The Future of Hematology in the Private-Practice Setting

Ann ArborHematology Oncology Associates, P.C., Section Head, Division of Hematology/Oncology at Saint Joseph Mercy Hospital in Ann Arbor, MI.

Over the past decade, ASH has increasingly focused on the shortage of hematologists in the United States. While this has been readily apparent in academic institutions, the effect has been much more insidious in the private-practice setting where many of the areas of expertise traditionally attributed to the hematologist have gradually been taken over by other disciplines—pathology, cardiology, and pulmonary and general internal medicine, among others. At the same time, some fellows elect medical oncology training alone, and fewer fellows who have completed training requirements for dual-Board certification ultimately choose to certify in hematology over medical oncology.

We may now have come to the crossroads. In Michigan, we are seeing lawsuits involving benign hematologic disorders in which the defendants include not only the treating physicians but also the groups and hospitals that allowed members without hematology Board certification to practice hematology. In addition, the Joint Commission has decided to focus upon delineation of privileges. Our Chief of Medicine recently informed me that I must separate the privileges for hematology and oncology within our division. Our group has been fortunate in that all of us have had dual training and certification or were "grandfathered" in. However, the newest member will not be Board eligible in hematology, and this requirement would mean an inconvenient back-up system for handling patients in the hospital and complex hematology consultations. As I opened my mouth to protest, I realized that I couldn’t. Not only is it the right thing to do, but it validates the role of the hematologist in a tertiary-care teaching hospital such as ours.

Hematology has long been considered to be primarily an academic discipline devoted to complex clinical problems and research. Until the last few years, ASH has been, for the most part, an academic organization with a strong commitment to educate community hematologists, but has had limited involvement in the realities of private practice. The role of the private-practice hematologist has never been well defined, and there is no role model within academic training programs. As a consequence, it is very difficult to encourage medical students and house officers interested in private practice to consider hematology fellowships. Those who are interested in hematology but not oncology have been indoctrinated to believe that there are no opportunities to practice "pure" hematology in the community setting, and those who are interested in oncology don’t perceive a need to fulfill the requirements for dual certification, particularly in view of the requirements for ongoing recertification.

Hematology/oncology practices have also been at fault. In an era when there is a growing shortage of oncologists in the United States, it has become difficult to recruit qualified physicians. All aspects of the practice of oncology—clinical, financial, administrative, and regulatory—have grown increasingly complex. Reimbursement for chemotherapy services far exceeds reimbursement for the more time-oriented services associated with benign hematologic diseases. In practices where income is apportioned according to billing, there is little incentive for the overworked oncologist to see anemias and coagulation disorders, and these problems are willingly ceded to other specialties whenever possible. However, it is the hematologist/oncologist who ultimately must deal with the most complex problems—those that fall outside the algorithms or encounter the serious complications.

ASH leadership has been actively addressing these issues over the last few years, in part by the basic work of defining what a hematologist is and what value the hematologist provides. Those of us who practice hematology in the community setting need to participate in these discussions in order to provide our insight and perspective. We need to look at dual fellowship programs to determine whether they adequately prepare physicians to practice hematology. We need to educate fellows regarding the changing requirements for hematology practice in the community. We need to look at ASH’s educational programs to determine if there are ways in which we can improve the practice of hematology in the community. We need assistance in developing a curriculum that will stimulate an interest in the field among our house officers, who are most likely to remain in private practice. We need to work with our hospital systems to determine the best way to deliver hematology services including multidisciplinary approaches. We need to think about models other than the hematologist/oncologist that might work better in the community setting—the hematologist/internist or the hematologist/pathologist.

It is likely that many more of my colleagues in the community will encounter the challenge that has been posed to our practice. I hope that it will provide the stimulus for us to join ASH in addressing the concerns about the future of our subspecialty.