Trailblazing the Oncology and Palliative Care Fellowship Experience and Finding Your Niche: Richa Thakur, MD, and Nida Khan, MD

Richa Thakur, MD: Hi, I'm Richa Thakur. I'm a first-year Hematology/Oncology (Heme/Onc) Fellow at Northwell, and I'm one of the members of the Fellows Forum. Today, I'm really excited to introduce you to Dr. Nida Khan. She's a third-year Medicine Resident at Northwell as well, and in July, she's going to be starting her first year of a joint Medical Oncology and Palliative Care Fellowship in Ohio. I'm really excited to bring her, because these programs are so new, and I really can't wait for you guys to hear more about them. So welcome, Dr. Khan. It's so great to have you.

Nida Khan, MD: Thank you, Richa. Thanks for the great introduction. It's a pleasure to be here.

Dr. Thakur: Oh, I've been looking forward to this ever since you matched, so I'm really excited. Could you introduce yourself and tell us a little bit more about your interest in oncology and palliative care?

Dr. Khan: Of course, definitely. As you said, I'm a post-graduate year 3 (PGY-3) Internal Medicine Resident, currently at North Shore Long Island Jewish Medical Center in Manhasset, New York. I grew up in the New York area. In terms of what brought me to oncology and palliative care, I think it was a long time coming, thinking about it. I went to medical school at Temple in Philadelphia, and that was my first exposure to oncology and palliative care. Serendipitously, a lot of my core medical school rotations ended up being at the cancer center at Temple, so I was exposed to that cancer patient population and I was exposed to the unique type of palliation that they require.

When I entered internal medicine residency, I knew I wanted to do oncology and oncologic care for sure. The palliative care part, not so much until I went through residency, and I realized that oncology and palliative care are so connected and interwoven. I was surprised to see that at a lot of times, there's not much training otherwise. Oncologists who are trained in these traditional fellowship programs or Heme/Onc programs probably don't get as much exposure to palliative care as you would think so.

So, I knew that this was something that I wanted to do just to be the best oncologist, the best physician, and the best palliative care physician I could be. That's what started getting the wheels turning on what I was looking for in my training and what I wanted to pursue. That's how I came across wanting to do both of these fellowships.

Dr. Thakur: Oh, that's really good to hear, because I definitely agree. In medical oncology, we have to do a lot of primary and secondary palliative care, but that formal training is something you really can't get outside of a palliative care fellowship sometimes. One thing I want to ask you is, a lot of fellows choose a very traditional palliative fellowship, like a one-year palliative care fellowship or a joint geriatric-palliative (geri-pal) fellowship versus a three-year Heme/Onc fellowship. Some of these new programs that combine palliative care with hematology or medical oncology are so new. What made you consider doing a joint program versus one over the other?

Dr. Khan: Yes, that's a great question. It was something that I really had to sit down and think about. As I said, when it came time to apply, I knew at that point that I wanted to do palliative care and I wanted to do oncology. It was really just the order of them and what I thought was the best for the type of training that I saw for myself. When I applied, I knew that the palliative care portion would provide me with the foundations and a different type of outlook for the oncology part. I came in with the idea that, you know what, I'm going to do the palliative care year first so that I have this type of palliative care foundation that I can apply and see my oncologic patients through that lens, which I think for me was very important, and it's the type of physician I wanted to be.

When it came time to apply, I applied mainly to palliative care programs plus these few unique combined programs. As you said, there aren't many of them. Currently, for this past cycle, there were only, I believe, four, and I believe there are a couple more opening for the next cycle. There will be up to six to eight new ones in total for this next cycle. They're very few and far between.

Each program is unique. Each program has their own little timelines, board certifications, and all of that. So, I had to read about it. A lot of these are brand new. A lot of these times, you're going to be the inaugural class. You're going to be the one that's leading the torch in this new field with these new programs. So, you also have to think about that—is that something you're comfortable with? I thought about all these things, and I knew that for me, I wanted that palliative foundation regardless.

When it came to applying, I applied to mainly palliative care programs, looking at unique programs that offered the palliative care training that I wanted, plus these combined programs that I knew from reading about them were able to offer the type of palliative care and oncology training that I was looking for. That's how I approached it, and it was a lot of research and it was a lot of talking to people, including yourself, to just figure out what I wanted.

Dr. Thakur: Great. I think you made a very tough decision, but knowing you, this is such a good fit for you. One thing I've noticed is, these programs are so new—when I applied, they didn't have these. There had been talks for a while, but I think your class was the very first class where they had the four programs, right?

Dr. Khan: Yes, exactly. In some ways, you're in a niche. These programs are part of the American Society of Clinical Oncology (ASCO) Communities of Practice initiative. I went to a lot of these forums and spoke on a lot of Zoom meetings like this where people talk about how they foresee these programs and how they see professional development and careers forming from these combined programs. For me, I think I really connected with that. There's a unique and small community on Twitter that is just so interested in these combined programs. Through talking with them, I was able to talk to some of the people who matched in the other programs and talk about our shared interests.

