Hematology and Oncology: Natural Allies Or Time To Part Ways? Results Of a Medicine Resident Survey
Authors: Kaul Esha , Flores John Paul , Paulus Jessica K , Gunturu Krishna S. 
Published: October 2019

Abstract

Background
Over the last decade there has been a rapid increase in the body of knowledge in Hematology and Oncology with major changes in treatment strategies and available therapies. In this current climate, the majority of physicians with Hematology-Oncology training focus their practice on either Hematology or Oncology. However, currently most fellowship programs combine the two specialties. In 2012, only 16 Hematology-specific fellowship positions were available nationwide, and the number of applicants per position in the NRMP Match for Hematology and Hematology-Oncology (Hem-Onc) was 7.4 and 1.5, respectively.
A report from the American Society of Clinical Oncology (ASCO) predicted an acute shortage in the Hem-Onc workforce by the year 2020. As we attempt to meet this demand by training more fellows, it is important to understand the Hem-Onc environment in which the internal medicine residents are surrounded as they choose their career pathways. We therefore conducted a survey of internal medicine residents to understand their perceptions about this field and how they make decisions about fellowship training.

Methods
The content and wording of the survey were developed in focus group discussions of the authors. A 5 point Likert scale was used to identify a range of responses. A pilot was performed with the Hem-Onc fellows to test the survey for clarity and relevance. The Research Electronic Database electronic capture (REDCap) software was used for survey development and distribution. Program directors were contacted via email regarding study participation. The invitation to complete a 4 page anonymous web based survey was sent to Internal Medicine residents at 4 residency programs in Massachusetts (1 university-based and 3 community-based) between January 2012 and July 2012. Counts and proportions were used to summarize survey responses.

Results
77 out of the 171 current residents enrolled in the 4 residency programs completed the survey (response rate: 45%). 59 (77%) of the respondents were either committed to or had considered pursuing fellowship training. Among these residents, Hem-Onc was among the top three choices for 20 (26%) of the respondents. The top three factors that led them to consider a fellowship in Hem-Onc were intellectual stimulation, the rapidly expanding field, and a personality fit (Table 1). The top reasons cited for not considering a career in Hem-Onc were the lack of curative options, personality fit, and dealing with end of life issues (Table 2). Of the 57 residents not considering a combined Hem-Onc fellowship, 16 (26%) were willing to consider fellowships in Hematology or Oncology if tracks where offered separately [11 (69%) for Hematology alone or 5 (31%) for Oncology alone]. Even among those considering combined Hem-Onc fellowships, 3 (15%) would consider fellowships in Hematology alone and 3 (15%) would consider oncology alone.
In terms of the residency training environment, the areas of Hem-Onc training where most residents felt their exposure to the field be lacking were outpatient oncology (59,77%) and benign hematology (49, 64%). (Fig.1)

Discussion
While Hematology and Oncology have traditionally been offered as a combined 3 year fellowship, there is substantial interest in separate Hematology and Oncology fellowships as evidenced by our survey results and NRMP data.
A greater number of Hematology- or Oncology-specific fellowships could attract more residents to these subspecialties and help meet the increasing demand for Hematologists and Oncologistsin clinical practice. Also, increased exposure to outpatient, in addition to inpatient, Hem-Onc during residency would be more representative of actual practice, could dispel misconceptions about dismal outcomes in Hem-Onc, and may help attract more residents to the field.

Disclosures:
No relevant conflicts of interest to declare.