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Feature

Identity Crisis
Anyone newly interested in the field of hematology may notice that there are some inconsistencies in how practitioners or departments refer to the specialty . “ General hematology ” may refer to a practice or practitioner that specializes in all types of disorders related to the blood – malignant or otherwise .
Roger M . Lyons , MD , is a board-certified hematologist in private practice with Texas Oncology , a member of The US Oncology Network . Dr . Lyons refers to himself simply as “ a hematologist .” Earlier in his private practice career , he treated mostly patients with acute leukemias , but he has “ partners to do that now ,” he told ASH Clinical News . Instead , he devotes more of his time to treating nonmalignant disorders and estimated that there are about 20 to 25 other practitioners with this focus nationwide within The US Oncology Network .
The terms “ benign hematology ” or “ nonmalignant hematology ” have been widely used as well . Dr . Marshall believes these are the most widely understandable to describe the specialty . However , the field is seeing another recent shift toward referring to the field as “ classical hematology .”
“‘ Benign hematology ’ is the term that we historically used at Yale , but the problem is that these disorders are often not benign for patients , and many can be debilitating or life-threatening ,” Dr . Lee said .
According to Dr . Lee , classical hematologists see patients with a wide variety of disorders such as sickle cell disease , thrombosis , anemias , bleeding disorders , hemoglobin disorders , thalassemia , autoimmune hematologic diseases , and other rare diseases .
“ These terms are all synonyms and none of them are really perfect ,” said Robert A . Brodsky , MD , professor of medicine and the director of the Division of Hematology at Johns Hopkins School of Medicine .
“ Some people would even lump certain malignant hematologic conditions – like leukemia – under the classical hematology umbrella . What they all definitely mean , though , is no solid tumors ,” said Dr . Brodsky , who is also the 2021 ASH Vice President .
There has even been a shift from the mentality of the “ old guard ” of hematologists – about a quarter of whom stated in 2015 that they were considering retiring in the next five years – and the new . 3
In hematology , there is a deep-rooted appreciation of clinical mastery , pathophysiology , and clinical reasoning , Dr . Lee said . “ A lot of the older figures in classical hematology – master clinicians who published great works – focused on the physical exam , blood smears , and diagnostic techniques that formed the basis of the field ,” he said . “ Those aspects should never go away , but just like in the field of oncology , there have been a lot of major molecular advances in classical hematology in recent years .”
This is a huge new element taking the field by storm , Dr . Lee said , and these cutting-edge advances need to be captured when shaping the future of the field and attracting new talent .
Why the Shortage ?
Several years ago , ASH began funding a study to look into the status of the hematology workforce , with the hope of understanding factors that contribute to fellows ’ plans to enter hematology-only careers . In addition to a lack of mentorship , the research identified several other factors influencing these plans , including a lack of exposure to hematology patients in medical school or fellowship and lack of exposure to hematology research experiences . 2
Respondents who were seeing hematology outpatients during their current fellowship year were five times more likely to say they had plans to enter hematology-only careers . Those who reported participating in a hematology research project were almost seven times more likely . 2
However , exposure to a mentor or senior faculty directly influences the likelihood of exposure to hematology patients and research .
“ Without seeing us as role models , it is difficult for trainees to know what life would be like as a classical hematologist ,” Dr . Lee said .
“ Even if a large number of trainees wish to pursue training and research in nonmalignant hematology , there are limited numbers of potential mentors ,” Dr . Marshall said . “ I think that , with the current era of virtual connections , opportunities for mentorship can be expanded so that those with an interest in nonmalignant hematology can seek mentors outside their own institutions .”
Other factors may dissuade trainees from the specialty , such as the prevalence of burnout in the field , lack of research funding , and perceptions about job availability and earning potential .
“ There is definitely a problem with National Institutes of Health [ NIH ] funding as it relates to classical hematology ,” Dr . Brodsky emphasized . Funds for hematology-focused research have been split across three NIH agencies and , across all three , hematology is not always the top priority , he explained .
