If your hospital or practice is like mine, it has one or more open positions for a hematologist with expertise in “non-malignant” or “benign” hematology that remains unfilled year after year. In a 2019 survey of 2,500 practicing hematologists, 46 percent of respondents reported a shortage of hematologists practicing classical hematology, which is generally defined as the care of non-neoplastic blood conditions. The demand only seems to grow, and yet the number of trainees choosing this career path is pitifully small. Why is it that our trainees, seemingly “undifferentiated” at the beginning of their hematology/oncology fellowships, decide to focus on solid tumor oncology or the hematologic malignancies and not “non-malignant” hematology? The pandemic, with its high rate of COVID-19–related hematologic complications, has focused the spotlight on many of medicine's weak links, among them the shortage of well-trained hematology consultants. Too often, those who spend the lion's share of their time taking care of malignant disorders often fill the schedule of hematologists on-call praying that their often remote training and UpToDate will suffice.
The dwindling hematology workforce did not appear overnight. I remember participating in the ASH Working Group on Recruitment and Retention in 2011 when the late Dr. Evan Sadler was ASH president. How did this shortage of hematologists come to be? In 1995, when combined hematology/oncology fellowships were first accredited by the Accreditation Council for Graduate Medical Education, programs were evenly distributed among hematology (n=74), medical oncology (n=83), and hematology/oncology (n=83). Nearly 25 years later, in 2018, only two stand-alone single-specialty adult hematology fellowship programs remained. To better understand the underlying forces that led to this situation and to provide the basis for an intervention likely to be successful in controlling the hemorrhage, ASH developed a survey sent to all hematology/oncology fellows in 2018 (Masselink LE et al. Blood Adv. 2019;3:3278-3286). Shockingly, less than 5 percent of trainees planned on a career in “benign” hematology. Rather than lifestyle or compensation, exposure to hematology during medical school and subsequent training, research experiences, and mentorship were the primary determinants of career path. To grow and strengthen the workforce pipeline, ASH recently committed $19 million to fund 10 new hematology-focused fellowship tracks with the goal of producing 50 new academic hematologists by 2030. A rigorous process to evaluate 23 very competitive applications resulted in funding of nine academic medical centers. Three additional centers that were not funded have indicated that they will use institutional funds to follow the blueprint proposed in their applications. Hopefully, these new fellowships will make a difference, but will they be enough?
Although not addressed in the 2018 fellowship survey, the terminology used to identify hematology that deals with non-malignant disease may not be helping our cause. We all tend to toggle back and forth between “benign” and “non-malignant,” and sometimes “classical” hematology. Are we doing ourselves and the field of hematology a huge disservice? A very provocative recently published editorial (Al-Samkary H et al. Lancet Haematol. 2022;9:E455-E459) suggests that a “rebranding” of “benign” or “non-malignant” hematology as “classical hematology” may be in our and our patients' best interests. Better to define the field by what it is rather than what it is not. What kind of message do we send to our patients when we call their life-threatening diseases “benign?” To this end, the ASH Executive Committee recently voted to adopt “classical” hematology as the preferred term over “benign” or “non-malignant.”
What else can be done to fill the pipeline? Each and every one of us can commit to mentoring the next generation. The message about mentorship in the 2018 survey rang loud and clear. Those who find mentors are more likely to become hematologists. Given the workforce shortage, classical hematologists are very busy people. If you're like me though, doing anything with a fellow or trainee is so much more fun than doing it on my own (not to mention their superior IT skills and facility with EndNote).
