key: cord-0975313-8pp2xr6z
authors: Moerdler, Scott; Gampel, Bradley; Levine, Jennifer M; Chou, Alexander; Madhusoodhan, Pallavi; Oberg, Jennifer A.; Pierro, Joanna; Roberts, Stephen S.; Satwani, Prakash
title: COVID‐19 has changed the way we think about training future pediatric hematologists/oncologists
date: 2021-04-29
journal: Pediatr Blood Cancer
DOI: 10.1002/pbc.29088
sha: ea2d753dd495fdac0144a70110caf69968070285
doc_id: 975313
cord_uid: 8pp2xr6z

COVID‐19 has upended medical practice and education, but has also catalyzed enhancements in the field. Early on, a local group of researchers united to investigate the impact of the pandemic on pediatric hematology oncology (PHO). From this group, a regional educational series was established, “virtual‐Symposium of Pediatric Hematology/Oncology of New York” (v‐SYMPHONY). The implementation of these endeavors while PHO fellowship applications are declining has highlighted our perceptions that education, mentoring, and career expectations are not keeping up with the needs of current trainees. We describe our regional experience joining together to further education and research, and reflect on the current landscape of PHO training and workforce.

The COVID-19 pandemic has created unprecedented challenges across medicine. Sequential waves of infection have drastically altered our health care systems, clinical practices, and research programs. [1] [2] [3] Abbreviations: CT, Connecticut; IRB, institutional review board; NJ, New Jersey; NY, New York; PHO, pediatric hematology oncology; v-SYMPHONY, virtual-Symposium of Pediatric Hematology/Oncology of New York.

We have watched our pediatric hematology oncology (PHO) fellows redeploy to COVID-19 units, capsizing their fellowship rotations. Clinical learning has been altered by social distancing, inpatient and outpatient restrictions, and the increased use of telemedicine. In some instances, the need for "COVID beds" closed PHO centers entirely, sending patients off to other institutions. Research activities were put on hold: labs closed, mice sacrificed, human subjects unavailable for study participation. Importantly for our fellows, social connectedness with peers and mentors has been disrupted. Remarkably, this extreme adversity generated innovation and collaboration in PHO research and education within the New York (NY)/New Jersey (NJ)/Connecticut (CT) tristate region, an early United States pandemic epicenter, making this group of authors hopeful for future training possibilities and job satisfaction among our fellows. However, when we learned that 43/176 (24%) of PHO fellowship positions went unfilled, 4 affecting 32/72 programs nationwide (44%) for the 2021-2022 academic year, we were compelled to reflect upon the current state of our discipline and our regional experience during the pandemic.

These alarming results reflect a worsening trend within our field.

PHO fellowship slots have doubled over recent decades, while applicant numbers have decreased. 5, 6 The roots of this trend are multifactorial. A recent analysis found that hematology/oncology is among the pediatric subspecialties where fellowship results in a loss in lifetime earning potential compared to general pediatrics. 7 Currently, PHO fellows complete 1 year of clinical immersion, which is traditionally followed by 2 years of bench research. Historically, this was a time for fellows to develop their "niche" and hopefully, gain a competitive edge in a job market whose promotions value individual achievement as measured by grantsmanship and first author papers. However, traditional early career jobs are less available due to increased competition for research funding, increases in advanced practice providers, and overall decreases in medical reimbursements. 6 Despite this, fellows continue to focus their second and third years of fellowship in bench or clinical research. For many, this may be their first research experience. Basic and clinical research has become far more complex, making it increasingly complicated to develop a meaningful research foundation and product during this timeframe. 8 Also, research opportunities at their home institution might not align with their career aspirations, necessitating additional years of research at another institution to establish their niche. Some fellows seek further clinical training in a specific area of PHO, with increasing numbers of fellows opting to pursue additional years of subspecialty training. 6 All of this has led to a shift in the fellow experience and may contribute to the declining numbers of applicants each year.

In addition, these perturbations have taken a toll on wellness, with nearly 40% of both PHO faculty and fellows self-reporting high levels of burnout. 9,10 Alarmingly, 20% of PHO faculty overall and up to 36% of those with high levels of burnout report that they would not choose the same career again. 9 Beyond job satisfaction, the grave effects of burnout on patient outcomes have been described. [11] [12] [13] [14] [15] [16] These challenges combined with a global pandemic, where society is facing its own mortality, 17,18 may be influencing career decisions while examining work/life balance. As we contemplated the reasons why our field is struggling to attract applicants, we describe here how our regional experience collaborating during COVID may provide beneficial insights for guiding the future of PHO training on a larger scale.

At the onset of the pandemic, the importance of describing the experience of children with cancer and COVID was quickly recognized. In the NY/NJ/CT region, three separate clinical studies were independently created, [19] [20] [21] Ultimately, the key to our success was identifying the unique characteristics among the individual studies, prioritizing fellow and junior attending leadership, and streamlining data collection in areas of overlap.

These collaborative efforts led to the development of a regional PHO While mentorship within institutions remains paramount, fellows benefit from additional interactions with, and mentorship from, experts at other institutions, especially those that specialize in rare diseases. Giving trainees and junior faculty the opportunity to present cases has provided them visibility and has supported engagement in regional mentoring relationships.

