Flailing MD/PhD Thinking of Back-up Career

[ONC2023]

Hello, everyone -

I have a story as old as time (or at least as old as the NIH MSTP training pathway), and I just wanted help getting some perspective. Highlights:
- MD/PhD graduate late 2010s
- did a fast-track IM residency
- and now in a second year of a heme-onc fellowship, physician-scientist track

I didn't match at my dream place by any stretch for fellowship, but it had a critical mass of research and is a place with some great scientists. The program also tried to recruit me and promised me support because of my research background, including money and a tech, for my research endeavors. This is where things kind of fell apart.

First, the program has never mentioned this support again, and when I brought it up gently, no one did anything. The promise of support wasn't in writing, so I've basically accepted this as a lesson that nothing means anything unless it's written.

Second, I started the second year of my fellowship (research years, 90% protected) with the absolutely wrong mentor. He was superficially nice but used me as an administrative assistant and clinical research coordinator and was just generally very inconsiderate of me. I did the most utterly menial, non-fellow work imaginable. To be clear - I don't have opposition to doing things to help, but it was clear he didn't have any robust research program with sufficient staff for me to join and that I was going to be used as a tech/clinical research coordinator/admin.

I started over in a new lab that's much more considerate and well-organized. I have two exciting projects but lab work of course takes forever to gain momentum so I am 10 months into my 3 year post-doc and have absolutely nothing to show for it. Lesson learned. I know 10 months isn't a lot, but when you're as old as I am in this training pathway, it feels like a lot.

Which brings me to my question: in terms of having a back-up plan if my scientific career fails, which it looks like it might, what level of specialization is too much clinically? If I leave my fellowship trained to see every GI tumor in the lumen + pancreas/gallbladder/cholangio/HCC but utterly unable of treating any other organ system (much less malignant heme), do you think I am doing a disservice to myself? I essentially want to have a purely clinical career available to me if I cannot start a scientific career in industry or academia.

Thank you very much for any input.

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[caulfield830]

Hello, everyone -

I have a story as old as time (or at least as old as the NIH MSTP training pathway), and I just wanted help getting some perspective. Highlights:
- MD/PhD graduate late 2010s
- did a fast-track IM residency
- and now in a second year of a heme-onc fellowship, physician-scientist track

I didn't match at my dream place by any stretch for fellowship, but it had a critical mass of research and is a place with some great scientists. The program also tried to recruit me and promised me support because of my research background, including money and a tech, for my research endeavors. This is where things kind of fell apart.

First, the program has never mentioned this support again, and when I brought it up gently, no one did anything. The promise of support wasn't in writing, so I've basically accepted this as a lesson that nothing means anything unless it's written.

Second, I started the second year of my fellowship (research years, 90% protected) with the absolutely wrong mentor. He was superficially nice but used me as an administrative assistant and clinical research coordinator and was just generally very inconsiderate of me. I did the most utterly menial, non-fellow work imaginable. To be clear - I don't have opposition to doing things to help, but it was clear he didn't have any robust research program with sufficient staff for me to join and that I was going to be used as a tech/clinical research coordinator/admin.

I started over in a new lab that's much more considerate and well-organized. I have two exciting projects but lab work of course takes forever to gain momentum so I am 10 months into my 3 year post-doc and have absolutely nothing to show for it. Lesson learned. I know 10 months isn't a lot, but when you're as old as I am in this training pathway, it feels like a lot.

Which brings me to my question: in terms of having a back-up plan if my scientific career fails, which it looks like it might, what level of specialization is too much clinically? If I leave my fellowship trained to see every GI tumor in the lumen + pancreas/gallbladder/cholangio/HCC but utterly unable of treating any other organ system (much less malignant heme), do you think I am doing a disservice to myself? I essentially want to have a purely clinical career available to me if I cannot start a scientific career in industry or academia.

Thank you very much for any input.

Don't worry. MANY MD/PhDs have been in your shoes. Starting anew in research at a new institution is a daunting task. Don't beat yourself about it. We all know that LUCK plays a large part in succeeding in research.
You can just become an academic GI medical oncologist like almost all the other clinical attendings at your institution with some translation research/clinical trial on the side - this is an easy and valid backup plan.

