Driving through downtown Cleveland on a recent September evening, there is hardly a mask in site. People are strolling down the street, laughing with friends, eating and drinking without a care in the world. For many, the coronavirus disease 2019 (COVID-19) pandemic is something they hear about or read in the newspaper, but it doesn’t have any immediate impact on their circle of loved ones.

For the population of hospitalized patients with cancer, many of whom who have not contracted the disease, COVID-19 has real, immediate consequences. The pandemic has radically altered their end-of-life care.

While home has surpassed the hospital as the most common place of death in the United States for the first time since the early 20th century, 40% of people older than age 65 who die with cancer are admitted to the intensive care unit in the last 180 days of life.

 More than 47,000 people older than age 65 die with cancer in the hospital each year.

 A critical aspect of end-of-life care involves frank discussion of goals of care with patients and their loved ones, and allowing patients to die with their loved ones at their side. Under normal circumstances, Cleveland Clinic, like many other hospitals, welcomes visitors for these patients at any time.

During the pandemic, we have been forced to adjust our visitation polices to protect our patients, staff, and visitors, and prevent the spread of COVID-19. At first, all visitors were forbidden except in the case for patients undergoing emergency surgery or end-of-life care and those who required a caregiver for a disability. On the oncology services floor, we are allowing 1 designated visitor for the entirety of the hospitalization with limited exceptions for rotation. However, for most patients, their support system extends beyond 1 person, leaving both patients and families devastated.

As a third-year fellow, I felt prepared to start my last 1-month rotation on the bone marrow transplant service. I started with zeal and high spirits—entirely naïve to the reality that this rotation, under these circumstances, would be more emotionally exhausting than any of my prior rotations. Traditionally, care of hospitalized patients starts with rounds by a small army of medical professionals that includes nurse practitioners, nurses, a pharmacist, a social worker, and a staff attending physician. My first day started with a dial-in call from the conference room.

Other team members logged in from a distanced hospital workstation or unused offices. After 90 minutes of “rounding,” my staff and I would see patients on our own and message the nurse practitioners with recommendations after exiting each room. In the afternoon, the nurse practitioners would page me their updates and I would discuss the patients 1-on-1 with my staff physician.

Despite our efforts to maximize communication with one another and with patients and families, this fragmented approach to maximize safety naturally made our patients feel isolated and dehumanized during a time when intimacy is critical. Worst of all, end-of-life conversations and experiences for patients and families were more painful and unforgettable given the limitations on visitation and impersonality of virtual meetings.

RN was a 48-year-old woman with recurrent acute myeloid leukemia (AML) following bone marrow transplant who was admitted for neutropenic septic shock.

During her hospitalization, we found she had multiple infectious sources, including pyelonephritis, fulminant 

colitis, and a gluteal abscess. Despite early intervention, RN arrested. Although we achieved return of spontaneous circulation, she remained gravely ill.

We requested her husband come in for an end-of-life discussion. He wanted her mother and her children to be present, but due to our visitation policy, he had to come alone. Ultimately, he decided to change her code status to “do not resuscitate.” We requested special permission for her mother and children to visit the hospital. We couldn’t get approval in time and RN died before seeing the rest of her family.

RH deferred all his medical decision-making to his wife. She was elderly and fearful of entering the health care system, so we had all conversations about goals of care over the phone. During these 7 days of lengthy conversations and tears, discussing the risks and benefits of his disposition, I never saw her face. These moments are when nonverbal cues and affirmations are the most important. I left these meetings feeling unsettled, wondering if she felt at peace with her decision.

Ultimately, she made the decision for him to return home on hospice so she could hold her husband’s hand when he passed away. They wouldn’t have had that final moment of tenderness had he returned to his subacute rehabilitation facility.

DS was a 66-year-woman with AML hospitalized for cord transplant. Although she and her sons anticipated a long hospital stay on admission, no one imagined that she would not only still be on the floor 50 days later, but that there would be talks about a second transplant for potential graft failure. Her 3 sons wanted to be by her side because they knew their mother struggled with depression, but only 1 designated son was allowed for the entire hospitalization. She would ask us daily if her other sons could come, knowing our response.

