Continuing progress in the science of oncology must be matched by an increased responsibility toward providing oncology trainees around the world with the academic guidance, emotional support, and lifelong mentoring needed to navigate an increasingly complex environment. Although the realities on the ground determine the practicalities, there are important universal lessons to be learned from heeding diverse experiences. In this paper, three faculty at different stages of their careers from countries with different resources and infrastructure share their insights into caring for trainees.
- Oncologists make up a global community with shared responsibility to support and educate our trainees, within and beyond our borders.
- Personal connections go a long way in helping our junior colleagues secure opportunities for training, collaborative research, and mentorship.
- The ASCO IDEA program for early-career oncologists in low- and middle-income countries has been hugely successful; trainees should be encouraged to apply and faculty members to participate.
- Trainees can be directed toward the wealth of online educational resources offered by ASCO and other international cancer societies.
- We have a duty of care toward our trainees extending beyond education and career advice.
- Establishing a culture of debriefing after critical incidents, role modelling, and addressing issues such as bullying and harassment in medicine are key to serving the needs of the next generation of oncologists.
“Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.”
This excellent observation from Albert Einstein contains the essence of medical training, which is to awaken the curiosity and self-expression of young physicians, so they may find their own place in the storied profession of medicine. Skills, resources, materials, and the patient population vary from place to place, but it is the shared duty and, indeed, privilege of all experienced clinicians to help our trainees prosper so that our patients may be the final beneficiaries.
Below, three oncologists based in different countries share their reflections on supporting trainees. Each country, namely Lebanon, Mexico, and Australia, has a unique environment that shapes the conditions and challenges encountered by its trainees. The contributions bring together different perspectives from which all training programs stand to gain something to enrich the experience of future oncologists.
A GLOBAL PERSPECTIVE FROM AN INTERNATIONAL TRAINING PROGRAM
The Naef K. Basile Cancer Institute at the American University of Beirut Medical Center (AUBMC) in Lebanon is a leading tertiary referral center and teaching hospital in the Middle East. We see over 3,000 new patients per year from Lebanon and the region including a substantial proportion of patients from Iraq and Syria.
The hematology/oncology fellowship training program at AUBMC has an annual intake of two fellows for a 3-year program. In line with the U.S. system, this includes training in benign hematology, malignant hematology, and solid tumor oncology. Potential fellows are eligible to apply for the program after completing a 3-year residency training in internal medicine and passing a test of English language proficiency.
Trainees are assessed annually by taking the American Society of Clinical Oncology (ASCO) and American Society of Hematology (ASH) in-training exams. These exams provide a benchmark for the trainees’ progress and guide program development. They also serve as an objective measure of knowledge acquired during the 3 years of fellowship compliant with the Accreditation Council for Graduate Medical Education requirements. Our institution is currently accredited by the Accreditation Council for Graduate Medical Education International, and we are working toward accreditation specifically for our hematology/oncology fellowship training program.
Hematology/oncology fellows at AUBMC benefit from a month-long elective, usually arranged at a prominent cancer institution in the United States such as Memorial Sloan Kettering, MD Anderson, or the Winship Cancer Institute. Visa issues for trainees have led us to widen our reach to Canadian institutions. A key element of our electives is that they are financially supported by the Naef K. Basile Cancer Institute, therefore removing a key barrier for many trainees.
In contrast to the U.S.-focused experience we offer to our trainees at AUBMC, a European focus is offered by the training program at the Faculty of Medicine of the Université Saint-Joseph de Beyrouth, a leading French-language academic institution in Lebanon. Their program consists of 2 years hematology/oncology training in Beirut in which trainees also take the ASCO and ASH in-service exams followed by a further year of training in Europe, routinely at the Institut Gustave Roussy in Paris, France. Graduates are also encouraged to take the European Society for Medical Oncology examination.
In common with many other training programs, we aim to provide a 3-year educational experience covering the fundamentals of three rapidly expanding areas of medicine: benign and malignant hematology and medical oncology.
Although many graduates go on to enter advanced fellowship programs elsewhere, the aim of most of our trainees is to work in the Middle East. The majority of physicians practicing hematology/oncology in the Middle East do not subspecialize and are expected to remain up to date with evidence-based practice in all areas. Our challenge, hardly unique to our program, is to furnish our graduates with the skills to be able to stay current with their knowledge but have the ability to adapt best-practice guidelines to resource-limited environments.
As our academic mission increasingly focuses on advanced diagnostics, precision medicine, and immunotherapy, our fellows have to be able to provide the best available care to patients who have often heard about high-cost therapeutics but cannot afford access.
