Innovative education, training strategies needed to address shortage of benign hematologists

Nearly a quarter of the nation’s practice-based hematologists are expected to retire within the next 5 years, creating a void that could dramatically alter the way patients with blood disorders are treated.

“Many of the physicians who specialize in benign hematology, coagulation and hemoglobinopathy are in their 70s and 80s and about to retire, and we don’t have a pool to replenish them,” Rakhi P. Naik, MD, MHS, associate director of the hematology/oncology fellowship program and assistant professor of medicine at Johns Hopkins School of Medicine, told HemOnc Today.

“In fact, we’ve been trying for about 3 years to find a faculty member who exclusively practices benign hematology and we’ve had a tremendous amount of trouble,” Naik added. “It’s even difficult to find someone who has been trained adequately in benign hematology.”

The looming shortage — revealed in a 2013 ASH survey of more than 5,000 hematologists — prompted the society to partner with George Washington University Health Workforce Institute to conduct a national 3-year longitudinal workforce study of hematologists.

The study is designed to identify trends affecting the hematology physician workforce, as well as key factors likely to affect the supply of and demand for hematologists. Researchers also hope to determine whether job availability, mentor influence or other factors have dissuaded fellows from choosing careers in hematology, and to propose solutions to preserve and further hematology as a profession.

HemOnc Today spoke with hematologic educators and fellows about the factors that led to the shortage; misconceptions about job availability; alternative practice models designed to offset the lack of onsite hematologists; whether hem/oncs are prepared to treat patients with rare or serious benign hematology disorders; and strategies to recruit, integrate and retain fellows interested in pursuing the field of hematology.

‘Dramatically understaffed’

Alfred Ian Lee, MD, PhD, associate professor of hematologic medicine at Yale School of Medicine and associate program director of Yale’s internal medicine traditional residency program, is chair of ASH’s Recruitment and Retention Working Group, which is overseeing the ASH/George Washington University workforce study.

Lee said he noticed several fellows entered Yale’s hematology/oncology program interested in pursuing hematology, but many gravitated toward medical oncology during their 3-year training program.

“We thought maybe there was something we were doing wrong to make them less interested,” Lee told HemOnc Today.

Results of ASH’s 2013 survey showed 24% of respondents planned to retire within the next 5 years. In addition, 42% of practices surveyed were actively recruiting new physicians.

“It’s a profession that is dramatically understaffed nationwide,” Gerald A. Soff, MD, chief of benign hematology service at Memorial Sloan Kettering Cancer Center, told HemOnc Today. “There is a tremendous need and a tremendous shortage.”

To identify reasons for the decline, Lee directed a qualitative survey of fellows enrolled at Yale presented, in part, at the 2016 ASH Annual Meeting and Exposition. He also led a series of focus groups during the meeting, where he met with hematology fellows, fellowship program directors and practicing hematologists across the United States.

Results of these efforts revealed five recurring factors have led to the shortage of fellows pursuing hematology: lack of mentorship, intellectual difficulty, inadequate fellowship training, lifestyle and finances, and a perceived shortage of job opportunities.

Lack of mentorship

Many hematology fellows who participated in Yale’s qualitative study reported that performing research under mentors helped direct them toward the field.

“One thing that was kind of distressing to all of us were the stories that highlighted serendipity in the mentorship program,” Lee said. “People just sort of happened upon mentors and projects and ended up in hematology careers without really putting a lot of thought into it.”

Deva Sharma, MD, a third-year fellow at Vanderbilt University Medical Center, received her undergraduate degree at University of Pennsylvania and her Master of Science in biotechnology at Johns Hopkins School of Medicine before attending 4 years of medical school at University of Maryland. She completed her residency training at University of Vermont and her postdoctoral fellowship at University of Pittsburgh before being accepted into Vanderbilt’s fellowship program.

Receiving mentorship early in her educational journey proved instrumental in Sharma’s decision to pursue a career in hematology.

