Exploring Educational Opportunities During Hematology/Oncology Fellowship With Matthew Hadfield, DO, and Richa Thakur, MD

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Matthew Hadfield, DO: Hey, I'm Matt Hatfield. I'm one of the Fellows as part of the Fellows Forum with Oncology Data Advisor. I'm here with Dr. Thakur today, and we're going to be talking about how we learn in fellowship, which is a vast topic because staying on top of information in fellowship is incredibly challenging. To introduce myself, I'm Matt Hatfield. I'm a third-year Oncology Fellow at Brown University in Providence, Rhode Island. I'm interested in immunotherapy toxicities, as well as early drug development and phase 1 clinical trials. Dr. Thakur, I'll let you introduce yourself.

Richa Thakur, MD: Hi, I'm Richa Thakur. I'm a second-year Hematology/Oncology (Heme/Onc) Fellow at Northwell in Long Island. Before I started Heme/Onc, I also did a Palliative Care Fellowship prior to that. My research interests are really in quality of life, especially with patients in malignant hematology. I am really excited to do this podcast with you guys too, because learning in fellowship is so overwhelming and it often feels like you just don't really know what you're doing. Hopefully we can provide some insight and give you guys some comfort to know you're not alone.

Dr. Hadfield: Awesome. To get started, one of the things I find most interesting about training in general in oncology is just the vast amount of information that you have to sift through every day, both in clinical decision making and big picture management for patients. I'm curious, what types of avenues do you use to stay on top of information? What are the different ways you learn, both about standard-of-care things and to stay on top of new data that's coming out?

Dr. Thakur: I feel like that's been a huge challenge for me, especially starting with oncology because there weren't a lot of resources that were geared towards beginning in fellowship. Fortunately, I listen to two really good podcasts that have come out, the Fellow On Call and then obviously Oncology Data Advisor.

Dr. Hadfield: How have you incorporated those into your learning?

Dr. Thakur: When I first started, I didn't really know where to even start, because one thing with Heme/Onc is you never really learn a lot of basic information in residency. Usually what I would do is I'd try to go through a few different podcast series. There were a few different series I used—the Fellow On Call was really good and also Two Onc Docs. I would match up the podcast to do groups at a time. If I wanted to do breast cancer, I would go through everything with one of the podcasts and then I would go back and use the second one to create my own outlines. Then I would also try to pair it with some of the patients I was seeing on consults because for me, seeing the patient in front of you and how you treat the patient makes the information stick more.

In terms of keeping up on all of the newest trials, I feel like that's something I've also really, really struggled with. Most of what I've been really doing is trying to focus on a couple of different cancer types, and then I learn best from podcasts because I can at least listen to them while I'm driving to and from work. Looking for a couple of podcasts in those areas and trying to focus on them has been really helpful. What about you? What have you been using both to keep up and to get basic knowledge too?

Dr. Hadfield: Honestly, to echo what you were talking about, I find it to be the same thing. When you first start fellowship and you leave residency training, you have a scaffolding for how to manage things like congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), but something like metastatic melanoma, you don't know how to manage that. That's completely foreign. For me, podcasts too have been huge too. I listen to the same ones that you mentioned. Oncology Data Advisor has definitely helped.

In terms of managing patients, there's so much gray area, and there are so many new trials that are coming out with new data so frequently that it really helps to hear from experts in the field. I think when you can hear opinion leaders in certain areas talk about how they manage patients, it at least gives you something to go off to make your own clinical decisions. I think those are the things that I've been trying to glean the most from.

I find that in oncology specifically, it's become harder and harder to just rely on things that I used in residency, like home-based things that you'd use to learn. Board prep materials haven't been quite as relevant to me in learning oncology just because the field changes so fast that you just can't rely on those types of sources of information like you could in residency for different types of diseases. It's definitely a field that changes quickly and it's hard to stay on top of.

Piggybacking off that, with the idea that things change quickly and there's always vast amounts of new data and new things to stay on top of, what has been your strategy or method for balancing your clinical time and trying to work things in throughout the day? Do you find that there are different sources that you go to frequently to learn about new developments in fields, or are there any specific ways that you learn to stay on top of things?

Dr. Thakur: It really depends, because I just started my second year, so I feel like there are areas where I'm still developing very basic fundamental knowledge, which is where I use things like question banks or podcasts and general review articles to get that. But in other cancer areas where I've had much more experience, usually I start with one or two articles that I would either get in my news inbox as an email or those articles you get in the mail from Blood or from the American Society of Clinical Oncology (ASCO). I always read the "How I Treat" articles, look at what was cited in the back of those, and then go to those publications for the areas that I felt were most interesting.

