A Guide to Planning Careers in Hematology and Oncology

It is no exaggeration to say that never before in the history of medical science have the opportunities for advancement in the fields of hematology and oncology been greater. The sequencing of the human genome and the genomes of relevant animal models (including C. elegans, Drosophila, and mouse) has facilitated the identification and subsequent characterization of disease-specific and disease-related genes. These advances will lead to an improved understanding of the genetic basis of cancer predisposition and molecular pathogenesis. NIH funding for investigator-initiated biomedical research has grown by 86% since 1983 (from $4.2 billion to $7.8 billion),¹ and further increases have strong bipartisan congressional support. New federal support for clinical and translational research (e.g., K23 and K24 grants) complements existing sources of support for basic cancer research. Medicare and some insurance vendors now pay for certain cancer clinical trials. Discoveries in biomedical research have led to the emergence of a robust biotechnology industry and the investment by the pharmaceutical industry in cancer and hematologic drug development. The growth and prosperity of the biomedical private sector have led to new opportunities for collaboration with academia and for the employment of physician scientists in the biotechnology and pharmaceutical industries. Finally, the market for both private practice and academic jobs in hematology and oncology is excellent. A recent manpower survey in medical oncology² demonstrates that the field is not oversaturated.

Whereas the majority of training in the disciplines of hematology and oncology takes place within the context of combined training programs, trainees must decide whether to seek American Board of Internal Medicine eligibility in medical oncology, hematology, or both. The minimum duration of training required for Board eligibility is two years for each discipline separately or three years for education in both subspecialties. For trainees who anticipate a career in private practice, dual Board certification offers the greatest flexibility for employment opportunities. Since the practice of hematology as a single discipline is largely restricted to major referral hospitals and academic medical centers, fewer private practice opportunities are available for hematologists without medical oncology training and Board certification. On the other hand, most private practitioners will be expected to be knowledgeable about non-malignant hematologic conditions despite a predominance of patients with solid tumors or malignant hematopoietic diseases. For careers in academic medicine, the choice of clinical training and Board certification matters less, although hematology training alone may reduce employment flexibility.

Within the disciplines of hematology and oncology, emerging areas of subspecialty emphasis offer new opportunities. For example, the field of bone marrow stem cell transplantation is emerging as a separate subspecialty due, in part, to the acuity of care provided. Although allogeneic transplantation programs generally exist in academic centers, newer “non-myeloablative preparative regimens” (“mini-transplants”), if widely accepted, may be transferrable to the community setting. A shortage of hematologists with expertise in coagulation disorders³ has created opportunities for hematologists to serve as directors and participants in hemophilia treatment centers or multidisciplinary thrombosis/hemostasis centers.

Trainees must decide between pursuing careers in private practice and academic medicine. The factors that influence this decision include a preference for a patient care focus, interest in conducting research and/or medical education, control and flexibility over work schedule, and compensation. Although some opportunities for medical teaching and clinical research exist in private practice, they are generally the purview of academicians. For trainees interested in basic or translational laboratory investigation, “hot” areas of emphasis include the regulation of hematopoiesis and stem cell biology, the molecular pathophysiology of coagulation disorders, cancer genetics (e.g., oncogenes, tumor suppressor genes), cancer cell biology (e.g., cell cycle regulation, signal transduction, regulation of cell death/apoptosis), tumor cell invasion and metastasis (e.g., angiogenesis, adhesion, proteases), tumor immunology (cellular and humoral immunity to cancer, vaccines, etc.), cancer etiology (virology; chemical, physical and hormonal factors), and cancer pharmacology. There is a shortage of (and therefore an opportunity for) individuals interested in clinical research, which combines clinical care with clinical investigation. This career pathway focuses on experimental therapeutics of cancer and nonmalignant hematopoietic conditions using pharmacologic and biologic forms of therapy. Clinical investigators take the lead in the design and execution of phase I, II, and III clinical trials, which generally involve collaboration with translational scientists in academic centers and/or in industry. Health services/outcomes research is another new and increasingly popular focus of clinical investigators. Some academic physicians are active participants in both basic/translational research and clinical investigation. Although it is professionally gratifying to translate progress made in the laboratory to the clinic (bench-to-bedside), it is challenging for any single individual to achieve sustained progress in both the laboratory and the clinic. The more common alternative is for laboratory and clinical scientists to collaborate.

