With the costs of biologic drugs increasing, biosimilars have emerged as an attractive option for containing costs and expanding access to treatment. However, some barriers to wider uptake still need to be addressed, according to a presentation at the National Association of Managed Care Physicians Virtual Spring Managed Care Forum.

Sanjiv S. Agarwala, MD, professor of medicine at Temple University, explained that biologics have revolutionized the treatment of serious conditions, including cancer, over the past few decades. However, costs are a pressing issue for all providers and biologics are a major culprit, accounting for half of Medicare’s drug spending in 2018.

As a melanoma specialist, Agarwala has used biologics for a long time, and they have “changed melanoma care completely and are curing people, but the cost is tremendous. Biologics are a major factor in both the success of cancer treatment and the costs,” he said.

Enter biosimilars—highly similar, though not identical, versions of biologics that are derived from living sources and have a complex manufacturing process. It’s important to note that biologics cannot have generics because they are too complicated, and, in fact, the biologics themselves undergo natural variability with time, making an identical copy of a biologic unnecessary because even the reference drug is not identical to itself over time.

That understanding has given rise to the current bio-similar approval pathway in which sponsors must only provide evidence that their drug candidate is not significantly different from the reference in terms of efficacy and safety. They are not required to repeat the clinical trials establishing the drug’s benefit or prove superiority over a placebo; instead, clinical studies are conducted with sensitive end points designed to detect any difference from the reference.

Agarwala outlined some unique issues relevant to biosimilars, including interchangeability, which would allow pharmacists to substitute a prescribed drug with a biosimilar but requires many different study designs; no biosimilars have received an interchangeable designation from the FDA yet. The naming of biosimilars also holds potential for confusion, which is why the FDA adopted rules using the core name and a unique suffix.

Aside from approval, there are challenges to biosimilar uptake in the reimbursement landscape. Although the FDA has approved dozens of biosimilars, far fewer are actually available on the market due to ongoing litigation. Also, the “rebate trap” that occurs when manufacturers of higher-priced drugs offer rebates for preferred status can muddy the waters of cost savings by allowing health systems to actually pay less for expensive biologics than they would for biosimilars.

However, there is increasing recognition among architects of value-based care programs that biosimilars can improve affordability, access, and outcomes. The lower price point of biosimilars can enable additional doses of biosimilars to be given to more patients in need.

Education and familiarity are key in helping providers and patients become more comfortable with biosimilars, Agarwala said. In oncology, for instance, prescribers are more willing to accept biosimilars for palliative care rather than curative treatment because they may feel like they have only one shot at curing a patient’s cancer. Misperceptions around biosimilars can lead to uncomfortable conversations with patients who receive a biosimilar that does not improve their outcome and feel that the reference product would have worked better, when in fact the biosimilar and the reference have the same level of efficacy.

Although reports have predicted large cost savings from biosimilar uptake, right now we have too little experience to assess their effect on lowering biologic spending.

“This mixture of collecting data to show that costs are going down and more people are getting access to it, coupled with the fact that these are fair to use—you’re not using some snake oil here; these are actual drugs [and] the FDA regulates how they can be approved—will help us,” Agarwal said.

“This problem is not going away,” he added. “Biologics are going to be the [agents] that cure cancer for us one day, so we’d better be ready to make them more affordable for everybody.”

Sanjiv S. Agarwala, MD, Professor of Medicine at Temple University in Philadelphia, PA

Articles

Sanjiv S. Agarwala, MD, explains that biologics have revolutionized the treatment of serious conditions, including cancer, over the past few decades, however, costs are a pressing issue for all providers and biologics are a major culprit.

Overcoming Hurdles to Biosimilar Uptake

I used to be an elite gymnast. I competed all over the world, including the Olympics, for my home country of Venezuela. I was never the tallest or the strongest or the most flexible gymnast on the team, but I was small and somehow graceful. My favorite event was floor exercises, where I could escape into the music and lose myself in the dancing, jumping, and flipping.

