Ask the Hematologist: Recruiting Residents to Become Hematologists

Shaun is a new intern who was assigned to the hematology consultation service in September. He is interested in general internal medicine and has several years of experience working as a case manager in an outpatient HIV clinic in San Francisco prior to coming to medical school. Shaun found that dealing with complex patients who benefited from his advice and counsel was the most rewarding part of his prior job. He enjoys the gamut of internal medicine and is reluctant to subspecialize, fearing he will lose the generalist perspective. During your month together, you find him to be a curious and thorough physician. As you sit down for your post-rotation evaluation, he asks whether he should consider a fellowship in hematology and/or oncology.

How do you advise Shaun? In other words, how do you recruit residents to become hematologists?

Choosing a career path after an internal medicine residency can be a stressful situation for young physicians. Data suggest that fellowship choice is a complex and heterogeneous process, and individuals typically give weight to factors such as lifestyle, income, practice variability, and availability of mentors.

Hematology remains a “competitive” fellowship. Last year’s fellowship match shows there were 140 combined hematology/medical oncology fellowship programs in addition to four oncology and three hematology stand-alone programs. The fill rate for the combined programs was 99.1 percent (60% filled with U.S. medical school graduates), 100 percent for the oncology stand-alone programs (10% U.S.), and 100 percent for the hematology stand-alone programs (85.7% U.S.). Hematology combined and stand-alone fellowship programs had the second highest number of positions in the match, second only to cardiology. Applicant trends show an increase in hematology/oncology combined fellowship applications within the past five years, with the number of applicants for hematology fellowships holding constant, and the number of applicants for oncology fellowships decreasing as more programs are now combined hematology/medical oncology fellowships.

In advising Shaun, it is necessary to recall why we ourselves chose careers in hematology.

First, to be a good hematologist/medical oncologist you must be a good internist. Hematology does not separate itself from internal medicine, but rather, subspecialty training in hematology augments the knowledge and skills of an internist. Think about the daily practice of a hematologist, who must understand all other medical specialties because patients with malignant disorders have a panoply of symptoms referable to every organ system in the body. This includes prescribing antibiotics for febrile patients, managing renal injury in myeloma patients, performing a careful neurologic examination to detect a cord compression, and even managing a very sick patient with bone marrow failure in the intensive care unit. Hematologists are medical detectives who use the breadth of internal medicine to make diagnoses and solve complex problems. Shaun should spend his month experiencing life as a hematologist — a subspecialist who is also an excellent generalist.

Second, as specialists, hematologists often find themselves in educator roles, especially in academic medicine. Perhaps this is because of the reimbursement model for cognitive specialties, because hematologic diseases are so manifest, or maybe just because of the inherently inquisitive nature of hematologists. ASH recognized the importance of medical education for its membership several years ago in initiating the ASH Medical Educators Institute, to train the next generation of hematology educators and to hopefully expand the hematology workforce by enticing “undifferentiated” medicine residents into a specialty that truly supports and respects educators. Since Shaun has shown a passion for patient education, remind him of this initiative frequently.

Hematology is a visual science. Just as a cardiologist enjoys the pattern recognition inherent in interpreting an EKG, or a dermatologist recognizes the pattern of a rash, hematologists like pattern recognition in interpreting a blood smear or marrow. When we look at art, we use a part of our brain that is tightly connected to pleasure centers and that causes the release of dopamine. Dopamine release can be addictive. When working with Shaun, bring him to the lab often. Show him the beauty of a marrow affected by cobalamin deficiency, explain the elegance of hematopoiesis in a marrow spicule, and remind him of the dire omen of a bone marrow aspirate riddled with blasts.

Finally, to quote Dr. Morie Gertz from the Mayo Clinic, “Go into hematology. Every day is amazing.” When I was finishing my residency, my colleagues and I would ponder the future of medicine. When it came to scientific advances, most of us were convinced that the greatest advances would be in our field. Whether it be the newest treatments for hematologic malignancies, discovery of novel molecular bases for hematologic diseases, targeted drug development for leukemia, or harnessing the immune system to fight malignant diseases through a better understanding of immunology, we were certain that a career in hematology would be “amazing.”

Getting back to Shaun, be a mentor for him: Check in with him even after his month of consults is finished. Show him the passion that we have for our field. Allow him to make a diagnosis after looking under the microscope and allow him to see the spectrum of diseases inherent in our field. Show him that hematologists embrace the breadth of internal medicine. Show him that he can be an educator for his patients and trainees as a hematologist, and that what we do every day is, and will continue to be, truly amazing.