 

[gutonc]

Hello, everyone -

I have a story as old as time (or at least as old as the NIH MSTP training pathway), and I just wanted help getting some perspective. Highlights:
- MD/PhD graduate late 2010s
- did a fast-track IM residency
- and now in a second year of a heme-onc fellowship, physician-scientist track

I didn't match at my dream place by any stretch for fellowship, but it had a critical mass of research and is a place with some great scientists. The program also tried to recruit me and promised me support because of my research background, including money and a tech, for my research endeavors. This is where things kind of fell apart.

First, the program has never mentioned this support again, and when I brought it up gently, no one did anything. The promise of support wasn't in writing, so I've basically accepted this as a lesson that nothing means anything unless it's written.

Second, I started the second year of my fellowship (research years, 90% protected) with the absolutely wrong mentor. He was superficially nice but used me as an administrative assistant and clinical research coordinator and was just generally very inconsiderate of me. I did the most utterly menial, non-fellow work imaginable. To be clear - I don't have opposition to doing things to help, but it was clear he didn't have any robust research program with sufficient staff for me to join and that I was going to be used as a tech/clinical research coordinator/admin.

I started over in a new lab that's much more considerate and well-organized. I have two exciting projects but lab work of course takes forever to gain momentum so I am 10 months into my 3 year post-doc and have absolutely nothing to show for it. Lesson learned. I know 10 months isn't a lot, but when you're as old as I am in this training pathway, it feels like a lot.

Which brings me to my question: in terms of having a back-up plan if my scientific career fails, which it looks like it might, what level of specialization is too much clinically? If I leave my fellowship trained to see every GI tumor in the lumen + pancreas/gallbladder/cholangio/HCC but utterly unable of treating any other organ system (much less malignant heme), do you think I am doing a disservice to myself? I essentially want to have a purely clinical career available to me if I cannot start a scientific career in industry or academia.

Thank you very much for any input.

In March of my last year in your shoes, I was told (after a change in division leadership) that the position I'd been promised by the (hastily departed) former chief was not going to materialize and that they could only offer me a clinical position in a community-based 'academ-ish' setting.

Up to that point, I'd been doing 100% GI clinic and actively avoiding anything above the diaphragm (unless it was a met). For the last 3 months of fellowship I dropped my (not particularly stellar anyway...but that was on me, not my mentor) research and spent that time in Breast, Thoracic, Prostate and benign heme clinics instead.

11 years out, it was the best decision I could have possibly made. You'll have a pretty decent idea in a year or so which way things are going to bend. You'll be able to sort it out and get on with your life from there no matter which way it goes.

 

[ONC2023]

Hi Caulfield and GutOnc.

Just wanted to say that I read your reply a while back and it provided me with some sense of relief, so thank you.

Instead of making a new thread I wanted to ask a followup question for anyone who sees this.

I’ve seen a lot of GI + GU jobs. Is GU the most common paired organ system with GI? The reason I ask is that I am considering talking to my PI and program director and telling them that I want to spend a bit of extra time broadening my clinical skills while still seeing if I can get a scientific career off the ground. I’m sure they’ll be fine with it, but I wanted to see which organ system you’d pair with GI. I’m probably most interested in thoracic as a second organ system, but I’ve never seen a GI + thoracic position.

Thanks.

 

[gutonc]

Hi Caulfield and GutOnc.

Just wanted to say that I read your reply a while back and it provided me with some sense of relief, so thank you.

Instead of making a new thread I wanted to ask a followup question for anyone who sees this.

I’ve seen a lot of GI + GU jobs. Is GU the most common paired organ system with GI? The reason I ask is that I am considering talking to my PI and program director and telling them that I want to spend a bit of extra time broadening my clinical skills while still seeing if I can get a scientific career off the ground. I’m sure they’ll be fine with it, but I wanted to see which organ system you’d pair with GI. I’m probably most interested in thoracic as a second organ system, but I’ve never seen a GI + thoracic position.

Thanks.

Can't really comment on that. I think GU gets paired with a lot of stuff (I've seen it paired with GI, GYN, melanoma and sarcoma). I would say that your best bet is to just spend some time in various other clinics (thoracic, GU, breast, whatever) so that you can get an honest LOR from somebody in one of those sub-specialties for a job you're interested in.

