James N. George, MD: Why I Chose Hematology

American Society of Hematology President - 2005
George Lynn Cross Professor of Medicine, Department of Biostatistics and Epidemiology
University of Oklahoma Health Sciences Center, Oklahoma City, OK

Q: How did you become interested in the field of hematology? Academia in particular?

A: My interest in a career in hematology began during my third year of Ohio State College of Medicine clinical rotations by a series of exclusions. Although I was initially attracted by the drama of surgery and obstetrics, I quickly appreciated that I was more interested in patients as people rather than as procedures. I was also attracted to psychiatry, but as a third-year student who was enamored with medicine, I had the sense that I would leave my medical skills behind if I entered psychiatry, and I was too excited by "hands on" medicine to devote my career to the conversational interactions of psychiatry. This left internal medicine as my primary interest, and this process began my fascination with hematology.

First, hematology was the most active subspecialty at Ohio State at this time, 1960, and the faculty of hematology were - I thought - the best clinicians because they cared for the sickest patients. In 1960 there was no cure for hematologic malignancies and little effective treatment. There was also little effective treatment for other hematologic disorders such as hemophilia. However the meager treatments only enhanced my esteem for the hematologists, as they cared for chronically ill patients with progressive disorders. I was impressed that among the faculty at Ohio State, the hematologists were effective physicians because they knew their patients so well, not only their diseases but also their families and their lives.

Second, I was impressed by the esthetic features of hematology. Diagnoses were typically based on examination of peripheral blood and bone marrow, and at Ohio State at this time, this was an art. Evaluations of blood and marrow are now done more by pathology than clinical hematology, and all current evaluations are done from stained fixed permanent slides. At Ohio State in 1960, all peripheral blood and bone marrow examinations were performed on live cells stained with supravital dyes and examined by the hematologists immediately. They often said, "How can one learn anything from dead cells? You have to see them living and moving under the microscope." The ability to examine living blood and marrow cells led to remarkable observations, such as Bertha Bouroncle's description of hairy cell leukemia, among many other clinical syndromes. I was fascinated by the ability to interpret aspects of disease from microscopic observation of living cells.

The next step in my career, internship at Vanderbilt University, was the next step in my commitment to a career in hematology. For the first time I became a principal physician for patients. I clearly remember one of the patients I admitted on my first day of internship on the Vanderbilt University Hospital Ward. Lucindy was thought to have an unusual variant of acute monocytic leukemia (AMoL). Although AMoL was then rapidly fatal, her course seemed indolent. The diagnostic issues were beyond my experience and knowledge, but I followed her throughout the course of residency, when I was on other services and she would return to the hospital. Well, it turned out that she had a disseminated non-tuberculous (called Battey bacillus then) infection. Lucindy was an education in hematology and more. Through this experience I bonded to the hematologists at Vanderbilt and they were critical in the third step of my road to hematology.

The third step was initiated by my draft notice from the U.S. Army in June, 1963. With the assistance of the hematologists at Vanderbilt and Ohio State, I landed a position in the laboratory of the Walter Reed Army Institute of Research (WRAIR) headed by a noted hematologist, Bill Crosby. This happened by an amazing set of unbelievable circumstances, but that's how careers are launched. I was actually assigned to a malaria taskforce, with the hematology aspect being red cell G-6-PD deficiency. My memorable patient here was Bruce, a physician who had just received his orders to go to Vietnam, but who truly couldn't because the severe G-6-PD deficiency that had been diagnosed in medical school would have prevented him from taking the required antimalarial prophylaxis. So Bruce became one of my patients for an intensive study rather than going to Vietnam - for which, I'm sure, he is continually grateful. I spent three years in the WRAIR lab, and this cemented my career goals for an academic career in hematology.

The final step in my career development was the completion of my training at the University of Rochester. There, as a hematology fellow, another patient was a major part of my experience. Keith was a freshman medical student when I was a hematology fellow, and I was his first physician when he came to the hospital on a Monday morning in February 1969 and was diagnosed with acute myelocytic leukemia (AML). I followed Keith throughout the remainder of my time at Rochester. He was the first person to be treated with Ara-C, an agent which soon became the standard of care for AML and remains the standard. He was only the second patient to achieve a remission of AML at Rochester, but he soon relapsed and died just weeks before I finished my training in June 1970 and moved to San Antonio for my first academic position.

