Questions related to Hem/Onc fellowship and career

[DZero]

I'm currently finishing my intern year at a reputable academic IM residency program. I did MSTP training in immunology using cardio-inflammation as my main model. My career goal had always been clear: going into Cards to build a clinical career related to my basic-science research background. Then, throughout my intern year, I've realized I'm attracted to Hem/Onc a lot more than I am to Cards for many reasons. I'm considering switching my career pursuit into Hem/Onc, but there are still many occupying questions in my mind. I hope to hear inputs from you, and I apologize some of these questions may be very silly (as you would probably expect from a naive intern):

1. Getting into Hem/Onc fellowship: although I have published a couple first-authored manuscripts during my PhD time, they are mainly in cardio-inflammation and not in cancer (though arguably the concepts can still be translated into certain subfields of Hem/Onc). Would this be viewed as a disadvantage? How much research output in Hem/Onc should I aim to have during residency, in balance of clinical training time, to make myself an attractive Hem/Onc applicant, like an abstract, a co-authored manuscript, or a first-authored manuscript?

2. Life as an attending: in terms of patient demand, how much is it in Hem/Onc? I've heard malignant Hem and BMT/SCT patients are sicker and therefore are more demanding. Onc patients are mostly not that sick. Would you say patient demand in Hem/Onc is probably as equal to general Cards?

3. Research as an attending: one thing occupying my mind a lot is the perception that research in Hem/Onc is moving so fast, and I may not do well as a physician-scientist doing basic science/translational work down the road, compared to being in Cards which seems to move a lot more slowly. Is this perception accurate?

4. Interactions with other specialists: would you say you have to interact with a lot of jerks in your daily practice (like Surg Onc, Rad Onc, during tumor boards, etc)? Or is it more like you have ownership of your patients and they often don't argue with your decisions? I'm asking this question because in Cards, the culture seems way worse, with tensions between cardiologists and cardiac surgeons, and often between cardiologists themselves. The culture in Hem/Onc at my institution appears to be very awesome. Is this true in general at other places as well?

Thank you for your inputs!

Naive intern

---

Members don't see this ad.

 

[gutonc]

I'm currently finishing my intern year at a reputable academic IM residency program. I did MSTP training in immunology using cardio-inflammation as my main model. My career goal had always been clear: going into Cards to build a clinical career related to my basic-science research background. Then, throughout my intern year, I've realized I'm attracted to Hem/Onc a lot more than I am to Cards for many reasons. I'm considering switching my career pursuit into Hem/Onc, but there are still many occupying questions in my mind. I hope to hear inputs from you, and I apologize some of these questions may be very silly (as you would probably expect from a naive intern):

1. Getting into Hem/Onc fellowship: although I have published a couple first-authored manuscripts during my PhD time, they are mainly in cardio-inflammation and not in cancer (though arguably the concepts can still be translated into certain subfields of Hem/Onc). Would this be viewed as a disadvantage? How much research output in Hem/Onc should I aim to have during residency, in balance of clinical training time, to make myself an attractive Hem/Onc applicant, like an abstract, a co-authored manuscript, or a first-authored manuscript?

Your pre-residency research/pubs can only help you, not hurt you, so don't worry about that. If you want to buff your app for H/O fellowship, get working with an attending that publishes regularly now and get on a project (clinical or translational) that will at least have a poster/presentation in the next 12 months. It's OK to also try to do some bench work during a research month if you have the opportunity, but you will NOT get anything publishable out of it in time for applications.

2. Life as an attending: in terms of patient demand, how much is it in Hem/Onc? I've heard malignant Hem and BMT/SCT patients are sicker and therefore are more demanding. Onc patients are mostly not that sick. Would you say patient demand in Hem/Onc is probably as equal to general Cards?

This completely depends on your clinical practice and setup. If you're in community practice, it will depend on your, and your partner's patient panels and what things look like in your community. The vast majority of my patients are solid tumor and benign heme and don't require much actual work day-to-day. You're right that acute leukemia/BMT/Cell therapy patients are a lot sicker and a lot more work. The good news, as an attending at least, is that you're generally doing that in an academic setting where the residents and fellows are handling the bulk of the day-to-day work.

3. Research as an attending: one thing occupying my mind a lot is the perception that research in Hem/Onc is moving so fast, and I may not do well as a physician-scientist doing basic science/translational work down the road, compared to being in Cards which seems to move a lot more slowly. Is this perception accurate?

That perception is inaccurate. If you're "in the game", you're in the game. If you have a classic physician-scientist position as an attending, where you've got a couple of R01s (or equivalent) to fund your lab work, you're going to be staying on top of the science, and you'll be fine. Now, the likelihood that you'll have that is vanishingly small, but that's a different issue altogether.

4. Interactions with other specialists: would you say you have to interact with a lot of jerks in your daily practice (like Surg Onc, Rad Onc, during tumor boards, etc)? Or is it more like you have ownership of your patients and they often don't argue with your decisions? I'm asking this question because in Cards, the culture seems way worse, with tensions between cardiologists and cardiac surgeons, and often between cardiologists themselves. The culture in Hem/Onc at my institution appears to be very awesome. Is this true in general at other places as well?