World-class gymnasts start young. I was just 5 years old when I began training. It was fun—a lot of fun, actually—but the work was grueling. I trained up to 8 hours a day, and 8 hours every day before major competitions.

The discipline and commitment required to compete at the highest level proved valuable in multiple areas of my life, including school. There was no time for naps or television. I remember doing my homework at school because I had to go to the gym and train for at least 4 hours every afternoon. Planning life around those long hours in the gym taught me time management skills that proved invaluable when juggling my responsibilities as an oncology fellow.

Unfortunately, I had to retire at 16 because of multiple injuries. I twisted both ankles, injured my back and right knee, and fractured multiple fingers. Eventually, I became too old and too injured to continue, but this allowed me to focus on school. 

Gymnastics gave me the discipline and commitment to do my best in all the diff erent areas of my life. Therefore, I decided to apply to medical school, which became the most important competition of my life. I attended the Universidad Central de Venezuela, where 19,000 applicants competed for 150 medical school spots. Getting in felt like the most crucial gold medal I'd ever won.

While in medical school, my former coach asked me to join her as a gymnastics coach for the Special Olympics teams. I accepted her off er and managed to teach gymnastics 3 days every week whenever I wasn't on call. I worked with 17 athletes who had intellectual disabilities, mostly Down syndrome and autism, from ages 8 to 32.

In 2011, I became the National Team's head coach for the World Summer Special Olympic Games. I traveled with 8 athletes, all with Down syndrome, to Athens, Greece. As with any national team, we trained together, slept together, ate together, and lived together. I had to make sure the athletes took all their medications as prescribed and help them get dressed for the training sessions and competitions.

My 8 gymnasts won 30 Special Olympic medals: 15 gold, 8 silver, and 7 bronze. In 2012, 6 athletes brought home 22 medals from the Pan-American and Caribbean games, including 13 gold.

The transformative power of sports to infuse confidence, improve health, and inspire a sense of competition is at the core of Special Olympics. The experience changed my life completely. When trying to find any available extra time to teach, I realized that I learned more from these athletes than what I could ever teach.

Sometimes people ask me what the biggest challenge is when training athletes with special needs and intellectual disabilities; the honest answer is just patience. They can achieve anything and everything asked of them. It takes a little more practice and a little more time, but eventually, they will get there.

On the other hand, I learned so much from these athletes and their unconditional love, open hearts, spirit, and dedicated and supportive families. I have no words to describe how grateful I am for having them in my life. They still own a piece of my heart.

Outside of gymnastics, my athletes are very high-functioning professionals. The younger ones went to integrated schools, and most of the older athletes work in multiple areas. One, for example, works as an accountant for one of the largest national banks; another for an internationally recognized soda company. They venture outside the barriers of society by choosing courage over comfort every day.

Today, I can recognize and appreciate how my early life experiences have made and will make me a better hematology/oncology physician. I can see how some of the tools I learned, like patience and the power of listening, are extremely helpful in guiding patients through receiving their diagnosis, treatment, follow-up, and even their end-of-life care. It has given me a greater awareness of the mental challenges and concerns for a patient’s quality of life and their family’s experiences.

The compassion I developed while working with people with special needs taught me how to lean forward, sit down at the same level, and communicate effectively to make sure my patients and their families understand my message. Moreover, teaching is something I enjoy doing inside and outside of gymnastics and will continue to do as part of my career as a medical educator.

I strongly believe that I am the best version of myself when I’m helping others, especially those in need. Despite the long hours, multiple calls, and sleepless nights, I always remember that no matter what I want to do in life, I have to keep going, keep training, be patient, take risks, and keep doing it. With wholehearted commitment and perseverance, anything is possible. I learned that from the best—my athletes.

Valentina Baez Sosa, MD: Hematology/Oncology Fellow at MedStar Washington Hospital Center, Washington, DC

Valentina Baez Sosa, MD, shares how her early life experiences in gymnastics and coaching have helped her become a better hematology/oncology physician.

