinic/conference After meeting with the colorectal surgeons, we share clinic space and time with our hepatobiliary surgical colleagues. Like the colorectal conference, this multidisciplinary clinic provides us with an opportunity to see patients as close to the time of diagnosis as possible. In this
half-day clinic, we see up to 7 patients. Pancreaticobiliary malignancies often need neoadjuvant/adjuvant therapy, which requires delicate timing and effective collaboration between medical oncologists, radiation oncologists, and surgeons. This collaboration is both clinically and academically rewarding. Patients like to be able to have a “one-stop shop” to see multiple health care providers, and the close collaboration across specialties maximizes our patients’ potential for the best clinical outcome. In addition to the clinical benefits, this multispecialty coordination allows for direct research collaboration among 3 different sets of research disciplines, since each subspecialty has its own multi-institution research group. We are an Eastern Cooperative Oncology Group (ECOG), Radiation Therapy Oncology Group (RTOG), and American College of Surgeons Oncology Group (ACOSOG) site. Furthermore, having other clinical and research experts from other departments working closely together and reviewing common literature helps keep all of us at the top of our games. At the conclusion of clinic, the most complicated cases are often also reviewed with our colleagues from radiology and pathology, which allows them to offer their insights as well.
1–2 pm GI Research Group meeting In this meeting, the GI oncologists gather with the research program manager, our mid-level providers, and clinical research assistants to review the status of our study patients for the last week. We review all open study protocols in our disease group. In a systematic way, we also discuss the status of each patient in terms of duration of treatment, toxicity, response to treatment,
Patients like to be able to have a “one-stop shop” to see multiple health care providers, and the close collaboration across specialties maximizes our patients’ potential for the best clinical outcome.
4 | June 2012
WHY ONE CANCER CENTER CARES FOR MORE NEW JERSEY RESIDENTS THAN ANY OTHER and is the Only New Jersey Cancer Center Ranked in the Top 50 by U.S. News & World Report
THE JOHN THEURER CANCER CENTER AT HACKENSACK UNIVERSITY MEDICAL CENTER The most nationally acclaimed cancer doctors in New Jersey as recognized by: • Castle Connolly America’s Best Doctors and Best Cancer Doctors • New York and New Jersey Magazines Best Doctors and Best Cancer Doctors • Who’s Who in the World • Who’s Who in Health Care The most innovative cancer doctors and nurses in New Jersey: • Over 100 peer reviewed contributions to advancing cancer care • Featured speakers at international conferences • 14 specialized divisions with cancerspecific teams of experts
The greatest access to breakthrough technologies: • Most daVinci® surgical robots in New Jersey, and one of 20 training centers • Most experienced TomoTherapy® radiation center in New Jersey • First cancer center in New Jersey to acquire TrueBeam™ radiotherapy system • Tumor bank for personalized cancer therapy development • One of the nation’s largest blood and marrow stem cell transplantation programs jtcancercenter.org/research
The largest facility dedicated to delivering innovative, personalized care: • New 155,000 square foot facility solely for cancer care - Inviting, dramatic atrium space - Soothing “living wall” - Above ground radiation facility - A walk-through terrace garden • Personalized care programs as unique as each patient: - Elizabeth and Donlon Hurtubise Patient Resource Library - Cyber café - Demonstration kitchen - Yoga and exercise facility jtcancercenter.org/patientresources
jtcancercenter.org/doctors 201.996.5900 jtcancercenter.org
CANCER IS HARD ENOUGH. EVERY PATIENT DESERVES EXTRAORDINARY CARE, WE’RE COMMITTED TO DELIVERING IT.
and survival. Protocol deviations and serious adverse events are reviewed for attribution, and we brainstorm ways to avoid future problems. We review the progress of proposed future studies and evaluate where they are in the regulatory process and how we can speed these ideas through the necessary regulatory bodies. At this meeting, the 4 GI oncologists bring up clinical trial ideas, and we review one another’s proposals, protocols, and grants and provide constructive feedback.
2 pm–? (end of the workday) Administrative time After a busy first part of the day working with my partners and seeing patients, it is nice to have some time to catch up on clinical administrative work: dictating notes, following up on the results of lab work, scans, and biopsies, and making phone calls to patients. All of these tasks are vital for good patient care. It really takes a dedicated block of time to stay on top of clinical information, and, ideally, some time with the all-too-rare space of peace and
quiet. Sometimes it feels as though there is no way to ever be caught up with the administrative work, but it is really essential to make a regular effort to stay on top of clinical documentation. I’m very thankful that I work with very good nurses and administrative assistants, who help to keep me organized and also do as much of the administrative work as possible. But as the doctor, there are some things that I have to do myself. If I have patients in the hospital, I check in on them during my inpatient time. I’ll also coordinate with the inpatient team to see if guidance is needed. For my research work, I use some of my administrative time, in addition to my dedicated research hours scattered throughout the week, to review protocols, make study-related conference calls, and meet with study monitors and basic science collaborators. It is especially challenging to find time when more than 2 busy schedules can coordinate, but it is imperative that an academic investigator have regular meetings with mentors and collaborators to keep research heading in the right direction. This is true for both clinical or basic science research. My colleagues who perform basic science research use their administrative time to meet with students and techs in their lab, ensure that their experiments are progressing to the next step, and troubleshoot ahead of time.
