Medical Specialties - Oncology (10 May 2023)

SPEAKER_00 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal with live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. Hello everyone and welcome to another episode of Career Conversations brought to you by the Royal College of Physicians of Edinburgh. My name is Dr. Marilena Gianudi and I'm a member of the Training and Members Committee. Today I'm delighted to be joined by Dr. Mahaz Kayani, who's a medical oncology registrar based in West Yorkshire. He has previously worked as a clinical oncology registrar, so I can't think of anyone better to discuss oncology with us. So, Mahaz, welcome.

SPEAKER_01 0:57

Hi Marlene, thanks for having me.

SPEAKER_00 1:00

No problem. So I think one of the big questions that possibly our more junior listeners may have is what is the difference between medical and clinical oncology?

SPEAKER_01 1:10

How long do you have? It gets quite complicated. I think it's useful to think about what happens in the rest of the world where you have medical oncology and radiation oncology, which is a bit different. So in most places outside of the UK, you have one specialty that will treat cancers using medications or systemic cancer therapies, and another specialty that has traditionally treated tumours with radiotherapy or radiation-based techniques. In the UK, medical oncology is still very much the same, limited to, or not limited, but mainly using treatments that are drugs. Clinical oncology doctors are also able to use medications and systemic cancer therapies, but they're also able to use radiation-based techniques as well to treat cancer. And so there's an area of overlap and the boundaries do get blurred to an extent.

SPEAKER_00 2:04

And obviously, you've worked as a registrar in both. What is it that you enjoyed about clinical oncology? What is it that you enjoy about medical oncology? How did you ultimately make that decision to work in one over the other?

SPEAKER_01 2:20

So I think the first thing I'd say is that any kind of oncology is great. It's a very exciting specialty where in an era where things are rapidly changing. I graduated in 2014, and even in the eight years since I graduated, I feel like a lot of what I learned as a medical student has already become obsolete. Every year you go to an oncology conference and they will announce several new breakthrough trials, and that is often just in one single tumour type. Often when our consultants go around to do post-ate ward rounds, they'll be seeing patients who might have a tumour type that they don't personally treat anymore, where the treatments have already changed so much compared to when the consultants did their training. So I think it's really exciting to be in a specialty where there is such rapid flux and rapid change. So the things I enjoyed about clinical oncology, so often you're treating patients with localized disease with curative intent. And so that's quite satisfying. I often get told by family members and friends who don't really understand how oncology works that my job must be horribly depressing. And I say, well, actually, no, a lot of our patients will get cured and will have long and happy lives. The other thing I enjoyed about clinical oncology is a very anatomical specialty. So anyone that likes looking at scans, anyone that enjoyed anatomy at medical school will quite enjoy clinical oncology because you spend a lot of time in front of a computer looking at images, learning to interpret images, understanding where the anatomy might be distorted by underlying cancer. It's also quite satisfying to be able to look at a scan for someone you've treated months down the line and see how effective the treatment's been. Metal oncology, then, by contrast, often you're dealing with patients with metastatic disease, patients where they can't have curative treatments like surgery or radiotherapy, or patients where they might be too frail or for other reasons couldn't have those other treatments. Because we're talking about medications or drugs that are given repeatedly over time, they're patients that you will get to know quite well. So it's quite common to see a patient once every three weeks, once every four weeks. And for some tumour types, they may be having treatment for a period of several years. I guess the downside to medical oncology is that often a lot of our patients will eventually die. And I think that can be difficult for people who aren't necessarily comfortable looking after with patients at the end of life or dealing with challenging communication scenarios. And often the inpatient workload is more intense. So with clinical phoncology, it's very much the norm that you will see a patient consent them for treatment, and then you may see them, or you may talk to them on a telephone a few weeks or a few months after their treatment to make sure that everything went okay, but you won't have that same level of rapport with them because you're not seeing them as frequently. But because often these patients have had curative treatment, they also shouldn't need to come into hospital very much. And that can be appealing for someone who doesn't particularly enjoy looking after lots of inpatients. Because metaphoremcology patients are sicker, because they have metastatic disease, they're more likely to get complications from their treatment. And also the treatments themselves can come with significant toxicities. I think everyone knows about mutopic acceptance with chemotherapy, and in the current age, um we see a lot of immunotherapy-related side effects as well. So there's a lot more in the way of inpatient work, and for some people, myself included, actually that's one of the satisfying bits of the job. I actually quite like seeing patients in a ward round. I do think of myself as a hospital physician rather than someone who's primarily based in a clinic.