Gymnastics Makes Me a Better Oncologist

I walked through the empty halls of the hospital on the morning of my patient’s mastectomy. I was hyper-aware and, for the first time, noticed the gentle hum of the building’s inner workings, feeling my every step in my sweaty surgical shoes. I passed several banners spelling out the values of this hospital which I had seen so many times in the past, but only today did the words fully register in my mind. “Compassion is our core.” “Service is our calling.” “Commitment is our promise.” Many days in medical school had felt like a monotonous exercise of mental stamina. But today, these words deeply resonated with me and reminded me of my sense of purpose. Because today, I would play a role in my patient’s healing process.

It started with my patient; let’s call her C. She was in her late 40s and had no family history of breast cancer.

She didn’t remember me on this day. When we had first met, weeks earlier, I was simply another white coat pestering her with a litany of questions. She was likely still reeling from her recent breast cancer diagnosis and the upcoming chemotherapy to shrink the tumor. If she noticed me at all, she was probably annoyed that a lowly medical student was prolonging her time in the hospital. She just wanted to see the surgeon and return home as quickly as possible, to any semblance of normality, at a time when reality seemed to be slipping through her fingers.

I recognized her immediately when I saw her in my clinic for a hospital follow-up and chronic disease management. My family medicine clerkship site, a federally qualified health center, served as a safety net clinic for our community’s Medicaid and uninsured patients. Patients coming into this busy clinic would generally see a different physician or midlevel provider on each visit, depending on availability, making longitudinal patient follow-up complex and disjointed.

I walked into C’s room knowing that my work-up, be what it may, was likely going to be the most thorough care that she would receive that day. Despite the new and ever-present masks interfering with our interpersonal connection, I still recognized her by her tired eyes and the way she sat with the heaviness of her diagnosis hanging over her. I reintroduced myself to her and her sister, reminding them that I was there for her hospital visit. Her sister remembered me first, then remarked on how they had seen so many doctors recently that it was all becoming a blur.

At that moment, I felt a surge of empathy for C. Here she was struggling with what was likely the most stressful challenge in her life so far, with nobody to truly guide her through the confusing intricacies of her upcoming journey.

I wanted to walk with her through her illness and recovery, see the medical system and its flaws through her eyes, and advocate for her as best I could. I got permission from C and my school’s administration to be her unofficial “patient advocate” along her breast cancer journey. I was inspired by a few of my mentors who had done something similar during their clerkships. She and her sister were grateful for my interest in her well-being and promised to keep me in the loop on upcoming treatments and appointments.

Over the next few months, I saw health care through C’s eyes. I witnessed her anxiety while waiting for hours on an infusion bay, followed by overwhelming nausea, fatigue, and general malaise that carried on for weeks.

I saw her hope rise before each appointment with her oncologist as she waited for a report of a decrease in tumor size and the sense of despair that set in when her implant port had become clogged and needed to be replaced.

I understood what she felt like when she entered the hospital expecting to get her last chemotherapy infusion right before the holidays only to find out that her oncologist recently received a diagnosis of COVID-19. I felt her sense of dread as she wondered how long the pandemic would delay her treatment plan and how that would affect the tumor’s growth. 

I saw what it meant for her to cling to the few good things in life—her family, the nurses who kept her comfortable during the mindless hours in the infusion bay, and even the medical student who answered her questions and continued to cheer her on as she moved toward healing. When the interdisciplinary tumor board team decided that her tumor had withered to the point where it could be excised, I said a silent prayer of gratitude. This was the light at the end of the tunnel for C. 

There I was, walking toward the operating room, running the surgical videos I had watched the night prior through my head over and over so I would know exactly what to expect during her procedure. Yes, I had always cared about my patients—so many of us embark on a career in medicine because of the classic combination of a love for science and an empathetic heart for patients who need help. But today, I had truly gone to the mat for C because I felt responsible for the quality of her care. Though I would likely only be retracting and suctioning for my preceptor in the surgical suite, I wanted to do the best retraction and suction that a medical student had ever done, as if my patient’s life depended on it.