“By the time people enter fellowship, a lot of them have decided what they want to do,” Sharma, who serves as a fellow representative on ASH’s Recruitment and Retention Working Group, told HemOnc Today. “In terms of generating excitement in hematology, particularly nonmalignant hematology, earlier is better. For me, the prime time was medical school, when I was very strongly encouraged and supported to pursue this path. Since then, I’ve been unwavering in my desire to do hematology.”

At Memorial Sloan Kettering, Soff said many of his colleagues have actively discouraged fellows from training in hematology because they feel it takes them away from their research responsibilities.

“I don’t think that’s good advice,” Soff said, “but I am only one voice and there are a lot of other voices.”

Fellows must understand how to treat the adverse side effects and comorbidities associated with therapies, Soff said. Complications from cancer therapy may include thrombosis; bleeding; suppression of white cells, red cells and platelets; and coagulopathies.

“I try to make the fellows understand that, to be a good oncologist, you need benign hematology,” he said.

Intellectual difficulty

A study published in 1960 in TheLancet showed that heparin with a vitamin K antagonist, such as warfarin, effectively treated patients with thrombosis, but few research breakthroughs in hematology occurred over the next 50 years.

According to educators, interest in the field waned because of that inactivity, swaying medical students away from what then was considered a stagnant field.

“Nobody was going into the field to manage those patients because it wasn’t academically interesting and there was the perception you couldn’t make a living at it,” Soff said.

That inactivity no longer defines the field.

Since 2010, the FDA has approved four new oral anticoagulant drugs — dabigatran (Pradaxa, Boehringer Ingelheim), rivaroxaban (Xarelto, Janssen), apixaban (Eliquis; Bristol-Myers Squibb, Pfizer), and edoxaban (Savaysa, Daiichi Sankyo) — each with its own properties, indications and dosing schedules. Further, between 2011 and 2014, at least a dozen drugs received marketing approvals for nonmalignant hematology indications.

“All of a sudden it requires a high level of expertise to know how and when to use [these agents], and we don’t have people trained to do that,” Soff said. “That just makes the problem worse. Rather than everyone just getting warfarin, we need people who know when to use these different anticoagulants. We haven’t trained doctors to do that.”

Although the introduction of new anticoagulants created a renewed interest in hematology, fellows still showed an aversion to it. When Lee reviewed survey responses and took part in round table discussions on recruitment and retention, two findings surprised him.

“We didn’t expect fellows to think hematology was more interesting than oncology, and we certainly didn’t expect them to think it was more intellectually difficult than oncology,” he said. “What’s emerging from our research is that people think hematology is very fascinating, but a very different type of field than oncology, mainly because — in real-world medicine — the hematologist is often called in to solve a problem when the diagnosis is unknown.”

Sharma said she enjoys the “Sherlock Holmes-type investigation” associated with hematology, but many of her colleagues have told her the science behind hematology is too challenging.

“I’ve had so many people tell me hematology is too cerebral, and when they try to think through a coagulation problem they just develop a roadblock in their mind,” Sharma said. “Not to berate medical oncology — there are great opportunities for patient care and it’s a very exciting translational field — but there is no algorithm in hematology.

“If I come to the bedside of a patient who has massive bleeding on day 2 after her delivery, there’s no cookbook to tell me how I am going to work up and treat this patient,” Sharma added. “It’s really up to me to synthesize and integrate the history, the physical exam and the lab results to come up with a diagnosis for the patient. I like that cerebral aspect.”

Inadequate training

In candid conversations with fellows, Lee discovered hematology/oncology curriculums are heavily geared toward solid tumor indications.

As a result, fellows are not adequately trained in hematology and are less comfortable with their ability to make informed diagnoses.

Johns Hopkins School of Medicine employs 10 clinical faculty members in its nonmalignant hematology division and is one of the few medical schools in the country with a hematology-only fellowship track, accepting one to two single-board hematology fellows a year since 2005. However, Naik said there is a significant shortage of applicants interested in benign hematology compared with malignant hematology.