As a phenomenon distinct from medical tourism, conflict-related cross-border travel for cancer care is common in the Middle East in both refugee and nonrefugee populations. Conflict-related deficiencies in health care and security may force patients to undergo treatment in neighboring countries, but continuity of care can often be compromised by variables including travel, housing, childcare, finances, and physical and emotional trauma. There is no coordinated medical record; patients often carry health reports from various places that they have been seen.
Providing care under these circumstances can be difficult for providers and patients. Consequently, our trainees are required to develop advanced communication skills to manage discussions surrounding both medical and financial toxicity and handle logistical issues that are not as readily apparent in resource-rich countries.
Another challenge, again common to many institutions, is finding the balance between education and clinical service provision. We have partially tackled this issue through the recruitment of nononcologist clinical associates who review outpatients attending our chemotherapy infusion unit. This has allowed fellows to spend more time seeing new patients in the clinic and have dedicated time for clinical research.
Our trainees are privileged to undertake electives abroad and benefit from networking and mentorship opportunities provided during these experiences. We are assisted in this initiative by a distinguished diaspora of hematologists and oncologists of Lebanese origin who are unfailingly supportive of our trainees who undertake electives at their institutions and make special efforts to interact with trainees when they attend conferences in the region. Our faculty members are committed to medical education at all levels and importantly leverage their academic contacts to ensure that trainees have access to the best opportunities. For instance, a former chair of the Department of Hematology and Medical Oncology at Emory University School of Medicine and now president of the American University of Beirut dedicates time to see patients with fellows in an educational bimonthly clinic.
Our institution has strived to set up strong relationships with prominent international cancer centers. In addition to electives, our trainees are expected to participate in regular tumor boards via videoconferencing and attend conferences in Lebanon and overseas. We have found that our personal connections have been key to fostering institutional collaboration in education and research, thereby setting the standard for a future generation of oncologists.
Resources for International Trainees
Financial support for trainees to attend electives and conferences is desirable but not always easy to achieve. We encourage programs to take advantage of opportunities such as ASCO’s International Development and Education Awards (IDEA) for early-career oncologists in low- and middle-income countries. Recipients are paired with ASCO members in the United States or Canada, supported to attend the ASCO Annual Meeting and a postmeeting visit to their mentor’s institution. One award recipient who could not travel to the United States was able to attend the Best of ASCO Meeting held annually in Beirut and be mentored by a prominent local oncologist with involvement in the ASCO International Committee. Being flexible with opportunities has been a key to the success of our trainees.
It has never been easier to access information and practical know-how, to the benefit of oncologists and our patients. The international cancer societies ASCO, ASH, and European Society for Medical Oncology all provide a wealth of online resources for both practicing physicians and trainees, and discounts on products are available for trainees in low- and middle-income countries. A key role of the program director, and, indeed, senior faculty, is to talk to trainees about their needs and direct them to the most appropriate resources. Our fellows at AUBMC have particularly benefitted from the ASCO University Education Essentials for Oncology Fellows program. This provides a personalized learning dashboard, access to over 100 eLearning courses, and the ASCO Self-Evaluation Program e-book and mock examination.
The strength of any training program lies in the enthusiasm of its faculty members to provide education, support, and mentorship during the training years and beyond. The majority of our graduates will deliver clinical care instead of pursuing a career in academic medicine. However, it is our mission to instill all our graduates with a passion for lifelong learning because we believe that their excellence ultimately benefits all patients. Consequently, we strive to maintain relationships with academic centers and create new ones through our personal connections.
Oncologists make up a global community, and trainees in resource-limited countries can be supported through a variety of means including online resources, professional development opportunities, and networking, all brought about by a keen knowledge of our trainees and a genuine interest in using our personal connections to advance the next generation of oncologists.
PREPARING FELLOWS FOR THE REAL WORLD: A CULTURAL PERSPECTIVE
Training programs in oncology are expected to graduate fellows with well-developed diagnostic skills to treat patients with cancer.1 However, one of their most important challenges is to prepare graduates for real-world practice and provide them with the abilities and attributes that will make their careers successful.
The educational experience of an oncology fellow may vary significantly according to the country and institution of training. American trainees at a tertiary referral center constitute an elite group with countless academic opportunities. These trainees are exposed to cutting-edge research, advanced methods of clinical practice, multidisciplinary tumor boards, niche drug discovery programs, an opportunity to prescribe novel agents, and access to many clinical trials. Their experience is bolstered by the availability of one or multiple supervisors and a mentor who may be extremely prominent, well connected, and generous with ideas and networking opportunities. It is easy to forget how far removed this is from the experience of the majority of trainees who come from middle- to low-income countries. In this case, the trainee is often an apprentice struggling to deliver adequate clinical care in a small facility, starved of all kinds of resources, including blood tests and common medicines, let alone mentorship and research opportunities. Therefore, program directors and senior faculty may be rightly concerned that an individual with equal ability may not approximate equal academic success in this contrasting environment. However, the truth is that successful oncologists have arisen from all sorts of conditions. One explanation for this phenomenon is that the underdeveloped world offers unique advantages to trainees.
