During the Training Program Directors’ meeting at the 2008 ASH Annual Meeting, an anecdote was told about an “unnamed Hematology/Oncology program in the Northeast” that is internationally renowned for non-malignant hematology. Even at this institution, the presenter noted, where hematology features prominently in research, education, and patient care, a “benign” hematologist is produced at the rate of just one graduate every one to two years, from a class of six to eight fellows per year. The program referred to was mine. Although a majority of our graduates obtain ABIM certification in hematology, only a few go on to careers dedicated to the practice of caring for patients with non-malignant hematologic disorders. This translates into an enormous problem, not just for today, but for future generations: Who will be the master clinicians, the pioneer laboratory-based investigators, and the translational researchers in benign hematology 20 years from now? Furthermore, as someone who believes that even physicists should read Shakespeare, I lament the possibility that some of those who train in combined hematology/oncology training programs may not receive a well-rounded education, whether by their choice or by default.

In ASH News (Spring 2002 issue), 2002 ASH President Robert I. Handin, MD, addressed some of these issues. He attributed some of these trends to the failure of hematologists to embrace fledgling fields and new technologies, as well as to the jaded attitudes of some senior hematologists who may portray the field negatively (or at least who may fail to promote it actively and positively). It has also occurred to me that the combined hematology and medical oncology training program structure may be somewhat to blame.

Most of us choose our careers based on a personal experience: motivated by a cherished mentor, the illness of a loved one, or an “ah-ha” moment in scientific or clinical pursuits. For the most part, residents are choosing to train in hematology/oncology because they want to become oncologists. The fact that less than 6 percent of graduates plan to practice primarily in non-malignant hematology1  likely reflects the already-determined preferences of the residents who choose this training. How could this be? Very few internal medicine residents really see what hematology is all about. Residents uniformly rotate on oncology floors, attend oncology clinics, and see oncology patients. Cancer is common; nearly all of us have been touched by it personally in some fashion. Oncology is compelling because it is everywhere. So is hematology; the residents just don’t see it. And all too often, neither do our fellows.

By allowing trainees to join combined fellowship programs, and then not be exposed to a true benign hematology training experience, we are depriving them of the opportunity to fall in love with our field. Hematology is marginalized in some training programs, either by design or by necessity, and hundreds of trainees are never exposed to the intricacies of what we do. Even at Penn, where exposure is mandatory, we are only training one benign hematologist per year. But one out of seven or eight fellows is still about 12 percent — double the number that we are producing nationally as of our last look in 2004. I know for a fact that Penn has turned the heads of several talented physicians who thought they were here to train in oncology, and this could happen more often, in more programs, if hematology were given its due in training.

This problem is going to become more acute in the future. A 2007 study has projected a shortage of oncologists by 2020,2  and ongoing discussions about health-care reform have heightened these concerns. This shortage will affect patients with blood disorders as well: Anemia, myelodysplasia, myeloproliferative diseases, hematologic malignancies, and venous thrombosis are just a few of the many hematologic conditions that preferentially affect the elderly. Thus, unlike medical oncology, which is currently felt to exist in equilibrium between supply and demand, hematology is facing a dearth of well-trained specialists who care for and study non-malignant hematologic problems, in real time as well as in the future.

The efforts of ASH to educate the public about our field are truly laudable. We should as well put similar efforts into advertising the wealth, breadth, and beauty of hematology to our trainees. Certainly, ASH is attempting to address some of these concerns. For instance, the ASH Alternative Training Pathway Grant seeks to fund innovative training experiences combining hematology with another field; pharmacology and combined pediatric/adult hematology were the two proposals funded last year. However, I also believe that this problem should be addressed at the level of individual programs. If we are truly calling ourselves combined hematology/oncology training programs, then including at least three to four months of dedicated benign hematology training should be expected — truth in advertising. Certainly this is not a simple decision, as it necessarily adds time to the training experience (or takes away from dedicated research time). Nevertheless, not only would such a requirement ensure a broad-based education appropriate to any combined hematology/oncology trainee, but also it would undoubtedly draw more fellows toward a career in benign hematology.

References

References
1.
Todd RF III, Gitlin SD, Burns LJ, and the Committee on Training Programs.
Subspecialty training in hematology and oncology, 2003: results of a survey oftraining program directors conducted by the American Society of Hematology
Blood.
2004;103:4383-88.
http://bloodjournal.hematologylibrary.org/cgi/content/abstract/103/12/4383
2.
Erikson C, Salsberg E, Forte G et al.
Future supply and demand for oncologists: challenges to assuring access to oncology services
J Oncol Prac.
2007;3:79-86.