“Oncology is a giant in terms of research funding and faculty,” Naik said. “If somebody goes into a combined [hematology/oncology] fellowship — and most do — they end up wanting to do oncology because oncology is dwarfing hematology.”

A trend away from hematology in the classroom is complicating matters.

The Accreditation Council for Graduate Medical Education no longer mandates the number of months nonmalignant hematology training is required for a hematology/oncology fellowship program to be certified, according to a report by Wallace and colleagues published in 2015 in Blood. Consequently, many programs no longer conform to the traditional model comprised of one-third nonmalignant hematology, one-third malignant hematology and one-third solid tumor oncology. Robby Reynolds, MPA, director of training at ASH and staff lead for the ASH/George Washington University workforce study, noted that ASH plans to use the findings of the workforce study to identify opportunities to reverse this trend.

Additionally, the number of investigators submitting and receiving NIH grants in the field of hematology has declined by about 70% over the past 15 years. The lack of research funding has had a trickle-down effect at academic institutions, where many programs employ only one or two faculty members specifically trained in hematology.

Soff likened the shortage of hematologists to farmers who eat seed corn during a famine.

“In a short-term crisis, you basically lose the ability to grow the next year’s crop and that, in essence, is what we’ve done,” Soff said. “We’ve lost the ability to train the next generation of hematologists. You can imagine if a fellow says, ‘I like clotting. I read the articles and they’re interesting.’ But they look around and they don’t even have a faculty member who can teach benign hematology. That’s the most critical thing we’re facing right now.

“There’s tremendous pressure during fellowship to go away from benign hematology,” Soff added. “The overwhelming number of faculty members are cancer-treating doctors. An entire major medical center can have nobody, or maybe one person, who does benign hematology. Unless that doctor is a superstar, they’re not going to get any fellows looking to do research with them.”

Lower salaries, fewer opportunities

A perceived lack of job opportunities — compounded by a lower salary — may sway debt-saddled fellows away from hematology.

The average hematology fellowship graduate enters the workforce having spent a minimum of 10 years in graduate training. Further — according to a 2015 report in The Hematologist, ASH’s member newsletter — 37% of hematology/oncology fellows graduate with more than $100,000 in debt.

Women account for 48% of fellows in hematology/oncology training and many, like Sharma, are beginning their families.

“People perceive that if you pursue hematology, particularly classical or nonmalignant hematology, there won’t be diverse or interesting job opportunities,” said Sharma, who recently had her first child. “There is also a feeling the pay scale is a lot lower than medical oncology, which can be a limiting factor for people looking at $150,000 to $200,000 in student loans. They may also have multiple children and are the bread winners for three or four people in their household.”

A 2016 American Medical Group Association report showed the median income for a hematologist/oncologist was $416,738 in 2015, compared with $435,000 for a medical oncologist. Starting salaries for hematologists can be less than $300,000, and pay scales vary considerably by region.

Hematologists earn less than medical oncologists, in part, because they administer less chemotherapy and, therefore, are not reimbursed for it, Naik said.

“Our salaries are much more like a department of medicine division than a department of oncology division,” Naik said.

In his research, Lee found that many fellows shied away from hematology because they believed hematologists had poorer work-life balance than medical oncologists, working longer hours and often being called into hospitals for acute blood emergencies.

There also is a widespread misconception that there are fewer jobs available in hematology than oncology, Lee said.

“Several cancer centers are actually looking for hematologists to join their faculty, mainly because their patient loads are so high, and yet for some reason fellows going through training programs are being misinformed that there aren’t enough job opportunities,” he said. “We need to address this idea head-on because, in talking with other cancer center directors, it is absolutely not true that there is a dearth of hematology job openings, certainly not in academia. We need to disseminate that information.”

Sharma, who plans to remain at Vanderbilt and specialize in the care of women with sickle cell disease, said some of her colleagues have found work with industry, private practice and the FDA, whereas others have entered private practice in adult or pediatric hematology.

