Center News Magazine: Training the Next Generation of Cancer Specialists

By Jim Stallard, MA, Allyson Collins, MS, and Celia Gittelson, BA
Thursday, March 1, 2012
Pictured: David Panicek & Barbara Raphael David Panicek, Director of Educational Programs in Radiology, with radiology fellow Barbara Raphael

Training and education are mainstays of Memorial Sloan Kettering’s mission. As early as 1927, John D. Rockefeller, Jr.— who, along with his father, founded the hospital that became Memorial Sloan Kettering — established the first grant for postdoctoral fellowships for the training of clinicians, scientists, and nurses.

“The mission of our Graduate Medical Education (GME) Program is to provide highly specialized educational opportunities for physicians pursuing advanced training in oncology and cancer-related diseases,” says Mary Jane Massie, Chair of Memorial Sloan Kettering’s Graduate Medical Education Committee and a psychiatrist specializing in the psychological treatment of patients with breast cancer and their families. As Chair of the GME Committee, it is Dr. Massie’s role to oversee the education of medical students, residents, and fellows and to work with other committee members to maintain excellence in the Center’s teaching programs. Dr. Massie also serves as Chair of the New York State Council on Graduate Medical Education.

Pictured: Mary Jane Massie & Monika Shah Mary Jane Massie (left) chairs Memorial Sloan Kettering’s Graduate Medical Education Committee. Monika Shah is Associate Chair for Educational Affairs in the Department of Medicine. As of July 2011, Memorial Sloan Kettering offered 80 clinical training programs plus a small number of special fellowships. During 2010, approximately 1,625 men and women — residents and clinical fellows — trained at Memorial Hospital. In addition, Memorial Hospital offers programs for medical students. The Summer Student Fellowship Program was established in 1977 and is supported by a National Institutes of Health/National Cancer Institute grant with additional funding provided by Memorial Sloan Kettering’s Office of Diversity Programs in Clinical Care, Research, and Training; the Program for Women Faculty Affairs; and the Brain Tumor Center. The program brings first- and second-year medical students to Memorial Sloan Kettering for an eight-week, mentored experience in research and clinical oncology. Since the program’s inception, approximately 1,000 medical students have participated.

Memorial Sloan Kettering is also one of the teaching hospitals of the Weill Cornell Medical College, offering both elective and required courses for Cornell medical students. During the 2010–2011 academic year, Memorial Sloan Kettering trained approximately 400 medical students. “We recognize that if you want to have extraordinary oncologists in the future, you start in medical school — and that’s why our summer program is so important,” says Dr. Massie. “You’ve got to begin early.

“Young Physicians, Genuinely Passionate about What They Do”

“Because we are an institution focused on cancer, we have a hybrid form of house staff,” explains infectious disease expert Monika Shah. Dr. Shah is the Associate Chair for Educational Affairs in the Department of Medicine. “Our programs range from student rotations to residencies to oncologic- and non-oncologic-based fellowships. We have a large complement of internal medicine residents who rotate from other institutions within the city and are usually with us for one month at a time. And we have our own ‘transitional-year’ interns.” The goals of both the rotating internal medicine residency and the transitional-year internship include exposing  young physicians — before they go on to subspecialty training — to the complex internal medicine problems seen in cancer patients. While transitional-year interns spend a major portion of their year working on the hospital’s inpatient floors, they also rotate onto the surgical, ambulatory, and emergency medicine services. “We have one of the largest transitional-year programs in the country — expertly directed by [Memorial Sloan Kettering hospitalist] Barbara Egan — and one of the most highly sought after,” says Dr. Shah. She reports that in an average year, out of thousands of applications received, approximately 100 applicants are interviewed for 18 transitional-year positions.

“We are of course looking for top-caliber people,” says Dr. Shah, “but because collaboration is so important at Memorial and in cancer care generally, we want team players — young physicians genuinely passionate about what they do and about working with others.” Dr. Shah also points to diversity as a key component. “It’s very important to have a balance and make sure that people bring different life experiences to the table.”

Radiology: “A Sophisticated Understanding of How Tumors Behave”

Diagnostic imaging has gained increasing prominence in cancer care as technological advances have improved ways to detect and monitor the disease. Memorial Sloan Kettering’s Department of Radiology has been at the forefront of the field for years and today trains exceptional young physicians — both fellows and residents — in the finer aspects of cancer imaging using computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), radiography, and ultrasound.