SPEAKER_00 6:00

What is like to be a career competition? Skills that kind of broadcast by the Royal College of the Well, where we joined a members' committee and we'll be running alongside our membership broadcast clinical compensation within the new training and we'll be focusing on all our careers from job situations to preparing for your exams. So you can we get what you refined with all of that.

SPEAKER_01 6:25

So a few years ago, training changed with the introduction of a common STEM year. So most trainees now will complete two years of IMT, and after IMT two, they'll go into an ST3 year. And that year is very much with a specific training program. You will either apply for clinical or medical oncology. But once you're onto that training program, your first year, regardless of which specialty you're doing, should actually look quite similar. And so that first year should be a combination of learning about systemic cancer therapies. So those are the drugs that we use, and learning about the basics of radiotherapy and radiotherapy-based techniques. From the ST4 stage onwards, then the programs do diverge. And in medical oncology, the focus is thereon purely on systemic cancer therapies, whereas in clinical oncology, we have to learn about both modalities. In terms of teaching, so as an ST3, typically we had a morning a week of teaching. Sometimes I know in other deanaries, they might have a whole day of teaching. So that's quite nice. It makes quite a nice change from internal medical training where it does feel like a bit of service provision sometimes. It's quite nice to become an ST3 and suddenly have 20% of your time be dedicated towards teaching, and that can be in a classroom or more commonly now, post-COVID online via Teams.

SPEAKER_00 7:53

If you could provide me with some kind of websites, then I'll make sure that they can go into the footnotes for the show for our listeners as to what training looks like and how you apply and so on. And I guess another question for you in preparation for your training, was oncology something that you always wanted to do? And if so, how did you kind of try to incorporate that into your CV earlier on before you got your registrar position?

SPEAKER_01 8:21

So I think the simple answer there is no. And perhaps I'm not the best role model for your listeners on how to become an oncologist. So when I did oncology as a medical student, I thought it was a very intimidating and somewhat grim specialty. And I remember learning a lot about all these chemotherapy drugs. And I remember seeing patients in the world who seemed to be falling apart. And I thought, absolutely not, this is not a specialty that I would ever ever want to do. I actually thought I was going to be an intensive care doctor, and for a long time that's where my career was going. And I took some time out after foundation training at worked intensive care and also worked intensive care in Australia. And I realised that I really missed talking to people, that I was at heart a physician and one that quite valued getting to know my patients. I had one particular experience of working in a hospice, which I found really rewarding, but it was too far the other way. I wasn't always the best at palliating. I wanted to do something with patients with cancer that involved more than just symptom relief. Choosing my rotations for IMT or CMT as it was back then, I specifically chose rotations that had an oncology block. And that was actually quite challenging in that again, as an SHO on a busy inpatient oncology unit, I was dealing with lots of acutely unwell patients, many of whom were approaching the end of life. And at that point, I was less certain that that was the right thing for me. After my CMT ended, I then chose to do a year as a clinical fellow working in oncology research, and that involved some clinical time as well. And that was where I really sort of cemented my love for oncology. And the difference there was that we are actually ultimately an outpatient specialty. Most of our patients will be at home, they won't be in hospitals, and that's where all the exciting stuff happens. I would say that for anyone considering oncology as a career who may have done an oncology job as an SHO, don't be put off because that is just a tip of the iceberg. Most of our patients are quite well, most of our patients are at home going about their everyday lives. And that's perhaps different to other specialties, where actually what you see on the wards is quite a good representation of what your life would be like as a registrar or consultant. So, in terms of preparation, I had done my fellow year, but a lot of my colleagues, the large majority, hadn't done anything outside of their foundational internal medicine training. So I don't think that's a necessity at all. Historically, oncology has been quite a research-heavy specialty, and that's one of the things that attracts a lot of people to it. But again, I'm not someone who had been through an academic foundation program. I hadn't done any formal research training beyond what I'd learnt at medical school, and I still got onto the training program. I think having something else on your CV is definitely desirable. And so it doesn't have to be research, it could be education or teaching, for example, or it could be something else on your CV that demonstrates you are a well-rounded trainee or a well-rounded candidate. I think having publications or posters is always useful. And those don't necessarily have to be oncology posters or publications. You're demonstrating that you have the skills to write something for publication or that you have the skills to undertake an audit or a quip that can then be presented at a conference. Everything else will come later.

