Translating 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 patient’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 room 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 four 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 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:

 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.

 I communicate the importance of blood cell counts by telling patients that white blood cells, red blood cells, and platelets represent the armed forces, the Navy, and the Air Force. All three are needed to fight disease and stay in homeostasis; inadequate levels of any of them can render the patient’s health in major jeopardy.

 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 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.

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 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.

 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.

 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 dark-colored 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!

 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! 

Jaideep Shenoi, MD, is a third-year senior hematology/oncology fellow at the University of Washington/Fred Hutchinson Cancer Research Center in Seattle, Washington.

Articles

Translating 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?

The Art of Analogies in the Clinic

The field of oncology has undergone a significant transformation in the last few years. In this era of individualized medicine, we are learning new ways to tailor treatment based on the molecular pathways of the tumor. There has never been a more exciting time to be in the field of oncology, especially in academic oncology. In addition to the ability to develop a disease-focused clinical career, an academic oncologist can also build a research, educational, or administrative career (as, for example, a cancer center medical director or a department section chief). Academic oncologists have a critical role as opinion leaders and shape the future of cancer care by research and training future oncologists, residents, and medical students.

	If you are planning to pursue an academic career, make sure you have a mentor who can guide you through the application, interview, and selection processes. Generally speaking, there are usually many academic oncology practices in universities and cancer centers that actively search for young talent to build their department or join their established staff. A fellow should start looking for an academic job opportunity before the end of the second year of fellowship or during the early part of third year. A good place to start is with advertisements in major oncology journals or postings at national meetings such as the American Society of Clinical Oncology or the American Society of Hematology Symposium.

	Preparing an adequate curriculum vitae (CV) is probably the most important step in the job application process. The CV should include the following information in a clear and organized manner: contact information, academic background and training history, research experience, grants and publication, awards, and voluntary work experience. Emphasizing teaching or mentoring experience and research skills (while avoiding falsifying information) will make a candidate more desirable for an academic job. A candidate should also identify mentors who know him or her well, and who are willing to write letters of recommendation or serve as references if needed.

	Institutions that have great interest in a candidate will send an invitation for a job interview. This is an opportunity for the candidate to make a lasting impression and also take a closer look at the work environment. To prepare for the interview, the candidate should inquire about interviewees—including other cancer specialists such as radiation oncologists and surgical oncologists&mdash;and their clinical interests. This information can be used to emphasize potential areas of collaboration in the future. In general, the candidate is expected to give a presentation related to his or her work and research interest. It’s vital to tailor the depth of the presentation based on the audience’s clinical interest and background. For example, if your audience is predominantly clinicians, try to focus on the translational or clinical aspects of your research as opposed to basic science. The interview is also an opportunity to highlight individual strengths such as involvement with investigator-initiated clinical trials and prior publication.

	It is important to understand the different aspects of a tenure vs non-tenure academic oncology track, including the academic ranks and specific requirements for each. A proper understanding of the responsibilities associated with a specific academic position, as well as the culture and expectations of the cancer center and department, is crucial for the candidate’s success in that environment.

	Usually, a candidate who has recently completed fellowship is accepted as an assistant professor or, in some cases, as a tutor or clinical instructor. In general, the candidate is offered a position in either tenure track or non-tenure track. In the past, tenure track meant guaranteed, permanent job appointment and benefits. The definition, however, varies from one institution to another. It is very important to find out if you are interviewing for a position in the tenure or non-tenure track and what the specific requirements are for each track. The type of appointment and the requirements needed to achieve tenure status should be made clear in the offer letter.

	A key factor to advancing the academic ladder is identifying a mentor who shares common clinical and research interests. On average, an assistant professor is usually eligible to be promoted to an associate professor rank after five to seven years. Each institution will have its own criteria for promotion, and new faculty should familiarize themselves with them. The promotion process involves a thorough review of performance in various aspects of the particular track the you are in. It is important to maintain a high level of academic, research, and clinical productivity.

	In general, there are three types of academic appointments in oncology: clinical track, scientist track, and clinician scientist track.

 Academic oncologists in a clinical track spend most of their working hours (up to 90%) in direct patient care-related activities. This can involve an assigned number of outpatient clinics per week (sometimes up to four days of clinic), along with hospital setting or inpatient coverage. The remainder of the time is dedicated to teaching and some research. Since this is a primarily patient care-focused track, the research expectation is limited. However, the faculty member is strongly encouraged to enroll patients in clinical trials and participate in national cooperative oncology group or industry-sponsored studies. A clinician track oncologist is rarely expected to write an investigator-initiated trial due to their limited time.

 In this track, the emphasis is primarily on research (bench or translational). These oncologists can have up to 90% protected time for research, with less emphasis on patient care and teaching responsibilities. In general, academic oncologists in this setting are guaranteed lab space and initial funding to buy supplies and cover other overhead costs for the first one to two years. In addition, other ancillary services (eg, animal facilities and tissue banking) and access to other collaborative facilities (eg, clinical trial research units and statisticians) is provided. Academic oncologists are expected to eventually bring extramural support for research and mentor fellows with research interest. The patient care responsibility is usually minimal, consisting of one or two half-day clinics per week.

 Clinician scientists are usually translational investigators. They are the bridge between clinicians and basic scientists or oncologist in the scientist track. Clinician scientists are expected to write investigator-initiated trials and be principal investigator for national cooperative oncology group or industry-sponsored trials. Clinician scientists are also expected to acquire financial support through clinical trials or extramural funding. Usually, clinician scientists are in the clinic two or three days per week, with the rest of their time dedicated to research and clinical trial activities.

	The financial compensation for an academic oncologist is significantly less than an oncologist in a private practice. The starting salary for an academic oncologist is $160,000 to $200,000, compared with $175,000 to $300,000 for an oncologist in private practice. However, the financial risk in academia is less since academic oncologists work within the structure of university hospitals where the costs and profits are spread over multiple departments. Academic oncologists can choose to supplement their salary through research grants or by giving lectures at pharmaceutical-sponsored conferences.

	Academic oncologists are not isolated from real-world medical-financial concerns; they will need to learn about the “ins and outs” of medical billing including, for example, assigning the correct Current Procedural Terminology code for Medicare patients. Familiarity with reimbursement measures such as Relative Value Units (RVUs) is essential since it is also used as a productivity indicator (ie, many practices set RVU goals based on the number of years in practice and assigned academic track).

