Using wearable activity monitors may eventually supplement standard assessments of performance status (PS) and functionality that could inform clinicians, especially because objective evaluation of PS is difficult to determine. Patients spend most of their time outside of the clinic, self-report to providers, and undergo changes throughout treatment. Findings from a recent study at Cedars-Sinai Medical Center (CSMC) in Los Angeles, California, demonstrated the feasibility of using these wrist-worn devices to correlate with Eastern Cooperative Oncology Group (ECOG) PS and Karnofsky PS (KPS) scales.1 PS is affected by bias, resulting in patient activity being over- or underreported, which can affect short- and long-term treatment plans and clinical trial eligibility.

“Before we can ask if these devices can change practice or replace these standard assessments, we need to determine if it’s feasible for the patient to use them, [and] to wear them, and if there are any challenges with their use,” said Gillian Gresham, PhD, lead author and postdoctoral student at CSMC. “After establishing short-term feasibility, we can begin to explore whether these measurements correlate with standard assessments, patient-reported outcomes, and predict clinical outcomes,” she added.

Additional objectives of the study included measuring patient reported outcomes (PROs). “We were able to correlate PROs such as improved physical functioning, better pain tolerance, improved sleep, and lower levels of depression with increased activity, as measured using the devices,” Gresham said.

Thirty-seven patients (20 men) with stage IV or unresectable advanced stage III cancer agreed to participate in the single-center, single-cohort study that evaluated the Fitbit Charge HR device to measure daily activity. Patients of varying ECOG PS and KPS ratings participated, with participants agreeing to wear the Fitbit for 3 consecutive clinic visits over 2 weeks, in which ECOG PS and KPS were assessed. Associations between metrics (steps, distance, and stair climbing) and PS, clinical outcomes (adverse events [AEs], hospitalizations, and survival), and PROs were determined.

Heat Map of Average Activity Intensity for Each Patient Over a 24-hour Period, as Measured by a Wearable Activity Monitor and Sorted by ECOG PS Categories

Median age was reported as 62 years (range, 34-81). At baseline, patients’ ECOG-PS scores were 0 (24%), 1 (35%), 2 (24%), or 3 (16%). The majority of patients were diagnosed with gastrointestinal cancer (n = 27) and had stage IV disease (n = 34). There were 2 patients with locally advanced stage IV pancreatic disease and 1 patient with stage IIIB endocervical serous carcinoma.

The highest correlations were observed between average daily steps and both PS scores. Each 1000 steps/day increase was associated with reduced odds for AEs (odds ratio [OR], 0.34; 95% CI, 0.13-0.94), hospitalizations (OR, 0.21; 95% CI, 0.56-0.79), and hazard for death (hazard ratio [HR], 0.48; 95% CI, 0.28-0.83). On average, patients walked about 3700 steps, or 1.7 miles, a day, climbed 3 flights of stairs daily, and slept 8 hours/night as measured by their wearable device (

Although the device doesn’t measure heart rate the same way electrocardiograms do, it estimates heart rate by measuring blood flow through pulse readings. “We lined up measurements of the heart rate at a specific time in the clinic and matched it during the time that the patients were wearing the Fitbit and looked at the comparison of those 2 findings for each clinic visit,” said Gresham. “They were very closely related. That was encouraging but warrants further investigation.”

The investigators were, however, intrigued by the poor correlation between sleep quality and duration (as measured with the device), said Gresham. “I think we need more granular-level data with regards to sleep,” Gresham said. “[Although] Fitbit has improved its sleep recording quality since we completed the study, it opens up a new and interesting facet of research,” she said. “It also highlights the importance of the patient’s voice in their management, and is an example of how a patient’s perception of their sleep quality may not always match what is measured. Perhaps in this case, quality does not mean quantity.”

Using the device did allow patients to engage more with their physicians, according to the authors. Patients could discuss symptoms, provide information about their level of activity, and ask questions that providers don’t usually get a chance to talk about with the patient. “It’s a way to engage both with the patient and providers—something that I think is highly valuable in patient care,” added Gresham.

