Cancer care is changing rapidly, and understanding and incorporating new practices is challenging both for practicing oncologists and oncology trainees. With more than 100 approvals of oncology drugs and devices in 2022 alone,

 oncologists increasingly subspecialize in specific cancer types to stay abreast of the everexpanding treatment landscape. 

However, oncology fellows do not specialize immediately and must learn the fundamentals of all cancer types, struggling with not only the expansive volume of cancer-related information but also the rapid rate of change in the field. Unfortunately, medical oncology is often taught through passive approaches such as lectures, which are less beneficial than active or interactive learning approaches.

 Additionally, available resources such as the American Society of Clinical Oncology Self-Education Program (ASCO-SEP) textbook

 and the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines

 have daunting density and breadth. As a result, oncology fellowships need active learning approaches that flexibly incorporate new knowledge and treatment paradigms while ensuring that fellows learn core principles. 

To fill this need, Sam Brondfield, MD, MAEd, an assistant clinical professor at the University of California, San Francisco (UCSF), created oncology scaffolds to help improve the fellow education experience.

 Passive lectures are common in oncology, while constructivist approaches that may improve learning are rare. Therefore, we piloted updatable online modules (“scaffolds”). These modules were web-based, editable slides that highlighted key topics within each of the 12 categories of solid tumors: non–small cell lung, small cell lung, upper gastrointestinal, lower gastrointestinal, breast, head and neck, salivary/thyroid, germ cell, bladder/ renal/adrenal, prostate cancer, melanoma, and sarcoma. Each scaffold was built with Google Slides and was limited to a maximum of 20 slides, with 5 bullet points per slide and 7 words per bullet point. Individual slides were dedicated to key components of cancer work-up and treatment. 

These bullet points captured key information from the ASCO-SEP and NCCN Clinical Practice Guidelines, and slides included tables and figures from these resources. The scaffolds were intended to be brief so that fellows could learn key concepts about each cancer type, providing them with a framework to which additional knowledge could be added. Similar approaches to learning have been used before in other areas of medical education

 but not in oncology education. Importantly, the scaffolds were not merely slides intended for a didactic presentation but were meant to be directly edited and updated by fellows in Google Slides. 

As oncologists at UCSF and Stanford University, we piloted these scaffolds at both institutions. Results showed that fellows were willing to engage with and update the scaffolds. After sending links for the scaffolds to all UCSF and Stanford oncology fellows, we kept track of how often fellows edited them over 2.5 years. Fellows from both institutions made a total of 60 edits to the slides, which all correctly incorporated new knowledge about medical oncology, including data from landmark trials and novel treatment approaches. 

Since this educational approach was meant to improve upon fellows’ learning, we conducted focus groups of UCSF and Stanford oncology fellows to discuss and evaluate the scaffolds. Fellows detailed the benefits, saying these modules served as effective preparation for clinical work, readily provided information for rapid review, and aided in the navigation of NCCN Clinical Practice Guidelines and other resources. Fellows found the scaffolds were easily accessed and could be used at any time, including on the way to work. The scaffolds filled an important gap in educational materials available to oncology fellows during training, they concluded. 

However, fellows also encountered challenges with the use of scaffolds. Some fellows felt underqualified to update them, whereas others did not take accountability to update them, explaining that they were not ultimately responsible for the scaffolds’ accuracy. 

To help overcome these barriers, it was clarified that fellows should update the scaffolds as part of the learning process. Additionally, although the scaffolds were designed to represent an initial basic framework, some fellows found this frustrating, citing the scaffolds’ lack of depth as a barrier to their application to nuanced clinical care in the real-world setting. 

Based on our experience designing and implementing these scaffolds as well as our interactions with fellows during the focus groups, our team has several suggestions for educators wishing to create a similar resource: 

Because of the time required to create scaffolds, we recommend dividing their creation among multiple faculty and/or fellows. 

To ensure that fellows update the scaffolds, we recommend assigning fellows to edit the scaffolds rather than simply encouraging them to do so. Faculty mentorship of fellows would help ensure that fellows’ lack of experience is not a barrier to updating the scaffolds. 

To help fellows claim individual responsibility for the scaffolds and maximize learning, we do not recommend sharing the responsibility for updating the scaffolds among multiple institutions. Instead, we recommend that each institution maintain its own version of scaffolds, with individual fellows internally updating them. 

Fellows’ understanding after using the scaffolds should be assessed, because such assessments are likely to promote learning.

Given the current breadth, depth, and pace of change in the field of oncology, creating resources to help oncology fellows actively learn both fundamentals and changes in practice is essential. Few resources that address these needs exist, and it will be increasingly important for oncology educators to consider how to convey new knowledge while not overwhelming fellows with details and overlooking fundamentals in the process. Beyond the scaffolds serving as a tool for fellows, we hope that our experience serves as a scaffold on which oncology educators can build dynamic and sustainable learning resources to help fellows engage actively in their education. 

Oncology Regulatory Review. FDA. Published online February 3, 2023. Accessed May 8, 2023. https://www.fda.gov/about-fda/2022oce-annual-report/oncology-regulatory-review 

Lim J, Ko H, Yang JW, et al. Active learning through discussion: ICAP framework for education in health professions. 

. 2019;19(1):477. doi:10.1186/s12909-019-1901-7 

2022 ASCO Self-Evaluation Program (SEP). The American Society of Clinical Oncology Education. Accessed April 18, 2023. https:// education.asco.org/product-details/ASCO-SEP-Digital-Subscription 

Treatment by cancer type. National Comprehensive Cancer Network. Accessed April 18, 2023. https://www.nccn.org/guidelines/ category_1 

Brondfield S, Schwede M, Johnson TP, Arora S. Online scaffolds: a constructivist approach to oncology fellow learning. 

. 2022;40(suppl 16):11010. doi:10.1200/JCO.2022.40.16_suppl.11010 

Larnard J, Zucker J, Gordon R. The stairway to antibiotic heaven: a scaffolded video series on empiric antibiotic selection for fourth-year medical students. 

