Is there a bench at the bedside?

PERSPECTIVE

The good news about hematology and hematology/oncology fellowships is that they're doing well. Applications are steady, and most programs are strong. That doesn't mean that there isn't room for improvement, and, in an article by Todd and colleagues (page 4383), members of the American Society of Hematology (ASH) Committee on Training Programs have suggested some improvements, including more graduation medical education (GME) support, more recruitment of both minority candidates and foreign physicians, and some changes in the processes of training. But underlying their positive outlook are several trends that bode poorly for one of hematology's most enduring characteristics: its long tradition of “bench-to-bedside” medicine.

The newest of these trends is the mismatch between a growing number of oncology patients and an oncology workforce that not only is too small but also includes more older physicians, who tend to practice less, and a cadre of younger physicians who wish to devote more time to family and lifestyle. This problem is not unique to hematology/oncology. With too few students being educated and too few residents being trained, physician shortages are developing throughout medicine,¹  and there's little relief in sight. The misguided planning efforts of the 1990s ensure that this problem will continue for another decade or more. Faced with this reality, physicians will have to devote more of their total effort to the immediate needs of patients. But if they do, how much time will be left for research, and how much of that research will be laboratory based?

This question also emerges from the analysis of hematology fellowship programs. While pediatric programs, which are characteristically based in academic medical centers, have continued to emphasize research, a very different picture exists on the adult side. Only half of the adult programs are based in academic institutions and most are too small for a vibrant research experience. Indeed, fully half of them offer research for 9 months or less, and most of that research is in the arena of clinical trials. Relatively few fellows appear to be committed to laboratory research. The ASH survey indicates that this number may as few as 30 per year.

Hematology has broadened in scope since I entered it 40 years ago. Combination chemotherapy for childhood acute leukemia, which was being tested then, paved the way for the robust clinical trials enterprise that now exists. But along the way, something happened at the bench. With fewer than 25% of faculty now engaged in laboratory research and with fewer than 10% of their trainees expressing such an interest, the multigenerational phenomenon of bench-to-bedside medicine that spawned many of today's leaders in hematology seems to be on the wane. Even when fellows express an interest, grant support is not readily forthcoming, and even when it is, opportunities to conduct laboratory research are detoured by the demands of patient care. Clearly, there are many factors that make hybrid careers in the lab and at the bedside difficult to pursue. Added to these is the new and powerful trend of inadequate physician supply. Creative responses will be needed if hematology's long tradition of bench-to-bedside medicine is to persist.