The device data also revealed interesting details about the patients’ daily lives that may not always be apparent during clinic visits, according to Gresham. For example, an older patient appeared frail during clinic visits, and scored a lower PS rating. The investigators found that after a week of wearing the Fitbit, the patient averaged almost 15,000 steps a day. “It turns out, this particular patient was probably one of the most active patients we followed…and they didn’t just start walking more steps because of the study…they said it was part of their daily routine. These observations suggest that the use of devices can help inform and even change the course of treatment decisions and importantly, help inform treatment decisions in the future. It also reminds us that assessments should not be made based solely on age or physical appearance, but on a patient’s overall activity levels and functionality.”

The data collected by the devices can be used to fill in the gaps between clinic visits, said Gresham. “Throughout their care, we’re seeing that performance status assessments tend to be rather static and are often missing from the patient medical chart. We can now detect changes in real time by anticipating potential [adverse] effects or try to intervene a little bit sooner if complications or adverse events occur. It also allows for the patient to self-monitor themselves and notify their care team if there are changes to their usual activity levels.”

Data were collected through the device’s online dashboard, and each patient was provided an anonymous, de-identified email account that was used to register the Fitbit, access their activity data, and receive email summaries of weekly activity levels. Investigators observed a range of attitudes towards the devices. Some patients “explored the technological abilities of the device, and others just wore it like a watch,” Gresham said.

The data collected by devices like these could give oncology fellows access to information that they otherwise would not have had before, said Gresham. “Currently, along with the enterprise information services department here at CSMC, we’re working to integrate the wearable data into the patient’s medical chart,” she said. “The more knowledge that can be gathered about the patient beyond the clinic assessment could give the fellow an idea about the patient’s daily routine, levels of activity, and the patient’s standard for normal.”

In the long term, the data can be tracked from initial diagnosis, treatment, potential cure, and recurrence. The fellow has a way to monitor the patient, especially for patients who might have difficulty going to the clinic for various reasons such as socioeconomic or reliable transportation, she added.

The findings provide new information regarding the use of an emerging technology in cancer clinical settings. The incorporation of wearable activity monitors to correlate with functional and clinical outcomes are only beginning to be reported, according to the authors.

It is not clear whether activity monitor data can replace ECOG-PS or KPS assessments, but they can provide supplemental data for current functionality tools. Not only were step counts and other activity metrics correlated with PS, but they also provided a more detailed and continuous account of patients’ activity levels with the added benefit of being recorded in the patients’ free-living environments.

In the future, Gresham said the investigators would like to see if the data could be used as stand-alone functional outcomes to evaluate the impact of a particular intervention or treatment on the patient’s daily activity. “Like patient reported physical function and activities of daily living, frailty status, or provider assessed performance status, we would like to see ‘activity,’ as something clinicians can use to assess a patient’s functionality. Maybe some day in the future, we can incorporate physical activity recommendations or ‘activity prescriptions’ into the routine care of patients with the goal of improving health outcomes,” she said.

Gillian Gresham completed this work under the supervision of Steven Piantadosi, MD,PhD, Curtis Meinert, PhD, and Arvind Shinde, MD, MBA, MPH (senior author of the paper).

Gresham G, Hendifar AE, Spiegel B, et al. Wearable activity monitors to assess performance status and predict clinical outcomes in advanced cancer patients. 

 2018;1(27):1-8. doi:10.1038/s41746-018-0032-6.

Articles

Using wearable activity monitors may eventually supplement standard assessments of performance status and functionality that could inform clinicians, especially because objective evaluation of performance status is difficult to determine.

Should Fitness Trackers Be Used to Assess Performance Status in Patients With Cancer?

A National Center for Health Statistics (NCHS) briefing stratifies liver cancer mortality by sex, ethnicity, and age for adults aged 25 years and over. Overall, death rates increased significantly for both sexes, with death rates for men 2 to 2.5 times the rate for women from 2000 through 2016. The news for non-Hispanic white, non-Hispanic black, and Hispanic adults is not good, either, with increased liver cancer death rates reported for these populations. However, liver cancer deaths declined for non-Hispanic Asian or Pacific Island (API) adults during the same time period.

