I envisioned my first year as a hem/onc fellow to be a time of significant growth. I would begin to tackle a steep learning curve, hone my skills in the bone marrow biopsies and lumbar punctures in which I had assisted as a resident, and—most important—increase in emotional intelligence as I helped families navigate difficult decisions about topics whose fundamentals I was still learning. I would do all this while trying to stay up to date on the scientific advances and trial data I was still trying to interpret.

I did not expect, however, to witness the health inequities I saw in midtown Manhattan. It has been a privilege to meet and care for extremely resilient patients from around the globe who have had to overcome the life-changing consequences of a cancer diagnosis while facing systemic barriers to care. Their experiences have reminded me of my roots.

I am a proud first-generation American. My family is from a small agrarian town on the banks of the Nile in northern Egypt, where my grandfather owned a cotton farm. My relatives were intelligent, resourceful, innovative, and tenacious. They worked hard to make the best of their circumstances.

Unfortunately, opportunities often fell short of their needs, particularly when it came to health care. I remember my grandmother’s stories about the long trips she had to take to receive the most basic of medical services and about the friends who, diagnosed with cancer, quickly died after getting little if any care.

For my family, inequity and disparities were tangible obstacles that had to be overcome every day. It is the same for my patients, and this shared reality has strengthened our bond.

I have trained in a variety of settings, including an NCI-designated comprehensive cancer center, the oncology clinic at Bellevue—one of New York City’s safety net hospitals—and a rural cancer center in Rwanda. What I have learned is that this disease, more than any other, reveals the systemic disparities in health care. To illustrate, allow me to mention a pair of patients with breast cancer I have seen.

In one case, a woman discovers her cancer during a biennial mammogram. Her primary care provider (PCP) immediately refers the patient to an oncologist with whom he has a longstanding relationship.

In the other case, a woman notices a mass in her breast but fears the communal stigma of a cancer diagnosis. She may determine that medical help is beyond her geographic and financial reach, which leads to delays and limited options.

The first woman has access to the latest standards of care, including treatments tested in a plethora of clinical trials. The other cannot access basic therapies that have been available in wealthier countries for more than a decade.

One woman has insurance to shoulder most of the financial burden. An oncologist familiar with the latest techniques will oversee her care.

The other will have to spend a substantial amount of her family’s income just to make the trip to the cancer center, which could take hours or even days. She could have been my mother or grandmother.

At Bellevue, we can easily see the role geography plays in cancer outcomes. Patients come to us from all over the world, and we strive to offer them advanced diagnostics, targeted therapies, immunotherapy, and a comprehensive clinical trial portfolio. We do this regardless of who they are and where they come from.

Nonetheless, I can’t help but think about those who weren’t able to pay for the flight, became too ill to make the trip, or simply didn’t know about Bellevue. I can’t help but think about my patients, who must return home owing to the intricacies of US immigration policies. I have started them on regimens that would save their lives if only they were able to continue treatment.

That’s why I ask all members of the oncology community: When will our best work reach everyone? When will people no longer have to travel halfway round the world to receive what we in the US call standard? Are we even considering ways to bring the best to them and the places they call home?

In my first year of training, I have learned that cancer affects all of us, that it is one of the most expensive diseases to treat, and that, although we share a common humanity, we do not share the same armamentarium.

To really advance equity in cancer care, we must think long and hard about where we apply innovation and how we measure success. It is essential that we accept the challenge of analyzing the process of innovation at their foundation to ensure that equity is intentional rather than retroactive and that equity includes all patients. Innovation that misses the many is innovation that misses its potential.

As professionals dedicated to fighting one of humanity’s greatest enemies, we must remember the millions who cannot access the fruits of our labor. For the sake of people like the mother in Africa with HER2-positive breast cancer and those in Egypt who my family knew and loved and lost, we must consider the democratization of innovation as a monumental innovation in itself.

Kevin Diasti, MD, is a Hematology and Oncology Fellow at Perlmutter Cancer Center at NYU Langone Health in New York, New York. 

Articles

To really advance equity in cancer care, we must think long and hard about where we apply innovation and how we measure success. 

Geography Should Not Be Destiny

I remember exactly where I was when I first saw the footage of George Floyd’s murder.

I was at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center, where I spent most of my time as a first-year oncology fellow. Walking to the team room after consults, I got a notification on my phone and opened the video. The hall around me went dark. I felt nauseous and had to brace myself against a wall.