I think as a fellow, there are two areas. You're always building up your general knowledge, but to also keep up with the most cutting-edge research, you need to have a really good fundamental of knowledge, and it's really tough to manage that in so many different cancer types. I've found that starting with a review article and then finding the ones that are cited is the easier way to go so that at least I have fundamentals to understand the next level. Then I look at more citations for whichever articles seem interesting in the next level.

Dr. Hadfield: That's a fantastic point. I don't know if you agree, but I think oncology has much more data to stay on top of and also much more controversial data. Not every trial that gets published is necessarily going to be changing your management practice or become the standard of care. You really have to determine if you want to integrate that into your practice and how to do so. Some of that, to your point, is figuring out where we were, where are we now, and where are we going and trying to anticipate. You're trying to learn the fundamentals and you're trying to figure out what the future looks like all at the same time.

Similarly, I also use review papers to try and have quick summaries of what I'm learning. I think for fundamental knowledge, that's perfect, because then you can go back and reference a review paper on the management of metastatic non–small cell lung cancer and have all the pivotal trials right there. When you have time, which you never have time, but when you do have time, you go back and read those clinical trials and try to tease out what is important about them and what is relevant for your own practice. Then as we mentioned earlier, for staying on top of new information that's coming out, I do rely on things like podcasts that you can integrate into your day pretty seamlessly while you're commuting or while you're catching up on notes or things like that.

For instance, i3 Health has a podcast now on management of small cell lung cancer, which I think is a field that's rapidly evolving and difficult to stay on top. Having something that's a little bit more contemporary and current on those types of things is super, super helpful. That makes me think of another thing that's really relevant in oncology fellowship. There's our day-to-day clinical management and there's also the big picture—these are the trials in the different disease states that you have to think about and the controversies within those disease states about how different people manage different things. What are your go-to sources or how do you stay on top of more of the clinical management things, those questions that come up while you're in clinic or on consults where you just need a quick answer fast? How does that differ from maybe more your long-term learning, the things that you're trying to use to build your foundational knowledge?

Dr. Thakur: I guess it really depends on the situation. If it's looking at next-line chemotherapy or possibly a complication of some sort of treatment we've been giving the patients, I would start from a different resource for each one. With National Comprehensive Cancer Network (NCCN) guidelines, I didn't realize this when I first started fellowship, but there's a really nice summary section at the end. If you're really looking for one or two short points, those are where I would go to find at least for some of the things that I'm just not used to managing—for example, gynecological malignancies, because at some institutions the chemotherapy is given by the surgeons versus the medical oncologists. That's where I would start.

The other thing that I also found very helpful is that in NCCN, there's another section for supportive oncology too, and that's really helpful for a lot of the side effects in terms of immunotherapy. That's been a really good go-to for at least looking up dosing on something very, very quickly. I usually use the NCCN guidelines for at least the structure of the fundamentals to make sure I'm not missing something for staging and workup. But in terms of choosing the right treatment, with NCCN guidelines, it's really tough to navigate which one's next.

Dr. Hadfield: It's very challenging, I would agree. In my practice too, I feel the same way Take stage IV lung cancer, for instance—you look up the NCCN guidelines and you see non–driver-mutated, you use carboplatin/pemetrexed/pemetrexed (carbo/pem/pem), but you could also use ipilimumab/nivolumab/chemo like the CheckMate 9LA regimen. The NCCN guidelines don't break down which one's better than the other. When you look at the papers for the trials, they're very similar. Between the toxicity profiles and the efficacy benefit, there are nuances between the two. At my institution, we use mostly carbo/pem/pem, but you have to augment those types of sources with things like podcasts or articles with some of the leaders in the field, as well as your mentors at your local institution, to try and understand why we do this versus that. The NCCN guidelines make everything seem as though it's very cut and dry.

You mentioned immunotherapy toxicities, which are a particular interest of mine. I think we've all looked at the European Society for Medical Oncology (ESMO) guidelines, the Society for Immunotherapy of Cancer (SITC) guidelines, and NCCN, and they're all very similar, but when you manage patients, it doesn't look like that. People don't respond within two days to steroids. You often have to manage steroid-refractory cases of pneumonitis and colitis, and it gets very, very nuanced, very fast. Having those other sources where you're actually hearing from people who are doing these things and are experts in the field is pretty critical in my opinion.

Dr. Thakur: I think another thing is to gain more collective clinical experience, because no matter what, you just won't have enough patients to know every single thing there is about Heme/Onc. One thing I've also really loved is going to tumor boards for cancers and just listening to what other people say, because you'll hear from different people that have a lot of experience in this one type of cancer, and it'll at least help you troubleshoot how to manage another patient moving forward. I think textbook knowledge is one thing, but also translating it to clinical practice is really tough. For me, tumor boards have really helped with transitioning.

