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Filling the Gap: Hematology Fellowships Prepare APs for Specialized Career Paths

March 29, 2022

April 2022

Sandy Kurtin, PhD, ANP-C, AOCN
Hematology/Oncology Nurse Practitioner, University of Arizona Cancer Center
Assistant Professor of Clinical Medicine and Adjunct Clinical Assistant Professor of Nursing, University of Arizona

 

In recent years, advanced practitioners (APs) have been taking on a bigger role in the care of hematology and oncology patients, acting as crucial parts of the care team. However, many hospitals are finding that these providers don’t get enough hematology-specific training in school to confidently deliver top-notch care. According to surveys, recent graduates from AP programs agree with this. To help address this gap in education, several care groups have initiated sought-after fellowships that help APs quickly develop a deeper expertise in a particular oncological specialty.

ASH Clinical News spoke with the directors of four U.S.-based fellowship programs. Lisa Hwa, APRN, CNP, is the DNP program director of the Nurse Practitioner/Physician Assistant (NP/PA) Hematology/Oncology Fellowship at Mayo Clinic in Rochester, Minnesota. Kelly Haviland, PhD, FNP-BC, is the co-chair of the Advanced Practice Provider’s Professional Development Council at Memorial Sloan Kettering Cancer Center in New York City. Cherise Gleason, MSN, NP-BC, AOCNP, is the advanced practice provider chief at Winship Cancer Institute in Atlanta, Georgia. Carrie Graham, ARNP, is the advanced registered nurse practitioner at Seattle Cancer Care Alliance in Washington. These advanced practice experts discussed why their programs were started, how they work, and what they hope to achieve.


ASH Clinical News: Why are hematology-specific AP training programs needed?

Ms. Hwa: APs are a part of a growing cancer care workforce. However, current graduate education programs for NPs and PAs tend to have very limited curriculum focused on hematology practice. Hematology is an extremely complex field for newly graduated APs. Prior to launching this fellowship, we conducted a prospective needs-based assessment survey of our APs working in hematology as well as blood and marrow transplant at Mayo Clinic. The majority of our APs, over 90%, reported that when they were hired as a new grad, they had very limited school education, and they did not feel prepared by the traditional AP education to confidently work in hematology.

Dr. Haviland: Part of the issue that we’ve run into with some of our new hires is that there’s varied experienced and varied exposure to oncology in master’s level education, whether it be NP school or PA school. So, when we have new hires, there is often a steep learning curve. What we really wanted to do with our fellowship programs is give APs the exposure and dedicated educational time to learn all about hematology and oncology in general as well as specialized tracks within the field.

Ms. Gleason: We found that for oncology, many new grads were just not ready. That was really the driving force: how can we better prepare APs so when they came come off a year of fellowship, they’re ready to go? The program is structured to develop and strengthen proficiencies within the clinical setting and develop a well-rounded health care provider.

Ms. Graham: Postgraduate education programs for APs have gained more attention and popularity in the last decade, although these programs have been in existence for quite some time, I believe dating back to the 1970s. These fellowship programs are needed for a host of reasons. With a known shortage of hematologists and oncologists in the U.S., there is a demand for well-trained APs in this field. One of the primary reasons for a fellowship is to address the lack of hematology and oncology focus that is offered in graduate PA and NP programs. APs come out of grad school with a strong internal and family medicine foundation, yet then have job opportunities in subspecialized areas of practice. To prepare future APs for success, we need to ensure that hematology and oncology APs have a strong foundational knowledge in the principles of hematology, oncology, immunotherapy, cellular therapy, and blood and marrow transplantation (BMT). Our fellowship program provides a structured environment for building this knowledge base, giving our fellows the tools they need for future career success.

ASH Clinical News: Describe your training program for APs and how it prepares graduates to work in the field of hematology.

Ms. Hwa: Our curriculum includes both didactic course hours and mentored clinical rotations. For the didactic part, our fellows participate in five weeks of half days of hematology-specific lectures with our medical students. They also receive pharmacology lectures, and we include some online learning modules. The program provides an opportunity for fellows to attend a regional or national education conference related to hematology and BMT practice. For clinical rotations, they are required to take a core rotation among all disease-focused outpatient clinic groups, as well as hematology and BMT inpatient practice. Additional clinical rotations include hematopathology, palliative care, transfusion medicine, and infectious disease. The unique part of our fellowship is that we’ve also built in 100 hours to provide an opportunity for our fellows to engage in any clinical research or quality-improvement project.