The weekly v-SYMPHONY lectures offer the opportunity to see and reconnect with familiar faces on the screen, offering reprieve from social isolation. We anticipate that this will have a significant social impact on the well-being of participants. Participants have commented on how much they are enjoying the lectures, that they look forward to subsequent lectures and topics, and emphasize their appreciation of fellow involvement and opportunities for career guidance from these sessions. Furthermore, informal conversations that stem from these lectures are likely to boost wellness and resilience, 22, 23 and potentially enhance learning by mitigating "Zoom fatigue." 22 Participants have the ability to develop personal learning networks within this regional community, which have the potential to further facilitate learning, mentorship and collaborations, as well as improve career satisfaction. 24 Future development of a regional mentorship initiative, in areas not available at one's own institution, can arise from these meetings and support a stronger interconnected workforce. 25 While existing young investigator mentoring programs offered through our national and international societies have demonstrated success, 26, 27 these programs connect investigators across the country. We foresee that the development of a local mentoring network, currently in the brainstorming stage, will allow trainees and junior faculty to collaborate across institutions on a variety of academic projects. This type of regional initiative may help broaden fellows' clinical knowledge beyond the diagnoses seen at their home institution and introduce them to different research methodologies. 28 However, such an endeavor will require significant institutional support and planning, as well as input from fellows. We have begun soliciting this input from both fellowship program directors as well as fellows to help ensure our goals are attainable, while also meeting the needs of local programs and trainees. The hope is that this local mentoring network, given the geographic proximity, will improve the frequency of interactions and promote multi-institutional collaborative scholarly productivity.

Continued scholarly collaborations focusing on opportunities for fellows and junior attendings have resulted in multi-institutional publications. 19, 20, 29 Ironically, in a field where consortium treatment studies are the norm, regional collaborations remain relatively uncommon. A major goal of this group is to create opportunities for PHO fellows to conduct multi-institutional scholarly projects that otherwise could not be accomplished at individual institutions. We seek to streamline the institutional research review process to facilitate minimizing overlap in study-specific content, distributing leadership and support roles, maximizing institutional "cross-talk" and mentorship.

We hope this will foster opportunities for fellows while providing additional avenues for collaboration and career growth in a field struggling to attract a new generation of providers.

In a time of quarantine and isolation, we have fostered a collaborative are building a website to distribute the series. We will distribute endof-the-year evaluations to assist with improving the curriculum, and we are currently developing a regional career day to provide practical job search guidance, such as CV and cover letter advice, as well as presenting the variety of clinical, academic, and scholarly paths represented in our field.

While born out of necessity, these initiatives foster autonomous motivation 31 and enhance wellness and education. With a deliberate shift from individual achievement to a model of success based on collaboration and a sense of community, we believe that we can affect a positive change on education, scholarship, career development, and wellness within our field. While ours is a region rich with PHO programs, this can be adapted and implemented elsewhere to improve connectivity, collaboration, and community. We hope that by concentrating on these areas, we can redefine the expectations for a successful career, experience a boost in morale, and shift the perception of our field to help strengthen our workforce in the future. Stephen S. Roberts https://orcid.org/0000-0001-8258-756X

Summary of COVID-19 clinical practice adjustments across select institutions

Delayed presentations of pediatric solid tumors at a tertiary care hospital in the Bronx due to COVID-19

How we make choices and sacrifices in medical education during the COVID-19 pandemic

National Resident Matching Program. Results and Data: Pediatric Specialties Match -2020

National Resident Matching Program. Results and Data: Specialties Matching Service 2020 Appointment Year

The American Society of Pediatric Hematology/Oncology workforce assessment: part 2-implications for fellowship training

Differences in lifetime earning potential for pediatric subspecialists

The evolution of the pediatric hematology/oncology fellowship: what does it mean to be productive?

Career burnout among pediatric oncologists

Burnout in pediatric hematology oncology fellows: results of a cross-sectional survey

Physician burnout: contributors, consequences and solutions

Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis

Healthcare staff wellbeing, burnout, and patient safety: a systematic review

The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review

Physician wellness: a missing quality indicator

Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev

Coping with 'Death Awareness' in the COVID-19 era

From quiet acceptance to 'crippling fear,' medical workers confront their own mortality

COVID-19 disease in New York City pediatric hematology and oncology patients

Characterization of COVID-19 disease in pediatric oncology patients: the New York-New Jersey regional experience

Pediatrics HOT COVID-19 Database in NY

Social connectedness in virtual learning contexts

Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises -practical tips for an 'integrative resilience' approach

The connected educator: personal learning networks

Emerging from the COVID-19 crisis with a stronger health care workforce

Early career mentoring through the American Society of Pediatric Hematology/Oncology: lessons learned from a pilot program

Mentors' perspectives on the successes and challenges of mentoring in the COG Young Investigator mentorship program: a report from the Children's Oncology Group

Career planning and mentorship: a few key considerations for trainees

Well-being of pediatric hematology oncology providers and staff during the COVID-19 pandemic in the New York and New Jersey epicenter

Applications in continuing education for the health professions: chapter five of "Andragogy in Action

Supporting motivation in teams working remotely: the role of basic psychological needs

COVID-19 has changed the way we think about training future pediatric hematologists/oncologists. Pediatr Blood Cancer