When Mona D. Shah, MD, MBA, finished her medical training in pediatric hematology/oncology in 2007, she estimated that most of her fellow trainees went on to accept academic positions composed of 80% research and 20% clinical practice. More recently, though, she has seen that trend change, as young physicians seek work-life balance or more lucrative positions that can help with crushing medical school debt.
"People seem to be looking for opportunities that are higher-paying and more clinic-heavy, as opposed to academic positions where salary is often more limited," said Dr. Shah, an associate professor in the Department of Pediatrics at Baylor College of Medicine/Texas Children's Cancer and Hematology Centers. "It is also more challenging to get research funding, with early career professionals losing out to more senior faculty members getting longer-range grants."
This trend is a signal of larger changes in clinical practice that are affecting the relatively small specialty of pediatric hematology/oncology. New care delivery models that increasingly rely on advanced practice providers, more subspecialization in pediatric hematology/oncology and, as Dr. Shah witnessed, a greater appreciation for work-life balance have all contributed to a shift in the pediatric hematology/oncology workforce and its daily practice.
In 2017, Dr. Shah and colleagues on the American Society of Pediatric Hematology/Oncology (ASPHO) Workforce Advisory Taskforce surveyed specialists and division directors to find out how they have responded to changes in this field – from providers taking on more clinical work to charting different career trajectories.1,2 ASH Clinical News spoke with Dr. Shah and several physicians in the subspecialty about these findings and the trends they have noticed in their day-to-day professional lives.
Who Practices Pediatric Hematology/Oncology – and Where?
"When I was a first-year fellow, I attended a national meeting where a presenter discussed … an impending shortage of pediatric hematologists/oncologists because the current generation of physicians in the field were going to retire or age out," Dr. Shah recalled. However, this anxiety was based on limited data on the size and makeup of the pediatric hematology/oncology workforce. "The survey helped us to see national trends to get a better sense of what we need – and where."
In the 40-year period between 1974 and 2015, the American Board of Pediatrics (ABP) certified 3,027 pediatric hematologists/oncologists.1 Today, the ABP estimates that there are between 2,100 and 2,300 active physicians in the specialty in the U.S., with an average of one pediatric hematologist/oncologist for every 38,300 individuals aged 20 or younger.3
Great gains have been made in the representation of women in the pediatric hematology/oncology workforce over the past three decades. Prior to 1988, only 32% of board-certified providers were women; since 1988, women represent 53% of all people who have become board certified. Now, women represent between 45% and 50% of the active pediatric hematology workforce.
Still, survey results have highlighted a lack of diversity among pediatric hematology/oncology providers. Only 3% to 8% of providers were of Hispanic background, 10% to 14% were Asian/Pacific Islander, and only 2% of specialists were African-American.1
"This lack of diversity is important in many ways because our field – with disorders like sickle cell disease and thalassemia, which are more common in people of African descent – has patients who would like to see someone who looks more like them in the doctor's office," said Alexander Boucher, MD, assistant professor in the Department of Pediatrics at the University of Minnesota, who specializes in nonmalignant hematologic disorders.
This high patient-to-physician ratio may not quell fears about a looming provider shortage, but data about the geographic distribution of providers signals that access to specialized care varies greatly by location. Pediatric hematologists/oncologists were more likely to reside in major metropolitan centers, rather than rural areas. For example, there were 15 subspecialists serving 115,305 children in Washington, DC, for a ratio of 1 physician per 7,867 children; in Wyoming, there were no board-certified subspecialists for the state's 138,323 children.1
"In Minnesota, most of the pediatric hematology/oncology providers are located in the Twin Cities metropolitan area," Dr. Boucher commented. "Elsewhere, there are three providers in Duluth that are having to do everything – hematology and oncology – and serving the entire upper half of the state."
There also is an uneven distribution in the types of workplaces where pediatric hematology/oncology providers practice. "I would estimate that 90% of pediatric hematology/oncology programs, and by extension fellowships, are at medical centers in academic environments, which is a much different landscape from that in adult hematology/oncology," said Dr. Boucher.