The hurdles that oncology trainees face in constrained-resource settings are exemplified in this section by one of us (M.T.B.), who works as a young faculty member at the National Institutes of Health in Mexico. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán is a tertiary referral academic center in Mexico City, Mexico, recognized nationally for high-quality specialists in the field of internal medicine and associated research activities.
The Hemato-Oncology Department has two training programs, one for medical oncology that focuses on solid malignancies and a hematology fellowship that teaches management of benign and malignant blood diseases. Our trainees are mainly Mexicans, but during the last decades, we have had an increasing number of fellows from other countries. Currently, our medical oncology program has 14 fellows; among them, five are foreigners from other Central and South America regions. Of our 12 hematology fellows, three hail from other countries.2
This phenomenon is a sobering reflection of the fact that Mexico’s neighboring countries have even more limited health resources, and hence, physicians lack access to a medical oncology training program. The lack of a language barrier and less stringent visa requirements encourage aspiring oncologists to join our program.
Given the severe shortage of oncologists, fellows centered in underdeveloped regions have the unique opportunity to be exposed to far greater numbers of patients early in their training and are required to develop the responsibility to decide treatment plans and manage toxicity on their own.3
At our institution, a second-year fellow in a single week will attend up to three different clinics, take care of 30 patients in each clinic, be in charge of up to 10 inpatients, and take the lead presenting up to 10 cases at the tumor board meetings. Although these numbers can sound intimidating, our fellows receive expert guidance. We find that assuming patient care and being accountable from an early stage fuels the motivation and commitment to be well informed and well prepared to achieve good outcomes for patients.
The absence of complicated medical records that take hours to complete and involve many bureaucratic needs means that trainees can have more free time to devote to the doctor-patient relationship and build trust and rapport.4 With skillful and deliberate supervision built into such routines, oncology trainees can emerge with sound clinical skills and a sense of shared humanity with patients.
Oncologists in underserved and low-resource areas will remember that just some decades ago, their training opportunities were limited to what was available locally. Thankfully, the world has become more connected since that time, and today, oncology training can take place in a global environment. Presented below are some examples and reflections about the modern era of oncology training in Mexico.
Access to Knowledge Is Readily Available
Access to scientific data and practical clinical knowledge used to be restricted to those with access to well-stocked libraries. Despite current restrictions to access certain journals and articles, the internet has made information more readily available to any practicing physician around the world and has reduced the knowledge disparity. Oncologists in Mexico have benefited greatly from this access to data. Currently, the National University provides access to UpToDate, Ovid, Nature, Journal of the American Medical Association, SpringerLink, Elsevier, and ScienceDirect, among other platforms.
Fellows can gain access to the Journal of Clinical Oncology through sharing the login details of their attending or colleagues who have earned awards and have received access to the Journal of Clinical Oncology. Data presented at meetings and oral sessions are similarly shared.
A debatable way of accessing other articles is via databases like Sci-Hub. Sci-Hub provides free access to both open access papers and research papers that are usually behind a paywall. This manner of access violates copyrights and the viability of publishers, but in contrast, it gives physicians free and efficient access to knowledge generated by the scientific community that in the end is critical to sound decision-making.
Having an International Mentor Is Possible
Universally, physicians learn clinical skills from their more experienced colleagues. However, many centers around the world are so overwhelmed by clinical demands that they do not have the expert faculty or the time to mentor trainees in methods of conducting research, publishing papers, or securing grants. Medical societies such as ASCO, European Society for Medical Oncology, or ASH have helped greatly by launching programs to match mentees from low-resource settings with mentors.5-8 Seeking a mentor across boards is now feasible through these initiatives and can help underserved trainees fulfill an unmet need.
Five years ago, I found myself in the middle of my fellowship willing to pursue an academic career in urologic oncology and could not find a mentor or program locally. I had the good fortune to receive the ASCO 2013 IDEA from the Conquer Cancer Foundation. Dr. L. Michael Glodé, a genitourinary cancer expert at the University of Colorado, was assigned to be my mentor.
