I will never forget the first code I witnessed. It was like an orchestrated chaos. Everyone in the room assumed their position as CPR was started and orders were shouted. 

At the time, I did not fully understand all the noise: the sound of the chest compressions, ribs cracking, or someone yelling across the room for “epinephrine” or “asystole.” I was merely a premedical student, at home during finals to visit my father, who was hospitalized with pneumonia. I was overwhelmed by the urgency in the room and paralyzed by the vision of my father lying lifeless with an endotracheal tube in place. 

As I saw them rolling him off to the intensive care unit, I was overcome with grief—the same personal grief that still follows me today. 

As an oncology fellow, I was never taught how to deal with grief, either my own or that which I experience for my patients. In recent years, many academic programs have incorporated curricula on handling end-of-life conversations, but what do those programs teach us on managing the grief that follows? 

Oncology is rife with daily emotional stress, something we may or may not have realized when we decided to pursue this field. We observe the roller coaster of emotions that most of our patients and their families encounter throughout their oncologic course. The shock that comes with the initial diagnosis, the hope that endures while receiving treatment, and the relief that comes with remission. Sometimes it is as if the world has been lifted off their delicate shoulders. And if the disease recurs, we are there to witness the oftentimes overwhelming feeling of defeat. 

Each day, with each encounter, we experience those peaks and valleys of intense emotion alongside our patients. Without a doubt, these joys and pitfalls have an impact on our mental health as well as oncologists. 

Laurel Lyckholm, MD, wrote about this experience in 

 many years ago. In his article, "Dealing with stress, burnout, and grief in the practice of oncology," Lyckholm discusses the high prevalence of stress and burnout in our oncologic colleagues, what causes this stress, and also how to prevent it.

 I agree with most of his techniques, but many are difficult to accomplish as a trainee, particularly: the frequent short breaks, sufficient rest time, regular physical activity, and/or getting 8 hours of sleep each night. Nonetheless, it is essential to learn how to cope with our grief, especially early in our careers to ensure a long career in our practice. 

As we prepare ourselves during training, it is just as important to learn the clinical skills that define an excellent oncologist as it is to learn the skills to cope like one. Afterall, how can we manage the daily emotional and psychological trauma over 30 to 50 years of our careers in clinical medicine? How do we build resilience? 

As I finish my last year of training, I have grown reflective on the many levels of personal loss I have already experienced. I was just 20 years old when my father passed away, and more recently I lost my husband during fellowship training. These life events have certainly shaped my interactions with my patients and their families, especially during difficult conversations. But more fittingly, these losses have influenced how I manage the stress and grief I experience related to becoming an oncologist. The insight I have gained from these losses include the following: 

I repeated this phrase to myself after my husband died. It can be difficult during clinical training, but after that loss, I gave myself permission to prioritize myself and my mental health. It was okay to cry. It was okay to feel frustrated. It was okay to take a few extra minutes for myself after having a challenging end-of-life conversation with a patient and their family. 

For the first time, I learned to practice compassion for myself, even though for my whole life, I strived to be compassionate towards others. I allowed myself to start journaling, a simple pleasure that provides me some relief from the daily stresses I encounter. However you may approach this mantra, I also urge you to find ways to be kind to yourself. 

After my husband’s death, I was inundated with messages and support from my colleagues and friends. Their compassion helped to fill some of the loss I felt. I recognized how vital those relationships were to my well-being and remembered why I choose to become a physician and oncologist: because of the relationships I hoped to build with my patients. Afterall, no man is an island, as the saying goes. It is community and friendships that profoundly make us human. This support from others ultimately helps us to cope with our daily tragedies. 

Previously, my husband was my support person, the confidante I ran to talk about work stress, the trials of training, or challenges with patients. Now, I look to my friends, colleagues, and family members: my new community. I believe we can rely on each other, to ensure we can handle the emotional adversities of oncology. 

Whether is is with colleagues or in solitude in my journal, reflecting on my emotions sheds new light to what I am feeling. It allows me to better pinpoint my exact emotions and equips me to communicate my thoughts, my grief, and my desires. After my husband's death, it was therapeutic to reflect and express how I felt. 

Additionally, it allowed me to articulate to my friends and community how best they could help me through these challenging times. 

Furthermore, sharing these stories and sentiments validates these feelings and helps alleviate the emotional burden felt. Sharing my loss helped me to the face the reality of grief. And although difficult, it was necessary to assist in coping. 