Heading home My workday really ends whenever the rest of those tasks in my administrative time are done. Before I head home, I stop by my department mailbox to see if there are any journals I can pick up and read at home. It is vitally important for any research or clinical physician to make time every day, whether at work or at home, to try to stay current with the literature. I must confess that I have not been able to carve out that reading time at work, so I do my reading after I put my little guy to sleep. That’s a pretty full day. ■ Sam J. Lubner, MD, is assistant professor at the University of Wisconsin School of Medicine and Public Health and oncologist at the University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.
Interested in contributing to Oncology Fellows? If you’d like to submit an article for consideration in an upcoming issue, please e-mail Donna Bonura at firstname.lastname@example.org.
6 | June 2012
to find the cures.
Komen Tissue Bank volunteer and Purdue University graduate student, Rebecca Fega, helps process breast tissue samples November 2009 in West Lafayette, Ind.
But scientific minds cannot solve breast cancer alone. Susan G. Komen for the Cure®, the leader of the global breast cancer movement, is leading in science again. We’ve just tapped 50 of the world’s top cancer experts to Komen’s new Scientific Advisory Council, to drive innovation and breakthroughs in cancer research. We think of it as the Ultimate Cancer Think Tank. We’re also supplying the tools that will help global researchers unlock the secrets of breast cancer. How it begins and grows. How we can stop it in its tracks. The answers may lie in the Susan G. Komen for the Cure Tissue Bank at the Indiana University Melvin and Bren Simon Cancer Center -- the largest source of healthy breast tissue in the world, soon to be available digitally to researchers around the world over the Internet.
Make an impact and donate today. Visit komen.org/donations.
This space provided as a public service. ©2010 Susan G. Komen for the Cure ® The Running Ribbon is a registered trademark of Susan G. Komen for the Cure.
Medical Writing Basics:
Cringe-Worthy Errors and How to Avoid Them By Laura Bruck
8 | June 2012
As an oncology fellow, you are among the best educated individuals in the country. From basic science to applied clinical technique, what you didn’t learn in the classroom you will continue to learn, every day you spend in the office, the clinic, the lab, and the operating room, as long as you practice. Over the course of what you hope will be a long and illustrious career, you will likely be expected to share the benefits of your research, education, and experience with your colleagues, primarily by writing articles for publication in reputable peer-reviewed journals and trade publications. If you are among the vast majority of physicians, however, you may not be properly prepared for this leg of your career journey. Your medical school curriculum likely didn’t include a single course on clinical writing.
his reality notwithstanding, are physicians really expected to be effective writers? The answer to this question is both “yes” and “no.” You might ask, “Isn’t that what editors are for?” Certainly every medical publication has an editor (or a staff of editors) whose job it is to ensure that all accepted articles conform to the publication’s standards and read as clearly, concisely, and error-free as possible. But the responsibility for producing accurate and effective articles remains with the author(s). In fact, the “cleaner” and more publication-ready the manuscript is as written, the less editorial work it will need. Less extra editing reduces the chance that your intended meaning could be changed inadvertently or that your article will read as if it’s been written by the copy editor and not by you. Because a complete medical writing primer is far beyond the scope of this brief article, the following tips are intended to help you recognize and avoid a few of the most common writing errors. These are the key pitfalls to avoid since they make copy editors cringe when they catch them and, if they should happen to miss them, reflect poorly on you when they appear in print. When you avoid these errors in your writing, you
ensure that your articles will retain your voice and effectively reflect and communicate your expertise. One-size-fits-all Writing The content and tone of your article, the amount of detail and background information you provide, and the explanations of medical terminology you include will differ substantially depending upon your intended readers. After all, an article describing a technique used specifically by those in your subspecialty will be written differently if it is intended to provide an overview for primary care physicians than if it is detailing the specifics of how to perform the technique for an audience of medical oncologists, surgical oncologists, those in your subspecialty, etc. This is why knowing your readers should be the “first commandment” for any type of writing, including medical writing. If you don’t reach your audience appropriately, you run the risk of alienating, confusing, or even insulting at least some of your readers. If you’re not sure who reads the journal you want to submit your article to, visit the journal’s website for a description of the scope of the journal and its target audience. Many journals’ editorial information also identifies their readers. June 2012 | 9