During the week I spent with him, I was immersed for the first time into a comprehensive cancer center. I was able to see the clinic, research facilities, inpatient halls, and infusion area and attend tumor boards. However, most importantly, my mentor inspired me and gave me the enthusiasm to strive to become the urologic oncologist I wanted to be. The next year, I returned as a fellow to the genitourinary cancers program at the University of Colorado, where I spent 1 year. One advantage of this system is that mentors can connect trainees with other experts, paving the way for further international collaborations to boost their academic career. Thanks to the commitment of my mentor, I have found continuous guidance from other experts over the last few years.9
To expand this benefit, program directors and senior faculty must shoulder the responsibility of ensuring that their trainees are aware of such facilities and help them apply. We encourage medical oncology and hematology fellows to apply to such programs every year. One of the most successful programs for our institution has been the IDEA. Participation in IDEA has allowed our faculty and former trainees to obtain additional awards, as well as international fellowships at cancer centers in the United States, Canada, and Europe. Previous awardees give a presentation every year to new trainees to provide them with useful information and tips for a successful application. Consequently, several past IDEA award recipients now mentor new recipients. In this stepwise way, we are realizing our aspiration that trainees should not merely be comfortable within the confines of our training institution but seek global expertise.
Exposure to Experts and High-Quality Academic Discussions Is Easier
A chance to experience a world-class cancer facility can provide great inspiration to young oncologists from resource-poor countries to envision the way in which they could benefit their institution and, ultimately, their patients. The logistics and expenses associated with traveling abroad remain prohibitive for most trainees, but fortunately, exposure to a high standard of care through online resources is within reach.
For instance, because of our continuing relationship with the genitourinary cancer program at the University of Colorado and a grant obtained from the Aramont Foundation and Canales de Ayuda A.C. Foundation, we have established a long-term mentorship program that includes visits to our institution by American professors. American faculty members regularly provide advice on challenging cases, discuss urologic oncology cases directly with our fellows, and assess our research developments.
Similarly, we have established an ongoing partnership with the Global Cancer Institute, a nonprofit organization based in Boston, MA. In collaboration with Global Cancer Institute and other global centers, we have developed an online virtual multidisciplinary tumor board to facilitate the discussion of cases of breast cancer between oncologists in low- and middle-income countries and in cancer centers in the United States. Currently, Global Cancer Institute multidisciplinary tumor board participants come from 18 countries in Latin America, Eastern Europe, Africa, and Asia.
Short travel grants, visiting fellowships, and preceptorships are becoming more common as organizations become more aware of the importance of conducting research in developing countries to reduce the burden of cancer. Grant recipients in developing countries need resilience and agility to address the particular needs of their communities. Oncologists should be aware that replicating models from high-income nations and their health care systems in resource-constrained settings could be risky and even harmful. For example, implementing PET scans or treatment with radiopharmaceuticals in a region without the appropriate nuclear medicine units and security requirements may cause more damage than the actual benefit. Similarly, participating in an international trial of second-line therapy does not make sense when most patients do not have access to first-line therapy. Therefore, it is incumbent upon senior faculty to oversee that models are appropriately adapted to the local setting and changes are implemented wisely and sustainably. Nonetheless, the exchange of ideas constitutes a unique opportunity to learn from each other.
Getting a Job Remains Challenging
Even highly capable and well-qualified graduates can find it difficult to get a job. Government jobs are associated with low pay and many years of a temporary contract, with renewal dependent on budget rather than achievement. New attending physicians typically have the highest clinical loads, limiting the opportunity to build an academic profile.
Given the inadequate compensation in public medicine, many physicians seek to work in private practice, splitting their time between the two. This situation may not be optimal for holistic patient care, scientific productivity, or work-life balance for the physician.10
Less than 10% of the Mexican population is privately insured; therefore, the majority of remuneration in the private setting comes from directly billing the patient. The cost of office rent, certifications, and hiring an assistant might initially exceed earnings. The Mexican Society of Oncology has a website dedicated to employment opportunities. It is also involved in initiatives to support women in oncology and reduce the gender disparity in pay.
Our developed-world colleagues might imagine that oncologists in countries like Mexico might experience a sense of despair, but this is not true. Although some settings limit academic progress, many oncologists adapt to their circumstances and find job satisfaction within them. Being a successful oncologist requires many attributes, including good interpersonal skills. By working closely, sharing resources, and discussing our obstacles, we manage to build a supportive community that nurtures our fellows and attending physicians.
Political and Societal Instability Have a Price
In a developing country such as Mexico, political transitions might have a greater impact on the health policies than in the developed world. The ruling party may elect to fund or remove funding from a program according to its priorities.11 Payment of health care personnel, funding of drugs, and promotion of screening programs can all change quickly. Therefore, it is essential for our fellows to learn how to be resilient in the face of changes that may leave oncologists and communities feeling helpless.