I spoke with one of her sons, who lived out of state, on the phone. Every day, he pleaded for me to let him come in place of his brother. He could tell his mother was becoming more depressed and was fearful she was losing hope. Ultimately, we obtained permission to allow her son to take his brother’s place for a week. The joy when they finally saw each other was indescribable.

We were elated when DS finally engrafted and we began planning her discharge. Unfortunately, she developed hypoxic respiratory failure that necessitated transfer to the ICU. That was the tipping point for DS and her family. We requested special permission for all 3 of her sons to come to bedside. When she saw all 3 of them, she cried and told me she knew she was dying.

Thirty days never felt so long. Each of these people reminds me of the price we pay for the ongoing pandemic. Nothing will break your heart more than watching another human suffering and crying in the face of death. Nothing will ease the pain of hearing their loved ones’ sob over the phone. Nothing I do will make any of it any better.

But I am holding onto hope. I am hoping and praying for the day that everyone wears masks outside and abides by social distancing. I am hoping that medical science discovers a treatment or a vaccine for COVID-19. I am hoping we can lift hospital visitation policies and provide patient-centered care at the end-of-life as we once did.

Iris Y. Sheng, MD, PGY-6, is a Hematology/Oncology Fellow at the Cleveland Clinic Taussig Cancer Center in Cleveland, OH.

Cross SH, Warraich HJ. Changes in the place of death in the United States. 

. 2019;381(24):2369–2370. doi:10.1056/NEJMc1911892

Bekelman JE, Halpern SD, Blankart CR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. 

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Articles

For the population of hospitalized patients with cancer, many of whom who have not contracted the disease, COVID-19 has real, immediate consequences; the pandemic has radically altered their end-of-life care. 

Struggling With COVID-19 on the Cancer Floor

There are multiple factors influencing career plans for physicians trained in the United States. At Indiana University, 1 of the largest medical schools in the nation, we decided to study some of these factors, focusing on current fellows and recent graduates of the hematology and medical oncology specialty in the United States.

We sought to evaluate the effects of student loan debt and visa status as 2 factors affecting the career choices of fellows. We also wanted to evaluate whether fellows were aware of available resources or mentorship to help them deal with these factors. To do so, we surveyed current fellows and recent fellows who graduated from 2017 to 2019 at 159 hematology and medical oncology fellowship programs in the United States. All programs included in the study are accredited by the Accreditation Council for Graduate Medical Education (ACGME).

The survey consisted of 13 questions regarding student loan debt and visa status, research experience, initial career plan, current career for graduates, the influence student loan debt and visa status had on career decision, and whether the respondent was aware of available resources or mentorship that could help them address debt and visa concerns. We used a 5-point scale, from extremely unaffected to extremely affected, to determine how much each factor influenced career choice.

A total of 220 physicians participated, 80% of whom were fellows and 20% were graduates. Thirtyfive percent of graduates reported taking out student loans during their fellowship. Of those, 40% felt their loans strongly affected or extremely affected their career choice. In addition, 93% of graduates who had student loans said they weren’t aware of resources or mentorship programs to address their loans’ effect on their career.

Forty-four percent of graduate respondents were on a J1 visa for students or an H-1B visa that allows US companies to employ graduatelevel workers in specialty occupations that require theoretical or technical expertise in specialized fields during their training. Of those, 74% of respondents felt their visa status strongly affected or extremely affected their career choice. Further, 63% of graduates who were on a visa answered that they weren’t aware of resources or mentorship programs to address visa status as a factor influencing their career options.

For the current fellows, 51% have student loans and one-third of those with loans said their loans strongly affected or extremely affected their career choice. In addition, 77% of fellows with student loans answered that they weren’t aware of resources or mentorship programs to address their loans’ effect on their career.

