Dr. Jain is an academic Hematology/Oncology physician in the Chicago area. She discusses the heme/onc docs role and what she likes so much about it.
Full show notes coming soon!
Dr. Ryan Gray: Specialty Series, session number 8.
Whether you’re a premed or a medical student, you've answered the calling to become a physician. Soon you'll have to start deciding what type of medicine you'll want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome to the Specialty Stories, my name is Dr. Ryan Gray, and I am your host for this podcast as well as many other podcasts. You can check out everything that I do, or we do here at the Medical School Headquarters. You can see all of our podcasts at www.MedEdMedia.com. That's www.MedEdMedia.com.
This week I have another specialty for you to learn about. This one is a specialty that has a lot of sad facets, but also a lot of awesome facets, and you'll hear Shikha talk all about it, about being a hematologist oncologist.
Meeting Dr. Shikha Jain
Dr. Shikha Jain: My name is Shikha Jain, and I'm a hematology oncology physician.
Dr. Ryan Gray: And are you in an academic or community based setting?
Dr. Shikha Jain: So I'm in an academic setting. It's a little bit of a hybrid group because it used to be a community group that was bought by the academic center. And so now we are academics who practice more clinical medicine but also have research involved.
Dr. Ryan Gray: Interesting. Okay and how long have you been practicing?
Dr. Shikha Jain: For about a year and a half.
Dr. Ryan Gray: Relatively new. Is it as exciting as you thought it would be still this fresh?
Dr. Shikha Jain: Absolutely it is. The first couple of months are a little bit scary because you don't really have anybody to oversee what you're doing, and when someone says, ‘Who's the attending?' and they say your name you think they've made a mistake the first couple of times. But it is definitely still exciting a year and a half in.
Dr. Ryan Gray: That's great. When did you know you wanted to be a hematologist oncologist?
Dr. Shikha Jain: So it actually was the second year of my medicine residency, and I remember it very clearly actually. I was on the bone marrow transplant service, and I had this patient who was so involved in his care, and he was so engaged, and so interested in what we were doing, and wanting to work with us as a team, and it was extremely collaborative which I hadn't seen in a lot of other sub-specialties. And I really liked that aspect of working with the patients, and having the patients respect what you were saying, but also give their own opinions. A lot of the patients have done their own homework and done their own research, and I joined at a public hospital so I saw a lot of different types of patients, and no matter what background they came from they would always come with at least some questions because when it comes to cancer medicine there's a lot of stuff online, and a lot of people when they find out they have cancer, they do a lot of their own research. So I really liked that kind of team approach that a lot of the patients viewed their cancer diagnosis as. So once I realized that I could actually practice medicine working with my patients as opposed to just dictating to them, I realized it was a really amazing field to be able to practice.
Dangers of Dr. Google
Dr. Ryan Gray: So I'm going to go off on a tangent here which I normally don't do, but how is that different than when we often hear physicians complaining about patients using Dr. Google, and coming in and telling the physician what they want?
Dr. Shikha Jain: So Dr. Google is very dangerous. I still to this day tell all my patients, ‘Do not Google what I'm about to tell you,' and it does happen, and it can get frustrating because they do come in with a lot of misinformation, they often come in with a lot of cancer myths or things that are not really based in fact. So that can get frustrating if you let it get frustrating, but the really cool thing in oncology is when- I mean it's really scary for patients when they find out that they have cancer, when they hear the big ‘C' word they get really scared, and so it's human nature to go start looking for all this information. The really cool thing is they're interested in their diagnosis and they really want to work to fight it so they bring in this information because they think- they want to give themselves- they want to give you the most information that they have, and oftentimes they are more willing to listen because it is a cancer diagnosis, and because you're a cancer specialist, and they want to do everything they can to get rid of the cancer. A lot of times when I was doing my medicine residency I'd get really frustrated when patients would come in with information on diabetes, and hypertension, and say, ‘Oh I don't need my medication anymore because my diabetes is fixed, and this website said that I don't need my insulin.' And it's harder for people to really wrap their minds around the complications and the long term effects that can happen by having uncontrolled diabetes or uncontrolled hypertension because it's just not something that we talk about as much in the general public. But cancer is a diagnosis that everyone knows can be very dangerous, can be very difficult to deal with, so I found that patients were more willing to listen and work with you even if they came in with their own research. And you know just like in any specialty there's patients who will come in and they won't necessarily believe what you're saying, or they'll believe Dr. Google more, but it seems to me at least through training and as an attending that it seems more collaborative and they're more willing to listen to your opinion, and listen to your medical advice, and when it comes to cancer it's just a very different mind-set and a very different mentality than some of the more chronic illnesses that people don't necessarily realize can cause long term problems.