Despite the challenges, our faculty has consistently applied high standards to academic achievement and patient care. We showcase these through presentations at important meetings and through day-to-day care. In supporting our fellows, we remember the words of Ralph Waldo Emerson, “If you would lift me up you must be on higher ground.”
Remaining Motivated and Resilient in Your Career Is Key
Starting a career as an oncologist is a unique opportunity for continuous growth. It is not restricted to a promotion in one’s institution, but invites a larger presence such as being an active member of a society, volunteering for a committee, or engaging as part of a collaborative group or task force. In addition, serving others as their mentor and leader is an important calling. Adapting to the environment in which one lives is paramount to success.4 Limited-resource setting trainees must be willing to improve their environment, while recognizing that this task takes time.
Despite the fact that we treat a deadly disease, oncologists are highly motivated professionals.12 We engage in a continuous battle against cancer. In review, testicular cancer and Hodgkin lymphoma were deadly diseases that are now curable.
Metastatic melanoma outcomes have greatly improved with targeted therapy and immunotherapy approaches. These gains have happened through the perseverance of others. Finding a purpose in medicine is a cornerstone of remaining motivated.
We should believe in the saying that the sky is not the limit when there are footprints on the moon.
In conclusion, the training opportunities for oncology fellows may vary widely according to country and resources, but success comes in many forms. Trainees from resource-strained countries must embrace the unique opportunity they have to take care of patients directly and develop sound clinical skills. In addition, they must take advantage of the more connected oncology world that we live in today, in which knowledge is readily available, mentoring and travel grant opportunities through international societies are a reality, and online resources for networking are expanding.
It is incumbent on faculty to encourage trainees to step outside their institution to enrich their learning and form new relationships that will inform better patient care.
The transition from fellowship to a career always imposes challenges, although these are again different depending on the country. However, this is another opportunity to define ourselves and the work we do on behalf of our patients.
PREPARING THE NEXT GENERATION: SERVING THE NEEDS OF ONCOLOGY TRAINEES
This final section discusses the way all oncologists, whether they are program directors or training supervisors, can care for trainees. It starts with a personal account from one of us (R.S.), who works in an academic hospital in Australia. Australia has a world-renowned universal health care system with generous access to cancer care, and its cancer survival rates are some of the highest in the world. Trainee education is governed by the rules of an established training program, and supervisors must have completed periodic formal supervisor training. Consequently, trainees in this comparatively resource-rich country do not face many of the issues of their counterparts, but nevertheless, training in such environments carries its own challenges.
A few years ago, while cross-checking a trainee’s references, I came upon a somewhat dissatisfied supervisor and wanted to get to the bottom of her concern. There was nothing really wrong with the trainee, the supervisor shrugged. His knowledge, bedside manner, and problem-solving skills were consistent with his level of training, but he always seemed conscious of the number of hours he was spending at work, which somehow gave the impression that work was not his number one priority. The supervisor continued that on rare occasions, she had to stay back and check on patients because she was worried, but in fairness to the trainee, there had never been a sentinel event or an error. I was relieved to hear this, and as we continued, the supervisor took on a more reflective tone.
She said she felt bad making the point that things were not the way they used to be. She recalled her own training as relentless and unforgiving. Her bosses had expected a lot from her, and the hours spent at work were seen as a reflection of her commitment. As a result, she had finished her residency with a strong work ethic and an intensity of focus that had lasted for 30 years. She conceded that as she became older, she was trying to adjust to the demands of a new generation of trainees who, like her, were drawn to medicine, but, unlike her, were disinclined to make it their life’s only work.
In a phase of life between a new trainee and seasoned faculty, I could appreciate both sides. The trainee was in his early thirties, with a young child and another on the way. His academic wife and he had recently taken on a mortgage. With little outside help, they adhered to a strict schedule to govern their activities. His wife had already made sacrifices to move where his training took him, and he did not want her to give up her work, which she enjoyed. The dual task of being a trainee and a person with competing responsibilities at home was tough. It meant that sometimes he ran a few minutes late, made full use of his allocated sick leave, and was occasionally distracted by an illness in the family. These aspects of the trainee’s life had once resembled my own.
I also understood the thoughts of his former supervisor who was trying to redefine her expectations of a modern-day trainee. She had chosen to become a supervisor because she wanted to help trainees, but she had to work hard to recognize the differences from her own time. It took some thought to redefine what the expectations of a modern-era trainee ought to be. She was genuinely interested in trainee welfare, but she had to adjust to the fact that increasingly, trainees were not inclined to exclude all other goals in life, such as being an able parent, an available partner, or someone with outside interests. Their desire to become a confident and capable specialist was matched by their wish to find a balance in life.
