38: Discussing Pediatric Oncology with an Academic Doc

Session 38

Dr. Julie Krystal is an academic pediatric oncologist. Julie has been out of training now for two years. She discusses what she loves about her job, where she sees the specialty going and what you should do.

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[01:00] Interest in Becoming a Pediatric Oncology

Julie always knew what she wanted to do. Back in high school, she wanted to be child life person where you get to do arts and crafts with kids in the hospital. So she was volunteering at Stanford Children's Hospital where she grew up in California. She was working with a lot of oncology patients. She then realized that the more she got to work with the doctors and see the fellows, they were actually doing a way cooler job than the child life people. That's when she decided it's what she wanted to do in high school and stuck with that. She felt strongly better all throughout her training, through college and all the way through her residency.

She did give other things a try since pediatric oncology as she describes is a tough path in many senses. So at some points, she tried to convince herself to like other things - better hours, better pay, etc. But nothing else was the right fit for her except for pediatric oncology which she felt was the one thing she really wanted to do.

What she likes about the subspecialty is you get to have a sort of primary care relationship over long periods of time. They remove the kids from their pediatrician while they're with them and while they're getting chemo or treatment. So the relationship goes over many years because these kids get to stay with them.

"You have that longitudinal sense that you get from primary care but you have much more interesting complex medical problems."

Julie describes it as somewhat the best of both worlds. It's something really interesting subspecialty-wise and that relationship that's so important. Whenever she tells people what she does, their first reaction is almost always negative. They think it's awful and sad. So she always tell them that it's not sad actually. The majority of children are cured from their cancer and they go on and have wonderful adult lives. It's her privilege to be with the family during the worst, most horrible thing that's happening to them and to see them through to the other side. So this part of it just really appeals to her where there is challenge and mostly a happy ending. And if it's bad, it's really bad and really sad. But most of the time, there is knowledge that you're able to get the family over something that's really hard. Then you get to see their child go on and grow up and do wonderful things. So for her, it's a wonderful role as a physician to get to do that.

[03:40] Traits that Lead to Becoming a Good Ped Onc Doc

Julie cites a few things to become a really good ped oncology doctor. First, is being a sunny and optimistic person. There are sad and depressing moments. The lifestyle is tough. It's academic and it involves long hours. There's no money in it. If you're doing grants and you're fighting to the nail against everyone else to get funding, things can get challenging. So you have to be willing to devote yourself. This job involves long days and long nights. So you have to go into it knowing that.

"You have to be accepting that this is your life and it's not a glamorous, fancy, sports car kind of gig."

[05:18] Types of Patients and Doing Clinical Trials

Julie mostly takes care of kids with brain tumors. In peds oncology, things can  be specialized these days. There's hematology and oncology. She's specialized to oncology and within oncology, there are doctors who do leukemia. Some doctors do bone tumors. While she mostly takes care of kids with brain tumors, like everyone else, they have to do a certain number of weeks of the year of in-patient service. When you're on it, you take care of admissions and all the new diagnoses that come in. Nevertheless, she keeps up to date with everything by doing that kind of work. She gets to see a little of everything. The vast majority of childhood cancer is leukemia. Those are the things that in the average week of service, one or two diagnosis of leukemia will come in or one brain tumor. But the vast majority of new diagnosis every week are leukemia. Other things common in the pediatric age group are the bone tumors. Brain tumors are the most common phallic malignancies and there are a lot of those. The majority of those have a good outcome.

Julie explains there's not a lot of jobs in academic peds oncology. There's more fellows graduating every year than they have open positions. Part of the reason has to do with funding since it's only academic institutions that have a lot of NIH funding. So it's very hard to find academic positions. Hence, people tend to shy away from brain tumors but Julie did otherwise. She found it to be interesting and it's a place where there's a real need.

"By doing something that other people are hesitant towards, I was able to get a job that I really love."

The other piece of work she does that's not directly clinical is working on early phase clinical trials. This is also something she loves and feel passionately about. There's a lot of new cancer therapies in adults and it's much harder to get those in the kids. So she works on getting early phase clinical trials up and running in her hospital. It's something she never envisioned doing but the opportunity kind of fell on her lap. She further says you don't really foresee all the stuff that are coming ahead of you but if you keep your mind open, really cool things will come your way.

[8:20] Why People Shy Away from Brain Tumors

Julie thinks people shy away from brain tumors because they're this own little thing. Leukemia and lymphoma are things everybody knows about. We all know what to do with it. But for brain tumors, they're much more of a niche.

"If one walks in the door and you don't know what to do, it can feel really scary because it's a whole different world."