	All in all, finding your niche in academia and tailoring your career to suit your personal strengths and interests is instrumental. As Confucius said, “If you enjoy what you do, you will never work another day in your life.”

Sidebar: Keys to Success in Academic Oncology 

	• Thoroughly understand the expectations and goals of your track.

	• Identify a mentor who is familiar with your career goals and who is willing to help you.

	• Focus is essential for academic success; concentrate on your strengths and focus on your goals.

	• Always try to be a good team player and treat others with respect.

	• Take care of your patients, yourself, your family.

	• Remember to keep a positive outlook and have fun!

Mohammed Almubarak, MD, is assistant professor of medicine in the hematology/oncology section of Mary Babb Randolph Cancer Center in Morgantown, West Virginia. Jame Abraham, MD, FACP, is Bonnie Wells Wilson Distinguished Professor and Eminent Scholar; co-leader of the Breast Cancer Program; chief of the hematology/oncology section; and medical director of the Mary Babb Randolph Cancer Center at West Virginia University in Morgantown.

The field of oncology has undergone a significant transformation in the last few years. In this era of individualized medicine, we are learning new ways to tailor treatment based on the molecular pathways of the tumor.

Achieving Career Success in Academic Oncology: What to Know When Deciding On a Career in Academia

Ifreke Williams, a third-year med student, stands in front of a camera holding a print-out of her outstanding student-loan debt to date, and the numbers are sobering: “Medical School Debt: $226,000 (Now)—$295,000 @ Graduation.”

	Williams shared her story with HuffingtonPost.com to raise awareness of the staggering amount of debt many medical students face, along with the difficult career and life decisions that result from it.

 “The thought of starting life with such a huge debt is very frightening, especially since I plan on going into primary care and not a lucrative medical specialty or subspecialty,” she writes.

	Medical students in the Class of 2009, including both public and private schools, graduated with a median student-loan debt of $160,000, according to a survey by the Association of American Medical Colleges (AAMC).

 But that figure is skewed by the number of students who receive financial assistance from their families, schools, scholarships or other forms of aid. Students like Williams who need to rely almost entirely on loans to pay their education costs often borrow far more: The AAMC survey found that 17% of private-school grads had incurred debt of $250,000 or more.

	Students leaving med school with the equivalent of a mortgage in debt is severely limiting the choices young physicians can make—both in terms of their families and their finances. More residents burdened with six-figure debt are shunning family medicine and primary care, concerned with the relatively low pay and looming threat of sharp reductions in government Medicare payments. Physician shortages in primary care are the most pronounced in rural areas and in regions of the country where the cost of living is high. And, regardless of their chosen field, many young physicians find they must make sacrifices in their personal lives to service their debt, such as putting off buying a house or starting a family.

	Policy makers are finally starting to take notice of the impact education debt is having on the U.S. healthcare system, and new legislation is being considered to help ease the burden. We’ll look at some new and existing government programs that are attempting to help physicians manage, or in some cases eliminate, their student-loan debt.

Married couples get a break with new IBR rules 

	Two important changes went into effect on July 1, 2010, that may make some physicians eligible for the Income-Based Repayment (IBR) plan that were not eligible before. A change in the way household income and debt is formulated could mean lower payments for married couples.

	IBR is a payment option for federal student loans that keeps monthly loan payments affordable with payment caps based on the borrowers’ household income and family size. In most cases, loan payments are less than 10% of their adjusted gross income. Borrowers in the plans are also eligible for forgiveness of any remaining student-loan debt after 25 years—or just 10 years if they work in the public service sector, including jobs in government and nonprofit 501(c)(3) organizations. The program covers most federal loans. The 10-year payment period doesn’t have to be consecutive; so, for example, a borrower can work in public service for five years, go into the private sector for a few years, and return to complete the 10-year requirement when the time is convenient.

	Under the rules that went into effect in July, IBR eligibility will be based on either the balance when the loan first entered repayment 

 on the current loan amount—whichever is greater. So borrowers with loan balances that have increased due to accrued interest would be eligible to qualify based on what they actually owe. An online calculator available at www.ibrinfo.org/calculator.php, can tell you if you’re eligible for IBR under the new rules.

 had federal student loans typically paid higher monthly IBR payments than single borrowers. For married couples who file jointly, lenders will now use a formula that factors in the couple’s total outstanding federal student-loan debt and adjusted gross income to come up with the minimum monthly payment. Previously, the formula didn’t combine the couple’s total student-loan debt, leading to monthly payments that were up to twice the amount that two single borrowers would have to pay.

	If you’re married and your spouse has federal student loans too, contact your lender to ensure your payments reflect this new rule change.

	Physician shortages have vastly increased the number of national, state, and local loan-forgiveness programs offered to young physicians, most with the aim of boosting the number of physicians in primary care. Currently, there are a number of state and federal bills under consideration that would offer loan-forgiveness or partial-repayment programs to physicians who agree to work in certain fields or underserved areas of the country.

	There are already a number of loan-forgiveness programs available for physicians. The most widely known is a program by the National Health Service Corps (http://nhsc.hrsa.gov), which makes loan repayments for physicians who practice for a certain number of years in areas of the country with severe physician shortages. Its full-time program starts with an initial award of $50,000 for two years of service, and a new part-time pilot project begins with an initial award of $50,000 for four years of service. Participants in the program may be eligible to extend their service until all of their debt is paid.

	A growing number of hospitals and private healthcare systems are extending loan forgiveness to attract young physicians as well. A listing of hospitals and other organizations that offer loan forgiveness can be found at www.finaid.org/loans/forgiveness.phtml.

New ombudsman to resolve disputes with private lenders 

	Finally, the new provision of the 2010 financial reform bill creating new Federal Student Aid Ombudsman may help borrowers find relief in dealing with problems they encounter with private lenders. The ombudsman will be dedicated to helping students with private student loans resolve disputes and other problems with lenders. An ombudsman position already exists in the Education Department for federal student loans, but it excluded private loans.

	The need for more oversight of non-government loans became abundantly clear over the last decade as the use of private student loans exploded: Between 2000 and 2008, total education borrowing with private loans soared from $6 billion to $24 billion, according to the College Board.

 In 2009, private loan borrowing was slashed in half, as access to credit dried up in the wake of the financial crisis.

	Often students who borrow with private loans do so because they’ve already maxed out the federal loan borrowing limits. Generally, there are no borrowing limits for private student loans, which can often lead students to overextend themselves. There are also no limits on private loan interest rates. With the exception of subsidized Stafford Loans, the rate on government loans is currently capped at 6.8%. Variable private loan rates can climb to 20% or more, and penalties for late payments can be equally steep.