Private practice careers generally offer higher levels of compensation than academic careers (Tables 1  and 2 ).^4,5 For basic or laboratory investigators, industry may provide greater compensation than academia. Within academic health centers, market forces influence compensation: clinical investigators generally have higher salaries than laboratory scientists; among clinical investigators, stem cell transplanters generally command the highest salaries.

A recent time and activity analysis conducted by the American Society of Clinical Oncology (ASCO) provided a comparison of the work activities (as a percentage of total professional effort) by individuals pursuing careers in private practice as compared to those individuals emphasizing either laboratory research or clinical research in academic settings.² As shown in Table 3 , the amount of time spent in patient care activities as compared to research was generally consistent with the expected responsibilities associated with these distinct career paths.

For trainees who wish to pursue a career in academic medicine with an emphasis in laboratory or clinical investigation, the following elements contribute to the success of the training curriculum.

In academic hematology and oncology, there has been a general trend over the last decade toward subspecialization in which the clinical investigator develops expertise in a major type of cancer or hematologic disorder. Accordingly, trainees interested in careers as clinical investigators should identify a single area of emphasis (or a limited number of emphasis areas) with the goal of becoming an expert in the natural history, diagnosis, and management of a specific disease entity. For those who choose to focus their research efforts in the laboratory, a specialized clinical emphasis is not a requirement. However, if a clinical subdiscipline is chosen, ideally it should complement the area of laboratory research.

A successful fellowship research experience depends upon the availability of a committed faculty mentor. The choice of a mentor will often influence the specific area of research interest. Therefore, mentor selection is often the most crucial decision a trainee will make. Mid-career faculty are often ideal mentors because they have established reputations in their fields yet have time to mentor. Young faculty who are attempting to launch their own careers often lack the time and experience to mentor others. Similarly, it may be prudent to avoid the “international superstar” whose professional commitments leave little time for personal contact. The prospective mentor's experience and interest in mentorship can be assessed by the level of satisfaction and academic success of former students. A good mentor serves as a professional role model who should engender excitement and enthusiasm about the research arena. The mentor will not only facilitate the trainee's success during fellowship but will also influence post-fellowship employment opportunities.

With the help of the mentor, the trainee should identify a research project that has the following characteristics: (a) it is hypothesis driven as opposed to a data-gathering, “fishing expedition”; (b) it addresses an important, unanswered or underdeveloped question in the field, which should yield novel, publishable information; (c) it has some clinical relevance to the field (e.g., a basic science project whose results may serve as a foundation for subsequent clinical research or a clinical research study whose conclusions will directly influence patient care or serve as a foundation for subsequent clinical studies); (d) it provides a good foundation for an independent research career (e.g., the project should not be too narrow or highly controversial, but should be broad enough in scope to interest others in the field and to serve as a “springboard” for continued research); and (e) it has goals that are achievable given the level of mentorship, resources, and time available: choose a project that will yield useful (publishable) results whether the hypothesis is proved or disproved; avoid projects that are beyond the expertise of the mentor or relevant on-site collaborators.

Training for a career in clinical investigation should include an experience in the design and writing of a clinical trial. Since statistical consultation is generally required to determine the appropriate sample size and other design factors necessary to achieve experimental aims, formal training in statistical analysis is advantageous. Moreover, trainees should gain experience in the protocol review process including applications to the institutional review board (IRB), other institutional committees (e.g., Cancer Center Peer Review Committee), and relevant federal agencies (e.g., Food and Drug Administration, Recombinant DNA Advisory Committee). Finally, clinical investigator trainees need to be knowledgeable about federal policies governing the protection of human volunteers in clinical research. Trainees must be aware of compliance and reporting responsibilities, including the reporting of “adverse events.” Evidence of serious non-compliance may lead to personal financial liability!