 

[ONC2023]

Thank you, appreciate it. I am going spend some time rotating in GU, thoracic, etc

The decision I need to make now is heme board eligibility. The second year of my ABIM physician-scientist fellowship has left such a bitter taste that I'm beginning to consider giving up my scientific career. I have just under two years left in the research pathway until I'm eligible in med onc. I am considering leaving the research pathway and just finishing the next two years with clinical work so I'll be double board eligible and able to do private practice if I want.

Never thought I'd say that… ever. I’m going to talk to my program director about what it would look like to leave the research pathway.

 

[gutonc]

Thank you, appreciate it. I am going spend some time rotating in GU, thoracic, etc

The decision I need to make now is heme board eligibility. The second year of my ABIM physician-scientist fellowship has left such a bitter taste that I'm beginning to consider giving up my scientific career. I have just under two years left in the research pathway until I'm eligible in med onc. I am considering leaving the research pathway and just finishing the next two years with clinical work so I'll be double board eligible and able to do private practice if I want.

Never thought I'd say that… ever. I’m going to talk to my program director about what it would look like to leave the research pathway.

I'm not double board eligible. I have only ever done community based clinical practice. Nobody cares.

in retrospect, it might have been nice to do a little extra benign heme during training, but not a full 6-12 months...maybe 6-12 days.

 

[caulfield830]

Hi Caulfield and GutOnc.

Just wanted to say that I read your reply a while back and it provided me with some sense of relief, so thank you.

Instead of making a new thread I wanted to ask a followup question for anyone who sees this.

I’ve seen a lot of GI + GU jobs. Is GU the most common paired organ system with GI? The reason I ask is that I am considering talking to my PI and program director and telling them that I want to spend a bit of extra time broadening my clinical skills while still seeing if I can get a scientific career off the ground. I’m sure they’ll be fine with it, but I wanted to see which organ system you’d pair with GI. I’m probably most interested in thoracic as a second organ system, but I’ve never seen a GI + thoracic position.

Thanks.

I am at an academic center where people try to subspecialize within GI and GU, so I didn't see any GI + other pairings. As the way oncology is getting sub sub-specialized, I doubt academic centers would commonly hire a doc for combo subspecialty like that. In private practice, what cancer you decide to see is completely up to you and your group/employer. Learning broadly in fellowship about every cancer is probably the best preparation, with emphasis on GI, GU, breast, and lung. Don't worry, you'll be fine. There are so many MD/PhDs in every corner of the globe doing fine. Running a lab has become much more difficult these days; even the famous big labs are having a difficult time recruiting postdocs as fresh PhDs are leaving for industry etc., getting paid multiple times the postdoc salary. So I'm not regretful of having left the traditional physician-scientist path (and not doing postdoc forever) and that I just became an academic oncologist.

 

[nakedmolerat]

caulfield I am also in your boat- just commiserating with you- also a graduate of an MSTP in late 2010s- did IM residency and now i am in my 3rd year of my research (post-doc) fellowship and have not produced any meaningful data yet- doing clinical work 100% seems much easier than going down the lab-PI path-

 

[gutonc]

caulfield I am also in your boat- just commiserating with you- also a graduate of an MSTP in late 2010s- did IM residency and now i am in my 3rd year of my research (post-doc) fellowship and have not produced any meaningful data yet- doing clinical work 100% seems much easier than going down the lab-PI path-

It is infinitely easier. It also needs to be the right thing for you.

 

[nakedmolerat]

It is infinitely easier. It also needs to be the right thing for you.

thank you gutonc- its just so relieving to hear from other mstp grads that it is definitely "OK" to choose to go into clinical medicine (whereas people at my institution think that i am a failure of the mstp if I either 1) go into industry or 2) practice 100% clinical medicine

 

[gutonc]

thank you gutonc- its just so relieving to hear from other mstp grads that it is definitely "OK" to choose to go into clinical medicine (whereas people at my institution think that i am a failure of the mstp if I either 1) go into industry or 2) practice 100% clinical medicine

My school actually had me give a talk to their MD-PhDs a couple of years ago as someone who had ultimately chosen a fully clinical career. I was initially like "I don't think you want me to talk, I'm 100% clinical" but they specifically wanted me to talk because I was 100% clinical. Was a refreshing approach.

