The traditional path to a career in hematology in the U.S. involves at least nine years of graduate-level training, starting with medical school and ending with a hematology or combined hematology-oncology fellowship that is certified by the Accreditation Council for Graduate Medical Education (ACGME), which accredits teaching hospitals, residencies, and fellowships. However, a small number of physicians choose to extend their training with an additional one- or two-year fellowship in an ultra-specialized area.1
These fellowships are available across a range of conditions and practice areas, including lymphoma, leukemia, cellular therapy, hemostasis and thrombosis, and sickle cell disease (SCD), among others, and vary in length and in the amount of time spent on clinical and research work.
For Melissa Azul, DO, a pediatric hematologist at Children’s Wisconsin in Milwaukee who specializes in treating SCD, the decision to complete one of these fellowships was a difficult one. “Generally, trainees want to get out of training, and they are eager to start practicing, earning money, and being autonomous professionally,” she said. “By the time they reach the end of their hematology-oncology fellowship, another year of fellowship just seems like a lot to ask.”
But Dr. Azul wanted to spend her career focused on caring for children with SCD and saw advanced fellowship as the best path to achieve that goal. “I felt like if I did an extra year and focused on sickle cell, that would put me in a better position to promote myself as a hematologist, not as a hematologist-oncologist,” she said.
ASH Clinical News spoke with Dr. Azul, other physicians who have recently completed hematology-oncology fellowship, and directors of these fellowship programs to find how they rate the value of additional fellowships and how these programs fit into the overall development of the hematology workforce.
What Are These Additional Fellowships?
Fellowship programs offering in-depth training in a particular specialty area are a relatively new concept, developed over the last two decades at large research institutions. Before that, specialized training after hematology-oncology fellowship was mostly done on an informal, ad hoc basis. At MD Anderson Cancer Center in Houston, for instance, physicians from around the world would spend anywhere from a few weeks to a few months – however long their home institutions could spare them – to train on advanced concepts and techniques in leukemia.
“We saw that there was a need for a structured program where we could formalize the training of these individuals,” said Guillermo Garcia-Manero, MD, training program director for MD Anderson’s leukemia fellowship.
What developed was a fellowship program where trainees from the U.S. and around the globe could spend one or two years learning about leukemia care and research. Fellows in the program spend a few months on the inpatient service before rotating through various clinics and spending time on research. The program, which is about 20 years old, trains 10 fellows each year.
The bone marrow transplantation (BMT) and immunotherapy fellowship at Fred Hutchinson Cancer Center (Fred Hutch) in Seattle had a similar start. The center, which is well known for pioneering BMT, has long trained physicians from across the country and around the world, who would be funded by their own institutions.
“We have trained many physicians from all over the world for decades, and some of them, after training here, have started [hematopoietic] cell transplantation programs at their sites in the U.S. and on all continents,” said Marco Mielcarek, MD, PhD, medical director of the adult blood and marrow transplant program, co-director of the BMT and Immunotherapy Fellowship Program, and a professor at Fred Hutch.
Hematology-oncology trainees have been reaching out to Fred Hutch faculty asking if they can train as fellows to gain more experience in BMT and immunotherapy, Dr. Mielcarek said. This interest prompted the institution to begin the fellowship program three years ago, as a pilot with one adult and one pediatric fellow per year.
“The purpose was to train fellows more formally because the current hematology-oncology program only requires one or two months of rotations in BMT. So, after going through the regular fellowship, if you wanted to hire someone, they haven’t had a lot of experience, a lot of exposure to transplant patients, and this in-depth additional year puts trainees in the position where they can really take care of transplant patients,” Dr. Mielcarek said.
The fellowship includes a significant amount of clinical time but also has a research component. Fellows complete eight months of clinical work rotating through BMT and immunotherapy services, including the outpatient clinic, inpatient service, and long-term follow-up. In the final two months of clinical work, they are attending on the inpatient service independently. The remaining four months are devoted to research, working with faculty at Fred Hutch.
Lack of Standards
Fellowships exist in virtually every specialized area of hematology-oncology. An additional fellowship does not lead to board certification, so these programs are not accredited by the ACGME. Every program is different, with a mix of clinical and research offerings, often based on the mission of a given institution.