Trainees should explore educational opportunities that supplement or enhance the education provided by the mentor. Career development in clinical investigation may be enhanced by formal course work with a focus on biostatistics, protocol design, etc. The ASCO/AACR (American Association for Cancer Research) Summer Clinical Research Course provides an excellent opportunity for senior fellows and junior faculty to design a clinical research project with the help of leaders in the field who serve as faculty. Laboratory scientists in training can audit courses in specialized areas to enhance the scope or depth of training in a chosen scientific discipline. Whereas some individuals may seek comprehensive scientific training leading to a Ph.D. degree, such a degree is not essential for a successful career in basic biomedical research. What is essential is extensive self-education in the discipline relevant to the research project. Trainees must gain knowledge of a scientific area that is broad enough to serve as a foundation for a lifetime of scientific productivity. Conversely, students should avoid narrow areas of expertise that are restricted to single technology or a specific research project.

Trainees should acquire expertise in scientific writing, including the authorship of abstracts and full-length manuscripts. To become skilled scientific writers, trainees must be dedicated scientific readers. Extensive reading in the chosen discipline not only provides essential context for the project to be pursued but also exposes students to the unique style of scientific writing. Learning and applying the principles of good scientific writing can be a painfully slow process, but with the help of a dedicated mentor, most students demonstrate rapid improvement.

Abstract writing provides an opportunity to enter the field of interest. An abstract helps to crystalize and focus the results of a research project as a prelude to a full-length publication. That is, do the results recorded provide a convincing rationale for the conclusions made? Do the results and conclusions tell a complete story?

A fellowship research project should yield a minimum of one publication in an established, peer-reviewed journal. Two or three peer-reviewed manuscripts provide a more convincing foundation for an independent scientific career. Experience in writing review articles, book chapters, editorials, etc., helps to develop useful scientific writing skills and “name recognition,” but peer-reviewed journals carry more weight than other publications with respect to career advancement. “First author” publications rank higher in professional recognition and advancement since “first authorship” reflects a primary role in the design, execution, and writing of the project. The last or “senior authorship” is generally ascribed special recognition since it usually reflects the significant contribution of the mentor to the design and execution of the study and assistance in writing the manuscript.

Trainees should gain experience in the critical review of manuscripts through the supervised critique of published articles in the setting of a journal club or participation in the mentor's editorial review responsibilities. Recognizing the strengths and weaknesses of the written contributions of other investigators will assist trainees in developing good writing skills for their own work.

Next to manuscript writing, there is no skill more important than the writing of grant applications (“grantsmanship”). With the help of the research mentor, trainees should learn the key principles of grant writing. Trainees may also attend grant workshops at professional meetings or take advantage of numerous educational materials found in the medical literature.

It may be advantageous for the trainee to apply for independent fellowship support at the outset of research training: (a) independent research support is considered to be a mark of professional recognition and advancement, (b) an independent grant may provide the financial opportunity to extend the fellowship training experience, and (c) independent fellowship support will help to offset institutional training support, which can be used for other trainees. Trainee/fellowship grants are available from federal agencies and numerous foundations. Examples of federal support include the NIH F32 Postdoctoral Individual National Research Service Award (NRSA), which supports postdoctoral research training in specified health-related areas. The Department of Defense (US Army) also provides funds to support fellowships in clinical translational research, postdoctoral traineeships, and research targeted to prostate cancer. Table 4  is a brief listing of foundations that provide postdoctoral fellowship support.⁶ 

Trainees need to become proficient in the preparation and delivery of short presentations as well as full-length research seminars. Such speaking opportunities provide the main venue for communicating the results of scientific work at scientific fora; therefore, effective public speaking is an essential skill for a successful scientific investigator. To enhance the quality of communication, trainees should acquire expertise in the preparation of effective visual aids such as slide and PowerPoint presentations.