Specifically, liver cancer death rates for adults aged 25 and over increased 43%, from 7.2 per 100,000 US standard population in 2000 to 10.3 in 2016. Age-adjusted death rates for liver cancer increased 43% for men (from 10.5 to 15.0 per 100,000) and 40% for women (from 4.5 to 6.3) (

). When ethnicity was considered, the age-adjusted death rate increased for non-Hispanic white, non-Hispanic black, and Hispanic adults but decreased for non-Hispanic API adults (Figure 2).

When particular age groups are stratified, Jiaquan Xu, MD, author of the data brief, said that among patients aged 55 to 64 years, liver cancer death rates rose from 2000 through 2013. Since 2013, the rate remained stable until 2016, the last year that records were available.

“If we look at the age group [of] 45 to 54 [years] from 2000 to 2005, the rate has increased, but from 2005 through 2012, the rate has remained stable. Further, since 2012, it has decreased by about 20%. That looks like a good sign for the younger age group,” said Xu, an epidemiologist at NCHS.

Figure 1. Age-adjusted Death Rates for Liver Cancer Among Adults Aged 25 and Over, By Sex: United States, 2000-2016

For adults aged 65 to 74, the rate increased 7% from 2000 to 2008 (from 18.7 to 20.0 per 100,000) and 37% from 2008 to 2016 (from 20.0 to 27.3). The 2000-2016 rate increased 35% (from 29.8 to 40.2) for adults aged 75 and over. The liver cancer death rate was the highest for adults aged 75 and older, followed by age groups 65 to 74, 55 to 64, 45 to 54, and 25 to 44 years.

Although the non-Hispanic API group had the highest liver cancer death rates during 2000 to 2014, among the 4 races and Hispanic-origin groups, this group experienced the only decrease (22%), from 17.5 in 2000 to 13.6 in 2016. For Hispanic adults, the liver cancer death rate increased 27%, from 11.5 in 2000 to 14.6 in 2016, surpassing the rate for non-Hispanic API adults that year.

Figure 2. Age-Adjusted Death Rates for Liver Cancer Among Adults Aged 25 and Older, by Race and Ethnicity: United States, 2000-2016

In 2016, Washington, DC, had the highest age-adjusted liver cancer death rate (16.8 per 100,000 US standard population), and Vermont (6.0) had the lowest rate. “When we look at liver cancer among non-Hispanic blacks, the death rate for liver cancer seems to be rising. Given the population of the Washington, DC, area, that could be 1 of the factors that led to the higher rate,” Xu said.

Behind Washington, DC, age-adjusted death rates for liver cancer among adults were highest in Louisiana (13.8), Hawaii (12.7), and Mississippi and New Mexico (12.4 each) in 2016. The 5 states with the lowest age-adjusted liver cancer death rates were Vermont, Maine (7.4), Montana (7.7), and Utah and Nebraska (7.8 each).

Xu J, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final Data for 2013.

Xu J. Trends in liver cancer mortality among adults aged 25 and over in the United States, 2000-2016. 

A National Center for Health Statistics briefing showed that liver cancer death rates increased significantly for both sexes, with death rates for men 2 to 2.5 times the rate for women from 2000 through 2016.

Steady Increase in Liver Cancer Death Rates Observed in Adults Aged 25 and Older

 It was a common question to be asked as children, as soon as we learned the meaning of the words “job” and “work.” By the time I graduate from high school, I am answering earnestly, “I want to be a doctor.” I am blissfully unaware that no one at age 18 has any inkling of what that means. And so emerging adulthood begins, as described by Jeffrey Arnett in 2000, pertaining to young adults between 18 and 25 years of age who do not have children, do not live in their own home, or do not have sufficient income to become fully independent.¹ It is the period of time when adolescents become adults by exploring the seemingly endless possibilities of life directions.

What do you want to be when you grow up? 

In college, my understanding of this mysterious guild guarded by the Hippocratic Oath does not grow much. I know that I want to help people, change the world, and have enough money for a comfortable lifestyle. Medicine still seems like a great career to accomplish those goals.

