During my second year of fellowship, I witnessed numerous events that hit me close to home. All seemed clustered together, multiplying my grief, which left little time for thoughtful reflection. When I interviewed for my fellowship and was questioned about how I planned to cope with all that I might experience, I knew the answers. We all do. But now it wasn’t just a simple interview question. It was real life and I realized that I was not coping well with the turmoil that surrounded me.

Just like my patients, I needed to develop a solid plan based on tried and true guidelines. So, I did what we do best and researched treatment options. Seeking the advice of those I greatly respect, I developed strategies that I now use in my own life and in clinical practice to help me deal with those disappointing events that we all will occasionally encounter.

Removing the judgment from who should or should not have X Undesirable Disease is imperative. It is not uncommon to ask, “Why me?” We certainly don’t always have the answers, but if we’re honest perhaps the question should be, “Why not me?”

Horrible things happen to young people, old people, people we like, and people we find more challenging to like. Our human bodies are not perfect. If we allow ourselves to think such thoughts as “Mrs. Jones should not have this cancer, she is too kind!” then we have personalized her condition in a dangerous way. Yes, death or other undesired outcomes do happen. But we must also remember that life and cures happen!

If we would honestly keep track, the good events we witness could far outweigh the bad, though it is easy to let our focus slip and momentarily think otherwise. When an undesired outcome does occur, we can still find joy in helping each patient reach their individual goals. Perhaps it won’t be through providing a cure to a patient, but we can direct our efforts to help our patients accomplish something they may deem as equally important—whether it is ensuring that our patient makes it to their child’s wedding or helping control symptoms so he or she can enjoy a family vacation.

When a patient does die, often writing a card or talking with the patient’s family can bring important closure. Despite anything else going on with our other patients, we must always remember that when we enter the next patient’s room and the door closes, our feelings and thoughts about other people and events must wait outside. We must focus all of our attention on that single patient, provide the care that they need, and avoid spreading ourselves too thin emotionally.

Lastly, though it may sound obvious, patients do rely on us to be their doctors. There will always be a proper place for holding someone’s hand and sharing tears, but if we become excessively involved to a point that we cannot professionally guide or care for them as a doctor should, we will be unable to provide the quality care that prompted them to seek out a physician in the first place.

We have all worked hard to get where we are now. However, this pattern of “Work harder, get a better grade” or “Spend more time reading, know everything for the test” doesn’t apply to life outside the classroom.

Although we hate to admit it, we do have limits. We must learn to set realistic boundaries, know when to ask for assistance, and be willing to do so to avoid complete exhaustion which would make us incapable of helping those with whom we can really make a difference.

Joining a practice with colleagues who share similar styles of patient care is important so that we can fully trust others with the patients that we care so much about. This also allows us to occasionally take much-needed time off. Along this same line, some may find it important to seek balance in their practice by maintaining a certain number of patients with benign rather than all malignant conditions. Although physicians tend to be very giving by nature, we must also set personal boundaries with our time. Not even the most well-meaning colleagues or patients will usually ask you to stop spending time with them so that you can accomplish other necessary tasks.

Developing a list of both short- and long-term professional goals can help. Although there are many cases with which we may like to be involved, we simply cannot do it all. Although we should all seek to lend a hand to others whenever possible, we do have physical, emotional, and time limitations, and acknowledging our finite resources is healthy practice.

Finally, finding a mentor or other colleague within a similar field with whom we can occasionally discuss what we experience is also important. Just as we may not be the best sounding board for someone in a field in which we are not proficient, it is frequently difficult for those in other lines of work to fully relate to the struggles we frequently encounter.

Since beginning fellowship, have you ever had a headache and wondered if it was reflective of a brain tumor? If so, you’re not alone. The things that we are surrounded by on a daily basis are frequently the conditions we fear, and may assume we have, when we don’t feel well. Just like our patients, we should seek appropriate medical care when needed.

However, acknowledging this pattern of thinking can be enlightening. We must realize that we do have a life outside of work, and there are certain places in which we are truly irreplaceable. Although it may be hard to hear, if we’re honest, another physician could take over our practice if needed. That is why we continue to train new physicians each year.

Where is it that you are truly irreplaceable? Is it as a child, parent, friend, or spouse? Make an effort to embrace and maintain relationships where there simply could never be another you and intentionally share special moments on a regular basis with those people or events that matter the most to you. Lastly, participate regularly in a hobby outside of work that you enjoy.

If we are intentional about creating and practicing guidelines for our emotional health early on, perhaps we really will be able to enjoy a balanced lifetime of practice and be capable of making a difference for generations of hematology and oncology patients, just as we all hoped to do when we joyfully began our journey in medicine.

Marci Allen, DO, is a hematology/oncology fellow at University of Kansas School of Medicine.

Articles

During my second year of fellowship, I witnessed numerous events that hit me close to home.

Maintaining Balance

	After Years and Years, What Are the Options?

Medical education and training is very intense, long, and expensive. When nearing the end of training, it is time to select a career path. In the hematology and oncology fields, there are a variety of paths which fellows can explore depending on their area of interest. To help you narrow down your options, it is important to determine whether you are interested in a clinical or nonclinical position.

Clinical practice can be broadly divided into careers that are 1) academic or 2) nonacademic.

