Perspective
Procedure Skills in Hematology Training: Lost Cause or Worth Fighting For?

At Boston City Hospital nearly 40 years ago, hematology fellows obtained marrow samples and made smears on coverslips from the aspirate squirted on a watch glass balanced on crushed ice in a Styrofoam cup (avoiding anticoagulants for perfect staining). Then, a fresh batch of Wright-Giemsa stained the coverslips, and with atlas open on laps, manual cell counters dinged as purple-stained fingertips hammered out a 200-cell differential. An interpretation note was in the patient’s chart soon after.

A visiting professor recently marveled at our efforts in pushing fellows to acquire morphology skills, bemoaning that it was a lost cause. Our fellows also learn how to take “cellfies” (a snapshot of an oil immersion field on their cellphone camera held carefully at the microscope’s eyepiece) to share instantly with faculty or peers, or to upload into the patient’s chart.¹ 

Is acquiring procedure skills during hematology training a lost cause? Among the 13 procedures listed by the Accreditation Council for Graduate Medical Education (ACGME) as core competencies for hematology-oncology fellows are the assessment and interpretation of a complete blood count, interpretation of peripheral blood smears, and performance of bone marrow biopsies and aspirations.²  Interpretation of marrow aspirate smears does not make that list.

Despite significant efforts, fellows face several barriers: Some incoming fellows have weak procedure skills from their residency training; procedures are no longer performed in clinics and have been relegated to hospital-based procedure rooms, where they are performed by skilled advance practice providers (APP); and many procedures are outsourced to interventional radiology. Furthermore, some faculty sense an attrition in their own skills and do not feel confident in supervising fellows. In practice, outsourcing procedures to interventional radiology suites has also become the norm,³  and data have emerged regarding the quality of marrow samples obtained by radiologists.⁴ 

While confident interpretation of blood smear morphology is an essential skill for hematology trainees,⁵  simulation training exercises and digital formats are insufficient teachers.^6,7  Hematology faculty must maintain skills and teach fellows, both at the bedside and at the microscope. Echoing the sentiment of former ASH President Robert A. Brodsky, MD, “the excitement of making a diagnosis from a peripheral blood smear never fades,”⁸  and so should one made from a glance at an aspirate smear. Marrow-smear morphology skills should be as important as the skills used to obtain the sample. Training hematologists of the future to be fearless morphologists who can provide ideal patient care in environments without instant availability of hematopathologists, APPs, and interventional radiologists is a practical goal.