Clinical Advances in Hematology & Oncology

November 2018 - Volume 18, Issue 11

Growing My Practice, Keeping Up With Medical Knowledge, and Handling Adverse Outcomes

Sundhar Ramalingam, MD

Medical Instructor 
Department of Medicine, Division of Medical Oncology
Duke University Medical Center
Durham, North Carolina


Becoming an attending physician in our field requires a decade of hard work and is a test of both physical and mental endurance. It’s no wonder that after finishing my hematology/oncology fellowship 2 years ago, I was very much looking forward to starting my practice. I joined a community oncology group associated with my training medical center. It was a good fit for me because I wanted a clinically focused position with the ability to subspecialize, and also have an academic component to my work. As prepared as I was clinically, just like many before me, I experienced unforeseen challenges during my first year as an attending. I would like to share my own experience in relation to the 3 particular challenges below. 

Challenge #1: How do I grow a practice and develop a reputation?

The future challenges of growing a practice never crossed my mind as a trainee. There is no class in medical school or formalized training that goes over how or why to do this. As with most new hires, I was not very busy at first and was happy to see anyone who was referred to our clinic. As time went on, I realized I was allowing myself to take a passive role in shaping my practice. When I thought harder about my goals as a medical professional, I realized I needed to take a proactive role in building my practice and engaging my community. Although I was broadly trained in hematology and oncology, my passion since fellowship has been treating genitourinary cancers; I knew this was where I wanted to focus my efforts and career as an attending. 

As I explored my community, I realized I did not need to immediately have a full clinic schedule in order to make contributions and help others. For instance, I volunteered to be the physician representative at a monthly support group for men with prostate cancer. I found it valuable to interact with patients in a less-formal environment outside of the clinic. Patients seemed to be more comfortable opening up about their experiences, uncertainties, and thoughts when given the opportunity to share among others going through similar situations. I found that the men often were overwhelmed by their own research when they tried to achieve a detailed understanding of medical tests and treatments, such as different types of prostate magnetic resonance imaging tests, nuclear medicine imaging, molecular testing, surgical options, cryotherapy, high-intensity focused ultrasound, radiation therapy, androgen deprivation, chemotherapy, and immunotherapy. Being involved in this support group allowed me to share my knowledge and expertise with these men, which was a satisfying experience. It also provided me with a unique perspective into the questions and emotions of those going through the disease.

I took other opportunities to be involved in the community by agreeing to give talks at local Continuing Medical Education events designed to highlight advances in genitourinary cancers. When I gave my first talk on the exciting results of a trial of docetaxel in frontline metastatic hormone-sensitive prostate cancer, I saw that sharing my enthusiasm for new treatment possibilities and contributing to the knowledge base of other providers was extremely fulfilling. Discussions I had with local urologists and radiation oncologists who attended these talks spurred strong relationships with providers that I still have today.

Finally, I took the opportunity to be involved in multidisciplinary discussions at tumor board conferences. A few months into my job, I found several general and subspecialty tumor board meetings between various hospitals in our community, and I began to attend on a regular basis. I especially felt I was making a solid contribution to patient care with my input on the treatment of genitourinary cancers. At the end of my first year as an attending, I volunteered to become a tumor board co-chair at one large community hospital in our region. This is a role I continue to serve in today, and I find it is a great avenue for contributing, communicating, and learning.

Challenge #2: How do I keep up with new medical knowledge?

During my training years, part of my schedule routinely consisted of daily educational activities, grand rounds, and conferences. Now that I am an attending physician and have a busier clinic schedule, it is hard to participate in all of these events and keep up with new trials and data. This is especially the case in the broader field of oncology, where we are in an era of unprecedented rapid change in the way diseases are treated.

There are many ways to learn, and no way is ideal for everybody. Subscribing to newsletters and journals, attending tumor board conferences, and attending educational conferences are common methods that I and many others employ for self-education. There is one other system that has served me well—something I started when I was a fellow, and continue today. Every day, I ask myself a specific real-time question that pertains directly to one of my patients and write it on a sticky note I place on my desk. I find that even on days when all my cases are straightforward, there is always a question for which I do not know the answer. I found that this system works well for me because I tend to remember things more clearly when I can associate a particular trial or review with a specific clinical scenario or patient encounter. For instance, the question could be related to symptom management, such as “what is the best topical therapy for managing hand-foot syndrome in patients receiving oral chemotherapy?” or something more therapy-related, such as “what is the survival benefit of neoadjuvant chemotherapy in patients with urothelial carcinoma and sarcomatoid variant histology?” By the end of the day, I do a quick literature search to pull up at least 1 or 2 review articles or clinical trials that pertain to the question. This typically does not take much time—usually less than 5 minutes to find a good reference and another 10 to 15 minutes to read it, either at the end of clinic, or at home in the evening or over the weekend. The hard part is trying to stay disciplined to do this on a daily basis, but over the course of the year it adds up to 200 or more additional articles read that relate to specific clinical situations I encounter. 

Challenge #3: How do I handle it when my patients have adverse clinical outcomes? 

One of my earliest patients as an attending was a young woman who received an unfortunate diagnosis of stage IV Hodgkin lymphoma the summer before starting graduate school. This was a very unexpected and stressful diagnosis, and she had to put her whole life on hold to go through treatment and recovery. She did very well with treatment and was cured of the disease, and a year later was back on track to start her graduate school education. Being able to share in the happiness she and her family experienced from this outcome is one of the greatest satisfactions of being a primary treating provider. However, as we all know in medicine, and especially in oncology, there are always instances that go in the opposite direction and patients who may suffer unwanted side effects or comorbidities. I am reminded of specific experiences of direct treatment-related side effects from chemotherapy or immunotherapy that led to significant morbidity or mortality in my patients in my first year as an attending.

Especially at this early stage in my career, I find that this can be a significant weight to shoulder. It is the nature of oncology and the privilege of our field that we are meeting people at what is often the most crucial and fragile time in their lives. As an attending, adverse outcomes carry an even heightened sense of remorse and responsibility. When complications occur, it is human nature to ask what could have been done differently. However, even in the setting of doing all the right things, following guidelines, and using one’s best medical judgment, outcomes are hard to control and predict. I find that the best approach I can take is to continue to constantly push myself to practice with the utmost care, up-to-date knowledge, and attention to detail, all of which promote sound decisions. 


My first year as an attending taught me a lot. My main advice to those entering their career as an attending is as follows:

• Take a proactive role to go beyond your direct clinical responsibilities. Engage your community by becoming involved in cancer support groups, giving talks/lectures, and participating in tumor board conferences.

• Develop an effective system for self-improvement. Become a lifelong learner in a changing medical practice environment, where it is crucial to keep up with the latest guidelines and practices.

• Adverse patient outcomes are hard to deal with, whether they are expected or unexpected. Strive to practice with care, up-to-date knowledge, and attention to detail in order to make sound decisions.