Academic careers can be further subdivided into the clinical track, scientist track, or clinical scientist track.

 Involves mostly patient care and education of fellows and other staff, with zero to minimal research and some administrative tasks.

 This job consists almost entirely of research, with a very minimal amount of patient care. Research may be laboratory based or clinical trials and involve grant writing, protocol writing, and manuscript preparations as well as presentation of research at conferences at national and international conferences.

Involves a combination of patient care and research.

Nonacademic clinical practice options include working for a private practice or accepting a position as an employee of a hospital.

Once very popular, this model of practice is becoming less lucrative due to health care reform and the buyout of small private practices by larger groups and hospitals. The focus of private practice is to generate revenue through patient evaluation while keeping overhead costs low.

Many private practices have onsite laboratory services, imaging capabilities, and radiation oncology services to keep revenue within the practice. Additionally, most private practices have their own infusion center because infusion service time charges and profits on drugs generate decent revenue. In most private practices, an average of 60% of income is generated through drugs and infusion services, compared with 40% from evaluation and management.

Successful private practice requires business and administration skills. With an increase in the number of developed oral drugs, and the rise in drug prices, most practices now utilize specialty pharmacy rather than the method of buying and billing the insurers because of increased inventory costs. Consequently, this has decreased drug and infusion revenue.

One has to be very careful before joining private practice. If it’s an extremely large group, you may experience abuse by senior partners during the beginning of your career, and you may never become a partner. Another major factor to consider in becom- ing a partner is the high buy-in cost. If joining a solo practitioner, the overhead costs could be intimidating. A group of 3 to 4 physicians is ideal because the chance of abuse is low and overhead costs and calls are shared among all physicians.

No matter what, it is essential to market yourself and network with other physicians to increase the chances of referral during the beginning of your career.

This model of employment has become increasingly popular. The buyout of small practices by large hospitals or groups and the resultant decrease of referrals to private practice, decrease in revenue from oral and expensive oncology drugs, and increase in overhead costs are a few reasons why.

The starting salary of a hospital-employed position is lucrative and includes attractive bonuses. You work as an employee of the hospital and in most places the salary is guaranteed for a couple of years, after which you are switched to productivity-based payment.

If the referral in the hospital or group is very strict, you will likely keep getting patients because of referral patterns and you probably do not need to aggressively market yourself. In the event that the referral system is not strong, you will want to market yourself aggressively because after your guaranteed salary time period you may lose money.

Some important private/hospital employed practice factors to consider are:

		Number of patients per day including new versus old patients

		Onsite infusion, labs, radiation, and imaging capabilities

		Inpatient coverage by hospitalist versus hematology/oncology

		Rounding on inpatient (rotation policy or everyone rounds on own patients)

		Boards exam coverage and license coverage

		Production relative value unit (RVU) based? How is RVU calculated?

Non-clinical positions can include working within the pharmaceutical industry, health insurance sector, for the US Food and Drug Administration (FDA), or for a managed care organization.

Pharmaceutical industry careers vary. Job descriptions may include positions for providing active scientific contributions to teams developing a compound being studied for new hematology and oncology applications or becoming a liaison between a company and clinical investigators running a clinical trial and monitoring adverse events. Other positions available include project management, regulatory affairs, data management, medical writing, biostatistics, medical affairs, clinical pharmacology biomarkers, transla- tional medicine, patient-reported outcomes, and health economics.

The FDA regulates and approves the drugs in the United States. The FDA has a variety of divisions including biologics, small molecule, immunology, and medical device, among others. A position with the FDA includes reviewing the variety of new drug or equipment applications, evaluating clinical trial data, and collecting post marketing data for adverse events. After extensive review and research, the new drugs are approved through vote of committee. The compensation is typically low, but comes with good government benefits and stability. The work experience of the FDA is of immense importance, especially in the pharmaceutical industry. Most physicians will work in the FDA for a few years and then enter into the pharmaceutical industry for far better financial compensation.

Job opportunities with managed care organizations can vary and include clinical and nonclinical responsibilities. Positions mainly involve contract negotiations with practices and hospitals, reviews of claims, and review processes for the approval of oncology drugs prescribed by physicians, as well as laboratory and imaging investigations requested by physicians.

Factors including the implementation of the Affordable Care Act, also known as Obamacare, and its unknown consequences, the decreasing reimbursements in Medicare and other insurance companies following the Medicare path, and the drying up of research dollars from government as well as nongovernment grants all make the future of health care seem uncertain. One has to be extremely careful when choosing a career path.

Vishal Ranpura, MD, is a practicing hematology/oncology fellow at the Washington Cancer Institute.

Medical education and training is very intense, long, and expensive. When nearing the end of training, it is time to select a career path.

Selecting Your Career Path

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 patientfriendly 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 department of Harborview Medical Center. He seemed to be dazed at the frenetic pace of activity around him as he lay 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 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 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.

: 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 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!

: In patients who are mostly well, I cannot overemphasize that regular medical follow-ups are 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.

Translating medical nomenclature into language
that is easily understood by patients can be difficult.

December 2013 | Oncology Fellows

Maintaining Balance

Selecting Your Career Path

The Art of Analogies in the Clinic