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

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.”

Raskin talked with Oncology Fellows about time management, the importance of taking time off, and teaching fellows how to listen to their inner voice.

What attracted you to medical education?

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.

Just how intense is the experience?

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.