Post-Fellowship Career Decision-Making in a Changing Hematology Practice Landscape

A survey of practice-based hematologists that was recently commissioned by ASH’s Committee on Practice highlighted the changing nature of clinical hematology. Fellows completing their training will inevitably encounter a dynamic landscape as they enter the workforce. With this in mind, it is worth examining the unique opportunities and challenges that hematology fellows face during this transition, and how fellows may be modifying their clinical training in response to these changes.

Workforce Shortage Predictions and Job Opportunities

In ASH’s Committee on Practice survey, one in four respondents (24%) indicated that they were considering retirement in the next five years. Over the next 10 years, the physician retirement rate, combined with changing population demographics and Medicare use patterns are estimated to increase the overall demand for hematology and oncology services by 40 percent, whereas the supply of full-time equivalent hematologist-oncologists may only grow by 25 percent.¹  Additionally, with the implementation of the Affordable Care Act, approximately 25 million Americans will gain insurance coverage by 2017.²  These newly insured individuals are projected to increase demand for hematology-oncology services by 500,000 visits in 2025 alone.¹ 

Though practicing physicians have voiced concern that physician shortages will lead to demands for increased physician productivity, current fellows in training view the open job market as one with increasing employment opportunities and job security. In fact, 42 percent of physicians responding to ASH’s survey indicated they are actively recruiting new hematologists into their group.³  While practices owned by academic medical centers are the most active in recruiting new physicians, 40 percent of fellows training at academic institutions are choosing to pursue diverse opportunities in private practice, industry, and government.⁴ 

Blurred Lines and Practice Changes

Interest in alternative career paths may not only be driven by decreased federal research funding, but also by the fact that the distinction between careers in academic and nonacademic practice careers is becoming less clear. Opportunities for both research and patient care can now be found throughout traditional private practice, industry, and academic settings. In fact, an impressive 95 percent of practice-based hematologists participate in clinical research.³  Fellows considering careers in practice-based hematology are more likely take note of declining reimbursements for medical services, increasing costs related to running private practices, and the trend toward practice affiliation with large institutions when contemplating practice-based careers. In response to these changes, fellows are not only adapting their career decisions, but also choosing to modify their training environment.

Who is the Hematology Fellow?

The average hematology fellowship graduate enters the workforce having spent a minimum of 10 years in graduate training (four years of medical school, three years of internal medicine or pediatric residency, and three years of fellowship training). A small subset will have advanced degrees, including PhDs, and will enter training much older than their counterparts. Most fellows commencing training are in their mid-30s, and many have young families. The degree of educational debt varies, but one nationwide study found that 37 percent of hematology-oncology fellows have more than $100,000 of debt.⁴  Women make up 48 percent of fellows in hematology-oncology training programs, and international medical graduates comprise 43 percent.⁵ 

Factors influencing career paths are a function of individual fellows’ professional goals, expectations of personal time, financial obligations, and mentorship. Some fellows prioritize financial compensation, restricted call duties, predictable work hours, and time for leisure activities, while others may choose job opportunities based on their desire to teach, interest in research, or perception of academic prestige.^6,8,9 

Emerging Trends in Post-Fellowship Career Choices

Despite the diversity of factors that influence fellows’ career paths, there appear to be several emerging trends. Most fellows (69%) report that geographical location is one of the most important factors informing subsequent career choices.⁸  While job openings are available throughout the United States, desirability and compensation vary considerably. At present, there is a greater demand for jobs within large metropolitan hubs where the job market is relatively saturated. As a result, fellows are often seeking jobs in higher-cost-of-living environments with a paucity of opportunities, rather than less-densely populated areas where compensation and demand may be higher.

