• The Evolution of the Hematology Fellowship
• The Second Time Around: A Dynamic MMSAP Student/Mentor Match

The Evolution of the Hematology Fellowship

By Mark A. Schroeder, MD

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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The Second Time Around: A Dynamic MMSAP Student/Mentor Match

Dr. Barabino is Vice Provost for Academic Diversity at Georgia Institute of Technology and Professor and Associate Chair for Graduate Studies in the Wallace H. Coulter Department of Biomedical Engineering, a joint department of Georgia Institute of Technology and Emory University.

In 2003, ASH created the Minority Medical Student Award Program (MMSAP) as part of its Minority Recruitment Initiative (MRI). The program is an eight- to 12-week summer research experience for minority medical students in their first or second year of medical school. The MMSAP is designed to increase the participation of underrepresented minorities in hematology careers. Olabunmi Agboola, from the University of Illinois at Chicago, has had a long-standing interest in hematology and applied to the MMSAP in 2007 to explore hematology research as a possible career path. Ms. Agboola was paired with research mentor Christopher Flowers, MD, of Emory University. Dr. Flowers and Ms. Agboola focused on patients with lymphoma and multiple myeloma who are deciding whether to have an autologous stem cell transplantation.

Ms. Agboola said, "Dr. Flowers is one of the most kind and caring individuals you could ever work with, and to top that off he is a great teacher. My experience was very well rounded. I got the opportunity to shadow him in the clinic and attend grand rounds. He is the type of person that will meet you where you are and bring you to where you need to be."

Motivated by her previous experience and with encouragement from Dr. Flowers, Ms. Agboola applied for a second year of research. She said, "I wanted another year to refine my research abilities. I learned a lot under Dr. Flowers. I wanted to be able to use what I learned and expand upon it."
This past summer they focused on decision-making models in patients with sickle cell disease who are contemplating whether to have an allogeneic stem cell transplantation.

When asked to describe his experience working with Ms. Agboola, Dr. Flowers said, "She is a great pleasure to work with. She brings a great spark of enthusiasm to her research work, which is key in clinical and epidemiological studies that involve patient interaction. Her commitment to learning and her work ethic were an inspiration to others in my lab."

Dr. Flowers first got involved in MMSAP in 2004 and he said that he will continue to serve as a mentor in the program. Since 2004, he has served as a research mentor to four students. Three of those four students have returned for a second year of research. He said that the MMSAP is rewarding in more ways than he can count. He expects that many of the relationships he has developed with students in this program will be longstanding as their careers develop.

"The MMSAP provides an ideal experience for personal and scientific interaction with some of the nation's best, brightest, and most talented young scientists. Two of my former students have used the MMSAP as a springboard to perform additional research for one year at the NIH. This clearly shows that the program is promoting minority students to pursue training toward academic careers," Dr. Flowers said.

Ms. Agboola is currently in her third year of medical school. She plans to do her residency in an internal medicine/pediatrics dual program and then continue on with a fellowship in hematology. She would like to focus on patients with sickle cell disease, thalassemia, and leukemia.

Ms. Agboola and Dr. Flowers exemplify the intent and success of the program in developing future physician-scientists in hematology through effective mentoring.

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