....of a Heme/Onc fellow.
My family often asks what it is I do all day. They know I work ridiculous hours and am ridiculously busy but it's hard for them to understand what the heck I am DOING all day. So here's the play by play:
6am. Time to get up. I check facebook and email since this is the only quiet time I'll likely have for the entire day. I give myelf 5 minutes for this tops.
6:05-6:35. Get ready for work. Scrounge together some assortment of food for "lunch". The quotation marks will become more clear once we near lunchtime.
6:35-7. Drive to work.
I should stop here to explain the structure of the rotation I'm currently on. I'm on the Red service which is the inpatient service for liquid tumors- leukemia, lymphoma and multiple myeloma. Other members of my team include the attending (my boss), a senior resident, one or two interns, and a pharmacist. All of these folks change every two weeks, whereas I stay on the rotation for a month. And the switches are staggered so the team is constantly changing.
My job as the fellow is to supervise the residents and take care of 'fellow' level activities such as writing chemotherapy orders, and doing procedures like bone marrow biopsies and intrathecal chemotherapy injections. I also talk to patients about their chemo regimens, their prognosis and any other cancer related questions.
7-7:30. Prepare for "rounds". I review the past day and overnight events for those w/ active cancer related issues with special attention to the ICU patients since they are sicker and I am the primary oncology presence for them as opposed to the floor patients who have our whole team looking after them. If there's time, I start working on chemo orders or correspondence during this time.
AM: Rounds with the team. This is where we discuss each of our 14 patients in great detail reviewing past events and making decisions about next steps. We also hear about any new patients that were admitted overnight. The interns present this info. I try to stay in the background as much as possible to give the intern and resident independence to learn and take ownership of patient care, but I interject if I think they are missing an important point or making a suboptimal decision. The attending and I also use this as a time to do some teaching about oncology points as they relate to our patients. Then we go see all the patients and relay the plans to them and see how they are doing.
That's the basic structure of the morning. The afternoon is spent talking to patients, families and the primary (outpatient) oncologists, seeing the ICU patients (writing their notes and making recommendations to the primary team), and doing procdures. Oh- and attending or presenting at educational conferences.
Here's a play by play of an actual day:
7:30-9:00 round with the team
9-9:30 bring IT (spinal) chemotherapy over to the other hospital (2 blocks away) to interventional radiology where I inject the chemo via a lumbar puncture.
9:30-10 catch up on what I missed on rounds, continue rounding
10-10:30 I stay back after rounds to talk to a patient and his wife about his relapsed disease in greater detail. We talked about side effects of the chemo we plan to use as well as success rates. We discuss the stem cell transplant process. His wife is understandably very upset. His prognosis is poor and they realize this. I encourage him to take vacations and do all the things he's always wanted to do while he still feels up to it.
10:30-11 catch up on what I missed on rounds, continue rounding
11-12 go over to Feinberg (the other hospital) to explain intrathecal chemotherapy to a young patient just diagnosed with aggressive lymphoma, run back to Prentice to write the chemo orders, bring the orders back to Feinberg and push the chemo
12-1 write chemotherapy orders, talk to attendings about their preferences for certain aspects of the chemo orders
1-1:30 go see our ICU patient. He is very sick and we are making some critical decisions so my attending and I spend time talking to his family and to each other about our chemotherapy options. We decide to continue to hold off on treatment until his other organs improve.
1:30-2:00 write daily progress notes, email updates to primary attendings, answer questions for the interns/residents. sometimes I eat my breakfast cereal at this point, sometimes I don't. Hence "lunch".
2:00-3:00 I learn of a new admission- a guy I know really well with relapsed, impossible to treat leukemia. He's very sick and likely won't make it out of the hospital alive. I talk to him and his wife about goals of care and we conclude that he does not want to go back to the ICU, he'd rather focus on comfort. I reaffirm that he is making a very reasonable decision and that we will do everything we can to keep him comfortable. I inform the nurse, the team, my attending and his primary oncologist about his decision.
3-3:30 There's a big hullabaloo about trying yet another chemo agent on the guy mentioned above. It has little to no chance of working; he is very sick. I think he's actively dying. At his outpatient attending's request, I present the option of the medicine to the patient. He declines. I'm relieved because I know another medication will not help him with comfort, which is his primary goal. (Post script- he dies peacefully 36 hours later.)
3:30-4:00 Talk to the team, run the list with my attending. ("Run the List" or RTL, means we touch on key issues that are worth talking about- we don't talk about everyone every time- just the most active high level stuff)
4:00-5:00 start working on signouts for my covering co-fellow because I have the next day off. Taking a day off is hard work. I write a document with all the patients, their cancer history and the important active issues to give to the covering fellow. I ask the housestaff to put in orders they may have missed as I review the patients. Try to find something to eat, hopefully I brought something from home because I can't spare the 15 minutes to go to the cafeteria.
5:00-5:15 walk over to the outpatient building to get a signature on chemo orders, call a recently discharged patient to let him know his bone marrow was clean (no disease) though, in his case, this doesn't change the prognosis.
5:15-5:30 go over chemo orders for a new patient with the attending.
5:30-6:00 walk back to Prentice to drop off the chemo orders (they literally have to be walked over). Get a call from Pathology that another patient's bone marrow is NOT clean (meaning there is still disease). This also doesn't change her management. Final check in w/ housestaff before I leave.
This particular evening is "day-off eve" meaning I can sign my pager out since I have the next day off. Therefore I don't have to keep the pager on at all times, and I won't get called in the middle of the night. Day off eve is a good night.
That's a pretty typical day. Lots of running back and forth, procedures, diffucult patient conversations, lots of discussions about patient management. Usually there are some bone marrow biopsies thrown in for good measure. Two days a week I have clinic in the afternoon so all my daily work has to be done by noon. That's always interesting:) At least two days a week I give a lecture to the housestaff to teach them about heme/onc. I often spend time looking up research articles and reviewing new literature as it comes out. So much to learn!
To my family: Does this shed any light? Or are you only more confused? ;)