Failure to Look Beyond the Guidelines It can be argued that knowing your journal is as important as knowing your readers. Every peer-reviewed publication has a clear set of author guidelines (or “information for authors”). This information is usually available on the journal’s or publisher’s website and may be periodically published in the journal itself. These guidelines list essential details about how to submit an article for publication and how to prepare it for review. These requirements often list everything from article length and types of articles accepted, to the specifics of preferred font size and acceptable table and figure formatting. Different journals may also have distinct specifications for clinical art or diagrams, rules for how to reference drugs and devices, and instructions on how to format references. To increase the chances of your article being accepted for publication, all of these requirements must be followed to the letter. In addition, read several different articles already published in the journal to get a sense of how the guidelines are applied, and to get a sense of valuable information that isn’t typically found in the guidelines, such as the tone and style (eg, formal versus informal) expected by the readers. Find 2 or more articles similar to the type of article you want to submit (case study, research-based, review,
etc) and use those articles as guides through the writing process. Trading Clear and Concise for Confusing and Wordy Run-on sentences, unnecessary adjectives, and flowery descriptions have no place in a description of a minimally invasive technique for tumor resection. In fact, a rule of thumb for any type of writing is to communicate clearly and concisely, using only the words needed to convey the information. Anything more is distracting. Poor Choice of Words As the author of an article, your readers and colleagues must accept you as an authoritative expert on the topic at hand or, at the very least, as someone with knowledge and experience that might be useful to them. You will have a hard time keeping your credibility if you misuse medical or even lay terminology, or simply choose the wrong words to convey your message. For example, the word data is plural, not singular (“these data were analyzed” is correct; “this data was analyzed” is not) and patients don’t fail therapy; instead, they undergo a failed course of treatment. Also, remember to target your word choice to your intended audience. Avoid the use of subspecialty jargon in an article for a general physician audience.
You will have a hard time keeping your credibility if you misuse medical or even lay terminology, or simply choose the wrong words to convey your message.
10 | June 2012
Sloppy Work There’s no need to raise your hand and ask; yes, spelling counts (as do grammar, punctuation, and sentence structure). A misplaced comma or sloppy sentence structure can change your intended meaning, and can easily slip past even the most careful copy editor or proofreader, since they can’t read your mind to know what you intended to say. Do not rely on “Spell Check,” which will accept anything that’s an actual word, even if that word was not the one you intended to use. A non-medical but real-life (and amusing) example from a classified lost and found ad makes the point quite effectively: “Found. Large white rabbi hopping down Route 80.” How can you avoid such snafus? Long before submitting your article, read it and reread it. It can often help to read it slowly, even reading it aloud. Perhaps most importantly, ask someone else to read it. The more familiar you become with your article, the easier it is to miss such errors, and a fresh pair of eyes is frequently the best safety net. The Bottom Line Writing of any kind is about communicating. To ensure that you are, indeed, communicating effectively, share your manuscript with a colleague and invite (and be open to) constructive criticism. Your ability to clearly communicate your findings, experience, or ideas to an appropriate audience reflects on your credibility as a medical professional. In turn, your contributions to the published literature will help to advance cancer prevention and treatment by providing the clear and concise sharing of knowledge. ■
Laura Bruck is a Cleveland, Ohio–based freelance writer and editor who has specialized in health care since 1987.
Bringing the Oncology Community Together
OncLive.com features full, exclusive online access to all the articles in each issue of Oncology Fellows. For the latest on the issues and concerns facing oncology and hematology Fellows, go to OncLive.com and click on â€œPublicationsâ€? for free, unlimited access to Oncology Fellows.
ÂŠ 2012 Genentech USA, Inc. All rights reserved. BIO0000960401 Printed in USA.
Explore our latest research at BioOncology.com/research
Exploring uncharted territories — bringing advances in oncology to light
At Genentech BioOncology, we’re transforming the way cancer is treated by gaining a broad understanding of cancer biology and following a comprehensive approach to drug discovery. A robust pipeline — We currently have more than 40 new molecules in clinical development across a range of pathways, from angiogenesis to apoptosis. Innovative molecules — Our new molecular entities target the fundamental mechanisms of cancer growth and include antibody-drug conjugates, a HER2 dimerization inhibitor, a type II glycoengineered anti-CD20 antibody, and a one-arm antibody targeting Met. Extensive clinical trial program — We and our partners are currently enrolling patients in over 600 ongoing trials for both postapproval and pipeline products in more than a dozen tumor types. Our goal is to fundamentally change the way that cancer is treated — not just with incremental advances, but with new standards of care.
