Heme/Onc Career and Fellowship Advice

[premedUVA]

Longtime lurker, first time poster (no I'm no longer a UVA premed). Thanks in advance for any advice you can provide, especially gutonc, aPD:

I'm a PGY-2 at a mid-tier academic internal medicine program. I have been 100% sold on heme/onc since entering residency, and am 85% sold on pursing private practice, despite a hefty research resume. Long term goal is to be a well-respected community oncologist and have enough time outside of work to raise a family.

My internal struggle is trying to decide what programs to target for fellowship. Ideally, and maybe selfishly, I would like to train at a top-tier program with leaders in the field to learn from the best and gain exposure to cutting edge therapies/clinical trials.

However, I have a hard time envisioning myself staying in academics after fellowship. I want to know about the research going on and have access to clinical trials for my patients but have little desire to run the trials, write grants, climb the academic food chain, etc.

As it stands, I think I have a decent shot at training at a top program with my research background, current mentors/connections, and the fact that I'm doing well clinically in residency. But in order to match at one of these programs, I feel I will have to misrepresent myself as devoted to an academic career. I have no qualms about continuing research in fellowship and feel certain I can be productive, but I'm pretty sure that I will enter PP after fellowship.

Therefore, my questions are twofold:
1) Will I be any worse off for private practice if I do match to a top program (less clinical exposure, more research)?

2) How honest should I be with personal statements, interviews, etc about my desire for PP?

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[CatFactorial]

Good question; I would also like to know what people think.

Then again what is the utility of a top program? I can understand that going to such a place would keep doors open if you changed your mind and opted for academics. However, if you are more than reasonably certain that private practice is what you want to do, wouldn't you be better off by targeting tertiary care, high-volume university programs (which would also probably keep academic options open)?

 

[visari]

I really like how honest and clear you are about your future career plans.

I think even if you want to pursue a PP career, graduating from a large fellowship program that has a long and good reputation in the community will serve you well and open more opportunities to you. A lot of the PP groups sell themselves by showing that they're recruiting graduates of big academic centers. Now that being said, you have to be really careful before and during the interview season. It's not entirely true that the big academic programs will not give you a good clinical exposure. Some of the big programs will indeed push you really hard for research and limit the clinical exposure to a a bare minimum that won't leave you comfortable practicing in the PP world right after graduating (you'll still find a job easily anyway but you you'll struggle). Others will acknowledge that people might be interested in PP and limit their research time to the minimum while maximizing their clinical exposure. some would even go further to have a PP or community oncologist track.
It's usually difficult to assess that from looking at the websites. You have to go to interviews and ask them (Especially the fellows). Some programs are notorious for pushing for research and I'd avoid those from the get go (like NCI, MSKCC, Farber ...etc). I find it hard to impossible to match at one of those places if they know your plans, and there's no reason for you to push hard to match there anyway.
There are probably small or tiny programs here or there that wouldn't care about research at all, but I wouldn't recommend going there just because of that. You need to have the full fellowship experience.

Now do you have to lie on your personal statement or during interviews?
There's not a single mid-tier or top-tier program who'd say "I don't care about research" even if they actually don't. But you can't just flat out say in your personal statement or during interviews that you have zero academic interests and you just want to finish fellowship and go to PP to raise a family. That's a recipe for not matching. That will cause a lot of programs to reject you regardless if their current fellows actually do any meaningful research or if any recent graduate went to the academic world or not. I know it's stupid but it's the way it is. So if you want to call that lying then yes, you will have to say in one way or another that you're interested in some form of research.

My advice for you is to go to the best place you can that will give you adequate clinical exposure and not make you sit in a lab or behind a computer screen for 2 years of your fellowship.

 

[premedUVA]

I really like how honest and clear you are about your future career plans.

I think even if you want to pursue a PP career, graduating from a large fellowship program that has a long and good reputation in the community will serve you well and open more opportunities to you. A lot of the PP groups sell themselves by showing that they're recruiting graduates of big academic centers. Now that being said, you have to be really careful before and during the interview season. It's not entirely true that the big academic programs will not give you a good clinical exposure. Some of the big programs will indeed push you really hard for research and limit the clinical exposure to a a bare minimum that won't leave you comfortable practicing in the PP world right after graduating (you'll still find a job easily anyway but you you'll struggle). Others will acknowledge that people might be interested in PP and limit their research time to the minimum while maximizing their clinical exposure. some would even go further to have a PP or community oncologist track.
It's usually difficult to assess that from looking at the websites. You have to go to interviews and ask them (Especially the fellows). Some programs are notorious for pushing for research and I'd avoid those from the get go (like NCI, MSKCC, Farber ...etc). I find it hard to impossible to match at one of those places if they know your plans, and there's no reason for you to push hard to match there anyway.
There are probably small or tiny programs here or there that wouldn't care about research at all, but I wouldn't recommend going there just because of that. You need to have the full fellowship experience.