I stopped by to greet C when she was being prepared for surgery. I held her hand and answered her questions. I informed her anesthesiologist of her complaints of constipation so they would be aware when managing her postoperative care. I’d like to think I saw C’s shoulders relax a little when she saw me before her surgery. I was a familiar face in a frightening place.

A few weeks after her mastectomy, I visited C again at her follow-up radiation appointment. I noticed she was sitting up straighter and there was a new brightness in her eyes. I knew her well enough now to see that hope had returned to her life.

We talked about how things were going. When she pulled off her hat to show me her new hair growth, I grinned from ear to ear. All of the medical appointments and struggles so far had been worth it—remission was in sight! That day, I saw the joys of health care through her eyes too, and I was very grateful for her.

Wouldn’t it be incredible to carry this sense of personal responsibility to every patient interaction we have? Just imagine the improvement in the quality of care of our patients if we took ownership over their health outcomes. It may sound like extra work, but I truly believe that this depth of connection to our patients will help us prevent physician burnout.

As medical students, we often allow our clinical education to be something that “happens to us,” often coming home from rotations exhausted by the dichotomy of either terror-induced adrenaline or mind-numbing shadowing. We fulfill requirements set forth by the Liaison Committee on Medical Education and our medical schools, and we want to run out of clinic early so that we can study harder for the next shelf or board exam.

I want to transform that narrative. We as medical students have the power to fully engage in our clinical education, which begins with taking responsibility for our patients today.

How do we exemplify this in modern-day medical education that is primarily focused on quantitative outcomes, transitioning care, and shift-based work? How about when the longest longitudinal relationship we will have with a patient during clerkships is likely a weeklong hospital stay?

Medical schools must adopt a new modality of learning, one that allows students to engage in health care through the eyes of the patient through the use of continuity clinics and integrated clinical clerkships. This method of education helps us as students not only recenter our efforts on the patient but also enrich our knowledge acquisition by tying our learning to patients we grow to care about, creating a new generation of more empathetic physicians.

Patient-centered medical education put me behind the eyes of the patient and will fundamentally change the way I practice medicine. As the legendary Francis W. Peabody, MD, said, “The secret of the care of the patient is in caring for the patient.”

Bharat Sanders: Codirector of the Student Taskforce on ACEs and Resilience, and Fourth-Year Medical Student, at Georgia Institute of Technology

Bharat Sanders sheds light on how patient-centered medical education put him behind the eyes of the patient and fundamentally changed the way he practices medicine. 

Taking Back Our Empathy: Reflections on a New Model of Medical Education

Santosh Saraf, MD, changed his major 3 times as an undergrad at Penn State University, bouncing from premed to mathematics to marine biology before settling back into medicine. He was studying deep-sea ecosystems when his desire to become a physician became clear.

“I took a course on the biology of aging and got really interested in biology,” Saraf said. “I focused on algae and applied my math background to understand the genetics.

“The first and second year [of premed] have a lot of general courses, and you don’t get really into the depths of the field you're interested in,” he continued. “Once I was able to experience the science of medicine, I liked it more.”

He went on to earn his medical degree from Temple University in Philadelphia, Pennsylvania, then completed his internal medicine residency and a hematology/oncology fellowship at the University of Illinois at Chicago (UIC). He later got a master’s degree in clinical and translational research from UIC School of Public Health. Today he’s an assistant professor of medicine in the Division of Hematology/Oncology and fellowship training program director at UIC.

Saraf said he’s always been interested in education, even as a medical student and a resident. He spent 8 years working with fellows as a faculty member. “It’s a really important personal mission to make sure that we are educating the next generation, giving them the opportunities that people gave,” he said.

Saraf spoke to Oncology Fellowsabout helping his first-year fellows through the COVID-19 era, learning how to deliver bad news, and handling unethical behavior in the program.

How has the fellowship experience changed with COVID-19 when you haven’t had the normal level of face-to-face interaction?

It’s been a big challenge. I still feel bad that with our first years, we haven't really had the chance to meet and physically interact with them. It’s probably hard for them when they're first starting at a new institution. We do a lot of our lectures in didactics and journal clubs in pathology through Zoom and Webex. We actually have better attendance using these tools, but I think that there is a lot of face-to-face interaction that's lost.