This story has stayed with me over the years because it highlighted the dual responsibility we often feel of being a good doctor in the context of being a whole person, something that our predecessors might have had less room for even if they were so inclined.
I am on faculty and a trainee supervisor in an academic hospital. Apart from being a mother to three primary school–age children, I have an active writing career. It doesn't escape me that the most frequent question I am asked by trainees is how to address the balance between being a committed oncologist and having a life outside medicine. This is a challenge for all doctors, but there is a unique pressure on female trainees who are conscious of a declining window of fertility and are at risk of being judged by, or discriminated against, their colleagues and their institution. There is no one-size-fits-all answer to the issues faced by trainees, but being a supervisor is one of my most cherished roles, and I am always thinking about how best to prepare the next generation of trainees.
Following are five things that I have learned.
Knowledge Should Be Exchanged, Not Merely Dispensed
Training used to be seen as a one-way transfer of knowledge from a more experienced clinician to one less experienced. In the past, it was often hierarchical and deferential.
A better way may be to view the modern relationship as one of mutual exchange, otherwise known as mentorship. Mentorship is not the same as tutoring; it is a relationship of greater depth, based on shared interest, guidance, support, and confidentiality. Good mentors do not focus on teaching and supervision alone but on helping trainees succeed more broadly in life.
A successful mentoring relationship should not be onerous, but mutually enjoyable. Senior faculty have as much to learn from trainees as the other way around. In an era in which it is increasingly difficult for an individual clinician to keep up with all of the advances, faculty stand to gain valuable insights about technology, clinical trials, new drugs, and developments from trainees while sharing with them something common to all good medicine: how to pair the knowledge gained from books with the wisdom of experience. This approach turns out to reward the mentor and the trainee.
Faculty Are Key to Realizing a Career Path
A few years ago, I realized that all of my trainees and residents were asking me for advice that I had not anticipated dispensing. There was no protocol I could teach and no flow chart I could point to. It was not something that was contained in any supervisor training module I had completed, but it was definitely something I had pondered in my own life and through my writings.
Their questions concern where to work, how much to work, whom to work with, how to merge various interests, and, in particular, how to reconcile children with a career.
The first trainee I met wanted to interrupt her training to have a child, something that she felt would be frowned upon by her institution. The second trainee was a man who was having second thoughts about pursuing a full-bore academic career because he wanted to spend time with his family and care for his aging parents. His views had been met with some alarm from senior faculty, and he was confused. A third trainee was attracted to a community practice but was feeling pressured to pursue a higher degree that did not interest her. She was caught in a dilemma and asked whether following her heart would compromise her future.
We owe it to our trainees to help them strive for excellence without being needlessly exhausted by the pursuit of perfection. A good relationship makes room for all kinds of musings to help trainees arrive at a decision that is in their best interest. Academic institutions, where trainees are based, are biased toward subspecialization, higher degrees, and research. Obviously, this is important to the advancement of medicine, and many trainees are themselves driven to influence change, especially when they are inspired by exceptional coworkers. However, the best advisors are aware of their own biases and acknowledge that there are many roads to a successful and fulfilling career. They have the confidence to help trainees take a different route and introduce them to professionals who have done things differently. In fact, listening attentively to trainees articulate their goals and asking interested questions may be the best way of helping them arrive at their own considered conclusion.
The most memorable thing a mentor did for me was seat me next to an accomplished writer at a faculty dinner. That one dinner more than 10 years ago fired my imagination and inspired me to continue writing. The writer and I are still in touch, and it has been a most gratifying association.
In supervising trainees, I make no secret of the fact that I did not follow an academic track, because at the time, it interfered with my plans to have children, especially after my first pregnancy ended in a miscarriage and upset my well-laid plans for my future. It took me a long time to find my feet as faculty, and then, I was still keen to stay a writer.
I view my writing in the mainstream press as an extension of bedside medicine, and it has allowed me to make a difference on a larger scale than I had imagined. Being able to express my creativity has almost certainly aided my longevity in a career in which burnout is increasingly common.
As a mentor, I do not have a neat narrative of career development but am always surprised when my story of self-discovery is said to normalize the experience of other trainees. I have learned that we can shape the future of our trainees by being unstinting in our efforts to share our achievements and disappointments. We should also strive to introduce trainees to professionals with different experiences and perspectives so that they are exposed to the many different ways of being a good doctor. This is the kind of advice and practical support that many trainees remember into the future, and it is how we will help them discover their own meaning in one of the most meaningful professions within medicine.