. 2020;16:11036. doi:10.15766/mep_2374-8265.11036 

McConnaughey S, Freeman R, Kim S, Sheehan F. Integrating scaffolding and deliberate practice into focused cardiac ultrasound training: a simulator curriculum. 

. 2018;14:10671. doi:10.15766/mep_2374-8265.10671 

Epstein RM. Assessment in medical education. 

. 2007;356(4):387-396. doi:10.1056/NEJMra054784

Articles

Cancer care is changing rapidly, and understanding and incorporating new practices is challenging both for practicing oncologists and oncology trainees. 

Building Upon Scaffolds

It's July 2021, and Vinay Edlukudige Keshava, MD, is making his rounds as a PGY-4 hematology-oncology fellow at Allegheny General Hospital and West Penn Hospital System, both part of Allegheny Health Network (AHN), in Pittsburgh, Pennsylvania. But something happened just 2 months prior that affected the clinical practice firsthand for some of his patients with lung cancer.

That something was the May 2021 FDA approval of the RAS GTPase family inhibitor sotorasib (Lumakras) for the treatment of patients with 

 G12C–mutated locally advanced or metastatic non–small cell lung cancer, specifically for those who previously received at least 1 systemic therapy.

The KRAS G12C subtype must be determined by the QIAGEN therascreen KRAS RGQ PCR Kit and the Guardant360 CDx companion diagnostics, which were approved in conjunction with sotorasib.

“One of the targets that has been elusive to oncologists and researchers everywhere is KRAS G12C. When the research with [sotorasib] came out, we at AHN were quick to adapt to that,” Edlukudige Keshava said in an interview with 

. “[Approximately] 8 weeks after the major journal publication came out about the drug, we gave it to one of our patients. I was a fresh, first-year fellow when that happened. Now that patient is still doing well and is on the same medication. And I got to meet the patient. These are exciting times.”

Being on the front line for these changes was one of the valuable experiences Edlukudige Keshava said he held close during his fellowship. The journey has its challenges—moving to a new city and getting acclimated to a new environment, for starters—and a fellowship requires persistence and a sense of stubbornness to carry through.

But it’s worth it, according to Edlukudige Keshava. In the interview, he shared the story of his fellowship and provided advice on how to best transition to the next step in an oncologic career.

: What were your reasons for pursuing an oncology fellowship?

: I was going through residency training, and we used to see some patients who used to be referred to specialists in nephrology, hematology-oncology, etc. The fact that you could be a subject expert at something interested me. Once I started looking into hematology-oncology with all the new, exciting research that was going on and all the new types of treatments that we could offer our patients, all that excited me. So I gravitated toward hematology-oncology.

What specifically drew you to the fellowship program at AHN?

I had heard about the AHN fellowship program when I was in residency training through one of my friends. I looked it up, and then I talked to some of the fellows. All the camaraderie [among] the fellows was good.

There are programs they have in terms of cellular therapy, [chimeric antigen receptor] T-cell therapy, and tumor-infiltrating lymphocyte [TIL] therapy. All this was up and coming in West Penn Hospital as a part of our fellowship program.

Also, the 1 thing that also struck me was some of the fellows stayed back within the system as attending [physicians after they] graduated. In fact, most of our attending [physicians] at West Penn Hospital are trained in this very fellowship. That gave me comfort that the training is so good that they’re retaining the fellows as attending [physicians]. All these [were] factors.

A fellowship is a big undertaking. What concerns did you have about this new chapter?

I’m on a [J-1 classification] visa as an immigrant, so some of [them] would be visa [concerns]. For example, if we start a fellowship program, then we have to start our J-1 process all over again [for] the new institute. These are all streamlined processes, but when it goes through a new program, there will always be a fear of [that process not working out].

Other than that, with relocating to a new city, you’re packing your bags and then leaving. I got married in my third year of residency. My wife was in Texas, and I was in Philadelphia during residency. The thought of us finding a job in the same city, personal things—those were some of the fears. It did turn out OK.

Don't underestimate the move to a new city! What advice do you have for others trying to go through a similar moving transition?

One of the issues that I did not go through was changing state licenses, [because] I was coming from Philadelphia to Pittsburgh within Pennsylvania. Other than that, just finding a new apartment closer to the hospital we work in, the commute, and that sort of thing. We started looking at all this before we even finished the third year [of residency], so by the time I was done and had to start here, most of it was going to work out well.

Currently, what do you enjoy the most about your fellowship?

We have a continuity clinic in our fellowship program. That means fellows are designated as the primary hematologist-oncologist for our patients, and the attending [physicians] are there to guide us. It’s not [that] we are shadowing another physician; we are the oncologist [for] the patient. We get to answer their questions when they call back, and we see them in clinic every so often. I didn’t know this much before we got into fellowship, but you tend to become their go-to physician.

When someone has cancer, they tend to have all the questions with you. That brings a personalized relationship with the patient. A lot of my patients send me cards for [National] Doctors’ Day and so forth. That brings a lot of joy that cannot be quantified in any metrics. That is the best part of my fellowship.

Firsthand doctor-patient interaction is very important. What is it about AHN that perhaps sets their fellowship program apart from other institutions?

All the attending [physicians] are supportive. Some of them have freshly graduated fellowship, and some of them have worked with a lot of fellows in the past. That puts them at ease initially, because when you are starting a hematology-oncology fellowship—and I don’t know compared with other fields—it’s like you’re starting to learn a new language. In the first few days of whatever I learned in the past 10 or 12 years of medical training, I thought, “What did I even do? All this sounds new to me.”

You feel lost, and then sometimes you start questioning your own intellect. However, the attending [physician]’s job is to ease you through and say, “Everybody who chooses this goes through the same thing.” That really helped. You have all the other fellows who have gone through that and are in the same boat in their first, second, and third year, and we have 12 fellows in total. That helps rather than having 1 or 2 fellows. [We] all hang out, and it gives a sense of family. All the nursing and the ancillary staff have [also] been so wonderful.

What advice do you have for someone looking to apply for a fellowship?