For a moment, I forgot everything else—the consult service, the bone marrow biopsies I had to perform, the patients starting chemotherapy that day, the notes I had to write. Floyd’s pleas, the fear in his voice, and the cold, emotionless look on Minneapolis Police Officer Derek Chauvin’s face as he knelt on Floyd will be forever etched in my mind.

That afternoon, the other fellows and I were trying to process the horrific act we and the nation had seen. The deaths of Breonna Taylor and Ahmaud Arbery just months before only sharpened our feelings of helpless anger. We talked about the brutality of the killings, the distrust that exists between Black Americans and the police that are supposed to protect them, and the injustice of our society as a whole.

But we also talked about the problems we saw in the hospital every day: racial gaps in health care, the challenges colleagues of color face, racism in our profession, and the way the health care system has its knee on the necks of the underserved.

Those conversations continued over the ensuing days and weeks. Someone pointed out that it was the first time we had talked as a group about pervasive racial injustice in the US. As difficult as the discussions were, it felt good to talk, to get those topics out in the open. But we wanted to turn that talk into action.

Jacquelyne “Jackie” Gaddy, MD, and I had an idea. We wanted to expand the conversation beyond our team room and into the division as a whole. We wanted to challenge the faculty, leadership, and our colleagues to make institutional changes to better care for patients of color, better support faculty and trainees of color, and fight injustice in the health system.

Of course, we weren’t the only ones advocating for change. Across the nation, institutions of all types were grappling with the same questions. Fortunately, UNC had already begun working on a training course for internal medicine residents about race and racism in health care that would soon be introduced.

 Jackie and I began to adapt that course to the needs of oncology fellows. After some work, we approached leadership about discussing the course at the divisional conference. Thankfully, they shared our view and spotlighted the proposed course at divisional meetings.

Our course, which was delivered via Zoom, consisted of 4 sessions. The first focused on implicit bias, and we asked participants to take the Implicit Association Test beforehand and discuss what they had learned. In session 2, we presented a case in which implicit bias impeded high-quality cancer care and talked about how to mitigate such bias. Session 3 was devoted to a “journal club” on the use of race in clinical calculators across medicine, and we debated how this could influence delivery of care and affect disparities.

Session 4 featured a highly respected health services researcher in genitourinary oncology who spoke about his decades of work on advancing equity in clinical care. Our division chiefs also participated in this session, which centered on creating a more equitable health system. We surveyed participants and found that they were “significantly” interested in future sessions. Finally, we presented the series at the 2022 American Society of Clinical Oncology (ASCO) annual meeting and submitted a manuscript.

Did we achieve what we set out to do? Partly. Racial inequity has developed over centuries, and we cannot hope to reverse it with a course for oncology fellows and an ASCO poster. But we do see our efforts as a first step, and we encourage other institutions to follow. To that end, we want to share what we have learned.

First, collaboration is critical in diversity, equality, and inclusion efforts. Because we partnered with colleagues in other divisions and training programs, we benefitted from their experience and were able to reach a wider audience. Our work is now aligned with that of the Lineberger Equity Council, which is tasked with improving equity at UNC’s cancer center.

Second, nuanced conversations about race and bias can promote equity. A training course doesn’t change policy, improve access to care, or mitigate bias. But by inviting faculty and fellows to discuss these topics, we can help realign priorities and encourage leadership to hire diverse faculty, fund care delivery projects aimed at reducing inequities, and emphasize community outreach. Shifts in priorities are what lead to progress.

Finally, trainees can have an impact on their institution. After those conversations in the team room, Jackie and I were able to change the divisional curriculum. Our energy and enthusiasm have influenced others. And we hope that many more will use their passion to make equity in cancer care a reality.

Jacob N. Stein, MD, MPH, is an assistant professor in the Bone and Soft Tissue Oncology Program in the Division of Oncology at the University of North Carolina School of Medicine in Chapel Hill, North Carolina. 

Nuriddin A, Mooney G. White AIR. Reckoning with histories of medical racism and violence in the USA. 

. 2020;396(10256):949-951. doi:10.1016/S01406736(20)32032-8

Internal medicine residency program holds noon conference series EMBRACE: “Ending Medical Bias and Racism by Advocating for Change and Equity.” News release. UNC School of Medicine. October 29, 2020. Accessed August 23, 2022. https://unc.live/3KfkLmZ

Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms. 