Dr. Ryan Gray: Yeah there's a figurative clock ticking when you get that cancer diagnosis so I think it opens up peoples' eyes. Okay that makes sense, no I'm glad I went off on a tangent there. What traits do you think lead to being a good- actually before I even ask that. So the term hematologist oncologist, why are there two specialties wrapped into one?
Hematology and Oncology Wrapped Into One
Dr. Shikha Jain: So hematology and oncology are very different and they're also very similar. As medicine progresses they're actually becoming more and more different as we go through care, but they're also becoming more and more similar. And it sounds like very contradictory but I'll explain why. So hematology is the study of blood disorders, so that can be anything from an iron deficiency anemia, to a lymphoma, to chronic leukemias or acute leukemias. The oncology part is cancer diagnoses like solid tumors, so breast cancer, lung cancer, GI cancer. The reason they are so different is because hematology also includes a lot of benign disorders like gestational thrombocytopenia where you see a pregnant woman who has a low platelet count, or a B12 deficiency leading to anemia. So you also encompass these benign disorders but then you also see what we call blood tumors, or blood cancers. The oncologist specifically only focuses on solid tumors. So they're different in that sense, but the really cool thing that's happening in HemOnc these days is the latest and greatest treatment options out there are actually immunotherapy which is different from chemotherapy, and the reason I bring that up is these new treatments- we're finding similar treatments actually work for both the liquid or the blood tumors and the solid tumors. So there's actually becoming now a bit more overlap in some of the hematologic disorders and some of the oncologic disorders. But they are two separate fellowships that typically are combined, but you can do just a hematology fellowship or just an oncology fellowship at certain institutions if you so desire.
Dr. Ryan Gray: Okay and remind me again, so your training is in both?
Dr. Shikha Jain: In both. So I'm triple boarded in internal medicine, hematology, and oncology.
Dr. Ryan Gray: Okay, lots of tests. That's fun for you.
Dr. Shikha Jain: Lots and lots of test.
Traits of a Good HemOnc Physician
Dr. Ryan Gray: What traits do you think lead to being a good HemOnc doc?
Dr. Shikha Jain: So I think there's- some of them are traits that are just good traits for if you want to be a clinic clinician- a clinical physician. So I think communication is really important. A lot of times you're dealing with very, very sensitive topics and you have the privilege of being involved in people's most intimate parts of their life. You will be guiding them through positive curative treatments and you'll be guiding them through positive palliative and hospice treatments. So it's really important to have good people skills, good communication skills, and good- the ability to really be empathic. On top of that, because there's always changes and new developments, and new treatments coming out, having a real thirst for knowledge and that desire to be a constant learner, and to continue educating yourself, continue being involved in online forums or whatever it is to keep you up to date on the latest treatment options is very important. You need to be willing to be constantly updating your repertoire. And then it's always- in a lot of medicine research is important, in HemOnc clinical research I think is extremely important because there are so many changes that are coming about. A lot of clinicians don't end up doing any research in their career, but being able to really read and appreciate research studies and understand how to analyze and interpret them is something important when you're trying to figure out what type of treatment to give your patients as the treatment paradigms change.
A Day in the Life
Dr. Ryan Gray: Okay. Describe a typical day for you.
Dr. Shikha Jain: So HemOnc is typically an outpatient field. My typical day- so I have clinic- most HemOnc docs who are in the community have clinic about four days a week. If you're in academics it's typically a couple of days a week. My clinic starts around 8:00 in the morning and goes until about 5:00 in the evening, and you see patients throughout the day. I'll see anything from people who are very, very sick, to people who are cured, to people who are just coming in for iron infusions for their iron deficiency. I see my patients who are admitted to the hospital as well, so if I have a couple of patients on the inpatient service either before clinic or after clinic I'll go and round on them. And a couple days a week I attend the tumor boards that we have at the hospital. There's different tumor boards for different cancers, and I try to at least go to a couple a week just to make sure that I'm keeping myself up to date on the different treatments, and getting the opinions of a multidisciplinary board in some of my patients and how to treat them.