In medical school, I still want to help people and change the world; but in the meantime, I need to study, study, study; then choose a residency; and then match. I keep my head in the books because fear of failure is always crouching at the door. Selfishly studying sucks out the sense of personal achievement and feeds professional burnout, especially when nostalgia for the college days, when I used to help people in tangible ways, hits. I console myself and strengthen the delayed gratification muscle: “It’s just temporary. Study now, so you can be a better doctor and help people more effectively in the future.” Even after I start rotating wards and studying is no longer occupying the majority of my days, I’m at the bottom of the totem pole and not sure how to navigate my role. Confidence and the sense of personal achievement are at all-time lows. By the time I graduate with my medical degree, I begin to wonder, “When am I ever going to graduate from emerging adulthood and reach adulthood?”

 I want to help people, and as an intern, I finally can. Those moments, I think “I’ve finally arrived.” My new goal is to be a competent physician. Being a consistently excellent physician seems like an unrealistic goal on most days. I’m just trying to survive, like Cosette sweeping the floor, singing “Castle on a Cloud.

The only way to stay afloat is to figure out what my superiors want of me. But I start learning to tell stories, narratives that illuminate different perspectives of familiar situations faced by the medical trainees; that acknowledge and interpret the challenges common in our interactions with our colleagues, patients, and society; that absorb and interpret experiences in a way that shapes our character and how we see our role in the world.3-7 Stories become a modality for discernment: “Of all the things I do, which things matter? Which threads do I want to keep and weave into the narrative of my life? How do these threads give me hope for a meaningful future?”

What do you want to be when you grow up? Having miraculously survived internship, I am now a resident applying for hematology-oncology fellowship, after meeting several admirable attendings and thinking to myself, “They are great people. I want to be that efficient and effective, influence medical students and residents, practice fantastic communication skills, and show compassion to patients and colleagues.” By now, I’ve been in a rigorous academic environment for 20 years. The atoms of academic curiosity make up the air I breathe and are embedded in every cell of my soul, becoming the framework for an academic career.

What do you want to be when you grow up? Fellowship is like intern year all over again—in other words, survival mode. Two years pass, I’m in 26th grade, and oops, I realize the feeling that I’m Cosette hasn’t left me, that I’m sweeping the floor, but I am increasingly urged to straddle 2 worlds, as well-intentioned superiors admonish me, “Start building your castle now. How many floors? How many staircases? What color walls?” as the adult questions percolate in a befuddled puddle in my mind. Do I want to join a group private practice and have a comfortable lifestyle, with time to be a human being outside of medicine, but stoop to conniving business relationships and grovel for referrals? Do I want to stay in academics, preserving my naïve, idealistic self who doesn’t have to plot shrewd business moves, but remain under the mercy of institution politics? Do I want to spend my days being creative, asking questions and designing research studies to answer them, but under the gun of submitting grants every 6 weeks? And then there’s industry&mdash;I don’t know much about that aspect of the medical world, but I’m pretty sure I don’t want to travel that much.

I begin to realize that we have stereotypes of all these careers, and we’re expected to apply for jobs based on these skewed stereotypes. Additionally, we are trained to be perfectionists and excel at everything—teaching, clinical acumen, communication, research&mdash;just like Cosette is certainly trained to sweep, wash dishes, do laundry, scrub the floors, and more.

Does it come down to “just do/pick something?” Maybe there is no wrong choice. My theory is that many of us make decisions based on the stereotypes of these careers and the stories we tell about ourselves. We develop an identity as an altruistic person, and the only way we can be in underserved care is to stay in academia. Or we develop an identity as an altruistic person, but we have too much debt, so we need to go into private practice, and we tell ourselves we’ll make up for it in the future by donating to worthy causes. Or we develop an identity as a smart person who thrives during tumor board discussions, and we get on the academic clinician-educator track. Or we develop an identity as a smart person who wants to leave a mark forever on medical history, and we jump on the academic physician-scientist track.