	The new ombudsman won’t have the authority to impose changes in the terms or conditions of individual student loans. Still, the office is designed to help find a fair and equitable solution for student problems.

	If you are having a problem with a private lender, contact the ombudsman at http://fsahelp.ed.gov or call (877) 557-2575. You may also email a detailed letter explaining your problem to fsaombudsmanoffice@ed.gov, or write to the U.S. Department of Education, FSA Ombudsman, 830 First Street, NE, Fourth Floor, Washington, D.C. 20202-5144.

	The new ombudsman’s office will also be responsible for issuing annual reports to congressional lawmakers on prevailing issues and trends within the private student loan industry, shining some much-needed light on practices that may be harming borrowers.

Sidebar: How Student Loans Affect Your Credit Score 

	For many graduates, taking out a student loan marks the beginning of their official credit history. Credit-rating companies consider student loans installment debt, in the same category as a mortgage or home-equity loan. Though you may have hundreds of thousands of dollars in debt, the size of your student loans isn’t as much of a factor in calculating your credit score as your ability to repay it. This is why it’s so important to never miss a payment to any lender.

	Many students ding their credit scores quite by accident because they miss making their first student-loan payment—often because they weren’t aware it was due. Students move, addresses on file aren’t kept up to date, and payment notifications get lost in the mail. To avoid this, make sure you keep careful records on all of your outstanding student loans, and notify lenders when you move.

	If you’re in a financial bind and you miss a payment, your credit score could drop by as much as much as 50 points. But if you enter a deferment or forbearance program with your lender, it shouldn’t adversely affect your score. Credit-scoring companies generally view these as temporary programs and so generally don’t factor them into the scoring. If you’re struggling to make payments, contact your lender to explore available debt-relief programs immediately before you miss a payment. To learn more about credit scores and how they’re formulated, visit MyFico.com (www.myfico.com).

	The most comprehensive source of up-to-the-minute student financial aid and student loan information, including advice and tools for parents, students, and graduates.

	Run by the National Consumer Law Center, this site provides student loan borrowers with information on their legal options and rights, and has breaking news on government rules and legislation that may affect your loans.

	A Web site with news, information, tools, and advice on the Income-Based Repayment (IBR) plan run by the Institute for College Access & Success.

	(www.aamc.org/programs/first/students/factsheets.htm)

	Brief informational financial aid and student loan worksheets for help with repaying student loans from the Association of American Medical Colleges.

For many graduates, taking out a student loan marks the beginning of their official credit history. Credit-rating companies consider student loans installment debt, in the same category as a mortgage or home-equity loan.

Defusing the Student-Loan Debt Bomb

	Since the time of Hippocrates, practicing the art of medicine has involved the passage of knowledge and experience from one generation of practitioners to the next. Unlike other fields of study in the sciences and humanities, the process of educating physicians tends to involve a much more intimate relationship between the instructors and trainees. While the earliest years of medical school education are usually carried out in the classroom, there is an early transition to education in small teams, often led by the attending and residents. During the latest years of residency (most often during subspecialty training), the relationship between instructors and trainees gains sufficient permanence; instructors will usually know the trainees well enough to provide detailed guidance in educational and career development. In this aspect, the fellowship training period provides the most intimate one-on-one training in a clinical setting. And, perhaps, the most developed form of this relationship is that of the mentor and mentee.

	Mentorship has been defined as “a dynamic, reciprocal relationship in a work environment between an advanced career incumbent (mentor) and a beginner (protégé), aimed at the development of both.”

 Strictly speaking, “mentorship” indicates a personal developmental relationship in which a more experienced (often more senior) individual helps a less experienced or knowledgeable individual who is usually newer to that particular organization. Mentorship should not be confused with similar methods of imparting knowledge, such as tutoring (or instructing, which is the dissemination of knowledge), coaching (which dwells on the development of skills), or serving as a role model (in which one provides examples of specific behaviors). Mentorship incorporates these aspects, but builds upon them with the addition of guidance in career development.

	While formal mentorship programs were first launched in corporate America in the 1970s as a way to develop junior staff, they weren’t officially introduced into medical education until the 1990s.

 The mentoring process is now considered to be an essential responsibility of medical school faculty in an effort to enhance the educational mission, and is clearly helpful in encouraging career satisfaction and success.

 Despite its inherent added value, mentorship is often not deemed important by the institution (such time is not billable, after all) and thus, is often beset by the competing demands of clinical care and research on both the mentor and mentee. Although not all institutions may have a formal mentorship program in place, it should not deter fellows from being proactive and seeking out mentors in areas of common interest.

	Mentorship can accord significant potential benefits to fellows, such as providing access to networking, which may be one reason why those who are mentored tend to do well in institutions.

 Multiple studies have shown that having a mentor has a positive influence on overall career enhancement; one study even demonstrated that those who received mentoring were more than twice as likely to receive a promotion.

 Mentoring has also been associated with improvements in research, teaching, and patient care.

	A mentoring relationship can be very helpful when deciding on which specialty and subspecialty to pursue. Two of the major decisions that fellows must make are whether to specialize in hematology, oncology, or both; and whether to pursue a career in academics, private practice, or industry. The two decisions are actually closely related. For example, if one desires to enter into a private practice setting, it would be reasonable to become double board certified in hematology and oncology. While there is a move among larger practices to develop some tumor or disease-specific expertise and local recognition, most private practitioners must still function in a fairly general manner.

	By itself, hematology as a discipline is more or less restricted to academic centers and larger hospitals, especially nonmalignant hematology. If such arrangements are made between a private practice and either a university or consortium of practices, it may also be possible to participate in “bedside” teaching of students and residents, as well as larger phase II (proof of concept) and phase III (confirmation of activity or benefit) trials, although there may be very little time, infrastructure, or opportunity to initiate and support one’s own clinical research interests. On the other hand, a career in academic clinical research affords many of these opportunities, though usually with somewhat smaller patient loads, protected time to carry out research and teaching, and a lesser amount of financial compensation than seen in private practice.

	Those who are more interested in basic research will find an outlet in either academics or private industry, usually with a pharmaceutical company. However, the options in industry also involve the initiation and conduct of clinical trials (though it usually involves little or no patient interaction), while also requiring more than a little business savvy during the process of drug development. Regardless, a mentor can help fellows choose a career track by assisting them in identifying and focusing on their strengths and academic interests, while constructively illustrating any potential areas of weakness and developing methods to seek improvement.

