Miserable Fellow - Seeking Advice

[orange sherbert]

Hello SDN,

I am struggling with fellowship and would greatly appreciate insight from other oncologists/fellows outside my program. I want to provide some background information so I apologize for the long read.

I'm 3 months into my second year of fellowship (PGY-5) at a small, community-based academic center. Our hospital is classified as a "safety net" hospital thus we care for everyone regardless of insurance status or citizenship. From an oncologic perspective, we don't have BMT, radiation oncology, PET machines, cardiothoracic surgery, or urology at our institution - everything is referred out. The hospital is completely run by students, residents, and fellows thus communication can be abysmal at times. From my perspective, almost every employee appears burnt out to some degree - not just medical personnel.

Regarding my program, there is only 1 fellow per PGY class. Our fellowship is heavily inpatient-focused: during first year we do ~9 months of inpatient (8 weeks back-to-back) where we carry the pager 24/6. The inpatient load is what you'd expect but can vary day by day but being on call that much sucks.

We are also responsible for our clinic patients regardless of rotation. Our clinic is completely autonomous - attendings and fellows have separate panels. The clinic environment can be nightmare-ish with high nursing/MA/CNA turnover. I do all the prior authorizations, FMLA, and coordination of referrals. Simply put: I don't have any faith in the clinic staff which leaves me organizing and arranging my follow-ups and refills etc.

Even recognizing all of this, I am miserable. I have been told several times that I am underperforming as a fellow (mostly due to medical oncology knowledge deficits - my IM knowledge is quite strong). However, I am not motivated to improve by studying at home (outside of preparing for my clinic). I did terribly on my ITE first year and one attending is disappointed with me and mentions this all the time.

I am extremely burnt out and find myself missing little things about my patients and I am terrified I will eventually hurt someone. I want to quit every day. I applied to medical school with the dream of being an oncologist since I was 16. However, this is not what I expected. I felt more fulfilled during my residency rotations through oncology. Despite my strong IM background, I'm struggling to keep myself motivated and falling behind with my oncology studies - I'm not excited anymore. I find it difficult to manage my clinic follow-ups, study for clinic/inpatient, study for ITE/boards, and stay up-to-date on the newest publications. How can I do this as an attending?

My attendings tell me it only gets worse/harder once you graduate. I am afraid I won't be able to keep up with the fast-paced medicine. I hear my attendings comment on how hard it is being a community oncologist (in regards to staying up to date on everything) and how they wish they could subspecialize etc. One attending mentioned I would be a better fit for a palliative care fellowship. I am so lost.

My patients adore me and I always have stellar feedback from them. I go above and beyond to help these patients who don't have great access to health care otherwise. I have received gifts, hugs, kisses on the cheek, etc for my efforts. I truly believe I have the personality and compassion to make a great oncologist but I am concerned my motivation/knowledge won't be enough based on my attending's feedback. If this is my new lifestyle, I don't know if I can make it :'( I have been trying to decide if the oncology life is for me but my judgment feels clouded by my experience in this program. The hospitalist 7 on/7 off sounds so lovely right now.

Is it me or the program? What is life like for you after fellowship?

I sincerely thank you for your time.

UPDATE 3/9/25:

It’s been six months since I last shared my struggles online. I was nervous to make that first post, hesitant to acknowledge that I might be the problem after nearly 10 years of chasing this dream. It was a dark and lonely time. While it's no secret that many fellows struggle, I knew I wouldn’t last much longer unless I asked for help.

If you don’t read further, the TL;DR is that I stayed in fellowship.

After my initial post, I took two weeks of PTO for an emergency mental health break. I spent that time talking to friends, family, and other medical professionals (both in and out of oncology) while trying to picture a different life for myself. I ruminated over this for a long time-ultimately, the pros of staying outweighed the cons. SDN (and other fellows from outside my program) helped me realize that much of my struggles were due to my environment. My program is... terrible. I’ll spare the details, but I truly believe I could've thrived in a better program. That said, I take responsibility for my own part in this. My motivation, work ethic, and study habits were subpar. That might've been because I was miserable here but other fellows have survived and graduated from this program as strong clinicians, so I know it’s possible to be strong too. So, I've spent the past six months working hard to learn what I should've learned during my first year.

I haven’t been absolved of all my insecurities and struggles, though. I’d say I’m about 35-40% better. My oncologic knowledge is still catching up (and keeping it in my brain is a separate issue, ha). I’m still constantly trying to “prove” my growth to my attendings but they remain distant. The doubts of success still annoyingly creep in, like an itch you can’t quite reach. My biggest fear remains that I won’t be able to keep up with practice-changing literature (as a generalist) and that it will lead to me eventually hurting someone. You'd think that all of this would drive someone to work even harder but for me, it results in a paralyzing fear in which I shut down. Yes, therapy is coming next lol.