There's a little bit of this, mostly because people are a-holes in general, but I find it to be a lot less prominent in the cancer world than other areas in medicine. Some of this is the truly multidisciplinary nature of cancer care, such that surgeons (and rad oncs, and med oncs, but...let's be honest, the surgeons are usually the problem here) know that surgery often isn't either enough, or even appropriate and that they need rad and med onc. Also, even when they can cure with surgery alone, they don't want to be the ones following their patients for 5-10 years for surveillance. One thing I really like about med onc is that we're at the intersection of so many other specialties and have some insight in to how to work well with everyone (even if not every oncologist has the interpersonal skills to do so). As an example, just this last Thursday, I spoke with or messaged: rad onc, Head and neck oncology surgery, colorectal surgery, GI, HPB surgery, radiology, IR, pathology, breast surgery, pulmonology, derm, primary care, GYN, hospitalists and palliative care. And that's all in the outpatient setting and all regarding patients I saw that day. I'm going to go out on a limb and say that's a pretty unique variety of interactions, especially in the outpatient setting and that's not an atypical day for me.

Bottom line is that, if you've already set yourself up well for cardiology at this point in your career, you can easily pivot to any other medicine sub-specialty that interests you, and you will likely be successful. Step one is to find yourself a good oncology mentor now. Ask current senior fellows who they recommend and go from there.

 

[DZero]

Your reply is super helpful! Thank you very much! I do have a few follow-up questions:

This completely depends on your clinical practice and setup. If you're in community practice, it will depend on your, and your partner's patient panels and what things look like in your community. The vast majority of my patients are solid tumor and benign heme and don't require much actual work day-to-day. You're right that acute leukemia/BMT/Cell therapy patients are a lot sicker and a lot more work. The good news, as an attending at least, is that you're generally doing that in an academic setting where the residents and fellows are handling the bulk of the day-to-day work.

Do BMT/SCT/cellular therapy attendings in academic hospitals make as much as medical Onc attendings in private practice? Or do they still follow the typical rule-of-thumb of making $100k-$200k lower for being in an academic hospital even though these patients are sicker and require highly subspecialized expertise?

There's a little bit of this, mostly because people are a-holes in general, but I find it to be a lot less prominent in the cancer world than other areas in medicine. Some of this is the truly multidisciplinary nature of cancer care, such that surgeons (and rad oncs, and med oncs, but...let's be honest, the surgeons are usually the problem here) know that surgery often isn't either enough, or even appropriate and that they need rad and med onc. Also, even when they can cure with surgery alone, they don't want to be the ones following their patients for 5-10 years for surveillance. One thing I really like about med onc is that we're at the intersection of so many other specialties and have some insight in to how to work well with everyone (even if not every oncologist has the interpersonal skills to do so). As an example, just this last Thursday, I spoke with or messaged: rad onc, Head and neck oncology surgery, colorectal surgery, GI, HPB surgery, radiology, IR, pathology, breast surgery, pulmonology, derm, primary care, GYN, hospitalists and palliative care. And that's all in the outpatient setting and all regarding patients I saw that day. I'm going to go out on a limb and say that's a pretty unique variety of interactions, especially in the outpatient setting and that's not an atypical day for me.

Which sub-fields of Hem/Onc have "less multidisciplinary nature"? I'm aware this question may not be well-worded, but for example, I have not seen patients with hematological malignancies/BMT/SCT/cellular therapy require surgeons to be onboard. Is my experience just limited and I haven't seen it all?

That perception is inaccurate. If you're "in the game", you're in the game. If you have a classic physician-scientist position as an attending, where you've got a couple of R01s (or equivalent) to fund your lab work, you're going to be staying on top of the science, and you'll be fine. Now, the likelihood that you'll have that is vanishingly small, but that's a different issue altogether.

With the current job market and funding landscape, what are some examples of common research models MD/PhD physician-scientists in Hem/Onc are pursuing in addition to their clinical work?

 

[ilovecorgis]

Just wanted to throw in the field of cardio-oncology (superfellowship after cards), if you still have some affinity for the heart but just want to work with cancer patients. Where I am now, they largely help manage patients with cardiotoxicity related to either their cancer treatment or the cancer itself (myocarditis from immunotherapy, anthracycline cardiotoxicity, etc). Would seem to fit well with your prior research, too.

 

[gutonc]

Your reply is super helpful! Thank you very much! I do have a few follow-up questions:


Do BMT/SCT/cellular therapy attendings in academic hospitals make as much as medical Onc attendings in private practice? Or do they still follow the typical rule-of-thumb of making $100k-$200k lower for being in an academic hospital even though these patients are sicker and require highly subspecialized expertise?

Academics make less. Period.

Which sub-fields of Hem/Onc have "less multidisciplinary nature"? I'm aware this question may not be well-worded, but for example, I have not seen patients with hematological malignancies/BMT/SCT/cellular therapy require surgeons to be onboard. Is my experience just limited and I haven't seen it all?

Heme malignancies in general.

With the current job market and funding landscape, what are some examples of common research models MD/PhD physician-scientists in Hem/Onc are pursuing in addition to their clinical work?

I have no clue. I bounced from that toxic game a decade ago and haven't looked back.

 

[CatFactorial]

Your reply is super helpful! Thank you very much! I do have a few follow-up questions:


Do BMT/SCT/cellular therapy attendings in academic hospitals make as much as medical Onc attendings in private practice? Or do they still follow the typical rule-of-thumb of making $100k-$200k lower for being in an academic hospital even though these patients are sicker and require highly subspecialized expertise?



Which sub-fields of Hem/Onc have "less multidisciplinary nature"? I'm aware this question may not be well-worded, but for example, I have not seen patients with hematological malignancies/BMT/SCT/cellular therapy require surgeons to be onboard. Is my experience just limited and I haven't seen it all?



With the current job market and funding landscape, what are some examples of common research models MD/PhD physician-scientists in Hem/Onc are pursuing in addition to their clinical work?

HCT in academics 200-250 base + incentive

HCT in hybrid ~ 400s

HCT in private practice more than that

Most outpatient med onc 300-500k

All heavily dependent obviously on location