I think that when you meet like-minded people like that and you're in that bubble of people who have the same interests as you, it really helps, and you just feel more connected and more sure that this is the right path for you. For anybody who's looking for this as a potential to look into these programs as a possibility for themselves, I think you'll feel it and you'll connect to it when you talk to the people who are interested in the same thing. You'll feel it for sure. That's how I felt it.

Dr. Thakur: That's really good to know. So, I think most of the people that listen to this podcast are usually medical oncology fellows, some attendings, and then also some residents that might have an interest in palliative care. What would you recommend for them to look for if they wanted to do more palliative care, either in terms of applying for a formal fellowship, rotations, or any other advice you would have?

Dr. Khan: Certainly. As I said before, when I was looking at palliative programs and what was important to me, I think a lot for me was finding programs that were really big on symptom management and making sure that their trainees were comfortable with that. As someone who sees the bulk of their practice being oncology with symptom management, I wanted to have that foundation. When you look at these palliative care programs, each program has its own niche. Some programs are more hospice-focused. Their focus is more on training the trainees that are going to becoming hospice directors or become involved in the hospice world, the hospice realm.

Others are focused more on symptom management, making sure you know how to control cancer-related pain and the symptoms that come with cancer. Some of them have palliative care units and are trying to train the type of physician who is able to run inpatient palliative care units. Some have all three. Really, I was looking at all of those for sure.

But I think for me, I was looking mainly at programs that would give me a great foundational training in symptom management so that when I am treating these patients, I feel really comfortable in managing cancer-related pain and in making sure that if I'm not completely comfortable in managing that, I have the tools to look that up because I have this great foundational training in palliative care. That's what I was looking for. I think it's different for everybody, but speaking to a group of people that are interested in oncology, I think a lot of that for like-minded people is symptom management. So, that's what I looked for. As I said, every program is different, and you really have to do your research to see which ones fit that mold best.

Dr. Thakur: I think you brought up a very good point too, because palliative care is really brought up with the needs of different groups. It's most closely associated with hospice because that's what people think, but there's such a huge need with geriatrics, some of it in the intensive care unit (ICU), and then also in the oncology realm. Making sure that there's a good cancer basis and symptom management, of course, is a very good point.

Dr. Khan: Yes, 100%. Palliative care itself is a field where you have people coming into it from all different specialties—internal medicine, emergency medicine, pediatrics, people who are going on to surgery, or home critical care. Each one of those people has their own type of reasons for doing palliative care, but it's also because palliative care is so applicable to all these specialties. I think that's what makes it so great, and it can only be beneficial for people who are interested in pursuing that type of training.

Dr. Thakur: Absolutely. Do you have more specific interests within palliative care and in medical oncology in terms of research, patient population, or advocacy?

Dr. Khan: Yes, for sure. Ever since my whole arc in medical school, I think part of what I'm interested in and my whole medical training is global health. Before I went into medicine, I worked at the United Nations for a bit. Global health has always been something I'm super interested in. Part of that, now that I'm going into palliative care and oncology, is seeing how that applies to global health, so part of the patient population I'm interested in is the global health population.

Recently, back in February of this year, I had the great opportunity to go to Uganda, specifically southwestern Uganda. I worked for a month in a rural government hospital there. I worked really closely with the inpatient wards and also palliative care and oncology. The needs and resources are completely different than in the States, but I just really love that patient population. I really love how palliative care and oncology are different in different areas and learning how we can tailor what we learn to that patient population. That's something I'm interested in exploring more about. I've spoken to the Uganda Palliative Care Association and have seen how their needs are different than here. That's just something that I think will always be dear to my heart, something that I really love, and something that I'm working on as well in the palliative care realm.

Dr. Thakur: Absolutely. That sounds like such a life-changing experience. I think a lot of people don't have that opportunity to look for global health opportunities, but for people that are interested in global health, do you have any recommendations, advice, or resources?

Dr. Khan: For sure. I got lucky because my residency has this partnership in Uganda, so I think the first place to start would be looking in your training program. I'm sure that there's somebody in your training program that has been involved in global health at some point and can offer some insight. If not, then there are a whole bunch of associations. There are actually, as I mentioned before, the ASCO Communities of Practice, and one of them is a global oncology group that I'm a part of. There are always posts on those about people doing work across the world and in different countries. You can definitely connect with people that way. There are a lot of programs across the world, and there's no shortage of it where there's this longitudinal type of clinical work that you can do depending on the region you want to be in. I think it'll take some research, but those programs are out there for sure.

Dr. Thakur: Thank you for sharing that, because I think these areas of oncology palliative care aren't talked about enough, and making sure people have exposure to this is very important. The last question I have for you is for any of our viewers that are interested in applying for a joint palliative care with either hematology or medical oncology program. Do you have any advice specifically for the application process?