Hematology/Oncology Trainee Experiences During the COVID-19 Pandemic and Beyond With Samuel Kareff, MD, MPH, and Ana Velazquez Mañana, MD

This Oncology Data Advisor® Fellows Forum Interview features Dr. Samuel Kareff, Hematology/Oncology Chief Fellow at the University of Miami Sylvester Comprehensive Cancer Center, in discussion with Dr. Ana Velazquez Mañana, an Assistant Professor of Medicine in the Division of Hematology-Oncology at the University of California, San Francisco (UCSF), regarding the unique challenges faced by hematology/oncology trainees during the COVID-19 pandemic. Dr. Velazquez Mañana outlines the impacts on clinical training, research, and career development, as well as the positive changes that have been incorporated into the landscape for hematology/oncology trainees.

Samuel Kareff, MD, MPH: Hello, and welcome to this episode of Oncology Data Advisor’s Fellows Forum. This is a new resource featuring expert perspectives geared towards Hematology and Medical Oncology Fellows. Today, I’m humbled to be joined by Dr. Ana Velazquez Mañana. She carries several titles, a few of which I’ll mention here. She’s an Assistant Professor of Medicine in the UCSF Division of Hematology-Oncology at Zuckerberg San Francisco General. She’s a Thoracic Oncologist at the UCSF Helen Diller Family Comprehensive Cancer Center, and she’s also the Assistant Director of Diversity, Equity, Inclusion, and Accessibility for Trainees at the UCSF Helen Diller Family Comprehensive Cancer Center.

Dr. Velazquez Mañana, welcome. Thank you for joining us today.

Ana Velazquez Mañana, MD: Thank you so much for having me, I’m very excited.

Dr. Kareff: Likewise. So, on today’s edition of the Fellows Forum, we are hoping to discuss a little bit about how the COVID pandemic affected trainees in hematology and medical oncology, specifically. We know from taking care of patients with cancer that the pandemic has had several effects, including delayed diagnosis, difficulty in accessing treatments, complications from disease, et cetera, but we thought it would be really important to highlight the toll that the pandemic has taken on trainees. Since you and I have both transitioned through our training at various stages of the pandemic, I thought it would be wonderful to have you on today.

With that introduction, let’s go ahead and jump into some of the questions that we can discuss for our audience. Dr. Velazquez Mañana, what are some of the clinical challenges that trainees faced during the height of the pandemic?

Dr. Velazquez Mañana: That’s a great question, Dr. Kareff. I think it depended a lot on geography and location. As we know, the pandemic hit in different stages and with different severities in different areas of the country. We heard from many of our friends in the Northeast—in the New York and Boston areas—that they were moved from their oncology rotations towards having to serve in inpatient medicine or intensive care units (ICUs) and really be part of those frontline workers that were seeing patients who were severely sick with COVID every day.

That adds challenges when you have moved on from your time as an intern or resident in the ICU, and all that you remember nowadays is oncology, and you are now going back to managing ventilators and doing things that may feel at this point like they are of your spectrum of practice. We know that some of those teams were also supervising physicians and working with physicians who may have never been in an inpatient setting. I think that that was definitely quite a challenge for many of the trainees who had that experience.

Even when we think about our day-to-day oncology activities, we moved a lot of the inpatient work and treatments into completely outpatient and remote, because everything was shut down—from surgeries, to not being able to get computed tomography (CT) scans or positron emission tomography (PET) scans or biopsies for patients, and definitely not be able to do what would be considered elective admissions, which we can debate what that truly means. But a lot of the core of what our regular day-to-day in oncology training and services would look like really changed into either being completely virtual and remote or also just outpatient-based.

Dr. Kareff: Certainly, like you’ve outlined, there were just so many ripple effects throughout all of health care. Then, as you also touched on in cancer care specifically, there have been several unforeseen consequences. Reflecting on my own experience, I remember being pulled to the emergency room for several months in 2020 and joking that I should have gotten board-certified in emergency medicine as well, given all the clinical experience I had there. But as we addressed, seriously, there were a lot of clinical challenges that trainees faced, so thanks for sharing that.