Towards the end of last year, one of my patients decided to pursue hospice. We discussed her next steps and how to disclose her decision to her family. Her daughter was away at college, about to start finals. My patient asked if she should have her daughter come home. I reflected back on my own college experience, when I left during my finals week to return home when my father was hospitalized. It was likely one of the best decisions I had ever made: to see my father one last time before he unexpectedly passed away. “She should come home,” I said. “The school will understand.” 

Although grief never leaves us, we learn how to cope. And as we become seasoned oncologists, I hope we can not only empathize with our patients, but learn to manage this storm of emotions, so that ultimately, we can touch so many more lives in the future. 

Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. 

. 2001;2(12):750-755. doi:10.1016/S14702045(01)00590-3

Articles

Although grief never leaves us, we learn how to cope. And as we become seasoned oncologists, I hope we can not only empathize with our patients, but learn to manage this storm of emotions, so that ultimately, we can touch so many more lives in the future.

Grief and Oncology: Lessons From a Trainee

Over the past 2 decades, we have learned that a majority of what is thought to be high-grade serous ovarian cancer in fact originates in the fimbriated end of the fallopian tube. Data from multiple studies have shown that the outer cells of the distal fallopian tube are transformed into malignant cells and subsequently spread to the neighboring ovary.

 This implies that surgical removal of the fallopian tubes may prevent certain types of ovarian cancer.

Our new understanding of the pathogenesis has given rise to a promising prevention strategy for women at an average risk of developing ovarian cancer through surgical removal of the fallopian tubes, referred to as an opportunistic salpingectomy (OS).

OS refers to the removal of fallopian tubes instead of tubal ligation, or during hysterectomy, while leaving the ovaries intact. Study findings suggest that OS is associated with an ovarian cancer risk reduction approaching 80%.

 Recent findings from 1 of the largest cohort studies conducted to date show that none of the 25,000 women in the study’s OS cohort developed a serous ovarian cancer throughout the duration of the study.

 Additional data have demonstrated that OS is safe and cost-effective and has not shown indications of an earlier age of onset of menopause.

With the hope of expanding the surgery to even more women across the population who have completed childbearing, investigators have moved to assess the efficacy of OS during nongynecologic surgeries, such as during removal of the appendix or gallbladder, colorectal surgery, hernia repair, and others. This opens a window of opportunity for hundreds of thousands of women undergoing these procedures annually.

A prospective European feasibility study of 105 women investigating OS during elective cholecystectomy found that surgeons performed the procedure successfully in 93% of cases. The median additional operating time was 13 minutes (range, 4-45).

 A cost- analysis study looking at qualityadjusted life years has suggested that OS during nongynecologic surgeries can be a cost-effective strategy to prevent ovarian cancer among average-risk women.

The Markov Monte Carlo simulation model by Kwon et al demonstrated OS with hysterectomy was less costly ($11,044.32 ± $1.56) than hysterectomy alone ($11,206.52 ± $29.81). Additionally, for surgical sterilization, OS was more cost-effective long term with an incremental ratio of $27,278 per year of life gained.

Despite the projected cancer prevention and population health benefits of OS during nongynecologic surgeries, these results have been seldom reported and surgeons rarely conduct the procedure outside early studies as there are currently no guidelines to rely upon. It is imperative that we delve further into this novel prevention strategy with prospective trials. This will require buy-in, collaboration, and training from both general and gynecologic surgical teams. Cross-disciplinary efforts to garner more information regarding long-term effects and outcomes will be necessary before OS conducted during nongynecologic surgeries can become a standard recommendation for women who have completed childbearing.

If achieved, widespread implementation of OS holds the potential to reduce ovarian cancer mortality in the United States by 15%—the equivalent of thousands of lives saved.

 Surgery has always been an all-encompassing team sport, requiring the collaboration of all teams involved to work toward improved outcomes for individual patients. OS now has the potential for surgical teams to join forces in the hopes of improving outcomes for women across the world.

The future widespread implementation of the OS serves as an opportunity for fellows across different surgical specialties—including but not limited to gynecologic, colorectal, general, urologic, and hepatobiliary—to collaborate. First, raising awareness regarding the potential of OS across different specialties is essential. Next steps will include expanding training during residency and fellowship across various disciplines, which will help with feasibility as well as future implementation. This will require both buy-in and teamwork from many to learn the OS procedure in a safe and effective manner.

Ryan M. Kahn, MD, is a gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center in New York, NY. 

Sushmita Gordhandas, MD, is a fellow in the Gynecologic Oncology Department of Surgery at Memorial Sloan Kettering Cancer Center in New York, NY. 

Kindelberger DW, Lee Y, Miron A, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: evidence for a causal relationship. 