Attendance at the meetings of professional societies and scientific conferences provides an opportunity to present the results of research through oral presentations and poster sessions. This experience also allows trainees to become known by senior colleagues in the field, including prospective manuscript reviewers, grant reviewers, and employers. Attendance at meetings also provides an important opportunity for self-education since these fora are the venue for the presentation of the newest information in the scientific disciplines (often in advance of publication). In addition to large professional society meetings (such as the American Association for Cancer Research [AACR] and the American Society of Hematology [ASH], which feature a mixture of basic and clinical research, and the American Society of Clinical Oncology [ASCO], which emphasizes the results of translational and clinical research), trainees should also consider attending small, focused research meetings or conferences (e.g., Cold Spring Harbor Symposia, Gordon Research Conferences, Keystone Conferences), which foster direct communication between trainees and senior scientists in the field.

Benefits of membership in relevant professional societies such as ASCO, ASH, and AACR include: (a) subscriptions to the society's journal at a nominal cost; (b) opportunities for career development and networking; (c) web-based reading lists of classic/key articles of interest to trainees; (d) web-based listings of employment opportunities; (e) educational programs targeted to subspecialty trainees at national meetings; (f) special grant programs for trainee members; and finally (g) effective lobbying organizations that represent the interests of the subspecialties at the federal and state government level.

As part of the fellowship experience, trainees should receive formal training in the ethical conduct of investigation with a curriculum that includes the following core areas of instruction: data acquisition, management, sharing, and ownership; mentorship/trainee relationship; publication practices; peer review; collaborative science; human subjects; research involving animals; research misconduct; conflict of interest and commitment; and compliance with existing PHS and institutional policies.

One or two additional years may be necessary to complete the aims of a research project with the publication of research findings in peer-reviewed journals. A history of publication is necessary to be competitive for academic positions. An extension of the fellowship training period may require independent salary support from an individual training or career development grant (see above). If this supports career development, fellows should explore opportunities to stay at the home training institution as senior fellows, lecturers, or instructors, which may or may not involve clinical responsibilities. Moreover, an extension of the fellowship may provide an opportunity to pursue supplemental clinical training (e.g., in stem cell transplantation).

The process of finding an academic position involves identifying suitable employment opportunities, completing an academic employment interview, and carefully reviewing the offered positions, including the careful assessment of the responsibilities and benefits of the position as articulated in an offer letter.

Trainees can identify employment opportunities from several sources: advertisements placed in national journals (e.g., Blood, Journal of Clinical Oncology); the websites and national meetings of professional organizations such as ASH and ASCO; personal contacts resulting from scientific and clinical interactions; and, perhaps most importantly, contacts facilitated by research or clinical mentors. Employment opportunities in hematology and oncology are widely available both in academic and practice settings.

Commonly, the top candidates from an applicant pool (who have generally submitted letters of inquiry along with curriculum vitae) are selected to interview for academic positions. Such interviews provide an opportunity for both applicants and prospective employers to meet, seek relevant information, and assess the level of mutual interest and compatibility. In preparation for the interview, applicants should request advance information such as the roster of interviewers and the unit's annual report or other summary information describing the professional/clinical activities of the unit. This background information allows applicants to direct the interview to seek information most relevant to a decision about the suitability of the job. Applicants should be prepared to present a polished 50-minute seminar as a means of reviewing their progress in the field and vision for future directions. The presentation should be targeted to an audience with a general knowledge of the topic but sufficient background information should be provided to clarify the rationale for the experiments or clinical studies performed and results presented. Applicants should pay special attention to the quality of the presentation and the visual aids. Applicants should also be prepared to succinctly describe their research interests and results to interviewers unable to attend the seminar presentation. In advance of the interview, applicants should try to learn about the career interests and background of the interviewers. This information will serve to highlight areas of mutual interest and could form the basis of future interactions and collaborations. It is important for applicants to determine if there are opportunities for collaborations that will enhance career development. Most importantly, the interview makes it possible for applicants to determine whether the position is a good fit. Accordingly, it is useful to prepare a list of relevant questions in advance of the interview. Overall, it is important for the applicant to project a positive, confident, professional image while, at the same time, avoiding the appearance of arrogance!

