By Samer Al Hadidi, MD, MS, FACP
The majority of the trainees who decide to pursue a clinical training in either hematology or medical oncology are forced to do a combined training in both.1 Per the most recent medical specialties matching program statistics of 2019, there were 149 certified hematology and oncology combined programs compared to three certified hematology-only programs and four certified medical oncology programs. A total of 637 trainees were accepted across all those varieties in 2019. Most of the trainees spend 3 years in combined training, though graduates will end up practicing in either hematology or oncology. There will be a 15% difference in overall demand for hematology and oncology services and the supply of hematologists-oncologists per Medicare use patterns, which predicts increased need for more qualified trainees and training programs.2
The hematology and oncology fields are different. Adult hematology and oncology board certification exams are separate. In part, that reflects the differences in objectives of training across both of the specialties. Hematologic diseases can be generally divided into benign or malignant. The only overlap between hematology and oncology is malignant hematology. Specific training guided towards the trainee interest will be needed.
There is a concern that combined training in both specialties can be imbalanced. Although the fellowship programs are built to try to equalize the training in both specialties, the actual training exposure is variable. Even in the same fellowship program, trainees may have different exposure according to their schedules.
The presence of separate specialties may help medical students and medical residents to decide on their future plans with a better understanding of the nature of two different fields. Limited exposure may result in underestimation of the demands of the future careers and possible career dissatisfaction.3
A previous study showed that fewer than 5% of graduates among academic adult hematology and oncology programs will maintain a primary focus on benign hematology, and fewer than 20% on malignant hematology.4 A single board track may increase the retention in benign hematology.5 Overall this may help trainees to better choose their specialty of interest and increase future retention.
The fields of hematology and oncology are expanding. This includes basic knowledge of the different diseases and the explosion of newly approved medications. This is expected to increase in the future with ongoing research and discoveries. Although this is a magnificent development, it will increase the difficulty of keeping up with two fields to better provide ideal care for patients.
Primary care physicians or internists usually address benign hematologic conditions. More complex benign hematologic diseases will require the expertise of hematologist.
Most oncology specialists will not feel comfortable addressing such conditions due to lack of experience. Even though some oncologists will see patients with benign hematologic conditions in private practice, this is usually because the practice does not have a hematologist with a benign hematology focus. Oncology-only board certified physicians treating patients with benign hematologic conditions is not ideal for appropriate patient care.
It is extremely difficult to structure an ideal training in both hematology and oncology in one fellowship. Many institutions may send their trainees to nearby institutions to receive further required training, though this is governed by availability. Some programs have the ability to provide training across all disease categories, though this is limited by the training duration.
Re-structuring of training to best fit the interest of the trainee is possible, and could potentially result in better patient care. The length of training can be shortened to 2 years for each of the specialties. Trainees who decide to pursue benign hematology training can have a well-structured curriculum to address various benign hematologic conditions.
They can also be exposed to malignant hematologic conditions according to their interest. Trainees with a solid interest in medical oncology can spend their training time on the diverse oncologic conditions, without the need of exposure to benign hematology. Finally, trainees with interest in malignant hematology can obtain the required training either through a hematology fellowship with a malignant track or oncology fellowship with malignant hematology focus.
Figure 1. Suggested Training Restructuring.
A 3- to 4-year track to fit a combined training in hematology and oncology may be a potential solution, especially for physicians interested in practicing the two fields simultaneously in the setting of private practice or community settings. This track can be structured as clinical rotations with limited research requirements so the trainee will be able to gain the experience needed to practice both of the subspecialties. A culture change at academic centers to decrease the emphasis on research is needed for the trainees who are interested in community/private practice jobs.
Another major issue is compensation: compensation in a benign hematology practice is much less favorable than oncology due to volume, chemotherapy use, and other factors. The hematology/oncology community should address the difference in compensation when restructuring the training programs to avoid underutilization of the hematology track.
The new proposed training can accommodate trainees who are interested in a specific branch of hematology/oncology. One example is bone marrow transplant, where a trainee can have a 2-year hematology track with 1 year of specialized training in transplant. This can be applicable for any field according to the trainee’s interest.
The hematology and oncology community may find such change difficult, albeit it will propel the field forward for the better. Ultimately, this will result in focused training fulfilling our united goal of better patient care. Today, ending a long-term relationship between hematology and oncology may be seen as an intriguing option, but in the future, it will be necessary.
Dr. Al Hadidi is a third-year fellow in the Section of Hematology and Oncology at Baylor College of Medicine, and a member of the ASCO Trainee Council. His research interests include areas related to hematologic oncology, with a focus on drug development, health equity, and medical education. Follow Dr. Al Hadidi on Twitter @HadidiSamer. Disclosure.
- Electronic Residency Application Service. ERAS 2020 participating specialties and programs. Accessed 8 November 2020.
- Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract. 2014;10:39-45.
- Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows' career plans, expectations, and well-being: do fellows know what they are getting into? J Clin Oncol. 2014;32:2991-7.
- Todd RF III, Gitlin SD, Burns LJ, et al. Subspeciality training in hematology and oncology, 2003: results of a survey of training program directors conducted by the American Society of Hematology. Blood. 2004;103:4383-8.
- Naik RP, Marrone K, Merrill S, et al. Single-board hematology fellowship track: a 10-year institutional experience. Blood. 2018;131:462-4.