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Pediatric hematologists: a vanishing breed?
On a damp rainy evening in California the two of us — one a “hardcore” oncologist, the other a “passionate” hematologist — were discussing the apparent shortage of true hematology experts, both in the pediatric and the internal medicine worlds.
It seems like there is a lost generation of pediatric hematologists. In recent years it has become obvious to those of us in leadership positions that fewer individuals are entering the field of pediatric hematology.
During the last few decades, pediatric hematologists have provided a paradigm for successful implementation of therapeutic strategies from bench to bedside. Pediatric hematologists were the ones to successfully apply molecular analysis for the prenatal diagnosis of thalassemia, unravel the molecular underpinnings of bone marrow failure syndromes, develop strategies for the treatment of iron overload in the hemoglobinopathies, establish the molecular basis for chronic granulomatous disease in order to target gene therapy and attenuate morbidity by employing gamma interferon. Pediatric hematologists have also played a critical role in developing age-appropriate strategies to treat coagulation disorders in childhood thrombosis.
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These contributions fill the pages of many outstanding journals and have truly impacted the lives of newborns, toddlers, children, teenagers and young adults who experience a hematologic disorder, whether primary or secondary.
Opportunities exist
The need for experts in benign hematology continues. At Children’s National Medical Center, for example, we serve more than 1,200 patients with sickle cell disease who are younger than 18 years old.
In addition to the need for expert clinicians to care for these patients, the area of sickle cell disease provides ample opportunity for creative, ambitious young men and women to unlock certain doors that have served as barriers to truly impact this devastating chronic disorder.
For example, fundamental research into unraveling the basis for fetal hemoglobin switching represents an opportunity to develop techniques to produce more fetal hemoglobin postnatally.
Pediatric hematologists have conducted studies evaluating drugs such as hydroxyurea as a way to increase fetal hemoglobin and ameliorate secondary symptoms in patients with hemoglobinopathies.
Pediatric hematologists are also conducting multicenter trials to compare chronic transfusions with hydroxyurea for children with sickle cell anemia and previous stroke as well as study the utility of periodic phlebotomy as a novel means for managing iron overload.
But more needs to be done in this arena.
For example, pediatric hematologists, if they are not already doing so, should be playing a key role in curing children with sickle cell disease using both traditional and nontraditional stem cell donors, as well as gene therapy approaches.
Finally, until true cures have been found, patients with sickle cell disease need to be transitioned much more effectively to our colleagues in internal medicine. Pediatric hematologists have an important role in improving this transition.
Transfusion medicine
Another important area that has not seen a decrease in demand is transfusion medicine, an area that is often not considered by trainees as an exciting career opportunity and essential to overall patient care.
At a few centers around the country pediatric hematologists are the ones responsible for managing blood banks, and as a consequence they have taken a major leadership role in the field of transfusion medicine by performing important clinical and basic science studies.
A third area of opportunity involves the bone marrow. Boxer recently attended a workshop on bone marrow failure disorders held at the NIH. It was apparent at the workshop how far the field has progressed in recent years in terms of unraveling the molecular underpinnings for a large number of bone marrow failure syndromes.
Opportunities now exist to develop registries for many of these rare disorders that will bring together patients, their families and investigators interested in particular disorders such as Shwachman-Diamond syndrome.
More research is needed to document the natural history of many of these rare disorders as well as unravel basic mechanisms underlying their pathophysiology. In particular, ribosome dysfunction has been identified in Diamond-Blackfan anemia, Shwachman-Diamond syndrome and Dyskeratosis Congenita. Additionally, further studies are needed to understand the mechanistic consequences of ribosomal dysfunction as to how it predisposes some patients to cancer.
A final area of benign hematology looking for new experts is that of bleeding disorders. In 1973 the National Hemophilia Foundation launched a campaign to establish a nationwide network of hemophilia centers. Today there are about 141 federally-funded hemophilia centers devoted to treating patients and supporting their families through continued supervision of all medical and psychosocial aspects of a bleeding disorder.
There is now a need to identify and train tomorrow’s leaders of these centers. Pediatric hematologists are, of course, also involved in the management of patients with thrombophilia, thrombocytopenia, strokes and thrombi.
With so many exiting opportunities why does it seem that the number of pediatric hematologists is drying up even though the number of patients certainly does not seem to have decreased?
What can be done?
We have the strong impression that trainees in the vast majority of pediatric hematology and oncology training programs go on to pursue careers in oncology. Why is this and what is the responsibility of today’s leaders in the field to ensure that we encourage enough trainees to choose hematology, ensuring adequate supply?
Since two-thirds of their training is devoted to research, we wondered whether funding for research endeavors may play a role in how fellows decide their research projects. It is apparent that even in these challenging times for federal funding more opportunities for grant support exist through philanthropy.
Private institutes such as Hope Street Kids, the ACS, the Leukemia and Lymphoma Foundation, the Doris Duke Foundation and the Ludwig Institute for Cancer Research are primarily focused on supporting cancer research. As a consequence, future trainees may indeed be discouraged from considering careers in nonmalignant hematology. Furthermore, it is our impression that there are fewer available faculty members to mentor trainees in hematology than in oncology.
What then can be done to attract more trainees into pediatric hematology?
First, trainees have to become aware of the opportunities. We suggest that training programs with a strong interest in pediatric hematology become more aggressive in educating their own residents, and those attending the National Pediatric Academic Society meeting and the American Society of Pediatric Hematology/Oncology, about the opportunities they provide in pediatric hematology.
Second, the identification of funding sources for careers in pediatric hematology needs to be more widely disseminated.
Third, we would strongly support more foundations or other funding organizations to establish fellowship support specific for those aspiring to a career in pediatric hematology.
Fourth, we need to reward those who devote focused attention to this problem. Pediatric departments that consider mentoring essential should acknowledge and reward faculty who successfully train pediatric hematologists.
Finally, achievements by pediatric hematologists need to be recognized and celebrated at national and international meetings, attended by pediatricians and pediatric residents.
For more information:
- Laurence A. Boxer, MD, is director of pediatric hematology/oncology at the University of Michigan Medical Center. He serves as section editor of Hem/Onc Today’s Pediatric Hematology & Leukocyte Disorders section.
- Max J. Coppes, MD, PhD, is executive director of the Center for Cancer and Blood Disorders at the Children’s National Medical Center in Washington and professor of medicine, oncology and pediatrics at Georgetown University. He serves as section editor of Hem/Onc Today’s Childhood Cancers section.