Successful candidates who emerge from a competitive national search for academic positions share several qualities: (a) evidence of broad clinical training in the desired discipline with, if necessary, focused expertise in a targeted clinical area (particularly important for a clinical research position); (b) a strong foundation for an independent scientific career as evidenced by authorship of peer-reviewed publications, design and execution of clinical trials, presentations at national meetings, and letters of reference; (c) success in competing for initial grant support, preferably support that is transferable to the new institution; and (d) a positive professional image at the interview, demonstrating excellent interpersonal skills.

Academic positions generally involve university or institutional appointments in one of several tracks: the major categories are “tenure” and “non-tenure.” The concept of tenure may have different definitions at different institutions particularly as this relates to job security and level of institutional support. At most medical schools, tenure does not mean lifetime job security at full salary. At some institutions, tenure is restricted to laboratory-oriented faculty, while clinical investigator faculty may be candidates for tenure at others. Many medical schools also have “clinical” or “clinical/educator” tracks. At some schools these tracks are targeted to the appointment of faculty whose major responsibilities are clinical care and medical education. There may or may not be an expectation to pursue clinical investigation. Generally, clinical track faculty have renewable academic appointments without long-term (tenure) employment contracts. At some institutions, clinical track faculty may be full-time employees of the academic health system or affiliated hospitals who serve as volunteer teaching faculty. Because of the variability in types of appointment from one institution to the next, applicants must fully understand the scope of the appointment for which they are applying.

The content and scope of information provided in offer letters may vary considerably from one institution to the next, so it is important that the candidate and the employer reach an understanding of the benefits and responsibilities associated with the position. The best way to ensure that this information is mutually understood is to put it in writing. Since the resources and responsibilities necessary for the success of the laboratory-oriented physician scientist differ somewhat from those required by the clinical investigator, these will be considered separately.

For a laboratory-oriented physician scientist at the assistant professor level, the major responsibility is to conduct independent scientific research with a lesser effort expended in clinical care and teaching. The resources that are necessary to support a laboratory-oriented career include: independent laboratory space, generally 500-1,000 square feet; office space; and laboratory start-up funding (generally in the $200-500,000 range). Laboratory start-up funding is used to purchase equipment and supplies, pay recharge rates for shared core facilities, hire technical support, etc., sufficient to run a small laboratory operation for 2-3 years, pending successful receipt of extramural support. Other requirements for the physician scientist include the availability of ancillary support (e.g., secretarial and grant management assistance), access to critical core facilities (use of shared sophisticated instrumention and technology whose costs would exceed the budget of any single investigator), and availability of relevant collaborators (since success in academic medicine often requires the collaborative efforts of other faculty with shared scientific interests). Critical to the success of the physician scientist is the availability of a senior faculty mentor who functions in much the same way that the mentor serves the interests of the fellowship trainee.

For the patient-oriented clinical investigator at the assistant professor level, the majority of professional effort is split between clinical research and clinical care with a small proportion of time devoted to teaching. Since professional advancement in this position depends upon the availability of protected time (usually 20-30%) to pursue academic efforts (e.g., the writing of clinical protocols, manuscripts, and grants), the offer letter should ideally delineate the extent of protected time and the criteria for maintaining it (e.g., expectations for extramural support). Patient-oriented clinical investigators must have access to sufficient numbers of potential volunteers for clinical research studies. Ideally, expectations for clinical service should complement the clinical research focus. That is, the major clinical effort should be targeted to the area of research emphasis such that the majority of patients seen have diseases within the investigator's scope of research interest. Other needs include availability of relevant laboratory and clinical collaborators; access to ancillary services critical to clinical research (e.g., radiology, nuclear medicine, clinical laboratory); availability of key support personnel, including secretarial/administrative support, physician extender support, and data management personnel; and access to core facilities such as availability of assay laboratories, biostatistical support, etc. The counsel of a senior faculty mentor is just as critical for the career development of a clinical researcher as it is for a basic laboratory investigator.

