SPOTLIGHT cannot possibly care for all the patients with hematologic disorders .
“ Patients with specific conditions like sickle cell disease and thalassemias are often cared for only by nonmalignant hematologists , but patients with conditions such as thrombosis are often cared for by general hematologists , cardiologists specializing in vascular medicine , or general internists ,” Dr . Marshall explained . “ Patients with bleeding disorders manifesting as menorrhagia may be cared for primarily by OB-GYN providers who have experience in such conditions .”
Advanced practice providers ( APPs ), such as nurse practitioners and physician assistants , are also helping to address demand . Earlier this year , Dr . Marshall discussed the role of APPs at a meeting of ASH ’ s recruitment and retention working group . In her presentation , she discussed results from a workforce study published by ASH in 2019 , in which 675 practicing hematologists and oncologists reported that APPs were assisting with managing palliative care , conducting hospital rounds , managing patients with low complexity benign hematologic disorders , and performing invasive procedures such as lumbar punctures . Notably , in this study , community physicians who worked with APPs reported fewer burnout symptoms .
Finally , incorporation of a systems-based hematologist may also help ease the burden on hematology-only specialists . A systems-based hematologist is employed by a hospital or health system to try to optimize individual patient care and the overall system of health care delivery as it relates to hematologic disorders . Early research shows that the new subspecialty can be successful , but it cannot be the sole solution to the shortage . 5
“ In some settings , having a systems-based hematologist may be the best a system is able to do , especially in places with a small hematology / oncology division ,” Dr . Brodsky said . “ It is not the best longterm solution for the field , though .”
Righting the Ship
Dr . Brodsky believes one of the easiest ways to start addressing the workforce shortage is with training programs .
“ Many people want to focus on hematology rather than solid tumor , but that option is just not available at most academic programs in the country ,” Dr . Brodsky said .
Instead , most fellowship programs are combined hematology / oncology programs run by cancer centers . These centers have a huge volume of patients with cancer , and fellows are often naturally steered toward the care of patients with solid tumors rather than those with hematologic diseases .
“ A lot of reimbursement to these centers relates to administering chemotherapy ,” Dr . Brodsky added . “ It is much more lucrative for hospitals and hospital systems to see large volumes of solid tumor patients than it is to treat members of the sickle cell population or the hemophilia population .”
The hematology / oncology fellowship program at Johns Hopkins introduced a single-board hematology track in 2005 . At 10 years , the program demonstrated “ high retention in academic benign and malignant hematology , both in terms of clinical and research focus ,” according to a review of its progress . 6 Initially , candidates for the program were selected based on their expressed interest during the interview . Later , an option was added to the Electronic Residency Application Service allowing candidates to independently apply to the hematology track . In 2018 , of 414 applicants to the hematology / oncology fellowship program , 51 applied to hematology-only track and 26 candidates expressed an interest in benign hematology , contradicting “ the perceived lack of enthusiasm for hematology .”
To help increase the number of hematology / oncology fellowship programs that prioritize training and careers in hematology , ASH committed $ 19 million to create its Hematology-Focused Fellowship Training Program . This program will fund the creation of 10 new innovative hematology-focused fellowship tracks within existing hematology / oncology training programs and will fund one or two new fellows in each program for five years . The ASH program is expected to produce 50 new academic hematologists by 2030 . 7 The deadline for program proposals is November 15 , 2021 , and the institutions selected for the program will be announced in March 2022 .
Some specialists are also pushing for a separation of hematology and oncology fellowship training because of the complexities of both fields .
“ Without seeing us as role models , it is difficult for trainees to know what life would be like as a classical hematologist .”
— Alfred Ian Lee , MD , PhD
“ We are in a historical moment ,” Dr . Brodsky said . “ When I was in training , there were eight to 10 chemotherapy drugs . For anticoagulation , there was aspirin , heparin , and warfarin .” Now , there are more than 15 anticoagulants , and numerous antiplatelet agents , with more coming . And , “ as far as cancer therapeutics go , forget it !” Dr . Brodsky said .