14 | June 2012
Balancing Clinical Education With Scientific Research By Hatim Husain, MD
One of my mentors once told me that it was unrealistic to expect to excel in research and simultaneously excel in the clinic. Initially, I had a hard time believing this idea. In fact, I had evidence on my side. He is a leader in his field, and I saw him maintain a very busy clinic schedule, while he was also involved about some of the most interesting research. I thought that he was voicing his frustrations about his own experience of needing to be in 2 places at the same time. But now, at the end of my fellowship, I can far better appreciate his advice to me.
ome of the skills that are essential for advancing in clinical education are similar to the skills needed for the successful practice of structured research. With careful attention to detail and conscientious efforts, those clinical skills are likely to be transferable from clinical education to meeting research goals. But in order to make this transition possible, you must be patient, constantly reading, willing to collaborate, open to suggestions, forward thinking about your goals, and not afraid to spend long nights in either the clinic or the lab (or both). Aside from the overlapping skills needed to succeed in clinic and research, I believe that the key to being successful in a hybrid translational role is the use of effective time management skills. Translational medicine is becoming more popular
as physicians get involved in hybrid roles. There are tremendous opportunities in designing clinical trials, contributing to early drug discovery, learning regulatory principles, and engaging in biomarker related work. There are variations on aspects of all of these opportunities in academia, industry, regulatory agencies, and the government. I would like to share my thoughts on 5 time management skills that I have found to be fundamental elements for succeeding in clinical medicine and laboratory-based research.
Concentrate on 1 thing Acknowledge that you cannot bend the laws of physics to be in 2 places at the same time. You cannot attend 2 lectures simultaneously, and it is not feasible to be in the lab when you have a busy clinic waiting for
you, or need to be with a patient who is not doing well. It is very important to prioritize your commitments, and the sooner you do this, the more efficient you may become in managing your time effectively. Many people have found the smart phone app Things useful in helping to manage daily tasks for small and mediumsized projects. This app can be particularly useful as a note-taking tool since it allows you to connect audio, image, and text notes with a certain task or project. Find the organizational tool that works for you and use it consistently.
Seize the moment Take every possible opportunity to learn. Utilize your down time to attend as many lectures as possible and make time to read clinical publications and the biographies of June 2012 | 15
The ability to redirect and revise your plans when things are not going as anticipated will help you throughout your professional and personal lives.
the speakers who will be presenting throughout the week. You might be surprised to find a rewarding educational experience that you did not expect. The smart phone app ReQall will allow you to take video or audio notes (when permitted) to replay at later times to reinforce oncology information recall.
Maintain balance and avoid burn-out No matter how busy you are or how many competing clinical and research tasks you are juggling, it is very important to find a way to keep some balance in your life. This means that you have to make a determined effort to schedule time for exercise, to eat a healthy diet, and to spend time with your loved ones. Especially when it seems hardest to carve out time in your schedule for these things, this valuable time will allow you to recharge yourself. With this down time, you are better able to be your best with your patients. Be flexible and willing to consider alternate strategies when things do not go as planned. The ability to redirect and revise your plans when things are not going as anticipated will help you throughout your professional and personal lives. Keep your schedule on your computer and/or your smartphone so you can set electronic notifications, reminders, and alarms. These alerts can be critical to keeping you on target and on schedule.
16 | June 2012
This way, you can optimize your time, which will also make it possible to schedule and keep your appointments for quality time for personal commitments.
Maintain effective communication Sometimes itâ€™s hard to recognize how much time we can waste and how undermined our efforts can be because of miscommunication. As your schedule fills up and you take on increasingly demanding responsibilities, the skills of writing, presenting, and effective communication are more important than ever before. Speak to mentors in your field and ask for their advice on building strong communication skills. Study successful techniques until you find the tools that work best for you. Also, check into any available resources or education that might be available through a university professional development office that could help you in developing these skills to meet your goals.
Try hard not to procrastinate This is usually far easier said than done; and we all likely have some room to improve in this arena. Once you are making frequent use of your electronic calendar and reminders, take it to the next step and plan all of the necessary steps before the deadline or appointment. Plan to complete the initial tasks well in advance, and assign yourself a deadline
for each step of the process. Make frequent lists, on paper or electronically, whichever will work most consistently for you. Divide large jobs and daunting projects into smaller pieces and keep them on your to-do list. Make use of your scheduling system to send you alerts and reminders of each step of the process. This way, you are not faced with 3 daysâ€™ worth of work to do, 1 day before a deadline. Force yourself to get into good habits of planning ahead and chipping away at your tasks each day. With good time management techniques, you will be able to increase your productivity, expand your skill sets, and be more successful in translational medicine. You will also greatly reduce your stress, since you will have a plan of how to manage larger tasks over time. We have more technology available now than ever before that can increase our efficiency. Utilizing these tools effectively in training provides a solid foundation (and good habits) that will help you to implement them throughout your career. With less stress and more productive hours, you will expand your horizons of successful growth in translational medicine. â–
Hatim Husain, MD, is a third-year medical oncology fellow at the Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD.