Dr. Ryan Gray: Explain a little bit more what a tumor board is.
Dr. Shikha Jain: So a tumor board is actually something- I think it's a really cool experience. It typically is several oncologists, you'll also have radiation oncologists, surgical oncologists, pathologists will be there, sometimes- depending on the tumor board you go to, if you go to a long tumor board, the pulmonary doctors will be there, if you go to a GI tumor board the GI doctors will be there, and it's basically a multidisciplinary approach to treating patients. So what'll happen is you'll submit a case and you'll present that case. So if you had a 25 year old with metastatic lung cancer, you would present the case, the pathologist would describe whatever biopsies have been done, the radiologist would then describe the imaging, and then we would discuss the case with everybody who is there. The surgeons would weigh in to see if there's anything that would be a surgical option, the radiation doctors would give their opinion on whether radiation is a good idea, and then oncologists talk about systemic therapy. And that way we come up with a plan as a multidisciplinary team, so everybody kind of weighs in, and that way the patient's able to get a really great team approach to whatever plan they're going to have for their cancer.
Dr. Ryan Gray: Are patients ever involved in that?
Dr. Shikha Jain: So they typically aren't because of HIPAA, we can't really have patients there hearing about other patients. Typically what we do is we'll see the patient that week, we'll tell them we're going to present you to a board later this week, and then we'll tell you what we discussed next week and come up with a plan that works for you.
HemOnc Doctors Being on Call
Dr. Ryan Gray: Okay. Is there a lot of call for HemOnc docs?
Dr. Shikha Jain: So it depends on your practice that you're in. For us, what we do is we take our own patients call during the week. So Monday through Thursday if any of our patients get admitted to the hospital we get paged, which typically results in maybe one page a week- one or two pages a week I would say for me. And that is just from home, so you just have to answer questions over the phone, you don't typically have to go in. And then on the weekends, the way my group does it is we take call about once a month on the weekends, and what that entails is going in and rounding on the patients who are in the hospital for a few hours in the morning, and then taking the pager call for the weekend. So if any patients called with questions, or if someone got admitted, we would get paged. But the nice thing about HemOnc is you very rarely have to actually go into the hospital, most things can be handled over the phone when you're on call.
Achieving Work Life Balance
Dr. Ryan Gray: Okay. Do you feel like you have good work life balance?
Dr. Shikha Jain: Absolutely. I have a two and a half year old daughter, and my husband's also a physician, and there are days where I'll get home later than he does, or I have to leave earlier in the morning, but I really have the flexibility with this position and with this career to do as much clinic or as little clinic as I want. I can start clinic when I want, I can finish when I want, and taking home call and not having to go in the middle of the night is really great. I'm able to make it to a lot of my daughter's activities. When you're in a field like this, people typically are very supportive, and so if you need to take a couple of hours off to go to an activity or a doctor's appointment or something, people are pretty willing to cover and help each other out. So I have a lot of flexibility and I think a lot of HemOnc docs feel that way.
Path of Training to Hematology Oncology
Dr. Ryan Gray: Great. Describe the path through training to end up where you're at now; the length of training, and applications, and stuff like that.
Dr. Shikha Jain: Sure. So after the four years of medical school, first you have to match into an internal medicine residency program. So you do three years of internal medicine, and during your internal medicine residency you apply for your fellowship. So that'll be a HemOnc fellowship which is another three years. So it's four years of med school, three years of residency, and then three years of fellowship. If you decide you only want to do Hem, or only want to do Onc, then you could do a fellowship in two years but most people do both.
Dr. Ryan Gray: The Hem only and Onc only fellowships, can you do those at a HemOnc fellowship but you just tell the program that you only want to do one? Or are they very specific Hem only fellowships and Onc only fellowships?
