Training program in cancer and blood diseases: Pediatric Hematology/Oncology Fellowship Program, Children's Hospital Boston/Dana‐Farber Cancer Institute
Authors: David A. Williams, Elise S. Porter, Samuel E. Lux, Holcombe E. Grier, Jennifer W. Mack, Stuart H. Orkin
Journal: American Journal of Hematology (2010)

The Pediatric Hematology/Oncology program at Children's Hospital Boston (CHB) and Dana-Farber Cancer Institute (DFCI) was found in 1945 by Drs. Louis K. Diamond and Sidney Farber. The modern program dates from 1967 when Dr. David G. Nathan replaced Dr. Diamond as Division Chief. In 1974, Dr. Nathan assumed responsibility for all Pediatric Oncology at CHB and DFCI and established the program as a joint activity of DFCI and CHB. Soon thereafter, a bone marrow transplant (BMT) program was begun. In 1985, Dr. Nathan assumed the role of Chairman of the Department of Pediatrics, and Drs. Samuel E. Lux and Steven J. Burakoff were appointed to direct the combined program. Dr. Burakoff moved to New York University in 2000 and was replaced by Dr. Stuart H. Orkin. In 2007, Dr. Lux stepped down after 23 years as Division Chief and was replaced by Dr. David A. Williams. The program is currently led by Drs. Orkin (DFCI) and Williams (CHB). The program admits six new fellows per year and is geared to broadly train MD or MD/PhD fellows in many of the areas of clinical, basic, or translational research. The clinical fellowship and scientific training for the Hematology/Oncology program is a shared activity with an outstanding tradition of success (Table 1). The Hematology/Oncology Program at CHB and DFCI is an outstanding training environment for physician-scientists in clinical, translational, or basic science fields. All staff and faculty hold joint appointments in the Department of Pediatric Oncology at DFCI and the Division of Hematology/Oncology at CHB, and Harvard Medical School. Within the program are superb faculty situated at these institutions and Brigham and Women's Hospital, the Whitehead and Broad Institutes at Massachusetts Institute of Technology (MIT), and Harvard University. There are currently 107 faculty members in the Division of Hematology/Oncology at CHB/DFCI with academic appointments in the Department of Pediatrics in Harvard Medical School. Our long-standing mission is to train first-rate physician-scientists including both basic and clinical researchers, and we encourage our trainees to take advantage of the numerous research opportunities at any of the prestigious institutions in the Boston area. The program has had unparalleled success in training leaders in the field. The faculty are highly productive, receiving >$18 million/year in NIH funding, which includes >30 individual R01s, multiple program grants, and Centers of Excellence Awards. Total research funding for the division is >$33 million/year in direct costs. Research space includes more than ∼50,000 square feet of wet-bench space and additional clinical research space located in both parent institutions. Faculty publish regularly in top-tiered research and clinical journals (Fig. 1). The division currently includes five investigators of the Howard Hughes Medical Institute, and 12 trainees are or have been members of this research institute. Eleven former trainees are currently members of the National Academy of Sciences and/or the Academy's Institute of Medicine. Over four decades, the program has continuously produced a cadre of outstanding physician-scientists that have become leaders of the Pediatric and Hematology/Oncology academic community. Total pediatric hematology/oncology faculty publications in top clinical and basic science journals from 2002 to 2009. A through F show publications from other leading pediatric hematology/oncology programs. Journals were selected using impact factor. Articles were identified using a PubMed search of address lines which identified the pediatric hematology and/or oncology program at each institution. Clinical activities occur in both CHB and DFCI. All inpatient clinical activities and outpatient benign hematology care takes place at CHB. Outpatient clinical activities for pediatric oncology and hematopoietic stem cell transplant (HSCT) are housed in the Jimmy Fund Clinic at DFCI. Fellows do 1 year of intensive clinical training and rotate through six services: hematology, oncology, hematopoietic stem cell transplantation, ambulatory hematology, neuro-oncology, and off-service (consultative) oncology (Fig. 2). They also receive training in transfusion medicine and laboratory medicine. With more than 15,000 patient visits in 2009 and more than 80 bone marrow transplants, the program is able to provide exposure to a wide range of diagnoses. In addition, there is a high degree of “hands-on” clinical responsibility. Fellows follow 20–25 oncology patients, 5–10 stem cell transplant patients, and 30–40 hematology patients, on average, for all three years of fellowship (and beyond), and function as their primary caregiver. A queue system is used to be sure that fellows have patients with a broad distribution of diseases. The program is similar for most fellows, but is big enough that it is possible to vary the clinical experience for fellows who desire a special program or want additional training in other specialties (e.g., infectious disease, immunology, nuclear medicine, genetics/metabolism). Although most fellows have been trained in Pediatrics or Medicine-Pediatrics the program