“I need an inpatient classical hematology service, a Johns Hopkins resident on service, and a single-board hematology fellowship program.” This was my answer in 2003, when the Chair of Medicine asked what was needed to revitalize the division of hematology at Johns Hopkins Medicine. Twenty years later, I would not change my answer, but of the three proposed changes, the fellowship program has paid the greatest dividends.
Hematology remains popular among medical students and internal medicine residents. It is intellectually challenging, offers captivating pathophysiology, and is at the vanguard of biomedical science. The excitement of making a diagnosis from a peripheral blood smear never fades. Long-term relationships with hematology patients and families are valuable and rewarding, and research opportunities are boundless for those interested in academics — hematopoiesis, coagulation, immunology, genetics, and tumor biology all reside in hematology. So why is there a critical shortage of hematologists in the United States?
One reason for the shortage is the paucity of single-board hematology fellowship programs. Until recently, there were fewer than three single-board hematology fellowship programs in the United States, and hematology at most training programs is subsumed by oncology. ‘Hem/onc’ trainees spend 70 percent or more of their time caring for and learning about solid tumor oncology. Trainees spend more than 37 percent of their time caring for and learning about hematologic malignancies, and 52 percent on solid tumor oncology. Meanwhile only 10 percent of their time involves classical hematology. Most heme fellowship programs are administered by oncologists and supported by a cancer center whose priority is to treat patients with oncologic diagnoses. Few programs have more than three faculty dedicated to classical hematology, limiting the number of role models, mentors and research opportunities.
My vision was to train fellows in classical and malignant hematology with no solid tumor — basically, the content of the ASH and the hematology boards. It seemed counterintuitive to pursue a career in classical hematology and to spend more than 50 percent of one’s time listening to lectures and managing patients with solid tumors. Likewise, why would someone interested in solid tumor oncology want to spend 20 to 30 percent of their training managing thrombotic microangiopathies, hemoglobinopathies and bleeding disorders?
My initial first-year curriculum included three and a half months of classical hematology, managing six inpatient beds and performing hematology consults for Johns Hopkins Hospital (usually 4-6/day); two months of leukemia; two months of bone marrow transplantation; and one month each of hematopathology, transfusion medicine, and laboratory medicine/coagulation. Outpatient clinic (half-day) took place in my first two years, and the remaining time in my second year and all of my third was research oriented. It was a tough sell at first. Well-meaning but misinformed program directors and faculty told house staff how risky it would be to train in hematology without solid tumor training. “It’s going to be hard to find a job,” was a common remark hematology trainees might hear. We started with one fellow per year, increased to two and in 2023, we will have three first-year slots.
I have learned a lot since we implemented this program in 2005: 1) Demand is high — last year we received more than 100 applications for three single-board hematology slots; 2) more than 90 percent of our graduates continue to practice hematology (60% classical hematology and 40% hematologic malignancies); 3) more than 85 percent remain in academic careers; 4) jobs are plentiful — hematology fellows are in great demand; 5) starting hematology salaries are approaching those of oncology; and 6) a strong hematology program strengthens the oncology fellowship program and vice versa.
Hematology and oncology will always have synergy between them. Certainly, there is an ongoing need for double-board physicians to manage common hem/onc issues in smaller hospital systems. However, advances in both hematology and oncology make it difficult to be proficient in both disciplines. The current model for training academic hematologists and oncologists is inefficient and places those who know they are interested in one field over the other at a disadvantage. Our fellowship program has confirmed that there is a demand for single-board hematology. Recently, ASH has stepped up to address hematology workforce problems by establishing the Hematology-Focused Fellowship Training Program (HFFTP), an initiative investing $19 million to create 10 new hematology-focused fellowship programs in the United States, thus expanding the hematology workforce. Due to the Society’s groundbreaking investment in HFFTP, four institutions were inspired to launch additional hematology-focused fellowship programs. The bottom line is that because of this innovative and bold initiative, institutions are poised to create as many as 105 new hematology-focused fellows by 2030, revealing a bright future for these programs and for our profession as a whole.
