I've been on wards this past week. It's never easy, but this round seems particularly hard to me. Not physically hard (that was what residency was for), but emotionally hard. For my practice, we rotate who is on the inpatient unit by one week increments and when you are "on" you manage all the inpatients for the entire oncology section.

Since I do gastrointestinal oncology, and a lot of my patients end up being admitted for any number of reasons (blocked stents, bowel obstructions, dysphagia and so on) getting a hard ward week feels a little like karma to me. As if I somehow deserve it because of the number of my patients that have needed admission since the last time I was on wards.

I have been struck this past time with the difficulty of actively dying patients. I have struggled with patients who are dying too slowly and families asking me, can't we just do something to hurry this up? My response: No, we cannot. Then we have the equally-as-hard patient who dies too quickly. I find the latter may be a bit easier to explain - at least their final suffering was not prolonged - but still very, very difficult on families.

I've had to get multiple Medical Intensive Care Unit consults this week, tell multiple families news they weren't hoping for, changed people's life trajectories in awful and difficult ways. I feel completely empty and tapped out, and I am facing a Monday clinic with over 20 patients, all equally as deserving of my time, support and care. I hope 12 hours off pager is enough to refill the tank - it has to be.

Do you counsel your cancer patients and cancer survivors about exercise? If you don't, why not? If you do, how much and how often and what kind?

For me, we were not taught about this very important part of cancer survivorship in either residency or fellowship. We have a survivorship plan document for colorectal cancer survivors, which I find very useful when patients are completing their adjuvant therapy and are left asking, "what next?" The plan includes a prompt to discuss exercise. I generally tell patients that regular moderate exercise is helpful in preventing some cancer recurrences, in addition to being beneficial to their overall health and maintenance of a healthy weight. Here is an article which I cite for my patients that shows a particular benefit for colorectal cancer patients.

A recent study published in this month's Journal of Supportive Oncology highlights the ways we do and do not counsel our patients on physical activity. I was happy to see that 95% of oncologists (radiation and medical oncologists) inquired about physical activity with their patients at least some of the time. Older and longer practicing physicians, those who are physically active themselves and medical oncologists were most likely to recommend physical activity. The most common factors cited in not discussing physical activity recommendations are a lack of time, lack of patient interest and being unclear on the recommendations for activity. I find that recommending exercise only takes a minute or two, and for those who heed your suggestions can have some very positive benefits.

My husband is involved in fellowship training, and as such, he gets some graduate medical education journals which I will on occasion flip through. The most recent issue of the Journal of Graduate Medical Education caught my eye because of its focus on burnout. A particularly interesting editorial that addresses the changes in residencies over the years.

I was surprised to find out that there have been discussions about the exploitation of residents dating back to 1940. More surprisingly, though, is that the complaints of abuse did not surface until after World War II.

The article describes that residencies at that time were quite prestigious and difficult to obtain, so there was a sense of gratitude for the position. Additionally, there were high quality teaching activities, residents knew faculty well, and there was a lot of esprit de corps among the residents. For example, residents lived in the hospital (hence the name house officer) and recieved low pay and did not get married during residency, but everyone did it that way. Over time the balance between service and education may be shifting, and the expectations of the trainees is certainly changing.

I think more trainees now feel taken for granted. There is an expectation by some that they will not do any internal medicine in an oncology fellowship, which I find ludicrous. But the point the trainee is trying to make is well taken: I don't feel like I am learning anything new here. My job is to find those new teaching moments, and to get to know the fellows better on a personal level so that they know how vitally important they are to us.