A Word from Your Fellows
The Art of Analogies in the Clinic By Jaideep Shenoi, MD
ranslating medical nomenclature into language that is easily understood by patients can be difficult: how do you explain the pathology of cancer or the benefits of myeloablative chemotherapy in patient-friendly terms? Your ability to do so, however, can impact treatment adherence, health outcomes, and the perception of physician empathy during a patientâ€™s bleakest moment. The use of analogies, long recognized in medicine as a way to facilitate physician-patient communication, can help get your message across.
I still vividly recall the elderly Vietnamese male patient in the busy emergency department of Harborview Medical Center. He seemed to be dazed at the frenetic pace of activity around him as he laid on a gurney in a room created by curtains, grimacing in pain. Family members spanning 4 generations surrounded him and looked up at me as I approached and gently bowed in respect. There I was, a busy hematology/oncology consult fellow, who had to announce his diagnosis of metastatic pancreatic cancer and answer a multitude of questions that would likely make no sense to June 2012 | 17
A Word from Your Fellows
anyone. I’m certain that many of my peers have been in a similar situation countless times, in which translating clinical information into “human” terms proves difficult. In my experience, the effective use of analogies when communicating with patients has been an invaluable tool that is often met with a sigh of relief and a nod of understanding. While I have improvised analogies to cater to the educational background of patients and family members, I prefer to use basic analogies, as rudimentary explanations are best for even the most educated of individuals when it pertains to issues of life and death. Most patients appreciate this sort of explanation, and more often than not, the analogies generate a smile during even bleakest situations. Some of my most useful analogies have been as follows: Chemotherapy: I often explain to new patients who are about to start the first of many chemotherapy regimens that they are embarking on a marathon; the physician is the coach and the health care team, composed of the nursing staff and pharmacists, are track coordinators monitoring their well-being. Many patients ask about nail changes with chemotherapy. I often tell them that just like the annual circles in the cores of trees that demonstrate their age and reflect the harsh times they have experienced, each hyperpigmented nail line indicates the chemotherapy insult that they have received, and that normal nail usually develops once they discontinue chemotherapy. Blood counts: I communicate the importance of blood cell counts by telling patients that white blood cells, red blood cells, and platelets represent the Army, the Navy, and the Air Force. All 3 are needed to fight disease and stay in homeostasis; inadequate levels of any of them can put the patient’s health in major jeopardy. Neutrophils: Mostly needed to prevent infection, they are like policemen that curtail offenders (ie, microbial pathogens). When there is unrest (ie, infection) there is always an increased number of troopers (ie, leucocytosis); neutropenic patients are therefore vulnerable to infection due to less policing. Lymph nodes and metastasis: Lymph nodes are like security guards at multiple checkpoints or roadblocks in the body. When there is disorder and mayhem, the security guards radio for backup to swell their numbers. Similarly, lymph nodes enlarge when they become involved in an irregularity upstream, thus preventing it from dissipating downstream. If they are overwhelmed, metastases occurs. Myeloablative chemotherapy: This is like winter, in which the cold weather causes the grass to die and take on a pale hue. When new growth appears in small pockets during the 18 | June 2012
spring, it is difficult to ascertain if it is fresh grass or tainted with weeds (ie, disease). Oftentimes in patients with leukemia who have undergone induction chemotherapy, a day 14 marrow aspiration is performed to identify the persistence of blasts (ie, weeds), and another marrow aspiration and biopsy is performed on day 28 to identify if the new growth is devoid of blasts (ie, weeds in the grass). Another similar analogy is the effect of a powerful weed killer on grass. GI malignancies: Using the analogy of drilling though a timber frame wall is helpful to explain the stage of disease. If the cancer has penetrated most of the muscularis mucosa and serosa (ie, the insulation and sheathing of the home’s wall), its chance of metastasizing is high (ie, through the outside brick). The more the cancer has spread through its confining walls, the greater the chance that the cancer will disseminate. Proper hydration: Although need for proper hydration in patients with cancer is essential, many do not consume enough fluids due to chemotherapy-associated nausea, anorexia, and changes in taste. Such patients often have darkcolored urine indicating high urinary concentration and poor oral fluid intake. I use the analogy of a few drops of a blue coloring agent changing the color of water in a small glass, but not of a tub of water. Volume does matter. After hearing this analogy, they often return to tell me that their urine is mostly clear now, which is very gratifying! Non-malignant hematology patients: In patients who are mostly well, I cannot over-emphasize that the need for regular medical follow-ups is imperative for their well-being. Many patients do not keep their appointments or do so only when they need medication refills. I ask these patients how often they change the oil in their cars. It is like a light bulb turning on when patients see the connection between the maintenance of their vehicle and their body. Analogies are extremely useful when used in the proper way. If they are misused and misunderstood by the patient, it could lead to confusion and discontent. The central message is to use familiar concepts to help patients understand unfamiliar or complex issues to help ease their anxiety. One must always gauge the level of understanding of the patient and avoid overusing analogies. Always bear in mind the rule that analogies are like cars—if driven too far, they will inevitably break down! ■ At the time this article was written, Jaideep Shenoi, MD, was a third-year senior hematology/oncology fellow at the University of Washington/Fred Hutchinson Cancer Research Center in Seattle, Washington. He is currently an oncologist at Group Health Tacoma Medical Center, Tacoma, Washington.