“Because cell therapy is a new fellowship area and does not have a board exam, there is no overarching organization that says you need to teach fellows x, y, or z. It’s basically coming from our experience and what we feel is most appropriate. That’s an iterative process,” said Eapen K. Jacob, MD, cellular therapy fellowship director at Mayo Clinic in Rochester, Minnesota, where he oversees a small program focused on the manufacturing and lab side of cellular therapy. “As the field matures, we hope to develop standards and milestones for training fellows,” he explained.
Although the lack of accreditation and standardization can make it difficult for potential trainees to assess and compare fellowship programs, the directors of these programs said the flexibility is helpful. “It gives the institutions the opportunity to incorporate some institution-specific characteristics,” Dr. Mielcarek said. “It’s nice that we have the opportunity to shape it the way we want and place the focus on what we think is important.” At Fred Hutch, that flexibility means giving fellows more opportunities to explore an individual research project.
However, standardization appears to be coming in some areas. In 2021, the American Society for Transplantation and Cellular Therapy issued recommendations for the educational structure of BMT and cellular therapy fellowships.2 Meanwhile, in Canada, the Royal College of Physicians and Surgeons of Canada has developed an “area of focused competence” diploma for trainees who complete recognized fellowship programs in thrombosis.
Vinai Bhagirath, MD, program director for the one-year adult thrombosis fellowship at McMaster University in Hamilton, Ontario, said the standardization that comes from creating the “area of focused competence” has been helpful because it lets both trainees and the institutions hiring them know what they are getting. “I do foresee that it will be something that solidifies and maybe will take hold in the U.S. as well,” he said.
Drivers of Increased Training
One driver for the development of these fellowship programs is the growing complexity of hematologic care. In thrombosis, for instance, the complexity is being driven by patients with multiple medical conditions that implicate thrombosis and bleeding, in addition to therapies with bleeding complications and new classes of medication, Dr. Bhagirath said.
For trainees, this complexity, coupled with the wide range of areas that must be covered in hematology-oncology fellowships, means they may complete fellowship without gaining a deep understanding of their specialized area of interest. That was the case for Dr. Azul, who developed her interest in SCD after her first year of hematology-oncology fellowship at Mayo Clinic. She quickly realized that she would have little opportunity to see patients with SCD in Rochester, so she sought out the chance to complete her research years at the University of Minnesota, 90 miles north in Minneapolis, which had a larger pool of patients with SCD. Even with that additional exposure, she said specialized training was key to finding a job where she could focus on SCD.
Dr. Azul also serves as an assistant professor at the Medical College of Wisconsin in Milwaukee, where she is helping to develop a program that will transition patients with SCD from pediatric to adult care. “If I had come here straight out of hematology-oncology fellowship, there is no way that I would have felt as comfortable as I do now.”
She believes her additional training as a SCD fellow at St. Jude Children’s Research Hospital also gives more senior faculty confidence in her expertise. “It would be very challenging to prove my expertise as a junior faculty member if I didn’t have this extra year of training,” she said.
Although these additional fellowships have not become a formal requirement for academic employment, fellowship directors said they can set applicants apart.
Rahul Banerjee, MD, an assistant professor in the clinical research division of Fred Hutch, has researched the motivations of trainees completing advanced BMT fellowships. In a survey of 105 physicians who started fellowship between 2012 and 2021, the top reason for choosing an additional fellowship was the desire to increase their comfort with allogeneic BMT, followed by increasing their career prospects and providing additional opportunities for research.3
That is not a surprise when it comes to BMT and cellular therapy, Dr. Banerjee said. “ACGME only requires one month of exposure to transplant across all three years of hematology-oncology fellowship. Similarly, ACGME does not require any CAR-T exposure whatsoever. That can be a problem.”
The other factor driving institutions to launch additional fellowship programs is a desire to grow their own faculty. Annette von Drygalski, MD, PharmD, program director of the hemostasis and thrombosis fellowship program at the University of California, San Diego (UC San Diego), said the program was launched in 2015 because they “so urgently needed academic classical hematologists with expertise in hemostasis and thrombosis.” The program produces one to two fellows per year, most of whom have gone on to faculty positions at UC San Diego and other academic institutions.
Financial Considerations
There are many considerations when it comes to whether to pursue further fellowship training, but it often comes down to money. Physicians who continue with training are choosing to forego the salary of a full-time hematologist or junior faculty member in favor of a trainee salary. Salaries vary depending on the location and practice focus, but that difference could be well over $100,000, said Samer Al Hadidi, MD, an assistant professor at the University of Arkansas for Medical Sciences in Little Rock, who focuses on myeloma and BMT and cellular therapy.