has also trained 14 internists since 1965. Dr. Allison O'Neill, Clinical Fellow, examining a patient in the newly renovated Jimmy Fund Clinic. In addition, the program has developed a training pathway for fellows interested in international medicine. Building on relationships with programs in Central and South America, as well as the Middle East, trainees with special interest in this field are offered a 2–3 year curriculum that includes hands-on training in program building, education, and research in global health as well as rotations to regional centers in developing countries. Pediatric and Adult Training in Hematology (PATHway) is a shared program between the Hematology/Oncology Division at Children's Hospital and the Hematology Program at Brigham and Women's Hospital. Fellows interested in careers in non-malignant hematology, survivorship care for the formerly lethal pediatric malignancies; or trainees interested in transitional care for “pediatric” disorders, e.g., thalassemia and marrow failure are able to gain training in this combined pediatric/adult program. The program is funded by a special grant from the American Society of Hematology. The program has successful history of training individuals whose interests lie astride or between disciplines. The leaders of the program are willing to discuss unique arrangements and to try to accommodate our fellows' interests, even when out of the ordinary, because we believe such individuals enrich the program and the discipline with new views and experiences. We are committed to the training of fellows who will become world-class researchers in clinical, translational or basic research. About 60% of our fellows choose to do laboratory research and 40% choose clinical investigation. We strongly support both pathways. Fellows who seek a career in basic science research will receive training equivalent to a PhD. Fellows interested in clinical research will be broadly trained in biostatistics, clinical trials, clinical epidemiology, ethics, experimental design, and/or health services research. We offer tuition support for those fellows wishing to obtain a Master's degree in Public Health at Harvard School of Public Health. Fellows interested in translational research generally train first in a basic laboratory field, then round out this training with specialized coursework in clinical trials, linking laboratory to clinical investigation. We believe the training program should be individualized for each fellow since trainees come to the program with very different goals and experiences in research. A strong effort is made to maintain maximum flexibility. Fellows are able to work with any of the thousands of experienced clinical or laboratory researchers in the Boston area. Many of the graduates of the program have trained at Massachusetts Institute of Technology, the Whitehead or Broad Institutes, and many of the other major research academic centers in Boston. Regardless of the location of their laboratory, during the research portion of training fellows are supported by two institutional T32 training grants (a total of 19 slots/year). The fellow's time is carefully protected to permit at least 80% time for research. We strongly believe that most trainees need research training and protected time for research beyond the 3-year training period mandated by the American Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Our program extends mentored training for as long as necessary for the individual to attain independence, on average ∼6 years. The additional financial support is obtained through vigorous pursuit of competitive federal and nonfederal fellowships, supplemented by institutional resources. The program is steeped in tradition of training future physician-scientist leaders in the fields of pediatrics and pediatric hematology and oncology. Since 1965, the program has trained more than 225 fellows, 95% of whom are in academic medicine and 71% are doing primarily laboratory or clinical research. A remarkable number of the graduates of our fellowship program are members of the institutions that guide American medicine and pediatrics and that select their members based on scientific accomplishments. No other pediatric program, in any specialty, has such a record of accomplished alumni. The Pediatric Hematology/Oncology program at CHB and DFCI is able to provide a unique training environment that helps to ensure future success for physician-scientists. Key features of this environment include: (i) fellows are exposed to a wide range of diagnoses and are able to direct care in the role of primary caregiver; (ii) the program recruits and retains outstanding faculty who are internationally recognized experts in clinical care and clinical, translational, and basic research; these faculty are particularly well regarded as mentors and educators. Indeed since the inception of the American Society of Hematology Mentor Awards in 2006, five of the first eight awards have been given to our faculty (3) or our previous trainees (2); and (iii) our fellows are able to take advantage of the immense research expertise available in the Boston community through study or collaboration with local physicians and scientists. Thus, the Pediatric Hematology/Oncology Program at CHB/DFCI has an outstanding and sustained track record of training future leaders in academic medicine who are able to provide outstanding patient care and participate in cutting edge research.