Janis L. Abkowitz, MD
The American Society of Hematology (ASH) is calling for the creation of a new clinical hematology specialty that would be based in a medical center or health system and would focus primarily on patients with benign blood disorders while also helping to manage genomic testing and pathways-centered care.
The need for a “systems-based clinical hematologist” is driven by a variety of forces including changing practice models such as accountable care organizations (ACOs) that have shifted treatment of patients with nonmalignant conditions from primary care doctors to consultations with medical oncologists and other specialists, according to a report in Blood.1
Meanwhile, the FDA has approved at least a dozen new drugs for nonmalignant blood disorders in the past three years.
“What drove this paper was not workforce imbalance so much as looking at what are novel opportunities given ACO systems, given the current referral pattern, given the new explosion in genetics and genomics, and given new drugs such as novel anticoagulants. It’s not one single thing. There’s a whole bunch of different roles that hematologists could fill for a healthcare system and have a very important contribution to the health of the community,” Janis L. Abkowitz, MD, a former ASH president and senior author on the paper, said in an interview.
ASH has been collecting case studies and conducting interviews with hematology specialists in order to help “foster work force innovation to ensure sustainable professional roles for hematologists,” according to the report.
“Hematology over the years has been more difficult financially because there’s a huge amount of intellectual energy that goes into it,” noted Abkowitz, who is chief of the Division of Hematology at the University of Washington School of Medicine in Seattle. “That’s what makes it wonderful, but it hasn’t fit the prior billing schemes, and I think that’s what has driven it in a different direction as a practice.”Changes in Training Add to Pressures
The market forces affecting the profession have been compounded by changes in hematology training programs, Abkowitz and colleagues reported. Most hematology academic training programs have merged with oncology fellowships, with a resulting diminished focus on nonmalignant hematology as a separate, sustainable discipline.
Further, many training programs no longer conform to the traditional one-third nonmalignant hematology, one-third malignant hematology, onethird solid tumor oncology model, according to the report. The Accreditation Council for Graduate Medical Education no longer mandates the number of months of nonmalignant hematology training that is required for a hematology-oncology fellowship program to be certified, the report says.
As many “classic” hematologists trained in prior decades reach the age of retirement, many newly minted physicians focus elsewhere for a principal specialty; consequently, the time is appropriate to identify career pathways that attract and enable physicians to practice nonmalignant hematology in a sustainable manner, according to the ASH report.
Indeed, current staffing trends “should be a wake-up call for the training programs to assure that they cover the benign or nonmalignant part of hematology, not just the cancer part of hematology/oncology, because of this need for this expertise that’s missing,” Abkowitz said.
Currently, there are approximately 14,000 medical oncology and hematology specialists certified to practice in the United States, according to a recent American Society of Clinical Oncology report.2
Hematology care is provided through several practice settings (Figure)
“Nonmalignant hematologists vary in how much hematological malignancy they see as practitioners,” said Abkowitz. “Some will see low-grade processes such as chronic lymphocytic leukemia; others will see all malignant hematology as well as nonmalignant hematology, but not solid tumors, such as breast cancer.”Models for Future
Looking forward, Abkowitz and colleagues envision the position of systems-based clinical hematologist as a dynamic element of patient care.
“Based on our observations, there is not a single role description for a systems-based clinical hematologist. Rather, the key theme is flexible adaptation to combine individual expertise and interest with larger health system needs,” the authors wrote.
The ASH report identified four specific areas uniquely suited to the expertise and management skills of a systems-based hematologist, but noted that there are many other possibilities. These areas are: