Medicine requires by far the longest "schooling" of any career. By the time we finally become independent practice—eligible physicians, we are already in our mid-30s and have almost never had the opportunity to make an unsupervised decision on a patient’s care plan. The day that comes will be scary for most of us, because we are conditioned to always double-check with the boss, to be under someone’s wing. Suddenly we are the boss, with all the responsibility and liability that come with it. Until that day, we will always have several attending supervisors, some with whom we will work often and others with whom we may not even cross paths.

That’s the part of training no one tells you about: "managing up." I first heard this term during my 2-year career in the pharmaceutical industry, between medical school and residency. It was a mandatory training for new hires. A whole weekend was spent teaching me how to manage the different challenges I would face with the different types of personalities that might end up being my managers. Despite all the evidence- and science-based methods out there, nothing can fully prepare you to work one-on-one with so many people of different personalities and from different cultural and personal backgrounds.

At first, they don’t know you, they don’t trust you, and they almost never believe a word you say. With time, this cold start to your fellowship slowly changes—or not, depending on whom you are working with and the reputation you build. Attendings talk with each other, so expect your performance when working with one of them to be shared with the others. It’s human nature; accept it.

4. Render Caesar the Things that are Caesar's

The following is my approach to managing up, based on nothing but my own humble experience.

Find out about the person with whom you are about to work. I’m not talking about what they published last month or where they worked before they started at your hospital. Ask how they like to round. What are their pet peeves? Avoid doing that “one thing” certain to anger them early on.

The best thing you can do, regardless of whether you are alone or supervised, is to be on top of your game. Know everything about the patient, and I mean everything. Saying “normal” doesn’t cut it (I tried it; doesn’t work)—know the values. Sometimes a small detail of no relevance to you or your plan may be more important to your attending than the disease itself. Always have the numbers ready, regardless of whether you think they matter, and know what other services are involved in care, why they are used, and what they do for the patient. With time, as trust builds, your attending will ask for less information, so you will have more time to focus on the important stuff.

This is one of the hardest skills to learn, and I do not believe it can ever be mastered completely. Observe your attending and try to understand their baseline personality, current mood, anxieties (let’s be honest—we all have them), cultural background, and interests. You might have a hard time with a certain type of personality and get along beautifully with another, but at least try to understand how your attending thinks and reacts to a certain situation. Figure out if you are caught in a domino effect: Your attending is under pressure and consequently puts you under pressure. This will help you navigate rough days when you are not on the same page or one of you is not in your usual mood.

Most of the time you will agree with your supervisors, but sometimes you won’t. Most of the time they will be right, but sometimes they won’t. Most attendings will listen to you to see where you are going with your thinking, then nicely shut you down with data you never knew existed, because you either don’t know enough yet or didn’t attend ASH or ASCO last weekend. Inevitably, you will meet the attending who is set in the old ways, refusing to accept any suggestion that does not conform to their modus operandi. If it will not make much difference at the end of the day, let it go. I have yet to see any fellow win that battle (the “show me the data” approach almost never works, even if you do show the data). If you believe patient care and well-being are at stake, kindly suggest a tumor board presentation or ask an expert in the field to weigh in.

Notice I say “thrive.” Independence in training, as discussed above, is not possible. The next best thing is to get as close to it as possible. How? It took me quite some time to figure this out, but what worked best for me was to study hard to be as good as my attending. I found that this gave me independence of thought and streamlined my life. My presentations became more organized, more focused, and packaged with a solid plan. The results were fascinating: no more endless questioning, triple-checking, and looking at charts together. We simply discussed fine-tuning the plan and moved on to the next patient. Pseudoindependence…close enough. With this approach, you spend time learning the things you cannot find in books instead of having your attending teach you the basics that you didn’t read.

One of my chief residents told me once that we, as doctors, are the most compassionate people to our patients but the cruelest people to each other. I guess any physician can understand or relate to that statement. It doesn’t have to be that way; just remind yourself of why you and your attending are rounding on a sunny Sunday afternoon. Remind yourself that you are here to help patients as best you can and learn from each other. We all come from different walks of life and experiences, and it is always fascinating to discover what can be learned from an attending who has been doing this for years, before we even knew what cancer was.

At the end of the day, we need to remember that, as physicians, we all are overworked and strive every day to give our patients the best care in a new healthcare order that seems more concerned about saving money than saving lives. I was blessed to work with great attendings and not-so-great attendings. I learned from all of them, either what to do or not to do. The bottom line: Never take it personally, don’t sweat the small stuff, and remember—it’s temporary!

Articles

Simon Abi aad, MD, gives advice on how to navigate the professional side of a fellowship, including how to build relationships with your colleagues and supervisors.

Oncology Fellow Relationships and Challenges

As I looked at the glossy white dry-erase board and read the name of my new consult patient, written in crisp royal blue letters, I straightened my tie. I was ready to meet a new patient with a life-threatening cancer. I was ready to instill hope in someone who feared the end. Could I help cure this patient? I was confdent that, at the very least, I could offer this person more time managing the disease and a better quality of life.

I placed my palm over the computer mouse located to my right. The small white arrowhead outlined in black moved across the monitor until it found the medical record number of my new patient. My right index fnger pressed the left button, and I opened the patient’s electronic chart.

“Please evaluate this patient’s anemia” was noted on the chart. I exhaled slowly and rolled my eyes. I reviewed the laboratory workup, which had previously been obtained by the referring physician.

Hemoglobin is 1 point below the reference range

I proceeded to review the patient’s medication list.

I paused and shook my head. “So, it takes a hematologist to know that psychiatric medications and folate defciency can cause anemia? I chose this feld to take care of people with life-threatening illness—what a waste of time!” I thought.

I locked the computer and left the workroom. I turned to my right and walked 2 steps toward the door to Exam Room 2. I looked at the stainless steel door handle. Before turning it, I tried to relax my face and the muscles in my shoulders to conceal any tension. I knocked on the door 3 times, and then pulled down on the shiny lever.

“Hello!” I introduced myself. “I’m one of the hematology/ oncology fellows.”

As I greeted a man sitting in the chair directly across from the door, about 3 feet away, I forced a smile.

The man was wearing an old T-shirt and faded blue jeans. He extended his right arm to shake my hand. His body leaned forward and to the left, as his free arm rested on a cane. Scattered scabs covered his forearms. Each wound was between 1 and 2 centimeters, and all seemed to be of diferent shapes and at diferent stages of healing. His eyes met mine through a pair of thick lenses.

“Hello, Doctor,” the man replied. His face, hidden behind an uneven white beard, moved very little. His bottom lip quivered slightly.

I asked the patient, “What do you know about why you are here in the hematology clinic?” I looked to my left. A middle-aged woman smiled at me. We gently shook hands.

The man quickly responded, “My primary doctor says my blood counts are low.” His eyes remained still. “That’s right,” I said, “but I don’t think there is anything serious going on.” I spoke more softly and slowly as I tried to reassure him. “Some of the important medications your psychiatrist is prescribing can lower the blood counts slightly.”

I proceeded to obtain a full medical history and asked for his permission to examine him. He agreed and slowly walked toward the exam table. He leaned heavily on his cane and grimaced with each step. I ofered my hand and helped boost him up onto the table.

“You look like you’re in a lot of pain,” I said. The patient looked back at me with still eyes. His bottom lip continued to quiver slightly. “I’m always in a lot of pain,” he said. “It’s the arthritis.”

As I examined the patient carefully, I remembered the words of my internal medicine professor during hospital rounds 5 years prior. One of my fellow medical students had grumbled about the unnecessary transfer of a surgical patient to our medicine service for comanagement.

My professor had suggested that the transfer was ridiculous and surgeons could have managed the patient. Putting his arm around the student, the professor said, “Always remember this: We are internists. This is what we do. We take care of patients. Someday you will be asked to take care of a patient, and the task may not seem to be very rewarding.”

The students around me nodded their heads slowly and opened their eyes a little wider.

The professor continued, “Another doctor may ask for your help in consultation. The question may seem too simple—a waste of your time. Maybe a surgeon, busy in the operating room, will ask for your help managing a patient’s short list of medications. Each of you may even be asked to care for a patient without any actual medical issues.”

A few students stepped forward, shrinking the semicircle surrounding our professor. “When those situations arise, instead of complaining about the simplicity or lack of necessity of your task, ask yourself this question: ‘What can I do to help the person in front of me?’ If you keep that question in mind, I promise your career will be very rewarding,” the professor said.

I helped my new patient down of the exam table and laid my right hand across his back during the trek back to his seat.

“How are things going with your mental illness?” I asked. “OK, I guess,” he responded. I continued. “Are you seeing your psychiatrist regularly?”

“Any thoughts of hurting yourself or others?” I waited for the same answer to the question I had asked dozens of times of other patients.

“Myself,” the man said as he looked down toward the foor. I stood up slightly, lifted my chair a few inches, and repositioned just to the patient’s left. I put my right arm around his back.

“Why would you want to hurt yourself?” I asked.

“The voices in my head are always telling me I’m worthless and that I’d be better of dead.” A tear streamed down the woman’s cheek. She moved in closer. Her right hand covered her mouth, and she took his right hand with her left.

“Honey, I had no idea,” the man’s wife said. She embraced him, and they both cried.

“You’re not worthless,” she continued.

I felt a dull ache in the center of my chest as I watched the couple endure their anguish. I rubbed the man’s back softly as he told me of his plan to wait on the train tracks near his home, until he would fnally be free from the antagonistic voices. Then I stated with confdence in my voice, “We can help you. We can make this better.”

The couple gave me their permission to contact our emergency psychiatric team and arrange for admission to the hospital. As he gingerly walked out of the clinic, I attempted to reassure him one last time: “You’re a good person with a lot to offer. We can get through this.” He nodded his head slightly as his eyes looked toward the floor.

Sixty-three days passed. I sat in front of the same workroom computer, prepping to see the sixth of my 8 scheduled patients on another Tuesday afternoon schedule. I did not recognize the name of my follow-up patient. I opened the electronic medical record and the still face and white beard from 7 weeks prior appeared on the top left portion of my computer screen.

I smiled and quickly walked toward his exam room. I knocked 3 times, but this time, I was too eager to enter to wait for permission. I pulled down on the shiny steel lever.

“You’re back!” I said with excitement. I walked toward the bearded man, and he briskly propped himself to his feet with his cane. “How are you?”

The man smiled. There was no quiver in his lip.

“We celebrated our 25th wedding anniversary last night,” the man said. He pointed at his wife, who was standing to my left. “We got Mongolian food at Genghis Khan. It was a wonderful night. We can’t aford to eat out often, but we celebrated. All because of you.” He paused. “I was going to kill myself. Probably that same day we met. But you helped me. Now when I hear those voices calling me names and telling me to kill myself, I take control! I say, ‘If I kill myself, that means you die, too!’ ” He threw his arms around me again. “Doctor, thank you. You saved my life.”

Anthony Accurso, MD, offers a patient more time managing their cancer and a better quality of life.


December 2017 | Oncology Fellows

Oncology Fellow Relationships and Challenges

The Personal Touch: Patients Are More Than Their Charts