“ It is very hard to stay current in both fields ,” he acknowledged . “ With hematology and oncology , you can ’ t be good at both .”
Dr . Lyons believes that refocusing efforts on growing the number of hematology-specific training programs could benefit the field , but he was hesitant to endorse the idea of eliminating combined fellowship programs .
“ Eliminating the combined programs might remove hematology training from the hematology / oncology fellowships ,” Dr . Lyons said , “ but I worry that these trainees would think they know a lot more than they really do when they end up with a patient with an unusual coagulation issue or autoimmune disorder .”
ASH ’ s hematology-focused training program is a good start , but it is unrealistic for every hematology / oncology program to have single-track hematology training , he added .
In fact , Dr . Marshall thinks keeping the training combined may help expose others – as it did her – to a field they might not otherwise consider .
“ As long as we have a shortage of benign hematologists , it is good for hematology / oncology fellowship programs to ensure that they have appropriate education ,” Dr . Marshall said . In that way , they can “ ensure that their fellows are able to manage these conditions if they choose to enter a practice where they are responsible for both benign and malignant hematology conditions .”
However , she noted , a hematology-focused fellowship training program could offer those who already know they wish to pursue a career in benign hematology the chance to focus their clinical training and research only in their specific field of interest . “ This would allow for the development of close relationships with mentors in the field ,” she said .
Staying Focused
Increased attention and focus on the pending classical hematologist workforce shortage should be a priority for the field .
“ We have a shortage of hematologists who are comfortable treating the more complex benign hematologic diseases and it is a problem across the country ,” Dr . Brodsky said .
Hematology is a big field . For a quantitative demonstration of exactly how big , Dr . Lee estimated that 30 to 60 % of patients seen at many cancer centers have benign hematologic disorders .
“ This leaves us in a really interesting state , in which the existing supply of hematologists and oncologists in the United States cannot meet the growing clinical demand for specialty care of patients with benign hematologic diseases ,” Dr . Lee said .
“ We need more people trained in this specialty and we need more training programs to do that ,” Dr . Brodsky added . “ These diseases can be very acute and these patients need to be seen quickly . We have seen amazing advances in these diseases . It is incredible how treatable many of them are if they are diagnosed and managed appropriately .”— By Leah Lawrence
References 1 . Sharma D , Wallace N , Levinsohn EA , et al . Trends and factors affecting the US adult hematology workforce : a mixed methods study . Blood Adv . 2019 ; 3 ( 22 ): 3550-3561 .
2 . Masselink LE , Erikson CE , Connell , et al . Associations between hematology / oncology fellows ’ training and mentorship experiences and hematology-only career plans . Blood Adv . 2019 ; 3 ( 21 ): 3278-3286 .
3 . ASH Clinical News . Adapting to Changes in Practice-Based Hematology . May 15 , 2015 . Accessed October 4 , 2021 . https :// www . ashclinicalnews . org / spotlight / adapting-tochanges-in-practice-based-hematology /.
4 . Association of American Medical Colleges . Physician Education Debt and the Cost to Attend Medical School : 2020 Update . Accessed October 4 , 2021 . https :// store . aamc . org / physician-education-debt-and-the-cost-to-attend-medical-school-2020- update . html .
5 . May JE , Irelan PC , Boedeker K , et al . Systems-based hematology : highlighting successes and next steps . Blood Adv . 2020 ; 4 ( 18 ): 4574-4583 .
6 . Naik RP , Marrone K , Merrill S , et al . Single-board hematology fellowship track : a 10- year institutional experience . Blood . 2018 ; 131 ( 4 ): 462-464 .
7 . American Society of Hematology . Hematology-Focused Fellowship Training Program . Accessed October 5 , 2021 . https :// www . hematology . org / education / educators / resources-for-training-program-directors / hematology-focused-fellowshiptraining-program .
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