Stephen V. Liu, MD; Ronald J. Maggiore, MD; Sheetal M. Kircher, MD

Disclosures

July 27, 2015

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Stephen V. Liu, MD: Hello. I am Stephen Liu, assistant professor of medicine at Georgetown University and medical oncologist at the MedStar Georgetown University Hospital in Washington, DC. Welcome to this edition of Medscape Oncology Insights, coming to you from the 2015 Annual Meeting of the American Society of Clinical Oncology (ASCO).

Every year at ASCO there are more sessions focused on career development for young oncologists, but establishing yourself as an effective and valued junior faculty member involves day-to-day effort. This roundtable will focus on the unique challenges faced by junior faculty in oncology.

I'm pleased to welcome Dr Sheetal Kircher, assistant professor at the Feinberg School of Medicine and faculty physician in hematology and oncology at Northwestern Memorial Hospital in Chicago, Illinois, and Dr Ron Maggiore, assistant professor of medicine in the Division of Hematology and Oncology at the Oregon Health and Science University and staff medical oncologist at the Portland Veterans Affairs (VA) Hospital. I'm glad you could both join us.

Tips on Finding Your First Position

Dr Liu: A good place to start would be the process of finding and choosing your first position. With the benefit of hindsight, what advice would you offer colleagues looking for their first position?

Ronald J. Maggiore, MD: First of all, in terms of finding and looking for a position, be true to yourself and what your goals are. Where do you see yourself trying to establish a career and a niche, whether it's in academics or in community practice or perhaps not in practice—in consulting work or pharmaceutical industry?

You've just spent a decade in school and training, and you're essentially looking for your first job.

Also, if there's a particular setting in which you wish to practice, get advice from colleagues who've been in that institution or people who might know others at that institution, to get a sense of whether it might be the right fit and worth applying there.

Sheetal M. Kircher, MD: For fellows, you've just spent a decade in school and training, and you're essentially looking for your first job. The process isn't straightforward. Most people look online for job postings. In medicine, I think that there are a lot of other avenues to get into that job or to even know whether there is a job available.

What I ended up doing was talking to mentors, seeing where other people have trained, and using them as resources to help navigate the system and maybe reach out on my behalf. I did a lot of cold emailing and cold calling, which was really uncomfortable, but that's how I found my job after fellowship.

Dr Liu: I think that's how it works. While there are job postings in journals and online, not all jobs are posted. Often by the time they're posted, they've already got people in mind, so you need to reach out. Sometimes geography plays a role. If you have a city that you're looking in, you may start to email or contact those specific institutions.

Ron, how did you find your current position?

Dr Maggiore: I knew I wanted to have at least some of my practice and clinical experience at a VA hospital, so that narrowed down the search process a bit. There are formal websites to look for VA jobs, but if they're tied to an academic institution, they may not be readily posted, especially if there's a faculty appointment.

Mentors may know what institutions are looking for in their ideal candidates.

As Sheetal mentioned, it is important to send those cold emails or make those cold calls to institutions you may be interested in. There might be a potential mentor there, or for personal reasons—your spouse and family—you have to be directed to a certain part of the country. You need to make those connections because—I think we're all in agreement—in our field, at least the academic positions are not necessarily listed on Indeed.com or other job search sites. You have to call and ask.

If you don't know, work with your mentors as a trainee. Mentors may know people at other institutions or know what institutions are looking for in their ideal candidates, and that could help focus your search a bit more.

Dr Kircher: Exactly. In my own experience, a lot of my decisions on where I wanted to be depended on my family. At the time, I had two young children and a husband who was also in medicine. Although I was very committed to continuing in academics, I was open to a lot of different practice settings.

The Challenge of Staying Where You Are

Dr Liu: I think those are great points. My experience was a little different. I stayed at the same place where I did my fellowship. I know that's a common path, and in a lot of ways it's a very easy path. You know the system. You know the referring doctors, your colleagues. You can jump right in and hit the ground running. But I think we can certainly talk about some disadvantages to that as well.

Dr Kircher: There are definitely some challenges to staying at your own institution.

Dr Liu: Because the transition from fellow to attending physician or from fellow to faculty member is sometimes not readily acknowledged by everyone in the division.

Dr Kircher: What was it like on the last day you were a fellow and the first day you were an attending? Were you treated differently?

Dr Liu: I immediately started calling everyone by their first name.

Dr Kircher: Wasn't that hard? I had a hard time with that.