Maybe we need to start telling more nuanced stories about ourselves and these careers. We need altruistic, pragmatic people in industry, committed to the delivery of effective drugs to people in need. We need creative clinicians in communities everywhere, willing to use their brains in applying evidence-based medicine to each patient individually, rather than universally or blindly following heuristic techniques. We need business-minded entrepreneurs in global health who can negotiate, forecast, and lead within cost-effective, sustainable growth models.

Many of us may feel like we don’t have stories to tell. Where do we find the setting, the characters, and the storyline? We need to reach down into our memories, search for, and reflect upon:

The people with whom we enjoyed working with or the patients we have enjoyed helping

The working conditions that enabled us to work at our top form and effectiveness

The organizations most in line with our mission or purpose in life As Andrew Delbanco

 The Real American Dream: A Meditation on Hope

At the heart of any cohesive culture is a story that gives it hope, a story that helps us overcome the lurking suspicion that all our working and getting and spending amounts to nothing more than fidgeting while we wait for death. Hope depends on finding some end to be pursued more extensive than merely instant desire…Without it, we are, as the anthropologist Clifford Geertz has put it, “a kind of formless monster with neither sense of direction or power of self-control and a chaos of vague emotions.”

Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. 

. 2000;55(5):469-480. doi: 10.1089/jpm.2011.0458.

Hugo V. Les Misérables. 2nd ed. New York, NY: Signet Classics; 1987.

 2012;15(5): 615-616. doi: 1089/jpm.2011.0458.

Chang E. The paradox of professionalism. 

 2013;88(8):1128. doi: 10.1097/ACM.0b013e31829a6855.

Campbell SR, Chang E, Shah CJ. A spoonful of insight makes the medicine go down. 

 2014;17(5):621-622. doi: 10.1089/jpm.2013.0443.

Campbell SR, Chang E. Memoirs of an ACGME resident member. 

2014;6(3):595-596. doi: 10.4300/JGME-D-14-00260.1.

The Real American Dream: A Meditation on Hope. 

Cambridge, MA: Harvard University Press, 2000.

Faced with a persistent question from her teenage years, Elaine Chang, MD, may have come up with an answer.

Emerging Adulthood: From Adolescent to Attending Physician 

I eagerly awaited the next patient to be put into a room. I had reviewed his large pile of medical records the night before and knew he was coming in to potentially enroll in a phase I/II clinical trial that was evaluating a new drug in patients with a specific actionable mutation. His tumor had developed this alteration as his metastatic disease worsened, which had already progressed through multiple lines of prior therapy. He came to us as a last resort.

As I walked into the room and greeted him and his wife, I vaguely caught a sense of anxiety but ignored it because I had more important things to discuss. After taking a history, which I already knew from the night before and upon finishing a complete physical exam, I launched into my usual sequence of discussion. I spoke about the natural history of this cancer type and what our trial entailed. I discussed that we didn’t know if this treatment would work or not, but the preclinical data were encouraging, and we were enrolling patients to determine dose and toxicity. I then went on to discuss the adverse effects (AEs) that we had seen thus far and, finally, ended with the overall poor prognosis of this disease. I then stated that if the treatment did not have the effect we were hoping for, altruistically enrolling into this trial could potentially help another patient in the future.

The patient nodded silently throughout my rehearsed monologue. His wife frantically wrote down notes without making eye contact, and I noted that her face was flushed and she was almost in tears. When asked if they had any questions, they both appeared overwhelmed, so I walked out of the room, passively stating that I would be back with the attending physician after we discussed his case. The patient ultimately enrolled onto our trial but over time, he progressed and died.

I reflect on this and similar patient interactions that I have encountered throughout my fellowship. On the one hand, I am on the cutting edge of research and have the opportunity to enroll patients into clinical trials involving experimental therapies, often stating that we are giving “tomorrow’s cure today.” I do believe that the future of oncology is now, and in my lifetime, I hope to see cancer cured.

