Caroline Robert, MD, PhD, Head of the Dermatology Unit at Gustave Roussy and Co-Director of the Melanoma Research Unit at INSERM 981 Paris-Sud University, was born and reared in Paris. “I didn’t have a vocation for medicine when I was a kid; I wanted to be an archeologist. I’m not from a medical family, except one of my uncles was a gynecologist. I went to his clinic to see if what he was doing was interesting because medicine was one of my possible career choices. I saw some babies being born and thought it was wonderful. For a while I hesitated between political science and medicine, but I thought it was so incredibly interesting to learn how the body functions and how we can repair or reverse disease processes. So, that’s basically how I chose medicine as my career path.”
Medical education in France is administered by the Unités de formation et de recherche de médecine (UFR). The training takes a minimum of 9 years after the Baccalauréat and concludes with a thesis. “In France, you go to high school until 17 or 18. But for us, undergraduate is very tracked,” Dr. Robert explained. “If you choose medicine, you go into medicine. It’s not like the U.S. system, where you can continue to change courses until you’ve decided. For me, at 17, I entered medical school at Paris V University. The first year of medical school in France is very difficult, and only about 10% of candidates continue. If you failed, you were allowed to try a second time; but I liked it so much that I rapidly went through my first year and it was not difficult for me because I thought it was extremely interesting.”
Head of the Dermatology Unit at Gustave Roussy and Co-Director of the Melanoma Research Unit at INSERM 981 Paris-Saclay University, France
MD, Cochin Port Royal School of Medicine, Paris; PhD, in Immunology and Immunotherapy, Paris-Saclay University, France
ON PRACTICING MEDICINE IN FRANCE
"I'm so happy to live in a country where health care is provided to all our citizens, from a global perspective. Anybody can be cured with care from the best experts. I hope it continues like that. Patients receive the same attention whether they are rich or poor. We do not discriminate, and our inequities are few. I'm proud of the French health-care model."
Fascination With Immunology
According to Dr. Robert, she had an early interest in immunology, which at the time was just emerging in the oncology research world. “I remember I especially enjoyed immunology, particularly the theory of immunology, which I thought was fascinating. I was doing very well at the exam because I just enjoyed that. After the third year, we spent every morning in the hospital, changing service every 3 months with theory teaching in the afternoon. During these 6 years, we had to pass the exams for the different disciplines such as infectious disease, psychiatry, endocrinology, surgery, etc. Then after 6 years, there is a challenging exam called the Internat, which gave access to the choice of medical specialties according to the ranking of the student. Those who failed this exam could not become a specialist and had 1 additional year of general medicine training in a hospital. After passing this exam, we had 4 additional years of training while we learned our specialty as resident, then 2 years as a chief resisdent. In parallel with my medical studies, I followed an undergraduate and then a master’s degree in molecular biology and immunology.
Advancing the Field of Dermatology as Well as Patient Communication
Asked about her decision to pursue dermatology, Dr. Robert replied: “It’s quite ironic because now it’s exactly the opposite of what I’m doing. I chose dermatology because I thought it was not going to be too much work, with patients who weren’t too sick. And then, here I am as a chief resident in front of a patient with melanoma. At that time, we didn’t have any effective treatments, and I felt terrible because of that inadequacy, as I wanted to help them.”
Dr. Robert continued: “I followed the sort of formation developed by a clinician psychologist, who was my first mentor, on how to deal with your patients as they face mortality issues. We used a lot of role playing, which helped me to understand what I felt and that I could not cure everybody—which is important to know when you are a young doctor treating patients with cancer. We tend to see death as our failure, but to maintain a healthy and long career, it’s important from the beginning to acknowledge the difficult realities we deal with; we do what we can with the knowledge and the clinic tools we have. Even though the empathy needed to be a good doctor is fundamentally intrinsic to one’s personality, there are tools that one can learn to use and that can be of significant help when faced with cancer patients, which is vital to understand as a young doctor in this field.”
According to Dr. Robert, she developed active listening skills and formulated better ways to communicate with her vulnerable patients, which she later shared in workshops. “I became an expert and gave formal lectures and workshops all over France and even abroad on how to deal with the difficult psychological issues faced by our patients. And this is something I still do in my department with my young residents. Every 3 months, we have a formation where we address difficulties encountered with patients, and then we play roles together that help build empathy and listening skills,” she shared.
Research Builds Confidence in Career Choice
Dr. Robert believed in the need to bolster her career with research, which she began in France and completed during a research fellowship at Harvard, Brigham & Women’s Hospital in cancer immunology and immunotherapy. “I spent almost 4 years in Boston at Harvard to do research, in the immuno-oncology field. Then, I had everything I needed to go back to medicine and to take care of patients with cancer. The head of the lab, Tom Kupper, was a dermatologist and a valued mentor. Tom was a very good scientist who taught me a lot, and I would not be at my position if I had not done this period in Boston because it gave me a lot of self-confidence,” she explained.
“When I returned to France,” she continued, “I didn’t exactly know what I wanted to do and where I wanted to work. I decided to spend a year in big pharma at Johnson & Johnson, to see if it was going to be fulfilling for me. And very rapidly, I saw it was not where I wanted to spend my career. But I signed on for a year contract and kept my obligation.”
