5 Tips for a First-Year Fellow

It's July of fellowship. Your pager goes off just after midnight, with the dreaded words, “CONCERN FOR ACUTE LEUK. CALL TO DISCUSS. ED” displayed on the green fluorescent screen.

Still reeling from setting up emergency overnight apheresis for a patient with leukemia, you get 3 new consults the next morning, with requests ranging from interpreting a preoperative abnormal partial thromboplastin time test (surgery) to management of sickle cell crisis in an antepartum patient (OB/GYN) to evaluation of hemophagocytic lymphohistiocytosis in a patient with multiorgan failure (ICU). Taking a deep breath before calling the teams back, you suddenly remember that oncology continuity clinic is tomorrow morning and you still need to chart review the new patients…

Lots of fellows have drawn parallels between the hectic first year of fellowship and the intern year of residency—the inpatient services are fast paced, there’s plenty of assigned calls, and the volume of day-to-day learning feels like drinking from a firehose. In the eyes of other primary teams, the new fellow is suddenly expected to be the expert of all things hem-onc even if he was just a senior resident a few weeks ago. Nerve-racking much?

Like every stage of medical training, however, the days will get easier. Here are 5 tips that I found to be helpful as I look back on my first year:

1. Don’t Be Afraid to Ask Questions

This old adage still rings true in fellowship. Attending physicians are there to help you learn, and because fellowship is the terminal stage of medical training, it is even more important to ensure that you fully understand the rationale of clinical decision-making. In fellowship, attendings are less concerned with Christopher Su, MD, MPH double-checking your work (that’s what residency is for—now you’re a licensed physician). Instead, they want to help you develop into one of their colleagues. Always remember that you chose to go into hem-onc, so soak up the day-to-day learning as it comes.

2. Read Around the Patients

It can be challenging to stay on top of the list in the ruckus of a consult service, much less finding the time to do background reading. I found the reading that “sticks” the most is directly related to the patients I am actively following. UpToDate is an invaluable resource on the fly, and even a quick 5-minute refresher before heading into the patient room or presenting to the attending adds up. If you have more time, PubMed review articles relevant to the disease topic, How I Treat articles for hematology, and the “Principles of” sections in the back of each National Comprehensive Cancer Network guideline document for oncology are also great places to start. For more rigorous textbook-style review, check out the American Society of Clinical Oncology Self-Evaluation Program and the American Society of Hematology Self-Assessment Program.

3. Take a Hemepath Elective

In the vast majority of fellowships, first-year fellows are expected to respond to new acute leukemia consults from the emergency department. Hematologic emergencies aside, you will also be asked to review numerous peripheral smears during hematology rotations. A secret gem, and one of the most enjoyable rotations of first year, was my hemepath elective. Working with a seasoned hematopathologist, I had the opportunity to enhance my peripheral blood smear review skills, and I even learned to interpret flow cytometry plots and bone marrow biopsies.

Despite having seasoned pathologists ready to help with interpreting diagnostic studies at most academic institutions, there is still nothing quite like coming face to face with pathognomonic cells under the microscope—especially at 3 am. In fact, hematology-oncology fellows are expected to interpret their own bone marrow biopsies in many countries outside of the United States.

4. Connect With Research Mentors Early

Most fellowships now allot up to 18 months for research. Hematology-oncology research spans the spectrum from basic, clinical, and translational to health services and global health. Even if your career plan does not include academia, fellowship still provides plenty of protected time to explore a subfield of hematology-oncology that might be of interest and dovetail with your future career.

The clinical demands are high during the first year but keep research plans in the back of your mind. Beginning in January, start reaching out to potential research mentors; by that point of your first year, you will have a good handle on how the hospital operates and can start laying the groundwork for research. Then hit the ground running once protected research time starts either later in the first year or second year.

Always remember to stay flexible with your plans, though. Highly anticipated projects may not ultimately get funded or an exciting data analysis may turn out to be a flop. Projects come and go, so find trusted mentors who will guide you through the ups and downs.

5. Remember the Big Picture

Like so many have said before about medical training: The days are long but the years are short. Don’t lose track of life outside the hospital—your family, friends, and hobbies are important. We live in an era of constant access to the electronic medical record on our portable devices and computers, but make a conscious effort to not log on during your off days. At this final phase of medical training, it is a good time to reflect upon the long journey up to this point (approximately 11 years not including gap years) and have a bit of “protected time” to determine your career goals before setting out into practice.

Congratulations! According to the National Resident Matching Program, hematology-oncology fellowship programs offered just 615 positions nationwide during the last cycle. We are joining a cadre of subspecialists tasked with providing cutting-edge and rapidly evolving care to an aging population with increasing hematology-oncology diagnoses by the year. Getting to this phase of training is an achievement but also an immense privilege and responsibility. In the words of the immortal Steve Jobs, “Stay hungry, stay foolish.” Read up on patients, tackle those smears, keep calm, and hem-onc on.