Dr. Haviland: We have seven tracks now, all with a focus of oncology as our overarching theme at Memorial Sloan Kettering, but each with their own specific focus. For example, we have a solid tumor track, in which all our fellows rotate through the various solid tumor areas to gain experience. We also have critical care with a focus in oncology, hospice and palliative care focused in oncology, as well as pediatric, neurologic, and geriatric oncology. Additional programs include pediatric oncology, solid tumor medicine, and perioperative oncology.

We’ve carved out a dedicated team to produce fellow-specific education so our fellows come together as a cohort. Participants in many of those seven tracks come together on one afternoon and sit down and have a syllabus of learning that they partake in, in addition to the Grand Rounds and the various symposia that we offer. Our AP fellows are asked to partake in a quality assurance or research project.

Ms. Gleason: It’s a one-year fellowship at the Winship Cancer Institute. They start off with a boot camp, because a lot of these APs just need a refresher on the basics. Then they rotate through most of our disciplines, including hematology, followed by electives. They learn how to do procedures in our procedure clinics, like bone marrow biopsies and lumbar punctures. We also coordinate so our AP fellows can attend some of the lectures with the physicians.

Ms. Graham: We offer three fellowship opportunities annually at Seattle Cancer Care Alliance. Our fellowship is a 12-month program with two tracks offered – a hematology and medical oncology track, and a hematopoietic cell transplant and immunotherapy track. Our fellowship program provides a blend of clinical and didactic learning opportunities. Our clinical program is a series of robust rotations through various clinical services. Our fellows are providing direct oncology patient care with increasing levels of independence while supervised by an experienced preceptor. Along with the clinical curriculum, we also have a well-developed didactic schedule to complement our fellows’ clinical learning. The didactic portion covers the foundation of cancer care, specific hematology and oncology disease management, supportive care topics, and oncologic emergency management – all topics critical to the care of the hematology patient. There is also a focus on professionalism and issues related to entry into practice.

ASH Clinical News: Why is it important for practicing hematologists to be aware of and understand the benefits of these programs?

Ms. Hwa: It’s very important to foster a collaborative working environment, with our hematologists realizing that APs can provide safe, high-quality patient care.

Ms. Gleason: An AP who comes out of a hematology and oncology-specific fellowship overall is just better prepared for a subspecialty like oncology. They’ve already been in those clinics with physicians, so they’ve had that opportunity to work together and they’re ready to go.

Ms. Graham: APs here at the Seattle Cancer Care Alliance are integral members of a patients’ care team and truly are pivotal to the overall functioning and success of our hematology program. From a resource perspective, there is a known shortfall of hematology and medical oncology physicians, and well-trained APs provide high-quality, hematology-directed patient care in collaboration with their physician counterparts. We have many physicians who are clinician researchers, so their time and efforts are split between clinical, research, and leadership responsibilities, with the need for APs to provide significant clinical support.

ASH Clinical News: How do APs with hematology-​specific training affect the hematology workforce?

Dr. Haviland: We’re not looking for fellows to come in and fill a gap, so all our fellows have a preceptor and they’re not counted in staffing numbers in the same way. They’re really working with someone throughout their fellowship to bolster their confidence and their ability to make decisions. We then have this amazing pool of fellows to look to for hiring purposes that understand the workforce at Memorial Sloan Kettering since the fellows get to know the teams and teams get to know them. What we have in our AP workforce is clinical expertise and being able to relay that to other practitioners so that they can either come to work for us or go out into the community and translate and use the knowledge they’ve gained from us for cancer treatment.

Ms. Graham: The role of postgraduate education has become more appreciated and understood in recent years. In medicine, we are using APs in very sub-specialized areas and really feel that the opportunity for a fellowship program to provide a specialty-focused education is critical for the future workforce. A fellowship program will help set up new hematology and oncology APs with the tools needed for career success and the ability to make strong contributions in hematology. Ultimately this will positively affect the entire field of hematology, both for research-based practices as well as community-based practice.