For people trying to gear up for the fellowship application, some of the stuff I did was to talk to a lot of people [as a way to build] connections. Of course, once you start talking to people and expressing your interest, they might have insights as to how to proceed or places they know and places where they think you fit well. Going to some of these conferences, [such as those for] ASCO [American Society of Clinical Oncology] and ASH [American Society of Hematology], and trying to meet up with people would help.

The second thing is [that] as daunting as it looks, if you’re persistent in your journey, you make it in the end. Keep doing your research, keep working, find out about the place where you want to go, and talk to people about where they are.

The other thing that might help is doing an outside elective at a place where you like to go. I had applied to do an outside elective here at AHN, but [because of] COVID-19, I couldn’t do it. Now I see people are coming again and doing outside electives.

Your oncology specialty is lung cancer. How have some of your experiences in clinic been affected by the novel treatments and approaches brought to the lung cancer arsenal in recent years?

I don’t know where to begin. I was talking to one of our other thoracic oncologists, who has been doing this for 30 years or more. Twenty years ago, it sounded like stage 4 lung cancer treatments, with the chemotherapy treatments that we had, didn’t give a lot of benefit or hope to patients. In the past 10 years, with the advent of immunotherapy and all these targeted therapies that have come through now, overall survival and quality of life [have] gone up so much.

[In addition to sotorasib,] TIL research is also going on, and West Penn Hospital has a site opened for that as well. It is a lot to remember for a fellow, but it’s good for patients.

You can talk to patients, look them in the eye and say, “Hey, I have a lot of treatments that we can offer you, and then you would lead a good life. You could make it [to] your grandson’s graduation.” Those are some of the things that have come into our discussions with patients because all they care about is living longer and living better.

Vinay Edlukudige Keshava, PGY-5, is a hematology-oncology fellow at Allegheny General Hospital and West Penn Hospital System, Allegheny Health Network, in Pittsburgh, Pennsylvania.

FDA grants accelerated approval to sotorasib for KRAS G12C mutated NSCLC. FDA. May 28, 2021. Accessed May 10, 2023. https://www.fda. gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-sotorasib-kras-g12c-mutated-nsclc

Vinay Edlukudige Keshava, MD, shares the story of his fellowship and provides advice on how to best transition to the next step in an oncologic career.

Persistence Is Key to Success

As you begin to up your oncology fellowship, you may be questioning the right path for your career. Do you travel down a road that leads to an academic field? Does pharmaceutical work speak more to your passion? Or, do you have a desire to work more in the community setting?

Megan M. Dupuis, MD, shares the complex journey she traveled during medical training and how it brought her to the academic setting.

As an academic hematologist/oncologist with a unique path, I am often asked how I ultimately chose my current position at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee. For me—as it will be for you—the answer is multifaceted and deeply personal, and was ultimately rooted in what I value most: patient care and education.

To understand how I arrived here, my past training bears mentioning. As an MD/PhD candidate, I had fully intended to study microbiology for my PhD and become a physician-scientist.

Then, in a twist of fate, my intended principal investigator (PI) had to suddenly leave, and I was left adrift. Panic-rotating through a cancer immunology lab at Roswell Park Cancer Institute that I was fortunate to join, I received exceptional training over 4 years, finished my PhD, and made lifelong friends. I also sealed my fate as a future oncologist, since I found both the science and patients deeply interesting. However, during that time, I also discovered that basic research did not “spark joy”—to quote professional organizer and declutter expert Marie Kondo. I found myself feeling depressed, lonely, and truly missing patient interactions.

This left me in a bit of an identity crisis. If I wasn’t going to be a physician-scientist, who was I going to be? For the first time in my life, I had to potentially disappoint others—my MD/PhD program and my PI, especially. Ultimately, I recognized that what did bring me joy was teaching and education. Through my undergraduate years, the first 2 years of medical school, and throughout my PhD program, I worked for Kaplan as an instructor for standardized tests including the MCAT, served as a teaching assistant, and was invited to create curricula for our PhD program. It was in cramped classrooms, hospital workrooms, and clinic spaces that I felt most alive.

Thus, I began to pursue education intentionally both during residency and fellowship. I completed training programs in adult learning theory; created new curricula still in use at my residency and fellowship programs; and served as education chief for 2 years during fellowship. I felt confident that I knew my path: academic medicine with a focus in education.

When I began thinking about applying for positions, my mentor and program director, Nishin Bhadkamkar, MD, of The University of Texas MD Anderson Cancer Center, gave me exceptional advice. “Megan,” he told me, “You need a list of needs and wants. The needs are nonnegotiables, and the wants are bonuses that help to decide between jobs. The needs list should be short, and the wants list should be as long as you please.”

A job that allowed dedicated access to learners; 

And a job that was in a warm part of the country.

As I began my third year of fellowship, I wondered whether either an academic or private practice setting could potentially meet my needs and thus applied to both. Like other trainees, I knew what academics involved but wanted to better understand the responsibilities and practice patterns of community oncology, as well.

To my surprise, I discovered that several community-based positions had opportunities for educators, too. For example, some of the private practice physicians I interviewed with had positions within community residencies, ran tumor boards at the local hospital, taught rotating PA and NP students, and worked with national organizations, such as ASCO or ASH. Conversely, I also discovered that just because a role is academic does not mean that it would guarantee contact with learners. If a position had an expectation for heavy clinical work or research, it would not necessarily afford protected time to work with learners, too.

I learned to hold my needs at the forefront of my decision-making, which allowed me to authentically pursue my current position at VUMC. Here, I wear 2 hats: one as a general hematologist and oncologist, the other as the associate program director for the fellowship program.

However, the details are so much more rewarding than that one-liner. I see patients 2 days per week in one of the regional centers in the greater Nashville area; I can care for nearly everyone that comes through the door. Additionally, I serve on the inpatient oncology service 10 weeks per year, allowing me to work with our fantastic medical students and house staff. The diversity of patients in my clinic is both personally satisfying and allows me to better teach and advise trainees. Seeing a range of clinical cases helps me stay up to date with the latest research and developments in oncology, which I can then share with my learners.

