When did you start feeling comfortable?

[Plutarch02]

I'm a new attending in my first year out from fellowship. I feel like a significant number of things I learned in fellowship are already outdated and it seems to be the trend is intensification of therapies (and hence side effects).

How long did it take for things to start slowing down for you, or is it just the nature of the beast now that our field is perpetually at high speed.

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[gutonc]

I'm a new attending in my first year out from fellowship. I feel like a significant number of things I learned in fellowship are already outdated and it seems to be the trend is intensification of therapies (and hence side effects).

Everything is outdated all the time. I feel like therapy de-escalation is the flavor of the month in everything but myeloma and prostate cancer. But you are going to have to keep up, or get left behind, for the rest of your career. It's honestly one of the things I love about oncology (and medicine in general).

How long did it take for things to start slowing down for you, or is it just the nature of the beast now that our field is perpetually at high speed.

Once you have a grip on your clinic flow and referral patterns, and have caught up with inherited patients, it will be much easier. Took me 3 or 4 years. But yes, the field is changing every week, it's the nature of the beast.

 

[Plutarch02]

The most stressful part is referrals for pts with mass but little to no w/u. We used to require a path report but as I'm new they've been letting in these undiagnosed pts and I can't really push back because I don't want to harm the referral relationship. In some ways it's good because I can send NGS at the start but I wish we had in house IR and path because it's stressful waiting weeks on these.

 

[gutonc]

The most stressful part is referrals for pts with mass but little to no w/u. We used to require a path report but as I'm new they've been letting in these undiagnosed pts and I can't really push back because I don't want to harm the referral relationship. In some ways it's good because I can send NGS at the start but I wish we had in house IR and path because it's stressful waiting weeks on these.

Don't let it be stressful. Just make it part of the process. Understand that it's going to take 3-6 weeks to get your answer, and make the patient aware of that from the beginning.

I recently moved from a tertiary care setting with every conceivable subspecialist at my beck and call, to a rural CAH with 3 (wonderful) general surgeons, 1 (very nice) ENT and a few (mostly useless) PT urologists, as well as host of mostly FM primary care folks who are used to not having anyone around to help them at all). I used to get pissed off when every single patient didn't come neatly wrapped with path, imaging and an NGS bow on top. Now I'll take anyone, at any stage of workup just because I know that if I don't take the reigns, that 4-6w workup becomes 4-6 months. It's just how the medicine is practiced here, and once I embraced that (which only took me a few months), it became a lot easier and much less stressful.

 

[gutonc]

Everything is outdated all the time. I feel like therapy de-escalation is the flavor of the month in everything but myeloma and prostate cancer. But you are going to have to keep up, or get left behind, for the rest of your career. It's honestly one of the things I love about oncology (and medicine in general).

Once you have a grip on your clinic flow and referral patterns, and have caught up with inherited patients, it will be much easier. Took me 3 or 4 years. But yes, the field is changing every week, it's the nature of the beast.

Yes, I'm replying to myself...how gauche. But something came to mind today when I was trying to figure out what to do with a R/R myeloma patient. The beauty of managing metastatic/incurable cancers is that, while there are certainly going to be wrong answers as to what to do, it's rare that there's one absolute right answer in any given situation.

Is Docetaxel/Lupron/Abi "better" than Docetaxel or Lupron/Abi alone? Yup. Does that mean Docetaxel/Lupron/Abi is the right choice for every metastatic prostate cancer? Nope. Can you start with one and then add the other? Sure. Can you start all 3 and then dial back for toxicity or really phenomenal response? Absolutely.

While medicine is clearly both science and art, I find oncology to involve more of both of them than a lot of other specialties. Is a Whipple a procedure that only a few highly trained people can do, and even fewer still do well? Absolutely. But a Whipple is a Whipple is a Whipple. But how do you get the borderline resectable patient to that Whipple? I can think of half a dozen ways off the top of my head, and that doesn't include clinical trials or rare mutations. And guess what? They're all "right" for the right person.

 

[HemeOncHopeful19]

As another new attending I’d be curious from some of our older folk what you do to keep up with the new changes outside of an Academic environment

 

[Plutarch02]

I'll chime in that I have found steak dinner talks to be useful from academics who are giving them for their own side hustle. Not many other oncologists show up so I get 1-2 hours with an expert in the field to bounce questions off of.

 

[gutonc]

As another new attending I’d be curious from some of our older folk what you do to keep up with the new changes outside of an Academic environment

I personally do a lot of reading on my own. I get the ASCO Post, MedPage Today and Cancer in the News emails every day. They tend to have a fair amount of overlap, but It results in 10-15 unique headlines a day. I take a quick glance at the headlines and will read the summary emails on 1/3-1/2 of them and then the primary literature on a couple of them, depending on what's on the menu for the day. I don't read the studies as in-depth as if I was presenting them at Journal Club or anything, but I give them a once over and note how practice changing I think it will be for me.

Obviously going to meetings is great, but time consuming and expensive. ASCO and ASH are obviously fun, but overwhelming. I've found the Best of ASCO and some of the smaller meetings (ASCO GI, ASCO GU, IASLC, SABCS) to be much more manageable. Depending on where you are geographically and the presence of a cancer center nearby, they may sponsor local summary meetings after ASH and ASCO. We have one here in town that I've presented at previously. They do an ASCO Updates meeting in late June and an ASH/SABCS update in early December each year.

The other thing I still do, a decade plus into practice, is read about patients. Someone comes in that I have a question about, I'll just read up on it. I usually start with PubMed rather than UTD or the Google machine.

I know it sounds like I'm spending a LOT of time on this, but TBH, it's only 20-30 minutes a day (not every day) and it's interspersed with other things so I don't consider it a real burden.