Dr. Velazquez Mañana: One of the positives, or silver linings, is that we’ve expanded so much the use of virtual visits to see patients and being able to connect with people who are in their home. I think that facilitates care, honestly, a lot, and it provides more patient-centered care. So, even though it has had challenges, one of those positives that comes with clinical care is that now people are trained to do this. Now we know what the rules are to provide video visits or telephone visits, and you feel a little bit more comfortable with that than you did before. I don’t know what your experience is, but in our cancer center, there’s still quite a bit of telemedicine that is happening. I see it as a way to really expand access when we think about disparities in care for people who live in remote places or who may have challenges socioeconomically to be able to drive and come to the office, et cetera.

Dr. Kareff: Yes, without a doubt. Looking at silver linings of this monumental change during the pandemic, we have been able to expand access like you alluded to. We do also conduct telehealth visits here at our cancer center. Like you said, I think this is an imperative skill moving forward for trainees of all levels, because like you said, in terms of disparities—whether it be geographic, socioeconomic, or other sort of barriers that lead to seeking care—this is one of the tools we have. It’s definitely a good thing that’s come out of the pandemic, if we can say anything like that.

Shifting gears, I wanted to hear a little bit about some of the research challenges that trainees faced during the height of the pandemic, and afterwards as well.

Dr. Velazquez Mañana: This was really hard, because as everything shut down, so did laboratories for anybody who was interested in doing bench science. The focus on some of the studies also changed quite a bit. I think most trainees ended up doing COVID-related research. I think that’s what we all did. We were trying to understand what was happening. It was the projects that were available, ad it was the patients who were available. I have friends who, for example, were in labs, and their labs changed completely to develop now vaccines or to develop new tests for diagnosing COVID and trying to understand immunology behind the patients who had severe infection versus those that didn’t, et cetera. It really changed quite a bit how people did research and the types of research that they did.

If we think of our more classical clinical research or clinical trials, those were completely shut down in terms of people not having access to seeing patients directly in clinic to enroll them on a trial, seeking new participants for specific intervention study or a survey, or even getting samples for some translational work. None of those things were available, really. Again, if we think about the positives, big data is something that is always accessible. I think people had to pivot and think about whether they were going to take on new COVID projects or if they had access in their institution at one of the big cancer registries or databases to try to use that as a pivot point in new projects.

But several things, like the Vail Workshop and different career development opportunities that trainees use to get experience and to get new research methods, were canceled or were moved and delayed for a year, so people were graduating fellowship. It became quite a challenge to try to get the skills that you would normally get at meetings in which you learn new ideas, or the scientific meetings in which you’re able to go and present your work and highlight it for others. Having all of those moved to virtual or being canceled was something that definitely affected a lot of our trainees.

We also experienced a lack of connecting with mentors, similarly, because there’s this organic aspect of relationship building and mentorship that happens when you’re in a clinic together or when you’re sharing a workspace with your teachers and faculty. If we’re all working remotely, some of that is also lost. It makes it harder to make those connections and be able to say, “I saw this very interesting case. Why don’t we do a retrospective chart review about it?” or, “Oh, Dr. Kareff, what are you working on? Are there any projects I can help you with?” I think those were all some of the challenges faced by our trainees and by myself. Sam, do you have other thoughts or experiences?

Dr. Kareff: Certainly, in all of these domains, I think you correctly alluded to what we’ve all really struggled with. When it came to research challenges, thankfully, I had had at least one research mentor identified at my residency institution prior to the outbreak of the COVID virus. That being said, moving on and trying to identify new projects or looking for other sorts of opportunities to develop research acumen were severely limited.

But keeping in line with your optimistic viewpoint on the silver linings, I agree with you. Because there was such a shift in a lot of the research priorities while we were trying to find vaccines towards COVID-19, it seems like a lot of that has translated well into the oncology research arena as well. We know that there are a lot of vaccine trials that are incorporating the mRNA technology that was used so successfully for the COVID immunizations that are now being looked at in various solid tumors, like melanoma, breasts, et cetera. I think that the public acceptance and familiarity with this technology will hopefully lead to greater amounts of enrollment moving forward. Certainly, we have to keep in mind that there were some positives with this change as well.