. 2020;383(9):874-882. doi: 10.1056/NEJMms2004740

Stein JN, Gaddy JJ, Sorah JD, et al. Seeking racial equity in hematology and oncology: a fellow-led educational series to promote reflection and action. 

. Published online June 2, 2022. doi:10.1200/JCO.2022.40.16_suppl.11004

UNC Lineberger Equity Council phase 1 recommendations. UNC Lineberger Comprehensive Cancer Center. Accessed August 23, 2022. https://bit.ly/3AIYr1S

Oncology fellows at the University of North Carolina turned their despair over the murders of George Floyd and Breonna Taylor into an effort to improve racial equity. 

From Anguish to Action: Turning Despair Into Efforts to Improve Racial Equity

Abhinav Deol, MD, grew up in Punjab, India, and earned an MBBS in 1999 from Government Medical College in Amritsar. After a relative died of head and neck cancer, he became interested in oncology, but because in India cancer is treated primarily with surgery, he decided to study medical oncology abroad.

“I did not see many training avenues in India, [so] I decided to pursue it in the United States,” he explained, adding that he “really liked the program…at Wayne State…because we got a chance as…residents to work at [an] NCI-designated cancer center.”

His time at the Institute deepened his desire to pursue a career in hematology/oncology, and he became a fellow at Karmanos in 2007 and joined the Wayne State faculty in 2010. In 2018, he became director of the Karmanos Hematology/Oncology Fellowship Program. Teaching is his way of keeping his skills sharp and influencing the next generation of physicians. 

“If you decide to be a teacher, you have to know your topics,” he said. “That’s what made me interested in… medical education, and being able to interact with people who are so passionate and starting off in the field. They’re passionate about learning more, and that keeps me interested and able to keep up with all the [new] information…in…medical hematology and oncology.”

to discuss how Karmanos prepares trainees for their first job and helps them handle negative situations and deal with grief. But first, we talked a bit about why he chose to remain at the Institute after residency. 

“I wanted to stay…in the heart of downtown Detroit,” he said, to “offer clinical trials and innovative…therapies for a wide variety of cancers, not only to the patient population…here, but…also…[to] people…traveling… across the state for clinical trials. Having access to… innovative clinical trials, being able to provide care to the patient population that I had had the most experience [with] since I came to the States, and [working with] the people that I worked with during my training were the leading reasons that I chose this place for fellowship.”

: What do you want fellows to take away from your program? 

: I hope that fellows…take away a strong clinical training. We…[have a] very strong…program [and]…world leaders in the field…[as] part of our faculty. Also, the fellows get exposed to lots of innovative clinical trials. Our hope is that…they have…a passion for research and…can take that to the next level as they start their clinical careers.

How do you prepare them to look for that first job? 

Over the past couple of years, we’ve realized that that is…[what] is lacking in…academic medicine. We’re all focused on learning the best…way of…treat[ing] the cancer. But…there are very few opportunities…for… trainees to…make sure…their CV is in order…that they’re getting the research portfolio beefed up so that when they apply for their first academic job, they have the…background to…have a shot at that job. 

[O]ver the past 2 years [we] have [had] a series that we’ve dubbed…Job Talk. [O]nce a quarter…we focus… on clinical documentation with a view towards… what is needed from the billing standpoint. Also [we focus] on…mak[ing] sure…their CV is templated well and…they can…go out for interviews in terms of their research background. We plan to include a session on financial literacy in the future.

What advice do you give fellows who have to deal with sexual harassment or unethical behavior? 

Communication is the most important thing. We have multiple meetings with…trainees…to make sure that they don’t feel like it’s something that they can’t bring up to somebody in the department and always encourage them to reach me, our program coordinator, the associate program director, or any of the faculty members or other fellows that they feel comfortable talking to. We will do everything in our power to make sure that…[problematic] behavior is corrected right away, and they don’t feel like they are made to pay a price for bringing up an issue.

We recently also…[put a] box in the fellows office… [for] anonymous complaints in case they notice anything that they don’t feel comfortable bringing up on their own, so…[it] can be brought to the attention of the program. I have open channels of communication with the cancer center, with the graduate medical education office, so we can bring those [issues] up through the chain of command to make sure that…the fellows don’t have to be subjected to any kind of harassment.

