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Navigating Uncharted Waters: The Transition From Residency to Fellowship Training During the COVID-19 Pandemic

Well over a year ago in early 2020, the end of my PGY-3 internal medicine residency in New York City was looking promising. Having completed all inpatient floors and intensive care units (ICUs) and night float rotations, this particular resident was looking forward to quality time with friends and catching up on research projects that went on the back burner during the fellowship interview trail. Midway through February, we started receiving sobering updates that there was an acute respiratory illness sweeping throughout the globe and that NYC, being the melting pot of culture and travel that it is, had tested a cluster of patients with a new strain of virus named “SARS-CoV-2.” There were initial weeks of unbearable uncertainty as scientists raced to determine the airborne, droplet, or contact nature of spread while hospital administrators struggled with an unprecedented spike in demand for personal protective equipment (PPE) and mask mandates.

As one of the earliest, largest, and ultimately deadliest epicenters of the pandemic in the United States, NYC went into lockdown and there was a complete upheaval of the normal workflow from February 2020 onward. Our outpatient primary care clinics, which initially started off with compulsory masking and temperature checks, quickly shut down and became telehealth visits, marred by technological glitches and unsatisfied patients. Our hospitals turned into COVID-only centers. Meanwhile, as a senior resident who was part of the “pandemic jeopardy schedule” implemented by our residency program, I got pulled into service in the many ICUs that were expanded, as well as inpatient isolation floors and stepdown units filled to the brim with patients with COVID-19. The 12 weeks that followed have been etched in the memories of all of us on the front lines during that deadly spring peak — leading “COVID codes” whose outcomes were overwhelmingly poor, incessant pages from nurses and interns regarding decompensating patients requiring intubation, heartbreaking virtual conversations with families explaining the critical state or the passing of their loved one who was alive and well just days ago, trying to ward off ventilator-alarm fatigue, the physical and the crippling emotional fatigue accompanying harrowing shifts, coming home to our loved ones fearful of unwittingly passing on COVID-19, and secretly hoping to somehow contract asymptomatic COVID and get protective antibodies. Charles Dickens’ quote in The Tale of Two Cities resonates: “It was the best of times, it was the worst of times.” It was the best of times when we stepped up and collectively took care of the sickest; it was the worst of times as this deadly pandemic ravaged on and took an unfathomable toll on humanity.

Meanwhile, the inexorable march of time continued as, following a virtual residency graduation, it was time to start my fellowship training in hematology and oncology. The month of orientation took place in-person as caseloads in NYC eased in the summer, albeit masked with social distancing measures and a series of virtual lectures. Though protective and now the “new normal,” not being able to see the lower faces of co-fellows, attendings, nurses, our patients, and everyone in-between has been challenging, especially in trying to establish a personal rapport with others at a new workplace. While navigating the ever-adapting protective protocols, our fellowship training started. On hematology consults, teams were approached with novel COVID-related questions, including thrombocytopenia, leukopenia, arterial and venous clots at unusual sites, and massive inflammatory states raising concern for secondary hemophagocytic lymphohistiocytosis. These were an exercise in appraising the minimal data available amid a vacuum of guidelines in the early days, while combining anecdotal experience with clinical judgment. Not to be outdone, solid tumor oncology consultations poured in regarding patients presenting with new diagnoses of cancer, often in late stages as the fear of seeking medical help during the pandemic prevented patients from reporting symptoms at a much earlier point in time. Representing oncology in multidisciplinary family meetings continues to be an incredibly difficult task with a steep learning curve, now compounded by nearly all meetings being held on virtual platforms due to visitation restrictions and distancing measures that have taken away the personal touch and conveyance of empathy and support to grieving families.

Perhaps the most challenging aspect currently is coordinating outpatient follow-up visits and planning “COVID-friendly” regimens for patients undergoing active treatment and surveillance. As oncology fellows-in-training, familiarizing ourselves with standard-of-care treatment regimens for various malignancies is an expected milestone. Adding on a complex layer of patient logistics, including travel, pre-therapy COVID testing, and avoiding prolonged hospitalizations or infusion chair periods to reduce exposure times in the hospital setting, we are learning to adapt standard-of-care regimens to alternate routines with equivalent potency that are faster to administer, as with subcutaneous routes, oral agents, depot preparations, and staggering outpatient follow-up visits. Clinical trial enrollment during the pandemic has also been challenging, from changing protocol requirements to ensuring best standard-of-care treatment for patients awaiting trial enrollment.

With the advent of the groundbreaking COVID-19 vaccines came profound relief, but a new set of obstacles. Fielding patients’ concerns regarding vaccine information, availability, and hesitancy are daily routines, while balancing the timing of vaccines before, during, or after myeloablative chemotherapy, bone marrow transplantation, or cellular therapeutics poses a complex clinical task. As large conventions and conferences move to all-virtual platforms, we as fellows can attend more scientific sessions, but the human touch of reuniting with old friends, meeting new people, and networking have all but vanished. On a personal note, the pandemic has prevented physicians like me with families abroad from visiting our loved ones for more than a year, with no clear end in sight.

With the accelerating pace of vaccinations within the country, I hope that our vulnerable immunocompromised patients are protected from this pandemic, that we start returning to a semblance of pre-pandemic normalcy regarding patient care and our own lives, and that we get to finally see the faces of our coworkers and spend time with our loved ones. For new trainees entering our field, I hope that you are armed with an improved understanding of COVID-19 and clear guidance from academic societies regarding the care of patients with cancer during the pandemic, that your transition may be smooth and adaptability be your mantra during this era-defining time.