There and Back… By Ted Huang, MD
ne of my teachers in medical school was fond of saying, “Internal medicine isn’t sexy.” Hematology/oncology is no exception to this rule. Certainly, it is not as glamorous as cardiology or as hands-on as gastroenterology. More often than not, practicing hematology/oncology lacks the instant gratification and immediate results associated with rapid intubations and acute resuscitation. Rare is the mad dash to the emergency department, and even rarer is a patient who thanks an oncologist an hour after receiving treatment. Regardless of these realities, there’s a reason I’ve chosen to work in hematology/oncology: it encompasses what I enjoy most about medicine. In this field,
we face a wealth of diagnostic dilemmas, therapeutic challenges, and unique interpersonal relationships. While this is all true, my circuitous path to a Heme/Onc fellowship was drawn out. In medical school and in residency, I was fortunate (and unfortunate) enough to find every field intriguing. This made the decision of which subspecialty to pursue an especially difficult one. In the end, I narrowed it down to cardiology with an emphasis on congestive heart failure or hematology/oncology. To be fair, CHF is the oncology of cardiology, which makes the 2 fields more similar than one would think. By the time I finally decided on Heme/Onc, I was a third-year resident. This late choice all June 2012 | 19
A Word from Your Fellows
While I enjoyed a great number of things about being a hospitalist, I found myself continually drawn to cases that involved a hematologic disorder or a new diagnosis of malignancy. but guaranteed that I would spend at least 1 year in transition as the ubiquitous hospitalist. In fact, I spent 4 years as a hospitalist at a large academic institution on the East Coast while my wife finished her own residency. As hospitalists around the nation can attest, the transition from resident on June 30 to a attending on July 1 was quite intimidating. I was suddenly working without the builtin safety nets of a training program and the sage advice of a supervising attending physician. I found myself carefully scrutinizing and second-guessing medical decisions that previously had been completely routine and mundane. Patient disposition was no longer my ultimate goal. Instead, I was focused on the supreme goal of avoiding an embarrassing “bounce-back.” My discharge summary became a surrogate performance evaluation that all other medical providers had access to and could pass judgment on. I was acutely aware of (and frightened by) the fact that I was solely responsible for the care a patient received. I quickly discovered what it truly meant to take responsibility for a patient’s care. In time, I grew more comfortable with my new role as an attending and eventually found my own rhythm. Rounds went smoothly and efficiently because I no longer had to preround or present my patients to another physician. I had the freedom to determine treatment plans and adjust those plans as needed without double-checking with or getting approval from a supervisor. Consults were called and studies were ordered because I wanted them…and I actually understood the questions I was asking. I moved from clinical instructor, to physician unit director, to general medicine ward attending complete with my own entourage of eager medical students and hard-working house staff. It was profoundly gratifying to teach medical students the basic principles of medicine, work through complex medical issues with residents, and provide helpful recommendations to colleagues as a consultant. But, to be honest, it was the flexible work schedule and the generous financial incentives that are unique to a career in hospitalist medicine that I sometimes appreciated the most. 20 | June 2012
Although at times it seemed like a dream job, there were obvious downsides to being on the front line at a busy tertiary care center in a large metropolitan city. “Continuity of care” could often be an unwanted experience, depending on the patient population in question. The perpetual sense of urgency and pressure from the hospital administration to evaluate and discharge a large number of patients quickly led a number of my colleagues to burn out. Our department alone averaged a yearly turnover of at least 30% in a group that grew from 14 to 24 full-time employees by the time I left. While I enjoyed a great number of things about being a hospitalist, I found myself continually drawn to cases that involved a hematologic disorder or a new diagnosis of malignancy. Once my wife’s training program was complete, I applied for and was accepted for a heme/onc fellowship in the Pacific Northwest. Now, as I near the end of my first year of my heme/onc fellowship, I still field the same questions from future heme/ onc hopefuls as I did from interviewers during my fellowship application process. “Do you feel that your years as a hospitalist were beneficial or a detriment?” “Was the adjustment difficult?” In the interest of full disclosure, I usually start by answering the latter question and admit that leaving a 2-week on/off schedule and a 6-figure salary was disheartening. But that change was actually easily overcome. Most people who ask me these questions assume that the transition from attending to house staff is a difficult prospect, since it involves a loss of both stature and autonomy. In truth, the transition was quite effortless because I came into my heme/onc fellowship with the utter certainty that I knew absolutely nothing, and I relished the opportunity to unabashedly ask the “dumb questions.” While hematology/oncology is not without its own intrinsic frustrations and challenges, it has been an undeniably exciting and fulfilling experience to be able to address medical issues in which I am truly interested and invested. Aside from the realization that medical students I have trained are now my co-fellows and that my former co-res-
