Teaching Hematology to Fellows: A Qualitative Study

BACKGROUND:

The Accreditation Council for Graduate Medical Education (ACGME) specifies that ≥18 months of hematology/oncology fellowship training must be dedicated to clinical work evenly divided between hematology and medical oncology, incorporating inpatient and outpatient care, multidisciplinary case conferences, tumor board discussions, and scholarship. Learning styles among fellows necessarily differ from those of medical students or residents, but few studies have examined the impact of such differences on the content and caliber of fellows' educational experiences during training. We performed a qualitative study of senior fellows in an ACGME-accredited hematology/oncology fellowship program to explore their perception of hematology training and elucidate how fellows might best learn hematology.

METHODS:

Senior fellows in the hematology/oncology fellowship program at Yale School of Medicine were invited to participate in this study. Semi-structured interviews were conducted utilizing a standardized set of questions addressing clinical experiences, educational conferences, hematopathology, changes in adult learning styles from medical school through fellowship training, and design and optimization of an ideal curriculum for teaching and mastering hematology. Interviews were recorded, transcribed, and analyzed using the framework method.

RESULTS:

Eight 3^rd year fellows were enrolled in this study. Four were women; three held dual M.D. and Ph.D. degrees. All were planning on a career in academic medicine; most were doing basic science research with a focus in medical oncology, while one was focused on benign hematology. All fellows completed 6 months of dedicated hematology training that included rotations on inpatient malignant hematology, consultative hematology, laboratory medicine, and hematopathology services. Several common themes emerged from the interviews. Hands-on clinical experience and self-directed learning were identified as central components of effective learning during fellowship. All fellows identified a progression in learning styles from medical school through residency and fellowship. Medical students were viewed as benefiting from didactics and structured educational experiences for foundation-building, while fellows tended to center their learning around patient care experiences and literature reviews and viewed didactics as most effective when occurring after encounters with real cases. Excessive patient volumes and clinical demands were prohibitive to fellows' learning. All fellows viewed mandatory presentations and other fellow-as-teacher opportunities as particularly effective venues for cementing knowledge. Perceptions of weekly tumor board conferences varied according to individual interest and whether fellows had acquired a sufficient knowledge base to follow the conference discussions. A clear distinction was made between benign hematology and all other subsets of the fellowship curriculum, with benign hematology being viewed as more "intellectually difficult," "complicated," and "overwhelming" than malignant hematology or medical oncology. All fellows viewed the hematology consult service as the best setting for learning hematopathology, particularly blood smear interpretation due to its incorporation into the clinical decision-making process.

DISCUSSION:

Hematology/Oncology fellows are cognizant of being adult learners who thrive when their education is context-based. Optimal fellowship learning involves devoting the majority of time to direct patient care and centering didactics, conferences, and hematopathology around such patient care experiences. Mandatory presentations and fellow-as-teacher experiences are particularly effective tools for knowledge mastery. Teaching in benign hematology may require more oversight due to the complexity of the material.