Dr Liu: I had to force myself to do that. A lot of times when people ask you to do certain things that are what they would ask fellows to do, you have to speak up and say, "I am not a fellow. It's not appropriate for me to be doing those things." That can be a very difficult transition.

If you're at a new institution, that part of the transition may be a bit easier.

Dr Kircher: Right. Not only them seeing you now as an attending physician and a colleague, but also seeing yourself as an attending physician and a colleague of theirs.

Selecting a Subspecialty: Marrying Need With Passion

Dr Liu: I think that can transition into the next part: finding a niche, finding a subspecialty. None of us here are general oncologists. We all have areas that we focus on. How do you make those choices?

Ron, you are involved in head and neck cancer and lung cancer. Was that something you experienced in college, residency, or in fellowship?

Dr Maggiore: For me, it was a bit of serendipity because I had trained originally as a hematology fellow and was transitioning to focus more on solid tumors and pursuing a medical oncology fellowship specifically. Because of that, I didn't have to repeat all of my hematology training in my medical oncology training period. In my fellowship, I was on the chemotherapy service a lot more, where it was predominantly head and neck cancer patients. Fortunately, it worked out that it was a patient population I liked taking care of, and then it transitioned to getting more outpatient experience.

Be flexible, especially while you're figuring out your place in the institution.

I fell into that niche, not by choice necessarily, but it ended up working as a win-win.

Dr Kircher: I think that it's important to be flexible, coming right out of fellowship, especially while you're figuring out your place in the institution, private practice, or whatever setting you are in. It's important to marry your need with your passion. I think that is really important to success.

When I first came to my current position, I focused on gastrointestinal (GI) cancers, which I had been doing since fellowship, but I was also seeing some genitourinary (GU) patients and prostate cancer patients because that needed to be filled. I enjoyed seeing those patients as well. Especially right out of training, I think we can probably treat the most number of diseases. As we specialize more and more, it gets harder to be as flexible.

Dr Liu: Demand can come into play when you're looking for a position as well. For me, my focus during fellowship and my research was in GU cancers, but because staying at the specific institution was important to me, I knew that if I took a job in that specialty, I would be redundant. Redundancy is not a great characteristic for a young faculty member. So I made a switch to an area where there was a need, where I knew there could be growth, where I knew there were opportunities to take advantage of. That can be an important factor in where you start.

Dr Kircher: Both clinically and in research, developing that research mentorship, especially within academia, is important, and so is distinguishing yourself in your specific niche. In my case, I'm very interested in the impact of cancer policy and cost. That was a niche that my institution really needed. Finding that place makes you valuable.

Dr Liu: Sometimes it does work out, but it's something you have to factor in. If your passion is GU oncology and the institution that seems perfect for you has six GU oncologists and you're going to be number seven, maybe it makes more sense to go to a different institution or to choose a different specialty.

Dr Maggiore: The key for people who are transitioning to junior attending physicians or junior faculty is flexibility. When you are looking at jobs and are then in the early or final negotiations of that tradeoff, maybe you do have to focus on a few other disease types to eventually get to that focus that you really, really want in the end.

Dr Liu: Certainly, in choosing your initial position, everyone's experience is going to be unique. There's no blueprint. There's no roadmap to follow. Every specific case is going to be a little different.

Relocating to a New Position

Dr Liu: Sheetal, you and I have some experience on the opposite end of things: leaving your first institution at a relatively early point in your career. What was that experience like for you?

Dr Kircher: That was a challenge. Right after fellowship, I had a position, a faculty position, for about 2 years. I had gone there for family reasons and was leaving to come back to my home institution where I trained, and it was a little uncomfortable. I hadn't been there long enough to really establish myself and have what I felt was the authority to even leave at that point.

But it's important, ultimately, to do what's best for your career, your life, and your family. Sometimes that means leaving after 2 years, and ultimately people understand. Complete transparency is what made that less of a barrier. I went into that position being very clear that I may be leaving soon, and they continued to support me and support my growth, which turned out to be fantastic.

It's important, ultimately, to do what's best for your career, your life, and your family.

Dr Liu: When we think of the time to move, we may not think that after 2 or 3 years is the ideal time. There is no ideal time. Whenever the circumstances necessitate that kind of a move, then you should move. As long as you're open, I think your colleagues will be very supportive of you.

Dr Kircher: Exactly.We spend so much time in training that sometimes we also run this parallel thing called our own lives, with families and, potentially, children. So, finding that balance is important and really does guide what our career decisions are.