For both laboratory- and patient-oriented investigators, the offer letter should clearly define the academic appointment (tenure or non-tenure track) with the criteria for achieving tenure or reappointment. The letter should also delineate the expected professional responsibilities including the extent of “protected time” devoted to laboratory or clinical research (generally 70-90% for the laboratory investigator; 50% or less for the clinical investigator) as well as the expectations for clinical service and teaching. The laboratory investigator is generally guaranteed substantial protected time for 2-3 years pending the acquisition of independent extramural support for salary and laboratory operation. The clinical investigator may have varying proportions of salary guaranteed in a decremental fashion to allow time to build a practice. Finally, the letter should indicate the first year salary and benefits and include productivity criteria for merit raises, bonuses, and other factors that may influence the salary in subsequent years.

Fellowship trainees anticipating careers in hematology and oncology private practice should know the training requirements for a successful practice career as well as the different types of private practice opportunities. Finally, they should be prepared to critically evaluate a private practice offer letter to ensure that the position best meets their career goals.

Trainees anticipating careers in private practice should strive for a broad, comprehensive experience in the disciplines of medical oncology and hematology. Unlike the academician who can succeed as an expert in a narrow, disease-specific area, the private practitioner needs to be a skilled generalist. For most private practice opportunities, training in medical oncology is essential given the volume of patients with malignant disease relative to those with non-malignant hematopoietic disorders. On the other hand, training in benign hematology (e.g., thrombosis and hemostasis) provides the greatest flexibility for employment opportunities.

A clinical research experience during the fellowship is valuable training for a career in private practice. Since the difference between established and “cutting edge” therapy is often blurred in the disciplines of hematology and oncology, private practitioners must be able to critically evaluate the experimental basis for new and emerging therapies. Personal experience with the principles of clinical investigation during the fellowship provides this perspective. Moreover, opportunities to conduct clinical research may exist in certain private practice settings including involvement in community clinical oncology programs (CCOPs) and contract research organizations (CROs). Effective participation in these research efforts depends upon prior knowledge of the fundamental principles of clinical investigation.

The private practice of hematology and oncology generally occurs in one of three practice settings: solo practice; the subspecialty group; and the multispecialty group in which one or more hematology/oncology practitioners participates in a group practice with other subspecialists (e.g., an HMO model).

Each of these private practice categories may be independent, hospital-based, or university-affiliated. Independent practitioners are groups of practitioners who develop self-sufficient business units that are responsible for both the revenues and expenses of the practice. Hospital-based or university-affiliated practitioners or groups generally receive a salary from the hospital or academic health center that provides practice space and ancillary support (practice overhead). University-affiliated groups may offer an opportunity to teach or conduct clinical research. Group members may be offered non-tenured academic appointments in return for voluntary teaching efforts.

Practitioners recruited to private practice groups are generally offered positions as probationary employees of the group. Accordingly, the letter should indicate the terms and duration of the probationary period including the expected compensation and benefits, criteria for raises and bonuses, and other opportunities for profit sharing. New recruits should be aware of the anticipated practice workload including the ambulatory clinic hours, hospital rounding responsibilities, and on-call time. The offer letter should indicate the level of ancillary support available to the practitioner, including nursing personnel to deliver chemotherapy and the availability of physician extender support where applicable. The extent of time for professional development (e.g., attendance at professional meetings) should be indicated. The requirements for hospital appointment and privileges should be described. The terms for achieving partnership in the practice including the duration of the probationary period (generally 1-3 years), the funds required to buy a percentage of the practice (i.e., repaying the practice for its up-front investment in salary, benefits, and overhead), and the terms of payment (e.g., pre-tax salary differential, loan) should be spelled out.

A convergence of propitious events makes this an excellent time to pursue a career in the fields of hematology and oncology. Opportunities for progress in these disciplines have never been greater. However, career development should not be a passive process. Trainees need to formulate specific career goals and take action to ensure that the content of the training curriculum is best suited to meet the chosen career pathway.