SPEAKER_00 12:06

And obviously, you mentioned a lot about what your job entails and why you enjoy this specialty because of your opportunities to talk with patients and the continuity that you get in seeing them through this journey, and perhaps possibly like the most difficult part of their life and the effect that their disease can have on their families as well. What skills do you think you need to have to be an oncologist?

SPEAKER_01 12:35

So I think you have to be a good communicator. And again, I think people can either go one of two ways. A lot of us either think we're excellent communication, overrate our communication skills, and a lot of us may think that we're terrible at communicating, or that actually we can't possibly deal with these difficult conversations about end-of-life care. A lot of the training is about learning those skills and refining those skills, and you have to be self-critical. I often have days where I will come out of a clinic or I will come out of a ward round and I will reflect that actually I haven't communicated well, that I didn't do things as well as I would have liked and try and learn from those experiences. I think you have to be comfortable with managing patients in both the outpatient setting, which isn't a skill that comes naturally to us once we've come through four years of foundation training and internal medical training. But again, that's something that you learn quite quickly as part of your oncology training. At the same time, we aren't general practitioners, you also have to be able to manage acutely unwell patients. And particularly as our treatments have become more sophisticated over time, and as the range of side effects and toxicities in our treatments has become more varied, you have to be able to deal with a lot. And there's a big push now across the UK to develop specialist acute oncology services where we see patients earlier, both in AE and also on acute oncology units, to provide specialist care.

SPEAKER_00 14:12

I knew that you alluded to this a little bit earlier, that it can be a little bit, I don't know whether upsetting is the right word, but potentially overwhelming to think of especially the inpatient work and seeing patients who are very poorly probably approaching the end of life. How do you find having those frank conversations with patients? Because I know that a lot of us may actually shy away from doing so. In my very limited experience within that world almost, patients appreciate your honesty and are actually always ready to hear what you're about to tell them. Is that your experience? Do you think that that's actually a good way of looking at it? Or what's your take on that?

SPEAKER_01 15:00

My personal experience is that the majority of conversations that I've had with patients or their relatives, where I've either had to break bad news or discuss the fact that the patient might be coming towards the end of life, have often had a lot of positive elements to them. I've often come away with either patient or their family member having thanked me for what I said. And so I think even though the thing that we're talking about is difficult, actually it's a moment for you to help the patient and their family to come to terms with something that they often already know is happening. Tell someone that their cancer is progressing in them not to have realized. It's also quite rare for me to talk to someone and explain that I think they're approaching the end of life where they haven't themselves realized that something is wrong. And often you're the one verbalizing something that they are already coming to terms with, already trying to accept, and you're helping them to then move on to the next bit, which is making the most of the time that they have left. There are always going to be some situations in which that communication is going to be harder, where patients or their relatives may be more reluctant to accept what you're about to say. We have a good team of consultants and cancer nurse specialists. And I think because we've got to know our patients over a period of time, we often have a relationship whereby it's easier to navigate some of those difficulties. I think it's a lot harder if you're an acute medical consultant or a Logan GP seeing a patient who you may not know that well and trying to have a conversation about end-of-life care. But where patients have built up a rapport, have got to know you over time, there's a certain level of trust often that you rely upon to get you through those difficult conversations.

SPEAKER_00 17:00

I think that's a very nice way of thinking about it. And I guess I just wanted us to discuss that for any listeners who may not want to even consider oncology because of the preconceptions that the specialty has with regards to having those conversations and to dealing with those patients. And so I think that's really interesting and really important that we talk about that. So thank you. Can we just briefly talk about what on calls are like as an oncology trainee? Because obviously it's a group two specialty. You guys aren't doing med-ridge on calls. A lot of people consider work-life balance when making these career decisions. What do on calls look like for you? And how does this specialty either help or not help you have a work-life balance?