Dr. Shikha Jain: They're very specific. So there's only a couple of hospitals that offer a Hem only or Onc only. For example the NIH I know offers only Hem or only Onc, but they also offer if you want to do both, you can do both. Typically people who only do Hem or only do Onc, they know going into fellowship that they want to only stay in academics, and by doing just one fellowship they're able to advance their research schools. So most people who aren't sure if they want to stay in academics or go into the community do both fellowships, and then if they decide afterwards that they want to specialize in just one, then they can decide that when they're done with fellowship. But it gives you a lot more flexibility if you do both fellowships.
Dr. Ryan Gray: Okay. Is- so two questions in one. Is matching competitive? And what makes a competitive applicant to a HemOnc fellowship?
Competitiveness in the HemOnc Field
Dr. Shikha Jain: So matching is pretty competitive. When I applied, HemOnc was I think the second or the third most competitive internal medicine sub-specialty field. So it is pretty competitive and part of it is because it's such a great work life balance, and because a lot of people find it extremely rewarding. So it has become more competitive in the last decade or so I would say. Things that would make you the most competitive applicant for HemOnc would be research is something that they really look at, so whether it's clinical research or bench research, those are two things that are very good to get started on as early as possible. Even if you don't necessarily get publications out of it, at least having that experience on your ERAS application and on your CV are very helpful and they often come up on interviews. I had published several case reports as well, and had posters at things like the American College of Physicians conferences, and things along those lines show that you're interested and continually learning. So those are also things that would make you very competitive. Obviously letters of recommendation are always helpful if it's possible. If you're interested in doing HemOnc and you're able to do one of your elective rotations in Hem or Onc that would be useful as well because you could get a letter from a physician in the field specifically who might also be able to help guide you into the types of fellowships that you want to be looking at.
Dr. Ryan Gray: Do you see any bias between or any bias towards DO students versus MD students?
Dr. Shikha Jain: So I think that it is becoming less and less than it used to be. I actually went to Michigan State Medical School in the MD program, but Michigan State has an MD and a DO program, so I have a lot of friends who are also DO's, and I actually had some people in my fellowship who were also DO's. So I think that that disparity from years ago is not there as much as it was anymore. I'm seeing less and less people looking at the MD versus the DO as opposed to looking at the actual application.
Dr. Ryan Gray: What should students be thinking about when choosing a fellowship training spot?
Dr. Shikha Jain: Do you mean like a location, or the type of hospital, or both?
Dr. Ryan Gray: The program itself. How do you evaluate, and obviously on this side of it now knowing the types of patients you're treating and so forth, and looking back at your training. What maybe would you have done differently, or what would you have looked at differently to choose where you wanted to do a fellowship?
Dr. Shikha Jain: So I think that is an excellent question. When I was in residency- and this is probably going to be more useful for the med students as opposed to the premeds who are listening to this podcast, but when I was looking at my fellowships I looked at a wide variety. I looked at very, very academically rigorous programs, and I looked at more community programs. I think the most important thing when you're in residency if you decide to do HemOnc is kind of figuring out if you think you're going to want to be more on an academic track down the line, or if you think you might want to be in more of a clinical seeing patients track down the line, or if you want something in between. Because there are some fellowship programs that are very, very focused on research, and very focused on getting the fellows focused on one cancer type. For example you might go to a fellowship and by the end of it see thousands of lung cancer patients, but only see two GI cancer patients. So those fellowships are really geared towards sending physicians into the academic world, and they're really focused on making you great academicians, and making you very ready for research, and ready for focus, and ready for one path. Other fellowship programs are very good at giving you a very good overall clinical experience and seeing every type of oncologic disorder, seeing every type of hematologic disorder that you can see in those three years, and they really gear you towards either a private practice clinical practice, or they give you the flexibility where if you decide to go into academics you can make that decision down the line, you don't have to make that decision in your first year of fellowship. So that's something I didn't necessarily realize when I was applying for my fellowships. I was definitely impressed with some of the very big academic centers that I was at- that I was interviewing at that were NIH certified, they were NCCN certified. So they had all these great qualifications but the majority of the fellows who came out of there went only into academics. And then I interviewed at other places where there was a good mix of the fellows coming out going to either academics or into private practice or clinical practice. So I think really looking at where the graduating fellows end up post-graduation is very useful in figuring out, ‘Do I already know I want to stay in the academic tract? Or do I think I want to do something less academic? Or do I not know? Do I want that flexibility to know in three years when I'm done?' And I think that's something that they don't necessarily teach you in residency but it's a very good thing to look for when you're looking at fellowships.
