Few physicians in this country are double board-certified in both Hematology and Critical Care Medicine. AUC alumnus Dr. PJ Miller happens to be one of them.
Dr. Miller’s career has been shaped by years of post-graduate education and training, and a growing realization that the futures of cancer/hematology care and intensive care are intertwined. Now, as Associate Medical Director of the Medical Oncology Intensive Care Unit (ICU) at Wake Forest Medical Center, he is leading this new field of medicine. In July, he will transition to the role of Medical Director.
After graduating from AUC in 2007, Dr. Miller matched into a combined Internal Medicine and Pediatrics residency—known as “Med/Peds”—at Albany Medical Center in upstate New York. This four-year program is one of the oldest in the country and operates a Patient Centered Medical Home serving more than 12,000 diverse patients. Each year, just four residents are accepted.
“When I was deciding on a specialty, there was a lot that stood out about Med/Peds,” said Dr. Miller. “For one, I liked the fact that after four years I could sit for both the Internal Medicine and Pediatrics boards. Because Internal Medicine and Pediatrics are each three-year residency programs, I was essentially doing six years of training in two-thirds that amount of time. Med/Peds residents can also do fellowships in either specialty so it gave me this vast amount of opportunity in two areas that I was really interested in.”
Med/Peds physicians can be great transitional doctors for complicated pediatric cases like congenital heart disease. They have experience with managing pediatric disease and are uniquely qualified to care for these patients as they age.
From a Combined Residency to Combined Fellowship
While he was initially interested in general pediatrics, Dr. Miller shifted focus little by little throughout residency. After completing his program in 2011, he spent a year as a hospitalist before entering a competitive three-year combined Hematology/Oncology fellowship at Wake Forest School of Medicine. A year in, he decided to focus on Hematology alone.
“Day to day, I didn’t love the cancer outpatient setting,” he recalls. “I soon realized the workup and diagnosis of the type of cancer was more interesting than the day to day practice in a clinic setting.”
Dr. Miller enjoyed the special bonds that he could develop with patients but he missed the adrenaline associated with those who were critically ill. Hematology on the other hand was like a big puzzle that he was ever curious to solve.
“Knowing the clinic setting was not ideal for me, a lot of the remaining practice was an inpatient consultative role,” he said. “It was less about managing a patient and more about being an expert consultant on a specific case. The missing element was continuity of care or the ability to make the final decisions for your patients.”
So, Dr. Miller chose to sub-specialize again, this time in Critical Care Medicine. With the support and encouragement of his Wake Forest network, Dr. Miller was accepted into the university’s fellowship program.
An Emerging Career in Intensive Cancer Care
The timing was serendipitous. Wake Forest was in the process of opening up a Cancer Center Intensive Care Unit (ICU) and Dr. Miller, with specialty training in both Hematology and Critical Care Medicine, was recruited to help lead the operation.
Today, as the Associate Medical Director, he oversees the clinical operations of the ICU, ensuring a high-level quality of care. The ICU focuses on patients with hematologic and cancer diagnoses that require ICU-level attention. The ICU team works closely with the medical hematologists and oncologists to optimize the complexity of care these patients’ illnesses demand.
“We’ve established a good multi-disciplinary approach that allows cancer specialists and critical care physicians to manage the patient together,” he said. “Ultimately, we want to be the leading medical oncology ICU in the country.”
While cancer center ICUs are just emerging, the model is quickly evolving. According to Dr. Miller, it’s estimated that in the near future around 25 percent of all ICU patients have had or will have cancer. That’s because more cancer patients are surviving due to targeted and less toxic chemotherapies, which also means they are at risk of developing additional complications.
An Unlikely Partnership with the FDA
In 2012, the CDC reported an increased number of patients presenting to the hospital with a physiologic similarity to thrombotic thrombocytopenic purpura (TTP) that intravenously abused oral Opana-ER. TTP is an autoimmune blood disorder that, unless caught early, can result in kidney failure and death.
Around the same time, Dr. Miller’s team also noticed an increase in patients with these symptoms.
“As we were seeing these patients, we discovered that they were taking the prescription opioid Opana-ER (oxymorphone extended relief),” he said. “They were crushing, dissolving, and injecting it into their bodies and by doing so became at risk of developing a syndrome with a similar presentation to TTP.”
His team questioned if the same aggressive life-saving treatments for TTP were necessary to treat this new syndrome (which they eventually named Oxymorphone-induced thrombotic microangiopathy). Ultimately, they were able to demonstrate that aggressive supportive care alone, in lieu of aggressive treatments for TTP, was adequate in resolving the process.
Dr. Miller also partnered with a researcher at the US Food and Drug Administration (FDA) who developed a guinea-pig model to study the underlying pathophysiology of the disorder. These findings were put in front of the FDA who then requested a halt to Opana-ER. In July 2017, it was voluntarily removed from the market.
A Piece of Advice for AUC Students
With his collection of experiences and certifications, Dr. Miller has spent a decade carving out a niche in medicine. Throughout the journey, he has been true to his interests and willing to pursue education.
“Maintaining flexibility is important,” he says. “It’s easy to go into medical school with blinders on for a specific field like surgery or orthopedics. But there are so many options out there that stem from Internal Medicine, Pediatrics, Family Medicine, and Psychiatry. Be open to those opportunities and be open to not seeing yourself practice only in one area of medicine while you are still young in your career. Find a field of medicine—or help create a new niche—that you enjoy practicing in every day.”