But I’ve also had many beautiful moments. I’ve formed many meaningful relationships with my patients. They’ve sent me cards, hugged me, and even kissed my cheek! Family members have called to thank me for my care on behalf of their deceased loved ones. One particularly touching moment was when my patient who was in the ICU on hospice asked me to come to his bedside while the pastor anointed his marriage to his fiancee (he passed away the next day). This is why I entered the field and it’s been the motivation to keep pushing forward.

The real reason I’m posting this update is not for myself, but for the struggling, lost fellow who may come across this post five years from now during a rampant evening of Google searching "is hem/onc for me". If you’re that fellow looking for a happy(-ish?) ending to a dreadful start - here it is. Maybe I’ll update in a few years with an even happier epilogue.

---

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[ONC2023]

I am a fellow like you who is miserable for different reasons. We are in very different style training programs, but I can provide some perspective.

First - your practice environment is absolutely unlike real world oncology. I just finished interviewing for jobs, and in the hospitals and private practice jobs I was considering, each physician has a nurse and MA. Chemotherapy order sets are built into the electronic medical record. You do not fill out FMLA paperwork, etc. You do not schedule things. Things move (relatively) efficiently, with enough support, that attendings are comfortable seeing 20 patients a day. Radiation oncology and surgery are pretty easy to consult and communicate with.

I do not want to tell you things are all wonderful - but out in private practice or hospitals, revenue depends on patient throughput. And that throughput is negatively affected by inefficiency. It sounds like you're at a hospital where they make up for low patient revenue by exploiting cheap trainee labor, which is cheaper than upgrading systems/workflows to become efficient.

Second - if you can stick with it, things get so much better. You are trained in general heme-onc, and you are going to have recruiters throwing themselves at you offering you $500,000 base salary jobs (and this is the floor for hospital-employed jobs, basically) for general heme-onc and subspecialized positions.

Let me just tell you this: My training is very narrow in only certain solid tumor types. I had to avoid so many jobs because I am not comfortable with general heme-onc and needed to subspecialize. And even with my limitations for only certain tumor subtypes, I did not have much difficulty finding a high-paying job. With your general heme-onc training, you will have absolutely no issues finding a job in a much much more functional environment than your current training program.

Third - your worry about keeping up to date and providing the best care is admirable. I have the same anxiety. However, once you're in a more functional clinical environment, you will have that time to keep up with the latest JCO and NEJM article.

Best of luck from another unhappy oncology fellow.

 

[hehe5347]

Hello SDN,

I am struggling with fellowship and would greatly appreciate insight from other oncologists/fellows outside my program. I want to provide some background information so I apologize for the long read.

I'm 3 months into my second year of fellowship (PGY-5) at a small, community-based academic center. Our hospital is classified as a "safety net" hospital thus we care for everyone regardless of insurance status or citizenship. From an oncologic perspective, we don't have BMT, radiation oncology, PET machines, cardiothoracic surgery, or urology at our institution - everything is referred out. The hospital is completely run by students, residents, and fellows thus communication can be abysmal at times. From my perspective, almost every employee appears burnt out to some degree - not just medical personnel.

Regarding my program, there is only 1 fellow per PGY class and 4 staff oncologists (3 of them are sponsored by Visas and I don't think they even want to be here if they had the choice...). At least 2 of the attendings are difficult to work with for various reasons.

Our fellowship is heavily inpatient-focused: during first year we do 9 months of inpatient (8 weeks back-to-back) where we carry the pager 24/6. I was on 8 weeks of inpatient while studying for my ABIM... During second year we have 6-7 months of inpatient and during third year it's 3-4. The inpatient load is what you'd expect but can vary day by day but being on call that much sucks.

We are also responsible for our clinic patients regardless of rotation. Our clinic is completely autonomous - attendings and fellows have separate panels. I could see anywhere from 7-14 clinic patients 1-2 days/week, even while on inpatient. There is a lot of pressure for me to see even more/double book if possible. The clinic environment can be nightmare-ish with high nursing/MA/CNA turnover - I've had 3 new clinic nurses in 1 year. I do all the prior authorizations, FMLA, and coordination of referrals. Simply put: I don't have any faith in the clinic staff which leaves me organizing and arranging my follow-ups and refills etc. I also have to handwrite all my chemo orders by the end of the day. With our patient population, this can consume several hours of my day.

Even recognizing all of this, I am miserable. I have been told several times that I am underperforming as a fellow (mostly due to medical oncology knowledge deficits - my IM knowledge is quite strong). However, I am not motivated to improve by studying at home (outside of preparing for my clinic). I did terribly on my ITE first year and one attending is disappointed with me and mentions this all the time.

I am extremely burnt out and find myself missing little things about my patients and I am terrified I will eventually hurt someone. I want to quit every day. I applied to medical school with the dream of being an oncologist since I was 16. However, this is not what I expected. I felt more fulfilled during my residency rotations through oncology. Despite my strong IM background, I'm struggling to keep myself motivated and falling behind with my oncology studies - I'm not excited anymore. I find it difficult to manage my clinic follow-ups, study for clinic/inpatient, study for ITE/boards, and stay up-to-date on the newest publications. How can I do this as an attending?