	Mentorship is a bidirectional relationship, with benefits accrued by the mentor as well as the mentee. For example, mentoring enables an individual to demonstrate leadership among his or her peers. The very act of providing personalized guidance in a field in which the mentor is passionate about is invigorating and often positively stimulates the mentor’s teaching and research efforts. Finally, there is the intangible satisfaction that one achieves by the act of “giving something back” and seeing one’s protégé succeed, based in part on the mentor’s efforts. In this respect, established faculty (especially those in mid-career or later) should also actively seek out fellows and newly-minted junior faculty and work closely with them to provide guidance that will enhance not only the careers of their charges, but their own as well.

	Fellows must remember that mentorship is a process, not an end in itself. A successful relationship with a mentor may last a lifetime, and he or she will often be willing and able to offer insightful guidance long after the fellowship has been completed. Such relationships can provide myriad benefits to the fellow in the development and direction of their early career, providing access to resources, experience and insight that would not readily be available to fellows on their own. Ultimately, having a mentor can be an invaluable resource for young physicians and provide a measurable boost to their career development and overall success.

Dennie V. Jones, Jr., MD, FACP, is a professor of medicine; medical director of the New Mexico Cancer Care Alliance; medical director of the Clinical Protocol, Data Management and Informatics Group; and chief of the section of thoracic medical oncology in the division of hematology/oncology at the University of New Mexico Cancer Center in Albuquerque. 

	1. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. 

	2. Buddeberg-Fischer B, Herta KD. Formal mentoring programmes for medical students and doctors—a review of the Medline literature. 

	3. Gray J, Armstrong P. Academic health leadership: looking to the future. Proceedings of a workshop held at the Canadian Institute of Academic Medicine meeting Québec, Que., Canada, Apr. 25 and 26, 2003. 

	4. DeAngelis CD. Professors not professing. 

	5. Wise MR, Shapiro H, Bodley J, et al. Factors affecting academic promotion in obstetrics and gynaecology in Canada. 

	6. Illes J, Glover GH, Wexler L, Leung AN, Glazer GM. A model for faculty mentoring in academic radiology. 

Finding a Mentor and Maximizing Your Relationship

	A successful career path in oncology is not accomplished alone. Whether your ultimate aspirations are in academic medicine, community practice, or industry, having one or more mentors during your fellowship is of vital importance.

	A mentor can be an invaluable source of practical knowledge; as you have probably realized, the management of patients with cancer is complex and involves as much art as science. A mentor can provide insight on the nuances of oncology that are not learned from textbooks or journals. When needed, he or she can also aide in stress management.

	Perhaps the most obvious role of a mentor is to assist in research. It is unrealistic for a fellow to accomplish much research without substantial guidance. A research mentor can help write protocol, as well as generate, present, and publish data.

	Lastly, a mentor can help you choose between various oncology careers. If your mentor has been in both academic medicine and private practice, he or she will be especially suited to give you the pros and cons of each. Near the end of your fellowship training, a phone call from your mentor can make the difference in obtaining a faculty position at a prestigious institution or landing a private practice job in the location of your choice.

	While many training programs have a formal mentor assignment process, finding a good mentor will take some initiative. A first step may be to ask yourself where you see yourself in five to 10 years. Ascertain your interests— are you more interested in patient care or research? Do you want to pursue clinical or basic science research? Does your ideal career involve working with a specific tumor type such as lung cancer or lymphoma, or in a discipline such as immunology or pharmacology? Most likely you are undecided right now, but identifying your interests can help you determine which mentor may be the best fit.

	The next step is to identify potential mentors. Review faculty profiles and read some of their publications. Speak to the senior fellows or junior faculty for recommendations (certain faculty members may have a track record as successful mentors). Look for mentors who have published with current or previous fellows. A mentor who is on the editorial board of a journal is a bonus, but certainly not mandatory. If you are interested in community practice, strongly consider identifying some of the clinical faculty as potential mentors. For those who plan to go into private practice, a community practitioner who is affiliated with an academic institution typically has a keen interest in teaching and can be an outstanding mentor.

	There are pros and cons to working with senior versus mid-career versus junior faculty. While senior faculty may have national and international reputations, they likely will have less time to commit to mentoring fellows. Junior faculty members may lack experience and may be more driven in advancing their own careers. Mid-career faculty, then, may be best suited to be mentors.

	When I was a fellow, one particular faculty member had at least three fellows and residents under his wing during any given year. Being the fourth or fifth mentee creates a less favorable ratio. A good mentor has sufficient time and interest in your career and is someone you feel comfortable talking to about your career goals.

	Finally, make contact with potential mentors. You may be lucky to connect with the perfect mentor during a consult month, clinic assignment, or ward rotation. Otherwise, send an email or call the faculty or his or her administrative assistant. It is a compliment to faculty to hear that you are interested in their research or in rotating through their clinic.

How do I maximize my relationship with my mentor? 

	As always, communication is paramount and being proactive will enable you to get the most out of your relationship. By mid-fellowship, you should be meeting periodically with your mentor and discussing your career aspirations. Naturally, academic faculty hope that you’ll follow in their footsteps, but are understanding if your interest lies in community practice. In the end, it’s your career and life.

	Do you want to publish? If so, discuss your original ideas, but realize that it may be unrealistic to initiate a research study and publish during your fellowship. Ask to be involved in the interpretation of ongoing data and potentially assist in writing the manuscript. Mentors may receive invitations to write case reports or review articles or book chapters. Early in your fellowship, these assignments may be a source of satisfaction and pique your interest in a specific area.

	The mentor/mentee relationship is a two-way street. Even if not specifically assigned, volunteer to rotate through your mentor’s clinic a half or full day per week throughout the year if your schedule will allow. While in clinic, be eager to complete dictations or contribute in other ways. These actions can gain your mentor’s favor in the future.

	If you realize that you are not working with the right mentor, there’s no need to panic. You may realize that another faculty member’s research or clinical interests mirrors yours more closely. Or, if your mentor is too busy to be involved, you may seek career guidance or mentorship from someone else.

	Although I worked with a number of outstanding faculty during my fellowship training, a handful of mentors were key in my career development. A faculty member who was well renowned in an area of my interest initially served as my mentor. When he left our institution during my fellowship, I worked with a non-clinical faculty member doing laboratory research and quickly realized that research was not my calling. Soon after, I picked up several clinical mentors, one of whom had connections with a practice and helped me land a job there immediately after fellowship.