Being part of a university system that has a diversity of learners was also a major draw for me. I appreciate the opportunity to work with medical students, residents, fellows, and other healthcare professionals. It provides a rich and stimulating environment where I can learn from my colleagues and my trainees, who expect me to remain current in my knowledge of medicine and oncology.

Additionally, I get to be part of an academic center offering the resources of a larger institution. For oncology alone, this includes access to tumor boards, clinical trials, and disease-specific experts. This also means I can quickly access specialists in other fields, such as endocrinology, rheumatology, and mental health—all of which are critical to the care of patients with cancer.

A significant portion of my time is focused on educational initiatives. In addition to my associate program director duties, I founded a Medical Humanities certificate program and direct the oncology sub-internship for medical students, and also participate in the ASCO Education Scholars Program, which requires monthly meetings and quarterly travel. The activity I have in educational spaces is possible because I have 3 days of protected time each week and a supportive division chair. In academics, so many things can demand your attention; therefore, having true protected time and support from your superiors for your needs is key to job satisfaction.

Academics also intrigued me because of the broad network of support for my career path. I have been blessed with a strong community of mentors and “friendtors” (an excellent portmanteau that is exactly what it sounds like—friends who can mentor you). I still regularly meet with Dr Bhadkamkar, my former program director and mentor, at least once monthly. I also heavily rely on my senior mentor at VUMC, Jill Gilbert, MD, for advice in education, oncology, and life. I have been lucky to collect several friendtors who have written letters of recommendation, made key introductions, and collaborated on projects. It is critical to surround yourself with a like-minded community to support your growth and embrace your purpose, especially if your career path is more unique.

Of course, the decision to pursue academic medicine does come with certain sacrifices. My pay is less than what I would make in a private or community practice—perhaps half as much, based on the salaries I was offered on the interview trail. However, the balance between my work and home life is fantastic. By working in a large system, my individual call time is reduced and the responsibility for patient care is divided over faculty, fellows, nurse practitioners, and physician assistants. This frees 40 weekends per year for me to pursue hobbies, such as ballroom dancing, camping, hiking, and enjoying city life. This balance is important to me; it allows me to be a more fulfilled and effective physician and educator.

It’s important to note that the decision to pursue a career in academic medicine should also not be based solely on the workload, as data show that oncologists in both academic and community practice spend about the same amount of time working each week. According to a survey published in the 

, oncologists reported working an average 58 hours per week in academic practice vs 62 hours per week in community practice.

 I believe that the less your work feels like 

, the more you are able to authentically dedicate yourself to it without burning out.

Academics can also be clunky. It can be challenging to make changes quickly when you are one voice of many; things are often decided by committee and require layers of approval. Moreover, your individual interests or passions may not be shared at a divisional, departmental, or even institutional level. I would absolutely choose this path again. Each day is different, challenging, and invigorating. My clinical practice allows me to stay up to date with the latest research and developments in oncology, while also providing me with the resources of a larger academic center. Being part of a supportive division and university system has been critical to my success and happiness in my job, and I am grateful for the opportunity to pursue what I love intellectually with support and mentorship.

Megan M. Dupuis, MD, is an assistant professor of medicine in the Division of Hematology Oncology and associate program director of the Hematology and Oncology Fellowship Program at Vanderbilt University Medical Center.

Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. 

. 2014;32(7):678-686. doi:10.1200/JCO.2013.51.8480.

Choosing Your Path

Amy Jones, MD, was on the inpatient service at Parkland Health in Dallas, Texas, while helping treat a young mother with an aggressive lymphoma. While it was time to discontinue therapy and move her to hospice care, and the patient agreed, she wasn’t ready to have that end-of-life conversation without her clinic fellow in the room.

“It was pretty rewarding as a program director, and as a teacher, to be able to have this fellow come in, lead this really important conversation, and have the patient completely trust the medical team, because that fellow was there,” said Jones, assistant professor of hematology oncology in the Department of Internal Medicine, and the director of the Division of Hematology Oncology Fellowship Program at UT Southwestern Medical Center.

This situation is one of many that Jones has witnessed her fellows experience. Along those lines, she’s seen them attack patients’ socioeconomic and language barriers head on. Dallas County has become more diverse in recent years, with approximately 80% of the population projected to comprise Black and Hispanic residents by 2050.

On the healthcare front, data show that more than 43% of individuals and 38% of families in Dallas County live below 2 times the federal poverty level.

 Additionally, the uninsured rate is 3.5 times higher for Hispanic residents, and nearly 2 times higher for Black residents compared with White residents.

The fellowship program comprises multiple sites for hematology oncology fellows to practice at in Dallas County: Harold C. Simmons Comprehensive Cancer Center, Parkland Health and Hospital System, William P. Clements Jr. University Hospital, and Dallas VA Medical Center.

“They get a lot of experience in different practice areas so that they can figure out what they like, but also be able to manage patients in all different types of situations,” she added.

, Jones details the socioeconomic challenges with patients coming into the Dallas County clinics and how oncology fellows become equipped to address them. She also provides advice for current fellows and lessons she learned during her own fellowship.

: How would you describe the fellowship program at UT Southwestern to someone thinking about applying?

: It is a fellowship that is undergoing tremendous growth, and evolution, just like our institution and our division in general. I applied to fellowship not excessively long ago, but it was a fellowship with about 12 fellows, [and it was] very clinical—not a lot of research. There were about 30 faculty or so at that time. Our division, in the past decade, has gone to pushing 80 faculty; we’re now going to have 24 fellows a year.

Our fellows have an excellent mix of clinical training and research training. One of the really cool things about our fellowship is that we have 3 very diverse clinical sites that our fellows spend time in.

Dallas is a very diverse city. What are some of the barriers patients who are coming into the medical centers face?

Some of the barriers are different based on what site we see patients at. We see patients at the university, which comprises Harold C. Simmons Comprehensive Cancer Center, a National Comprehensive Cancer Network–designated comprehensive cancer center, as well as Clements University Hospital, which is associated with the university. We see patients at Parkland Health and Hospital System, which is the safety net hospital system for Dallas County and is one of the oldest and most well-established county hospital systems in the country. Then, we also see patients at the Dallas VA [Medical Center], which is the second largest VA health care system in the country.