My attendings tell me it only gets worse/harder once you graduate. I am afraid I won't be able to keep up with the fast-paced medicine. I hear my attendings comment on how hard it is being a community oncologist (in regards to staying up to date on everything) and how they wish they could subspecialize etc. One attending mentioned I would be a better fit for a palliative care fellowship. I am so lost.

My patients adore me and I always have stellar feedback from them. I go above and beyond to help these patients who don't have great access to health care otherwise. I have received gifts, hugs, kisses on the cheek, etc for my efforts. I truly believe I have the personality and compassion to make a great oncologist but I am concerned my motivation/knowledge won't be enough based on my attending's feedback. If this is my new lifestyle, I don't know if I can make it :'( I have been trying to decide if the oncology life is for me but my judgment feels clouded by my experience in this program. The hospitalist 7 on/7 off sounds so lovely right now.

Is it me or the program? What is life like for you after fellowship?

I sincerely thank you for your time.

You sound like an amazing person who’s stuck in a super rough program. Trust me, the real world is a BILLION times better. Don’t let dumb attendings get you down, you will DEFINITELY BE FINE OUT THERE!!! You’re almost there! Keep your head up!!!!

 

[ShuperNewbie]

It's your program. It's 100% your program. If all of oncology were like this, there would be no oncologists left in America.

It's your program. Everything from your ITE score (telling you to just "look it up" and just "read more" is the laziest freaking teaching method in the world and I hate it - they're not holding up their end of this indentured servitude bargain), to the weird bitter and passive aggressive culture, to the lack of support. It's your program.

And please trust me, practicing oncology gets better in the real world. EVERYTHING gets better. You'll have more support, you'll have more respect, you'll have more autonomy, you'll have more money, and you'll have more free time.

It's your program, and I'm so sorry you have to put up with this. I went through a hard residency and a hard fellowship, both of which had rotations through safety net hospitals, but despite this they AT LEAST tried to teach me things and support me and didn't make a big deal when I bombed my ITEs.

That said, please see that you have a plethora of different options in front of you. You're not wrong that the 7 on / 7 off hospitalist lifestyle is ***wonderful*** (spoken from experience) and the paycheck ain't too shabby neither. You're not a slave anymore. If you quit you HAVE OPTIONS. You're a freaking board certified doctor (or at least board eligible) and if they can't understand that enough to appreciate you then they can absorb your 14 patients / day into their own panel.

You have lots of options for a happy life. Don't feel like you need to go through this to prove some modicum of success to society or your peers. No one would call a board certified doctor a failure by any measure. You have nothing to prove. Find your own happiness. I'm sorry your program is stealing that away from you.

... Rip them apart on the ACGME survey

 

[dozitgetchahi]

Hello SDN,

I am struggling with fellowship and would greatly appreciate insight from other oncologists/fellows outside my program. I want to provide some background information so I apologize for the long read.

I'm 3 months into my second year of fellowship (PGY-5) at a small, community-based academic center. Our hospital is classified as a "safety net" hospital thus we care for everyone regardless of insurance status or citizenship. From an oncologic perspective, we don't have BMT, radiation oncology, PET machines, cardiothoracic surgery, or urology at our institution - everything is referred out. The hospital is completely run by students, residents, and fellows thus communication can be abysmal at times. From my perspective, almost every employee appears burnt out to some degree - not just medical personnel.

Regarding my program, there is only 1 fellow per PGY class and 4 staff oncologists (3 of them are sponsored by Visas and I don't think they even want to be here if they had the choice...). At least 2 of the attendings are difficult to work with for various reasons.

Our fellowship is heavily inpatient-focused: during first year we do 9 months of inpatient (8 weeks back-to-back) where we carry the pager 24/6. I was on 8 weeks of inpatient while studying for my ABIM... During second year we have 6-7 months of inpatient and during third year it's 3-4. The inpatient load is what you'd expect but can vary day by day but being on call that much sucks.

We are also responsible for our clinic patients regardless of rotation. Our clinic is completely autonomous - attendings and fellows have separate panels. I could see anywhere from 7-14 clinic patients 1-2 days/week, even while on inpatient. There is a lot of pressure for me to see even more/double book if possible. The clinic environment can be nightmare-ish with high nursing/MA/CNA turnover - I've had 3 new clinic nurses in 1 year. I do all the prior authorizations, FMLA, and coordination of referrals. Simply put: I don't have any faith in the clinic staff which leaves me organizing and arranging my follow-ups and refills etc. I also have to handwrite all my chemo orders by the end of the day. With our patient population, this can consume several hours of my day.

Even recognizing all of this, I am miserable. I have been told several times that I am underperforming as a fellow (mostly due to medical oncology knowledge deficits - my IM knowledge is quite strong). However, I am not motivated to improve by studying at home (outside of preparing for my clinic). I did terribly on my ITE first year and one attending is disappointed with me and mentions this all the time.