In fact, between 2012 and 2015, half of surveyed pediatric hematologists/oncologists reported working in an academic setting. Just a few years later, 71% of pediatric hematologists/oncologists who took the board certification exam for the first time in 2015 reported their workplace to be a university/medical school, with only 14.8% reporting working in a community hospital.2
Navigating New Career Pathways
In addition to who is going into pediatric hematology/oncology and where they are working, training and career pathways also are changing.
"Many trainees are feeling as though their opportunities are limited," according to Sherif M. Badawy, MD, assistant professor of Pediatrics, Hematology, Oncology and Stem Cell Transplantation at Northwestern University Feinberg School of Medicine, and a co-author of the ASPHO workforce study. "In some cases, academic institutions are saturated with faculty. New trainees are having a hard time finding the right place, especially if they have geographic limitations."
In a survey of trainees who completed a traditional three-year fellowship in 2014 and 2015, approximately 25% remained in training for at least one additional year after graduation, as a fourth-year fellow or subspecialty fellow. That number is up from 16% in 2010.
Many graduates (51%) stayed at their training institution after graduation, and the type of position that graduates eventually accepted differed notably for those who left compared with those who stayed. Forty-one percent of graduates who left took assistant professor level positions, while only 20% who stayed had a position at a similar level.2
A fourth year of training is often used to gain more sub-subspecialty experience, according to Angela Smith, MD, MS, associate professor in the department of pediatrics and director of the fellowship program and Blood and Marrow Transplantation Division at the University of Minnesota.
"More recently, with regard to bone marrow transplant at least, more and more centers offer a one-year clinical fellowship," Dr. Smith said. "It may not be accredited by the Accreditation Council for Graduate Medical Education, but it allows young physicians to get more training dedicated to an area where fellows often get significantly less clinical exposure during their three-year hematology/oncology fellowship."
Dr. Badawy noted that he has seen similar fourth-year fellowships for other more specialized areas of nonmalignant hematology, such as coagulation or transfusion medicine.
He also has witnessed more academic institutions pushing trainees toward positions where they conduct more basic and translational research. "Basic and translational research is very important," he acknowledged, but it may not be what trainees are most passionate about. "Maybe they enjoy and are more interested in clinical research. It's important to give trainees more wiggle room to actually envision a career and develop a niche for themselves," Dr. Badawy said.
The Costs of Caring
During their subspecialty training, pediatric hematologists/oncologists can incur massive amounts of debt – a common scenario among most specialties. However, Dr. Boucher noted that the pay structure for pediatric hematology/oncology specialists and benign hematology specialists is "definitely different" from that for adult specialists.
Compared with general pediatric practice and adult specialty practices, pediatric hematology/oncology provides little opportunity for positive financial return (i.e., earning a higher salary or paying off student loans sooner).4
However, Dr. Boucher added that "pediatric benign hematology is one area out of [pediatric] hematology, oncology, and transplant that is more likely to get you a job right out of fellowship." Still, surveys have shown that less than 10% of graduating fellows are interested in taking on a focused benign hematology role.
"Although I was somewhat limited geographically when looking at positions, I was able to pick and create a position that fit my desires much more than many of my peers going into oncology, for instance," Dr. Boucher said.
Hematology or Hematology/Oncology?
Dr. Boucher attributes much of his ability to select a position that aligned with his career aspirations to his decision to specialize in benign hematology, as opposed to a combined hematology/oncology specialization.
In recent decades, much of hematology training has been merged into a single hematology/oncology pipeline – a fact that researchers explored in the 2018 Hematology & Oncology Fellows Survey, sponsored by the American Society of Hematology (ASH) and recently published in Blood Advances.5
"That nearly all future hematologists train in combined fellowship programs has caused concern in the hematology community that hematology/oncology fellows do not receive adequate preparation and exposure to hematology patients to motivate them to choose careers in hematology," the report authors wrote. "These concerns about whether fellows will pursue hematology are particularly acute given perceptions that the specialty is likely to lose many practicing hematologists to retirement, whereas the demand for hematology services continues to increase."
