By Mark A. Schroeder, MD

2008-09-01

Dr. Schroeder is a Hematology/Oncology Fellow at Washington University in St. Louis.

Much like child labor in the early 1900s, fellowship training has recently come under scrutiny. There is no doubt training has changed over the last 50 years but remains grounded in its underlying tenets. Philip Majerus, MD, and Stuart Kornfeld, MD, have served as mentors for numerous hematology fellows and as co-directors of the Hematology/Oncology division and fellowship program at Washington University. I turned to them for their perspective on how hematology training has evolved over the last 50 years.

The Fellowship Experience

Neither Drs. Kornfeld nor Majerus formally underwent hematology fellowship training, but the preeminent hematologist Dr. Carl Moore mentored them. Both recalled their early years of training in the 1960s. Dr. Kornfeld said, "Carl Moore started training hematologists in 1938 and he attracted fellows from all over the world." He gave "strong support to basic science and clinical investigation and was practicing bench-to-bedside translation prior to its recent [emergence]."

He added, "He had a strong influence on hematology fellows and emphasized high-quality patient care." Both recalled that Dr. Moore read all of their papers start-to-finish and handed back the corrected papers the next day.

They both remember Dr. Moore's interest in clinical investigation and history of self-experimentation, recalling a case when he took serum from a patient with ITP and administered it to himself, causing severe thrombocytopenia. Dr. Kornfeld interjected, "He would never do anything to a patient that he was not willing to do to himself." Nonetheless, some of his experiments, such as infusing type O blood to seniors in a Jewish retirement home to test his universal donor hypothesis, would not have passed initial IRB review. "There was no support staff and no informed consent. We used verbal consent," said Dr. Kornfeld. Both feel that increasing regulations and oversight have become burdensome. Dr. Kornfeld stated that there were no site visits by ABIM and no requirements for journal club or lectures. The amount of paperwork was a fraction of what it is today. Both say there is too much intrusive micromanaging today.

The Financial Incentives

There was one fellow per year in the beginning. He/she was on service all year, which meant making biweekly presentations, performing weekly rounds with Dr. Moore, seeing consults and hematology inpatients daily, and attending weekly hematology clinic. The clinic was free of charge, and the fellow operated independently, consulting with the attending as needed. The lack of financial incentives was "the biggest difference" between fellowships then and now, Dr. Majerus said. He added, "When we went to medical school it cost $1,000 per year … fellows were paid about $4,000 per year … [no one moonlighted]. Now fellows have massive debt and prolonging fellowship is a burden." Dr. Kornfeld added, "It was easier to get grants and there was less worry about funding at a time when the NIH was expanding. Now this is a major worry and may discourage fellows from entering research careers."

Arriving at a Diagnosis

Most diagnoses may not have changed over the last 50 years, but the way we arrive at them has. Morphology was heavily relied upon. All fellows learned from "the world-class morphologist," Virginia Minnich, said Dr. Majerus. Official readings of the bone marrow biopsy came from the fellow and attending. In contrast, treatments have become increasingly more effective, making the education of the hematology fellow that much more daunting. "Leukemia was 100 percent fatal and recombinant factor VIII was not available when we were first learning hematology," Dr. Majerus remarked. With advances in treatment came increased numbers of fellows who were attracted to hematology. As a result "the number of patients and intensity and acuity of their illnesses grew," Dr. Kornfeld said.

Both attested that fellows today are very well prepared to practice hematology. When asked what they would change in the fellowship, Dr. Majerus stated colorfully, "[Eliminate] the residency review committee." In his opinion, though good-intentioned, in its current form it does not ensure the education of the fellow.

Dr. Kornfeld interjected, "Fellows are too busy, and too much is asked of them. They spend all their time putting out fires … they do not have time to pull references and read, even if it is easier to access the information. … The one fellow who was on service every day in the '70s did not work as hard as fellows today." Dr. Majerus added, "The fixed terms of [clinical] rotations affect continuity. In the past we followed patients indefinitely." When asked how to fix these problems, Drs. Kornfeld and Majerus offered, "Restrict the number of patients and eliminate the monetary motivation."

It seems time and money will always be competing factors in education, but perhaps the constant of strong mentoring is what drives every fellow to learn and succeed.

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