Patients and oncologists can become very close during a treatment period that lasts for years. What do you tell fellows about managing grief when a patient dies? 

That is, I think, one of the most challenging parts in our field. What I find helps me deal with loss…is to make sure that the patient and…[I] are on the same page in terms of understanding that, whatever the… therapy,…there are certain things that are beyond our control. Most of the therapies don’t have [a] 100% response rate. And as we learn more about why certain patients respond…[and] don’t respond…we can continue to improve…outcomes.

Abhinav Deol, MD, discusses how Karmanos Cancer Institute prepares trainees for their first job and helps them handle negative situations and deal with grief. 

Fellows’ Passion Keeps Deol Sharp and Up to Date

Welcome to another professional milestone. As you embark upon your hematology-oncology journey, I want to tell you a few things I wish I’d known years ago. By way of introduction, let me say that I completed my fellowship in 2001 and have remained in academia. I have served in various capacities at several universities, focusing largely on professional development, and am a mentor for the American Society of Clinical Oncology Leadership Development Program. My thoughts are based on my experiences and observations.

The stakes are higher now that you are fellows, not residents. The goal is to prepare you for any situation and clinical scenario, and this is important because lives are at stake. So, your consult rotations will seem never-ending, and you’ll get little sleep on call nights. That’s all part of being an oncologist.

Expect to be tired but develop a sustainable self-care strategy. You cannot control the number of patients who need your services, but you can control how you handle the rigor of your training. Training in this subspecialty is a choice and an honor. Give yourself permission to ask for help, take an extra day off if you need it—with input from leadership—and take deep breaths. Your program believes in you and believes that you can do it. Out of all the applicants, they picked you for a reason.

See previous section. You are going to work hard, probably harder than ever. The nights will be long, the work will be challenging—even on the best days—and both fatigue and coffee will be your constant companions. But an exhausted fellow is an ineffective physician.

Only you know how much you can handle and where you need to draw the line. Fellowship, like all of oncology, is a team sport, and you will need to ask your teammates for help. Every program has “pop-off valves” to help with high patient volume and promote personal wellness. Learn about these resources and take advantage of them.

They care about you and want to help you succeed. They are invested in your future because, once again, they chose you. Assume that they have good intentions, but notify leadership if this seems not to be the case.

A lapse in professionalism is the quickest way to derail a promising career. Some of the most common lapses involve arrogance (you’re right and everyone else is wrong), victim mentality (others are always to blame for bad situations), habitual distrust (you focus on the negatives), and passive resistance (your silence is misinterpreted as agreement). 

One of the most important skills you can have is the ability to think about alternative ways to achieve a desired outcome. Don’t try to rally a fellowship class or program around your perceived grievance because the resulting chaos and hostility will reflect negatively on you.

We can all be our own worst critics, but the truth is that our thoughts about ourselves are not necessarily correct. I commonly see trainees and faculty who zero in on the one criticism they received while ignoring all positive feedback.

For days or months afterward, the person focuses on the negative reaction and sets up a spiral of shame and self-doubt. Coupled with the stress and fatigue of a hem/onc program, this way of thinking can destroy anyone’s mental health. Try to recognize cognitive distortion and find a colleague who can assess the situation objectively and help you look at the issue differently.

This can be a difficult concept to grasp. It is not the same as arrogance. Managing up means that you let mentors and program leadership know about your successes. It’s not bragging, which asserts that you are better than others. It’s about leveraging your successes into greater career opportunities.

As a former program director, I can tell you that if you are successful, the program as a whole is successful. Telling people about the amazing things you’re doing will increase your networking opportunities and the sponsorship and mentorship you’ll get within and without your institution. 

Remember that a fellowship is like a long job interview. Even if you don’t intend to stay at the hospital after graduation, the way you handle and prepare yourself during this period will affect the rest of your career. Good luck, and don’t forget to have fun.

Jill Gilbert, MD, offers advice for the start of a new fellowship in oncology and hematology.

Vol. 14/No. 3 | Oncology Fellows

Geography Should Not Be Destiny

From Anguish to Action: Turning Despair Into Efforts to Improve Racial Equity

Fellows’ Passion Keeps Deol Sharp and Up to Date

A Primer for New Fellows