Learning in Fellowship w/o Fellows Clinic?

[EEtoPre-Med]

I’m a 3rd year IM resident who is preparing to start fellowship in July at an NCI CCC, but not an extremely prestigious one. Although my program has a lot of positives to it, it does not have a fellows clinic, even at the VA interestingly enough. I have often heard about the value of the autonomy you get in a fellows clinic. Although I’m not sure I can close the clinical gap all the way, I would like to be as well trained as possible. How should I approach preparing for an attendings clinic to get the most out of the exercise and prepare for clinical practice? We do have continuity clinics where we are with the same clinic for 6 months but it’s just part of the attendings clinic. In lieu of doing reading in advance (because I’ve heard that’s fruitless), I’ve decided to study for boards and mentally prepare for fellowship by obtaining some advice!

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[ONC2023]

Hey. Third year fellow here in a program with a similar set up. No fellows clinic of any kind. I can honestly say I’ve only just started understanding how to think like an oncologist now. Things I’ve found helpful are:

1. You need a mental map of each tumor type. For example, 60 year old with jaundice comes in with a pancreatic head mass and a positive biopsy. That’s all the workup that’s been done. The question is: what imaging should you get for staging? What steps can you do on your own as a medical oncologist versus what requires multidisciplinary input? What are the relevant molecular markers that you need to be aware of for this tumor type? Before you start treatment, what tests needs to be done for any given treatment (eg, TTE for HER2 directed therapy)? What counseling does the patient need for any given treatment (eg, neuropathy for platinum agents)?

Each tumor type has a different answer to these questions, which is why a speciality clinic in each tumor type can be valuable since it’s concentrated exposure and you get really good at it.

2. Present at tumor boards. It forces you to summarize complex cases and makes you think about what information is relevant to surgery and radiation oncology.

3. The questions with the ASCO SEP question bank are very helpful (your fellowship should likely give you access). The HOQ q bank is much harder but what you should do after ASCO to solidify the details.

I do questions while having NCCN up.

4. Attending clinics can be a mess or not. Some attendings are extremely discourteous towards anyone’s time but their own (including of patients) and will triple book patients in a slot. I’ve had patients *walk out* of clinic because the attending had a research visit in the middle of clinic and made them wait 3 hours.

The key is to try to latch on to clinics where the attendings run the clinic well and then *follow patients longitudinally*. You want to see the same patients for followup as much as possible so you can see how they responded to treatment last week; did your anti emetic regimen changes work; how is their neuropathy doing; did their scans show progression and do you need to decide on next treatment?

Good luck!

EDIT: A while back I asked in a thread how many patients fellows should be seeing in clinic. This response form gutonc is very helpful.
Flailing MD/PhD Thinking of Back-up Career

 

[gutonc]

Hey. Third year fellow here in a program with a similar set up. No fellows clinic of any kind. I can honestly say I’ve only just started understanding how to think like an oncologist now. Things I’ve found helpful are:

1. You need a mental map of each tumor type. For example, 60 year old with jaundice comes in with a pancreatic head mass and a positive biopsy. That’s all the workup that’s been done. The question is: what imaging should you get for staging? What steps can you do on your own as a medical oncologist versus what requires multidisciplinary input? What are the relevant molecular markers that you need to be aware of for this tumor type? Before you start treatment, what tests needs to be done for any given treatment (eg, TTE for HER2 directed therapy)? What counseling does the patient need for any given treatment (eg, neuropathy for platinum agents)?

Each tumor type has a different answer to these questions, which is why a speciality clinic in each tumor type can be valuable since it’s concentrated exposure and you get really good at it.

See as many new patients as you can and before you present to the attending, have a full, rational workup/treatment plan in mind. It's OK to not get it completely right, but you should be getting 80-90% of the way there at the end of 2nd year and all of 3rd year. Keep in mind that there are regional/institutional/individual practice patterns that may override what you come up with. That's OK...these give you a chance to ask the "why this not that?" questions.

2. Present at tumor boards. It forces you to summarize complex cases and makes you think about what information is relevant to surgery and radiation oncology.

Don't just present, speak up and answer questions. When the colorectal surgeon presents a new rectal cancer patient and asks how to proceed, be the one to bring up the options of TNT/NOM and neoadjuvant FOLFOX per PROSPECT. Explain why you think one would be better than the other for a particular case. This is a 3rd year power move and definitely not for a first year fellow, but it will serve you well as you go forward.

EDIT: A while back I asked in a thread how many patients fellows should be seeing in clinic. This response form gutonc is very helpful.
Flailing MD/PhD Thinking of Back-up Career

Thanks for hunting that one down...that was a pretty good answer.

 

[HemeOncHopeful19]

On top of what everyone else has said, I wouldn’t sweat it too much.

Just learn as much as you can, and your first year out of training will shore up for whatever weaknesses there were in your program (and every program has some weaknesses).

It will also humble the crap out of you

 

[gutonc]

On top of what everyone else has said, I wouldn’t sweat it too much.

Just learn as much as you can, and your first year out of training will shore up for whatever weaknesses there were in your program (and every program has some weaknesses).

It will also humble the crap out of you

And the next 15+ years will also be great learning experiences.

The day you don't learn something new is the day you should retire.