Learning When to Say No

Dr Liu: That's a topic that we should probably talk a little more about. Once you start your new position and begin to build to your practice, competing responsibilities quickly grow, whether it's family or even something within work—different committees, job responsibilities. Balancing these commitments, I think, is one of the biggest issues that a young oncologist or a junior faculty member will deal with.

 
We're naturally inclined, starting out as a new attending physician, to say yes.
 

A readily available example would be different committees. I know for a fact that the three of us are on various committees at our institutions. Ron, what has your experience been with committees? Do you have any advice for people just starting?

Dr Maggiore: We're naturally inclined, starting out as a new attending physician, to say yes and to become leaders at our institutions, and maybe on national or international meetings or committees. By the same token, each commitment you make to serve on a committee or activity takes time away from other things, whether that's patient care, education, or research, as well as your family and personal life.

It's hard in the beginning because you're still learning things. You're still trying to develop your niche and your trajectory (how you see yourself in 5 years, 10 years) and to start prioritizing. I would say to look at each activity in terms of what the inherent worth is of that activity.

If it's something that you feel passionate about and you see that it's going to potentially lead to better patient outcomes, patient safety, personal satisfaction—it gets you to the next step of where you want to go in your career—you're going to want to continue and devote the time. It won't seem as onerous to do so. Then you need to try to figure out what doesn't contribute to your career development, personal growth, or growth in your division. All of that has to be taken into account.

Dr Kircher: I don't think you need to make that decision in isolation. Even though we finished fellowship, we still have mentors.

Dr Maggiore: Right. Talk with your mentors. Talk with your division or section head. Talk with your spouse and family, because they may want to weigh in if it requires a lot of travel. For example, if you're on a national committee, you may be pulled multiple times to do that. Figure out: "Is it worth that? Maybe I have to give up this other activity at work that may not be as significant." I think it's coming back to what your priorities and values are. Is it going to help you in the long run? Is that good stewardship going to pay off?

Dr Kircher: You've got to be part of the team, but not at your own expense.

Dr Liu: Because you're going to be asked.

Dr Maggiore: If that's going to contribute to burnout, which is obviously a hot topic for oncologists at ASCO[1] and other venues, then there is a potential downside to overcommitment.

Dr Liu: Certainly our patients deserve a lot of attention, but oncologists in general—and maybe young oncologists specifically—have a reputation of bringing some work home with them. You can't avoid that completely.

Do you have any advice on dealing with life outside of work?

The Double Pull of Home and Work

Dr Kircher: That was a big challenge for me that I actually didn't expect coming out of fellowship. I didn't realize, until I became an attending, that shelter we live under as fellows.

Dr Maggiore: Yeah, you're protected a little bit.

Dr Kircher: I didn't realize that existed until I was an attending, and all of a sudden the gravity of my decisions really affected me a lot. I had a hard time separating work and home. I'm busy enough at work, let alone at home, which is a whole other circus.

I don't have the solutions. I feel that as a community, work-life balance is something we all struggle with, and turning off work when you're at home is sometimes really hard.

Dr Liu: But I think it's important because when I'm home with family, if I'm checking emails related to work, if I'm taking calls, I'm not 100% there, and that's not really fair to my friends and family. In addition, that contributes to burnout, because when you go on vacation, if you don't come back fully refreshed, it wasn't really a vacation.

Especially on weekends or when you're not on call, set aside time.

Dr Maggiore: Correct. To add to that, everybody's home situation is going to be a bit different, but one thing I can offer: There is no prescription for how to juggle the work-life balance and to make that balance more positive in terms of less stress, less risk for burnout, less job satisfaction or more job satisfaction. But, especially on weekends or when you're not on call, set aside time.

I try to do that as much as I can with my spouse, to say, "Saturday, for sure, is our day where I'm going to do everything I can to avoid checking my email," although the temptation is high. Sometimes I'm weak and succumb, checking my work email or the electronic medical record if there's an alert. For our own personal health and happiness between work and life, we do have to set some boundaries.

Dr Kircher: We all want to take care of our patients. We have very sick patients who depend on us.

Dr Maggiore: You don't want burned-out physicians.

Dr Kircher: That's why we went into this. Taking care of ourselves, being kind to ourselves and our families and that aspect of our lives, will make us better physicians, which is our ultimate goal.

Dr Liu: And the patients will benefit.

Dr Kircher: Yes, patients will benefit.

Dr Liu: Sheetal and Ron, thank you for your insights. It's been a great discussion. Thank you for joining us in this edition of Medscape Oncology Insights. This is Stephen Liu, reporting from ASCO 2015.

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