On the other hand, I failed to truly recognize and understand the patients whom I treated. Somewhere during my short career, I had lost the ability to build genuine relationships with the person sitting in front of me. Sure, I knew everything about their oncologic history and the mechanisms behind tumorigenesis. I worked hard and long hours making sure each patient was properly cared for. I monitored for toxicities and managed AEs. But I knew nothing about a patient’s background, family, or values. I desensitized myself from my job. I later learned that this particular patient drove several hours to receive his treatment and had been laid off from work because of missed time. He had young children at home who did not know about his diagnosis or prognosis. His wife was barely able to cope with the unfortunate turn of events that had destabilized their livelihood, yet the patient remained stoic as a way to cope with his crumbling world.

I think this apathetic mentality develops as a coping method for oncologists when frequently exposed to death and dying. After all, we are people, too, each with set limitations of what we can psychologically handle. It is easy to keep patients at a distance and close ourselves off to feeling emotion when they die. It is overwhelming to open ourselves unconditionally and feel the effects of mortality on a regular basis. I used to think that oncologists were the “angels of death,” as patients often succumbed to their disease. I thought our role was simply to prolong life and, oftentimes, prolong suffering. This detachment led me astray from what my true focus should always have been— to help a person in need.

Learning from this case, we need to remember that building sincere and genuine patient—doctor relationships is just as important as treating their illness. We have a unique opportunity for a complete stranger to put their life in our hands, and we have the ability to provide comfort, hope, and assurance in a time of fear and doubt for a patient and their family. It isn’t easy, but remember that we are allowed to grieve. It’s not a failure or a fault to incorporate compassion with professionalism. Take time to get to know your patient and remember their life as they are. We treat people, not ID numbers.

Rachel Naomi Remen, MD, clinical professor of family and community medicine, University of California, San Francisco, School of Medicine has said: “The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet…We burn out not because we don’t care but because we don’t grieve.”

Gagandeep Brar, MD, reflects on patient interactions that she has encountered throughout her fellowship.

Personalized Medicine in a Time of Depersonalized Patient-Doctor Relationships

It is difficult to stay up-to-date with the changing treatment paradigm in hematology-oncology. This field is rapidly evolving, and the explosion of information is too much to handle sometimes. Fellows in training are generally expected to stay abreast of current treatment modalities and breakthrough research, but doing so is slowly becoming a challenge for all of us. It is important to note that in 2017, the FDA issued 58 new approval notifications in hematology-oncology, much more than in any other field of medicine.

 According to an estimate from a PubMed search, more than 1.17 million articles have been published in the field of oncology over the past 10 years. Jeremy Warner, MD, MS, published a review in 2015 noting that PubMed contains more than 2.7 million articles filed under the Medical Subject Heading “neoplasms.” He also observed that the number of articles published in oncology was much higher than that of other medical fields like cardiology and endocrinology.

 These observations are a testament to the explosion of data in the field of cancer medicine.

The constant interplay of research between the disciplines of oncology, molecular biology, genetics, and bioinformatics have made this a complicated field. Although medical research data are now readily available online to both physicians and patients, it is often a challenge to glean relevant information from them. As physicians, it is very important for us to develop skills to determine what is important in the context of clinical care. It is also essential for us to pay adequate attention to rapidly evolving guidelines in oncology for the benefit of our patients. But this is a Herculean task.

There are several ways to tackle the problem of information overload. I think the most important way to stay up-to-date is to develop a habit of continuous learning. We should make every effort to block out a specific time each day to catch up on reading, even if it’s just 30 to 45 minutes. For trainees, I believe reading about different topics each day or the literature around a case presented in clinic would be ideal.

We should also take a cue from lawyers—unbelievable, I know. A lawyer friend told me that group discussions are a common practice in law school and are quite helpful in preparing students for tough internal examinations. Group discussions are a great way of improving understanding of a subject. It also helps us identify our shortcomings and weaknesses in a short span of time. Routine peer-to-peer interaction can be a useful way of staying abreast of changing guidelines and cutting-edge research.

