Looking back: Lessons learned in fellowship

There are two months left in my fellowship. Starting soon, I will be rotating through the non-malignant hematology clinic, receiving valuable additional teaching and experience while fulfilling requirements necessary to sit for the hematology boards.

In June, I will be doing my best to wrap up some unfinished projects, move along some others, and get myself ready for my transition to faculty. Recently, I laughed with one of my patients that the “two for the price of one” encounters (ie, direct faculty precepting) were about to end, and soon enough I would be the only clinician that he’d be seeing during his visits. I thought about this some more as I walked back to the workroom.

On the one hand, the prospect of increasing my clinic efficiency is very appealing. And, on the other hand, getting ready to take flight on my own is intimidating, to say the least. Thankfully, I’ll have the insight and advice of all those who have trained and mentored me within easy reach — I will be staying here, at the same center, in July.

What have these last three years taught me — and which insights and lessons will I carry forward into the years ahead? Here are a few thoughts — a list that may seem intuitively obvious to many, but more real to me now, after my three-year experience as a fellow.

It is impossible to accurately predict an individual outcome, as no two cancers and no two patients are exactly alike — but published data and collective experience help.

I have taken care of and continue to see many patients who defy prognostic expectations. The variability in outcomes seems especially pronounced in diseases or conditions with a multitude of potentially predictive prognostic variables, and among demographic or otherwise stratified groups with high physiologic and/or psychosocial variability.

I have an older myeloma patient with complex, adverse cytogenetics who responded remarkably well to induction therapy, and who experienced over a year-long treatment holiday before biochemically progressing. I remember the early opinions of some, who pegged him as potentially “hard to treat” and “likely to be noncompliant,” but he has been dutifully compliant, and a model citizen throughout.

I also treat an older woman with multiple comorbidities and blastoid variant mantle cell lymphoma who also responded much better to standard therapy than we might have predicted.

William Wood

On the other hand, there are particularly challenging cases, where there are no clear or easy answers about what to do next. I know that it is tempting to reason toward treatment plans based on personal recollection, or one’s own understanding of basic principles of disease and therapy. However, I also now know the additional strengths and limitations of multidisciplinary consensus conferences, thorough reviews of published data in the medical literature, and realistic appraisals of the quality of that published data.

We are sometimes naive to think that we are the only ones who have been confronted with what seem to be uniquely challenging circumstances. Hopefully, current trends toward expanded observational disease registries and virtual off-site expert consultations will make it easier to share in the collective experiences of others.

Only the patient fully understands the patient experience.

How effective is my usual “review of systems” in the clinic, and how accurate is my interval history? I think of the enormity of this task — trying to elicit and transcribe weeks’ worth of medically relevant symptom-based data with the use of several questions and a few typed or dictated sentences for the medical record. How much does this actually reflect the patient experience?

Some might argue against the relevance of trying to be so faithful to this experience. After all, in the space of a clinic visit, laboratory data and imaging-based information, we think that we can usually get a handle on most of what is happening with the tumor response. I believe, though, that we should move toward capturing patient-reported rather than second-hand, clinician-generated symptom data, and that perhaps some of this data capture should occur outside of the space of the clinic visit.

I believe that doing this is a matter of respect — we would indicate through our actions that the lived experience with cancer matters, since the patient, and not the tumor, is central to our role as clinicians. I also think that to the extent that symptoms reflect the physiologic response to both therapy and disease, making full use of patient-reported symptom data might provide valuable prognostic information relevant to medical decision-making.

Empathy goes a long way toward effective care giving.

I have learned that it is hard to maintain an empathic stance toward our patients at all times. I am sure this has something to do with our instinctive attempts as humans to protect ourselves from suffering and pain. In these last few years, I have experienced loss and tragedy, just as I know many others have as well. Friends and peers have died of the diseases that I treat in the clinic. Each time something like this happens, I draw closer to the patients I treat. And in each instance, as time passes, I begin to pull back again.

True empathy — “living close to the fire,” as one colleague described it — invites tremendous vulnerability, and can be frightening. But I am a better doctor when I connect more deeply to the triumphs and sorrows of others; I am a better advocate, and I bring more passion to my work.

As the years in fellowship have passed, my work has continued to become more and more of a calling. Sites like Caring Bridge (www.caringbridge.org), in which I live the experiences of my patients in the days between clinic visits, have further reinforced my connections with the individuals I see in clinic and have enhanced my ability to provide effective care for them.

Academic research sustains (my) clinical engagement.

I love what I do in the clinic. Taking care of patients is the central part of what I want to do with the rest of my professional life. When I am back in my office, though, thinking and dreaming about ways to formally study questions that come up in day-to-day clinical practice — in my case, to give it a name, “outcomes research” — leads me to believe that there are ways in which we can learn from our collective experiences to provide even better care.

My current plate of projects touches on each of the clinical areas that interest and excite me: building evidence-based practice in allogeneic transplantation, quantitating “symptom burden” with treatment, and understanding the patient experience. I hope to further build upon this synergy between my clinical practice and my academic research in the years ahead.

William Wood, MD, is a third-year Hematology/Oncology Fellow at the University of North Carolina Chapel Hill and is a member of the HemOnc Today Editorial Board.