Themes identified in focus group discussions about the hematology workforce with adult hematology/oncology fellowship program directors
| Theme . | Interpretation . | Quotes . |
|---|---|---|
| Demand for hematology services | There is a perception that the demand for clinical care in hematology, particularly benign hematology, exceeds the current workforce supply | • “I was told recently that we had 600 new patient referrals in 6 months for benign hematology. That’s 100 new patients per month and I think there are 5 of us with variable numbers of clinics. And so you can do the math. There is a need for benign hematologists.” |
| • “[Our institution is] seeing this huge influx of [hematology] consults and outpatient referrals because the [organization] doesn’t want the nurse-practitioner to be wasting their time working at anemia or thrombosis and anticoagulation management so they’re coming to us actually. So we’ve had to create a rapid access clinic and a lot of new infrastructure to manage this influx. I don’t know if this is all going to change with the new administration. There is a need, and the workload is there.” | ||
| • “Within my practice, the hematology practice has grown exponentially while oncology is staying stable.” | ||
| • On the clinical workload in benign hematology: “We all need help.” | ||
| Trainee interest in hematology vs solid tumor oncology | The numbers of fellows interested in hematology vs solid tumor oncology vary according to institution, but invariably only a small number are interested specifically in benign hematology | • “The biggest problem that we have been having is actually retaining and maintaining people for growing … benign hematology. Malignant hematology has not held much [of a] problem, at least for our institution.” |
| • “Way back when I first worked … we didn’t have too much trouble tracking fellows to malignant … but benign has … much more of a challenge.” | ||
| • “[A] small minority [of our fellows] consider hematology, which is surprising because we have 1 of the largest, I would say most vibrant hematology faculty and research program diversity around the country.” | ||
| • “We do not turn out a lot of hematologists, I think in part because we don't actually have a full-time coagulation … faculty right now …. We [do] have a large hemoglobinopathy program. We keep trying to get people interested in sickle cell and sickle cell care to even join faculty and it’s been a really tough sell for a lot of people and that’s definitely been a real problem.” | ||
| • “The fellows who opt to train in hematology comprise probably anywhere from 30% to 50% of our fellows.” | ||
| • “I would say 50% of our fellows are interested in malignant hematology and about 1 or 2 also in benign hematology.” | ||
| Job availability and security | Hematology is perceived as having lower job availability and security compared with solid tumor oncology | • “I think the problem with general hematology is that … even fellows that are very well trained in general hematology are very concerned about job opportunities down the road, [whereas] they see job security in solid tumor oncology.” |
| • “I have fellows that would love to do hematology. And I could train them to be a hematologist, but then they could not find jobs.” | ||
| • “People do want to become hematologists. They love it…. They love hematology, but ultimately they are told by program directors, by peers, by other people that they cannot make a career on this.” | ||
| • “So if the jobs [in hematology] exist, the message with the trainees is that they don’t exist. That’s a big problem.” | ||
| • “There’s mixed messages that either there will not be a job for me or somebody else who is not a hematologist will be able to do my job…. And so it’s hard to reconcile these mixed messages.” | ||
| Financial factors | Hematology, particularly benign hematology, is perceived as being associated with a lower income potential, with fewer research funding opportunities, than solid tumor oncology | • “[The fellows] love heme because of all of the things that we’ve talked about, but the financial and other pressures are preventing them from doing that.” |
| • “Naturally, we’ve got a huge push for cancer. So you’re not going to get your CEO and all those people to say, ‘We’re going to put more money in hematology’ … Because they know that the money [comes] from cancer.” | ||
| • “I think also that funding is not available [in benign hematology]. So I think we should really come up with ideas on how to improve that and have more funding to benign hematology. Because that’s not where the money is.” | ||
| • “One of the challenges is … that at the end of the day it comes to money, and I think a lot of that is also funding. It becomes a circular problem where our benign hematologists are really mostly doing clinical practice. And they’re so overwhelmed with the clinical workload… Overcoming that, getting critical mass [so that benign hematologists are] able to do research is important, but getting them to do that really probably also has to do with funding. With oncologists, there’s a fair amount of funding through trials, through different malignancy-oriented research [opportunities] that don’t exist in the same way for benign hematology.” | ||