David M. Panicek, Director of Educational Programs in Radiology, oversees the selection and supervision of the clinical fellows, who come to Memorial Sloan Kettering to transition from a basic knowledge of general radiology to a more focused expertise in oncologic imaging. The 36 radiology residents are based at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, but spend a substantial part of their residency at Memorial Sloan Kettering.

Dr. Panicek explains that oncologic imaging is especially demanding because a radiologist must be able to identify subtle aspects of a complex disease. “Many scans have several abnormalities, so they are challenging to read, and you have to compare them with prior scans to see what has changed,” he says. “Our fellows must also develop a sophisticated understanding of how tumors behave because appearances can be counterintuitive. Sometimes an enlarging tumor is actually a good sign because it is hemorrhaging due to an effective treatment.”

The main clinical fellowship program, Oncologic Imaging, accepts a total of 15 fellows per year, with a subset of that group specializing in breast imaging. Other, more specialized programs accept a smaller number of fellows and focus on neuroradiology, nuclear medicine, and interventional radiology. All radiology fellowships are highly competitive, with numerous applicants vying for the small number of slots.

In addition to giving priority to applicants who present outstanding references and have engaging personalities, the radiology program favors those with inquisitive natures. “As a teacher, you do your best training when someone is asking you questions, stimulating discussion, and bringing up relevant journal articles,” Dr. Panicek says.

Most fellowships last one year, during which trainees read scans, consult with clinical staff, participate in multidisciplinary clinical conferences, and take part in clinical research projects. During most of the training period, fellows work with an array of attending physicians rather than being paired with one mentor. “We think it’s important for them to obtain a variety of perspectives as they gain proficiency,” Dr. Panicek says. “Each faculty member imparts specific knowledge about what is involved in imaging tumors in different sites in the body.”

Dr. Panicek says fellows arrive at Memorial Sloan Kettering already prepared for the high stress level that oncologic imaging presents compared with general radiology. “The type of person who applies for our fellowships has already self-selected,” he explains. “They know it’s more rigorous, they know what’s at stake for patients, but they find it interesting and intriguing. That’s what drew me to the field as well — just when you think you’ve seen all the ways a tumor can spread, a rare variant comes along that does something unusual. It’s a humbling experience.”

Musculoskeletal Oncology: “Intellectual… Compassionate… Altruistic”

After completing Memorial Sloan Kettering’s Musculoskeletal Oncology Fellowship in 1999, orthopaedic surgeon Carol D. Morris accepted a faculty position here. She has been a fellowship mentor for the past six years and the fellowship program director for the past three. “It’s a privilege on both sides — the teaching and the learning,” Dr. Morris says. “We’re here to take care of patients, but it’s extremely important to train surgeons who can carry on the legacy of the service.”

It takes a particular type of surgeon to bypass sports medicine and joint replacement to care for people with cancer of the bone or muscle, known as sarcoma, or metastatic cancer that has spread to the bone. “It’s a field that chooses you as opposed to you choosing it,” Dr. Morris says. “It’s an intellectual field; it’s a compassionate field; it’s the most altruistic field in all of orthopaedics.”

For more than 25 years, Memorial Sloan Kettering’s Musculoskeletal Oncology Fellowship Program — the only such program in New York State — has trained an average of two surgeons annually. One of only 11 accredited US programs, the fellowship includes one year of clinical work with the option of adding a year of research. Fellows participate in all aspects of care, from performing operations and examining outpatients to consulting for other services. “Because it’s such a small program, feedback is constant,” Dr. Morris says. “Fellows are at our sides every day, all day, and often far into the night.”

Friday mornings are reserved for a surgical conference, during which the team discusses patients from the past week, and tumor board, during which experts from a variety of specialties analyze upcoming cases. Fellows also observe pathologists and radiologists. “It’s unique that we are a cancer hospital with four dedicated orthopaedic surgeons,” Dr. Morris explains. “Fellows almost anywhere else train within a large orthopaedic department of a hospital that has many areas of focus. Often our fellows go on to places that don’t have cancer-specific pathologists and radiologists, so they need to know how to accurately interpret diagnostic studies.”

Along with training fellows, Dr. Morris and her colleagues teach more than 30 residents per year from six New York City institutions. Because most orthopaedic residents do not subspecialize in oncology, they receive practical training on how to recognize when a patient may have a possible sarcoma and when to refer that patient to an orthopaedic oncologist.

One of the challenges Dr. Morris faces is continually modifying her teaching methods to best suit her students. “When I was taught, you went to a lecture and read a book. That model doesn’t work for this generation,” she admits. “Our recruits read e-books and find information online. It’s exciting for us to keep figuring out new ways to share knowledge that our fellows can absorb in the most efficient way.”

