Combined Hematology Training Pathways: Med-Peds as a Roadmap

While the focus of hematology fellowship training has traditionally been on single-board pathways (e.g., hematology or pediatric hematology/oncology) versus the double-board pathway in adult training (hematology and medical oncology), there is growing interest in the utility of pursuing alternative, Accreditation Council for Graduate Medical Education (ACGME)-accredited dual-boarding pathways like combined adult hematology–pediatric hematology/oncology training. Here, we highlight the “why” and “how” of this dual-board training pathway of adult hematology and pediatric hematology/oncology, as well as discuss common challenges and mechanisms for success for individuals interested in combined training.

“But, You’ll Ultimately Only Use One”

Interest in dual-trained providers is growing in hematology, with greater recognition of the unique challenges facing adolescent and young adult (AYA) patients, improved interventions for conditions like sickle cell anemia, and growth of the cancer survivorship community resulting from advances in curative therapies. Combined training in adult hematology–pediatric hematology/oncology provides a unique perspective on the distinct cultures and approaches to the management of pediatric and adult providers. This has led to the establishment of lifespan sickle cell disorder clinics and the harmonization of pediatric and adult treatment paradigms through collaborative, practice-changing research, such as the phase III SWOG S1826 trial, which established the Nivo-AVD regimen as the standard-of-care treatment for advanced-stage classic Hodgkin lymphoma. Although some providers may ultimately practice primarily in either pediatric or adult hematology, they will often work in close collaboration with both pediatric and adult colleagues.

Pursuing Combined Training

A joint fellowship in adult hematology and pediatric hematology/oncology first requires board eligibility in internal medicine and general pediatrics, which is typically obtained through an ACGME-accredited, four-year combined internal medicine/pediatrics residency program. For fellowship, the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) require that approvals for joint training occur at the individual rather than programmatic level. This is a key distinction from the residency approach, in which training is ACGME-accredited, includes a set number of individuals per year, and is integrated with categorical programs. A joint fellowship trainee must combine training between two separate ACGME-accredited fellowship programs — with their own scheduling constraints, call schedules, weekend coverage, scholarly requirements, and budgetary limitations. While several institutions have long-standing traditions of training combined fellows, every fellow is approved on an individual basis by ABIM and ABP.

Having completed dual fellowship with pediatric training followed by adult (Dr. Molina) and adult followed by pediatric (Dr. Lee), we believe a preferred structure is adult hematology clinicals (fellow year [FY]-1), pediatric hematology/oncology clinicals (FY-2), and research (FY-3 & FY-4) based on the continuity clinic requirements and call coverage. Completing adult hematology clinical training first makes it easier to comply with the ABP requirement of two years of continuity clinic without the disruption of maintaining a pediatric continuity panel while on adult hematology rotations. Additionally, pediatric hematology/oncology fellowship programs tend to have less flexibility in call requirements; conversely, adult hematology/oncology programs typically have more fellows, leading to an easier ability for a program to absorb the loss of a fellow while he or she completes the pediatric portion of training.

Setting Yourself Up to Succeed

To be successful, it is imperative to begin conversations about joint training with desired programs in advance of the National Resident Matching Program fellowship application season to determine if it is feasible and how joint training will be conducted. Applicants technically only have to apply to the program with which they will “start” their fellowship, which can help save significant application costs. Throughout the interview cycle, candidates are encouraged to proactively engage fellowship leadership about important considerations: Is financial support secured for the full duration of training? What is the strategy for coordinating call schedules across both departments? Will certain clinical obligations be adjusted to safeguard time dedicated to scholarly and research endeavors? It is vital that both programs are in agreement with the commitment to combined training, have a plan in place for when the fellow has expectations for each specific program, and have established mentorship opportunities in place.

Disclosure Statement: The authors indicated no relevant conflicts of interest.

Acknowledgment: This article was edited by Carolina Velez-Mejia, MD, and John Molina, MD.