Each of those sites is very diverse, but in different mixes and ways. For example, I practice at Parkland, where 95% [of the patients are] socioeconomically disadvantaged, so over half of the patients don’t have insurance, and for the rest of them, most of them are on Medicare or Medicaid. Then, that 85% of that population [comprises] underrepresented minorities, with the majority of patients not having English as their first language. That’s probably the most challenging patient population, just because most patients are coming in with cancers who maybe have not had treatment, or are at the time where the patients didn’t have screening because they didn’t have any access to healthcare—whether that was an insurance or citizenship barrier.

Patients who don’t speak English is another barrier for care. While we have excellent translation services, it can be hard because sometimes patients are coming in with a language that doesn’t rank among the 200 different translation offerings that we have. Then, of course, there are a lot of socioeconomic things that we have to take into account both, in making treatment decisions, but then also in terms of resource allocation.

There are a lot of barriers there at the cancer center; we’re still seeing a very diverse patient population. One of the things that we struggle with at our cancer center— it is both a struggle, but also a strength— is that we want to enroll a lot of patients on clinical trials. There’s a lot of history, especially in the African American population, of distrust about clinical trials and the healthcare system in general.

Therefore, there’s a lot of patient education, outreach to communities and churches to say, “Actually, we want to take care of whoever is in our community.” Our most recent numbers showed that a little over onethird of patients enrolled on our clinical trials to the cancer center were underrepresented minorities, which is phenomenal, considering how a lot of papers you read note that 5% 10% [of patients enrolled included underrepresented minorities]. We are getting more than one-third, but it’s still a challenge.

Then the VA, of course, has its own barriers and own difficulties. Again, it is a very diverse population. There are a lot of patients who are coming from rural areas to the Dallas VA to get their cancer care, so there are a lot of transportation issues, and then just a lot of patients have not had good oncologic screening and workup because access to care may be more challenging.

Reflecting on these challenges, what trainings, protocols, or advice do you provide to fellows on caring for patients with these backgrounds and/or disadvantages?

The first thing is having fellows feel comfortable being able to communicate at patients’ health literacy levels. Incoming oncology fellows are eager to get the lingo right and start talking like an oncologist. But sometimes, we have to unlearn that to be able to reach our patients where they are. Being able to explain to patients, their treatment decisions and the plan, in a way they can understand is super important.

Just to give you an example, at Parkland, all of our written materials have to be on an eighth grade reading level or less for English and a fourth grade reading level or less for Spanish, which can be really challenging when you’re trying to write any printed publications. We’re lucky at Parkland in that we have a lot of support from social work, behavioral health, psychology, palliative care, physical therapy, and nutrition—a lot of things that maybe patients wouldn’t have that at other safety net institutions.

One of the things I always tell my fellows is that, as an oncologist, your job is to care for the patient, but you don’t have to do all of it yourself. It’s a lot of learning how to use the resources that we have. Learning when it’s right to ask your nurse or your nurse navigator, or the social worker, or the nutritionist or whoever it is, to help you out with an issue. We are lucky at Parkland that we have an extensive pharmacy staff that helps us get a lot of our medicines approved through patient assistance programs. It’s very rare that I am unable to give a medical therapy to a patient that I want to.

However, we do run into a lot of issues, sometimes with things like nuclear medicine intervention, or we can’t do things like stem cell transplant. We are treating some of these patients with an acute leukemia, who, outside of a safety net hospital, would go to transplant, but that’s just not an option if they’re not a citizen. You have to be a little bit creative. In some ways, for fellows, it’s good because it helps you really understand the decisions you’re making medically, and be able to interpret data for the patient in front of you, which can be challenging, but it’s a good skill to learn.

Asking for help as a fellow, is important, especially when you have resources such as nurse navigators around you, rather than trying to tackle some situations unknowingly.

Especially starting oncology fellowship, but anytime you’re practicing as an oncologist, there’s a lot of emotional burden that we take on dealing with death and dying every day. Then when you add on that next layer of, “My patient came to me, and they don’t have food. Now, what do I do about that?” Or, they’re the only breadwinner and they are a family of 6, and they can’t come to chemotherapy because that means they’re going to have to miss a day of work and then they can’t pay their rent. That’s stressful, and that’s a lot of burden—you’re learning how to emotionally manage that burden and spread it out. I think it’s really important for being able to plan for longevity of careers in a very emotionally laden subspecialty.

Are there recommendations or requirements for fellows to learn another language to better converse with patients?

We don’t have any requirement, and definitely the vast majority of our fellows do not speak the primary second language of Spanish; we have some that do. As a Spanish speaker, it does make clinic a lot easier, because I don’t have to dial in an interpreter or have one come in, but it’s not impossible. It does require additional skill sets to clinic management, because using an interpreter takes more time.

You have to figure out how to do that effectively, but it also requires another level of being able to communicate clearly to an interpreter, and then trust that that’s happening to the patient. It does add complexity to clinic. Maybe I’m biased, but I think it there is a huge reward to being able to serve a community that may not be able to see an oncologist in any other situation.

So many of our patients have gone to many different places and been told “no.” Then, they come to one of our UT Southwestern clinics, or at Parkland or the Dallas VA, and they’re so thankful to see an oncologist. It can be rewarding, because our fellows do get to be the primary oncologists for a lot of these patients. You’re getting to make the clinical and medical decisions, but also, you’re forming long-lasting relationships with patients, which is really important in training.

It seems that the fellows are getting involved in all aspects of care there.

It’s good for our fellows that they get to spend a little under half of clinical time over at the university too, because they are in very much a tertiary referral center, a comprehensive cancer center environment where they’re being exposed to the latest interventions, the most exciting clinical trials, and they’re seeing that with attendings in their clinics and managing those patients. Then, being able to take that back to more of a community, safety net hospital setting is great because the patients there benefit from the knowledge that you learn over at Simmons.