 

[ONC2023]

Hi all - it's me again. Appreciated the prior messages. I read them last month.

An update:

- I met with my PI and program director this past month. Basically told my PI I'm thinking of going more clinical. My salary is paid for by a grant I got and the hospital, so I felt ok saying this to him. I'm also helping the lab a lot with some needs they have that as a clinical fellow I am suited for, so I feel good that I'm helping out regardless. He basically said sure, whatever I want. I am still working on two projects and will see how I feel about them this spring. I think I'm going to give it a shot, and at the very least, they would help me get a translational/faculty spot if I chose to stay in non-wet lab academia. But I have basically 100% lost interest in wet lab science - it just doesn't make me happy any more, and this program helped me feel this way. So I am slightly bitter. (Not my current PI though - he's great, actually).

- I also met with my PD. He said again - basically I can do what I want, but that because my GME spot isn't a double-board spot but is a PSTP spot, I can't double board unless we fight for the hospital to change it, which will be very unlikely because that would cost them money. I didn't expect them to be generous because there's nothing in my experience here that suggests they would be generous in any capacity with trainees. I know it's been mentioned before that single onc boarded should be ok for jobs.

Sorry for length of post but this is the part I really wanted feedback on. I am going to dramatically up my clinic time in the last 20 months of fellowship. I want to leave fellowship ready to take any of the following type of jobs:
- a translational, true-GI specific disease job (GI has been my focus since my PhD, and by far the organ system I am most comfortable with overall and the one all my grants/publications are in)
- an academic-affiliated clinic where I see maybe two or three organ systems. To accomplish this, I'm spending time in GU and thoracic on top of GI. Will eventually spend some time in breast clinic as well.
- a community-ish job where I see everything except acute leukemia

It's the last one I need help with. Which parts of hematology should I focus on if I want to keep third option of a community-ish job (without acute leuks) a possibility? My program is specialized so there's a CLL clinic; myeloma clinic; amyloidosis clinic; etc. And everything is clinical trials, etc. So I have no idea what community hematology (benign and non-acute leuk malignant heme) looks like. Also, looks like I'm going to need to re-learn bone marrow biopsies, which I am not looking forward to.

Thanks again for the feedback.

 

[Mehena]

It's the last one I need help with. Which parts of hematology should I focus on if I want to keep third option of a community-ish job (without acute leuks) a possibility? My program is specialized so there's a CLL clinic; myeloma clinic; amyloidosis clinic; etc. And everything is clinical trials, etc. So I have no idea what community hematology (benign and non-acute leuk malignant heme) looks like. Also, looks like I'm going to need to re-learn bone marrow biopsies, which I am not looking forward to.

I'd lean towards myeloma first. Then, take a look at the clinic schedules of your leukemia attendings – some of them might be handling a mix bag of AML, MDS, cytopenia, iron deficiency, LGL, myelofibrosis, and so on. Reviewing smears together and planning follow-ups could be really helpful. If they're mostly focused on clinical trials and AML, consider checking out a good lymphoma clinic. No need to spend time in a benign heme clinic, your consult month should have you covered.

 

[nakedmolerat]

Hi all - it's me again. Appreciated the prior messages. I read them last month.

An update:

- I met with my PI and program director this past month. Basically told my PI I'm thinking of going more clinical. My salary is paid for by a grant I got and the hospital, so I felt ok saying this to him. I'm also helping the lab a lot with some needs they have that as a clinical fellow I am suited for, so I feel good that I'm helping out regardless. He basically said sure, whatever I want. I am still working on two projects and will see how I feel about them this spring. I think I'm going to give it a shot, and at the very least, they would help me get a translational/faculty spot if I chose to stay in non-wet lab academia. But I have basically 100% lost interest in wet lab science - it just doesn't make me happy any more, and this program helped me feel this way. So I am slightly bitter. (Not my current PI though - he's great, actually).

- I also met with my PD. He said again - basically I can do what I want, but that because my GME spot isn't a double-board spot but is a PSTP spot, I can't double board unless we fight for the hospital to change it, which will be very unlikely because that would cost them money. I didn't expect them to be generous because there's nothing in my experience here that suggests they would be generous in any capacity with trainees. I know it's been mentioned before that single onc boarded should be ok for jobs.