ASH Clinical News: Tell us about enrollment numbers and requirements.

Ms. Hwa: We admit four fellows each year. That’s including two in the hematology track and two in the medical oncology track.

Dr. Haviland: Last year, we received more than 60 applications from people who were all very qualified for our pediatric hematology track, and we have two spots, so it’s highly competitive. We look for a good fit for us and a good fit for them. It’s important for the AP to clearly want to have a fellowship and embark upon learning, not just want a job at our institution.

Ms. Gleason: This is the first time that we’re bringing in four fellows annually instead of two every six months. We had to take a pause due to the COVID-19 pandemic, so it will be starting again in April. We would like to consider more fellows because the candidates are so exceptional and we like to hire as many of the fellows as we can. You end up with practitioners dedicated to oncology.

Ms. Graham: We have funding for three fellows per year. The requirements include graduating from an accredited PA or NP program in good standing, passing PA or NP national certification exams, and licensure from Washington state. Each year, we have many applicants, significantly more than we can offer spots to. We envision growing our fellowship program in coming years and see the need for additional postgraduate programs throughout the country dedicated to cancer training.

One of the most important things we consider in our applicants is whether there is a true desire to practice in hematology and oncology following completion of their fellowship. We want to train and develop future leaders in cancer care, so really exploring a candidate’s motivations to participate in the fellowship is important. 

ASH Clinical News: What is the makeup of the student body?

Dr. Haviland: We’ve embarked upon a new recruitment strategy this year that I’ve been working very closely with our human resources business partners on in terms of diversity and innovation of thought and creativity. And that includes not just race or ethnicity, but multiple areas of diversity so that we can create a diverse cohort of fellows and have all different types of people to make up our fellowship. We’re very heavily invested in this, not to check off a box for race or ethnicity but to look closely at all the components of diversity.

Ms. Gleason: Most of our students have come from the Atlanta area and many from Emory’s PA or NP program. We do get applicants from out of state, and our goal is to choose the best match for our program.

Ms. Graham: We have attracted fellows from the Pacific Northwest, as well as across the country, both new graduates and experienced APs looking to break into the fields of hematology and oncology. We actively work on being more intentional with efforts to recruit candidates from underrepresented populations. One example of these efforts is to ensure that our recruiting materials are sent to historically Black colleges and universities that offer advanced practice programs. We are committed to building a fellowship program, with a focus on diversity, equity, and inclusion in both our recruiting efforts as well as in the content of our fellowship program itself.

ASH Clinical News: What attracts students to your program?

Ms. Hwa: Hematology practice is very complex and requires a lot of knowledge and skills. There is a growing demand to hire APs working in such complex clinical practice specialties, but it can be very challenging for newly graduated APs with limited hematology-focused training. The fellowship will prepare them to become highly skilled providers.

Ms. Gleason: I think more and more practitioners are looking for this type of program. In addition to new graduates, we also have interest from experienced APs looking to make a career change. Candidates that are really interested in hematology and oncology just want more training before they start. Graduates transition to practice with the expertise necessary to deliver quality patient care at the top of their licensure.

Ms. Graham: The opportunity to have dedicated learning. They come in as fully licensed and credentialed providers that can see patients independently, but they’re put in an environment of supervision and given an opportunity for an additional year of learning. Since that comes at a cost to our fellows, they’re generally offered a salary of approximately 80% to 85% of our first year APs.

ASH Clinical News: What are the ultimate goals of these programs? What benefits do students obtain upon graduation?

Ms. Gleason: This type of program increases the students’ ability to find a job in hematology. It allows them that opportunity to see everything that’s out there and decide what is best for them. Along with the clinical and didactic training that they get, they work with a mentor, so that can offer them continuing professional experience. And then they are also in a setting where there is exposure and opportunity for future employment.