First , there is a hematology branch of the National Heart , Lung , and Blood Institute , but Dr . Brodsky said the bulk of research funds in this branch go to cardiology and pulmonology . Next , someone studying malignant hematology or associated issues can pursue funding through the National Cancer Institute . Finally , studies related to nonmalignant hematologic topics such as iron physiology can be funded through the National Institute of Diabetes and Digestive and Kidney Diseases .
To address the limited funding for hematologyfocused research out of the NIH , ASH has committed $ 3 million annually to support research in blood diseases .
On top of the limited research funding , hematology training programs are also highly competitive . Every institution has a limited number of slots available to fellows and hematology / oncology slots are among the most competitive . However , hematology-only slots are even tougher , Dr . Brodsky said .
Dr . Brodsky is speaking as head of one of the few freestanding hematology divisions left in the U . S . “ We have two slots a year that train in benign and malignant hematology and we have more than 100 applicants ,” he said . “ If you compare the number of available slots and applicants in hematology to those in solid tumor oncology , the ratio is much more competitive .”
Yale ’ s fellowship program started a hematologyfocused track last year and , already , Dr . Lee said , interest in hematology-focused training has grown .
Finally , with most medical students graduating with more than $ 250,000 in debt , future earning potential could be a major influence on the specialty they choose . 4
“ Thankfully , in most academic settings , salary is generally similar for both benign and malignant hematologists as long as they are within the same division or department ,” Dr . Marshall said . “ In private practice , however , those who specialize in nonmalignant hematology may have a lower salary because the most highly renumerated portions of practice are things like chemotherapy .”
Even within academic settings , though , Dr . Marshall admitted that work relative value units ( RVU ) and bonus structures could still create some salary inequities .
When Dr . Lyons left academia for private practice , he did so because he could not afford to feed his family , he said .
“ I can ’ t speak to the differences in salary now , but it wasn ’ t for me ,” Dr . Lyons said . “ The academic setting may be perfect for people who want to have downtime for research or do not want to be on night calls . It is a different lifestyle that didn ’ t work for me , or for a fair number of my partners .”
Dr . Lyons explained that he wanted to spend his time seeing patients . He has stepped back in recent years , but he previously spent an estimated 4.5 days per week seeing patients and 2.5 days per week doing administrative work and clinical research .
“ I was by the hospital every day on the weekdays and on the weekend call schedules ,” Dr . Lyons said . “ I would have anywhere from five to 15 patients in the hospital and see an average of 20 patients in the clinic . They were very busy days .”
If Not You , Then Who ?
Classical hematologists may specialize in one or a few conditions or see patients with all “ nonmalignant ” disorders but , given the shortage of these specialists , there are only a few practitioners left seeing a disproportionately large number of patients .
“ Our field intersects with every other field of medicine because we operate in the realm of everything that has to do with blood ,” Dr . Lee said .
This can include different conditions or diseases , medications , surgical interventions , and technologies that affect the blood . It can also include patients referred to hematologists for rare or unknown diseases in which the only indication of a problem may be abnormal blood counts .
Dr . Brodsky estimates that more than half of the patients who he sees at his hematology clinic are from outside of the Baltimore area of Maryland , Virginia , Pennsylvania , and Washington , DC . In addition to patients who visit Johns Hopkins , Dr . Brodsky is often called upon to help in the remote management of patients at centers lacking the expertise to treat certain hematologic disorders .
To address the clinical demand , centers that specialize in classical hematology must often decline to see a large number of the patients who are referred to them .
“ Even in a place like Johns Hopkins , we have to send many patients that are referred to us out because we cannot possibly take care of them all ,” Dr . Brodsky said . “ We try to focus on the cases of interest or those that are the most complex , but if someone is referred for something like a deep vein thrombosis or pulmonary embolism , they might get referred back to a general internist or a hematologist / oncologist .”
Dr . Marshall agreed that classical hematologists
20 ASH Clinical News November 2021