Now do you have to lie on your personal statement or during interviews?
There's not a single mid-tier or top-tier program who'd say "I don't care about research" even if they actually don't. But you can't just flat out say in your personal statement or during interviews that you have zero academic interests and you just want to finish fellowship and go to PP to raise a family. That's a recipe for not matching. That will cause a lot of programs to reject you regardless if their current fellows actually do any meaningful research or if any recent graduate went to the academic world or not. I know it's stupid but it's the way it is. So if you want to call that lying then yes, you will have to say in one way or another that you're interested in some form of research.

My advice for you is to go to the best place you can that will give you adequate clinical exposure and not make you sit in a lab or behind a computer screen for 2 years of your fellowship.

Thanks for your thoughtful response. I think that's great advice and that talking to fellows will be the way to go. I will choose my words carefully on the application and when questioning fellows on the interview trail. Would appreciate any insight from more older and wiser posters if possible *gutonc batsignal*

 

[premedUVA]

Last time I'll bump in hopes that gutonc sees this

 

[bashwell]

Last time I'll bump in hopes that gutonc sees this

You could try to PM him or use @gutonc if you want to get his attention?

 

[gutonc]

Last time I'll bump in hopes that gutonc sees this

Not entirely certain what you want from me here.

Why bother going to a "top" (i.e. research heavy) program if all you want to do is community general oncology? The "top" programs will expect/demand research output, and may make you do an extra year (cough Mayo cough) to get it.

Tailor your PS and interview chatter to the programs you apply to/interview at. Blow smoke up their asses if you think they need that, but recognize that you're not dealing with idiots. They can see through your bulls***. And if you lie to them, and they buy it, then you both deserve the misery you'll get.

 

[premedUVA]

Not entirely certain what you want from me here.

Why bother going to a "top" (i.e. research heavy) program if all you want to do is community general oncology? The "top" programs will expect/demand research output, and may make you do an extra year (cough Mayo cough) to get it.

Tailor your PS and interview chatter to the programs you apply to/interview at. Blow smoke up their asses if you think they need that, but recognize that you're not dealing with idiots. They can see through your bulls***. And if you lie to them, and they buy it, then you both deserve the misery you'll get.

That's exactly what I was looking for- your honest advice on my situation.

I have no qualms about being academically productive in fellowship, and on the off chance that I do have a change of heart towards academia I would like to train at the best program I can. I just don't want the research expectations to be unreasonable and come at the cost of missing out on a large amount of continuity clinic, consult months, and inpatient rotations.

 

[premedUVA]

For those of you who have already gone through the interview process, what programs fit the bill of being programs with great research opportunities AND a focus on PP (or PP track)? Like @visari mentioned, I've had a difficult time gleaning anything useful from programs' websites except rotation and didactic schedules.

 

[blabbyblab]

For those of you who have already gone through the interview process, what programs fit the bill of being programs with great research opportunities AND a focus on PP (or PP track)? Like @visari mentioned, I've had a difficult time gleaning anything useful from programs' websites except rotation and didactic schedules.

My experience is that plans change a lot from day 1 of fellowship to the last day! Your goals may change.

It's easier to work in the community coming from a more research-focused institution than vice versa. The way the field is going I would venture that in our careers most patients will have a research component at some stage of their care. As you say, during fellowship it's nice to have exposure to some of the cutting edge therapies like immunotherapy and cell therapy, and maybe every heme/onc should have exposure to early phase studies. My general impression, maybe inaccurate, is that cancer care is shifting away from community practice as the number of therapies/experimental therapies expand, but that might be my ivory tower bias showing.

I can say that from my own experience that fellows at Hopkins and NIH can end up successful in private practice. I think of programs like Duke, Vandy, OSU, Penn as strong in both arenas, and MSKCC, MDACC, Mayo as having less standard of care.

Also, fitting into your program is more important than objective measures of a program's success. So, I would interview at a range of programs: a few stretch, a few middle, a few community-based, be honest about your goals (keeping an open mind and some humility).

 

[visari]

My experience is that plans change a lot from day 1 of fellowship to the last day! Your goals may change.

It's easier to work in the community coming from a more research-focused institution than vice versa. The way the field is going I would venture that in our careers most patients will have a research component at some stage of their care. As you say, during fellowship it's nice to have exposure to some of the cutting edge therapies like immunotherapy and cell therapy, and maybe every heme/onc should have exposure to early phase studies. My general impression, maybe inaccurate, is that cancer care is shifting away from community practice as the number of therapies/experimental therapies expand, but that might be my ivory tower bias showing.

I can say that from my own experience that fellows at Hopkins and NIH can end up successful in private practice. I think of programs like Duke, Vandy, OSU, Penn as strong in both arenas, and MSKCC, MDACC, Mayo as having less standard of care.

Also, fitting into your program is more important than objective measures of a program's success. So, I would interview at a range of programs: a few stretch, a few middle, a few community-based, be honest about your goals (keeping an open mind and some humility).

I totally agree that plans change quite a bit and almost universally from day 1 of fellowship to last day (me included and I'm not even done with training). This's not necessarily a bad thing. Most of the change that I've seen was people switching interests from academic to community practice simply due to the fact that working in real academics nowadays is an uphill struggle that is not very well compensated most of the time. And I still think that the majority of cancer patients in this country are being treated in the community and I don't see that changing anytime soon and that's simply for geographic reasons.