Opportunities to Sub-Specialize
Dr. Ryan Gray: Okay. After fellowship training, are there other opportunities to sub-specialize?
Dr. Shikha Jain: There are. So if you realize that you're very interested in bone marrow transplant for example, some places offer another year of training for bone marrow transplant. If you decide you want to sub-specialize in say just lung cancer or GI cancer, and you end up at a large academic institution, there's a lot of on-the-job training. There's not necessarily a second fellowship for that, but you have the option to do that. There's also some oncologists go into another year of palliative care training, so that's another sub-fellowship that you can do. So there's definitely other options if you decide to do further training after HemOnc.
Board Exams for Hematology Oncology
Dr. Ryan Gray: Okay. What do the boards look like for HemOnc?
Dr. Shikha Jain: Well they are not easy. They- so the HemOnc boards are two separate days, they're typically in October, and you do- they're basically back to back. So you'll finish your fellowship in July, and then the boards will be in October, and it's sometime in the end of October. So you'll have one on like a Tuesday and the next one on Wednesday. So it is difficult because you're taking two board exams, but the nice thing is because Hem and Onc do have some overlap, studying for one kind of helps study for the other, but there is a lot of stuff on the Hem boards that you wouldn't see on the Onc boards.
Dr. Ryan Gray: Do you know the pass rate?
Dr. Shikha Jain: I don't know the exact pass rate but I think it's somewhere between 85% and 90% I think, but I'd have to look at that for sure.
What Dr. Jain Wishes She Knew Then
Dr. Ryan Gray: Okay. In your position now on the other end of training, what do you wish you knew- other than what we kind of already talked about with fellowship training, what do you wish you knew before going into your fellowship training?
Dr. Shikha Jain: Well I think one thing that's really important- this is actually something I discussed with some of the fellows when I was a resident. HemOnc can be very emotionally draining, and I think you know that going in, but I'd never done really outpatient HemOnc going into my fellowship, I'd only done inpatient, and one thing I asked one of the residents because we were having a really bad month of just really sick patients, and I asked this fellow, I said, ‘Why did you choose this field? Everybody's dying. It's sad.' And he told me, he said, ‘Well first of all outpatient HemOnc is very different from inpatients. And second of all, there are very few fields in medicine where you can actually cure someone.' And the thing that I think helped me get through some of the tough times in fellowship was thinking back to that statement. That yes there are a lot of really difficult people we deal with, a lot of difficult cases we deal with, but we really have the opportunity in many cases to cure people. And I wish that someone had told me that early on because I think it would have given me that little silver lining, or that hope that you need sometimes to get through really difficult sad cases. So that's one thing I wish that I had kind of thought about before going in. And the other thing is just realizing- and this is something I knew but I don't think you really realize it until you get in there, is making sure you really keep a good work life balance. I'm very fortunate in that I have my husband who has been with me throughout a lot of this, and we've kept each other sane I think going through all of this training. But keeping a good work life balance, and making sure that you still take time to take care of yourself, and do self-care, and make sure that you're mentally doing okay, and make sure that you're still doing things that give you stress relief because everybody needs that and it's really easy to get kind of bogged down in the weeds of fellowship, and trying to learn everything you can. So it's actually something people used to tell me but I don't think I really took it to heart, so I guess it's more something that I wish that I had listened to more when I was going through it.
Working with Other Medical Professionals
Dr. Ryan Gray: Okay. What do you wish primary care providers knew more about HemOnc and what you do?
