The Future of Hematology: The Growing Demand for Subspecialists and Ideas to Increase Interest in the Field Among Medical Residents
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Cancer death rates when corrected for a larger and older population, have globally fallen about 17 percent overall from 1990 to 2016. Early detection and improved treatment have led to improved five-year survival rates. For instance, currently in the United States, patients with non-Hodgkin lymphoma have a five-year survival rate of 71 percent compared to 46.5 percent in 1990.1 With the advancement of diagnostic and therapeutic techniques in oncology, more people are being diagnosed with cancer and are also living longer than ever before. Consequently, there is an increasing demand for hematologists, oncologists, and radiation oncologists, with a report from the American Society of Clinical Oncology projecting a shortage of 2,250 hematologists/oncologists by 2025.2 It is therefore important to increase recruitment of physicians in hematology and encourage internal medicine residents to pursue careers in this specialty. Here, we examine some of the challenges to driving residents’ interest in this subject and approaches to address the issues.
The first and second years of residency are the most instructive years when it comes to choosing a subspeciality,3 and many training hospitals offer inpatient rotations in hematology and oncology. However, a study has shown that an inpatient rotation is associated with a decreased interest in pursuing a career in this field.4 From the resident perspective, the inpatient experience on an oncology service is composed primarily of patients in acute crises because of serious complications of the disease as well as patients who have planned admissions for chemotherapy and require only routine monitoring. This subset of patients varies greatly in terms of prognosis and intellectual challenge from those coming to the outpatient clinic for regular follow-up.5 Since most hematology/oncology is practiced outpatient, residents who only receive an inpatient experience glean a limited view of what real-life practice entails.
Seeing patients with cancer living meaningful lives is a significant motivator for residents to specialize in this arena. It is imperative that programs start offering both outpatient and inpatient experiences in hematology/oncology, with residents seeing patients in clinic under the guidance of a preceptor. A study should subsequently be done comparing resident experiences before and after an outpatient experience in hematology/oncology. For those residents who pursue an inpatient hematology/oncology experience, the goal should be to reduce distress, cultivate empathy, and help them find meaning in caring for patients who are near death.4,5
Another barrier for residents pursuing hematology/oncology is the lack of proper teaching and exposure as compared to other subspecialities. In a earlier study, when compared to nine other medical subspecialties, both internal medicine residents and program directors identified oncology as the least adequately taught subspecialty.6 This could be because most cancer patients who develop complications are admitted under the oncology service, although this may vary between hospitals. Owing to the complex intricacies and nuances of ever-emerging and evolving treatment, hematology/oncology requires an exclusive focus. Unlike other subspecialities of medicine, it is difficult to understand the basics of oncology while rotating on general medicine floors.
To overcome this obstacle, a standard set of objectives for this subject should be created for internal medicine residency programs, identifying the common topics that are essential for an internist. This will also serve to increase the consistency of hematology/oncology education across the United States and decrease program-specific fragmentation in education.6 Having a mandatory rotation in hematology/oncology could also be considered to ensure that residents have adequate exposure, both from the perspective of developing interest as well as creating more competent internists.
A third major obstacle is the demand for research in order to be considered a strong candidate for fellowship. It is well known that the field is more academic than other subspecialities. With new treatments emerging and ever-changing guidelines, it is essential for a budding hematologist to be able to understand as well as conduct research. However, residents can find it overwhelming to be involved in academic projects while pursuing comprehensive training in internal medicine. This issue can be addressed by emphasizing the importance of research in this field, conducting detailed courses on starting a research project, facilitating relationships with research mentors, and giving protected research time to complete projects.
Lastly, it is important for the perception of cancer to evolve. A notable deterrent for internal medicine residents to pursue oncology training is the negative connotation that this field is mostly associated with negative prognoses and dismal outcomes. While this specialty deals with significant morbidity and mortality, residents should be taught about the recent advancements in therapies and improvements in survival rates. The perception of this field among trainees needs to progress simultaneously with the advancements in research and therapeutics that are saving lives. From the perspective of creating a strong workforce in hematology/oncology, it is important that residents think of cancer as an exciting challenge to be undertaken, with the opportunity to create large-scale impact.
- Ritchie H. Cancer death rates are falling; five-year survival rates are rising. Our World in Data. 2019; Feb. 4.
- Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract. 2014;10:39-45.
- Loriot Y, Albiges-Sauvin L, Dionysopoulos D, et al. Why do residents choose the medical oncology specialty? Implications for future recruitment — results of the 2007 French Association of Residents in Oncology (AERIO) Survey. Ann Oncol. 2010;21:161-165.
- McFarland DC, Holland J, Holcombe RF. Inpatient hematology-oncology rotation is associated with a decreased interest in pursing an oncology career among internal medicine residents. J Oncol Pract. 2015;11:289-295.
- Back AL, Safyan RA, Edwards KA. What residents learn from inpatient hematology-oncology: A call to rebuild a community of practice. J Oncol Pract. 2015;11:296-297.
- Tam VC, Berry S, Hsu T, et al. Oncology education in Canadian undergraduate and postgraduate medical programs: a survey of educators and learners. Curr Oncol. 2014;21:e75-e88.