I am extremely burnt out and find myself missing little things about my patients and I am terrified I will eventually hurt someone. I want to quit every day. I applied to medical school with the dream of being an oncologist since I was 16. However, this is not what I expected. I felt more fulfilled during my residency rotations through oncology. Despite my strong IM background, I'm struggling to keep myself motivated and falling behind with my oncology studies - I'm not excited anymore. I find it difficult to manage my clinic follow-ups, study for clinic/inpatient, study for ITE/boards, and stay up-to-date on the newest publications. How can I do this as an attending?

My attendings tell me it only gets worse/harder once you graduate. I am afraid I won't be able to keep up with the fast-paced medicine. I hear my attendings comment on how hard it is being a community oncologist (in regards to staying up to date on everything) and how they wish they could subspecialize etc. One attending mentioned I would be a better fit for a palliative care fellowship. I am so lost.

My patients adore me and I always have stellar feedback from them. I go above and beyond to help these patients who don't have great access to health care otherwise. I have received gifts, hugs, kisses on the cheek, etc for my efforts. I truly believe I have the personality and compassion to make a great oncologist but I am concerned my motivation/knowledge won't be enough based on my attending's feedback. If this is my new lifestyle, I don't know if I can make it :'( I have been trying to decide if the oncology life is for me but my judgment feels clouded by my experience in this program. The hospitalist 7 on/7 off sounds so lovely right now.

Is it me or the program? What is life like for you after fellowship?

I sincerely thank you for your time.

I was a rheum fellow instead of Heme/onc - and I went to one of the fancy “name brand” places rather than a community program - but otherwise I can relate to your post so much. I dealt with it all - attendings who act like you’re an idiot if you can’t immediately answer every single obscure pimping question, to a dysfunctional clinic where YOU were personally expected to spend your time scheduling patient appointments, imaging and other studies, etc (although there were staff there that were supposed to be doing that …but weren’t doing their jobs!), to the weird high-pressure culture that was very harsh on fellows, the endless pressure to do more research and random BS “projects”, attendings dumping as much scut work on you as possible, etc.

One of the most discouraging moments (and there were many) came towards the end of fellowship. I was on one of the brutal consult rotations. It’s 11:30pm, and I’m literally standing in line at Walmart buying a new pack of boxers and a pair of khakis because I had run out of clean clothes and had no time to try to wash anything…my attending pages me and starts bitching me out on the phone, just absolutely yelling at me because she didn’t like something I put in one of the notes. While I’m in line, at Wally World, buying more underwear because I had no clean underwear to put on after working myself to the bone for the last few weeks. On those consult rotations, I had other attendings call me at 1 or 2am to debate something in the notes. It was just a ridiculously pedantic and absurd culture.

Another absurd moment that stands out in my mind (again on consults): we get two new consults. A different nasty attending tells me that she wants me to see these new patients and finish the notes in 30 minutes. I politely but directly point out that looking up two new patients, going to see them at opposite ends of an enormous hospital complex, and writing two perfect notes is almost certainly going to take more than 30 minutes. She literally growls into the phone: “you should be able to do that!!!” (To boot, I was like 3 months into being a fellow at that point, and didn’t even know my way around the hospital yet.) Yeah, no.

Prior to fellowship, I had done really well in medical school and IM residency - at solid programs too. I knew something was off when I went from being a well regarded, hard working IM resident (at a mid tier academic ACGME program) to being treated like a total ***** as a rheumatology fellow, despite putting in the same (high) level of effort. I actually think I worked harder as a rheum fellow than I ever did as an IM resident, but the way I was treated was much worse.

The good news: it ends! Training only lasts a defined amount of time, and then you’re out. (You don’t get treated like this in the real world.) And in the real world, it turns out I’m actually very good at being a rheumatologist. The training there had been very good, I’ve been praised by other attendings and patients for finally figuring out what was wrong with folks, etc. One of the game-changing moments for me was inheriting a patient from one of my nasty attendings at my first job, and making a correct diagnosis that had clearly been missed by said attending. Gee, perhaps I’m not an idiot after all.

 

[bobsmith]

Being the primary oncologist is a blessing and a curse, depending on how much you love patient care.

For what it's worth, I don't think that this is an all or nothing thing - (i.e., I don't think that to be a good oncologist, you have to let it take over your life). And then similarly, I don't think some people are destined to love their job just because they love patient care, and then others are doomed to hate it.

I think it's a skill to balance how much you let it take over your life, and just like any other skill, it requires some degree of practice and patience to get better at it over time.

For example, I remember when I started my first attending job, I would sometimes get a page / call / message about a patient while I was hanging out with my family / friends and then I would just be totally distracted as I thought (and then unproductively perseverated) about the situation for far too long, sometimes even after I had made a decision and there was nothing else to be done.

