Fellowship Engagement in Hematology/Oncology Professionalism Training

DOI: 10.1200/JCO.2013.54.6879 The patient, Mr J (all names changed to protect privacy), presented late to the medical system with advanced disease, and his condition was rapidly deteriorating. Despite a biopsy that resulted in a large tumor sample, extensive necrosis made a pathologic diagnosis difficult. The oncology fellow on service, Dr A, spent a large amount of time at the patient’s bedside, talking to multiple family members, who did not seem to be communicating well with each other. Estranged family members had appeared and were asking for “everything” to be done. The patient and his wishes were becoming lost in the turmoil. As the prognosis became clear—a meaningful response to therapy was not expected and Mr J would soon die as a result of his cancer—the oncology attending, Dr Z, called for a family meeting. Because the patient was no longer communicative, the meeting would take place without him present. The only time that could be mutually agreed upon as being best for the family was while the fellow, Dr A, was in the clinic. Dr Z had met the patient and family on several occasions, but Dr A had taken the lead and provided almost all of the communication of critical information to the family. As Dr Z led the family meeting, she outlined the clinical information, discussed the patient’s rapid decline, and reviewed Mr J’s wishes. Because Mr J was actively dying, Dr Z recommended a transition to a focus on palliation and supportive care. She had expected to meet denial or anger, but instead she was met with resigned acceptance. The family’s greatest concern was continuity of care for their patriarch. Dr Z reassured the family that the palliative care team was excellent. Mr J’s oldest son then made one final request, “As long as Dr A will stay involved. Dr A has met with us every day, sometimes very late into the evening. He’s met with my siblings and cousins and has been a source of information and comfort to us during this difficult time. He always treats Dad with respect, and Dad trusts him.” In the preceding vignette, the behavior of the oncology fellow, Dr A, is an example of the type of professionalism we wish to foster and ensure in the next generation of practicing oncologists. But how do we teach this? The accrediting body for residency training programs in the United States, the Accreditation Council for Graduate Medical Education (ACGME), established professionalism as one of the six core competencies that all residency and fellowship programs should be imparting. This competency requires that residents and fellows demonstrate compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population. In 2002, the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine jointly authored a decree, a physician charter, establishing a contemporary definition of medical professionalism and outlining a set of fundamental principles. These principles echo those of the ACGME core competency, including a commitment to the primacy of patient welfare, patient autonomy, and the principle of social justice. And, although professionalism is not a domain specific to the subspecialty of oncology, following the basic tenets of medical professionalism—patient autonomy, social justice, and the importance of patient welfare—is an imperative in the daily practice of all medical specialties. For example, two key aspects of professionalism that are essential in oncology are the need to maintain trust by avoiding conflicts of interest and the commitment to the proper use of knowledge on the basis of scientific evidence and guidelines, reinforced by lifelong learning. In most hematology/oncology (HemOnc) fellowship training programs, professionalism is cultivated by setting clear performance expectations, documenting and evaluating supervised behaviors, and providing direct feedback to trainees. Expectations can be established through the use of programmatic rules and policies such as the adoption of the American Medical Association’s Code of Ethics and hospital staff bylaws. Documentation of appropriate conference attendance and JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 11 APRIL 1