Sixteen percent of current fellows are on J1/H1-B visas and 66% of reported that their visa status is affecting their career choice. Adding to that, 62% of fellows who are on a visa answered that they weren’t aware of resources or mentorship programs to address visa status as a factor influencing their career options.

The 2 major career paths available for cancer doctors in the United States are academic and community practices. In academia, there are different tracks such as research, educator, and clinical. In hematology/ oncology, the focus is to build a career based on basic, translational and/or clinical research, and/or teaching. Physicians usually work at universities and major cancer centers.

Many academic oncologists find research and teaching deeply rewarding. The drawback to an academic career is that the average compensation is generally lower than in community practice. In addition, physicians in academia often have protected time for research and/or teaching, which offers some flexibility in their schedules compared with physicians in community practice. In other words, those physicians choose a career path with less pay to focus on research and/or teaching in addition to clinical duties because they have a passion for medical science.

Community practitioners, on the other hand, focus on working in the clinic. Although some community practices focus on research, usually clinical research, the majority of physicians in this setting are busy treating patients during most working days.

Hematology/oncology community practices are either hospital-employed or physician-owned groups. On average, the compensation in community practices is considerably more than in academic practice. It is worth mentioning that the greater portion of patients with cancer in the United States are treated in community practices since they are more common than academic medical centers.

Hematology/oncology fellows have the option of pursuing a career in the pharmaceutical/drug development industry. Physicians employed by pharmaceutical companies are directly involved in the development process of new drugs and conducting clinical trials. In addition, compensation at pharmaceutical companies is usually competitive but most of those opportunities are in urban and suburban areas.

From the fellows’ standpoint, student loan debt can push them toward a career with a potential higher income like in community practice, even if they would prefer to go into research and play a role in advancing cancer therapy. On the other hand, fellows on a visa are often pushed to work in community practices in underserved geographic areas due to their visa conditions. For example, fellows on a J1 visa are usually required to go back to their home countries for at least 2 years unless they agree to work in rural areas in the United States. However, a fellow working in a rural area is often unable to pursue research because the vast majority of academic practices that engage in research are clustered in urban or suburban areas.

With our survey analysis we were able to conclude that student loan debt and visa status are important factors affecting hematology and medical oncology fellows’ career paths. The majority of hematology/ oncology fellows in this survey weren’t aware of mentorship programs or resources to help them deal with those factors. Our message is that mentors at training programs need to be aware of these factors to give tailored advice to help fellows achieve their career goals.

There is a desperate need in oncology to develop more clinical trials and invent new therapies to help our patients. Because of concerns over student debt or visa status, we risk losing the talent of a group of physicians who have the ability to become investigators and significantly advance cancer therapy. When physicians are forced to make career decisions based on financial stress or immigration regulations, they may be unable to focus on research work

Al-Issa K, Rangaraju S, Al-Hader AA. Student loan debt and visa status influence on career choices for hematology and medical oncology fellows in the United States. 

. 2020;38:(suppl; abstr 11024). doi: 10.1200/JCO.2020.38.15_suppl.11024

Investigators from Indiana University decided to study some of the factors influencing career plans for physicians, focusing on current fellows and recent graduates of the hematology and medical oncology specialty in the United States.

Student Loan Debt, Immigration Status Often Drive Career Decisions for Fellows

The coronavirus disease 2019 (COVID-19) crisis has changed all aspects of medical education but perhaps altered clinical education most dramatically.

 Clinical rotations at outside centers, previously a critical part of the application process in many specialties, have been eliminated almost entirely. This is concerning as these “away rotations” help provide students with a sense for a program’s culture, a chance to connect with future mentors, the ability to further assess their specialty choice, and an opportunity to have prolonged contact with a potential training program on an “audition” basis.

The 2020-2021 residency application process will be similarly altered.

 With most radiation oncology residency and hematology/oncology fellowship programs considering a shift to virtual interviews this cycle, programs will be challenged by the impersonal nature of the virtual platform.