Luckily, as time has gone on and I've gotten more comfortable making decisions, this happens less frequently. It also is something I've chosen to work on - if I recognize something is going to distract me (and sometimes my partner can tell better than I can!), I try to decide right then whether I'm going to spend time doing it right away, or truly decide to put it out of my mind to work on it / think about it at some other time.

(Luckily, most things that we deal with do not require our urgent attention!)

 

[MifflinDunder]

For example, I remember when I started my first attending job, I would sometimes get a page / call / message about a patient while I was hanging out with my family / friends and then I would just be totally distracted as I thought (and then unproductively perseverated) about the situation for far too long, sometimes even after I had made a decision and there was nothing else to be done.

Luckily, as time has gone on and I've gotten more comfortable making decisions, this happens less frequently. It also is something I've chosen to work on - if I recognize something is going to distract me (and sometimes my partner can tell better than I can!), I try to decide right then whether I'm going to spend time doing it right away, or truly decide to put it out of my mind to work on it / think about it at some other time.

(Luckily, most things that we deal with do not require our urgent attention!)

Thanks. The bolded has been a struggle for me, and I wish the person on the other side didn't have CANCER so I wouldn't feel guilty about not opening the message. The barrier to contacting the primary oncologist is very low, and patients want to talk to you when they're admitted, even when you're not in service.

I've tentatively made up my mind for an inpatient malignant heme/BMT career. I'll take the lower pay and the higher call burden to not have to deal with the outpatient inbox and being the primary oncologist who get notified about everything.

 

[randomhemoncpd]

I cannot overstate how much better things will be once you graduate. I’m sorry you’re in such a malignant program, but rest assured that real world practice is very far removed from your current environment.

 

[orange sherbert]

I am a fellow like you who is miserable for different reasons. We are in very different style training programs, but I can provide some perspective.

First - your practice environment is absolutely unlike real world oncology. I just finished interviewing for jobs, and in the hospitals and private practice jobs I was considering, each physician has a nurse and MA. Chemotherapy order sets are built into the electronic medical record. You do not fill out FMLA paperwork, etc. You do not schedule things. Things move (relatively) efficiently, with enough support, that attendings are comfortable seeing 20 patients a day. Radiation oncology and surgery are pretty easy to consult and communicate with.

I do not want to tell you things are all wonderful - but out in private practice or hospitals, revenue depends on patient throughput. And that throughput is negatively affected by inefficiency. It sounds like you're at a hospital where they make up for low patient revenue by exploiting cheap trainee labor, which is cheaper than upgrading systems/workflows to become efficient.

Second - if you can stick with it, things get so much better. You are trained in general heme-onc, and you are going to have recruiters throwing themselves at you offering you $500,000 base salary jobs (and this is the floor for hospital-employed jobs, basically) for general heme-onc and subspecialized positions.

Let me just tell you this: My training is very narrow in only certain solid tumor types. I had to avoid so many jobs because I am not comfortable with general heme-onc and needed to subspecialize. And even with my limitations for only certain tumor subtypes, I did not have much difficulty finding a high-paying job. With your general heme-onc training, you will have absolutely no issues finding a job in a much much more functional environment than your current training program.

Third - your worry about keeping up to date and providing the best care is admirable. I have the same anxiety. However, once you're in a more functional clinical environment, you will have that time to keep up with the latest JCO and NEJM article.

Best of luck from another unhappy oncology fellow.

I want to thank you for such a detailed response. It was interesting to read a different fellow's perspective. I had not started looking for jobs, so I was discouraged that my life would be like this forever. I constantly hear my attendings talk negatively about the general oncologist's scope of knowledge and how it will be impossible to keep up. I thought I wanted to be a general oncologist (ignorance is bliss). Again, your response means a lot to me. Thank you.

 

[orange sherbert]

It's your program. It's 100% your program. If all of oncology were like this, there would be no oncologists left in America.

It's your program. Everything from your ITE score (telling you to just "look it up" and just "read more" is the laziest freaking teaching method in the world and I hate it - they're not holding up their end of this indentured servitude bargain), to the weird bitter and passive aggressive culture, to the lack of support. It's your program.

And please trust me, practicing oncology gets better in the real world. EVERYTHING gets better. You'll have more support, you'll have more respect, you'll have more autonomy, you'll have more money, and you'll have more free time.

It's your program, and I'm so sorry you have to put up with this. I went through a hard residency and a hard fellowship, both of which had rotations through safety net hospitals, but despite this they AT LEAST tried to teach me things and support me and didn't make a big deal when I bombed my ITEs.

That said, please see that you have a plethora of different options in front of you. You're not wrong that the 7 on / 7 off hospitalist lifestyle is ***wonderful*** (spoken from experience) and the paycheck ain't too shabby neither. You're not a slave anymore. If you quit you HAVE OPTIONS. You're a freaking board certified doctor (or at least board eligible) and if they can't understand that enough to appreciate you then they can absorb your 14 patients / day into their own panel.