Sorry for length of post but this is the part I really wanted feedback on. I am going to dramatically up my clinic time in the last 20 months of fellowship. I want to leave fellowship ready to take any of the following type of jobs:
- a translational, true-GI specific disease job (GI has been my focus since my PhD, and by far the organ system I am most comfortable with overall and the one all my grants/publications are in)
- an academic-affiliated clinic where I see maybe two or three organ systems. To accomplish this, I'm spending time in GU and thoracic on top of GI. Will eventually spend some time in breast clinic as well.
- a community-ish job where I see everything except acute leukemia

It's the last one I need help with. Which parts of hematology should I focus on if I want to keep third option of a community-ish job (without acute leuks) a possibility? My program is specialized so there's a CLL clinic; myeloma clinic; amyloidosis clinic; etc. And everything is clinical trials, etc. So I have no idea what community hematology (benign and non-acute leuk malignant heme) looks like. Also, looks like I'm going to need to re-learn bone marrow biopsies, which I am not looking forward to.

Thanks again for the feedback.

kudos for figuring this out for yourself! I also feel the same way about wet bench work- and have decided to go the ClinicianEducator route- and am also applying to 100% clinical positions in my field-

 

[gutonc]

It's the last one I need help with. Which parts of hematology should I focus on if I want to keep third option of a community-ish job (without acute leuks) a possibility? My program is specialized so there's a CLL clinic; myeloma clinic; amyloidosis clinic; etc. And everything is clinical trials, etc. So I have no idea what community hematology (benign and non-acute leuk malignant heme) looks like. Also, looks like I'm going to need to re-learn bone marrow biopsies, which I am not looking forward to.

Thanks again for the feedback.

Myeloma and lymphoma are going to be the highest yield. As would a benign heme clinic if you have that option.

Marrows are easy. I don't think I did any my last 2+ years of fellowship and didn't do many of them my first 10 years in practice because we had a good IR group that would get people in quickly. I do 2 or 3 a month in my new job because IR is over an hour away and schedules out 2-3 weeks.

 

[ONC2023]

Thanks all - I really do appreciate the needed advice. My program, despite being ostensibly one of those “big name” tertiary academic centers, just has abysmal mentoring - I say this as someone who is very self-critical and would normally blame myself first. But in this case, I feel very comfortable saying it’s the program’s fault.

I’m going to really dig into thoracic and GU cancers these next few months and then add some heme clinics with the focus you all mentioned.

I’m also gratified to read across the forum that, with some exceptions, I should be ok looking for jobs with single board oncology for the most part. I intend on taking onc boards in the fall of my last year (4th year, physician-scientist pathway). So hopefully being board certified already in fellowship will help too.

The thing I’m truly struggling with right now is when I just completely drop research - I don’t mean pull back, just drop it all. Entirely. It really doesn’t make me happy anymore. And I think about abandoning it literally every day. I’d rather just dedicate myself to being the best doctor I can be instead of spending the next 1.5 years trying to muster interest in some projects that won’t be anywhere near ready to publish by the time I finish fellowship - especially since I am absolutely sure I am not pursuing a lab career anymore.

My goal a few years ago was all about an R01 and running a lab. Now I honestly just want a job at well-run clinic that isn’t triple booked at the same time slot where I can provide good care and make enough to raise a family.

Honestly, don’t mind me. I’m mostly just venting here…

 

[caulfield830]

Thanks all - I really do appreciate the needed advice. My program, despite being ostensibly one of those “big name” tertiary academic centers, just has abysmal mentoring - I say this as someone who is very self-critical and would normally blame myself first. But in this case, I feel very comfortable saying it’s the program’s fault.

I’m going to really dig into thoracic and GU cancers these next few months and then add some heme clinics with the focus you all mentioned.

I’m also gratified to read across the forum that, with some exceptions, I should be ok looking for jobs with single board oncology for the most part. I intend on taking onc boards in the fall of my last year (4th year, physician-scientist pathway). So hopefully being board certified already in fellowship will help too.

The thing I’m truly struggling with right now is when I just completely drop research - I don’t mean pull back, just drop it all. Entirely. It really doesn’t make me happy anymore. And I think about abandoning it literally every day. I’d rather just dedicate myself to being the best doctor I can be instead of spending the next 1.5 years trying to muster interest in some projects that won’t be anywhere near ready to publish by the time I finish fellowship - especially since I am absolutely sure I am not pursuing a lab career anymore.