Another reason she sees is that we've made huge progresses in lots of pediatric tumors. Especially in leukemia, the cure rate is over 90%, and in some cases, 95%. This is phenomenal. But they haven't had that huge leap for all types of brain tumors. There are certain types of brain tumors where the cure rate is still very low unfortunately. And she thinks people shy away from that because it's intimidating. It's hard to go through that professionally. But the way Julie looks at this is we still have room to make that progress. It's exciting to be able to keep working and trying and keep doing studies until we find the next thing that's going to make the biggest difference for this diagnosis. Moreover, she's aware of the challenges and working with families can get overwhelming. But there's room for so many great things to happen still.

[09:40] Taking Calls and Work-Life Balance

For Julie, she doesn't necessarily take calls. It takes three years for the fellowship and the first year of it is purely clinical. And after being a fellow, you'd be an attending and things are so much easier. So the call they take is when they're on service Monday through Friday. They're on during the day and they're also available at night. But the fellows take the first calls - from the ER, from the service, parents calling in, or from outside hospitals. And the fellows only contact the attending doctors in cases where they're looking for guidance or they're not sure what's going on. Some nights they take ten phone calls, some nights, none. So she does a week of that, eight weeks for a year. It's not a fully clinical position since she has research time. She finds this to be manageable as she gets to do other things like research and clinical trials she likes to do. Attendings don't do in-house call of any type. It's something when you're available at night time from phone. So you can still live your life. the fellows call in and ask you questions. So it's very doable.

Being a mom with two kids, she explains your really have to try hard to make time outside of the hospital. On academic days, things go early in the morning and late at night. So you have to be really conscientious about it. As for Julie, she plans her schedule carefully to make sure she gets to see her kids. Since her kids are so little and they go to bed very early, she just sets an alarm or make a stopping point. She will set a time when she'd leave the office regardless of what she's doing with her work. So she gets to spend time with her kids. They go to bed and she goes to work at night. It's very important to her to make sure she has that time with them.

When she's on service, those eight weeks a year, it can be very challenging. Some nights, she doesn't get to see them since she can't just leave. She thinks it's really something you have to be conscientious about. So she makes sure she plans out all of her days. So yes, you can do that but you have to be flexible and you have to plan around that and make it a priority.

"It's really something you have to be conscientious about... and you have to be willing to work at home."

[12:55] The Path to Residency and Fellowship

Julie explains that you do a general pediatric residency for three years. Most people during this training may only have a month of peds oncology exposure. So she encourages people to get more exposure. Because during peds residency, she was terrified about oncology because they had to deal with really sick cases and they're complicated.

"Get as much exposure as they can to see what it's actually like."

She says that just seeing those kids on the inpatient side doesn't give you a glimpse of what is actually like to do this job. Like she said, it's only a job she does eight weeks our of the year. That leaves all the rest of they year where she's doing other things - not being with those super sick kids admitted in the hospital. So she encourages residents to try to get more exposure and get exposure to the outpatient side, the research side. See what attendings actually do.

Moreover, once you do peds residency, you do another three years of fellowship, the first year being a purely clinical year. The second two years are research years, be it laboratory research or clinical research or MPH. Then you're finished. But if you want to torture yourself some more as Julie humorously says, there are sub-fellowships. So you can do an additional year of training. In things like brain tumors, you can do an additional year of training. There are brain tumor fellowships for an extra year. There are bone marrow transplant fellowships for an extra year. If you wanted to super sub-specialize and do additional trainings to get more exposure, it's something you can go on and do an extra year in that.

The fellowship is all combined. The three-year fellowship is one thing you match into. It's Pediatric Hematology/Oncology. You do train in both. But most people during their fellowship are gravitating towards one or the other. They gravitate towards hematology or oncology. Most very large academic centers are separated. In her division, people are either hematologists or oncologists or bone marrow transplanter. There are smaller programs where it's combined. So they only have one service and the attendings take care of everybody. Some people like this to get a little flavor of everything. But most large academic centers are very specialized into specific niches. But everybody at this point still has to do everything in the fellowship. As opposed to the adult side, you can do a hematology fellowship or an oncology fellowship. You don't do both. But in pediatrics, it's a combined fellowship and you have to train. And the boards cover everything so you have to train for both things.

Julie says matching for fellowship is not competitive. Again, this is something people try to shy away from. So most people who want a spot can find one. So it's not out of your reach if you don't have good board scores. There are a lot of fellowship spots in the country so there's plenty to go around.

[16:26] Bias Towards DOs and Subspecialty Opportunities

There are lots of DOs in the field. In fact, she didn't even know some of the people who were DOs. She thinks people are accepting of it and they're treated the same as an MD.

Other subspecialty options available include coagulation, hemophilia, bleeding disorders, and survivorship. Survivorship is relatively new. Thirty years ago, there were no long-term survivors of childhood cancer because they have all died. Now, these kids grow up and they're thirty years old or forty. They do have certain health problems or at risk for certain health problems due to the treatment they got. Survivorship is a whole new discipline that follows these patients through their adulthood. They're being monitored in terms of what kind of testing they should get or what they should do in terms of their lifestyle. Fertility issues are a big deal for survivors.

