Considering Heme/Onc. Curious for perspectives from fellows/attendings

[Eyeaboutthat]

1. What does private practice heme/onc look like? Do you see all your patients that get admitted and follow them in hospital? How much time do you spend in the hospital in a month? What does the general model look like: all onc versus all heme or mix of both?
2. As a resident, the volume and complexity in heme/onc is scary. What’s your perspective on individuals interested in the field but who lack significant background in molecular bio/immuno/etc? How do you learn it all in just three years?
3. Do you ever feel like your day to day practice becomes monotonous because there’s no variation in your work week as in other subspecialties where for instance, u may be in endoscopy suite couple times a week and clinic the rest of the time, etc.
4. How much time do you spend counseling patients? How do you handle the inherent grief that comes with bad outcomes?
5. If you could do it again, would you? Why/why not?

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[whoknows2012]

1. What does private practice heme/onc look like? Do you see all your patients that get admitted and follow them in hospital? How much time do you spend in the hospital in a month? What does the general model look like: all onc versus all heme or mix of both?
2. As a resident, the volume and complexity in heme/onc is scary. What’s your perspective on individuals interested in the field but who lack significant background in molecular bio/immuno/etc? How do you learn it all in just three years?
3. Do you ever feel like your day to day practice becomes monotonous because there’s no variation in your work week as in other subspecialties where for instance, u may be in endoscopy suite couple times a week and clinic the rest of the time, etc.
4. How much time do you spend counseling patients? How do you handle the inherent grief that comes with bad outcomes?
5. If you could do it again, would you? Why/why not?

There was a recent thread in here on some of those same questions you’re asking, especially about private practice. I suggest you read that as there’s definitely some helpful info in there. I will try to answer some of your other questions, from a current 2nd yr fellow at an academic hem/onc program in NYC.

1) The private practice is model has changed drastically over the last several years and especially if you’re going to be in a populated area of the country it’s much more likely you’d work at a hospital affiliated practice as opposed true private practice. That being said, yes you do cover patients in the hospital and there are call duties, worse when you are more junior. The general model depends but I’ve seen practices that see all non complicated med onc and benign malignant heme (besides high grade lymphomas and acute leukemia’s). I also know some practices that are heme only and solid tumor only. There are even pp docs that have been able to carve out a niche in a single common solid tumor like breast, although that is fairly rare. @gutonc can probably speak a bit more about the pp lifestyle.

2) I don’t see having a background in molecular bio/immunology/genetics or otherwise as being a pre-requisite for practice in hem/onc. Yes the knowledge that you must obtain through your training as it pertains to molecular diagnostics, next gen sequencing, etc is quite “scientific” and also dense, it’s certainly manageable to digest. Chemotherapy regimens for all the different cancers, newly approved regimens, toxicitites for each drug/regimen these are definitely a lot of take in as well but again, manageable. Learning it all in 3 yrs and how important that is depends on what kind of job you will look for after fellowship. Solid tumor pp job certainly you’ll need to have a firm grasp of most common and some uncommon solid tumors and standards of care 1st line 2nd line etc. But ive only ever heard or issues arise when one trains at a program known for research and plan to do mostly clinical practice. There it can get a bit dicey as you will not have had the volume or depth during fellowship so the beginning of your mostly clinical practice could be tough but that too ameliorates over time as you see enough patients (and use nccn guidelines over and over again until it’s memorized).

As far as learning during fellowship between the large volume of patients in clinic and inpatient with all kinds of different diseases and different stages, didactics, following the major journals for new publications, nccn guidelines, tumor boards, various rotations,and call you build up quite the knowledge base. Of course during 3rd year there is also board review which further increases and consolidates that material.

3) I’ve heard this question asked before and while I imagine just like in any specialty it’s possible for your day to day to become monotonous I don’t seen it as any more likely in hem/onc. Lack of procedures only matters if that’s something you’re particular interested in. You may not realize it but even within one disease type there is immense variety in presentation diagnosis and treatment. I have heard other complaints about the field but monotonous day to day isn’t one of them. I think you should try an outpt onc rotation in residency if you can as this might help more in understanding the day to day.

4) Time spent counseling can easily approach an hour for a new patient or for restaging scans with progression of disease. This is just one way in which you have variety though as some pt are follow ups with no evidence of disease and others are nearing hopsice. Dealing with the emotional stress of the job definitely takes a toll, but I think having a healthy work life balance helps. Also a good relationship with colleagues fostering discussion about tough cases is also helpful.

5) I’d definitely do it again, but I’m only half way through fellowship so I may have a different answer in 5 yrs (hopefully not though).