idents are now established attendings in their own subspecialties, I truly believe that my years as a hospitalist were well spent. The confidence to make decisions and act on them comes more easily to me now. Years of admitting multiple patients and rounding on a large panel of acutely ill people have helped me to streamline my approach. This allows me to be more efficient when triaging and evaluating consults on a busy service. Numerous interactions with difficult patients have taught me the importance of simply listening and have helped me to refine interpersonal skills. This is especially important in a field in which patient communication is absolutely essential. Dedicating time for medical student and house-staff teaching rounds has ingrained in me the importance of recognizing that a good consultant provides education as well as recommendations. Having been on the other end of this interaction as a requesting provider, I have particularly come to appreciate the value of being a courteous and gracious consultant in an academic center where everyone is overworked and overwhelmed. Admittedly, I forget that last lesson at times, but as with all of the other lessons I continue to learn, it remains a work in progress.
National Cancer Institute
41594-NIH CSSC Oncology Net Ad-v5
Perhaps this is the most important lesson I’ve learned throughout my training journey to date: I am still a work in progress. We all tell bright-eyed medical students, petrified interns, and weary residents that “physicians are lifelong learners.” That’s how we justify the many years of higher education, the long hours of residency and fellowship, and the endless pursuit of CME credits to maintain “board-eligible” status. That is why we challenge ourselves to stay abreast of recent advances, fastidiously address our knowledge deficits, and battle complacency in our careers and in the care of our patients. The truth of the matter is this…that 1 statement is simultaneously a cliché, a humble reminder, and a source of perpetual encouragement. Taking it 1 step further, I try to remind myself every day that, no matter where my career takes me, I will always be a trainee. ■
Ted Huang, MD, is a first-year fellow in hematology/oncology at Oregon Health and Science University, Portland, Oregon.
our source for information on clinical trials at NCI’s Center for Cancer Research (CCR) is now smartphone friendly. Visit our easy-to-navigate mobile Web site for information on the more than 150 cancer clinical trials now enrolling at the National Institutes of Health in Bethesda,MD. CCR is currently conducting trials for many types of cancer including:
• Prostate Cancer • Thymoma • Kidney Cancer
• Lung Cancer • Pediatric Sarcoma • Brain Cancer
To learn whether your patients may be eligible,visit
bethesdatrials.cancer.gov or call 1-888-NCI-1937 (1-888-624-1937)
The Online Oncologist™ Mobile Medicine: Apps for the Health care Professional
Free, paid service available Platforms: iPhone, BlackBerry, Android, and other phones
ReQall offers impressive time management, reminder, and task organizer tools to track your ideas, appointments, and follow-ups with voice or text. The app can sync information with Web browsers, Outlook and other e-mail systems, Google Calendar, Evernote, text messaging, and instant messaging. www.reqall.com
22 | June 2012
iPhone, iPad, Android, BlackBerry, Windows Phone, and online Platforms:
Evernote makes it easy to track and sync all kinds of notes you want to remember––web pages, to-do lists, reminders, photos, itineraries, and more––from your phone, tablet, or computer. Tag, search, and share notes with colleagues wherever you are. http://evernote.com
STEM CELLS Translational Medicine App (AlphaMed Press/ Intstrux) Price:
NCCN Guidelines App (National Comprehensive Cancer Network) Price:
iPhone, iPod Touch, and Android Platforms:
and iPad This app offers quick access to clinical articles, videos, and podcasts on current research and news related to the use of stem cells in medical therapies. http://bit.ly/JyGsZF
With a free registration at NCCN.org and this free app, oncology professionals have instant access to the NCCN Clinical Practice Guidelines in Oncology. These evidence-based guidelines include guidance from multidisciplinary panels for the treatment of a range of cancers, as well as guidelines for supportive care and detection, prevention, and risk reduction. www.nccn.org/mobile
CTCAE v.4 $1.99 iPhone and iPad Price:
This app provides a quick reference to the Common Terminology Criteria for Adverse Events (CTCAE) during oncology research. Along with the definition of each term, the adverse events are provided with a grading scale to indicate severity. http://bit.ly/KFBa3z
By the Numbers Physician Income by Specialty were reported to be the seventh-highest paid specialists, with an average reported income of $295,000. The highest paid specialties, radiology and orthopedics, reported an annual income of $315,000. The lowest income was reported by internal medicine ($165,000), family medicine ($158,000), and pediatrics ($156,000). Interestingly, while oncology compensation showed a 4% increase in reported income since Medscapeâ€™s 2010 report, radiology and orthopedics each showed a decrease of 10% and general surgery had a decrease of 12%.