Of 626 hematology/oncology fellows surveyed, approximately half reported that exposure to hematology patients in medical school and fellowship positively influenced their decision to pursue hematology-only. Hematology research experiences and having a hematologist as a mentor also prompted trainees to pursue hematology. (See ASH Directions for more findings from the survey).
However, similar to many of the survey respondents, Dr. Boucher and Dr. Badawy reported that they had an interest in the field prior to exposure during fellowship.
So, knowing that exposure to hematology experiences increases interest in hematology, how are medical schools working to recruit more physicians to the pediatric hematology/oncology field?
Mentorship is key, Dr. Badawy said, and in his experience, more institutions are encouraging trainees to find their niche as early as possible, so that each trainee can clearly articulate how he or she will contribute to the field and future potential institutions as a junior faculty member. Although opportunities still exist for people who want to practice both hematology and oncology, they are more prevalent in academic in-stitutions. These centers tend to be interested in hiring graduates with advanced training in a specific area.
"Finding that niche may require a good mentor," he acknowledged. "I was fortunate to have an exceptional mentorship experience with Alexis Thompson, MD, MPH, and Robert Liem, MD, here at Lurie Children's Hospital."
In a review of experiences in the ASPHO Mentoring Program, which matches early career trainees with experienced pediatric hematologists/oncologists, Dr. Badawy and co-authors found that this type of mentorship offered a "clear benefit" to participants.
Mentors encouraged mentees to apply for additional fellowship training, provided guidance on going into clinical research, or advised them about where to look for a faculty position. "Most mentor–mentee pairs in the program were satisfied with the mentoring relationship, considered it a rewarding experience that justified their time and effort, and achieved their goals in a timely manner with objective work products. Most also planned to continue the relationship," he said.6
New Practices, New Providers
In states where recruitment has been difficult – such as Wyoming and other rural areas – institutions are turning to advanced practice providers (APPs) to satisfy the need for pediatric hematology/oncology specialists, according to Dr. Shah. "We have more flexibility with mid-level providers and are relying on them more heavily instead of trainees and faculty," she said.
"Pediatric hematology/oncology was one of the first subspecialties that recognized APPs as being vital to the team and allowed them to practice at the top of their license and scope," said Meredith Foxx, MBA, MSN, associate chief nursing officer and a pediatric clinical nurse specialist at Cleveland Clinic Health System. "Pediatric hematology/oncology has been ahead of the game and at the forefront of using APPs to the best of their ability."
Registered nurses who decide to specialize in hematology/oncology often undergo additional training such as chemotherapy competency courses provided by the Association of Pediatric Hematology/Oncology Nurses, or national certifications in oncology through the Oncology Nursing Certification Corporation.
In addition to this training, Ms. Foxx said that many of the registered nurses who specialize in pediatric hematology/oncology have a particular passion for caring for this patient population.
"These patients go from being a typical child – running, playing, and going to school – to having a cancer diagnosis," she said. "Although cure rates are great and long-term survival is good, the diagnosis comes with a host of issues and the child's life, and that of their family and any siblings, gets turned upside down."
APPs are typically a patient's first point of contact during a clinical visit and can aid in explaining treatment plans or handling side effects and in helping families access the support and resources they need.
In addition to these traditional nursing responsibilities, APPs are taking on more clinical responsibilities. Workforce studies have shown that 87% of pediatric hematology/oncology programs consider APPs to be regular members of their clinical care teams. That reflects a steady increase in the amount of clinical care delivered by APPs: In 2012, 40% of the clinical workload in pediatric hematology/oncology practices was carried by APPs, but by 2015 that had increased to almost half (47%). Specifically, APPs were used more often to provide outpatient care compared with inpatient care (70% vs. 30%).1
"I have been in APP nursing leadership for eight years and I have seen the expectations for the role grow exponentially," Ms. Foxx said.
Data from another large-scale study of nurse practitioners and physician assistants in oncology identified more than 5,000 oncology APPs and an additional 5,400 who might practice oncology – including in the field of hematologic malignancies.7 Of practitioners who responded to the survey about their role, APPs estimated spending an average of 85% of their time providing patient counseling, prescribing and managing treatments, and handling follow-up patient visits.