However, it can also be frustrating when you have an amazing clinical trial open that you would love to enroll this patient on, and you can’t because the funder doesn’t want to open an additional clinical site. It really makes our fellows acutely aware of the healthcare disparities in our country, and how some people are going to get the top of the line, best care— they’re going get the thing that just was published in the 

. Other patients may never see that because of financial issues, citizenship issues, insurance, whatever it is. I hope that we are training fellows that are attuned to those disparities and are able to try to mitigate those and whatever clinical practice they take in the future, whether that’s in academics, community, industry, or in any other setting.

As fellowship program director, what are the essential pillars that you try to instill in your fellows?

Number one is clinical competence; we want our fellows to be clinically excellent and be able to make complex medical decisions on their own. We do have the luxury with multiple sites that we’re able to have varying levels of autonomy at those sites. Fellows really feel like, by the end of the 3 years, they’re able to independently manage whatever oncologic disorder comes through the door. That is super important.

Second for me is I want to develop fellows who have exceptional emotional intelligence, both so they can interact with patients, but also so that, as we’ve mentioned, they’re able to be resilient and manage the emotional burdens that they will have throughout their career.

The other thing, too, is just to have fellows that are open to inquiry and kind of investigation with wherever their path leads, whether that’s going to be in the lab, whether that’s going to be working on healthcare disparities and helping to level the playing field throughout our country, or that the fellows that are going to be opening these clinical trials. I want our fellows to have these tools, to be able to answer the questions that they want to answer in their career.

What lessons do you still recall from your fellowship? Also now, as a fellowship program director, what lessons are you learning in this role?

I was lucky to do my fellowship at The University of Texas MD Anderson Cancer Center, which the majority of our time was at this huge multinational cancer center. However, 1 day a week, I was in a very similar setting to Parkland at the county hospital in Houston, with my own patient panel. I think I am biased, but I thought that was an incredible learning experience as a fellow to juxtapose those 2 environments.

Something I learned was: don’t settle for maybe the easiest path for patients—whether that is a patient who you don’t think can pay for something or there’s some issue, you can think creatively around that. Or, perhaps there is a patient who maybe everyone else has told that there are no other options, and they’re coming to your major cancer center. There probably is a trial; there is something you can think about with your colleagues to figure out for them.

As a program director, one of the things I’m learning more and more is just the diversity of clinical thought and learning styles of fellows, and trying to figure out how to best support that to make every fellow be successful in the path that they want to take. One of the things I really want to do is make sure that I’m nurturing our physician scientists, our clinician educators, our clinical investigators, our educators, and our community physicians, so that we can have excellent cancer care, no matter what setting a patient’s going to show up to.

What advice do you have for oncology fellows today?

Through my training, I always felt very inadequate as far as, “I just can’t keep up with the learning. I can’t keep up with the knowledge.” That’s true, you can’t, there’s no way you’re going to be able to memorize all of these new drugs, all the approvals for every single disease. The best advice I got from a mentor, which I’ve taken to heart, is try to learn something new for every patient you see.

Maybe you read 1 paper per patient, or you really nail 1 statistic for that disease with that patient. We will remember it better if you can attach it to a patient, but then also, it’s not super overwhelming; I don’t have to go home and read every single paper that came out in the 

. This week, I can focus on, “I have a new patient with colon cancer. I’m going to learn. What should I do for their new left-sided KRAS wild-type disease?

Is there anything else to add either with the program or fellowships in general?

The thing I always tell residents who are applying to fellowship and just fellows in general is that fellowships are really varied. It’s very different from an internal medicine residency, where you’re going to have a relatively similar experience, no matter where you go. Figuring out what you want out of fellowship will help you decide where you should be. If you want a certain environment, make sure that you’re getting that when you’re applying.

Amy Jones, MD, is an assistant professor in the Department of Internal medicine and program director of the Hematology Oncology Fellowship Program at the UT Southwestern Medical Center.

Texas Demographic Center. 1990-2015 Population Estimates and 2015-2050 Population Projections. Accessed April 26, 2023. https://demographics.texas.gov/

American Community Survey. CPPP analysis of U.S. Census Bureau, American Community Survey, Table S2701, 2009 and 2015 1-year estimates, Dallas County. Accessed April 26, 2023. https://www.cftexas.org/cft/files/70/7000d1c2-1958-4752-9bc2a0e411d3f9d4.pdf

American Community Survey. CPPP analysis of U.S. Census Bureau, American Community Survey, Table S2701, 2009-2015 1-year estimates, Dallas County. Accessed April 26, 2023. https://www. cftexas.org/cft/files/70/7000d1c2-1958-4752-9bc2-a0e411d3f9d4. pdf

Amy Jones, MD, details the socioeconomic challenges with patients coming into the Dallas County clinics and how oncology fellows become equipped to address them.

UT Southwestern Fellows Embrace Creativity in Managing Patient Diversity and Cancer Care

It is a time of new beginnings. Many of you are graduating and starting your first job as a hematologist oncologist. Many of you are just beginning your training in this field. Regardless of where you stand in the trajectory of it all, welcome to this exciting time in your professional development.

I want to focus on the concept of wonderment as a tool in new situations. A graduating resident or fellow may be quite confident in their ability to navigate a world they have just mastered. However, wonder can be used as a mechanism to humbly, and with some excitement, attain the competency that is required to gain mastery of your new environment.

Wonder can be used as a protective blanket to ask questions or even to challenge a status quo. How does this work? There is an inherent innocence to wonder—a pure desire to learn and contribute without posing a threat.

Let me give you a concrete example of how this may work. A fellow starts training at a new institution. The fellow observes that a particular educational conference lacks attendance. You have an idea of how to improve this experience for the fellows based on your prior training experiences. A common way that a novice might address this concern is by saying, “This conference needs to change. Attendance is not where it should be. The lectures are boring.”

Inherent in these comments is a sense of judgement, which may be perceived as arrogant or threatening to program leadership. Your message will get lost because of the way it is delivered.

By using wonder, you create a nonthreatening opening for a synergistic vision that, at its core, is not about you but about the program, a common good. A recommendation that uses wonder as a tool to achieve a similar aim is the following: “I’ve noticed that lectures are not well attended. I wonder whether by asking participants to turn on their cameras, we may foster interaction and a more robust learning experience that attracts attendees.”