Systems-based hematology

Outside of the academic setting, many patients with benign blood disorders are treated by dually trained, board-certified oncologists, some of whom have not been exposed to the latest research and treatment of hematologic disorders.

“As the practice of medical oncology has become more complicated, complex cases in benign hematology have become increasingly burdensome,” Edward S. Kim, MD, FACP, chair of solid tumor oncology and investigational therapeutics at Levine Cancer Institute at Carolinas HealthCare System and a HemOnc Today Editorial Board Member, told HemOnc Today. “Providers don’t feel confident making recommendations as medical oncology increasingly becomes more disease specialized. Training that overburdens medical oncologists on the nuances of benign hematology may not be the answer, as our medical systems move more toward subspecialization.”

Oncologists often are left to treat hematologic complications with which they are not familiar, Naik said.

“The result is that, when there are very complicated cases — of which there are many — doctors are left not knowing what to do,” she said. “Or, they never diagnose it to begin with, because they don’t have the resources to be able to figure it out.”

In response, ASH helped develop a novel and sustainable model for practices called systems-based hematology, in which a specialty-trained physician is employed by a hospital, medical center or health system. That physician is charged with optimizing individual patient care and the overall health care delivery for patients with blood disorders by creating guidelines for other physicians within the practice to follow.

In a report published in 2015 in Blood, Wallace and colleagues described a systems-based hematologist as a physician who, in addition to patient consultations, might be responsible for establishing and promoting policies and education programs that identify hematologic issues accurately and early, thereby avoiding complications, additional hospital visits and unnecessary costs.

“Essentially, it’s working through our health care system to better manage hematologic problems,” Colleen Morton, MBBCh, associate professor of medicine and chief of classical hematology at Vanderbilt University Medical Center, told HemOnc Today.

Morton considers herself a systems-based hematologist and expects the field to grow in the coming years.

“Nearly every specialty has patients on anticoagulation and there are guidelines for managing them,” she said. “I have a responsibility to help everyone follow the guidelines to make it as safe as possible for patients to have a procedure, come off an anticoagulant and go back on. By following guidelines and having everybody doing the same thing, you ensure you’re doing it the safest way possible.”

Morton arrived at Vanderbilt earlier this year, after spending 13 years at HealthPartners in St. Paul, Minnesota, where she developed care pathways for hematologic issues throughout a health care system that included six hospitals and more than 50 outpatient clinics.

In her role as a systems-based hematologist, Morton collaborates with Vanderbilt’s ED, blood bank, labs, cardiology, neurosurgery and ICU and places condensed versions of ASH’s treatment guidelines into easy-to-follow instructions in each department’s electronic health records.

“It helps physicians understand the intricacies of how to manage patients without needing to consult the hematologist,” Morton said. “You still need a hematologist to set this up and, of course, not every case will be simple and easy enough to just follow the guidelines. There will be more complicated cases that require the hematologist. It’s a very intricate dance but, in this system, you don’t need to consult a hematologist every time somebody needs to stop an anticoagulant.”

The need for a systems-based clinical hematologist also is driven by shifting payment incentives.

“In this era of affordable health care, we need to make sure that, if we’re using a very expensive drug for a hematological issue, it’s appropriate,” Morton said. “We do see unnecessary lab testing and treatments. By doing this type of work, you may not generate money by seeing patients, but you can certainly save money in terms of stewardship of expensive therapies.”

Although some see systems-based hematology as the future in the treatment of blood disorders, others see it as a stopgap while waiting for the next crop of hematologists, a cultivating process that could take several years.

“Do I think systems-based hematology is a good resource? Sure,” Naik said. “We’re not going to increase the number of benign hematologists overnight so, to a degree, an algorithm is probably useful. But I think there’s always going to be a point at which you really do need a specialist to figure the rest of it out.”