My goal a few years ago was all about an R01 and running a lab. Now I honestly just want a job at well-run clinic that isn’t triple booked at the same time slot where I can provide good care and make enough to raise a family.

Honestly, don’t mind me. I’m mostly just venting here…

You can drop research right now, BUT if you want to pursue your option 1 (academic GI onc), you will need some stuff to talk about at your job talk. It doesn't need to be bench research, but some clinical research, QI stuff or something. Otherwise, it will be difficult to get an academic GI onc job. Go to your institution's job candidate talks (it's going on right now) and see if what you have would be enough. For option 2 &3, you don't need research.

 

[ONC2023]

Hi all. Thank you Caulfield.

I'm basically entirely out of lab, and even the small amount I'm in lab is too much. This is what makes me confident quitting the physician-scientist path was the right thing for me. I have an entirely non-wet lab project that I can use for my job talks if I apply for an academic GI spot, and if I go for a non-academic spot, my research will be irrelevant.

I have 17 months left in fellowship, and I'm rotating heavily through GI, GU, and breast right now and will add thoracic later this year.

Question: just how many patients should a clinical fellow be aiming to see? This week is going to look like:
- Monday, GI: 5 follow-up (chemo, scan reviews)
- Tuesday, GI: 3 new patient visits in GI with 2 follow-ups
- Wednesday, GU (by far the most educational clinic with the best attending): 3 new patients visits with 7-8 follow-ups
- Thursday, breast: 7-8 follow-ups (these range from patients on tamoxifen for 4 years to stage IV HR+/HER- on AI/CDKi)
- Friday, breast: 1 new (usually high-risk, chemoprevention) with <5 follow-ups

Does anyone have a sense if this is enough from your past training? Any fellows out these struggling to get enough quality clinical exposure?

Thanks again.

 

[gutonc]

Hi all. Thank you Caulfield.

I'm basically entirely out of lab, and even the small amount I'm in lab is too much. This is what makes me confident quitting the physician-scientist path was the right thing for me. I have an entirely non-wet lab project that I can use for my job talks if I apply for an academic GI spot, and if I go for a non-academic spot, my research will be irrelevant.

I have 17 months left in fellowship, and I'm rotating heavily through GI, GU, and breast right now and will add thoracic later this year.

Question: just how many patients should a clinical fellow be aiming to see? This week is going to look like:
- Monday, GI: 5 follow-up (chemo, scan reviews)
- Tuesday, GI: 3 new patient visits in GI with 2 follow-ups
- Wednesday, GU (by far the most educational clinic with the best attending): 3 new patients visits with 7-8 follow-ups
- Thursday, breast: 7-8 follow-ups (these range from patients on tamoxifen for 4 years to stage IV HR+/HER- on AI/CDKi)
- Friday, breast: 1 new (usually high-risk, chemoprevention) with <5 follow-ups

Does anyone have a sense if this is enough from your past training? Any fellows out these struggling to get enough quality clinical exposure?

Thanks again.

There's never enough training

There are no wrong answers to this question, but I think there's a clear right one (which is a much different answer than I would have given to this question 3, 5 or 10 years ago.

As I see it, there are 3 ways to answer this question.
1. See as many cases as you can. There are no "boring" or "dumb" cases. See it all since you'll never get the chance to see it again with the support you have now. This may mean that you skip out on the 4th AI/tamoxifen Q6 mos in year 4 follow up of the day in order to see a new met TNBC, or maybe to go help your co-fellow who's drowning on the inpatient consult service. (This is the answer I would have given you 5 years ago)

2. See the "high yield" cases. This may sound like I'm saying "only see the cool stuff" or "only see new patients", but I'm not. Your attendings, if they care at all about your education, rather than caring about how you help them move the meat (and I had both kinds in my fellowship) will curate their schedule to give you the high yield cases as they understand it. It might not be the cases you think are high yield, but the attendings who do this will understand what that means for you (compared to your co-fellow who's planning an academic wet-lab position working on immune infiltrates in early stage breast cancer). As long as you trust the attending, trust the process. (This is the answer I would have given 10 years ago.)