We Must Debrief After Critical Incidents
As a trainee, I remember losing a patient unexpectedly and feeling rather guilty. As an attending and I climbed the stairs to a meeting, I told her the news, which she greeted with a cursory remark before continuing to wolf down her sandwich. Another time, I emailed a social worker to tell her that a young patient had died and was mildly chided for having sent her bad news on her holiday. These two incidents left me utterly dismayed and thinking that it was somehow imprudent to mention difficult cases. Of course, with many years of experience, I have realized that our colleagues are not uncaring; it is just that they are busy, hungry, distracted, or themselves upset. However, our emotional survival in a difficult profession depends on mutual kindness from those who share our experiences most closely.
The practice of oncology means colliding regularly with critical incidents. Every oncologist walks a tightrope between being too immersed in the tragedies of our patients and not being involved enough. The former risks ineffective management, the latter inadequate care. I often think that our trainees watch us most closely not when we are debating treatment protocols but when we are handling the far trickier aspects of communicating with patients and with each other about difficult things.
At their stage, trainees have all of the emotions we do but a limited catalog of experiences to use as an anchor. They are still searching for ways to navigate new and challenging experiences: how to break news to a patient as young as themselves, what to do when every plan fails, and how to handle conflict with an attending.
Experienced oncologists have typically seen one of everything and thus fail to attach the same level of significance to an incident. This happened to me recently when I counseled a first-time mother in intensive care about her rapidly advancing cancer that carried a poor prognosis. I fleetingly thought of the trainee present at the meeting but had to rush off to my next meeting. Sure enough, a nurse noticed the trainee’s distress, followed by the debriefing that I had intended. In hindsight, I should have let the trainee know that we would talk later.
Effective supervision involves remembering our own training days, anticipating emotion, and reflecting alongside our trainees. This helps them develop skills, professionalism, as well as the important awareness that we can all struggle with difficult situations. Trainees are often reluctant to be perceived as “bothering” oncologists with nonclinical concerns, but we must believe that trainees deserve the same holistic care that we aspire to give our patients. An active approach is required to recognize critical events, be open with our impressions and feelings, and provide a framework for discussion. These shared experiences can help us grow better in every phase of our career.
We Have a Duty to Address Bullying and Harassment in Medicine
Bullying and harassment in medicine are real. The 2013 Australian beyondblue survey of more than 40,000 doctors revealed 10% of doctors cited difficult relationships with senior colleagues as a source of stress, and 4.5% specifically noted workplace bullying as a source of stress. Oncologists and oncology trainees and residents had higher rates of complaints than the average, and overall, women had more concerns about bullying than men. A 2014 systematic review and meta‐analysis of harassment and discrimination in medical training, which reviewed 59 studies from a range of countries, found that approximately 63% of trainee doctors had experienced some form of harassment, with verbal harassment being the most common type of abuse. The extent of the problem may be underreported due to a fear of career repercussions, a lack of confidence in the complaints resolution process, or normalization of the issue.
Questioning the fortitude of doctors is to miss the point. Trainees can become resilient, agile, and resourceful without being subjected to bullying, harassment, or discrimination. These issues occur for no one reason but often due to a complex interplay of personal, professional, and institutional demands. But we must realize that such conduct does not strengthen anyone—rather, it diminishes us all. We will not create better oncologists through demoralization.
A very important task, therefore, for all oncologists, not only supervisors, is to individually support our trainees but also be prepared to defend them against unacceptable conduct from others and empower them to take appropriate action. This is undeniably tricky, but it is the way to effect real change. There is a power imbalance between trainees and specialists as well as trainees and the institution, and we must always be sensitive to this. Helping trainees who silently tolerate high levels of stress and distress poses an ethical dilemma to clinicians. Many institutions now have more developed and visible lines of reporting and action that trainees can be encouraged to use. However, attentive listening, genuine concern, and regular reassurance often prove the catalyst for future action.
We Go Nowhere Without Good Role Models
“Setting an example is not the main means of influencing others; it is the only means,” said Albert Einstein. Our own experiences should tell us that we are far more likely to remember how our colleagues and senior faculty behaved than what they taught us. Our trainees look up to us and are always watching us. Of course, technical skills matter, but good role models realize that they are simultaneously involved in teaching a hidden curriculum, although this may be a misnomer because our trainees are always observing us for our humanistic tendencies and ethical conduct. How we behave at the bedside, how we treat vulnerable relatives, and how we speak about each other and about our patients all matter greatly.