At Johns Hopkins, individual specialists in coagulation, hemoglobinopathies and thrombotic microangiopathies can confer with each other to accurately diagnose and determine treatment plans for rare blood disorders. However, very few institutions employ more than one hematologist, leaving many complications undiagnosed or inadequately treated.

“A single hematologist at an institution can easily become a silo, where there isn’t active learning about new therapies in multiple disorders,” Naik said. “Bouncing ideas off colleagues is extremely useful and allows us to adopt new therapies very quickly. I’ve talked to people in private practice settings who don’t even know about half of the therapies out there for benign hematology.”

Shaping the future

Strategies of the ASH/George Washington University workforce study — also led by Clese Erikson, MPAff, and Edward Salsberg, MPA, of George Washington University — to increase the number of hematologists include:

• expanding funding opportunities for students and trainees;
• targeting educational opportunities for students from diverse backgrounds who have demonstrated an interest and aptitude for science or medicine;
• upgrading the introduction to hematology course at medical schools around the country;
• creating innovative models for hematology care; and
• introducing predoctoral students to physician scientists through mentored laboratory experiences.

Traditionally, medical schools in the United States offer formal courses in hematology during the second year of instruction. In recent years, a number of institutions have begun teaching blood-related science earlier in the curriculum to allow quicker entry by students into clinical rotations.

To help address the shortage of faculty specializing in hematology, Soff is working with Reynolds and his team at ASH to develop a web-based curriculum that covers the full scope of benign hematology directed to fellows who receive limited training in benign hematology. The curriculum will be comprised of a series of 2- to 3-minute interactive learning modules designed to be quick and easy for busy fellows to consume.

“I wish every medical center had two or three experts onsite, but the reality is they don’t,” Soff said. “We could make this 1-year course available to fellows everywhere in the world, so someone at a smaller or medium-sized university hospital can learn the material while taking away the burden of having one or no faculty members onsite. This would go a long way toward finding a solution.”

Soff also created an advanced fellowship position at Memorial Sloan Kettering that provides 1 additional year of benign hematology training to an individual who has completed a 3-year hematology/oncology fellowship. He intends to send emails to cancer center directors across the country asking them to provide one worthy fellow to take part in next year’s program.

“It’s like the Statue of Liberty,” Soff said. “Give me your third-year fellows yearning to be clotters and I’ll train them for a year and promise not to poach you. I’ll send them back and we can start reseeding our faculty positions around the country and regenerate that core curriculum.”

Soff estimated the basic cost of developing a fourth-year fellow at approximately $150,000. It would be a worthy investment for pharmaceutical companies that make anticoagulants and hemophilia drugs, he said.

“If you’re a big pharmaceutical company, it doesn’t do you much good to have a multibillion-dollar anticoagulant if you don’t have the doctors out there who know how to use it and teach others how to administer it correctly,” Soff said.

“The bottom line is that, over the last several generations, the number of people going into classical benign hematology has been shrinking and we need to come up with innovative ways to address the problem,” he added. “It’s just one step to get these pharmaceutical companies to kick in a few bucks to fund these positions, but that’s my dream.” – by Chuck Gormley

Click here to read the , “Are malignant hematology specialists adequately prepared to care for patients with benign blood disorders?”

References:

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For more information:

Edward S. Kim, MD, FACP, can be reached at edward.kim@carolinashealthcare.org.

Alfred Ian Lee, MD, PhD, can be reached at alfred.lee@yale.edu.

Colleen Morton, MBBCh, can be reached at colleen.morton@vanderbilt.edu.

Rakhi P. Naik, MD, MHS, can be reached at rakhi@jhmi.edu.

Robby Reynolds, MPA, can be reached at rreynolds@hematology.org.

Deva Sharma, MD, can be reached at deva.sharma@vanderbilt.edu.

Gerald A. Soff, MD, can be reached at soffg@mskcc.org.

Disclosures: Kim, Lee, Morton, Naik, Sharma and Soff report no relevant financial disclosures.