By Alison W. Loren, MD, MS
2009-07-01
Dr. Loren is Hematology/Oncology Fellowship Program Director and
Assistant Professor of Medicine in the Division of Hematology/Oncology,
University of Pennsylvania School of Medicine.
During the Training Program Directors’ meeting at the 2008 ASH
Annual Meeting, an anecdote was told about an “unnamed
Hematology/Oncology program in the Northeast” that is internationally
renowned for non-malignant hematology. Even at this institution, the
presenter noted, where hematology features prominently in research,
education, and patient care, a “benign” hematologist is produced at the
rate of just one graduate every one to two years, from a class of six
to eight fellows per year. The program referred to was mine. Although a
majority of our graduates obtain ABIM certification in hematology, only
a few go on to careers dedicated to the practice of caring for patients
with non-malignant hematologic disorders. This translates into an
enormous problem, not just for today, but for future generations: Who
will be the master clinicians, the pioneer laboratory-based
investigators, and the translational researchers in benign hematology
20 years from now? Furthermore, as someone who believes that even
physicists should read Shakespeare, I lament the possibility that some
of those who train in combined hematology/oncology training programs
may not receive a well-rounded education, whether by their choice or by
default.
In ASH News (Spring 2002 issue), 2002 ASH President Robert
I. Handin, MD, addressed some of these issues. He attributed some of
these trends to the failure of hematologists to embrace fledgling
fields and new technologies, as well as to the jaded attitudes of some
senior hematologists who may portray the field negatively (or at least
who may fail to promote it actively and positively). It has also
occurred to me that the combined hematology and medical oncology
training program structure may be somewhat to blame.
Most of us choose our careers based on a personal experience:
motivated by a cherished mentor, the illness of a loved one, or an
“ah-ha” moment in scientific or clinical pursuits. For the most part,
residents are choosing to train in hematology/oncology because they
want to become oncologists. The fact that less than 6 percent of
graduates plan to practice primarily in non-malignant hematology1
likely reflects the already-determined preferences of the residents who
choose this training. How could this be? Very few internal medicine
residents really see what hematology is all about. Residents uniformly
rotate on oncology floors, attend oncology clinics, and see oncology
patients. Cancer is common; nearly all of us have been touched by it
personally in some fashion. Oncology
is compelling because it is
everywhere. So is hematology; the residents just don’t see it. And all
too often, neither do our fellows.
By allowing trainees to join combined fellowship programs, and then
not be exposed to a true benign hematology training experience, we are
depriving them of the opportunity to fall in love with our field.
Hematology is marginalized in some training programs, either by design
or by necessity, and hundreds of trainees are never exposed to the
intricacies of what we do. Even at Penn, where exposure is mandatory,
we are only training one benign hematologist per year. But one out of
seven or eight fellows is still about 12 percent — double the number
that we are producing nationally as of our last look in 2004. I know
for a fact that Penn has turned the heads of several talented
physicians who thought they were here to train in oncology, and this
could happen more often, in more programs, if hematology were given its
due in training.
This problem is going to become more acute in the future. A 2007 study has projected a shortage of oncologists by 2020,2
and ongoing discussions about health-care reform have heightened these
concerns. This shortage will affect patients with blood disorders as
well: Anemia, myelodysplasia, myeloproliferative diseases, hematologic
malignancies, and venous thrombosis are just a few of the many
hematologic conditions that preferentially affect the elderly. Thus,
unlike medical oncology, which is currently felt to exist in
equilibrium between supply and demand, hematology is facing a dearth of
well-trained specialists who care for and study non-malignant
hematologic problems, in real time as well as in the future.
The efforts of ASH to educate the public about our field are truly
laudable. We should as well put similar efforts into advertising the
wealth, breadth, and beauty of hematology to our trainees. Certainly,
ASH is attempting to address some of these concerns. For instance, the
ASH Alternative Training Pathway Grant seeks to fund innovative
training experiences combining hematology with another field;
pharmacology and combined pediatric/adult hematology were the two
proposals funded last year. However, I also believe that this problem
should be addressed at the level of individual programs. If we are
truly calling ourselves combined hematology/oncology training programs,
then including at least three to four months of dedicated benign
hematology training should be expected — truth in advertising.
Certainly this is not a simple decision, as it necessarily adds time to
the training experience (or takes away from dedicated research time).
Nevertheless, not only would such a requirement ensure a broad-based
education appropriate to any combined hematology/oncology trainee, but
also it would undoubtedly draw more fellows toward a career in benign
hematology.
Todd RF III, Gitlin SD, Burns LJ, and the Committee on Training Programs. Subspecialty
training in hematology and oncology, 2003: results of a survey of
training program directors conducted by the American Society of
Hematology. Blood. 2004;103:4383-88.
Erikson C, Salsberg E, Forte G et al. Future supply and demand for
oncologists: challenges to assuring access to oncology services. J
Oncol Prac. 2007;3:79-86.
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