We read with interest the op-ed from Anand B. Karnad, MD, “Procedure Skills in Hematology Training: Lost Cause or Worth Fighting For?” published in The Hematologist on April 15, 2024.
Reminiscing about his time at Boston City Hospital in the 1980s, Dr. Karnad recounts nearly word for word a current day in the life of a hematology registrar in Melbourne, Australia.
While bone marrow aspiration and interpretation may be a “lost art” in the United States, relegated to radiologists and advance practice providers, for more than 40 years in Australia, the vast majority of hematologists are jointly trained in physician and pathology disciplines, spending two years of training patient-facing and two years in the lab. During pathology training, bone marrow examination is a core competency, with trainees expected to perform and interpret upwards of 500 bone marrow biopsies.
As a hematopathology registrar, working full time in the lab improves understanding of both clinical and pathological components of hematology — two sides of the same coin. Insulated from the at-times-tumultuous clinical role affords trainees the time to reflect on disease biology. Disruption of normal hematopoiesis at each stage and its consequences are explored. The bone marrow is appreciated to no longer be just a factory but rather a complex milieu with interplay from seed, soil, and climate.
Additionally, actively participating in the translation from venesection through to diagnosis and management fosters a different mindset. Trainees develop a deep understanding of diagnostic hematology: Which samples require cytogenetic, flow cytometry, and molecular analyses? What length of trephine ensures accurate histology? How are diagnostic criteria formulated and why does it matter? They are also encouraged to question the integrity of sample collection, asking what pre-analytical, analytical, and post-analytical errors could be at play.
In our experience, appreciating the nuances of bone marrow examination and the limitations of the tests requested also provides a basis for rigorous debate between clinical hematologists and hematopathologists. Diagnoses have been revised following interrogation of findings at weekly morphology meetings.
We, two generations of hematologists, champion continuing integrated hematology training. As renowned morphologist and Imperial College Faculty of Medicine Professor Barbara Bain, MBBS, says: “Don’t forget that laboratory hematology is the basis of what we do — don’t leave it to pathologists.”1