	One last bit of advice—maintain communication with your mentors after you’ve finished your fellowship and moved on. After spending five years at my first position, I realized that I wanted to move back to where I trained for family reasons. An unsolicited telephone call from one of my mentors led to an interview with my current practice. Needless to say, I got the job!

John C. Rhee, MD, is an oncologist at UPMC Cancer Centers, Oncology Hematology Associates, in Pittsburgh, Pennsylvania. 

Since the time of Hippocrates, practicing the art of medicine has involved the passage of knowledge and experience from one generation of practitioners to the next.

The Importance of Mentoring in Preparing the Next Generation of Oncologists

	For an incoming first-year hematology/oncology fellow, July 1st is when you are once again the new kid on the block. Whether you are starting a fellowship at your home institution or in a new city, July 1st marks the beginning of the final phase of training that we have worked so hard to arrive at. Although completing fellowship at your home institution may give you a leg up on finding the bathroom, it will not, unfortunately, lessen the learning curve inherent to the most challenging year of training. And although you may initially still perceive yourself as a third-year resident mastering the skills of hypertension and diabetes management, to your patients, you are now their oncologist.

	The field of hematology/oncology is unlike many other medical sub-specialties in that there is very little exposure to it during residency. During the earlier part of your first year, you will rattle-off chemotherapy side effects and tell patients and their families “what they can expect.” At that point, however, you may barely be able to pronounce the drug, let alone provide patients the knowledge they need to prepare for toxicities. I spent my first year of fellowship studying the “hallmark” articles and memorizing National Comprehensive Cancer Network (NCCN) guidelines. I imagined myself going home after work to sit and read about each of my clinic patients. As the demands of first-year fellowship became obvious, however, I realized that this was not how I was going to gain my knowledge. Between learning to write orders, performing bone marrow biopsies, and running the oncology services, there were many days when I was glad to have an opportunity to eat lunch, let alone absorb the latest 

	Most of the knowledge I attained during the first year of fellowship came from interacting with patients and learning how to take care of them. As you make your way through the first year, you’ll realize that you are no longer memorizing a list of side effects, but rather explaining to your patients the toxicities that you have actually witnessed. As the initial feelings of being overwhelmed wear off, you will slowly become comfortable with this “new language” of oncology.

	As I entered fellowship, I prepared myself for the academic challenge and even cleared my weekends in anticipation of spending most of my time at the hospital. I studied NCCN guidelines and tried to read everything that I thought would prepare me. It was the emotional toll of learning how to be an oncologist, however, that proved to be the most challenging. No matter how hard I searched, I could not find an algorithm that explained how to tell my 21-year-old patient and his family that his cancer had progressed and he was dying. This part of the job did not become easier for me emotionally during the first year. As I learned the natural history of diseases, however, I became more comfortable with these difficult conversations.

	What surprised me about these encounters was the fulfillment and great satisfaction I found in supporting my patients through their treatment journey, whether it meant receiving more chemotherapy or making the difficult decision to transition to hospice. I was fascinated by the fact that cancer is the ultimate equalizer—it disregards race, gender, and socioeconomic status, and gives patients the same hopes and fears. As the year progressed, I grew to appreciate that fact that although the victory of remission is obvious, the less obvious victories such as controlling pain or nausea truly impact our patients’ quality of life.

	The first year of fellowship was more challenging for me than any other time during my training. At this point in our lives, many of us have families and other obligations that may seem incompatible with being a first-year fellow. After finishing clinic most days, I would frantically run to to pick up my two-year-old daughter from daycare by 6:00 pm. While balancing family and fellowship is not easy, it is possible to juggle both with careful planning, support from your family, and prioritization. In my experience, a personal support system—from a spouse, family member, friend, or coworker&mdash;is crucial during the first year of fellowship. Caring for patients with cancer requires you to give yourself both academically and emotionally, and having a support system is very important as you learn how to handle the death and dying of your patients.

	Another key to surviving your first year of fellowship is relying on the second- and third-year fellows for help as you navigate the first few months. Although senior fellows may seem like they have everything figured out as they diligently work on research projects and quote data from hallmark articles, remember that they started out just like you. The worst mistake you can make is not asking for help when needed. The senior fellows and attendings would rather be asked the important questions than have serious mistakes made.

	As you settle into your first year, you will become comfortable performing bone marrow biopsies and will not be scared every time your pager goes off. You will inevitably become more comfortable with the never-ending thrombocytopenia consults and will start thinking about your future as an oncologist. Finding a meaningful mentor that understands your clinical and research goals will be important to establish early. Many times, these relationships happen naturally as you get to know the faculty and learn about their interests. On the other hand, you may find yourself intrigued with a certain research topic and need to seek out people in the department. Either way, a good mentor will help develop your interests and open up opportunities.

	It is now July 1st of my second year, and although I can fully recognize how much I have learned about the science of oncology and the art of treating patients, I still cannot pronounce all of the chemotherapeutics and need to look up the staging systems of some malignancies. After so many years of learning general medicine, you have finally arrived at your specialty of choice. As you battle your way up the learning curve, it may feel at times that you are simply trying to survive. Rest assured that you will approach July 1st a resident, but leave your first year of fellowship as an oncologist.

Sheetal Kircher, MD, completed her first year of fellowship at Northwestern Memorial Hospital in June 2010.

	During my first year of fellowship in a combined hematology and oncology program, I spent much of the year trying to balance my clinical obligations with my life outside of the hospital. My first year involved 11 months of inpatient ward training in malignant hematology, solid oncology, and stem cell transplant rotations, interspersed with inpatient consult in benign hematology and oncology. In addition to the rigorous inpatient schedule, I also spent three half-days in disease-specific outpatient clinics. While the learning curve was steep, the bigger challenge was balancing work demands with a husband and toddler at home. I anticipated that the second year of fellowship would be the time to catch my breath, and in many ways, this was true.