3. See as many patients as you can. This is different than cases. Approach each room you walk into not as "Stage IA ER+ breast on tamoxifen year 4 of 10" but as "42yo woman with 3 kids, a BRCA1 mutation, a spouse who left when she got her breast cancer diagnosis and severe RA on remicade, struggling with the SEs of tamoxifen and wondering when she can stop it". The first one is easy. You can look that up, or remember a lecture, or it becomes second nature after awhile. The second one, exact same person walking into the clinic, is much different and managing that can be learned, but can't be taught. Treating cancer is easy, you can literally look it all up in a matter of minutes. Being a good oncologist is hard and means a different approach to every single person who walks into the room. If you're lucky, you'll have one or two attendings that you can learn how to do this from. You'll also probably figure out a lot of ways not to do this from the rest of your attendings.

You can probably guess which of the 3 approaches I would recommend you take. Note that I didn't answer your actual question, which was about numbers, because I think you can learn more from 3 or 4 quality interactions as you can from 12 where you're just checking the boxes.

As a real life example, yesterday I had 4 new Stage I ER+ breast cancer patients. All in a 2 year age range (72-74). On paper, it's a slam dunk, here's your letrozole and your rad onc referral, come see me in 3 months. But the reality was much different.

Patient 1: clinically node negative, having surgery tomorrow, otherwise healthy, but had a panic attack coming into the office because her husband died about a year ago from met prostate and was a patient of the clinic (before I joined the practice).

Patient 2: Stage IV CKD, CAD with exertional CP needing a cath but unable to do so because of kidney disease. Needs radiation due to LN+ disease but cardiology concerned given cardiac issues and left sided breast cancer

Patient 3: Pre-existing osteoporosis not responding to bisphosphonates and recent hip fracture.

Patient 4: "Chemo killed grandma, I'm only taking turkey tail mushrooms"

 

[ShuperNewbie]

^This is sage advice.

Volume is not important right now. Volume will come with time. It's like any famous chef will tell you, don't learn to chop the onion fast when you're first starting out. Learn to chop the onion. The speed will come.

The volume you're seeing is more than reasonable for a fellow. More importantly, learning how to think on your feet when encountering complex psychosocial or medical situations is the name of the game moving forward.

Also, considering the job market this year, the last thing you should need to worry about is finding a job (even an academic job) that pays enough to raise a family. From the sound of it, you're an excellent candidate who should not have trouble finding a good job, so put that out of your head as a worry. Focus on your own growth.

 

[bobsmith]

Patient 4: "Chemo killed grandma, I'm only taking turkey tail mushrooms"

So weird, I've also had a string of these recently

(more than usual, that is)

 

[gutonc]

So weird, I've also had a string of these recently

(more than usual, that is)

This is 25% of my patient panel.

 

[ShuperNewbie]

I feel that. I had a patient the other day who brought in his "doctor friend" (a naturopath) to argue that we were pumping poison into him and that he didn't have cancer. I tried to explain the principle behind adjuvant therapy for 40 minutes but it's tough to talk when you just constantly get shouted over lol. If AI could help me with these conversations I'd pay extra for that.

 

[gutonc]

I feel that. I had a patient the other day who brought in his "doctor friend" (a naturopath) to argue that we were pumping poison into him and that he didn't have cancer. I tried to explain the principle behind adjuvant therapy for 40 minutes but it's tough to talk when you just constantly get shouted over lol. If AI could help me with these conversations I'd pay extra for that.

I give these people one visit like that. I give them the data, explain why I recommend the therapy I did, and then I let them make their choice. I used to spend waste more time on this, but I stopped doing that a long time ago.

Here's what we sell at the chemo doctor store. You don't need to buy anything here, but stop coming here to try to purchase things we don't sell. No, I will not check the wackadoodle labs your naturopath wants you to get to monitor your mistletoe therapy. No I will not talk to your "doctor" in Mexico who told you he moved there because "America couldn't accept his simple cancer cure".

I still follow these people per standard of care/guidelines. And I tell them if anything changes, we can discuss it further. But it's just not worth my time and energy to try to move them back to a reality based frame of mind. Especially since it will never work.

 

[HemeOncHopeful19]

This is 25% of my patient panel.

I feel like this comes with the territory in being in the most naturopath-friendly region of the country