Dr. Shikha Jain: So I think one of the biggest difficulties that oncologists face when it comes to primary care physicians is we- whenever a patient has cancer, a lot of times they get very, very sick while you're treating them, and oftentimes most side effects or most complications, there's things that happen people kind of attribute to the cancer or to the chemotherapy, and don't necessarily always look for other issues because there's always this cancer diagnosis or this chemo treatment that's going on, so it kind of becomes a default that that must be the problem. So sometimes that can get kind of frustrating because we feel like sometimes things aren't looked into as closely because it's kind of written off as, ‘Oh it's the cancer or it's the chemo.' One thing I will say, the primary care physicians that I work with are fantastic, and they really work with us. I think that communication is really key, and we've educated each other when it comes to dealing with oncology patients. A lot of times- and I think a lot of primary care docs know this, but a lot of times the Onc patients don't necessarily hear what you're saying, so when you talk about prognosis, when you talk about goals of care, the conversations no matter how many times you have them, a lot of times they aren't necessarily registering for the patients. And so sometimes you get primary care physicians who are frustrated because they feel the oncologist isn't having these conversations, then the oncologist gets frustrated because the primary care physician doesn't understand that we are having the conversations, but they're just not- the patients just aren't registering the information because it's hard to process some of these very difficult things to hear. So I think that's probably one of the most frustrating things that happens on both ends, on both the PCP's end and the oncologist's end. But I think with good communication that's something that we can usually rectify and usually get through. It's more really making sure that the oncologist and the primary care doc has a team-like approach so that everybody's on the same page when it comes to those types of discussions.
Dr. Ryan Gray: Are there any specific specialties that you work more with than others?
Dr. Shikha Jain: Yeah so we work a lot with the radiation oncologists and the surgical oncologists. I work quite a bit with the pulmonary doctors and the GI doctors because they are- they do a lot of the scopes for us, and biopsies. We do a lot with the IR physicians as well because they do a lot of our biopsies as well, and port placements, [Inaudible 00:28:49] and things like that. And then pathology, we work quite closely with pathology and radiology as well.
Dr. Ryan Gray: Okay and IR I'll throw it in there is interventional radiology.
Dr. Shikha Jain: Yes, interventional radiology. Sorry about that.
Opportunities Outside of Clinical Medicine
Dr. Ryan Gray: That's okay, that's what I'm here for. Are there any special opportunities outside of clinical medicine for HemOnc?
Dr. Shikha Jain: There are, actually there's quite a few opportunities outside of HemOnc. So I know some HemOnc docs finish fellowship and go into the industry which basically means either working for pharmaceutical companies, helping create new drugs, or helping create new studies to help new drugs get on the market. Some HemOnc docs actually work with the pharmaceutical industries to create new drugs, so in the lab. There's opportunities to give- to educate, to give talks on new drugs and new therapies. So there's a lot of opportunities in industry, or in the pharmaceutical industry. There's also a lot of opportunities if you're interested in just doing research, people are always looking for really good HemOnc research physicians. And then there's always outside of clinical medicine when you have a background in hematology oncology, you have a lot of opportunities to do outreach, to do education, both patient education and other physician education. If you're someone who likes to write, recently there's been an outpouring of blogs written by a lot of physicians, and books written by a lot of physicians, and I think that there's quite a few HemOnc docs who are also starting to do that type of thing. So there are a lot of opportunities out there if you decide you don't want to stay in clinical medicine, or if you want to stay in clinical medicine and do these things along with that.
Best and Worst of Hematology Oncology
Dr. Ryan Gray: What do you like the most about being a HemOnc doc?
