September-October 2008, Volume 5, Issue 5
The Evolution of the Hematology Fellowship
Published on: September 01, 2008
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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