Ms. Graham: The goals of our program are to provide our fellows with a strong foundation in hematology, oncology, BMT, and immunotherapy. The fellowship program also focuses on the importance of interprofessional collaboration. Our fellows are not only working with other APs and physician colleagues, but additionally with nursing, social work, and a multitude of other supportive care services. AP fellows see first-hand how this type of collaboration can provide the optimal care for our patients. While working at Seattle Cancer Care Alliance, our fellows are exposed to the important role of research in the care of the cancer patient through the robust basic science and clinical research that is at the Fred Hutchinson Cancer Research Center and the University of Washington. They see how research is moved from the lab to the bedside, helping them gain a true appreciation for research as an important aspect of advancing quality care and developing improved treatment options in hematology.

With an additional year of postgraduate education, our fellows complete the program with a strong knowledge base, extensive clinical experience, and tools to make themselves very attractive to future employers. Whether fellows choose to continue their career at Seattle Cancer Care Alliance or secure a role with another employer, this year of postgraduate training sets our fellows up for future success as clinicians and leaders in hematology, oncology, immunotherapy, and BMT.

ASH Clinical News: Are there certifications in place or being developed?

Dr. Haviland: We are in the process of obtaining accreditation for our program this year. All our practitioners must have board certification in their area.

Ms. Gleason: Accreditation is available for established programs. We are currently working on our application for accreditation in oncology.

Ms. Graham: We’re going to need to come up with some options that can satisfy both our PA and NP fellows, too, so that we can go through the appropriate accrediting process. There is not a specific board certification for hematology and oncology PAs and NPs. The ONCC (Oncology Nursing Certification Corporation) does offer the AOCNP certification for nurse practitioners, but there is not a comparable hematology and oncology certification for PAs. Additionally, for hematology and oncology postgraduate fellowship programs, there are accrediting bodies that accredit postgraduate training programs, but again the options are limited in terms of accrediting bodies that provide accreditation for both PAs and NPs. We are trying to stay abreast of this topic through organizations such as APGAP (Association of Post Graduate APRN Programs) and APPAP (Association of Postgraduate Physician Assistant Programs), both of which are dedicated to postgraduate training for APs.

Literature Scan: Advanced Practice Edition

Recommendations of new and noteworthy research relevant to advanced practitioners from ASH Clinical News Associate Editor Sandy Kurtin, PhD, ANP-C, AOCN.

Christensen BE, Bazany C, Wittenberg T, et al. Oncology advanced practice providers chemotherapeutic prescribing practices. Abstract #1897. Presented at the 2021 American Society of Hematology Annual Meeting, December 11, 2021.

It is critical for APs to familiarize themselves with the design and conduct of clinical trials, including review and processing of orders. In September 2021, the National Cancer Institute (NCI) issued a statement allowing APs registered in NCI’s Registration and Credentialing Repository (RCR) to sign orders independently if the practice is in line with the institution’s policy, as well as local, state, and international laws and regulations. A qualified physician investigator will remain responsible for all trial-related medical decision making.

Bamigbola OA, Warwick LE. A comparative analysis of patient experience and patient-doctor communication in patients with lymphoma and CLL: Clinical trials versus non-clinical trials. Abstract #3047. Presented at the 2021 American Society of Hematology Annual Meeting, December 12, 2021.

All currently available therapeutics are a result of patient involvement in clinical trials. Patient-centered communication in discussing clinical trial participation with patients is an essential skill for APs to increase clinical trial participation.

Tinsley-Vance SM, Ali NA, Ball S, et al. Gender disparities in myelodysplastic syndromes: phenotype, genotype, and outcomes. Abstract #1984. Poster presented at the 2021 ASH Annual Meeting, December 11, 2021.

Retrospective review of patient registries to interrogate gender-specific disease attributes relative to clinical outcomes provides data that will inform future research aligned with the evolving standards for equity, diversity, and inclusion.

Jones RA, Hirschey R, Campbell G, et al. Update to 2019-2022 ONS research agenda: Rapid review to address structural racism and health inequities. Oncol Nurs Forum. 2021;48(6):589-600.

Jones RA, et al. Update to 2019-2022 ONS Research Agenda: Rapid review to promote equity in oncology healthcare access and workforce development. Oncol Nurs Forum. 2021;48(6):604-612.

Diversity (gender, race, ethnicity), equity, and inclusion have emerged as essential considerations in all facets of society, including health care. Best practices for incorporating these elements in the conduct and reporting of research are evolving and will require professional organizations, practices, and individual practitioners to consider them in every facet of their work.

 

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