Reflections on Fellowship Training for Community-Based Practice

“So, what are your research plans after first year of fellowship?” My colleagues and I were frequently asked this question toward the closing months of our first year of hematology and oncology training, which focused primarily on outpatient clinical care at our academic medical center. I was reluctant to answer the question because the explanation would take more than naming a mentor or a laboratory. In fact, my plans did not involve working with a translational researcher or a clinical trialist. I was searching for an alternate path for the remainder of my fellowship training, intent on pursuing a career in community-based hematology and oncology.

I found the application process for hematology and oncology fellowship somewhat confusing as I wanted to see patients and also wanted to maintain a connection to an academic center. I knew that clinicians in private practice were expected to see upward of 25-30 patients daily, with little time left for participation in research. I also knew from direct observation that physician-scientists ran laboratories and had a half-day clinical session per week. I saw other career paths exemplified by the clinician educators who spent time supervising trainees such as myself and were expected to publish in academic journals and clinical trialists who were subspecialized in disease groups and primarily based at academic medical centers.

I genuinely did not know where I fit in. Having completed my Internal Medicine residency training at the Beth Israel Deaconess Medical Center, an affiliate of Harvard Medical School, the benefits of being trained in academia were clear. My interest in hematologic malignancies had led me to an outcomes-based research project and a few publications during my residency. The clinical training was excellent, and learning from various experts who were leaders in their field was inspiring. We had access to cutting edge teaching and research opportunities throughout the Harvard system. Although the possibilities afforded by academia seemed immeasurable, I hesitated because I envisioned a different career path from those modeled by academic mentors. Ultimately, I matched at the Beth Israel Deaconess Medical Center hematology and oncology fellowship program, hoping to benefit from the broad patient exposure afforded in its strong clinical training program, while keeping the ability to move toward a traditional academic route.

During my first year of fellowship, I quickly realized that clinical care needed to be my focus and the center of my career. Around the halfway point during that first year, my cofellows started declaring their research plans and disease group focus. For me, this meant continuing patient care while seeking out extra clinical work and fulfilling my scholarship requirements. My fellowship program directors guided me toward our flagship community site, which was run by a graduate of our fellowship program, who would later be my primary mentor and supervisor. The community site was a much smaller setup than the downtown location. There were two full-time physicians, one advanced practice provider, and a similarly sized radiation oncology group. The satellite cancer center included faculty from the downtown campus who maintained a clinic at the affiliate 1 day per week. Supported by the flexibility of my fellowship program, I initiated a longitudinal continuity clinic at the satellite and also kept patients at the academic site.

To fulfill Accreditation Council for Graduate Medical Education requirements in a way that was relevant to my career, advisors suggested engaging in quality improvement (QI) work. Under the guidance of our QI director, I became involved in the ASCO Quality Improvement Practice Initiative. This experience taught me about the national standards for cancer care delivery processes, including the Quality Improvement Practice Initiative certification process. It also brought valuable experience in team management, project implementation, and opportunities to participate in related scholarship and networking. I helped implement and collect data for an oral chemotherapy education process that involved both the downtown cancer center and my community site. Motivated to learn more about the delivery of oncology services, I attended the national meeting of the Community Oncology Alliance where I learned about various reimbursement programs, and this, in turn, led to my participation in an intensive seminar hosted by the Harvard Business School on Value-Based Health Care. Finally, I enrolled in a course on disruptive innovation and creative design process at the Harvard Macy Institute, building upon my QI experience.

The diversity of my training exposed new ways to improve patient care. There were many institutions and meetings that went under the radar: The National Cancer Institute's National Community Oncology Research Program, the Association of Community Cancer Centers, the Association of American Cancer Institute's Network Initiative, and the ASCO Oncology Practice Conference. Formal graduate programs such as a Master of Business Administration, Master of Healthcare Management or Health Care Delivery Science, and other degrees were potential avenues to sharpen expertise in oncology care delivery. Specific initiatives continued to surface. These included Clinical Pathways implementation, integrating network tumor boards, buffeting community site clinical trial enrollment, and reducing health disparities in cancer care. These issues were neither built in nor emphasized in the current structure of my training program but gave me a deeper understanding on where cancer care delivery was moving nationally.

Moving to the interview trail, the value of my patchwork curriculum became clearer. For example, my QI experience was highly appealing to large academic-community partnership networks. My exposure to clinical trials in academia made plain the shortcomings of low trial enrollment at our community site and the heavy resources required to improve this metric. First-hand knowledge of the importance of effective communication and interpersonal relationships between the members of the care team at different clinical locations was of great value. At times, I had been a key link between the academic center and community site. As a physical team member, I was not just an e-mail address—instead, I provided a true sense of continuity to the patient. If the currency in academia is peer-reviewed publications, then the currency in community-based practice is field experiences—not just clinical but also cross-disciplinary teamwork projects that involve research, QI, business and operations, community engagement, and health policy.

Toward the end of my fellowship, I began to contextualize my own training experience with the current state of community-based practice on the national level. National trends obtained by ASCO, highlighting oncology workplace shortages in nonurban and rural areas, illustrate the need for an Academic-Community Hybrid model.1,2 This has garnered significant attention and traction with large health systems nationally.3 The goals of this model are to infuse greater academic rigor into cancer care networks, to serve populations outside of traditional academic medical centers, to leverage the best of community-based practices, and to fully integrate care processes with the academic hub. For me, this seemed like a perfect fit. If I felt confused about my place in the field when I applied for fellowship, I had found my passion and future with the Academic-Community Hybrid model.

Two years after completing my fellowship, I have been fortunate to work at the Dana Farber Cancer Institute in this hybrid model. I practice as a subspecialist in Genitourinary Oncology 1 day per week in an urban setting while spending most of my clinical time practicing both Genitourinary Oncology and also general hematology and oncology in our satellite cancer center, which serves a more suburban and even rural population. At this point in my career, I could not be happier. I love working with my colleagues at the academic hub, being part of the cutting edge in cancer research and participating in the excitement of the innovative process. At the same time, my community-based satellite site feels like my home away from home. I have developed wonderful relationships with our staff and can feel their deep desire to treat our patients with the best care in the world. Although each setting has its own feel and culture, we all share a mutual goal of delivering the best possible cancer care to our patients.

Looking back on how my training has prepared me for my current role, I am reminded of the importance of teamwork and collaboration in medicine and especially in oncology. Our current world of cancer care requires a successful integration between academic centers and affiliated practices within their network and catchment area. We need leaders to bring the academic-community partnership into the future. Fellowship programs will have to emphasize both hands-on clinical experiences and greater education about the forces shaping oncology care delivery to drive innovation in this space. It is time to reject the notion of an either-or decision between academics and community practice. If interested trainees can be given a novel path for training, we can produce a new generation of hematologists and/or oncologists to carry out the academic mission to every corner of the country.

© 2021 by American Society of Clinical Oncology

Author Daniel A. Roberts, Dana-Farber Cancer Institute and Beth Israel Deaconess Medical Center, Boston, MA

Roberts, Daniel A. "Reflections On Fellowship Training For Community-Based Practice". Journal Of Clinical Oncology, 2021, pp. JCO.21.01413. American Society Of Clinical Oncology (ASCO), https://doi.org/10.1200/jco.21.01413. Accessed 21 Oct 2021.

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