Is Hematology Having an Identity Crisis?

In the United States, hematology seems to have lost its identity. Ask any medical student or resident if they are interested in specializing in hematology, and instead of an answer, the inevitable first response will be, “Do you mean oncology?” In the era of combined adult hematologyoncology training programs in the United States, the standard term among trainees has become “hem-onc,” or more commonly, just “onc.” This terminology confusion extends well beyond trainees. Funding for academic hematologyoncology centers is often derived from federal or private cancer-directed grants, a reality that has resulted in the gradual disappearance of the term “Blood” from “Blood & Cancer Center.”

While on the surface this shift may seem subtle and inconsequential, it may be having a tremendous impact on the academic hematology workforce. A 2007 study sponsored by the American Society of Clinical Oncology projected a deficit in the U.S. hematology-oncology workforce expected to last at least through the following decade.¹  Data from the American Medical Association’s Physicians Masterfile and the American Board of Internal Medicine (ABIM) indicate that in the past 15 years, the number of U.S. physicians identifying as hematologists or seeking certification in hematology has been far outpaced by those identifying as medical oncologists or seeking oncology certification.²  In the field of hematopoietic stem cell transplantation specifically, a workforce deficit has also been projected.³ 

In nonmalignant hematology, however, the workforce trends are even more dire. In 2003, an ASH-sponsored survey of adult hematology-oncology fellowship program directors revealed that less than 5 percent of graduates maintain a primary clinical focus in nonmalignant hematology — a number that remained markedly low in a 2018 single-institution fellow alumni survey.^4,5  From a research perspective, the number of new R01 grants submitted through the Blood Diseases Division of the National Heart, Lung, and Blood Institute (NHLBI) decreased nearly 60 percent from 2000 to 2013, representing a more drastic drop than that seen in other disciplines.⁶ 

Given the widespread concerns about the future of hematology, ASH established a Recruitment and Retention Working Group in 2017 to assess the current and future state of hematology as a profession in clinical practice, research, and training, to develop strategies for increasing recruitment into the specialty. As part of this initiative, the working group collaborated with the George Washington University Health Workforce Institute to design the ASH Hematology Workforce Study. The goal of this multiyear study of the U.S. hematology workforce is to identify key factors affecting the hematology physician workforce and to assess the job market for new hematologists, with a particular focus on nonmalignant hematology. The first phase of the study, consisting of a survey of nearly 1,900 fellows in adult hematology-oncology programs in the United States, was completed in 2018 and has already revealed some concerning results. Of the 850 respondents (45% response rate), only 4 percent stated that they planned to pursue nonmalignant hematology as a primary career focus — a figure that has not changed at all since the 2003 ASH program director survey.

That this number has remained stagnant throughout the past 15 years is alarming; however, it is more worrisome when taking into account the rapid pace of advances in the classical hematology disciplines of thrombosis, hemostasis, and hemoglobinopathies. In academics, where subspecialization in a specific disease type is the norm, a dwindling workforce in exclusive nonmalignant hematology could have far-reaching implications, ranging from decreased availability of expert care for nonmalignant diseases to diminished exposure to nonmalignant hematology for trainees. Even now, many academic institutions only have a small number of nonmalignant hematologists on faculty, often in predominantly clinical roles.

With the decades-long low accrual in nonmalignant hematology and a projected shortage of hematologists from top to bottom, the recruitment conundrum can seem like an insurmountable challenge. One of the primary findings from the fellow survey is that exposure to hematology patients, research experiences, and mentorship was associated with a decision to pursue a hematology-only career focus. Additionally, the study found that trainees’ decisions to specialize in hematology or oncology were made along the entire spectrum of training, from medical school to residency to fellowship. Given these findings, the ASH Recruitment and Retention Working Group endorsed three primary recommendations to enhance recruitment of trainees into hematology: 1) to foster the development of single-board hematology training tracks in the United States; 2) to convene a national summit on mentorship, sponsored by ASH, to strengthen the impact of hematology mentorship along all levels of training; and 3) to expand the ASH Ambassador Program, a nationwide program consisting of ASH faculty “ambassadors” at different medical schools, to increase student and trainee recruitment into the field.

Of the workforce recommendations, the most drastic and provocative is the endorsement of single-board hematology fellowship tracks. ABIM offers separate board examinations for adult hematology and medical oncology, yet the majority of fellowships (134 participating programs) are structured as combined hematologyoncology training programs.⁷  Certainly, the original intent of combined training was to enhance training in two fields with substantial overlap. However, in the setting of diminished nonmalignant hematology faculty and resources, perceived and actual exposure to nonmalignant hematology is often dwarfed by an overall emphasis on oncology-related curricula.⁸  In this respect, academic single-board hematology programs may increase retention of fellows within the hematology disciplines by validating the field and increasing dedicated exposure to exclusive hematology training. Additionally, single-board hematology programs offer the possibility of a top-down recruitment effect by exposing medical students and resident trainees to hematology fellow role models.⁹ 

As part of ASH’s recruitment and retention efforts, we recently developed and administered a survey to U.S. hematologyoncology fellowship program directors to determine their attitudes and perceptions toward single-board hematology training. Of the 90 program directors who responded (65% response rate), the vast majority believed that single-board hematology training was both necessary and sufficient for fellows specializing in nonmalignant hematology. Furthermore, more than one-third of program directors reported that they would be interested in implementing a single-board hematology track at their own institutions if funding were available.

There are, however, several skeptics to this proposal to re-introduce single-board hematology programs. Since the Accreditation Council for Graduate Medical Education first recognized combined hematology-oncology fellowship programs in 1995, the number of hematology programs has steadily declined. From a peak of approximately 160 hematology programs in the 1980s, there are now just three institutions that offer formalized hematology-only programs/tracks in the Electronic Residency Application Service. On our recent program director survey, the most commonly perceived barrier to implementing single-board hematology tracks was a concern about job availability for single-board hematology trainees. To address this, the ASH Workforce Study is now entering its second phase of surveys of practicing hematologists to determine the demand for exclusive hematologists in various practice settings. Among the planned next steps, ASH also plans to convene a national summit on single-board hematology training, consisting of key stakeholders, including cancer center directors and hematology thought-leaders, to assess the acceptability for expansion of U.S. single-board hematology programs and training tracks.

Hematology as a specialty is more than 125 years old¹⁰ ; yet, despite our wisdom and history, we are training fewer academic hematologists in the United States. At a time when new therapeutics for sickle cell disease, hemophilia, and thrombosis are being developed at lightning speed, it is up to academic training programs to ensure that the U.S. keeps up with innovation in nonmalignant hematology. Perhaps the pendulum has swung too far in combined hem-onc programs. It is time for hematology to get its identity back.