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Kurman RJ, Shih IeM. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. 

. 2010;34(3):433-443. doi:10.1097/PAS.0b013e3181cf3d79

Matsuo K, Chen L, Matsuzaki S, et al. Opportunistic salpingectomy at the time of laparoscopic cholecystectomy for ovarian cancer prevention: a cost-effectiveness analysis. 

. 2022;10.1097/ SLA.0000000000005374. doi:10.1097/SLA.0000000000005374

Hanley GE, Pearce CL, Talhouk A, et al. Outcomes from opportunistic salpingectomy for ovarian cancer prevention. 

. 2022;5(2):e2147343. doi:10.1001/jamanetworkopen.2021.47343

McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. 

. 2014;210(5):471. e1-11. doi:10.1016/j.ajog.2014.01.003

Hanley GE, Kwon JS, McAlpine JN, Huntsman DG, Finlayson SJ, Miller D. Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada. 

. 2020;223(2):221.e1-221.e11. doi:10.1016/j.ajog.2020.02.005

Kwon JS, McAlpine JN, Hanley GE, et al. Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy. 

. 2015;125(2):338-345. doi:10.1097/ AOG.0000000000000630

Tomasch G, Lemmerer, Oswald, et al. Prophylactic salpingectomy for prevention of ovarian cancer at the time of elective laparoscopic cholecystectomy. 

. 2020;107(5):519-524. doi:10.1002/ bjs.11419

Dilley SE, Havrilesky LJ, Bakkum-Gamez J, et al. Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention. 

. 2017;146(2):373-379. doi:10.1016/j. ygyno.2017.05.034

Hughes BN, Herzog HT, Brown J, Drury LK, Naumann RW. Opportunistic salpingectomy would significantly reduce ovarian cancer mortality and would reduce overall health care expenditures. 

. 2019;153:e11. doi:10.1016/j.ygyno.2019.03.132

A new understanding of pathogenesis has given rise to a promising prevention strategy for women at an average risk of developing ovarian cancer through surgical removal of the fallopian tubes, referred to as an opportunistic salpingectomy. 

Ovarian Cancer Prevention With the Opportunistic Salpingectomy: An Opportunity for Multidisciplinary Collaboration

There are any number of ways to become a physician, but the path Kevin Raskin, MD, took to eventually joining the staff at Massachusetts General Hospital (Mass Gen) was a bit more circuitous than most.

He had thought about a career in medicine while in high school but wasn’t sure enough to pick a science major. Instead, he studied philosophy as an undergraduate at the University of California, Santa Barbara. It does not come up often, but he still uses those philosophy lessons on occasion, particularly the works of German philosopher Immanuel Kant and his categorical imperative. Simply put, one should “Act only according to that maxim by which you can at the same time will that it should become a universal law.”

“His categorical imperative is something that I do think about; I even talked to my kids about it here and there, about the ethics of X, Y, or Z and how the categorical imperative applies,” Raskin said. “He’s probably the one philosopher I think or talk about the most.”

Following graduation, Raskin worked for 2 years at a bone research laboratory at UCLA while applying to medical school. He was waitlisted twice and close to giving up on medicine when he found a program sponsored by the State University of New York that allowed American students to attend the University of Tel Aviv in Israel.

“And I got accepted. Next thing I knew, middle of July 1993, I was on a plane to Tel Aviv,” he said. “Happily, it was a fantastic 4 years—probably the best academic 4 years of my life by far.”

He started a residency at Albert Einstein College of Medicine in the Bronx, New York, planning to be a general surgeon. He quickly realized general surgery did not present him with the problems he wanted to solve. “I felt they were not necessarily in keeping with what I wanted to be when I grow up, so to speak.”

An orthopedic resident told Raskin that he was leaving the program, and that all the other residents wanted Raskin to switch to orthopedic surgery. “Fast forward 3 or 4 months and I was a second-year resident and orthopedic surgeon,” he said.

Raskin later completed a fellowship at Mass Gen, then joined the faculty there in 2003. He has overseen the orthopedic oncology fellowship for a decade and became chief of orthopedic oncology 4 years ago.

“Although I do think about some of the philosophers I’ve studied in the past, it’s not as though I still read [philosophy] much or practice things that I considered way back when. But I found it to be a wonderful intellectual exercise which certainly preps me for some of the intellectual exercises that I’m forced to do on a daily basis.”

 about time management, the importance of taking time off, and teaching fellows how to listen to their inner voice.