You have lots of options for a happy life. Don't feel like you need to go through this to prove some modicum of success to society or your peers. No one would call a board certified doctor a failure by any measure. You have nothing to prove. Find your own happiness. I'm sorry your program is stealing that away from you.

... Rip them apart on the ACGME survey

I applied to medical school with the aspiration of becoming an oncologist. However, I am rattled to my core after realizing fellowship is different than I expected... But I struggle to recognize the difference between "I am a poor fit for this field" and "my program is the issue". My program says it's me and the field is only getting harder etc. Anyway, I deeply appreciate your response and the reassurance you have provided me!

 

[orange sherbert]

I was a rheum fellow instead of Heme/onc - and I went to one of the fancy “name brand” places rather than a community program - but otherwise I can relate to your post so much. I dealt with it all - attendings who act like you’re an idiot if you can’t immediately answer every single obscure pimping question, to a dysfunctional clinic where YOU were personally expected to spend your time scheduling patient appointments, imaging and other studies, etc (although there were staff there that were supposed to be doing that …but weren’t doing their jobs!), to the weird high-pressure culture that was very harsh on fellows, the endless pressure to do more research and random BS “projects”, attendings dumping as much scut work on you as possible, etc.

One of the most discouraging moments (and there were many) came towards the end of fellowship. I was on one of the brutal consult rotations. It’s 11:30pm, and I’m literally standing in line at Walmart buying a new pack of boxers and a pair of khakis because I had run out of clean clothes and had no time to try to wash anything…my attending pages me and starts bitching me out on the phone, just absolutely yelling at me because she didn’t like something I put in one of the notes. While I’m in line, at Wally World, buying more underwear because I had no clean underwear to put on after working myself to the bone for the last few weeks. On those consult rotations, I had other attendings call me at 1 or 2am to debate something in the notes. It was just a ridiculously pedantic and absurd culture.

Another absurd moment that stands out in my mind (again on consults): we get two new consults. A different nasty attending tells me that she wants me to see these new patients and finish the notes in 30 minutes. I politely but directly point out that looking up two new patients, going to see them at opposite ends of an enormous hospital complex, and writing two perfect notes is almost certainly going to take more than 30 minutes. She literally growls into the phone: “you should be able to do that!!!” (To boot, I was like 3 months into being a fellow at that point, and didn’t even know my way around the hospital yet.) Yeah, no.

Prior to fellowship, I had done really well in medical school and IM residency - at solid programs too. I knew something was off when I went from being a well regarded, hard working IM resident (at a mid tier academic ACGME program) to being treated like a total ***** as a rheumatology fellow, despite putting in the same (high) level of effort. I actually think I worked harder as a rheum fellow than I ever did as an IM resident, but the way I was treated was much worse.

The good news: it ends! Training only lasts a defined amount of time, and then you’re out. (You don’t get treated like this in the real world.) And in the real world, it turns out I’m actually very good at being a rheumatologist. The training there had been very good, I’ve been praised by other attendings and patients for finally figuring out what was wrong with folks, etc. One of the game-changing moments for me was inheriting a patient from one of my nasty attendings at my first job, and making a correct diagnosis that had clearly been missed by said attending. Gee, perhaps I’m not an idiot after all.

Thank you for sharing this, especially from a different specialty perspective. I tunnel-visioned hard and thought "only hem/onc can be this brutal". I am sorry that you experienced that kind of abuse from your attendings. My attendings don't outright degrade me but they can be pretty passive and "hands-off" which is equally hard to navigate (I think). I feel passionate about taking care of sick patients and playing an active role in their care. I didn't realize oncology would be moving so fast and I fear I won't be able to "keep up" nor will I want to all the time, and that thought scares me. I appreciate you sharing your story!

 

[dozitgetchahi]

I want to thank you for such a detailed response. It was interesting to read a different fellow's perspective. I had not started looking for jobs, so I was discouraged that my life would be like this forever. I constantly hear my attendings talk negatively about the general oncologist's scope of knowledge and how it will be impossible to keep up. I thought I wanted to be a general oncologist (ignorance is bliss). Again, your response means a lot to me. Thank you.

Academics always love to talk **** about community docs. What they don’t realize is this: 1) a good community doc has to be very sharp and knowledgeable. A good “generalist” is IMHO way more knowledgeable and useful than some ultra specialized ivory tower doc who is only seeing some tiny segment of patients and 2) most really sick patients are actually managed in the community. You think tertiary care actually has the capacity to see all these really sick patients out there? Lol. The community needs smart docs too, imho even more so than the ivory tower, because that’s were most of the sick people actually are. 3) the tertiary care docs wouldn’t be able to cherry pick the handful of cases they want to see if the hardworking community docs weren’t out there grinding through everything else.