What were the most valuable lessons from your own fellowship experience?

Each provider has something special to teach you, and you can take the positives from different faculty members. With some, I really appreciated how they spent time with the patients. For others, I liked how they started at the microscope before seeing the patient. I had lots of positive experiences with faculty that I’ve tried to capture and emulate. With the didactic, there was a lot of self-learning. All of those things together helped my clinical skills, as well as my basic knowledge.

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

The most important takeaway is the clinical part of the training—knowing how to interact with the patient at the time of diagnosis and knowing how to explain the disease, the treatment options, and the process for treatment. [It is also important to learn how to] explain the prognosis and, at the end of the road, talk about palliative and hospice care and effectively communicate with the patient and the family when discussing goals of care. That’s something that we've been really trying to grow as part of our pro-gram over the past year or two.

Educationally, I want to make sure that they have a solid foundation in understanding the science of diseases and therapies. Because we're an academic institution, we also want to encourage our fellows [to participate in] scholarly activities, including research. That could be clinical bench or translational educational activities; educational activities tailored to students, residents, and fellows; and educational activities to the community. We really want to have well-rounded fellows that have both clinical and scholarly knowledge.

Many physicians say they don’t get much training in delivering bad news. Is there a way to craft one’s fellowship to get that experience, even if it's not explicitly part of the curriculum?

It’s a very, very tough thing. It’s one of those traits that you pick up from faculty. [Some faculty] do it well and you say, “Well, I want to do this when I interact with a patient in this situation.” Then there are some you see that you never want to emulate. I had one faculty member come into the room, sit down, and just stare at the patient for what seemed like a long time, but it was probably only about a minute. That is the kind of interaction that makes the patient really uneasy. We have to learn what not to do as much as what to do.

One of the other important things to discuss with patients is palliative care. That’s something we've recently developed as part of our curriculum. It’s something that's really underemphasized in many programs. Our palliative care team provides didactics, and trainees hear lectures on the topic. There are also inpatient and outpatient experiences where they learn how to communicate bad news and develop end-of-care, hospice-type plans with the patient.

What do you tell your fellows about reporting harassment or other negative experiences that can come up in a workplace?

We’ve developed resources for fellows if these situations happen. We have an open line of communication if there is a problem arising. Our fellowship coordinator, our associate program director, and I are available. We really try to keep our phones and our emails on so fellows have the option to report something right away. We strongly encourage them to report any of those situations either anonymously or to a faculty member.

Each of our fellows is linked with a faculty advisor. We try to match them by their interest. For example, if there's a young mother in the program, we might try to pair her with a young mother faculty member or a member who might share the same experiences. That way, they might have a bit more open communication. We have those advisers meet with the fellows regularly.

Santosh Saraf, MD, changed his major 3 times as an undergrad at Penn State University, bouncing from premed to mathematics to marine biology before settling back into medicine. 

Education Is a Personal Mission

Even if an individual or a group participated in virtual learning before COVID-19, the pandemic ushered in a need for everyone to attend virtual learning to move education forward.

The conversion to a virtual climate happened rapidly with subsequent updated recommendations from the American Council for Graduate Medical Education. In this piece, we pause and reflect on strategies to optimize virtual learning in the virtual environment.

 The best practices discussed are 1) speaker preparation, 2) creating a virtual learning climate, and 3) encouraging and enhancing interaction.

Speaker Preparation: Spend Time Preparing Your Virtual Background and Settings

Take time to set up your location and virtual background prior to the presentation. Decide whether you want to use additional light attachments for the computer and select the settings in advance.

Practice looking at the camera during the virtual session so that your learners will feel you are making eye contact with them. This may require more practice or memorization of your material, but it is helpful to increase the connection with the audience. There are a number of resources with tips for how to do this, including telemedicine-based settings that can be applied to your virtual teaching preparation. One example is a video, accessible on YouTube, by Tanya Elliott, MD, titled “How to Conduct a Professional Telemedicine Visit Using Good Webside Manner.”

