Does staying in academic heme/onc close doors to community role later?

[colognecancer]

I am a double-boarding third year fellow at a very academically oriented fellowship program. I have a compelling job offer to stay at my home institution in a pretty subspecialized solid tumor oncology role (i.e., not just one of breast/GI/GU/lung, but my focus will be on a subset of one of these disease groups). I will probably accept because it's a great personal fit and I find the disease group interesting. The thing is, I am still not really sure that academic heme/onc is what I want to do long term. My passion is caring for patients, and I feel like in the long run I would be fine doing patient care without research, but not vice versa. So, although I've ruled out going into community heme/onc straight out of fellowship, it's possible that I might want to switch into a community or hybrid role in several years, if academia doesn't work out and my personal situation allows more geographic flexibility in the future.

My question is whether going into subspecialized academic heme/onc is going to be frowned upon or close doors if I end up looking for a community position down the road, because over the next few years, I may become an expert in my subspecialized oncology niche but will also become rusty in all other areas of heme/onc. I would particularly appreciate thoughts on this from @gutonc and others who do hiring for their groups. Thank you!

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[gutonc]

It's tough, but not impossible. The big question you're going to get is how do you plan to make that shift and manage the huge breadth of oncology problems you've been able to ignore for the last X years. One way is to do an annual CME event like Dana Farber's Oncology Master Class to keep up your knowledge across disease types. Another is to precept the fellows at your institution in their continuity clinic (assuming they have a real generalist continuity clinic) so you can keep up.

I will say, as the hybrid guy who hires people, every time someone has come to me from academia saying they wanting to move to a general oncology practice, the reality is that they're looking for a sub-specialized clinic that just pays them more than academia, not an actual generalist job. So although I've interviewed a bunch of them, I've never hired one.

 

[blackcadillacs]

It's tough, but not impossible. The big question you're going to get is how do you plan to make that shift and manage the huge breadth of oncology problems you've been able to ignore for the last X years. One way is to do an annual CME event like Dana Farber's Oncology Master Class to keep up your knowledge across disease types. Another is to precept the fellows at your institution in their continuity clinic (assuming they have a real generalist continuity clinic) so you can keep up.

I will say, as the hybrid guy who hires people, every time someone has come to me from academia saying they wanting to move to a general oncology practice, the reality is that they're looking for a sub-specialized clinic that just pays them more than academia, not an actual generalist job. So although I've interviewed a bunch of them, I've never hired one.

Thanks for this answer! This is late, but does your answer change if the applicant was from an academic hematology position doing a 70/30 split of benign/malignant hematology? I imagine this would be even less desirable since you're more out of touch with administering chemo, dealing with toxicities, etc.

Similar to the original poster, I really like my current job offer but don't think I see myself in this location long-term, so am curious how taking this job could affect future prospects if I want to move.

Also, when you say you've never hired one, is that due to their work history/only doing one tumor type, or because you can tell they only want to do one disease and therefore not a good fit?

Thanks, @gutonc !

 

[gutonc]

Thanks for this answer! This is late, but does your answer change if the applicant was from an academic hematology position doing a 70/30 split of benign/malignant hematology? I imagine this would be even less desirable since you're more out of touch with administering chemo, dealing with toxicities, etc.

Similar to the original poster, I really like my current job offer but don't think I see myself in this location long-term, so am curious how taking this job could affect future prospects if I want to move.

In my practice, this would be a non-starter, simply because although we're relatively large, we're also widely distributed. So while the the group has ~15 docs, that's to cover 5 offices, so it works out to ~3/office, and you can't make a practice of one disease type in a setting like that.

But as I've said elsewhere, there are lots of larger groups who do have disease specific setups like this.

Also, when you say you've never hired one, is that due to their work history/only doing one tumor type, or because you can tell they only want to do one disease and therefore not a good fit?

Thanks, @gutonc

The latter.

 

[blackcadillacs]

In my practice, this would be a non-starter, simply because although we're relatively large, we're also widely distributed. So while the the group has ~15 docs, that's to cover 5 offices, so it works out to ~3/office, and you can't make a practice of one disease type in a setting like that. But as I've said elsewhere, there are lots of larger groups who do have disease specific setups like this.

Thank you for your reply @gutonc !! And sorry, what I meant was would someone coming from an academic heme background (but who is now willing to expand to full generalist practice) be seen as an unfavorable candidate given their prior area of disease focus? And is a prior heme focus more unfavorable than a prior solid onc focus?

 

[Ubba]

Thanks for this answer! This is late, but does your answer change if the applicant was from an academic hematology position doing a 70/30 split of benign/malignant hematology? I imagine this would be even less desirable since you're more out of touch with administering chemo, dealing with toxicities, etc.

Similar to the original poster, I really like my current job offer but don't think I see myself in this location long-term, so am curious how taking this job could affect future prospects if I want to move.