The most memorable teachers are not the people who were most brilliant, but those who paired their academic greatness with humility, good will, and genuine concern for human welfare.
One of my mentors died some years ago. He was in his mid-fifties when he sustained a fatal heart attack while getting ready for rounds. When he died, all of the rosters were quickly redone, as they had to be, but what people still remember him for was his kindness and concern for trainees. At his eulogy, a trainee recalled that when she failed her examinations, he was the only faculty to call her and offer to teach her. She felt that she owed her success to the confidence he gave her. At the same eulogy, a patient’s wife recalled that he was the only doctor to sit down next to her in intensive care and slowly explain what to expect. I decided that his wild popularity as a mentor came down to the fact that he was interested in more than the doctor-patient relationship; he actually thought about the doctor’s relationship with the patient, relatives, and the wider community. Preparing our trainees for the future may seem less challenging if we decided to examine our own attitudes.
In conclusion, trainee supervision is a privilege that can be made enjoyable by attending to a few key elements. There is more to supervision than handing down knowledge. Helping trainees define a career path involves active listening and a broad perspective about the different ways that medicine can serve people. Critical incidents need debriefing, and unacceptable conduct including bullying and harassment will be stamped out when faculty band together to stamp it out. Finally, nothing happens without a commitment to being a good role model, whom trainees would be proud to emulate no matter what route they decide to take.
ASCO University Education Essentials for Oncology Fellows: https://university.asco.org/education-essentials-oncology-fellows-eeof
Conquer Cancer Foundation IDEA: https://www.conquer.org/international-development-and-education-award
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST AND DATA AVAILABILITY STATEMENT
Disclosures provided by the authors and data availability (if applicable) are available with this article at DOI https://doi.org/10.1200/EDBK_238577.
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc.
No relationship to disclose
Maria Teresa Bourlon
Honoraria: Tecnofarma Tecnofarma
Consulting or Advisory Role: Asofarma Bayer Bristol-Myers Squibb Eisai Janssen Oncology MSD Oncology Novartis
Speakers' Bureau: Asofarma Bayer Bristol-Myers Squibb Eisai Ipsen Janssen Oncology MSD Oncology
Expert Testimony: Asofarma
Travel, Accommodations, Expenses: Asofarma Janssen-Cilag MSD Oncology
Honoraria: Astellas Pharma AstraZeneca Bristol-Myers Squibb Merck Novartis Pfizer Roche
Consulting or Advisory Role: Astellas Pharma Bristol-Myers Squibb MSD Oncology Pfizer
Research Funding: Bristol-Myers Squibb (Inst) Merck Serono (Inst) Novartis (Inst)
Travel, Accommodations, Expenses: Amgen Merck Serono
1.Dittrich C, Kosty M, Jezdic S, et al. ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology Edition 2016. ESMO Open. 2016;1:e000097.
2.Ponce-De-León-Rosales S, Gabilondo-Navarro F, Rull-Rodrigo J, et al. [The Salvador Zubirán National Institute of Medical Sciences and Nutrition]. Rev Invest Clin. 2010;62:97-99.
3.Mathew A. Global survey of clinical oncology workforce. J Glob Oncol. 2018;4:1-12.
4.Hlubocky FJ, Back AL, Shanafelt TD. Addressing burnout in oncology: why cancer care clinicians are at risk, what individuals can do, and how organizations can respond. Am Soc Clin Oncol Educ Book. 2016;35:271-279.
5.American Society of Clinical Oncology. Grants & awards. https://www.asco.org/research-progress/grants-awards. Accessed February 11, 2019.
6.Lim V-S, Adjei AA. ASCO Connection: Grant opportunities for non-U.S. citizens: Where to look and who to contact. https://connection.asco.org/tec/grants-awards/grant-opportunities-non-us-citizens-where-look-and-who-contact. Accessed February 11, 2019.
7.European Society for Medical Oncology. Research funding opportunities. https://www.esmo.org/Research. Accessed February 11, 2019.
8.American Society of Hematology. ASH awards. http://www.hematology.org/Awards/Career-Training/3061.aspx. Accessed February 11, 2019.
9.Glodé LM. ASCO Connection: A continuing commitment: A look into the IDEA Program. https://connection.asco.org/magazine/exclusive-coverage/continuing-commitment-look-idea-program. Accessed February 11, 2019.
10.Rampell C. How much do doctors in other countries make? https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/. Accessed February 11, 2019.
11.Frenk J, Gómez-Dantés O, Knaul FM. A dark day for universal health coverage. Lancet. 2019;393:301-303.
12.Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014;32:678-686.