| • “There’s fewer ways to offset the salary for a benign hematologist than there is an oncologist. They all just have investigator-sponsored trials, they offset their salaries, get thrown in more administrative things, but [to] say there’s a job for a benign hematologist [with] 10 [clinics] a week is not necessarily an appealing thing to give somebody.” | ||
| Timing of career decisions | Trainees may develop an interest in hematology at any point along their training pathway, although some fellows switch from hematology to solid tumor oncology during fellowship | • “[An interest in hematology] starts in medical school and it goes through residency.” |
| • “Something happens during fellowship that changes people who passionately wanted to do hematology into [saying], ‘Well solid tumor isn’t that bad and I could do that and still do some hematology on the side.’ That’s what happens during fellowship.” | ||
| • “I think the people who choose to do benign hematology choose early from medical school and from residency based on ventures for laboratory based and academics…. I can identify [those interested in benign hematology] from moment 1…. They don’t waver from that. It’s … the malignant people [who] may decide to do solid tumors.” | ||
| • “I think that a disproportionate number of [fellowship] applicants are interested in malignant hematology and then during fellowship they see the landscape a little bit more clearly and get switched to solid tumor oncology.” | ||
| Single-subspecialty training in hematology | Single-subspecialty training in hematology may improve the hematology workforce, although this may not be universally feasible | • “If we had a program that could dissect out heme-only and really offer the curriculum that does not require them to be exposed to the solid tumor biology of having a combined heme/onc program, I think we’d be more successful in training really good heme malignancies as well as nonmalignant heme folks who might want to do everything short of transplant.” |
| • “If we could … stop telling our fellows that they cannot choose hematology only, I think those proportionate people would want to single board [in hematology]. Benign hematology is very different in many respects than solid oncology.” | ||
| • When asked how to produce more trainees in hematology if provided with unlimited resources: “I would create a fellowship program solely for heme.” | ||
| • When asked how to produce more trainees in hematology if provided with unlimited resources: “I’d go the clinician route and create a track for the fellows who want to be excellent hematologists out in the community and lead teams with physician extenders out in the community.” | ||
| • “We asked our institution if they would support the addition of 2 additional fellows for [a] hematology-only program. Two per year, so we have 4 total for a 2-year hematology fellowship…. We’re already way above our debt-to-resident ratio cap and absolutely not …. It’ll never happen.” | ||
| New care models for clinical practice in hematology | There is a demand for new care models to support community-based hematology practices | • “We have 4 hematologists in my practice [in the community] and 10 oncologists, and we hematologists see benign and malignant; the oncologists see only solid tumor. But there’s very few that I’m aware of, programs that are like that outside of the university setting. So that’s where I would see the future of hematology going, is somehow being able to incorporate clinical hematology into more community settings, because that’s what the fellows want to do, that’s what they enjoy doing… So we need to have more jobs like I have which is where I’m a hematologist in the community.” |
| • “All of the big cancer centers are now diving into the community and eating up all of these community hospitals, and we have a lot of places that we’re struggling to figure out what should the training be there, who should be taking care of those patients, and I think that would be a great opportunity to have programs that are affiliated with a bigger academic place, but really train people to interface and be in those communities.” | ||
| • “It’s been interesting, because we do a lot of outreach in [a certain geographic] area, and there are several places where we send an oncologist 1 day and a hematologist the other day, and the hematologist is always twice as busy as the oncologist.” | ||
| • “We’re an academic fellowship. And all of our fellows we expect are going to stay in academics. We don’t have a clinician-clinician pathway, but we’re really thinking about do we need to create this? And then how are we going to fund it, because our fellows’ 2 years of research is all on training grants. We’ll actually have to create [a] funding mechanism for a clinician-clinician pathway. But we might have to do that if the pressures continue.” |
| Theme . | Interpretation . | Quotes . |
|---|---|---|