Interestingly, the factors of relative compensation and/or loan burden may not be as strong in influencing post-fellowship career choices as previously thought. One study conducted by Dr. Leora Horn and colleagues demonstrated that a higher percentage of fellows with an interest in academic careers had cumulative debt loads of greater than $100,000 when compared to their counterparts pursuing nonacademic careers.⁴ 

Beyond compensation, it appears that many new job seekers are increasingly conscious of controllable lifestyle factors. In fact, when the American Society of Blood and Marrow Transplantation polled fellows asking whether increased compensation or improved work-life balance (WLB) would motivate their entry into the field, it was apparent that WLB was a more potent factor in driving career decisions.⁹  The priority that fellows place on WLB should come as no surprise since many have spent the preceding five years of training working 60 to 80 hours a week while concurrently raising children, caring for aging parents, and investing time in personally meaningful activities. Various studies have shown that fellows suffer higher rates of burnout and emotional exhaustion when compared with population control samples, so it is natural for these factors to influence post-fellowship career plans.

Fellows are Changing Their Training in Response to This Changing Landscape

Given these changes in the hematology workforce, fellows are modifying their training agendas. With the knowledge that mentorship is critical to optimizing future career fit, fellows are seeking mentors with whom they not only share professional interests, but who are also able to model balance in their personal lives. Engaging in “team-based” science is one method to increase efficiency and productivity while still protecting personal time. To achieve this, fellows may align themselves with mentors who are able to provide connections with productive collaborative groups. Similarly, on the clinical side, fellows are recognizing the need to balance organizational pressure for increased productivity with the maintenance of WLB. To that end, in programs throughout the United States, fellows are learning how to work collaboratively with advanced practice providers to deliver team-based care.

Fellowship is a privileged time during which trainees have the flexibility to augment and diversify their marketable skill set. In this regard, fellows’ pursuit of advanced degrees or classes in education, epidemiology, pharmacology, and clinical research is now commonplace. For example, the University of Washington created a Clinical Biostatistics class that incorporates expert teaching from both academic and industry settings. Industry has likewise created training opportunities; for example, Genentech’s Clinical Fellows Program provides a one-year training grant that allows fellows to complete their own clinical research project, while obtaining training in decision-making about novel therapeutics.¹⁰ 

Persistent Challenges

The current training experience offered by most hematology programs provides minimal exposure to less traditional career choices. Additionally, fellows often complete their training without sufficient knowledge of the administrative and business demands of practice, promotion requirements for distinct career paths, and funding requirements. Without this exposure, fellows may underestimate the demands of their chosen careers and subsequently experience significant career dissatisfaction.^6,7 

To address these shortcomings, the ASH Trainee Council, working with the Committee on Training, has developed a number of tools and programs to help fellows during this period of transition. During the ASH annual meeting, both early and later-career speakers from academia, industry, government, and community-based practice provide didactics and break-out sessions that focus on mentoring, the diversity of career tracks, early career development, and job-seeking strategies. The Council has also created Career Development Timelines (www.hematology.org/Career/Timelines) tailored to the unique needs of MDs and MD-PhDs to help them transition from training to their first job. Additionally, the Council maintains a Grants Clearinghouse list on the ASH website (www.hematology.org/Fellows/Grants2015) to highlight funding opportunities during and after the fellowship period.

The role of social media and networking could be further developed to help fellows find their ideal work niche. Online professional networking hubs such as Doximity and LinkedIn could be used to connect fellows not only to jobs, but to more formal mentoring as well. Online social networks and media have the advantage of overcoming geographical barriers to showcase the diversity of career opportunities in hematology—from newly minted hematologists to medical students contemplating future careers.

Epilogue

Fellows are entering the workforce during a time when the demand for physician productivity will sharply rise due to major shifts in population demographics and insurance coverage. How fellows choose to practice hematology will ultimately be a function of their ability to understand the changing landscape. It is therefore imperative that fellows are provided with, and actively seek, opportunities to decipher the social, economic, and political forces currently affecting practice. With such insight, fellows, working together with their local training programs and ASH, will be able to better shape their own destinies.