Dr. Hadfield: Absolutely. There's such a wealth of knowledge you hear in tumor boards. Even for cases that you think are relatively straightforward in your mind, you present them at a tumor board and you realize there were several things you didn't consider or think about. That's just the wealth of knowledge and experience from people who have been managing this a lot longer than we have, and it's really, really good to learn from them. What have you found some of your mentors to do at your institution with regards to learning or staying on top of new data that comes out or controversial data that comes out?

Dr. Thakur: I feel like that's really tricky because everybody has their own system of how to manage some of these things, right? My mentors have them all over. It depends on the type of cancer we're working with and the mentor. Some will send out every review article to at least guide you through the pivotal trials and then will send out the newest articles that come out. Then we also have formal and informal journal clubs where we discuss it too, because sometimes when you just don't have enough clinical experience, you don't know how important a new article is or how to fit it into clinical practice. Maybe you may not have enough patients and you really shouldn't use it in your practice, but it has a lot of potential and you might just need a few more articles to come out before you would start using those findings.

Dr. Hadfield: Absolutely. It is a tough field in that regard to stay on top of. I would finish with, what would be one piece of advice you would give someone who's either a hospitalist about to become a Heme/Onc Fellow or a third-year resident or Chief Resident who's about to become a Heme/Onc Fellow? What's one thing that you wish you knew that you didn't know and what's one piece of advice you would give them?

Dr. Thakur: I think one of the misperceptions a lot of people have when they first come into fellowship is that they have to know everything. Realizing that the field is changing every single day, trying to stay on top of every article is going to feel like you're drowning. I think making sure that you're focused on having a really good fundamental knowledge at the beginning is probably what I would first focus on. Then once you have that, try to focus on your area of interest. It's much easier to be on top of all of the articles that come out for one type of cancer like leukemia or melanoma because you at least have the fundamentals to build up and you know how the trials change with one another. It's very tough to know every single thing about every single cancer. So, that's one thing I would say.

The other thing is to not forget some of the softer skills about being an oncologist too. There's really no textbook that tells you how to transition from being a resident or an internist to an oncologist. That's a very unique role. Not forgetting those skills about transitioning to a consultant, making sure you're taking care of the cancer portion but then also looking at a patient holistically, is one thing I tell people about not to forget.

Dr. Hadfield: Absolutely. That resonates so much with me. It's easy when you're in clinic and you're working with a thoracic oncologist. They rattle off data, but they've been living only thoracic oncology for 10 years. I feel like as a first-year Fellow, and I still feel like this now, that sometimes it's almost like you're joining a movie halfway through. You didn't see the first half of the movie, and you're trying to come up with the plot points, but you don't really know. It's challenging. I think for people transitioning to fellowship, it's important to know that even people who have been oncologists for 25 years go to tumor boards and are humbled by the things that happen with patients, the things that they don't know, and just how much we don't have control over some things in oncology.

I think the one thing too that I would say about oncology, in addition to just the vast amounts of information that you have to stay on top of, has been that it's a challenging field. The patients are sick, and I wasn't as prepared for that when I started fellowship. I think I thought that it'd be very similar to residency, but it's very humbling on a daily basis to meet people who are terminally ill. You run out of options quickly with them, and it can be very challenging. I think taking out time for yourself and connecting with your colleagues is really important. I know palliative medicine is something very important to you, and that's something that I think is really a big part of fellowship that I underestimated when I started.

Dr. Thakur: I feel like that's something that a lot of fellows and attendings just aren't prepared for until you get your hands in and are really practicing, because the patients are so sick and they have a reason to really be so overwhelmed. There's a lot of need for an oncologist to really manage so many of the primary aspects too. It's something that you just don't realize because other consultants can focus on one organ, but cancer and chemo affect every organ in the body, so you really have to be a good internist.

Dr. Hadfield: Right, absolutely. I would agree with that. Again, to pull things back to immunotherapy toxicities, I feel like we all have to be really great internists because you can't just be siloed into thinking about your one type of cancer. It's too complicating, the therapies are too complicating, and the patients are too complicating. But I think taking care of really sick patients every day, along with the vast amount of knowledge that we have to stay on top of, does make Hem-Onc Fellowship very unique even from other fellowships—I'm not sure other subspecialties would agree—but t I think it's a very unique and rewarding but very challenging field to be in.

Dr. Thakur: Oh, absolutely. What do you think your mentors or attendings have done to help you with some of those challenges?