 

[NewYorkDoctors]

Academics always love to talk **** about community docs. What they don’t realize is this: 1) a good community doc has to be very sharp and knowledgeable. A good “generalist” is IMHO way more knowledgeable and useful than some ultra specialized ivory tower doc who is only seeing some tiny segment of patients and 2) most really sick patients are actually managed in the community. You think tertiary care actually has the capacity to see all these really sick patients out there? Lol. The community needs smart docs too, imho even more so than the ivory tower, because that’s were most of the sick people actually are. 3) the tertiary care docs wouldn’t be able to cherry pick the handful of cases they want to see if the hardworking community docs weren’t out there grinding through everything else.

I am certain the academics are talking about the gaslighting, do nothing but cut down time on each 99213 visit, do not bother to send prior workup results into the academic doctors for consultation, and not doing the basics and making the specialist's job harder in general community docs (see my latest post is outpatient that bad for some hilariously bad google reviews).

I am certain they appreciate a good generalist or a good subspecialist (if the academic is a super subspecialist) who can manage the basics and sets the proper expectations for the patients.

but yes in fellowship, the attendings are really a bit overbearing. but community fellowships tend to have the attendings struggle between making RVUs and needing the ride the fellows hard and also educating the fellow. Don't forget the attending's own probably miserable personal lives lol.


To the OP, it's tough but ride it out you will have a good career once you are an attending.
Since you aer doing so much scut work, this "somewhat clinically useful training" might translate to your very quickly opening your own practice and chemo infusion center one day. At least you already know how the nuts and bolts of running a practice is there since you are doing all this scutwork. Just a glass half full approach.

 

[Ubba]

I'm personally very oriented toward community practice. However, let's not throw out the baby with the bathwater re: academic oncology. Let's appreciate that it's academic oncology (and academic medicine in general) that moves the ball forward in advancements in outcomes and therapeutic options, not to mention other guideline-streamlining. Often for overall worse QOL for the attending.

Let's not generalize from the OP's predicament to academics as a whole. You're in a rotten program and shouldn't have to go through this misery, but on the bright side, you will emerge stronger from the experience.

 

[gutonc]

I want to thank you for such a detailed response. It was interesting to read a different fellow's perspective. I had not started looking for jobs, so I was discouraged that my life would be like this forever. I constantly hear my attendings talk negatively about the general oncologist's scope of knowledge and how it will be impossible to keep up. I thought I wanted to be a general oncologist (ignorance is bliss). Again, your response means a lot to me. Thank you.

Being a generalist is hard, I won't pretend that it's easy. But as someone who entered fellowship planning to be one of those academics who only manages cancer of the neck and middle third of the pancreas (not head of pancreas or tail of pancreas, and certainly not any of those other stupid organs), I can't imagine NOT being a generalist. Sure, I do miss some of the depth I could go into in GI cancers early in my career, but I love the variety of people and conditions I see now and it's fun keeping up to date.

And it's honestly not that hard to stay reasonably up to date these days. There are so many avenues for keeping updated on changes in practice that you almost have to actively avoid learning. In my prior practice, i worked in an academ-ish community based, academic hospital owned group. We had easy access to the academic experts as well as local tumor boards with lots of subspecialists available. My own clinic had 5 docs and we did a little bit of subspecialization, but we all still saw pretty much everything, just skewed to what we were most interested in. My current job is a solo practice (soon to be two of us) rural CAH owned by a large regional healthcare system. Although I'm on my own in the office on a day-to-day basis, the regional cancer center (actually larger than my old academic hospital) is an hour away, has numerous clinical trials including a robust drug dev and phase 1 program and quaternary care, with some more advanced surgical specialty management than the academic hospital does. I'm having a ton of fun with this job and learning more now, 12+ years into my career, than I did in the first 10.

 

[hehe5347]

Being a generalist is hard, I won't pretend that it's easy. But as someone who entered fellowship planning to be one of those academics who only manages cancer of the neck and middle third of the pancreas (not head of pancreas or tail of pancreas, and certainly not any of those other stupid organs), I can't imagine NOT being a generalist. Sure, I do miss some of the depth I could go into in GI cancers early in my career, but I love the variety of people and conditions I see now and it's fun keeping up to date.

And it's honestly not that hard to stay reasonably up to date these days. There are so many avenues for keeping updated on changes in practice that you almost have to actively avoid learning. In my prior practice, i worked in an academ-ish community based, academic hospital owned group. We had easy access to the academic experts as well as local tumor boards with lots of subspecialists available. My own clinic had 5 docs and we did a little bit of subspecialization, but we all still saw pretty much everything, just skewed to what we were most interested in. My current job is a solo practice (soon to be two of us) rural CAH owned by a large regional healthcare system. Although I'm on my own in the office on a day-to-day basis, the regional cancer center (actually larger than my old academic hospital) is an hour away, has numerous clinical trials including a robust drug dev and phase 1 program and quaternary care, with some more advanced surgical specialty management than the academic hospital does. I'm having a ton of fun with this job and learning more now, 12+ years into my career, than I did in the first 10.

Out of curiosity, what made you switch from your old job to your new one after so many years into your career?

 

[gutonc]

Out of curiosity, what made you switch from your old job to your new one after so many years into your career?