| Demand for hematology services | There is a perception that the demand for clinical care in hematology, particularly benign hematology, exceeds the current workforce supply | • “I was told recently that we had 600 new patient referrals in 6 months for benign hematology. That’s 100 new patients per month and I think there are 5 of us with variable numbers of clinics. And so you can do the math. There is a need for benign hematologists.” |
| • “[Our institution is] seeing this huge influx of [hematology] consults and outpatient referrals because the [organization] doesn’t want the nurse-practitioner to be wasting their time working at anemia or thrombosis and anticoagulation management so they’re coming to us actually. So we’ve had to create a rapid access clinic and a lot of new infrastructure to manage this influx. I don’t know if this is all going to change with the new administration. There is a need, and the workload is there.” | ||
| • “Within my practice, the hematology practice has grown exponentially while oncology is staying stable.” | ||
| • On the clinical workload in benign hematology: “We all need help.” | ||
| Trainee interest in hematology vs solid tumor oncology | The numbers of fellows interested in hematology vs solid tumor oncology vary according to institution, but invariably only a small number are interested specifically in benign hematology | • “The biggest problem that we have been having is actually retaining and maintaining people for growing … benign hematology. Malignant hematology has not held much [of a] problem, at least for our institution.” |
| • “Way back when I first worked … we didn’t have too much trouble tracking fellows to malignant … but benign has … much more of a challenge.” | ||
| • “[A] small minority [of our fellows] consider hematology, which is surprising because we have 1 of the largest, I would say most vibrant hematology faculty and research program diversity around the country.” | ||
| • “We do not turn out a lot of hematologists, I think in part because we don't actually have a full-time coagulation … faculty right now …. We [do] have a large hemoglobinopathy program. We keep trying to get people interested in sickle cell and sickle cell care to even join faculty and it’s been a really tough sell for a lot of people and that’s definitely been a real problem.” | ||
| • “The fellows who opt to train in hematology comprise probably anywhere from 30% to 50% of our fellows.” | ||
| • “I would say 50% of our fellows are interested in malignant hematology and about 1 or 2 also in benign hematology.” | ||
| Job availability and security | Hematology is perceived as having lower job availability and security compared with solid tumor oncology | • “I think the problem with general hematology is that … even fellows that are very well trained in general hematology are very concerned about job opportunities down the road, [whereas] they see job security in solid tumor oncology.” |
| • “I have fellows that would love to do hematology. And I could train them to be a hematologist, but then they could not find jobs.” | ||
| • “People do want to become hematologists. They love it…. They love hematology, but ultimately they are told by program directors, by peers, by other people that they cannot make a career on this.” | ||
| • “So if the jobs [in hematology] exist, the message with the trainees is that they don’t exist. That’s a big problem.” | ||
| • “There’s mixed messages that either there will not be a job for me or somebody else who is not a hematologist will be able to do my job…. And so it’s hard to reconcile these mixed messages.” | ||
| Financial factors | Hematology, particularly benign hematology, is perceived as being associated with a lower income potential, with fewer research funding opportunities, than solid tumor oncology | • “[The fellows] love heme because of all of the things that we’ve talked about, but the financial and other pressures are preventing them from doing that.” |
| • “Naturally, we’ve got a huge push for cancer. So you’re not going to get your CEO and all those people to say, ‘We’re going to put more money in hematology’ … Because they know that the money [comes] from cancer.” | ||
| • “I think also that funding is not available [in benign hematology]. So I think we should really come up with ideas on how to improve that and have more funding to benign hematology. Because that’s not where the money is.” | ||
| • “One of the challenges is … that at the end of the day it comes to money, and I think a lot of that is also funding. It becomes a circular problem where our benign hematologists are really mostly doing clinical practice. And they’re so overwhelmed with the clinical workload… Overcoming that, getting critical mass [so that benign hematologists are] able to do research is important, but getting them to do that really probably also has to do with funding. With oncologists, there’s a fair amount of funding through trials, through different malignancy-oriented research [opportunities] that don’t exist in the same way for benign hematology.” | ||