Finally, I wanted to ask you—and you alluded to a couple already in terms of career challenges—were there any other career challenges specifically for trainees you’d like to highlight that were really challenging, especially at the height of the pandemic?

Dr. Ana Velazquez Mañana: Yes, I think that there are many. I think that we all worried about how much oncology knowledge or training people were getting if they were not necessarily seeing as many cases or seeing as many new diagnoses, including diagnoses at later stages. We all worried quite a bit about people feeling burnt out and tired and stressed with everything that was happening in the world—from COVID to a lot of social disruption around the country with events like the murder of George Floyd, and similarly seeing how everything in hospitals was changing, being in social isolation, in an apartment or in your home without your friends and sometimes without being able to see your family.

I think we really need to pay attention to that aspect, because we now literally have classes of people who graduated residency during a pandemic and now are graduating fellowship at still the tail end of this pandemic. A lot of the training has been disrupted in that if we are doing lectures completely remotely, if we are doing many meetings that are still remote, then our interactions as individuals really are lost. I know that different institutions have different levels in how much you’re back to fully in-person. Some of them have everything back to normal as it was before, but some, like mine, still have a very substantial amount of activities and lectures and things happening remotely. For me, it’s always that worry when we think about burnout and mental health of our trainees and this community building that is very classical of medical training, thinking about ways in which we don’t lose that again.

Dr. Kareff: Certainly. I think, like you said, maybe the most palpable of those changes has been the transition to either hybrid or completely virtual learning environments and the transition back to either hybrid or as you said, completely normal environments. That also has its challenges with it. It’s really hard to walk the line between safety and making sure that educational and other objectives like just being social creatures are met. Thanks for highlighting that.

I want to close off this discussion by asking you if there were any other difficulties in medical education for trainees during the pandemic that you consider highlighting, keeping in mind we just discussed the learning environment a bit.

Dr. Velazquez Mañana: Yes, I think the other big thing to think about is recruitment—thinking about how people select their training programs and how people select their job and next position, whether it’s in private practice or faculty. Because there were so many restrictions, and there still are, for fellowship recruitment, that has been really challenging in that people have not been able to really travel and get to know others. Interviews for fellowships are still happening remotely. It’s really hard to think about how you’re going to choose a place in which you’re going to live for two to four years or more, which is that steppingstone into becoming a specialist. Many times, people even stay as faculty in the places in which they train or close by without having been there, without visiting the city or visiting the hospital, getting to know the people, and knowing what living in X or Y place would look like.

I think that virtual interviews have some benefits. Of course, they decrease cost and time and make it easier for people to interview at more places when they’re super busy as a resident. But I do wonder, to a certain degree, if we’re going to see that people are more limited in staying within the area of what is known or where they went to college or medical school or where they have family just because of that factor of being unable to connect with others. Similarly, how are those experiences once you’ve met and arrived, if you really didn’t get a sense of the environment, the community of the program, and the personalities of the people who you’re going to work and interact with? Those are so important to us as social beings.

Dr. Kareff: I think you really hit the nail on the head there. One of the biggest milestones in any trainee’s career is that residency or fellowship interview trail. Getting to know the institutions, the people of the institutions, the communities of that institution, and the patients of that institution, is just so crucial in helping one select his or her preferred institution when going through that match process.

Of course, losing a lot of that through the virtual environment may have benefits, like you said, in terms of time, air pollution, these sorts of things. But it certainly has some drawbacks in terms of really identifying the key areas in which you’re looking to develop yourself as you go through your career. I think time remains to be seen. I just recently went through the interview trail myself and only had one in-person option, and that was as of two years ago. I’m not sure how the landscape will change for years to come, but there are certainly big changes to keep an eye on moving forward.

Unfortunately, our time is wrapping up, but I just wanted to conclude with one final question. I noticed you were very busy at ASCO this year, and I was wondering if you wanted to highlight any research piece that you presented or were part of a research team for?

Dr. Velazquez Mañana: Oh, thank you for asking that. Definitely. I presented work that was related to workforce development and medical education, similar to what we’re talking about today. That is one of my areas of main interest. One of the projects that we presented was actually looking at attrition of faculty in oncology and primarily thinking of who is leaving our field or who intends to do so. Unfortunately, we’ve seen an increasing trend of people shifting or making career changes over time. And since the pandemic, it seems to be heightened.