Certain parts of practice, however, cannot be learned from a book, electronic or otherwise. “You can’t teach surgeons how to pace themselves during a long surgery or how to maintain their composure when faced with a complication,” Dr. Morris says. “These are things a fellow has to observe.”

Medical Oncology/Hematology: “Everyone Is Rowing in the Same Direction”

Each year, Memorial Sloan Kettering’s Medical Oncology/Hematology Fellowship Training Program in the Department of Medicine, the largest  program of its kind in the United States, selects from approximately 450 applicants a group of 15 fellows with interests directed either toward clinical research or laboratory investigation.

Medical oncologist Dean F. Bajorin, director of the program since 1994, says that in addition to being outstanding physicians, prospective fellows must demonstrate that they are scientifically curious and highly motivated. “Besides a track record of academic success, we require a strong work ethic, ‘a fire in the belly,’” Dr. Bajorin says. “We’re training future leaders in oncology, so when our faculty interviews a candidate they’re looking to see whether this person will make a meaningful impact in the field.”

Pictured: Dean Bajori & Jean Lee Medical oncologist Dean Bajorin consults with medical oncology/hematology fellow Jean Lee. During the first year all oncology/hematology fellows concentrate on patient care, treating inpatients and outpatients while rotating through a range of other cancer subspecialties. By year’s end, fellows have selected a mentor and a research plan for the next several years, based on their interests in either the clinic or the laboratory. In the second part of the program, clinic-based fellows initiate and conduct clinical trials at Memorial Sloan Kettering, while laboratory-based fellows work as postdoctoral members of their mentor’s laboratory, spending about 10 percent of their time in a clinic associated with the laboratory’s research. Clinically focused fellowships usually finish after three years while research-focused fellowships may extend to four or five years.

“We want to make sure that fellows are doing innovative work, so we insist on prospective research that tests a hypothesis — such as whether a drug works, how it works, identification of the optimal dose and predictive markers — rather than a retrospective study that reviews how patients may have fared with existing practices,” Dr. Bajorin explains. “We ensure they acquire the skills they need to move immediately into a productive career — learning how to devise their own protocols, write research grant proposals, and design clinical trials that minimize patient risk and achieve statistically valid results.”

Like many current faculty members, Dr. Bajorin was himself a fellow at Memorial Sloan Kettering. He says the Center’s exclusive focus on cancer creates a fertile, multidisciplinary environment conducive to cultivating top physician-scientists. “It’s become clear that many of the inroads we’re making in cancer are the result of team-based research,” he says. “A big advantage of this institution is that everyone is rowing in the same direction to understand cancer and improve therapy. There are no fiefdoms, no fences or walls between different departments focusing on very diverse diseases. Here, cancer is king.”

Radiation Oncology: “Training Young Men and Women to Be Leaders”

Memorial Sloan Kettering’s four-year radiation oncology residency program is one of the nation’s largest and “one of the most comprehensive and prestigious,” says radiation oncologist Joachim Yahalom, who co-directs the residency program with radiation oncologist Suzanne L. Wolden. “We provide training in all aspects of radiation oncology, which many other programs do not do.” By the time a resident completes the program, he or she will have gained experience in radiation oncology as it is used in the treatment of pediatric cancers, head and neck cancers, and lymphomas, as well as prostate, breast, gynecologic, and gastrointestinal cancers. 

There are 20 full-time residents in the four-year program in any given year. As elsewhere in MSKCC, residents from other New York City hospitals also rotate for one to two months in radiation oncology. In addition, many elect to do their transitional-year internship here, prior to their Memorial Sloan Kettering residencies, “which is good for us and for them,” says Dr. Wolden. “There is great value in having institutional memory in our trainees.” Approximately 240 men and women apply each year for five available radiation oncology resident positions. “We have one of the most competitive programs in the country in one of the most competitive specialties, so we get the top medical students from the top schools,” Dr. Wolden says.

“Our graduates go on to be on the faculty at Johns Hopkins, Yale, and the University of Chicago, among other institutions,” adds Dr. Yahalom.

Besides the obvious technical and intellectual skills, “we look for certain personal qualities,” remarks Dr. Wolden. “Will these young physicians be empathic and good with patients? Do they have the personality to care for people with grave illnesses?” Residents also need to be enthusiastic about working as part of a team. “Because the nature of the field is such that we interact with medical oncologists, surgeons, technologists, medical physicists, and nurses, we want people who are good communicators and good advocates for patients,” observes Dr. Yahalom.