If you ask senior oncologists, they will probably tell you to read top peer-reviewed journals, such as the 

 to stay current in hematology-oncology. Although there is no question about the accuracy and quality of data available in these journals, it is a challenge to follow all the relevant information on different disease subtypes. Hence, it is important to carefully choose and pay attention to landmark studies that have led to new drug approvals or are changing treatment strategies.

 is another easy way of keeping informed if you don’t always have the time to read journals. National meetings like those hosted by the American Society of Clinical Oncology, the American Society of Hematology, and the American Society of Blood and Marrow Transplantation are an important source of updated information for most of us. These meetings give us an opportunity to interact with experts and obtain firsthand information about breakthrough research in our field. Prioritize listening to the keynote presentations if your time is limited at these meetings. These presentations are practice changing, and their findings are fair game for future board examinations. Board review lectures are also a great resource and highlight the most recent and clinically relevant data.

Another way to stay up-to-date is by creating email notifications on PubMed for topics of interest so that every time a new article on a specified topic is published, an email notification will be sent to your inbox, and you can quickly read the article on your mobile device.

Hematology-oncology fellows, unlike their counterparts in cardiology, nephrology, rheumatology, and endocrinology, have to pass 2 boards after graduating, which adds more stress to their lives post fellowship. According to the American Board of Internal Medicine’s 5-year report of first-time test takers, the average board passing rate for hematology has been one of the worst among all specialties of medicine.

 Although board pass percentages have started to improve, it will be interesting to see whether the trend continues.

Not to sound cynical, but there can be only 2 explanations for this trend: Either test takers are becoming smarter or the test itself is becoming easier. Honestly, I feel we are better prepared for these examinations than our predecessors because of increased awareness and easy access to board review materials these days. I guess it’s also reasonable for some of us to schedule these examinations at our convenience and not take both boards in the same year if we feel that our preparation is suboptimal. Fellows should also take in-training examinations very seriously. These may help us identify areas that need our special attention and time. Results from some studies have also shown that they remain a great predictor of hematology-oncology certification examination scores and are probably more accurate than a program director’s assessment of our medical knowledge.

The incorporation of medical decision-making tools and computer applications into clinical practices has signaled a major revolution in medicine. Oncologists already use mobile apps like the National Comprehensive Cancer Network Guidelines App, UpToDate, and Medscape as convenient sources of information and to streamline treatment algorithms of disease subtypes. Mobile apps and clinical vignette modules can also be upgraded to take advantage of better graphics and animations, to enhance physician engagement with their patients, and to make learning more fun. Animation-enhanced learning can be introduced to educate physicians about specific diagnostic, treatment, and follow-up scenarios. All these ideas, if implemented in a better way, could benefit all of us.

There is an urgent need to develop better learning tools for trainees to not only stay up-to-date but to also excel in this field. As future hematologist-oncologists, we are obligated to provide the best care possible to our patients and stay informed.

Hematology/oncology (cancer) approvals & safety notifications. FDA website. www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm279174.htm. Updated June 20, 2018. Accessed July 24, 2018.

Warner JL. Grappling with the data explosion in oncology. 

 2015;11(2):102-103. doi: 10.17925/OHR.2015.11.02.102.

First-time taker pass rates - initial certification. American Board of Internal Medicine website. Accessed July 24, 2018. abim.org/~/media/ABIM%20Public/Files/pdf/statistics-data/certification-pass-rates.

Collichio FA, Hess BJ, Muchmore EA, et al. Medical knowledge assessment by hematology and medical oncology in-training examinations are better than program director assessments at predicting subspecialty certification examination performance.

 2017;32(3):647-654. doi: 10.1007/s13187-016-0993-6.

Aditya V. Shreenivas, MD, MSCR, says a habit of continuous learning is the ideal way to stay informed about the latest data.

September 2018 | Oncology Fellows

Should Fitness Trackers Be Used to Assess Performance Status in Patients With Cancer?

Steady Increase in Liver Cancer Death Rates Observed in Adults Aged 25 and Older

Emerging Adulthood: From Adolescent to Attending Physician

Personalized Medicine in a Time of Depersonalized Patient-Doctor Relationships

Keeping Ahead of Oncology Advances Requires Vigilance