Graduate Medical Education (GME): Medical Oncology
National Institutes of Health - Bethesda, MD

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Graduate Medical Education (GME): Medical Oncology

Tito Fojo, MD
Entry Id: TP-66

Overview
The National Cancer Institute (NCI) recruits fellows for an intensive two- or three-year Clinical Fellowship in Medical Oncology or combined Medical Oncology/Hematology training. The first year consists of primary responsibility for the clinical care of both inpatients and outpatients with a broad spectrum of neoplastic diseases. In the second and third years, each fellow elects a research program and a mentor from the very wide range of options in clinical and/or laboratory research available at the NCI. During the second year, fellows continue with outpatient responsibilities for about one-half day per week; clinical activities during the third year are optional and driven primarily by the elected clinical research focus of the fellow. The major sites for clinical training are the Medical Oncology Branch (MOB) located in the NIH Clinical Center and Georgetown University's Lombardi Comprehensive Cancer Center.
Medical Oncology Branch (MOB)

The MOB and affiliated branches within the NCI form an adult medical oncology unit whose clinical programs emphasize the diagnosis and treatment of cancer in the context of clinical research. Accordingly, patients are selected for care in the MOB if they have a disease or disease-stage currently under study by senior members of the MOB. Current areas of research emphasis include: lymphomas, including Hodgkin lymphoma; malignant hematology including hairy cell leukemia and multiple myeloma; prostate cancer and urotheleial malignancies; ovarian cancer; thoracic malignancies including non-small cell lung cancer, thymoma, and pleural mesothelioma; gastrointestinal malignancies, including pancreatic cancer and hepatocellular carcinoma; endocrine malignancies, including adrenocortical carcinoma, pheochromocytoma, and differentiated and undifferentiated thyroid cancers; new drug development; autologous and allogeneic hematopoietic stem cell transplantation; and HIV/AIDS and its associated malignancies. Clinical fellows are involved in every level of the clinical research program, including concept development and protocol authorship, participant selection and evaluation, and trial management following their first year of training. There is close collaboration with related clinical units in the NIH Clinical Center such as radiation oncology, palliative medicine, and surgery.

Structure of the Clinical Training Program
Clinical fellows in Medical Oncology spend the majority of the first year caring for outpatients, with three inpatient experiences at the NIH Clinical Center. In the second and third years, eighty to eighty-five percent (80-85%) of the fellow's time is protected time devoted to research; for fifteen to twenty percent (15-20%) of the second year the fellow is involved in the care of outpatients.

Year 1
MOB clinical fellows participate in the care of the patient population enrolled in MOB and affiliate clinical research trials, and perform the initial screening of new patients accepted for evaluation by MOB physicians. Clinics are organized in a disease-specific fashion, and fellows attend clinic four days a week under most circumstances. In the MOB, first-year fellows care for both inpatients and outpatients during 10 block rotations, each of which is devoted to the treatment of one or a group of specific diseases. Six of these blocks are rotations at the NIH Clinical Center and Georgetown's Lombardi Comprehensive Cancer Center caring for outpatients with: aerodigestive malignancies; gastrointestinal malignancies; genitourinary malignancies; hematologic malignancies; women's cancers and HIV/AIDS malignancies. Each of these blocks has the strengths of providing experience in clinical research and standard of care for each group of cancers. One block each is devoted to: clinical research trials and methodology; an inpatient rotation on the Clinical Center's Pain and Palliative Care service, during which skills in handling difficult pain management cases are strengthened while improving communication strategies with patients under difficult clinical circumstances; an intensive inpatient rotation at the NIH Clinical Center caring for patients with a variety of lymphomas and other hematologic malignancies; and an inpatient autologous and allogeneic hematopoietic stem cell transplantation experience. Trainees acquire experience in treating a wide variety of neoplastic diseases, dealing with the entire spectrum of medical complications of cancer and its therapy, and developing a multidisciplinary approach to the treatment of complex cancer cases, while simultaneously gaining an understanding of the strategies and regulations for the conduct of clinical research in medical oncology, bedside-to-bench research, and clinical trial design and management.

Years 2 and 3
Second and third-year clinical fellows work with research mentors selected during their first year of fellowship, and focus on the development of clinical, translational, or basic research projects. Numerous opportunities at NIH are available for these collaborations, and clinical fellows have pursued paths in a wide range of research topics and have successfully competed for grants to continue their research activities beyond fellowship. During this period, there is also a one-half day per week continuity clinic obligation, as well as didactic activities, and continued development of clinical independence with supervision. In addition, one block is spent serving as the Clinical Center's oncology consultant under the supervision of a senior Attending Physician.