I’ve never not been in medical education. It’s been a cornerstone, a massive element of my life, my career. Patient care, education, and research make up the 3-legged stool, so to speak, of the academic surgeon. Certainly, in my case, patient care and teaching medical education are the 2 strongest principal underpinnings of my academic life. I love the uniqueness of it. I love the opportunity to work with young people. I love being questioned. I like asking questions. I like to challenge our students and learners. I find their enthusiasm and eagerness to be refreshing.

Fellows are incredibly busy. How do you help them manage all the demands on their time?

On one hand, you know, this fellowship is optional. It’s not mandatory. They don’t have to do it. They come here eyes wide open. We make no excuse for the time that’s required to be a fellow in this division. It’s time intensive, the cases can run long, and the patients are sick.

Part of their experience is downtime—weekends off where the residents, for example, can take care of the inpatients while our fellows can have some R&R, so to speak, with their friends and family. But even more than that, during the day there are periods of intensity and periods that are less intense.

There are periods of intensity and periods that are less intense. It’s a hard fellowship, there’s no question. There’s an intensity to taking care of patients with cancer. You can work for an hour, but if it’s patient who is perhaps young or dying or otherwise handicapped or disabled, that can be an extremely intense hour where you may not be able to come back to work for another 23 hours. Whether it’s a 12-hour day or a 2-hour day, it’s sometimes the intensity of the work that is what needs to be titrated in and out, not so much the hour requirement.

What do you say to a fellow who is struggling with the program?

Occasionally we get a fellow come through who’s perhaps having second thoughts. You have to listen and follow your internal compass. We all know what we really want. We all know [in] what direction we really want to point. We might be pushed or pulled by a variety of influences, whether it’s geography, or money, or status, or family. To prioritize, though, can be challenging. But an honest discussion with yourself is often all you really need to do to get pointed in the right direction. And I can sit here in my office with our fellows, and we can talk about the world and how they feel about potential jobs and where they want to go and what the jobs offer. I try to instill in them the ability to listen to that inner voice, because…that’s the voice that’s going to lead them in the right direction.

How do you help fellows capitalize on their free time?

There is mandatory downtime. There are days that they’re not to come in and work and we’re hoping that during those days, they can do the self-care that’s required for them. We certainly try to get them out of the hospital as soon as we can every day. We don’t want them lingering until 8, 9, 10 o’clock. Time away from the hospital is critical for your mental health and your physical health.

But…they’re adults, and as much as I can ask them or insist or suggest that they take off, go to the gym, go out, and go get some fresh air, if they choose that they don’t want to, then that’s up to them.

But what I want them to note is that it’s OK. Please do this; go on vacation. You have 4 weeks during your 12-month fellowship—use them. Use them wisely. Use them to explore downtime, explore other parts of the area where you might be new to Boston. We encourage them to not…be shy and to claim their downtime.

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

The ability to think, a technical skill, surgical knowhow, anatomic foundational knowledge, et cetera, [are] great. That will continue to build and evolve over time. What I want them to believe in when they leave here is that they can think through a problem, that they can rely on their mentors and teachers to help them think through problems, but [also] that they’ve developed the tools to build an oncology team and to use that team to think logically, safely, and effectively through some of these very rare problems that come their way in orthopedic oncology.

Kevin Raskin, MD, discusses time management, the importance of taking time off, and teaching fellows how to listen to their inner voice.

It’s the Intensity, Not the Hours, That Makes Fellowship Challenging

Most of us mark our calendars with big events like birthdays, major holidays, surgery dates, etc. that have specific dates. What about those major events that don’t have a defined date but are just as important? Your job search fits into that category. 

Although the formal process of investigating a job takes time and effort, the reality is that you started interviewing for your first job on the first day of your fellowship. Even if you aren’t planning to go into academic medicine, the faculty you’re working with now will be your references, and they open doors for you through networking and sponsorship. As such, it is imperative to seek their feedback and apply their advice to be the most mindful steward of your future. Otherwise, you risk being the surprised victim of your perceived actions or inactions. 

We are entering the time of active job searching for most second-year fellows, so I’m here to provide some hard-won wisdom. 

If you have a desired geographic location, try to meet with prospective employers in your first year or early in your second year of fellowship. Practices or academic centers do not always know their future hiring needs, so it is good to be on the radar sooner rather than later. Planning ahead to incorporate your talent is easier than creating a job within a short time frame. 

Use large membership directories such as those of the American Society of Hematology or the American Society of Clinical Oncology to find contact information for key providers in your desired practice or center. Send an inquiry email that includes your CV and a cover letter. The cover letter should include a brief overview of training, your anticipated completion date, your research and/or clinical focus areas of interest. If you are looking to move to a particular area (eg, if there is an anchoring reason to relocate), specify that in the email. 

