Longitudinal Clinical Experience II

I wrote a previous post on the patient population at my longitudinal continuity clinic. My LCE is in hematology and oncology. It's a very different experience than standard clinical rotations. Though it is outpatient clinic like family medicine, heme/onc is so much more specialized and management-based. We see a lot of breast, colon, and prostate cancers along with a few leukemias and lymphomas. The hematology side varies a lot, from increased clotting tendency to leukopenia to thrombocytosis. Patients range in age, but most are older than 50. Our patients are all referred to us from other providers.

Cancer diagnoses are usually made by primary care physicians who send patients to us for chemotherapy. My preceptor knows in depth the various chemotherapy regimens and the evidence regarding new cocktails and combinations. There is very little diagnosis involved. A lot of it is finessing side effects, education, coordination with surgery and radiation oncology, and specific therapies. Hematology patients vary a lot more. Consults range from benign "reassure the patient" to acute myelogenous leukemia. There's a lot more diagnosis, analyzing lab values, and problem solving.

In terms of content, I've realized outpatient oncology does not thrill me. I'm not hugely interested in learning the nuances of chemotherapy regimens. But it is fascinating to see the wide range of cancer presentations, from breast cancer in a 30 year old to a metastatic prostate cancer in a 90 year old. I really enjoy the hematology; the diseases there are so weird and interesting.

I am learning an incredible amount about how to relate difficult diagnoses and end-of-life considerations. My preceptor is incredible when talking to patients, building a solid foundation of rapport and trust. He approaches difficult topics directly, easily, and deftly; even when giving a young patient a terminal diagnosis, he frames the conversation in practicality and hope. He explains statistics and prognosis in a surprisingly clear, straightforward, and accurate way. He is able to sympathize with patients yet avoid being consumed by the intense emotions and serious topics. These skills are the hardest to learn and sometimes, the most useful.