Dr. Shikha Jain: Oh there's so much. I really- I really love the patient interactions. I mean so growing up I always- my father is a physician and so I saw those patient interactions back in the eighties and nineties where the docs really had a good connection with their patients, and had a long relationship with them. The nice thing about HemOnc is you get that continuity of care. You have patients that are your patients, and they think of you as you're their doctor. So they come to you for things, and some of them you see for ten, fifteen, twenty years. You get to know their families, you get to know where their kids are going to school, you get to know who just got married, who had a baby. So it's a really amazing relationship that you develop with a patient that I think a lot of other fields don't necessarily offer, or allow for because of the way medicine is going, you just don't have that ability to have the continuity of care in a lot of the other fields. And then on top of that, the new drugs out there for cancer medicine are just amazing in what they're doing for the way we're treating these patients. Since I've been in fellowship even there have been major breakthroughs that have resulted in people living much, much longer than they've been living before. I mean people who were told previously they would only be alive for maybe three to six months are now living two years with some of the newer therapies that we have out there. So that's really exciting. And then from the hematologic standpoint, I get to see patients who have problems like infertility because they have an antiphospholipid antibody which is a benign disorder because it's not a cancer, but it can be very devastating for these patients. And I'm often able to help them get pregnant by putting them on blood thinners. So I get to see these really special parts of people's lives, and they let me into their lives in ways that I wouldn't necessarily be a part of otherwise. And it's just- it's a really rewarding uplifting field. There are a lot of very sad experiences, and a lot of very touching experiences that can be- like I said they can be emotionally difficult, but you have to realize that for every couple of people you can't help, there are a couple people that you can. And the people who you can't necessarily cure, or prolong their life, you get to be the person who helps them kind of navigate a very difficult path that end of life care is. And end of life care is another whole part of oncology that we don't discuss very often, but it is really a privilege to be able to help people get to that point in their life where they realize that they need to start focusing on quality of life and focusing on time with their family, and really appreciating the time that they have. And it's not always an easy conversation, it's often not an easy conversation, but to have the privilege to help somebody through that is really- it really touches my heart every time I go through it and I still feel very, very close to many of my patients who I haven't seen in years, and their families, and it's just- it's a very rewarding field. I couldn't imagine myself doing anything else.
Dr. Ryan Gray: Wow, alright you answered a later question about would you see yourself doing the same thing? So what do you like the least about being a HemOnc doc?
Dr. Shikha Jain: So it kind of ties into what I was saying previously, it can be very sad when you have a young person who you're giving them every treatment you possibly can, and nothing is working. Or you have an older person who just wants to make it to their grandson's graduation, and you can't make that happen. It really makes you examine your own life, and examine the lives of those around you, your family, your friends, and it really makes you more reflective I think, and that can be very difficult to come to terms with because I'm dealing with mortality on a daily basis, and that can be very overwhelming. So I think that that's probably the hardest thing that I have to do is just coming to terms on a fairly regular basis that life does end, and that is something that we all have to think about. I think a lot of other fields you don't necessarily see it as often, so it's not something that you have to process as often, so that is something that can be very challenging in this field. And I think it takes a really- all the HemOnc docs I know are very special people. I think it really takes people who are willing to take that path, and be introspective at the same time as being reflective and empathic.
Future of Hematology Oncology
Dr. Ryan Gray: Okay. Do you see any major changes coming to hematology oncology?
Dr. Shikha Jain: I do. I think that in the next twenty to thirty years, even in community practice people are going to be focusing more on either hematology or oncology, or they'll be focusing more on specific tumor types. It's already starting to happen in the community now a bit more because there's just so much information out there. I still think that doing both Hem and Onc fellowships is very beneficial because I think they both feed off of each other, but I do think that down the line we're going to start seeing more and more people focusing on just certain tumor types, or just focusing on hematology. And right now- and I'm sure most people have been watching on TV and in the New York Times, there's all these articles on this immunotherapy I mentioned earlier. I think it's really going to change the way oncology medicine is practiced because chemotherapy is starting to become less and less exciting, and the immunotherapy is becoming more and more exciting. So I think that pretty soon- we've already started having immunotherapy and chemotherapies kind of treating patients with similar malignancies in succession. I'm anticipating down the line that immunotherapies are going to become more and more used in the oncology world.
Dr. Ryan Gray: Okay. And by exciting you mean just the results are very promising?
Dr. Shikha Jain: Yeah the results are very promising, we're finding patients who- I think my favorite story is I have a really sweet lady who has lung cancer and came to me, and her oncologist told her she had a couple months to live, and she was on her third line of chemotherapy, and she couldn't walk more than a couple blocks without getting really short of breath, and I started her on one of the newer immunotherapy agents, and this was a year and a half ago now, and her husband recently threw her a prom so she danced until about 1:00 in the morning and she had no problems, and then she recently sprained her ankle chasing birds on the beach. So- and this is a woman who came to me a year and a half ago, told she had three months to live, and couldn't walk more than a couple blocks without sitting down and taking a break because she was so short of breath. And we wouldn't have been able to do that with chemotherapy for sure because she'd already gone through three lines of chemotherapy and nothing had worked. So the immunotherapy is a really cool thing because it takes your own immune system and uses it to fight off the cancer as opposed to using chemotherapy which is a drug that just kind of kills off everything. So it's just a really neat way to start targeting cancers, and killing off cancer cells without causing a lot of side effects.