One more patient story from San Antonio. This is Sister M. whom I diagnosed with AML on her 40th birthday in 1975. She was among the very first patients with acute leukemia whom I actually cured. She was unbelievable during her long hospitalizations. Acute leukemia was still considered a uniformly fatal disease, so the residents and students were all quite grim when they saw her. And Sister M.'s role was to cheer them up - she was very effective. Some years later, when she moved to Dallas, I asked a hematology colleague, John Bagwell, to follow her. John has now retired, but when I visited in Dallas on April 1, 2009, he came to my lecture and asked me, "What ever happened to Sister M.?" And I was pleased to tell him that she would be 79 that month and that she is doing well. I know that because we get a Christmas card every year.

The reasons I became interested in the field of hematology are the same reasons I have enjoyed the field of hematology throughout my 40-year career.

Q: Why do you think it's important for people to get involved in this field?

A: Maybe, from a national perspective, what U.S. health care needs most is more primary care physicians. But from my personal perspective, I hope that many talented, motivated medical students follow careers in hematology, either as specialists in internal medicine, pediatrics, or pathology. The improved patient care since I first became interested in hematology has been unbelievable. This is the result of careful patient observations, remarkable molecular advances, and translation between these experiences. In the next 50 years, this will only become more exciting and more rewarding for patient care.

Q: In your experience, what is the most difficult or challenging aspect in becoming a hematologist in the United States?

A: Perhaps the most challenging aspect is the recognition of the difference between hematology as an isolated discipline in the medical school curriculum to hematology as a clinical practice. From the medical students' perspective, hematology is an academically rigorous and challenging discipline, filled with dramatic disorders from nutritional anemias to malignancies to bleeding and clotting disorders. Students are as enamored by hematology now as I was 50 years ago. Unlike 40 years ago, the practice of hematology is typically integrated with medical oncology, and in many ways becomes subverted by the clinical demands and financial rewards of oncology. The common oncologic disorders (breast cancer, lung cancer, colon cancer) overwhelm the less common hematologic disorders. The chemotherapeutic management of the common oncology disorders provides the major revenue source for clinicians and for academic programs. The reasons why medical students love hematology (the complex differential diagnosis of patients with multisystem disorders) is also the reason why clinicians may tend to avoid hematologic patients in their practice (complex patients require more time and provide less revenue). As U.S. health care evolves, hopefully the financial incentives will become less critical for career choices, and intellectual challenge can again become the primary motivation for career choice.

Q: How do you feel advances in technology (recent or past) have helped you along the way, be it in your studies or in general practice.

A: Technology certainly helped me in my early investigative career, as I began my studies of platelet structure and function at the same time that technology became available to characterize platelet membrane glycoproteins. In my later career, it has not been so much technology as it has been appropriate appreciation for the methodology of clinical research that has fueled my investigative career. Collaboration with scientists trained in the methodology of biostatistics, epidemiology, and research design and interpretation has provided me with the basis for a totally new perspective on investigation of platelet disorders.

Q: What do you find to be most rewarding about a career in hematology?

A: I cannot say enough for the lifetime rewards of a career in academic hematology. As my colleague, Barbara Alving, has said, the advantage is the opportunity to have serial careers. I use her phrase, "serial careers," many times in my discussions with students because it fits my career(s) so well. At different times over the past 40 years, I have been a nearly full-time clinician, as during my early faculty years in San Antonio. Subsequently, I was devoted to laboratory research focused on platelet structure and function. Following that phase, I had positions of leadership as Chief of the Division of Hematology-Oncology and responsibility for fellowship training for 10 years at the University of Oklahoma. Following this time of intense involvement with administrative issues, I became immersed in the application of clinical research methodology to better understand the community perspective of platelet disorders.

An academic career is a lifetime. If managed properly, it can be sustained with continuing rewards as long as good health permits.

Q: Finally, what advice might you have for a younger person who will be pursuing a career in this field?

Maintain good health, so you can enjoy hematology for many decades.
Be flexible about career opportunities and always choose something that is fun as well as sufficient to support yourself and your family.
Find a devoted mentor.
Take good care of your students, because they will become your next mentors.

Trainees

James N. George, MD: Why I Chose Hematology

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