Although the additional training is an investment in future earnings, it can create a financial hardship for physicians who are carrying significant student debt or who have families to support. Trainees also face additional costs if they must relocate for fellowship and then again for their next job.
“For a family, the lower trainee salary may not be enough,” Dr. Al Hadidi said. “Extending this for another one or two years on top of this long training path, for many people, is really a problem.”
Dr. Al Hadidi, who moonlighted to earn extra money during his third year of hematology-oncology fellowship at Baylor College of Medicine in Houston, said the financial pressure is even greater for trainees working in cities with a high cost of living. He decided against pursuing a fellowship in BMT and cellular therapy, in part, because he did not want to delay the start of his academic career. He also did not see it as necessary because he was able to have protected research time during his hematology-oncology fellowship through a National Institutes of Health T32 research training grant where he focused more on cellular therapies.
Giving trainees the opportunity to customize their hematology-oncology fellowship to meet their needs is a better option than adding more years of training, Dr. Al Hadidi said. “The program should serve the trainee, not the other way around,” he added.
Another way to allow greater access to specialized training is simply to pay fellows a higher salary, Dr. Al Hadidi said, by classifying these trainees as junior faculty members and giving them some additional independent clinical responsibilities.
At the end of the day, whether to pursue additional fellowships is an individual decision that hinges on what factors are most valuable to the trainee. Programs offering fellowships could help make this decision easier by making the program offerings more transparent, Dr. Banerjee said. Applicants need more clarity on what they will get out of a fellowship program. For instance, how much independent practice or protected research time will they have? Will they receive time off and reimbursements for attending professional conferences? Where have prior graduates of these fellowships continued their careers? Do many of them stay on at the same institution?
“The websites are all over the place in what they say people will do. A lot of them just don’t say, and people kind of negotiate it,” Dr. Banerjee said. “As you can imagine, most of us have only gone through the Match and we’re not good at negotiating.”
Future Hematology Workforce
What is the future of additional fellowship training in hematology? Many fellowship program directors expect these programs will continue to grow because of interest by trainees and the need for specially trained faculty at academic institutions.
“I think there will be more of these programs if the leaders of these other centers realize what’s happening. Medicine is becoming more and more super-specialized,” said Dr. Garcia-Manero.
These programs also play a critical role in growing the classical hematology workforce, said Dr. von Drygalski, by providing skills not emphasized in hematology-oncology fellowship. “You will find that most institutions provide more of an oncology edge, and so those who are really interested in hematology find that they lack the ability to practice since so much of hematology today is thrombosis and hemostasis,” she said.
St. Jude Children’s Research Hospital in Memphis started its SCD fellowship program three years ago with the specific aim of increasing the number of adequately trained specialists in this area, said Jane Hankins, MD, director of the global hematology program at St. Jude. The trainees who seek out their program are not exploring or buying time but are committed to improving treatment access for patients with SCD.
“When somebody comes to a specialized program, they have that passion and these programs nurture that,” Dr. Hankins said. “Those are the people who can really push the field forward. We are increasing the number and the quality of the hematology workforce by providing these highly specialized fellowships.”
Another effort to grow the classical hematology workforce is the ASH Hematology-Focused Fellowship Training Program (HFFTP), which has created at least 10 ASH-funded hematology-focused fellowship tracks within existing hematology-oncology programs at ACGME-accredited training institutions. This program, which begins accepting trainee applications in July 2023, is expected to produce 50 academic hematologists by 2030.4
The contribution of programs like HFFTP is likely to be significant, Dr. von Drygalski said, because of the current demand for classical hematologists.
References
- American Society of Hematology. The educational path of a hematologist in the U.S. https://www.hematology.org/education/trainees/medical-student-resident-resources/educational-path-of-a-hematologist.
- Jain T, Knight T, Alencar MC, et al. American Society for Transplantation and Cellular Therapy guidelines for fellowship training in hematopoietic cell transplantation and immune effector cell therapy. Transplant Cell Ther. 2022;28(3):125-133.
- Banerjee R, Kelkar AH, Durani U, et al. Demographics, motivations, and experiences of participants in transplantation or cellular therapy fellowships [published online ahead of print, 2023 Mar 17]. Transplant Cell Ther. doi:10.1016/j.jtct.2023.03.011.
- American Society of Hematology. ASH Hematology-Focused Fellowship Training Program (HFFTP). https://www.hematology.org/education/educators/resources-for-training-program-directors/hematology-focused-fellowship-training-program.