In the latter sentence, you have a suggestion, not just a complaint. Moreover, you couch this within the common good: the desire to promote an effective learning experience for all.

This same technique applies to those who will be entering independent practice. Right now, the recently graduated trainee is at the height of knowledge in the field given the proximity to training, studying for boards, etc.

However, the fellow is also entering a new professional reality in which the guardrails of Accreditation Council for Graduate Medical Education do not exist. For some fellows, this may be a difficult or unsettling transition in which duty hours don’t protect your time and patient caps are a thing of the past. The recent graduate may feel unsupported or unconfident in new surroundings. This is common, and it is normal to have trepidation.

A pitfall arises when feeling overwhelmed or inferior translates to defensiveness or arrogance. It is common for a new graduate to be unfamiliar with concepts comprising billing compliance, insurance authorizations, and posted patient reviews. In most cases, the business of practicing medicine is not a significant component of training.

This is all part of being a physician in this modern health care reality. Take every opportunity to learn on the job, ask questions, and identify key individuals in the practice who will help teach you the ropes. Meet with them early to obtain feedback along the way. Your sense of wonder is your power at this point.

For example, it is common to score poorly on patient reviews when new to a practice. A normal response is anger, especially if the message comes from a leader within the practice. A common retort is, “The patients are wrong. They have a bias. They do not understand me.”

However, take a deep breath and think about this as a problem that can be approached with wonder rather than anger. Use this experience to demonstrate maturity and professionalism and create relationships and sponsorship from within your practice environment.

Instead of an emotional attack, try the following: “I wonder whether there are tips to help me improve my patient rapport. Can you provide me with the name of an individual who scores well on patient reviews so that I can learn from them?” Or you could say, “I noticed that you have 5 stars on patient reviews. I wonder whether you could give me some pointers.”

Through this interaction, you have shown a desire to learn and a willingness to be taught. When you lead with wonder and humility, you open yourself to opportunity.

Jill Gilbert, MD, is a professor and associate director for Research, Education, and Professional Development at Vanderbilt University Medical Center in Nashville, TN. 

Wonder can be used as a mechanism to humbly, and with some excitement, attain the competency that is required to gain mastery of your new environment.

The Concept of Wonderment

My photographer set up the lights and steadied the camera. The surgeon before me was pale and fidgeting. As a seasoned television news journalist, I had seen this many times before—a surgeon at the top of their field, terrified that they would tank on television. I did my best to walk her through the process and calm her nerves. I would have been equally terrified in her role in the operating room. It’s natural to fear the unknown.

As the public affairs manager for Huntsman Cancer Institute at the University of Utah in Salt Lake City, I use my insider knowledge to empower and help ease the nerves of our physicians and scientists by preparing them for media interviews. Interviewing with journalists is one of the most effective ways you can share your work with the community and help promote your institution, which can be well worth the discomfort. 

Here are 5 tips and tricks to help you shine when the spotlight is on you.

Tip 1: Don't Avoid Interview Opportunities

Avoiding journalists means your institution’s public affairs coverage suffers. Half the battle is being willing to show up and agree to an interview. The more you do it, the easier it gets. 

See media interviews as a networking opportunity. Media interviews are a highly effective way to share your expertise. In a single 20-minute interview, you can reach thousands, hundreds of thousands, or more individuals with important messages about prevention, screenings, and general health. “I wish doctors and scientists recognized how many good stories they have in their day-to-day work,” Deanie Wimmer, anchor and reporter with KSL-TV in Salt Lake City, said. “When you know of encouraging treatments, new research, or inspiring patients, we’d love to know about it. These all offer meaningful information that we would like to relay to television audiences. Understandably, there are complications, [such as] peer review, scientific standards, and confidentiality, that sometimes preclude doctors from sharing that information. But I can’t help but think there are missed opportunities.” 

In my work, I have landed numerous stories, most recently with NBC News, by asking the reporter I was working with the simple follow-up question: “What kind of stories are you looking for?” Ask this question while the crew is setting up or after your interview. It’s a chance to pitch your institution’s research and clinical care. They are always looking for content to fill the page, show, or podcast, and this is your chance to see more of your work featured.

Understand that journalism is deadline driven. Newsrooms usually plan content from that morning’s editorial meeting. That’s when producers and the news director decide which stories to pursue that day. Sometimes they can give us notice ahead of time on a request, but other times, it’s last minute. It all depends on the news cycle. Joining a Zoom meeting on your lunch hour or setting aside 20 minutes for an in-person interview before or after clinic can be difficult, but fitting it in helps the place you work for become a trusted source among journalists. This increases the quality and quantity of stories that feature your institution, its reputation, overall mentions, and more. “The most common frustration is accessibility,” Wimmer, who has won multiple Emmy Awards for her work, said. “Their definition of ‘soon’ is often different from ours. I have in mind later today, [whereas] they’re thinking, ‘sometime next week.’” 

Brush up on your media training before the interview. Review this article or media tips provided by your public relations teams. If this isn’t your first interview, remember what worked well last time and what you’d like to do better in the future.

Draft key messages. Many clinicians do not realize how much control they have over the direction of an interview. By preparing key messages, you increase the likelihood that the information you want to communicate will be the focus of the story. In addition, keeping it to 3 to 4 talking points ensures it will come across in a clear, concise way. It will also ease pre- interview jitters.

Have a few facts or statistics in mind. Statistics back up your answers, but do not try to memorize them. You could write these on note cards and keep them with you during a television interview. It’s fine, and more natural, to look down and read the statistics or data. You can also follow-up with an email after the interview is finished. 

Avoid jargon. Keep it simple but remember the audience you are speaking to. “Doctors are experts in highly specialized and complex fields,” Wimmer said. “Anything they can do to help us simplify the information, illustrate it, and relate it to [individuals] will make the message more impactful.” A litmus test in broadcast journalism when writing scripts is often whether the viewer will understand and be interested in the material if they overheard the story while washing dishes.