If you are seeking a job in academic medicine, ask your division director to also send an email introducing you and your talents to key individuals in the field or at particular academic centers. In order to best help your division director, craft a statement of your professional goals and projected career path that the director can then modify and send to contacts. 

Be aware of approaching key professional society meetings. Reach out to possible employers and set a time for a meet and greet over a cup of coffee in the convention center. 

If you’re doing a Zoom interview, remember that this is still an interview. Dress appropriately. Do not get distracted. Be respectful. Call the interviewer “Doctor” unless they’ve said you can call them by their first name. 

If you do not get a response to your initial inquiry, send a follow up email after a few weeks. Hematologists and oncologists are busy people; a lack of response does not mean a lack of interest. You have a great deal more time than they do. 

Social media is part of our reality, so please recognize that what you post will reflect on you. Publicly viewed posts should remain professional. Be prudent in your choice of public posting, especially while searching for a job. Don’t let your social media narrative close doors before they have opened. 

Do not ask about call schedule or money during the first interview. The initial meeting is a litmus test of sorts in which both parties are trying to get to know each other. The interviewer will be determining if you can hold a conversation with someone you do not know, if you are able to make eye contact, if you have a personality that may fit the organization. 

When you do request a wish list, be realistic with your requests. You will likely not make $600,000 coming out of fellowship and if that is the offer, be very wary. It likely means that you will be incredibly busy. Inquire about what happens after the guaranteed salary time has ended. Take a look at Medical Group Management Association and Association of American Medical Colleges salary standards for your area and desired type of practice to get a sense of what would be a fair wage—and if it’s enough for your needs. 

Recognize that you will be a low person on the totem pole, and be flexible. To be clear, this does not mean that you should accept unacceptable behavior. However, Accreditation Council for Graduate Medical Education rules do not apply in practice, and you will need to see if a particular practice is a good fit for your expectations. 

Prepare to ask your interviewer questions that demonstrate that you have investigated the particular practice or academic setting. Avoid generic questions that seem to come from a “how to” manual of interviewing. You want to differentiate yourself by demonstrating maturity of thought and sincerity of interest. Avoid such questions as “Is there an opportunity to do research?” Rather, consider phrasing the question the following way: “In my training, I have seen how clinical trials can enhance patient experience and outcomes in oncology. I am particularly interested in clinical trials for this disease. I see on your website that you have trials open in this space. Can you tell me about the clinical trial support in place to provide this opportunity to my patients?” 

If you are interviewing at an academic center, be very specific about questions in terms of your research and your area of interest. Prior to the interview, look up the faculty with whom you will be interviewing and familiarize yourself with their work. You should also research the institution and the resources available, including the mentorship talent. Every potential mentor may not be in the division. Search your area of interest and you can also suggest people you would like to meet with. This demonstrates your insight, engagement, and sincere interest in this opportunity. 

If you are joining a private practice, ask if you will be building a practice from scratch or if you are taking over for someone who is retiring. This will affect what happens at the end of the start-up guarantee portion of your contract. If you are building a practice from scratch, you will likely have a larger proportion of benign hematology cases that don’t generate chemotherapy revenue and you may have a busier schedule than your initial schedule in order to make the salary benchmark. Ask about group’s market share of hematology and oncology, as this will also affect your compensation. 

Ask about availability of tumor boards, patient navigators, clinical trials, and the clinical support model. What ancillary services are at the practice or practice site? Not every practice will have surgical oncology, breast surgeons, neurosurgery, ENT, in-house pathology, endocrinology, gynecologic oncology, etc. 

Inquire how many clinical sites this job will cover. Although this seems like a question for private practice, my first academic job involved 4 hospital sites. When I was on service, I drove to 4 hospitals to do rounds and consults. Every day. It never occurred to me to even ask this question. This may not be a big deal in some places, but you should know what you’re in for. 

Congratulations! Remember that the perfect job does not exist. Instead, be flexible enough to roll with the changes that occur in every career. Importantly, give yourself permission to reevaluate your choice of employment regularly. Your first job does not have to be your last.

Although the formal process of investigating a job takes time and effort, the reality is that you started interviewing for your first job on the first day of your fellowship. 

Vol. 15-No. 1 | Oncology Fellows

Grief and Oncology: Lessons From a Trainee

Ovarian Cancer Prevention With the Opportunistic Salpingectomy: An Opportunity for Multidisciplinary Collaboration

It’s the Intensity, Not the Hours, That Makes Fellowship Challenging

A Primer on Job Hunting