It's a long story, but it boils down to "it was time for a change, and change came looking for me". It didn't hurt that the location was somewhere I wanted to move anyway.

Describing it as rural is kind of misleading. It's rural according to the Census Bureau, but it's rural in the same way that Jackson Hole, WY and Vail are rural (it's actually bigger than Vail and about the same size as Jackson Hole).

 

[Mehena]

I found this somewhat related to this thread. Take care of yourself and seek help if necessary. If you feel like you have no energy left, consider finding another career. Individuals with your level of intellect have infinite opportunities compared to previous generations. You're not alone—every physician faces the same dilemma, but it gets better, and more importantly, you improve in managing it.

https://www.washingtonpost.com/dc-md-va/2024/10/03/will-west-doctor-gwu-suicide-note-mental-health/

 

[dozitgetchahi]

Thank you for sharing this, especially from a different specialty perspective. I tunnel-visioned hard and thought "only hem/onc can be this brutal". I am sorry that you experienced that kind of abuse from your attendings. My attendings don't outright degrade me but they can be pretty passive and "hands-off" which is equally hard to navigate (I think). I feel passionate about taking care of sick patients and playing an active role in their care. I didn't realize oncology would be moving so fast and I fear I won't be able to "keep up" nor will I want to all the time, and that thought scares me. I appreciate you sharing your story!

Yeah, I totally agree that “hands off” attendings can be a problem also.

That was basically the culture at my program, too. The attendings were very busy with research and other things, and thus while they claimed to be available “for anything if you need them”, they really preferred the fellows to try to drive the boat as much as possible…until you did something they didn’t like. Then, there was hell to pay. It was a definite catch-22; bug the attendings too much, get chewed out (“you should know how to do this”.) Do something the attendings didn’t like, get chewed out (“why didn’t you tell me you were going to do this”). As you might imagine, we got chewed out…a lot. Way, way more than I ever did as a resident, and about things that frankly were much more trivial. I agree that it was very difficult to navigate.

 

[osprey099]

Describing it as rural is kind of misleading. It's rural according to the Census Bureau, but it's rural in the same way that Jackson Hole, WY and Vail are rural (it's actually bigger than Vail and about the same size as Jackson Hole).

Both are awesome ski towns! Hopefully yours is too

 

[orange sherbert]

Hello,

It’s been six months since I last shared my struggles online. I was nervous to make that first post, hesitant to acknowledge that I might be the problem after nearly 10 years of chasing this dream. It was a dark and lonely time. While it's no secret that many fellows struggle, I knew I wouldn’t last much longer unless I asked for help.

If you don’t read further, the TL;DR is that I stayed in fellowship.

After my initial post, I took two weeks of PTO for an emergency mental health break. I spent that time talking to friends, family, and other medical professionals (both in and out of oncology) while trying to picture a different life for myself. I ruminated over this for a long time-ultimately, the pros of staying outweighed the cons. SDN (and other fellows from outside my program) helped me realize that much of my struggles were due to my environment. My program is... terrible. I’ll spare the details, but I truly believe I could've thrived in a better program. That said, I take responsibility for my own part in this. My motivation, work ethic, and study habits were subpar. That might've been because I was miserable here but other fellows have survived and graduated from this program as strong clinicians, so I know it’s possible to be strong too. So, I've spent the past six months working hard to learn what I should've learned during my first year.

I haven’t been absolved of all my insecurities and struggles, though. I’d say I’m about 35-40% better. My oncologic knowledge is still catching up (and keeping it in my brain is a separate issue, ha). I’m still constantly trying to “prove” my growth to my attendings but they remain distant. The doubts of success still annoyingly creep in, like an itch you can’t quite reach. My biggest fear remains that I won’t be able to keep up with practice-changing literature (as a generalist) and that it will lead to me eventually hurting someone. You'd think that all of this would drive someone to work even harder but for me, it results in a paralyzing fear in which I shut down. Yes, therapy is coming next lol.

But I’ve also had many beautiful moments. I’ve formed many meaningful relationships with my patients. They’ve sent me cards, hugged me, and even kissed my cheek! Family members have called to thank me for my care on behalf of their deceased loved ones. One particularly touching moment was when my patient who was in the ICU on hospice asked me to come to his bedside while the pastor anointed his marriage to his fiancee (he passed away the next day). This is why I entered the field and it’s been the motivation to keep pushing forward.

The real reason I’m posting this update is not for myself, but for the struggling, lost fellow who may come across this post five years from now during a rampant evening of Google searching "is hem/onc for me". If you’re that fellow looking for a happy(-ish?) ending to a dreadful start - here it is. Maybe I’ll update in a few years with an even happier epilogue.

 

[ONC2023]

This is really, really wonderful to read. I’m so glad you’re in a better place and found a way to stay in fellowship. As someone who also went through a very very bad time in my fellowship and is about to graduate, I empathize with a lot of this. Keep us updated!

 

[ayjaystudent]

Thakns for the update! Glad to hear you're on your way up!