SPEAKER_01 17:49

So obviously, there will be a lot of variation across the UK from centre to centre. So at the uh cancer centre where I work, our on-call rotor is quite light in terms of on-call commitments. At any time, there will be two registrars on call, one for clinical oncology and one for medical oncology. But at smaller units, often there will simply be one. I'm expected to be here during the day at the weekends and the evenings until nine o'clock. And during that time, I will be taking calls from smaller hospitals, from other departments in the hospital and reviewing sick patients coming into our admissions units. So because we're a large centre, we have an acute oncology unit where we will assess and admit patients directly, a bit like an AMU would. Again, in some smaller hospitals where oncology trainees might end up, there may not be such a unit, and often patients will come through AMU instead. But in those situations, we would then go and review the patients on those wards and provide a liaison service. Overnight, I actually get to do my own calls from home. So that's, I think, definitely a positive. I will be literally on call. And so there will be a team of SHOs here in the hospital who will be looking after our patients with support from auxiliary staff. And they can call me if they need me. Similarly, if there's someone coming in through AE or in the community who someone would like to discuss, they might also call me as well. But it's not unusual for me to be able to get a full night's sleep. Calls will typically be about either oncological emergencies, so things like patients with suspected metastatic cord compression, or will be about patients who might have uh toxicities from their treatment, which I've already alluded to. So everyone knows about utopenic sepsis, um, but we now have lots of immune-mediated toxicities from our immunotherapy drugs and some other side effects that you can also get from radiotherapy treatment that sometimes might need patients to come into hospital out of hours.

SPEAKER_00 20:03

With regards to your work-life balance, how do you think, you know, your day job, your own course, any other work commitments that you have affect your personal and social life?

SPEAKER_01 20:18

So I think before I answer that, maybe it's useful for me to describe what a typical working week looks like for a registrar, just to give people an idea of what we're talking about. So within working hours, I will have two, maybe three clinics in the whole week. On some days of the week, I will do a ward round. For the remaining days of the week, our SHOs will often see the patients. Each team will have a small number of patients. So I'm at the moment with the renal team, and currently we have four inpatients. As a clinical oncology trainee, you'll also have some time in your week to sit down and do your radiotherapy planning, so that's protective time. You'll also have time for doing admin. So, actually, overall, that there is a lot of time in the week to do things like teaching, audit, and research. Again, there's a lot of variation depending on where you work and what the pressures in the system are like. I know that in some of the smaller hospitals where there are fewer oncologists, there is a greater demand on your time in terms of clinical responsibilities. I think the difficulties come with the extra stuff. So we spoke briefly about the fact that oncology has traditionally been a highly academic specialty, and everyone to some extent is expected to be involved in research. Now that takes lots of different forms. A lot of cancer research is not to do with drugs or fancy new ways of delivering radiotherapy, but it can be about the ways we deliver services or the way we help patients live with the long-term side effects from their treatments. Finding time to do that research can be difficult. And even though we have a certain amount of admin time within the working week, often I do find that eats into my evenings or my weekends at home. I think it's up to every individual to make that decision about where that balance is. And some people are quite happy to put in extra time. Other people are quite clear that they don't want to do any work outside of their Monday to Friday nine to five hours. The other thing I would say is that a lot of us will do higher degrees. Most medical oncologists, and increasingly a lot of clinical oncologists, will either do an MD or a PhD, and that can therefore give you that protected time to do your academic stuff to develop your research portfolio. Or we also have lots of trainees now who might look at alternative things, such as we have lots of trainees who will look at alternative bits to enhance their CV, such as doing a leadership fellowship, or other trainees will do fellowships in medical education.

SPEAKER_00 23:07

What would be your advice to anyone that's potentially interested in following an oncology career? And I won't, you know, narrow it down to medical oncology or clinical oncology because it sounds like actually there's a bit of an overlap, and I think you just need to decide that you want to do oncology before you make the decision as to what kind.

SPEAKER_01 23:29

Yeah, there's a lot of overlap, I agree. So my recommendations would be that some people will know quite early on that they want to do oncology, in which case that's great. But for those of you who might be like me where you've taken a circuitous route where you're not quite decided what you want to do, and where you might be thinking about doing a career in oncology, it's definitely helpful to have a rotation at some point in your training in oncology. But even then, I wouldn't let that influence your decision entirely. If you think you might want to do it, it is useful to have some experience of oncology as a fellow, or if you can, you go around with a registrar or consultant and you see that what they actually do on a day-to-day basis, which is, as I said, not confined to seeing lots of sick patients in a wardround. I think ultimately don't rush into it. There is absolutely no rush to do anything. It should be a well-informed and thought-through decision. But most oncologists in most hospitals are delighted if anyone ever expresses an interest in wanting to do oncology. So find your local oncologist or find some oncologists in the hospital where you work and ask about organising some time with them or ask them about research opportunities that they might have available and develop your interest from there.

SPEAKER_00 24:53

That's excellent. I think we'll leave it there, Mahas. So thank you so much for your time for speaking to me today and for all your insights into the world of oncology.

SPEAKER_01 25:03

Thanks, Marilyn.