Dr. Hadfield: I've had some really wonderful mentors throughout fellowship. I think the biggest thing that I've learned from my mentors is to always be humble. I've had some mentors who are just phenomenal at teaching on the go and can really help build that foundational knowledge quickly. But what I've always seen them demonstrate to everyone they work with—it doesn't matter who, patients, other physicians, the support staff, nursing staff that works with them—is that they're very humble and down to earth because they realize that so little is under our controlin oncology. It's a very challenging field, and you really can't be too sure of yourself with anything because we all are caught off guard by how patients do in terms of outcomes. It's a challenging field to be in. I think that's been one big thing.

The best mentors I've ever had are reading constantly. It's amazing how if something's published or presented at ASCO, they know about it before anyone else does, it seems like. I think in some ways, you do have to push yourself to keep reading and be a lifelong learner. I think that's where things like podcasts really help me personally, because I find it hard to sit down and read just journal articles. I would love it if I got up in the morning and over coffee, I was cranking through two or three journal articles, but that's not so much my speed. But if I can listen to a podcast, especially with some of the more prominent people in the field or people who manage these diseases, I can hear their opinions about new data. To me, it's almost entertaining in a way, but you're learning at the same time.

Dr. Thakur: It's much easier to fit in a podcast while you're multitasking versus really trying to digest 20 pages of something in journal.

Dr. Hadfield: If it's 6:30 in the morning and I'm like, "Well, this hazard ratio is different than that hazard ratio," I'm not getting there that way. For some people, that works. But I think podcasts and revew articles help distill information, and to your point, that serves as a good starting point. You listen to a podcast and someone mentions, for instance, carbo/pem/pem versus CheckMate 9LA and then it compels you to go and look up the trials and make your own decisions about how you want to manage those things. It can be just a good way to stay on top of the information and be a good starting point for other things that you want to look into.

Dr. Thakur: I think the other thing you said about just being a lifelong learner, that's so important in oncology, and I feel like you don't really understand it until you actually start practicing. Most of my favorite attendings, the best mentors I've had, it's not that they're just interested in learning the newest articles or the data. They're actually very curious about developments in all areas of medicine. I had an attending come up and ask me how to interrogate a patient-controlled analgesic (PCA) so that they could catch problems with our sick patients who have sickle cell disease. Knowing skills outside of just oncology, but also in internal medicine in general and other areas, really helps us create more research,be better researchers, and manage patients better.

Dr. Hadfield: Oh, absolutely. I couldn't agree more. I think the best mentor I've ever had, he and I were sitting at a Best of ASCO meeting, and during the meeting he was taking all these diligent notes in lymphoma, and he's a thoracic oncologist. I was like, "What are you doing? This doesn't have anything to do with you." And he was like, "Of course it does. It's oncology." You never know. You may hear about some new molecular target, or you may hear about a trial that had an interesting aspect or some type of toxicity from a therapy, or just hearing something outside your own area, to your point, makes you much more well-rounded. Those are the people who are really exceptional as opposed to just doing their job well. It really does get back to being a lifelong learner.

Dr. Thakur: Especially since so many of our patients live longer. They might actually have two or three cancers at the same time. You really have to learn how to manage both. You can't just pick one. Or your biopsy could be misdiagnosed, and you really have to know what was missed so that you can actually direct them to the right team or methods too.

Dr. Hadfield: And everyone can teach you. I've learned just as much from the Nurse Practitioners I work with or the Oncology Nurses as I have from attendings. Everyone has this wealth of knowledge, and the more you know, the easier your job is, the less you rely on other people, and the more enjoyable your job is. I would totally agree with that. Well, I think this was an awesome conversation. Thank you so much for taking the time. I think learning in fellowship seems like a very straightforward topic, but for me it certainly hasn't been, and I think I still refine how I learn and how I absorb information. It's great to catch up with you and talk about these things.

Dr. Thakur: Oh, thank you so much for having me. It was definitely a lot too for me to get into learning, so it's nice to hear that other fellows have also had similar struggles and how they've adapted to grow.

About Dr. Hadfield and Dr. Thakur

Matthew Hadfield, DO, is a Hematology/Oncology Fellow at Brown University/Legoretta Cancer Center in Providence, Rhode Island. Prior to fellowship, he completed his Internal Medicine Residency at the University of Connecticut in 2021. Dr. Hadfield's research focuses on melanoma and early-phase clinical trials. To date, he has published numerous peer-reviewed articles and studies, and he has presented his research at multiple national and international meetings. His main areas of interest include early-phase drug development, novel immunotherapeutic combinations to overcome therapeutic resistance, and predictive biomarkers for immunotherapy toxicities.

Richa Thakur, MD, is both a Palliative Care Physician and Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. She graduated from Washington University in St. Louis with a bachelor's in chemistry, medical school at Texas A&M, residency in Internal Medicine, and a fellowship Palliative Care at Zucker School of Medicine. Her research interests include improving quality of life in patients diagnosed with hematologic malignancies.

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