Your "experience" with the programs that you mentioned is quite different than mine. Fellows graduating from NIH have the bare minimum clinical experience and they usually have some catching up to do if you throw them in a community practice right after fellowship. MSKCC and MDACC are very research heavy too with limited clinical exposure in some aspects. I don't think you can lump Mayo with them because the program is the heaviest clinical program among all the big ones with the busiest fellow continuity clinic I've heard of. Their protected research time is jeopardized as a result unless they do that famous 4th year.

 

[blabbyblab]

Yeah, I would agree with all of that. I think research heavy programs are probably not the best training for community practice, but many people have made it work and are successful. When people in these programs realize they want to shift their trajectory they often do some add on clinical experience in another clinic or neighboring hospital. I agree wholeheartedly with the catching up statement too.

 

[premedUVA]

Thanks for your thoughtful responses. I'll probably post more questions as the application process heats up.

I really appreciate the input from the senior members of this forum and will give back as much as I can to the future applicants on SDN.

 

[premedUVA]

Longtime lurker, first time poster (no I'm no longer a UVA premed). Thanks in advance for any advice you can provide, especially gutonc, aPD:

I'm a PGY-2 at a mid-tier academic internal medicine program. I have been 100% sold on heme/onc since entering residency, and am 85% sold on pursing private practice, despite a hefty research resume. Long term goal is to be a well-respected community oncologist and have enough time outside of work to raise a family.

My internal struggle is trying to decide what programs to target for fellowship. Ideally, and maybe selfishly, I would like to train at a top-tier program with leaders in the field to learn from the best and gain exposure to cutting edge therapies/clinical trials.

However, I have a hard time envisioning myself staying in academics after fellowship. I want to know about the research going on and have access to clinical trials for my patients but have little desire to run the trials, write grants, climb the academic food chain, etc.

As it stands, I think I have a decent shot at training at a top program with my research background, current mentors/connections, and the fact that I'm doing well clinically in residency. But in order to match at one of these programs, I feel I will have to misrepresent myself as devoted to an academic career. I have no qualms about continuing research in fellowship and feel certain I can be productive, but I'm pretty sure that I will enter PP after fellowship.

Therefore, my questions are twofold:
1) Will I be any worse off for private practice if I do match to a top program (less clinical exposure, more research)?

2) How honest should I be with personal statements, interviews, etc about my desire for PP?

I owe it to this forum to give some closure and advice for those who may be feeling similarly when they apply:

Application season:

Stats:
Steps: 230s/220s/Pass/220s
Pubs: >5, mostly low-tier, a few first author, mostly in our field
Letters: Well known in the field, assume strong
Undergrad: ...take a wild guess
Med school: Mid-tier US MD
Residency: Mid-tier academic

As was suggested here, I applied to a range of programs ~20, "top 4" down to "safety" newly established community programs. Specifically targeted programs that had a clinician track. Got invites from almost every program I applied to. Like gutonc and visari say nearly every year, you're probably more competitive than you think you are. IMO, doesn't hurt to apply to too many and have excess invites to decline. Don't limit yourself at this stage of the game.




Interview season:
Went on 10 interviews and canceled the rest as promptly as I could (DO THIS for your fellow applicants). Depending on your stats and willingness to interview widely, you may not need to do this many. I went on 10 because I wasn't sure exactly what I was looking for in a program. Highlighted my prior research and my genuine research interests on the trail. "Where do you see yourself in 5 years?" was a little dicey, but was consistent across interviewers and programs and said some version of "assistant professor with both clinical responsibilities and protected time for research area of interest."

Otherwise, really enjoyed the interview process. Fit was really important to me and should be for you too. Do you jive with the fellows? Your interviewers? Pay attention how they interact with each other. There's less room for error this match because there are less fellows available to find your niche, crew, #squad, etc.



Ranking:
You have time after interviews are over to reflect. Try reaching out to your interviewers and fellows you met on the trail. How responsive are they? How friendly are they? These will be your co-workers and mentors for the next 3+ years. If they don't have time to answer an email from a prospective mentee, how helpful will they be once you match? It may sound harsh, but this was important to me. I want to be around people that will support me and truly enjoy mentoring.

After a LOT of reflection on what I truly want out of a program and career, I decided not to rank by prestige and ranked highest programs that had solid research opportunities but also had a clinician track. This way, I can give academics an honest try and if it isn't for me, there's already an established pathway to cut my chops in clinic for a year or more at the end of fellowship prior to starting a job.



Match:
I matched at my #1 that fits the description above, but will refrain from naming the program, for obvious reasons. Sorry @gutonc and @visari - I know this really grinds your gears but I hope you understand. I believe I speak for everyone when I say we truly appreciate what you and the more seasoned (and salty?) folks do for us newbies/lurkers. This community would be nothing without you.

How this program meets my needs/wants/desires remains to be seen, but I will update this from the front lines after a few months of fellowship. Congrats to all that matched. See you all (anonymously) at ASH/ASCO