Lastly, be prepared to adapt to technical issues that may come up during the live session or noise from a home environment such as a dog or construction. The main point is to remain calm and move forward with the presentation.

Create the Virtual Learning Climate You Want

Because there are no nonverbal cues or in-person interactions during virtual learning, one best practice is to prepare the session by discussing the expectations with learners and create a safe and collaborative environment. You can still create your desired learning climates, but it may take more deliberate and explicit discussions. When you have access to your learners ahead of the session, then expectations for class can be agreed upon in advance. If not, then the beginning portion of class can be used to set expectations and engage your audience.

Topics to discuss during this time include the use of video, use of the chat box, and how and when to indicate that a learner has a question. Encouraging the use of video will help the presenter gauge the understanding and engagement of the audience. However, for learners without access to video or if a class is too large to support video for all participants, an alternative will be needed, such as using the chat box feature to ask questions.

Take time at the beginning of the session to let the learners know whether you want them to ask questions at any time in the presentation or whether you would prefer to wait for certain points in the talk. Let them know whether you prefer that they ask a question by entering it in the chat, by unmuting themselves and speaking, or using the ‘raise hand’ button.

There is no right answer for which methods to use; however, letting the learners know the specifics about your speaker preferences will increase their comfort and confidence in asking questions and participating during the session. An additional option is to engage a learner to help moderate the chat and let the speaker know whether there is a question waiting to be answered.

Design the Virtual Learning Session to Include Interaction

As discussed above, although a virtual learning atmosphere means you and your learners are physically apart, the environment still has multiple options for interaction. There is a great deal of room for creativity with interactive exercises and the incorporation of technology to meet the needs of all learners and all sizes of virtual learning sessions.

A specific best practice to consider is starting the virtual learning session with a poll to pique learners’ interest and participation. Also, consider continuing to use audience participation during transition points between topics to help keep your audience focused.

When you are speaking or facilitating a discussion, consider using technology such as smart boards where the class can see what you are writing to simulate a physical classroom activity. You can also use interactive methods such as the flipped classroom approach in the virtual setting to increase engagement as well.

An additional specific tactic for engagement is using breakout rooms for more engagement among learners. Ideally, these breakout rooms would be small, with no more than 5 to 8 learners per group to allow them all to participate. If you let the learners know they will be circulating between rooms, that will take away awkwardness when you enter.

Design the breakouts to ensure the small groups have enough time to discuss the topic and will be ready to report back to the larger group without feeling rushed or feeling like there was excess time allotted. Staying up to date with educational literature and resources will also provide new and creative teaching methods to try.

Overall, this piece presents practical tips and best practices in the virtual learning environment that can serve as a primer for new virtual educators and a refresher for experienced ones. These tips are not meant to be exhaustive. As you continue to teach and learn in this environment, there will be new advances in your understanding and emerging learning theories and teaching strategies.

The virtual environment provides more opportunities for participation in education and connection by removing the physical barrier so that you can participate in more sessions at your own institutions as well as cross-institutional initiatives to connect you with other educators across the country.

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

. 2020;323(21):2131-2132. doi:10.1001/jama.2020.5227

Guidance on medical students’ participation in direct in-person patient contact activities. Association of American Medical Colleges. August 14, 2020. Accessed April 28, 2021. https://www.aamc.org/media/43311/download

Elliott T. How to conduct a professional telemedicine visit using good webside manner. April 23, 2020. Accessed April 28, 2021. youtube.com/watch?v=8bMFL56Zflc

Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. 

. 2018;18(1):38. doi:10.1186/s12909-018-1144-z

Cover Story

Strategies are important to optimize learning in the virtual environment including speaker preparation, creating a virtual learning climate, and encouraging and enhancing interaction.

Preparing and Delivering a Virtual Learning Session

Previously, I wrote about cultural sensitivity, things that can help support sustainability in your career, and the ability to identify your tribe (mentor, coach, and sponsor). Now, I want to focus on a different area: choosing your name.