	Although I felt an incredible sense of relief after the clinical marathon of first-year fellowship, my second year has been busy in a different way, with a shift in focus toward pursuing clinical, translational, or basic science research. The daily schedule during my second year provided me with a mental and physical breather. Holding a pager six days per week during the first year created a mental “bond” to the hospital; even when I was physically away from the hospital, it was hard to truly “exhale” and reflect. During my second year, I finally felt that I could exhale. Upon reflection, it became clear that although the first year of fellowship was intense, I had gained an immeasurable amount of knowledge in a short time. I also gained a sense of confidence and pride knowing the myriad challenges I overcame. As a second-year fellow, I was able to counsel the incoming first-year fellows and reassure them that the first year would not only be survivable, but also an incredible chance to lay a strong foundation for their career. Perhaps one of the biggest distinctions between the first and second year is that the second year was a time to solidify my clinical knowledge, build my resume, and prepare for the process of applying for jobs, which will begin relatively early during the third year.

	Much of the second and third years of fellowship are designed to allow time for research pursuits, particularly for physicians who are interested in an academic career. For those who hope to pursue a career in academic medicine, most agree that a successful and productive second year of fellowship begins with identifying the right mentor. Ideally, mentorship should begin during the first year of fellowship, although expectations for research productivity should be modest. If nothing else, establishing a mentor or network of mentors during the first year and meeting on a regular basis can help create the framework for a productive relationship and enable you to “hit the ground running” at the beginning of your second year. This is especially true for those who begin fellowship with a particular disease focus or interest, or who develop one early on. An ideal mentor is someone whom you respect; who is experienced and academically successful; and who is approachable, available, and invested in your own success.

	Many mentors may have projects that are near completion or in various stages of development, and a fellow is the ideal candidate to complete them. Faculty are usually very receptive to fellows who are interested in helping complete projects. This can be an opportunity for fellows to gain skills that will be applicable in the future, even if their disease focus or interests change with time. Such a situation is a “win-win” for both parties—the mentor benefits from the outside help, while completed projects can help fellows “build” their resumes and provide them with an opportunity to present at conferences and meetings. Although projects that are initiated during fellowship often take years to complete and may continue beyond fellowship, they can provide fellows with valuable skills that can transcend their professional career.

	For fellows interested in pursing a career in academic oncology, the second year of fellowship is an important time to consider applying to programs such as the American Society of Clinical Oncology (ASCO)/American Association for Cancer Research or the American Society of Hematology (ASH) Clinical Research Training Institute workshops to gain further skills useful in clinical research. These workshops focus on teaching fellows and junior faculty the various methods of clinical trial design and technical writing, and tend to take place in July and August, with application deadlines as early as December. If you are interested in applying for these programs, it is helpful to know about them ahead of time in order to identify a project for the application process. Furthermore, the second year of fellowship is a time to consider applying for fellow training grants that are available through various organizations, such as the ASCO Young Investigator Award or the ASH Fellows training awards. This is also an ideal time to begin projects that could be used when you apply for these awards during the third year of fellowship.

	The second year provides plenty of time to broaden your knowledge and solidify everything learned during the first year. Most fellowship programs have numerous conferences and tumor boards that can be more consistently attended during the second and third years. During your first year of fellowship, it can be a challenge to attend all of the didactic opportunities that are available while simultaneously balancing your clinical responsibilities. The second year may also provide more time to read the primary data in order to support your clinical decisions. Most fellowship programs have physicians continue in one or more clinics during the second year of fellowship while scheduling less inpatient service. This is crucial for developing and strengthening the clinical skills necessary for going into practice after fellowship, especially for those who may be interested in clinical practice.

	Whether you are pursuing an academic or clinical position post-fellowship, being productive during your second year is important. The time to start applying for jobs comes sooner than imagined (or at least sooner than I had imagined). Most faculty advised me that for academic jobs, resumes are sent as early as July through October. Since the job search begins early in the third year of fellowship, the latter part of my second year was also dedicated to updating my resume, completing projects that could be included in my resume, and asking for letters of recommendation and references. I personally chose to start the process quite early because I knew that I would be on maternity leave when I would need to send resumes to various institutions. If you know very early which particular institutions or geographic locations you prefer, the annual ASCO meeting is a good venue to begin to make some contacts for the job search.

	While the first year of an oncology fellowship may be the most physically and emotionally demanding, the second year is crucial for training and preparing physicians for their career post-fellowship. For me, the second year of fellowship was a time to really get involved with clinical research to prepare me for an academic career and improve my skills as a clinician.

Josephine Feliciano, MD, completed her second year of fellowship at Northwestern University Feinberg School of Medicine in June 2010.

	Congratulations—you’re a third-year fellow and there’s finally a light at the end of a long, dark tunnel. Suddenly “the real world” is a tangible reality. After years of training, you are entirely capable of dealing with the science of medicine, from looking up NCCN guidelines to treating solid and hematologic malignancies, from writing review articles to talking to patients about goals of care. An acute leukemia at 3:00 am no longer strikes fear in your heart. But nothing in training has prepared us for the next steps&mdash;looking for a job, navigating contracts, and trying to decide where you will be happiest for the rest of your professional career. Scary thought, huh?

	One of the first decisions to be made is whether to pursue a career in academia or private practice. While some decided this long ago, the choice isn’t so black and white for the rest of us. So why choose private practice over academia? The obvious answer is monetary compensation, but ultimately, it’s about personality. Being part of a practice provides a great deal of control over where, when, and for whom you work. You are the master of your fate and captain of your soul—how many times has that happened before? After years of self-discipline, finally what you want matters; how much it matters may be up for debate!

	On the other hand, why choose academia over private practice? Teaching, clinical and translational research, and subspecializing in a specific malignancy are all included in the mix, but again, it’s personality. Those who choose academia like to be constantly challenged and crave the feeling of juggling several balls at the same time. They focus on multiple problems while trying to advance scientific knowledge, always hoping that one of those balls won’t go splat at the wrong moment!

	Below is my advice for navigating the details after the private practice vs academia decision is made.

 Once the geographic area is decided, start networking with friends, colleagues, and physicians in the area—both in other specialties and your own. Determine which practices you’re interested in, whether they’re hiring, and send out interest letters and your curriculum vitae (CV). An extremely important asset are your faculty; the connections they have within the community and across the country is an invaluable tool&mdash;USE THEM!

	By September, actively gather information about where to apply, and by November, send out CVs and set up interviews. Winter and spring will be an interview merry-go-round. Ask the questions you never asked in residency or fellowship interviews: What is the base salary? Are there bonuses? How does partnership work? How is vacation decided? What is the call schedule? What are the details of the non-competence clause? The list is endless and will reflect what is most important to you. Remember to trust your instincts and pay attention to the intangibles—all the things that make you love your work environment. Don’t underestimate the importance of these factors.