“We also want diversity. Ethnic diversity and diversity in life experiences,” says Dr. Wolden. “So we have residents with PhDs in physics and biology. We have people who have done pediatric residencies. For example, one current trainee is a Rhodes scholar with an MD degree from Harvard and an Oxford MBA degree. It makes for an exciting and stimulating program.”

A recent change to the program has been to block out an entire year for a resident to focus on research. Although radiation oncology residents conduct research during their clinical training as well, there is now a “protected” year during which they can focus purely on research. “They have minimal obligations in direct patient care so they have the time to devote to it,” explains Dr. Yahalom. The range of investigations is vast. “We have residents who have done work in molecular biology focusing on mechanisms of DNA repair and others who have looked at the molecular profiling of tumors that will help predict their response or resistance to radiation therapy or chemotherapy,” says Dr. Yahalom.

Adds Dr. Wolden, “There’s a resident now who is doing clinical research analyzing a database of more than 1,700 pediatric Hodgkin disease patients. She has access to the biggest national trial to assess outcomes. So our residents are working on very high-quality clinical as well as laboratory projects.”

Memorial Sloan Kettering radiation oncology residents also publish their work. “Most of our residents graduate with four or five peer-reviewed papers published in the most prestigious journals in the field,” Dr. Wolden says.

Critical Care Medicine: “Training to Give the Best Supportive Care to Patients with Cancer”

Memorial Hospital has informally trained young physicians to practice critical care medicine in the oncologic setting since the 1970s, as one of the first US institutions with an intensive care unit (ICU) exclusively for people with cancer. Since 1990, when the program was accredited, more than 100 fellows have completed Memorial Sloan Kettering’s Critical Care Medicine Fellowship, which is one of only a few dozen internal-medicine-based critical care training programs in the nation and one of only a handful in New York City.

“In the US, we have a great need for critical care doctors,” says Stephen M. Pastores, Director of the Critical Care Medicine Fellowship Program and Director of Critical Care Research. “This is due to a variety of factors, ranging from the aging population dealing with chronic illnesses to advanced cancer treatments that can weaken the immune system and increase the chance of serious infections.”

Many physicians come to Memorial Sloan Kettering for subspecialized critical care training after completing a residency in internal medicine. These physicians enter a two-year program, with the first year dedicated to clinical care and the second year focused on elective clinical experiences and scholarly activity. Others complete a one-year fellowship after previous training in pulmonary medicine or infectious disease, among other areas.

Pictured: Stephen Pastores & Prabalini Rajendram Critical care physician Stephen Pastores talks with fellow Prabalini Rajendram. First-year fellows work with Memorial Sloan Kettering’s  multidisciplinary Critical Care Medicine Service for seven months. They practice alongside critical care physicians, nurse practitioners, nurses, respiratory therapists, and other specialists in the 20-bed medical-surgical ICU and rotate in the operating room, as well as provide consultations throughout the hospital. “Our fellows learn to be independent practitioners in a high-tech environment, but they also learn the skills of working as part of a team,” says Dr. Pastores, who has seen the program grow from six to ten fellows since he became director in 2003.

During their training, fellows learn advanced modes of ventilator support and airway management. In addition, fellows receive critical-care-specific training in communication skills through the Department of Psychiatry and Behavioral Sciences to understand how to most effectively and sensitively discuss medical complications and end-of-life issues with patients and families. “Though we are not oncologists, we train our fellows to give the best supportive care to patients with cancer in the ICU,” Dr. Pastores says.

To expand the breadth of their experience, fellows spend two months in cardiac surgery and neurosurgery ICUs at NewYork-Presbyterian Hospital; one month in a trauma surgery ICU at Bellevue Hospital Center; and one month in a community ICU at New York Hospital Queens. “We offer a very well-rounded fellowship in critical care,” Dr. Pastores explains. “We prepare our fellows to go into practice and care for patients who might not have cancer, but are just as sick.”

“A Hidden Gem”

Fellows who specialize in cancer care at Memorial Sloan Kettering learn their craft from leaders in the field. But even residents and fellows training at the Center who do not end up specializing in oncology still find the time spent at Memorial Sloan Kettering offers an invaluable education. “You can get the bread-and-butter stuff almost anywhere,” says Dr. Shah. “However, what you learn here is unique. I feel like Memorial is a hidden gem for all sorts of training.”

“I think what our trainees come to see is the astounding courage of our patients,” concludes Dr. Massie, “and their resilience as they struggle with the hand they’ve been dealt. A characteristic all our trainees share, I think, is a profound respect for patients. And if you decide to make oncology your life, you cherish the opportunity to work with these amazing people. What’s more powerful than that?”