The Future of Hematology: The Need to Reassert Its Identity

Andrew Schafer, M.D.

Dr. Schafer is the founding Editor-in-Chief of The Hematologist. He was previously Treasurer of ASH. He is the Frank Wister Thomas Professor of Medicine and Chairman of the Department of Medicine at the University of Pennsylvania.

There has been increasing concern about the future viability of hematology, particularly as a distinct clinical specialty. Is this just old-fashioned handwringing about an issue that has been extant since the very beginnings of hematology? Or are there more recent trends that really do threaten the integrity of our discipline? And why does it matter?

It is, after all, the proud tradition of hematology to spawn new fields of specialized interest. The science of hematology has pioneered many of the principles of modern chemotherapy, molecular genetic diagnostics, thrombosis, immunohematology, and stem cell biology, among others. These innovations were subsequently adopted by other medical specialties, such as oncology, cardiology, and pathology, or even spun off entire new fields, such as blood banking. In this sense, the fragmentation of hematology is not a new phenomenon. Nor is it necessarily an undesirable outcome, although I believe our patients would be better served if hematologists continued to be active participants in their care in these areas.

What may be of concern, however, is the apparent wholesale incorporation of hematology into mainstream oncology. This widening movement does indeed pose a threat to the identity of clinical hematology. More importantly, it is potentially deleterious to high quality patient care if unqualified oncologists, that is those who are not also trained in hematology, assume the care of patients with nonmalignant blood disorders. This appears to be increasingly occurring in some communities where "pure" oncologists diagnose and treat such patients essentially by default in the absence of available trained hematologists. The recently published survey of training program directors conducted by ASH concluded that "concern is raised over the small numbers of trainees who opt for single-board eligibility in hematology (10 percent) and pursue careers in nonmalignant hematology (<6 percent of graduates of adult training programs).”¹

The decades-long partnership of hematology with medical oncology is soundly based on common interests and expertise in chemotherapy and the management of patients with hematologic malignancies. The linkage has been largely constructive, mutually beneficial, and good for patient care. However, oncology clearly does not include the diagnosis and treatment of nonmalignant blood disorders. In some communities, especially in the private sector, hematology is now at risk of being subsumed by medical oncology practices. That this is a mostly economically driven phenomenon is illustrated by the continued vibrant health of benign hematology in many countries outside North America.

What can or should be done to reestablish the clinical practice of nonmalignant hematology as an attractive career path and a vitally important specialty of medicine? First, as superbly developed by Scott Gitlin, Ari Melnick, and the Hematology Curriculum Subcommittee of the ASH Committee on Training Programs, a comprehensive curriculum must be applied to hematology fellowship programs, incorporating expectation of a working knowledge and practical competency (not just familiarity) with a wide range of clinical problems related to blood diseases. It should include expertise in areas pioneered by hematologists which classical hematology has been subsequently abdicating to other disciplines: e.g. diagnosis and treatment of thrombosis, including vascular disorders, immunohematology, and the evolving field of stem cell therapy. As hematology research continues to break open new frontiers of clinical medicine, the hematology curriculum must prospectively, formally, and dynamically incorporate them into the core competencies of the practicing hematologist, something we have not done very effectively in the past. Ultimately, of course, it will be necessary for hematologists in the community to proactively embrace and legitimately "claim" these areas as routine parts of their practice profiles.

Second, health services research is urgently needed to establish (or refute) the superiority of outcomes of patients with nonmalignant blood disorders in the hands of hematologists compared to primary care physicians or other internal medicine subspecialists (e.g. pure oncologists who have had no hematology training or cardiologists). Proof of superior outcomes will be needed to convince regulatory agencies that care of patients with nonmalignant blood disorders by trained hematologists represents standard of care. Coupled to this need, the leadership of hematology should advocate for a comprehensive analysis of workforce needs for nonmalignant hematologists.

Finally, led by the American Society of Hematology, we must effectively market ourselves as a clearly defined and vital specialty of internal medicine. The public knows what cardiologists or gastroenterologists do, but seldom understands what hematologists do. Even within medical circles, hematology is often viewed as a largely academic discipline, the clinical practitioners of which deal mostly with rare and arcane diseases. In fact, our scope of clinical expertise includes common and important disorders such as anemias, bleeding, and thrombosis.

The future of hematology will continue to be a focus of interest for this publication. The first of a series of columns written by distinguished hematologists was contributed by Dr. H. Franklin Bunn in the summer issue of The Hematologist. As the Editor of The Hematologist, I invite our readers to submit their views for publication in our "Letters to the Editor" forum.

1. 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; 103:4383-4388.

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