	Before accepting the final offer, make sure a lawyer reviews the contract. The devil is in the details, and your responsibilities should be clear prior to signing on the dotted line.

 Geographic location, a specific research interest, or treating a particular tumor type may drive your choice. Sometimes having more than one goal makes it harder to find a perfect fit. Again, talk to faculty, as they will have the inside track on open positions or cancer centers that are hiring. Former fellows and colleagues are great resources to tap as well. Use ASH and ASCO to network; it may lead to interviews later.

	In September, start sending out letters of intent with CVs attached. Don’t limit the search to institutions with open positions—include all institutions you’re interested in. Sometimes the job you want isn’t being offered yet, but it never hurts to ask. Gently having faculty mentors call or email can also help open the door to an interview.

	Academic interviews usually include a job talk, which may entail discussing the clinical research you’re involved in or detailing the time spent in a basic or translational lab. THE most important aspect of the talk is your grasp of the subject matter. From the mundane to the most technical, you want to impart to the audience how intimately involved in the project you were, not that the post-docs in your lab did most of the work and you can’t tell the difference between a Western blot and a microarray. If you’re discussing a clinical project, know how the information was collected and how to interpret the statistics, and be able to explain the hypothesis behind the study. No one expects entirely independent data; however, if you can’t intelligently discuss your project, it’s very hard to be taken seriously. Confidence and the ability to answer queries serenely will make you stand out from the rest of the crowd.

	The tricky part is making sure the job they offer is the one you want. Is there enough research time? How does the tenure track work? How many clinics during the week? How many service months? How is salary determined (RVUs vs grants)? And finally, if your heart is set on lung cancer but the open position is in lymphoma, are you willing to compromise? Once more, get a lawyer to review the contract, although most institutions have basic stipulations that are set in stone.

	Last but not least, if you’re slightly insane, follow me down the path to yet another fellowship. There are a few options if you haven’t tired of a training salary and want to attain PGY-8 status. I chose a stem cell transplant fellowship, but there are others in transfusion medicine or pharmacogenomics. The application process was circumspect compared to a job hunt or even prior training positions. There are a very finite number of institutions that offer these positions and interviews are the same flavor as before, just longer.

	In the words of George Burns, “I look to the future because that’s where I’m going to spend the rest of my life.” After the stress and confusion wear off, you’ll realize that the hardest part is over and now begins the start of your career!

	A few words of wisdom for incoming first-year fellows:

	• This is toughest year of training you’ll ever experience. You will learn an immense amount, but there will be days (lots and lots of days) that you want to give up. Don’t! It will get better and you will sleep again.

	• Ask questions. You’re in fellowship to learn; the aim is for you to be taught and trained well.

	• Remember internship and the mantra “Eat when you can, sleep when you can, and just get through today.” Relearn the mantra.

	• It’s hard to tell people they are dying and you can’t change that reality. Burnout is real and you have to avoid it. Use everything you can to keep centered— family, friends, co-fellows, sports, alcohol…ok, I was kidding about the alcohol! But expect the emotional roller coaster; we all get on the ride but aren’t ready for the sudden fall.

	Understand that difficult patients (and families) are often a manifestation of fear and loss of control. It’s seldom personal and they don’t really hate you. Avoid saying, “I understand what you’re going through” unless you’ve experienced the same. Try, “I can’t imagine what you’re going through,” and then just listen….a lot.

Sairah Ahmed, MD, completed her third year of fellowship at Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, in June 2010. She is starting a stem cell transplant fellowship at MD Anderson Cancer Center in July 2011.

For an incoming first-year hematology/oncology fellow, July 1st is when you are once again the new kid on the block.

A Year-by-Year Look at a Fellowship Program

	A career in oncology can be a tremendously fulfilling and a meaningful venture. Oncologists care for the sick, advance medical science, and mentor the next generation of medical professionals. Despite the value and importance of these pursuits, an expanding body of literature reports that physicians are experiencing increased personal distress and decreased satisfaction with the medical practice.

 Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at early stages in their careers during medical school and residency. High rates of burnout and poor mental health among physicians can have a profound impact on patients’ quality of care and threatens the sustainability of the health care enterprise.

	What is burnout? Burnout is an emotional state seen in many individuals under constant pressure. It can be accompanied by a number of physical and behavioral signs and symptoms, such as exhaustion, perceived clinical ineffectiveness, impaired job performance, and lead to poor health, including hypertension, anxiety, and depression.

 The condition has been compared to a worker who has become separated or withdrawn from the original meaning and purpose of his work. Physicians experiencing burnout have been shown to have higher rates of divorce, suicide, job turnover, drug and alcohol abuse, and a shorter life expectancy.

	The risk of burnout increases in individuals who consistently experience work overload and a perceived lack of control. Simendinger et al suggested a three-degree model of burnout.

 The third, or most severe degree, is characterized by major physical and/or psychological breakdown including mental illness, heart attack, and ulcers.

 These individuals find their work unrewarding, believe they are treated unfairly, experience insufficient personal rewards (eg, loss of mentor support and intrinsic satisfaction) and are confronted with conflicting values.

	Several factors such as decreased autonomy, increased administrative tasks and paperwork, less time with patients, and difficulty balancing personal and professional responsibilities can contribute to burnout. Oncologists in academia may face additional stressors such as declining levels of funding to support their scientific research, and changes to the structure of fellowship that have increased their clinical responsibilities and decreased time for traditional academic pursuits such as research and education.

 As a result, physicians may not always have the opportunity to focus on the areas that they view as most personally meaningful.

	Interestingly, a study by Einhorn et al found that daily interaction with suffering and dying patients was not the greatest source of stress for oncologists.

 Rather, increased claims documentation requirements (such as those for Medicare) and bureaucratic hassles, which for many resulted in longer working hours, was the greatest concern among oncologists. Board certification may be modestly positively associated with satisfaction,and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.

	Although burnout affects many individuals under constant pressure, oncologists in particular are frequently overloaded with the demands of their profession. The stressors of caring for ill patients, responding to the needs and questions of families, and experiencing limited treatment success and the constant loss of patients can exert an emotional toll on oncologists. In a 2003 survey, Allegra et al found that the rate of burnout among oncologists in the U.S. exceeded 60%.

 The seeds of burnout may be sown in residency and fellowship training, during which fatigue and emotional exhaustion are often the norm. By mid-career, the momentum of burnout may be subtly reinforced by the fact that your peers perceive you as a hard worker who places service to others before self-care. As a result, some physicians may deny major negative aspects of their work considering their commitment to become a well-trained medical oncologist.