 A potential way to bridge the gap between students and program is to use virtual resources such as clerkships, meet-and-greets, office hours, visiting professors, and interviews. Herein we describe our experience transitioning to a fully virtual environment while capturing the immersive experience typical of an in-person environment. We hope our experience in the specialty of radiation oncology will be helpful to other residents and fellows and programs, even those outside radiation oncology, as they make similar adaptations.

In lieu of away rotations, structured online experiences have been constructed to provide clinical exposure and curricula at outside institutions. Specifically in radiation oncology, the Radiation Oncology Virtual Education Rotation (ROVER) provides access to introductory disease site-specific videos and organizes multi-institutional teaching sessions featuring experts across the country, geared specifically toward senior medical students.

 Patient cases are written and moderated by radiation oncology residents and discussed with attendings, including details on appropriate workup and treatment options for each case. These sessions are recorded and widely available to students.

Many programs also have been offering 1- to 4-week virtual clerkships to increase student exposure and engagement in radiation oncology.

 These clerkships are available through the Visiting Student Application Service, just as in-person away rotations typically have been, and qualify for course credit. Virtual clerkships integrate medical students into radiation oncology clinics, didactics, tumor boards, chart rounds, and treatment planning, and can give them an opportunity for an end-of-rotation presentation to the department on a topic of their choice.

To best approximate the in-person environment and ensure a successful rotation, students should have access to the electronic health record (EHR) system to prepare for clinic ahead of time. On clinic day, patients should be asked for permission before bringing medical students into the room. Medical students may be set up on a device capable of running videoconferencing software with audio and video capabilities. Mounting the camera on a tripod is a simple thing that can ensure that interactions between the patient and the resident or attending are as natural as possible.

In the room, the student should be positioned so that the entire clinical interaction is viewable. Between patients, students can stay with the attending and resident, discuss cases, and learn radiation oncology decision-making. Virtual mentoring opportunities can also become available through 1-on-1 interactions with faculty.

All of this is available without the added personal and financial burdens of traveling, obtaining lodging, and being away from family. The benefits of virtual rotations described herein may also improve diversity and equity in the field among applicants for whom financial and personal barriers might otherwise prevent pursuit of an away rotation. For these reasons, it is possible that virtual rotations may continue post pandemic.

Virtual meet-and-greets provide an avenue for medical students interested in virtually connecting with radiation oncology residency programs and residents without committing to a full rotation. Such sessions have been offered by many residency programs and provide information about the program, the field of radiation oncology, and the interview process. Most of these sessions occur before Electronic Residency Application Service opens for submission and can help educate students on which program or programs would help them be most successful.

Meet-and-greets can be held via platforms such as Zoom, Skype, GoToMeeting, Facebook Live, or Instagram. Students can be recruited through social media, emails from schools, word of mouth, or posting on medical forums. Students are encouraged to register and receive a private invitation via email to prevent deliberate disruptions (“Zoom-bombing”). Programs are encouraged to identify a moderator to help facilitate smooth transitions. Sessions are typically limited to an hour and can include residents only, attendings only, or a combination. Resident-led sessions are important to provide insight into the program’s culture, and attending engagement is important to provide insight into potential mentorship, educational, and research opportunities. These can help medical students gain a deeper sense for the attending and resident dynamic, especially in a time when they will not be physically visiting departments to observe interactions.

Topics of discussion can include program overview and curriculum, elective and professional development opportunities, residency benefits, alumni job placements, resident life, and open question-and-answer sessions—anything that can give prospective students a sense of the program and faculty. Organizers can arrange breakout sessions to provide a more intimate setting for discussion.

In larger sessions, the chat function may be especially helpful to moderate discussions. Meet-and-greets can help provide an easy way for students to get a glimpse into what their life would be like as a resident, in a more casual virtual setting.

