The average heme/onc fellowship program doesn’t have many “tough” rotations. The one that is universally feared is the erroneously named Bone marrow transplant service2. After spending six weeks on such rotation fresh out of (Chief) residency, I think I can understand—-though not agree with—-the reasons why.

It is not easy. The patients are either already, or about to become, extraordinarily sick, with little outward signs or symptoms to show it. Having cancer while not having an immune system is not a good combination, even if it is temporary. The ones who are months or years out from a successful transplant and still need to be hospitalized are usually miserable from longstanding severe graft versus host disease1. It makes for a tough bunch of humans to deal with day-to-day.

Then again, being on transplant service in an academic center can be the apex of your inpatient career. Months of residency spent on acute care floors and in intensive care units should have given you all the skills you need to do well. These are, in no particular order:

  • Clarifying ambiguity: The rounds are over, attendings and consultants have dispersed, and you have just heard more facts about T-cell activation than you realized existed. But—-do you know if that febrile-but-not-neutropenic patient should get an antibiotic? What’s that other patient’s target Tacro level? Send CSF for flow, or just give intrathecal Methotrexate? If those aren’t clear, you should have asked more questions, and not of the “Which cells have IL-6 receptors?” kind.
  • Identify attending priority: This is often the biggest cause of ambiguity. Between the floor attending, the study PI, staff ID consultant, and various other consulting services, whose advice do you heed? Not always the same person’s, and not even in the same order. Not much you can do, except be aware of it, and not follow everyone’s advice as soon as you hear it.
  • Asserting your autonomy: With all this asking and following, you may rightly ask if you were anything more than a glorified intern. In the field of hematology, oncology, and infections that affect this population, you most certainly are—-you are, after all, still in training. Not so for most other matters of internal medicine. Blood pressures, fingerstick, TSH levels—-if you are comfortable managing them, let the team know.
  • Being there early: An important trait often forgotten by senior IM residents. Just getting there an hour earlier than anyone else to get the work done makes you look like a superstar. One hour in the early morning save three in the late afternoon.
  • Dictating right away: Like, pronto. The answer to “How many pending dictations do you have” should always be “Zero”. It’s easier for you, and is just good patient care. No excuses.
  • Writing everything down: This is How to be an intern 101, but being at least two years removed from internship can make you stupid. Carry the patient list and a good pen with you at all times. Yes, that includes the restroom.

Nothing here is particular to transplants—-it is just good inpatient medicine. Which may be why so many oncology fellows loathe it—-it is, after all, an outpatient specialty. Then again, stem cell transplants are one of the few therapies we have that can cure cancer.

  1. Which is not to say that everyone who had a stem cell transplant is miserable—-a mistaken belief many oncology fellows have after the rotation, and a clear example of selection bias. 

  2. Most stem cells used for transplants are now harvested from the peripheral blood, not the bone marrow.