	Fellows coping with the demands of their practice by working harder and longer may experience severe inefficiency, psychological impairment, and poor patient care. Fellows’ expectations are often their greatest source of stress, and few spend time reflecting on themselves or attending to their own needs. Even so, fellows might be reluctant to recognize or talk openly about psychological problems resulting from their professional experiences to avoid having a psychological diagnosis or a “weak fellow” label pinned on themselves. The nature of medical training can reinforce false beliefs in one’s immunity to difficulties and prevent recognition of serious psychological problems.

	When physicians suffer from burnout, negative effects on patient care and increased medical errors can result. A study by Isen et al found that third-year medical students with positively primed emotions and in whom positive affect had been induced arrived at an accurate diagnosis more efficiently and with greater curiosity and less disorganization.

 Given the potential human costs of medical mistakes, the emotional impact of actual or perceived errors can be devastating for oncologists. It’s well documented that doctors with burnout get sued more often.

 Learning how to prevent burnout, then, is of great importance.

	The intensity and scope of stressors facing physicians require healthy and successful coping strategies such as cultivating professional and personal relationships, maintaining control over in your career, and preserving your well-being.

 Nourishing close relationships is perhaps the most important aspect of your balancing act. Good relationships with patients, relatives, and staff help promote professional status esteem, intellectual stimulation, and good management and organizational structure. An adequate support system can be a powerful source of strength and resilience for physicians, who over time may feel isolated in their careers. Such loneliness can be especially pronounced for physicians who begin to feel down or burned-out. Through socialization and sharing their feelings with others, oncologists can also more readily recognize indicators of stress and burnout in colleagues. In addition to personal and professional relationships, support can be found through professional organizations and groups settings.

 A sense of autonomy and control over work is important to ensuring job satisfaction. Control over your schedule, including interventions to improve the flexibility and predictability of work hours is the most important predictor of work—life balance and burnout. While such a goal may seem impractical given the increasing demands on physicians, studies have suggested strategies for increasing one’s sense of control and improving resilience.

	A study by Jensen et al found that a main aspect of physician resilience was setting limits in both professional and personal arenas.

 Setting limits means being able to know when to say “no” to avoid over-commitment and achieve balance. This may mean prioritizing responsibilities, reducing working hours, changing the way you practice (eg, solo vs group practices), and scheduling time for exercise and relaxation. Since saying “no” inherently involves a certain degree of confrontation, physicians may be reluctant to deny requests from others and consequently find themselves drained or resentful. Giving yourself permission to set limits can markedly improve your professional satisfaction. Physicians with a positive coping strategy know how to organize their work, delegate job duties, and be realistic as to what can be accomplished with available time and resources.

	In a separate study by Dunn et al, interventions designed to increase physician control over the work environment, improve order in clinic functioning, and deepen the meaning physicians found in their work were examined.

 The study found that strategies such as soliciting physician input on the scheduling template and accommodating scheduling requests (eg, length of sessions) and other practice preferences (eg, case mix) contributed to decreasing their emotional exhaustion. The possibility for flexible working schedules via part-time and job share options can also be examined.

	Given the diversity of career opportunities for a medical oncologist, it is increasingly important that fellowship training provide the diverse experiences needed to make informed career choices. It’s essential to begin your fellowship with an open mind. Fortunately, post-fellowship career choices are usually reversible, and the opportunity exists to switch practice settings. Many oncologists have successfully transitioned from academia to nonacademia and vice versa, for example.

 Preventing burnout necessitates the promotion of your well-being. Physicians must be guided from the earliest years of training to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work. Enjoying vacation or personal time will help alleviate burnout, while thinking positively can transform individuals for the better, making them healthier, more socially integrated, knowledgeable, effective, and resilient.

	A fellow’s greatest strength is a generally positive outlook. Thinking positively isn’t necessarily easy, but it’s essential. It would benefit fellows to realize early on that there are always going to be difficult situations during training; there is always going to be stress, and another fellow may get sick or need to leave and you will have to cover the call. It’s simply a part of life. Successful fellows dwell on the good times and not on the bad. At the end of each day, reflect on the positives and focus on what you learned. What went right and why?

	Mentorship programs are a valuable resource for supporting junior physicians in their career development and helping them navigate professional challenges.

 A mentor may also be able to detect dissatisfaction and help physicians reevaluate their interests and career paths. Opportunities for personal development, whether through medical education, personal hobbies, or sabbatical programs, can help physicians gain perspective and broaden their horizons. Spickard et al. emphasized that the principle “do no harm” is at the core of the medical profession and not incidental to physicians.

 As he put it, “doing no harm begins with one’s self.”

Mohamed Abdel Khalek, MD, is a clinical research fellow at Tulane Cancer Center in New Orleans, Louisiana. Emad Kandil, MD, FACS, is an assistant professor of surgery and medicine; adjunct assistant professor of otolaryngology; and chief of the endocrine surgery section in the division of endocrine and oncological surgery at Tulane University School of Medicine in New Orleans, Louisiana.

1. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. 

2. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. 

4. O’Connor PG, Spickard A, Jr. Physician impairment by substance abuse. 

Organizational burnout in health care facilities: Strategies for prevention and change

6. Campbell EG, Weissman JS, Blumenthal D. Relationship between market competition and the activities and attitudes of medical school faculty. 

7. Einhorn LH, Levinson J, Li S, Lamar L, Kamin D, Mendelson D. American Society of Clinical Oncology 2001 Presidential Initiative: impact of regulatory burdens on quality cancer care. 

8. DeVoe J, Fryer Jr GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? 

9. Allegra CJ, Hall R, Yothers G. Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. 

10. Isen AM, Rosenzweig AS, Young MJ. The influence of positive affect on clinical problem solving. 

11. Crane M. Why burned-out doctors get sued more often. 

12. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. 

A career in oncology can be a tremendously fulfilling and a meaningful venture. Oncologists care for the sick, advance medical science, and mentor the next generation of medical professionals.

August 2010 | Oncology Fellows

The Art of Analogies in the Clinic

Achieving Career Success in Academic Oncology: What to Know When Deciding On a Career in Academia

Defusing the Student-Loan Debt Bomb

The Importance of Mentoring in Preparing the Next Generation of Oncologists

A Year-by-Year Look at a Fellowship Program

Battling Burnout: Advice On Preventing and Dealing with Burnout in Your Future Career