Dr. Ryan Gray: Do you see cancer being cured? Or do you see it more like living with a chronic disease?
Dr. Shikha Jain: So it really depends on the type of cancer you're talking about. So the thing with cancer is every cancer is very different. Lung cancer is extremely different from lymphoma, which is extremely different from a pancreatic cancer. So there are some cancers that are absolutely curable if found early enough. There are some cancers that are curable even if they're found at stage four. There are some cancers like chronic lymphocytic leukemia that you can live with your entire life and never need to be treated for, so it would be living with cancer. There are some cancers that we think of as just chronic illnesses the way you would think of diabetes. So for example if you have something along the lines of a MGUS, or monoclonal gammopathy of undetermined significance. So that is kind of a precursor to cancer, and people live with that their entire lives and some people never need to be treated. So I think it's kind of a difficult question to answer because each cancer is so different, but there are cancers like follicular lymphoma that some people live with their whole lives and never need to be treated. Some people have follicular lymphoma and it progresses and they do need to be treated, and then the question is can they be cured or not? And that depends on a lot of variables. So when people say do you think we'll find a cure for cancer, my typical response is well we have found a cure for many cancers, but some cancers are chronic illnesses that people live with and it doesn't affect your life other than you have to come visit me every couple of months.
Words of Wisdom to Premeds
Dr. Ryan Gray: Okay. Any last words of wisdom for those that are thinking about HemOnc or maybe in their internal medicine residencies and aren't sure what fellowship path to take?
Dr. Shikha Jain: Sure. So I think the most important thing first when you're trying to figure out what fellowship you want to do is trying to rotate in that field, because you don't really understand what it is until you do it. I mean I thought I wanted to do pediatrics until I got into my third year of med school, and then I thought I wanted to do vascular surgery. I didn't decide internal medicine itself until my fourth year of med school. I didn't decide HemOnc until my second year of fellowship and that was after I'd done multiple HemOnc rotations. So I think it's really important that if you think you really love a field, make sure you rotate through it at least once so you get a feel for it. If you are really interested in HemOnc I would say try rotating through an outpatient HemOnc clinic at least once because it is very, very different from the inpatient Hem and the inpatient Onc service, and you really need to get an idea of if it's something that you love because it really does take a lot of- it takes a very special person I think to go into a lot of these fields. You have to have a very specific passion; cardiology, GI, HemOnc, pulmonary. They all require you to be very passionate about that field. I also think that a really useful thing would be talking to mentors. So talking to other attendings in the field, talk to fellows- fellows are actually a really great resource, and they're always- most of them are very willing to talk to med students and residents, and some of them will even be interested in getting you involved in research with them. I had med students and residents writing papers with me when I was in training because if you're interested in it, doing some reading and doing some background research in it would be really helpful in figuring out if you're interested in the science behind it, because the science behind it is also something that's really interesting and something you should make sure you're interested in. So I think really finding yourself good mentors, finding yourself good research projects, and rotating through whatever field it is you're interested in is really a good idea before you make that decision. If for some reason you aren't able to rotate through it, don't be discouraged, just make sure you're talking to a lot of people in the field because they'll be able to give you a really good idea as to what that particular field encompasses, and will be able to help you figure out if your personality is meant for that field, if your clinical interest and your science interest is in line with what that field does, and what goals that you want in your life, that they'll be fulfilled by that field.
Dr. Ryan Gray: Alright that was hematology oncology from Shikha, thanks for sharing your story. If you're interested in hematology oncology, I encourage you to re-listen to this podcast, and take some tidbits that Shikha talked about to help you on your journey.
If there's a specialty that you are interested in hearing about, or if you know somebody that would be a great guest for the Specialty Stories Podcast, please let me know. Ryan@medicalschoolhq.net. Even if I've had a specialty on that you want to hear more about, what I'm trying to do is cover academic, and community, and male, and female, and retired, and program director, residency director, so I want to cover all facets of it. So please shoot me an email if you have anybody interesting that you can think about.
I hope you have a great week and hopefully I'll have another podcast here for you next week here at Specialty Stories.
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