As a trainee, you are on a path to become a full-fledged hematologist-oncologist (or variant thereof). Your chosen job settings will differ, but the bottom line remains that these choices will ultimately be determined by your personal vision of success, and that can only be defined by you. Yes, there are metrics that you must achieve set by outside forces (hospitals, patients, etc), but the most important metrics are the ones that you set for yourself, such as those that take into account your professional vision and how this intersects with your vision of personal and professional balance. My goal is to provide some insight into the “secret sauce” of what I have learned and observed in over 20 years of practice. These items can have a tremendous impact on your sustainability and your satisfaction in a given job or career.

As a fellow, you are called a “trainee.” This name comes with a set of rules, guidelines, and expectations. Your program director answers to multiple entities to ensure that you are well educated and that the program remains certified and sustain-able. However, in labeling someone a “trainee,” there is a risk of saying that everyone’s needs can be lumped into competency-based categorizations. Is this true? My opinion is a resounding no. Although the Accreditation Council for Graduate Medical Education–sanctioned connotation of “trainee” affords an element of standardization across programs, if taken too literally, this title can stifle the professional maturation process that includes the ability to really figure out who you want to be.

During interviews, fellowship committees often hear that a candidate wants to do “translational research” or “remain in academic medicine” after fellowship. In many cases, these are the words a candidate thinks the committee wants to hear and can end up with the candidate characterized as an academic researcher when their passion is clinical care.

The ability to reflect and boldly choose a professional identity should be discussed, encouraged, and nurtured in every individual. Ultimately, the heavy lifting of this task remains with the fellow, but at the end of the day, I want to encourage you to go beyond the confines of a label—be it “trainee,” “doctor,” or “oncologist.” Be bold and choose whatever name suits you.

I can give a personal example. My labels over time have been about my accomplishments: valedictorian, chief resident, Johns Hopkins fellow, clinical investigator, professor of medicine, and more.

I thought that these were the important labels—the labels that mattered.

As I progressed through my career, I came to realize that those labels were creating an internal and external expectation of who and what I should be. These labels didn’t reflect who I really wanted to be in terms of my career trajectory and my passions. I found that as I veered off the expected path, there was some internal dissonance. Ideally, my life would fall in the middle of a Venn diagram (

But in reality, it looked more like this (

When I was trying to chase a label, I forgot to balance myself. I needed to name who I wanted to be and not who people expected me to be. The sweet spot is when you are excited to go to work every day. I ventured off the clinical investigator path and moved more into the medical education and administrative realm.

Ultimately, fulfillment and success can be inversely correlated if you use someone else’s definition of success instead of your own. If you have success and fulfillment together, you have hit the sweet spot. If you have success without fulfillment, you run the risk of burnout. As a consequence, your sustainability in a career path may be quite low. Thus, I encourage you to reject rigidity and boldly define your path. I suggest starting at the end point and then plotting backward with how to achieve this.

In my last article about secrets of success, I discussed the role of the mentor, the sponsor, and the coach. This is your tribe, and each of them can help you define this path. Often in medicine, as in life, I felt as if I was in a strong current that was pushing me toward a particular end point. But even the Mississippi River has multiple tributaries, and all of them provide sustenance to the land they serve. Once I embraced the actual fun of the exploration, I let go of the bank of the Mississippi River and enjoyed the rafting ride down my tributaries.

The lesson here is that even deviations can have a purpose and a meaning and may enrich your life. Vertical thinking will get you from here to there and may be viewed as “focus.” But it is important to stop, reflect, and constantly check your own temperature concerning your happiness with the course you find yourself navigating.

The ability to reflect and boldly choose a professional identity should be discussed, encouraged, and nurtured in every individual.

Vol. 13/No. 2 | Oncology Fellows

Overcoming Hurdles to Biosimilar Uptake

Gymnastics Makes Me a Better Oncologist

Taking Back Our Empathy: Reflections on a New Model of Medical Education

Education Is a Personal Mission

Preparing and Delivering a Virtual Learning Session

Success Beyond Science: Becoming a Hematologist/Oncologist