Rehearse, rehearse, rehearse! Review your talking points out loud—in the mirror, to a friend or family member, or with your public affairs colleague. You could even practice with a pet or the plant in your office. The point is: Saying your message out loud before the interview helps ease nerves and sets you up for success. “Imagine it’s the checker at the grocery store you are talking to,” Scot Singpiel, manager of TheScopeRadio.com with University of Utah Health, said. “Answer the [following] questions: What is the purpose of your interview? What do you want the listener to think, feel, [or] do after they hear from you? If the listener could only take away 1 thing from your interview, what would it be?”

Research the reporter. An internet search of the journalists’ bio, role, and background can reveal whether they are a general assignments reporter, covering a wide range of topics from breaking news to features. In this case, it’s especially important to frame your answers in the simplest terms. A specialized health reporter will have deeper background and insight into complex medical topics. Even still, they will appreciate you starting with the basics on any complicated research.

Find out which show or section of the newspaper or magazine the story will be on or in. If it’s a morning, midday, and afternoon show, the content and tone are usually lighter. Prime time, nightly newscasts are harder hitting. Front page stories in print or online also tend to be more serious. Make sure your answers reflect what you’ve learned about the placement of your story.

Tip 4: Request Questions Before the Interview 

Always ask for questions ahead of time. Your public affairs team can help with this. Even if the reporter doesn’t provide the questions beforehand, have some talking points prepared. “You have limited time to get your message across,” Cristina Flores, anchor and reporter at KUTV News in Salt Lake City, said. “If you have 1 minute to say something on camera, you want to ensure your words and your message are clear. If you don’t, you either waste the opportunity or leave it to others to interpret what you say.” 

Reinforce key messages. “During the interview, say, ‘The most important thing to remember is,’ followed by your most impactful response. It makes things clear for the viewer and for the journalist, who [are] often trying to figure out the hook or angle of the story,” Flores said.

Tip 5: Remember, "The Medium is the Message" 

This insightful phrase by Marshall McLuhan, a Canadian philosopher, is among the foundation of media theory and is still front and center in journalism classes across the country. It means that the nature of media platforms influences how your message is perceived and received. Knowing how each medium works empowers you to use that knowledge to your advantage. 

How you look matters. “Dress professionally; a lab coat or scrubs are appropriate most of the time,” Flores said. “Make sure your hair is tidy. Makeup for both men and women is appropriate to avoid a shiny complexion or to warm [an individual’s] face, as lighting can sometimes make the skin appear pale.” Primary colors such as blue, red, and yellow look great on television, as well as combinations of those colors, such as green, orange, pink, and purple. I encourage our physicians to bring their own style to the interview. There’s only 1 you, and by bringing your personality and style to the interview, you will find greater success. Ask whether there will be a green or blue screen at the filming to avoid wearing those colors at taping. 

How you say it often matters more than what you say. “Don’t be afraid to smile.” Flores said. “Even if you are discussing a serious topic, [such as] cancer, it is important to seem approachable during an interview. A smile also conveys warmth and care for others. Visual cues and how you deliver your message are [just] as important as the words.”

Sit or stand comfortably, as you would with a colleague. Adopting a relaxed stance or posture is a trick that national television consultants earn a lot of money teaching anchors and reporters how to do. It’s as simple as avoid standing or sitting stiffly, as you’ll appear on edge and your voice might be more strident. Get comfortable—if your body is at ease, your mind will follow. Be aware of your body language because it can send unintentional messages. Crossing your arms across your chest sends a message that you are closed off and less approachable. Leaving your arms open or placing them at your side is better. Try to be as natural as possible.

Strive for a friendly but knowledgeable tone. Pretend you’re telling the checker at the grocery store about it—or even better, one of your patients. Bring your bedside manner skills and warmth to the interview. “Think about visuals that can help portray the complex data,” Wimmer said. “Rather than describing precisely what is happening, can you show me what’s happening or compare the before and after to provide a general idea? Even patients can serve in this capacity to speak to and illustrate through their experiences.” 

Keep your talking points in front of you. This can help you maintain your focus during the interview. But be mindful to stay in the moment, and answer follow-up questions as needed.

Reiterate your message points at every opportunity. “I always want to make sure I represent my sources’ views and ideas accurately,” Sofia Jeremias, Innovation Lab reporter at The Salt Lake Tribune, said. “Expressing something a few different ways helps me do that. You may feel like you’re repeating yourself, [but] I often notice when reading through transcripts that the second or third time a source repeated an idea is often the most succinct, straightforward, and quotable version of their point.” 

Be available to clarify any points as the writer is working on the story. This is perhaps the most effective strategy to increase the chances the story will be accurate. It’s appropriate to text or email the reporter later—before deadline—to make sure they have everything they need. “When I sit down to write a piece, that’s when I generally realize what information I missed during the interview process,” Jeremias said. “I also like to check back in with sources and make sure I understood them correctly. It’s always better to realize where I’ve gone wrong or misunderstood something before a piece publishes rather than having to issue a correction.”

Know the format. Is it live or recorded? If it’s being recorded, do multiple takes. Reporters do this frequently and are used to interviewees asking to start a thought again. It may feel awkward in the moment, but remember that what goes on-air is most important, and it’s good to get it right—even if that means a few takes.

Use verbal illustrations. “[Because] radio and podcasts depend only on audio to communicate your message, use language that helps the listener see what is being talked about,” Singpiel said. “Verbal illustration techniques, such as analogies, metaphors, and similes, are powerful tools to help paint the picture, and [it] makes the difference between an interview that connects and communicates your message to the listener and one that doesn’t.” For example, when experts talk with media about sun protection, they might describe the amount of sunscreen needed for the average adult as, ‘a shot glass full of sunscreen.’ This paints a picture for the listeners. 

Vol. 15/No. 2 | Oncology Fellows

Building Upon Scaffolds

Persistence Is Key to Success

Choosing Your Path

UT Southwestern Fellows Embrace Creativity in Managing Patient Diversity and Cancer Care

The Concept of Wonderment

Media Training Helps Investigators, Institutions Shine