There are also programs for solid tumors and blood banking. Every hospital has a blood bank and the directors of the blood banks are all hematologists whether adult or pediatric. So you can work in blood banking.

"Blood banking is a more lifestyle friendly choice."

[18:06] Working with Pediatricians and Other Specialties

Julie says general pediatricians worry about missing something. They're worried they're going to miss a leukemia. She feels it could be hard being a general pediatrician. Kids come in and complain of headache. And how do you know who you should be sending for scanning and who shouldn't. When kids get diagnosed with brain tumors they always blame themselves. But Julie tells them it's okay. Most kids who have a headache do not have a brain tumor. The brain tumor is the zebra here. So she wants pediatricians to know to trust themselves and follow their workup and not to second guess what they're doing. Follow their normal steps and do the things that they're doing. Every kid doesn't need an MRI who has a headache. Similarly, when they see a kid and feel they need to get CBC and need to make a call to them, pedia oncologists are available. Pediatricians call their practice a lot and she really appreciates when they do that just to get general guidance."

"Pediatricians have a really hard job because they need to not miss these huge important things but also not overreact to everything."

What they should know, Julie adds, is that they're doing a great job. And not to second-guess themselves and regret they didn't do something sooner or later because they're probably doing it just right. Moreover, other specialties Julie works the closest with include surgery, ID, nephrology, pulmonology, GI, and others. They get to work with all other specialties because what they do affects every part of the body. Cancer and chemo affect every part of the body. So there's no service that they don't get to consulting. And because it's a unique population, their relationships with those subspecialists is really good since they work closely together. So they the opportunity to learn a lot from them and vice versa.

[21:11] Special Opportunities Outside of Peds Oncology

Julie explains how the industry is a big thing in terms of pharmaceutical companies. They are always looking for pediatricians to do drug development, clinical trials, etc. That is a very different lifestyle which a lot of people choose. She knows a lot of people who have gone that route. So if this is something you're interested in, it's a great career choice. There is a need for drugs. We need them to be studied in kids. Another would be clinical trials like the FDA. There's a whole group of peds oncology people who work at the FDA in terms of looking at new drugs.

Additionally, lab research is still a part of what they do. It's how they got to where they are with all of pediatric oncology treatment. And it's also how they're going to get as they go to the future. People not clinically oriented and just want to go into a lab and find out something cool, there's that opportunity as well.

Since Julie doesn't have a PhD, she really doesn't think it has hindered her ability to do the amount of research she wanted to do. She doesn't do bench research or research in the lab. But she thinks that if you want to do research in the lab, a PhD does give you an edge up for sure. That said, she knows people who've had successful lab careers and ran labs who don't have a PhD. But if you want to be competitive and if you're getting grants, Julie thinks having a PhD for lab work does make a big difference. Since most of the work she does are more early phase clinical trials and drug development, she doesn't feel it has made a big difference. She got an MPH when she was in Fellowship and she feels this gives her a little bit of an advantage. First, she knows a little more background about clinical trials. Secondly, she thinks people just take you a little bit more seriously. The more letters you have that you can say you're qualified for xyz even if it's bogus, it does get your foot in the door. It gets people to listen to you.

"If you're going to be having a lab career, the PhD is a very big boost."

[23:47] What She Wished She Knew & Most and Least Liked

What she wished she knew going into peds oncology is that it's so worth it. She has a job that she loves and gets to do it everyday. She is so grateful this is her job. During the many years of training and during fellowship, it's hard to see what your life is actually going to be like when it's over. If she could just go back, she'd tell herself this is so worth it. You're going to get to the end and you're going to have this awesome job. It's going to be the best thing ever. You can keep suffering for a little bit longer and then you're going to make it to the other side.

"So many jobs where there are so many long years of training, you can lose sight of what is actually at the end of it."

The thing she likes most about her specialty is the families and patients. She gets to go to work everyday and hang out with awesome kids fighting tough battles. But they don't care and they're just awesome about it. They're running around and playing. They're going to school. They fight so hard and they do incredible things. So the families and the kids are what makes her job so special. She gets to be with them. She gets to support them and help them in a way others don't get to do. So she feels privileged to be a part of that and a part of the family during that challenging time.

"Having a child with cancer changes the life of the child, of every person in the family. And I get to be a part of that."

Conversely, what she likes the least about her job is kids dying. It's hard. They know it's going to happen and they can't going to cure every child as much as they want to. It could be hard for her sometimes because she takes it personally. She finds it hard to accept that failure. One of her favorite mentors told her and that she's kept with her all the time is, "we're in charge of the process, but we're not in charge of the outcome." She says this to families every time she does a diagnosis talk. They can choose the steps they're going to follow and the path they're going to take. But ultimately, she can't choose the outcome. Otherwise, she could just make every child okay.

"I can't choose the...