After that, Dr. Robert returned to Paris-Saclay University Hospital in 2000 and has been here ever since. “I was hired by Prof. Thomas Tursz, a famous oncologist and a visionary in immunology who was Director of Gustave Roussy. There I had the opportunity to work on exciting clinical trials, becoming the principal investigator on many studies looking at immune checkpoint inhibitors as well as targeted therapy in melanoma. Although I opted not to make a career in the pharmaceutical industry, my year there was deeply enriching, and I still maintain a good working relationship with industry.
During the conversation, it was noted that in the United States, it’s not uncommon for academic oncologists to make several institutional moves during their careers, to which Dr. Robert responded: “In France, there are not many hospitals where we can run a lab and do clinic activity and research. And my hospital, Gustave Roussy, is a comprehensive cancer center, the biggest in Europe where I can do this double activity. To treat cancer, for me, it’s simply the best place. I had some other offers, but I think it would’ve been more difficult for me to do clinical care and research.”
A Busy Work Week: Lab and Clinic
Gustave Roussy has about 500 new patients with melanoma each year, which creates challenges and opportunities for a clinician-researcher. “It’s a huge number of patients to assess and treat. I had to create a team to cope with the sheer volume, but after some years, I began to initiate my research lab activity. Now I run a lab with about 10 scientists where we try to understand resistance mechanisms to develop new predictive biomarkers and new treatment strategies. This is a translational research lab where 50% of the work is done on patient samples close to the clinic.”
Dr. Robert shares her time between the lab and the clinic. “I see patients for 1 full day of clinic: new patients in the morning and existing patients I follow in the afternoon. I have 2 half days where I review patient reports and patients in clinical trials with my colleagues in tumor boards. Of course, there is a lot of e-mail correspondence with family members, colleagues, etc. And I have 1 full day in the lab and several interactions with my lab colleagues during the week. I also teach Dermatology in our Medicine Faculty. So, it’s a full life. I begin early and finish late,” she admitted.
Compare and Contrast
Asked for some specific differences and/or similarities between the U.S. and French health-care system Dr. Robert commented: “One difference is that our patients rarely sue us for malpractice. Unlike physicians in the United States, which has a notoriously litigious system, being sued is not something we’re afraid of. Honestly, the big difference is there are few places in France, apart from my center Gustave Roussy, where you can combine research and clinical work. In most places in France, you either do clinic or research, but it’s difficult to do both. Like the United States, we work a lot with pharma and usually it’s a win-win partnership.”
According to Dr. Robert, there is nowhere else she would rather be than France. “I’m so happy to live in a country where health care is provided to all our citizens, from a global perspective,” she noted. “Anybody can be cured with care from the best experts. I hope it continues like that. Patients receive the same attention whether they are rich or poor. We do not discriminate, and our inequities are few. I’m proud of the French health-care model.”
A Sea Change of Advances
Asked for a perspective of melanoma research and treatment over her career, “Dr. Robert replied: “More than 10 years ago, most of our patients were dying when they had metastatic melanoma. Now, we know some patients will be cured; it’s a wonderful feeling, but at the same time, it’s still difficult because you don’t know who is going to do well and who is not. And when they do not respond to therapy, you’re even more frustrated than we were before because now we say why. But that’s why I run my lab: to understand the resistance mechanism and to try to find predictive biomarkers to optimize treatment choices. So, over the course of my career, it has changed profoundly.”
Dr. Robert shared a decisive encounter about 15 years ago. “A banker, Jean Pierre Babel, who had lost his daughter to melanoma and had heard of my research told me that when he was done with his grief, he would contact me—and he did 2 years later. We raised a lot of money, and my lab is running mostly through that effort. It is a very impressive and positive thing, turning grief into action that helps patients with cancer.”
How does a super busy melanoma expert decompress? “First of all, although I would always like to do better, I tell myself first you do your best, and there is no physical possibility that you can do more, and that helps. Also, I do a lot of sports. Some people like to do meditation, but I prefer an active way to decompress. For one, I ride my bicycle back and forth to work. I also have a very happy life. I’m lucky to have three daughters, a wonderful partner and many close friends. Honestly, in France, we have a lot of vacation time. I always take my vacations, although years ago I did not. But I’ve learned that good, pleasurable time away from work helps me be a better doctor, more centered and connected. We must take care of ourselves to give our patients the best care.”
Advice to Women Thinking About a Challenging Career in Oncology
Any thoughts for young female medical students? “I’m very often asked this question about how to maintain a high-level career and have three kids? I think my kids are very proud that I’m a working mom. And I remember often telling them, ‘Oh I shouldn’t go to this meeting because I need to be home with you,’ and they always told me, ‘Mom, yes, you should go. It’s important for you.’ But if they called me for any reason, I would always respond. So, I think being happy in your job and then being happy when you come home is the best all-around answer to a long and fruitful career as a woman in oncology. And, of course, it helps a lot to be in a country where you have high-quality affordable daycare for kids, which is the case in France.”
Dr. Robert shared these closing thoughts: “A career in oncology can be difficult, but it’s the most rewarding one I can think of, and I strongly recommend it to young women who are up for the challenge. Given the rapid advances for our patients, it’s also the most exciting time ever to enter the field,” she said.