I think that we still have to say the jury’s out on whether that is true or not. But we’ve seen this trend in social media and in other places seeing more people move towards industry or towards other jobs in private institutions compared with our classical academic setting. As we think through all of the challenges that trainees and people in medical education face, they need access to having mentors and faculty, seeing faculty that are happy and that are engaged in their job, and having faculty who feel supported and are able to provide teaching and work with you on research projects and role model how to have work-life balance. It seems like that is getting harder every day.

So, one of the projects that we did was using a survey that the Association of American Medical Colleges (AAMC) pulls from medical school faculty across the nation and looking at who is staying within the oncology specialties, who is intending to leave their current practice, and who is intending to leave their current institution and academic medicine in general. What we found was that after adjusting for rank, age, the type of specialty, and if you had administrative responsibilities or not, women were significantly more likely to say that they were going to leave their current job and at least move institutions. A majority of those who were intending to leave also were intending to leave academics in general.

I think as we have seen a lot of revolution in how we deliver education, how we do research, and how we deliver care, we have to think similarly about what the things are that are making this job hard and the ways in which we can improve morale and improve how people are supported in their jobs and their ability to seek growth in the positions that they have. If you’re happy and you’re seeing that you have goals that you can achieve, and you’re in a supportive environment where you can achieve them, then it becomes a lot easier to find meaning in the work that you’re doing day-to-day. I’m hopeful that with our newer generation, as people in training become energized, we will thing about ways in which we can start transforming health care and transforming academics so that we see less of an exodus of some of the great talent that we have.

Dr. Kareff: I think that question is really crucial, not only for the oncology workforce, but like you said, for trainees when looking for mentors. We know that having a healthy and diverse set of role models to look up to is really what helps not only the field, but also our patients at the end of the day. Thank you for participating in that really crucial research, and hopefully this will help serve as a call for action to institutions, especially the academic ones you were highlighting, to be more flexible in accommodating not only in terms of recruitment, but also in retainment of faculty.

I wanted to say thanks again to Dr. Velazquez Mañana for joining us on this episode of the Fellows Forum. It was a great honor to have you today, and we look forward to collaborating again in the future. Thanks so much.

Dr. Velazquez Mañana: Thank you so much for having me. This was super fun.

About Dr. Kareff and Dr. Velazquez Mañana

Samuel Kareff, MD, MPH, is a Medical Oncologist and a Hematology-Oncology Chief Fellow at the University of Miami’s Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital in Florida. He has special research interests in health advocacy, public policy, and the development of cancer therapies.

Ana Velazquez Mañana, MD, is an Assistant Professor of Medicine in the Division of Hematology-Oncology at the University of California, San Francisco, and a Thoracic Oncologist at the UCSF Helen Diller Family Comprehensive Cancer Center, where she also serves as Assistant Director of Diversity, Equity, Inclusion, and Accessibility for Trainees. Her research focuses on promoting and advancing health equity and workforce diversity.

For More Information

Banerjee R, Kareff SA, Leyfman Y, et al (2023). Professional challenges for United States hematology/oncology trainees during COVID-19. Cancer Invest. [Epub ahead of print] DOI:10.1080/07357907.2023.2199216

Kareff SA, Sridhar A, Dhawan N, et al (2023). The democratization of hematology-oncology medical education during the COVID-19 pandemic. Cancer Invest. [Epub ahead of print]. DOI:10.1080/07357907.2023.2230495

Velazquez Mañana AI, Odei B, Florez N, et al (2023). Should I stay, or should I go? Factors associated with intent to leave academic oncology. J Clin Oncol, 41(suppl_16). Abstract 11004. DOI:10.1200/JCO.2023.41.16_suppl.11004

Velazquez Mañana AI, Idossa D, Franco II, et al (2023). Hematology/oncology program director perspectives on recruitment and inclusion of a diverse workforce. J Clin Oncol, 41(suppl_16). Abstract 11005. DOI:10.1200/JCO.2023.41.16_suppl.11005

Transcript edited for clarity. Any views expressed above are the speakers’ own and do not necessarily reflect those of Oncology Data Advisor.

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