Also, when you say you've never hired one, is that due to their work history/only doing one tumor type, or because you can tell they only want to do one disease and therefore not a good fit?

Thanks, @gutonc !

I'm just a fellow so what do I know, but if you've been doing some malignant heme, I assume you're familiar with the administration of inductions, consolidations, etc. for leukemias. I feel like compared to those, managing other inpatient malignancies would more or less be a piece of cake. Have to imagine that there would be room for you as an inpatient-oriented onc if you joined a large PP. And could probably fill any free time in the afternoons with heme clinic patients. Different lifestyle from outpatient, though.

 

[blackcadillacs]

I'm just a fellow so what do I know, but if you've been doing some malignant heme, I assume you're familiar with the administration of inductions, consolidations, etc. for leukemias. I feel like compared to those, managing other inpatient malignancies would more or less be a piece of cake. Have to imagine that there would be room for you as an inpatient-oriented onc if you joined a large PP. And could probably fill any free time in the afternoons with heme clinic patients. Different lifestyle from outpatient, though.

I say malignant heme to refer to more indolent diseases like indolent lymphomas (tho maybe some DLBCL in there too) and myeloid stuff like MDS, CML, etc. Not that indolent malignancies don't ever require chemo, but obviously much less so. The really acute stuff goes to our BMT dept.

 

[gutonc]

Thank you for your reply @gutonc !! And sorry, what I meant was would someone coming from an academic heme background (but who is now willing to expand to full generalist practice) be seen as an unfavorable candidate given their prior area of disease focus? And is a prior heme focus more unfavorable than a prior solid onc focus?

I would be concerned about your skills/knowledge base as well as your commitment, just as I would any other solid tumor focused physician unless it was maybe breast or thoracic (although most breast cancer oncologists forget there are parts of the body not in line with the axilla).

A lot would depend on time out of training as well. If you're 3-5y out, that's much different than somebody 10-20y out. In the first case you can easily spin it (and be telling the truth) as "I thought I wanted a subspecialized practice but I miss X, Y and Z". In the latter case, it's clear that you did a bad job of planning for retirement early on and just need to make more money, or have to move to a place where an academic option doesn't exist.

 

[gutonc]

I'm just a fellow so what do I know, but if you've been doing some malignant heme, I assume you're familiar with the administration of inductions, consolidations, etc. for leukemias. I feel like compared to those, managing other inpatient malignancies would more or less be a piece of cake. Have to imagine that there would be room for you as an inpatient-oriented onc if you joined a large PP. And could probably fill any free time in the afternoons with heme clinic patients. Different lifestyle from outpatient, though.

You're not wrong, but your academic undies are showing.

Out in the real world, the balance of outpatient to inpatient care is about 99:1.

There's a US Onc group here in town that will manage acute leuks, inpatient chemo for high grade lymphomas and do autos for lymphoma/myeloma. There are about 30 MDs in the group and a single, semi-retired doc does all that inpatient malignant heme for them. My group of 15 docs will manage inpatient lymphoma chemo and we treat 1-2 a month (if we're really busy).

So yes, those positions are out there, they're just not that common and will be harder to find than an outpatient generalist job, or even a disease focused/generalist position.

 

[Ubba]

You're not wrong, but your academic undies are showing.

Out in the real world, the balance of outpatient to inpatient care is about 99:1.

There's a US Onc group here in town that will manage acute leuks, inpatient chemo for high grade lymphomas and do autos for lymphoma/myeloma. There are about 30 MDs in the group and a single, semi-retired doc does all that inpatient malignant heme for them. My group of 15 docs will manage inpatient lymphoma chemo and we treat 1-2 a month (if we're really busy).

So yes, those positions are out there, they're just not that common and will be harder to find than an outpatient generalist job, or even a disease focused/generalist position.

1-2/month for a group with 15 docs is astonishing to me. But happy to hear, as the truth is that as things stand right now, if I had my druthers, I'd never touch an acute leuk after fellowship.

 

[gutonc]

1-2/month for a group with 15 docs is astonishing to me. But happy to hear, as the truth is that as things stand right now, if I had my druthers, I'd never touch an acute leuk after fellowship.

To be clear, that's the number of patients that our docs will manage who are admitted for inpatient chemo, on average.

We don't touch acute leuks with a 10 foot Jamshidi. The second we get a call about it, we're on the phone with the academic mothership requesting a bed. All I do is tell the hospitalists which labs to order and make recommendations on keeping the patient alive until a bed is available (which is usually pretty easy), and telling the patient that they're on their way "to get the best care possible".

During the peak of the pando, we had an AML sitting around for >3 weeks waiting for a bed on the leukemia unit across town and after 2 weeks of doing nothing, we gave vidaza/venetoclax just so we'd be doing something. That's once in 10 years that I can remember treating an acute leuk in our community setting.