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Are malignant hematology specialists adequately prepared to care for patients with benign blood disorders?
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Yes.
We clearly have a shortage of benign hematologists. However, systems-based hematology is the wave of the future.
As a program director, our trainees need to understand the hematology behind the guidelines. That is, we want the trainee not just to work within a systems-based hematology practice, but to actually learn the field in a classic manner and be able to apply the knowledge to develop and maintain meaningful guidelines in a systems-based approach. This is truly about mastering the craft. If someone is board certifying in only medical oncology — which includes malignant hematology — they will, in general, not know enough benign hematology to truly be the expert in a practice or institution.
As a program director, I recognize the critical need to expose fellows to benign hematology early in training to potentially spark their interest in this important clinical and research arena. Unless a fellow is absolutely set on a career in academic malignant discovery, my philosophy is to have the trainee try on the benign hematology hat to see if it fits.
Nationally, stand-alone benign hematology programs are becoming less common. Thus, program directors can support the development of future benign hematologists through robust exposure to benign hematology in fellowship, including research opportunities. However, we need a cadre of benign hematologists to train this next generation, and they are harder to find.
How do we combat this threat? We need to be creative. Can we develop loan payback programs for fellows who go into benign hematology practice? Can we develop faculty retention programs and incentives for our benign hematology experts? Do all benign hematologists need a background in hematology/oncology? As stand-alone hematology programs become less common, can we develop a short-track program for internists or other physicians who want to practice hematology?
Jill Gilbert, MD, is professor of medicine and director of the hematology/oncology fellowship program at Vanderbilt-Ingram Cancer Center. She can be reached at jill.gilbert@vanderbilt.edu. Disclosure: Gilbert reports no relevant financial disclosures.
No.
When there is a sustained inequality between supply and demand in any workforce, sooner or later, there is a problem. We have such a problem in the ever-shrinking number of adequately trained hematologists entering practice who can replace the steady attrition of older benign hematologists.
The growth of malignant hematology — as well as solid tumor oncology — has continued unabated, consuming Pac-Man-like most available time in fellowship training programs. Consequently, there is a paucity of opportunity to do justice to both the old and new aspects of benign hematology.
As with all shrinking skills — be they part of a profession or a trade — as the supply of trained individuals declines, so, too, does the number of individuals with the expertise to teach or instruct. We are witnessing an era in which the numbers of craftsmen belonging to the guild of benign hematology is in decline.
The scope of benign hematology broadly covers management of blood disorders characterized by nonmalignant causes of either too few or too many blood cells of various types and of perturbations of the blood coagulation system — bleeders and clotters. There is much within the ambit of benign hematology that requires a high level of expertise and that involves the interpretation of complex laboratory tests and the judicious application of an ever-increasing menu of therapeutic agents.
In the past decade, more than 30 new drugs for the treatment of benign hematologic conditions have been approved for use by the FDA. Who will be adequately qualified to deal with this nexus of blood disorders? Financial considerations provide a disincentive for physicians in training to enter straight hematology fellowship training programs. Despite several stalwart and well-intentioned efforts by ASH and other professional organizations aimed at preserving a robust component of benign hematology in combined hematology/oncology fellowship programs, it may be a case of “too little, too late.”
What are the default options if the wave of systems-based hematology crashes on the shore? General internists are already dealing with more of what lies in the domain of benign hematology. Vast numbers of generalists are eager to acquire new skills and to absorb areas that are being neglected by systems-based specialists. Alternatively, clinical pathologists with special interests or expertise in hematology are well positioned to diagnose and even manage patients with cytopenias and clotting or bleeding problems. This model has existed and been successful in Britain, Canada and Australia. Why not in the United States?
Unless the clinical hematology community takes on the increased responsibility of training younger members in their ranks to take care of patients with benign blood disorders, a traditional element of their specialty will dissipate, the pieces of which will be picked up by others.
Ralph Green, MD, PhD, FRCPath, is distinguished professor and chair emeritus in the department of medical pathology at UC Davis Comprehensive Cancer Center. He also is a HemOnc Today Editorial Board Member. He can be reached at rgreen@ucdavis.edu. Disclosure: Green reports no relevant financial disclosures.