Despite Limitations, Virtual Education Is Likely to Remain Here to Stay

The rapid evolution of medical student education and outreach during the COVID-19 pandemic comes with inherent limitations. Virtual clerkships and meet-and-greets help provide students insight into a program’s day-to-day operations but are still limited by their remote nature. Even with audio and video capabilities, it is easy to miss the many subtleties of in-person interactions, making it more challenging for students to demonstrate their clinical knowledge and skills while expressing their personalities. Travel and lodging costs are eliminated, but so, too, are the opportunities to tour the facilities, eat at the cafeteria, or experience life in the area where the program is located. Likewise, programs will not have the opportunity to observe students examining patients or interacting with their peers and future colleagues.

Medical education and the residency application process have been completely uprooted by the COVID-19 pandemic. Although many students have participated in away rotations in the past, new safety regulations shifted many facets of medical education to the virtual space. Virtual rotations, meet-and-greets, and other educational experiences have emerged to fill these voids and help provide students insight into programs and avenues for mentorship. Despite the inherent limitations, they may become a staple of interdepartmental experience even beyond the COVID-19 pandemic.

Meriem Mokhtech, MD, PGY-3, Department of Therapeutic Radiology at the Yale School of Medicine in New Haven, CT; Wesley J. Talcott MD, MBA, PGY-4, Department of Therapeutic Radiology at the Yale School of Medicine in New Haven, CT; and Henry S. Park, MD, MPH, assistant professor, Department of Therapeutic Radiology at the Yale School of Medicine in New Haven, CT; and the Yale Therapeutic Radiology Virtual Rotation Committee authored this piece.

Nipun Verma, MD, PhD; Megan E. Kassick, MD; Joseph A. Miccio, MD; Jason M. Beckta, MD, PhD; Vikram Jairam, MD; Suzanne B. Evans, MD, MPH; Roy H. Decker, MD, PhD; and Kimberly L. Johung, MD, PhD; contributed equally to this report.

Rose S. Medical student education in the time of COVID-19. 

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Hammoud MM, Standiford T, Carmody JB. Potential implications of COVID-19 for the 2020-2021 residency application cycle. 

Kouzy R, Abi Jaoude J, Yue J, et al. Applying to radiation oncology amid a pandemic. 

. 2020;5(4):777-779. doi:10.1016/j.adro.2020.06.017

Virtual Radiation Oncology for Medical Students. Accessed October 23, 2020. https://www.radoncvirtual.com

Pollom EL, Sandhu N, Frank J, et al. Continuing medical student education during the coronavirus disease 2019 (COVID-19) pandemic: development of a virtual radiation oncology clerkship. 

. 2020;5(4):732-736. doi:10.1016/j.adro.2020.05.006

The coronavirus disease 2019 crisis has changed all aspects of medical education but perhaps altered clinical education most dramatically.

Creating the In-Person Experience on a Virtual Platform

Michael J. Robertson, MD, took the road less traveled to a medical career. He was studying English literature at the University of Illinois at UrbanaChampaign when he suddenly knew what he wanted to do with his life. 

“Honestly, it sounds weird,” he said. “I had an epiphany walking across campus in the middle of my sophomore year saying, ‘You know what, I really think I want to become a physician.’”

He earned a BA in English literature while playing catch-up in his premed classes. Eventually he earned his MD from the University of Chicago Pritzker School of Medicine before completing clinical fellowship training in medical oncology and a research fellowship in tumor immunology at the Dana-Farber Cancer Institute and Harvard Medical School in Boston, Massachusetts.

He then returned to his Midwest roots, joining the staff at Indiana University School of Medicine in 1996. He’s been working with fellows ever since.

“It’s very exciting to work with young people—to teach them, to help them learn new things, and to learn from them. They’ve got all kinds of ideas and thoughts that old people like me would never come up with,” he said. “It’s very refreshing. I just find it a very exciting thing to keep me alert and learning new things.”

 about the value of fellowship, choosing a career path, and the second epiphany that led him to focus on one of the hottest topics in oncology years before it became a viable treatment option.

What did you gain by completing a fellowship?