| • “There’s fewer ways to offset the salary for a benign hematologist than there is an oncologist. They all just have investigator-sponsored trials, they offset their salaries, get thrown in more administrative things, but [to] say there’s a job for a benign hematologist [with] 10 [clinics] a week is not necessarily an appealing thing to give somebody.” | ||
| Timing of career decisions | Trainees may develop an interest in hematology at any point along their training pathway, although some fellows switch from hematology to solid tumor oncology during fellowship | • “[An interest in hematology] starts in medical school and it goes through residency.” |
| • “Something happens during fellowship that changes people who passionately wanted to do hematology into [saying], ‘Well solid tumor isn’t that bad and I could do that and still do some hematology on the side.’ That’s what happens during fellowship.” | ||
| • “I think the people who choose to do benign hematology choose early from medical school and from residency based on ventures for laboratory based and academics…. I can identify [those interested in benign hematology] from moment 1…. They don’t waver from that. It’s … the malignant people [who] may decide to do solid tumors.” | ||
| • “I think that a disproportionate number of [fellowship] applicants are interested in malignant hematology and then during fellowship they see the landscape a little bit more clearly and get switched to solid tumor oncology.” | ||
| Single-subspecialty training in hematology | Single-subspecialty training in hematology may improve the hematology workforce, although this may not be universally feasible | • “If we had a program that could dissect out heme-only and really offer the curriculum that does not require them to be exposed to the solid tumor biology of having a combined heme/onc program, I think we’d be more successful in training really good heme malignancies as well as nonmalignant heme folks who might want to do everything short of transplant.” |
| • “If we could … stop telling our fellows that they cannot choose hematology only, I think those proportionate people would want to single board [in hematology]. Benign hematology is very different in many respects than solid oncology.” | ||
| • When asked how to produce more trainees in hematology if provided with unlimited resources: “I would create a fellowship program solely for heme.” | ||
| • When asked how to produce more trainees in hematology if provided with unlimited resources: “I’d go the clinician route and create a track for the fellows who want to be excellent hematologists out in the community and lead teams with physician extenders out in the community.” | ||
| • “We asked our institution if they would support the addition of 2 additional fellows for [a] hematology-only program. Two per year, so we have 4 total for a 2-year hematology fellowship…. We’re already way above our debt-to-resident ratio cap and absolutely not …. It’ll never happen.” | ||
| New care models for clinical practice in hematology | There is a demand for new care models to support community-based hematology practices | • “We have 4 hematologists in my practice [in the community] and 10 oncologists, and we hematologists see benign and malignant; the oncologists see only solid tumor. But there’s very few that I’m aware of, programs that are like that outside of the university setting. So that’s where I would see the future of hematology going, is somehow being able to incorporate clinical hematology into more community settings, because that’s what the fellows want to do, that’s what they enjoy doing… So we need to have more jobs like I have which is where I’m a hematologist in the community.” |
| • “All of the big cancer centers are now diving into the community and eating up all of these community hospitals, and we have a lot of places that we’re struggling to figure out what should the training be there, who should be taking care of those patients, and I think that would be a great opportunity to have programs that are affiliated with a bigger academic place, but really train people to interface and be in those communities.” | ||
| • “It’s been interesting, because we do a lot of outreach in [a certain geographic] area, and there are several places where we send an oncologist 1 day and a hematologist the other day, and the hematologist is always twice as busy as the oncologist.” | ||
| • “We’re an academic fellowship. And all of our fellows we expect are going to stay in academics. We don’t have a clinician-clinician pathway, but we’re really thinking about do we need to create this? And then how are we going to fund it, because our fellows’ 2 years of research is all on training grants. We’ll actually have to create [a] funding mechanism for a clinician-clinician pathway. But we might have to do that if the pressures continue.” |
Seven themes were identified: demand for clinical hematology services, trainee interest in hematology vs solid tumor oncology, perceptions of job availability and security, financial factors, timing of career decisions, the prospect of single-subspecialty training in hematology, and the creation of new care models for clinical practice in hematology. Representative quotes are shown for each theme.
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