Feel free to pm me with more specific questions

 

[CatFactorial]

1. What does private practice heme/onc look like? Do you see all your patients that get admitted and follow them in hospital? How much time do you spend in the hospital in a month? What does the general model look like: all onc versus all heme or mix of both?
2. As a resident, the volume and complexity in heme/onc is scary. What’s your perspective on individuals interested in the field but who lack significant background in molecular bio/immuno/etc? How do you learn it all in just three years?
3. Do you ever feel like your day to day practice becomes monotonous because there’s no variation in your work week as in other subspecialties where for instance, u may be in endoscopy suite couple times a week and clinic the rest of the time, etc.
4. How much time do you spend counseling patients? How do you handle the inherent grief that comes with bad outcomes?
5. If you could do it again, would you? Why/why not?

1. Private practice, from my limited experience in my VA longitutidinal clinic, seems quite satisfying. I like the diversity of pathology and certainly feel like a real doctor for very sick patients. I see a good mix of benign and malignant hematology as well as solid oncology. I am a first-year fellow, I'm ALWAYS in the hospital.
2. My default is that I don't know what I am doing. NCCN guidelines, ASCO/ASH manuals, uptodate are usually open on my phone at any given time during the work day. You won't learn this in residency. Go to a busy clinical program to learn as much as you can (if clinical heme/onc is what you want to do).
3. Procedures are for chumps. The intellectual stimulation in heme/onc prevents monotony.
4. Misanthropy works well.
5. I've wanted to do heme/onc since before med school, and the same holds true now.

 

[gutonc]

What does private practice heme/onc look like? Do you see all your patients that get admitted and follow them in hospital? How much time do you spend in the hospital in a month? What does the general model look like: all onc versus all heme or mix of both?

I see them, but don't generally manage them primarily...that's what hospitalists are for. I also do a lot to keep them out of the hospital.

I have a mix of heme and onc but am about 85-90% solid tumor. One of my partners is closer to 50/50. I have other friends in community practice who do (nearly) all one or the other and some that are able to focus on a particular tumor type or 2 (these people tend to work in large groups with a single practice site...I work in a large group with 5 practice sites so that is impractical).

How much physical time do I spend in the hospital a month? 2 or 3 hours unless I have a weekend call...then it's more like 6-8. Clinic is a different story, but that's not what you asked.

As a resident, the volume and complexity in heme/onc is scary. What’s your perspective on individuals interested in the field but who lack significant background in molecular bio/immuno/etc? How do you learn it all in just three years?

You don't need all that background. You need a solid IM foundation and interest in the field. Plus all the other crap you need to get into a fellowship. And you definitely don't learn it all in 3 years. You learn enough to get started...and then you learn more every day. The day you come to work and don't learn anything is the day you need to retire.

Do you ever feel like your day to day practice becomes monotonous because there’s no variation in your work week as in other subspecialties where for instance, u may be in endoscopy suite couple times a week and clinic the rest of the time, etc.

I went into a non-procedural specialty because I didn't want to do procedures. I spend a great deal of time trying to talk myself out of doing the one procedure (bone marrow biopsyt) I'm still credentialed for (and very good at...usually 10-12 minutes from Chlora-Prep to walking out of the room with a 2cm core in a bucket of formalin and the sharps discarded). If I never did another one again, I'd be perfectly fine with that.

Worried about variety? Here was my patient list from last Thursday (I don't see patients on Fridays). I do have a clinical focus on GI cancer, but see a lot of everything:
Inpatient:
Met gastric w/ GIB and biliary obstruction (I was just there to do the laying on of hospice hands)
Recurrent unprovoked DVT in 28yo

Outpatient:
Locally advanced pancreatic getting chemoRT
Met colon (38yo)
Stage III breast on adjuvant endocrine
Met rectal (43yo)
Met colon on 4th line therapy
Stage I breast finishing up endocrine therapy
New colon, not staged yet. Surgery in a week.
Stage IV melanoma (NED) planning adjuvant Immunotherapy
Same as above only 3y out from adjuvant immunotherapy on a clinical trial
Met lung on first-line immunotherapy
Stage I SLL/CLL and Stage IV crazy
Met lung on 3rd line immunotherapy with new Grade 3 autoimmune hepatitis from treatment
Met mesothelioma on 3rd line chemo
New Stage IIIB rectal cancer, 3rd opinion...unfortunately she liked me and will be sticking with me
Limited stage small cell lung 4y out from chemoRT with new balance problems/weakness
New Stage IA ER+, low-risk, Luminal A breast awaiting surgical staging

Seem boring/repetitive/redundant?

How much time do you spend counseling patients? How do you handle the inherent grief that comes with bad outcomes?

Define counseling? Talking about prognosis, treatment, SEs, etc? Usually about 80% of each new patient visit. By the time they roll up in my office, there's rarely a diagnostic mystery to be solved, so I just dispense with that crap as quickly as possible, do enough of an exam/ROS to bill level 5 and get to the important stuff.

If you're asking about the squishier stuff...I do a little bit of that, but I have a SW in the office and access to a clinical psychologist who can see our patients within a week. Also palliative care.

If you could do it again, would you? Why/why not?

Absolutely. It's the only specialty that matters!