It’s a huge growth period. Even after you finish medical school and residency, when you start fellowship, you’re learning a whole new field. You don’t get much exposure to hematology/oncology as a resident, at least not in the days when I was doing my residency. Therefore, it was a gigantic learning experience to just learn all this new material. 

My second epiphany was that I decided I wanted to do research in immunotherapy which, way back then, was not what it is today. It was really kind of a black box and a lot of people thought it wouldn’t work. That led me to go in the lab for 3 years to study tumor immunology before I resumed doing mainly clinical things. It’s just a gigantic learning experience.

There are any number of potential jobs for a fellow. What do you tell your trainees about choosing a career path?

You’ve got to make sure what you choose is where your passion lies. You’ve got to make sure it’s [something that] really drives you. The worst thing I can imagine is for someone to choose a path and end up doing something that they find not compelling or not totally absorbing. I tell them to search deep in their souls to see what it is that really makes them click, what really appeals to them, what makes them want to get up every morning and go do it. Whatever that is, whether it’s clinical care, whether it’s clinical research and care, whether it’s basic laboratory research, whether it’s pharmaceutical development, whether it’s public health. Whatever that thing is, you’ve got to figure out what really is you.

Does a physician need to come into fellowship knowing where they want to specialize?

Most of our fellows at IU don’t come into the fellowship knowing for sure what area of hematology/ oncology they want to do. They usually have a pretty good idea of whether they want to do academics or private practice, but they usually don’t know, even if they know they’re going into academics, whether it’s going to be breast cancer research they want to focus on or lung cancer research. 

The first year is so incredibly busy, I tell them to just go out there during your first year of fellowship and be immersed in everything and see what grabs you and almost always something grabs them during that first year if they don’t already have a predilection. 

It is probably as likely that someone comes in thinking they know what they want to do and they change during that first year as it is that they continue with what they felt they wanted to do when they start. Until fellowship, they don’t really get exposed to the bread and butter of hematology/oncology. It’s usually skewed heavily toward inpatient experiences, which are totally nonrepresentative of most of what happens in our field.

How can fellows make the most of virtual mentorship when it’s difficult to have face-to-face interactions right now?

We still have to have the door open, metaphorically, if not literally. It’s tough to do this kind of stuff remotely, but we have to do it. We still do our meetings, and we still do our conferences, it’s just all done virtually now. That’s not the optimal way to do it. But we’ve still got to make life go on. We can still do those activities face to face, albeit through computer screens, as opposed to sitting across the desk from one another. Although I wish we could do it live, I think this is what we’re going to be doing for a while. I think it works. It’s just not optimal.

What have you learned about improving the process of mentoring online?

One of the things virtual mentoring requires is face time. Even though it’s through a screen, it’s much better to do it face to face. Doing it by telephone-only, you could miss a lot of cues in people’s expressions and gestures—that’s how people communicate. Being attuned to those cues isn’t much harder to do virtually, honestly. Those same cues are there. The main thing is just to try to make it feel as comfortable and as normal as we can. Try to treat it as if we were sitting across the desk from one another and not sitting and looking at a computer screen at one another.

How do you help trainees manage their time and their wellness?

The main thing there is collegiality and being supportive of one another. Fortunately, our program is a very collegial program for fellows and the faculty are very open to one another and talking to one another. Faculty always welcome the fellows to talk with them. If they have problems, we all know that we can find a sympathetic ear to talk to and more than one sympathetic set of ears to talk to. It’s really the fellows supporting themselves and the faculty helping to support the fellows. I don’t know of any better way to do it than everyone realizing we’re all going through tough things and we all have our bad days and we need to support one another. That seems to be what we do in our program very well, I think.

Michael J. Robertson, MD, discusses the value of fellowship, choosing a career path, and the second epiphany that led him to focus on one of the hottest topics in oncology years before it became a viable treatment option.

December 2020 | Oncology Fellows

Struggling With COVID-19 on the Cancer Floor

Student Loan Debt, Immigration Status Often Drive Career Decisions for Fellows

Creating the In-Person Experience on a Virtual Platform

Fellowship Is a Time for Growth