Clinical research in the MOB focuses on the development of more effective combinations of drugs for tumor types having partial sensitivity to chemotherapy, the integration of new agents into combination chemotherapy, the use of high-dose chemotherapy with or without cytokine support, high-dose chemotherapy with bone marrow or peripheral stem cell reconstitution, reversal of multidrug resistance, early clinical trials of new agents with novel mechanisms of action, the development of new antiretroviral therapy for patients with HIV infection, and gene transfer into hematopoietic stem cells. Areas of interest in the laboratory include oncogenic control of gene expression, development of gene therapy vectors, the biochemistry and molecular biology of the folate receptor and reduced folate carrier, repair of drug-induced DNA damage, multidrug resistance and its reversal, T-cell repertoire selection, and graft-versus-tumor effects in bone marrow transplantation.

Rounds and Conferences
Lectures, clinical conferences, research seminars, teaching rounds, journal clubs, and multidisciplinary conferences relevant to clinical oncology and cancer research are offered throughout the program. These are supplemented by additional didactic components required during the Clinical Fellowship in Medical Oncology, including a Clinical Research Training Seminar and morphology training at the microscope. Finally, there are numerous research seminars and lectures given throughout the NIH on a daily basis; these are regularly open to the entire NIH community. NCI Grand Rounds are usually on basic science topics or subjects of clinical relevance. Formal course work in the sciences is available through the NIH Foundation for the Advanced Education in the Sciences ( FAES ) [ disclaimer ] .

Combined Training Program in Hematology/Oncology
The NCI/MOB, in cooperation with the Hematology Branch, National Heart, Lung, and BIood Institute (NHLBI), offers a combined training program in Hematology and Oncology for those individuals who desire to be board eligible in both subspecialties. Oncology fellows who desire hematology training will spend their first year on the oncology service and six months of the second year on the clinical hematology service. The remainder of the training during the second and third years is protected time devoted to research.

During the second year of the combined program, fellows receive six months of board eligible training in clinical hematology, with three months spent at the NIH Clinical Center on rotations covering allogeneic and autologous stem cell transplantation, general acute hematology, consultative hematology, hematopathology, and transfusion medicine. In order to provide broader training in non-research driven hematology, fellows spend three months on rotations outside the NIH, including experiences on the acute leukemia service at the Johns Hopkins Hospital, the general hematology service at the Washington VA Medical Center, and the hematology/oncology service at the Washington Hospital Center, an excellent private facility with a large cancer center.

The American Board of Internal Medicine (ABIM) requires a minimum of two years of fellowship for oncology and three years of fellowship for combined hematology/oncology. Those fellows who elect to train in Medical Oncology are offered the opportunity to remain as fellows in the MOB for a third year.
Summary of Combined Training Program

Year 1

10 Blocks - 12 months

Outpatient: NIH Clinical Center, Georgetown Lombardi Comprehensive Cancer Center

Aerodigestive malignancies

Gastrointestinal malignancies

Genitourinary malignancies

Hematologic malignancies

Medical Oncology Branch Clinical Research Program

Neuro-oncology

Women's Cancers/HIV and AIDS malignancies

Inpatient: NIH Clinical Center

Pain and Palliative Care

Lymphoma

Hematopoietic Transplantation

Year 2

Hematology – 6 months (optional for combined ABIM Medical Oncology/Hematology Specialty Board eligibility)

Oncology Research – 5 months (11 months for Medical Oncology Fellows)

Oncology Consultation – 1 month

Continuity Clinic (½ day per week)

Year 3

Oncology Research

Continuity Clinic (½ day per week for fellows doing combined Hematology/Oncology)

Eligibility Criteria
Candidates must have a MD or DO degree from an accredited medical school. We require that applicants have successfully completed postgraduate training in an ACGME-accredited internal medicine residency program at the time of their appointment as a fellow in medical oncology. Our program accepts internal medicine residents participating in the American Board of Internal Medicine Research Pathway, whereby four years of fellowship follow two years of residency training in internal medicine (further information is available from ABIM).

Application Information
The fellowship is fully accredited by the Accreditation Council on Graduate Medical Education (ACGME). Fellows are eligible to sit for the American Board of Internal Medicine certifying exam in medical oncology after two years; fellows interested in the combined medical oncology/hematology program are eligible to sit for both exams after three years.

Candidates are selected through the National Residency Matching Program and the program accepts applications via the ERAS system [ disclaimer ] .

The NIH is dedicated to building a diverse community in its training and employment programs.

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