As more and more states broaden the rules and regulations around APPs, Ms. Foxx said it is important for practitioners to take ownership of their roles and make sure they have the proper knowledge and skills to provide high-quality patient care.
In addition to APPs, Dr. Shah said that her institution, Texas Children's Hospital, has started to hire more pediatric hospitalists.
"These are physicians who went through the same medical schools, fellowships, and board certifications, but instead of a career trajectory that was research-focused or administrative, knew they wanted to be 100% clinical," Dr. Shah said. "They may not have primary patients, and often are working the odd hours – weekends, nights, or holidays."
In 2012, it was estimated that 20% of pediatric hematology/oncology programs included hospitalists, but that increased to 45% in 2015. Within these programs, hospitalists made up 12% of the pediatric hematology/oncology physician clinical workforce.2
In some cases, Dr. Shah said, she has recruited physicians who really love the subspecialty, but were just looking for more flexibility.
Are the Kids' Doctors Alright?
Flexibility was a huge consideration for Dr. Boucher and his wife when he was looking for a position after completing his fellowship. "We had to think about how to best support a work-life balance," Dr. Boucher said.
That balance is important, with as many as 75% of pediatric hematology/oncology physicians reporting symptoms of burnout.2 Burnout can present in many ways: First, oncology and hematology are both emotionally demanding specialties, with physicians often being called in to deal with emergencies.
"It takes incredibly motivated and dedicated people to practice pediatric hematology/oncology, and I think physicians often feel a tug of war between trying to care for their patients and trying to make time for their own families," Dr. Shah said.
In addition, medicine itself has become more complex over the last decade or two, placing an increased pressure on providers to keep up with the science.
"As an example, we used to have clinical trials with one or two arms," Dr. Shah said. "Here, we are about to start enrolling for a clinical trial in leukemia that has 17 arms! I am sitting there trying to not only figure out how to enroll a patient correctly, but also how to best care for that patient who has cancer."
Added to that is the heavy administrative burden that has affected all areas of medicine. "When I was a fellow, you could jot down notes on a piece of paper, but the amount of information you have to fill out in an electronic medical record today is significantly greater," Dr. Shah recalled. "We actually give faculty time just for charting, and you sometimes feel like you are spending more time doing paperwork and less time actually talking with patients."
Addressing the aspects of pediatric hematology/oncology practice that contribute to burnout is an important goal in recruiting more trainees into the subspecialty moving forward.
There is a lot of work ahead for the field at large, and for program directors specifically, to figure out how best to prepare trainees and fellows to embark on a career that may look very different from the one they imagined.
"The field of pediatric hematology/oncology is definitely changing," she said. "We are all trying to prepare trainees – and ourselves – for what the future holds." â€”By Leah Lawrence
Hord J, Shah M, Badawy SM, et al. The American Society of Pediatric Hematology/Oncology workforce assessment: Part 1 – Current state of the workforce. Pediatr Blood Cancer. 2018;65:e26780.
Leavey PJ, Hilden JM, Matthews D, et al. The American Society of Pediatric Hematology/Oncology workforce assessment: Part 2 – Implications for fellowship training. Pediatr Blood Cancer. 2018;65:e26765.
"American Board of Pediatrics. Workforce Data: 2015–2016." Accessed November 10, 2019, from https://www.abp.org/sites/abp/files/pdf/workforcebook.pdf.
Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2011;127:254–60.
Masselink LE, Erikson CE, Connell NT, et al. Associations between hematology/oncology fellows' training and mentorship experiences and hematology-only career plans. Blood Adv. 2019;3:3278-86.
Badawy SM, Black V, Meier ER, et al. Early career mentoring through the American Society of Pediatric Hematology/Oncology: Lessons learned from a pilot program. Pediatr Blood Cancer. 2017;64:doi10.1002/pbc.26252.
Bruinooge SS, Pickard TA, Vogel W, et al. Understanding the role of advanced practice providers in oncology in the United States. J Adv Pract Oncol. 2018;9:585-98.