This graph shows selected data from the Medscape Physician Compensation Report 2012. Using an online survey provider, Medscape collected the responses of 24,216 US physicians to a variety of questions, including personal income, time spent with patients, number of patients seen in a week, and time spent on administrative tasks. The responding physicians represented 25 different medical specialties. The bar graph shown below represents reported personal income, broken out by specialty. In these data, oncologists
Medscape Physician Compensation Report: 2012 Results
Physician Compensation in 2011
Source: Medscape Physician Compensation Report: 2012 Results. http://www.medscape.com/features/slideshow/ compensation/2012/public. Accessed April 27, 2012.
June 2012 | 23
2012 Oncology & Hematology Meetings June 1–5
2012 American Society of Clinical Oncology (ASCO) Annual Meeting Chicago, IL http://bit.ly/uxqp4Y
BC3 Breast Cancer Coordinated Care Conference Washington, DC http://bit.ly/J9Akc3
2nd World Congress on Cancer Science & Therapy San Antonio, TX http://bit.ly/Jt3h3o
July 19-22 June 2
Advanced Ovarian Cancer: Current Concepts & Emerging Roles of Targeted Therapies Chicago, IL http://bit.ly/KMlW7s June 18–21
Pancreatic Cancer: Progress and Challenges Lake Tahoe, CA http://bit.ly/rwQ6fo June 28–30
MASCC/ISOO 2012 International Cancer Care Symposium New York, NY http://bit.ly/K2RrdT
13th International Lung Cancer Congress Huntington Beach, CA http://bit.ly/IYqsoG August 9
22nd Annual Mayo Clinic Hematology/Oncology Reviews Amelia Island, FL http://bit.ly/ILcG7T August 21–23
2012 CDC National Cancer Conference Washington, DC http://bit.ly/ILcNAi August 27–30
UICC World Cancer Congress 2012
Montreal, Quebec, Canada http://bit.ly/jcK3xw
11th International Conference of the International Mesothelioma Interest Group Boston, MA http://bit.ly/K2SB9i September 11–14
Breast Cancer, New Horizons, Current Controversies Boston, MA http://bit.ly/JeQT5M
Breast Cancer Symposium San Francisco, CA http://bit.ly/qyN51R September 25-26
Molecular Diagnostics World Congress and Exhibition
San Diego, CA http://bit.ly/Jt3CDl
24 | June 2012
Call for Papers We welcome submissions to Oncology Fellows, a publication that speaks directly to the issues that matter most to hematology/oncology fellows at all stages of training. Oncology Fellows aims to provide timely and practical information that is geared toward fellows from a professional and lifestyle standpoint—from opportunities that await them after the conclusion of their fellowship training, to information on what their colleagues and peers are doing and thinking right now. Oncology Fellows features articles written by practicing physicians, clinical instructors, researchers, and current fellows who share their knowledge, advice, and insights on a range of issues. We invite current fellows and oncology professionals to submit articles on a variety of topics, including, but not limited to: • Lifestyle and general interest articles pertaining to fellows at all stages of training. • A Word From Your Fellows: articles written by current fellows describing their thoughts and opinions on various topics. • Transitions: articles written by oncology professionals that provide career-related insight and advice to fellows on life post-training. • A Day in the Life: articles describing a typical workday for a fellow or an oncology professional post-training. The list above is not comprehensive, and suggestions for future topics are welcome. Please note that we have the ability to edit and proofread submitted articles, and all manuscripts will be sent to the author for final approval prior to publication. If you are interested in contributing an article to Oncology Fellows, or would like more information, please e-mail Donna Bonura at email@example.com.
makes all the difference
With CancerCare, the difference comes from: • Professional oncology social workers • Free counseling • Education and practical help • Up-to-date information • CancerCare for Kids® For needs that go beyond medical care, refer your patients and their loved ones to CancerCare. CancerCare’s free services help people cope with the emotional and practical concerns arising from a cancer diagnosis and are integral to the standard of care for all cancer patients, as recommended by the Institute of Medicine.
Help and Hope
1-800-813-HOPE (4673) www.cancercare.org
Published on Jun 20, 2012
Oncology Fellows features articles writtenby practicing physicians, clinical instructors,researchers, and current fellows who sharetheir kno...