Design and implementation of a novel advanced training curriculum in hemoglobinopathies
Authors: Richard Ward
Journal: American Journal of Hematology (2017)

The Hemoglobin Disorders represent a global burden of disease (World Health Organization). Approximately 3% of the North American population is a carrier for a significant hemoglobin variant, and there are an estimated 90 000 individuals with Sickle Cell Disease in North America. Toronto is home to one of the largest adult Hemoglobinopathy Programs in North America, serving more than 1300 patients. The University of Toronto (UofT), like other Canadian hematology subspecialty residency programs, is a two-year, postinternal medicine training program comprising benign, malignant, and laboratory aspects of hematology. Canadian programs are differentiated from US programs by their lack of solid tumor training. Despite the Canadian focus on hematology as a specialty, prior to 2009, there was no formalized exposure to hemoglobinopathies in Canada's premier training program. To address this deficiency, a peer-reviewed, competitive educational grant (Alternative Training Program Grant) was awarded by the American Society of Hematology (ASH) in 2009 to support the development of specific training in the management of hemoglobinopathies. Development of this novel curriculum illustrates the impact a specialist society can have on meeting gaps in training and ensuring future clinical demands can be met for treating unique patient populations. In addition, developing a curriculum specific for the care of patients with hemoglobinopathies is an example of implementation of an advanced subspecialty curriculum within a hematology fellowship. To define the scope of the problem, an electronic needs assessment survey of Hematology trainees at the University was administered that highlighted deficiencies in fellow training with respect to clinical hemoglobinopathies. Similar findings were found from an informal review of all hematology residency training program directors at their annual meeting. These findings were benchmarked against the Royal College's objectives and training requirements for certification in hematology. An environmental scan was undertaken to assess the current educational opportunities in Ontario for Hemoglobinopathy training. As well, a gray literature search was performed including courses available across North America and those available online. The primary mandate of this fellowship program is to provide a hematologist trainee with additional expertise in hemoglobinopathies for each province or major population center in Canada, and to then offer the same level of training to trainees from overseas, particularly in areas of the World where hemoglobinopathies are a significant burden of disease. The overarching principle for the fellowship's curriculum design was based on the multisystem nature of sickle cell and thalassemia, shifting the paradigm away from more traditional red cell focused perceptions of these disorders. The intention was to fully utilize the faculty working across five academic health sciences centers in the city, each with a different specialized focus of hemoglobinopathy care. Support for the curriculum was also committed from the regional hemoglobinopathy genetics laboratory service and the Canadian Blood Services. The architecture for the fellowship was divided over two years. The first year exposed the trainee to multiple specialties which play an important role in managing these disorders as well as laboratory exposure and core learning. The second year was based in the adult clinic with >60% protected time for scholarly activities. Flexibility also enabled electives to be taken in year two, tailoring training to the fellow's eventual career plans. An iterative approach was taken to the design of year 1, with new rotations, such as wound care and pain/addiction medicine, added in response to fellow feedback, and other rotations modified in length of exposure. Figure 1 outlines the 2018 iteration of the fellowship. Given the mandate to train the next generation of adult academic hemoglobinopathy physicians, it was an expectation that additional study would be undertaken concurrently, according to the trainee's academic interest, eg., Masters in Clinical Epidemiology, Quality Improvement, Education or Public Health. The proposed fellowship was successful in being awarded a peer-reviewed, competitive educational grant from the American Society of Hematology in recognition of the gap in training it filled across North America, as well as the quality of the syllabus. In collaboration with a librarian, a comprehensive, up to date online repository of educational resources was developed for the fellow's learning, hosted by the University library. This “LibGuide” has since been replicated by other universities as a resource for trainees. Timeline of fellowsip The fellowship was posted on the University Division website, and distributed by email to the fourteen Hematology Training Program Directors. The fellowship selection process consisted of an initial review of CV and personal statement. Short listing was based on personal qualities, academic achievements, clinical experience, career objectives, and research accomplishments. Those applicants shortlisted were invited to attend in person or by videoconference for interview. The Fellowship was open to all trainees who had completed post-graduate training in Internal Medicine and Hematology. To date, since 2010, six fellows have been accepted for the advanced training program. Of the three who have completed training, all are in academic positions as leads in hemoglobinopathy care and working in high hemoglobinopathy prevalence areas. Each has developed a different focus: clinical investigator, educator, and quality improvement expert. One has assumed an innovative appointment as a community based academic physician. The current fellow will be appointed to another provincial program and has an interest in public health. In addition, we have co-trained a fellow from Saudi Arabia who has now returned to his home institution with a focus on hemoglobinopathies. 2018 will see the first international fellow (Nigeria) begin the training program as well as another Canadian trainee. The latter will thereafter support the French speaking hemoglobinopathy population of Quebec. We have supported two other Canadian universities in development of their own advanced fellowship. The fellowship has been upheld as “best practice” by the University Department of Medicine's fellowship director. The scholarly output from the fellows consists of five published, peer-reviewed manuscripts, sixteen conference presentations and abstracts, and thirteen presentations (1 international, 5 national, 7 local). In addition they have been awarded three peer reviewed grants or awards. Their Master degrees have been obtained in Health Research Methodology, Health Informatics, and Public Health. Nine research projects are currently in progress. In response to positive initial feedback form the first fellow, and a desire to construct a pipeline of future trainees, a broader hemoglobinopathy training initiative was proposed. To fill a gap identified in the current Hematology training program, an elective rotation in hemoglobinopathies was introduced in 2011. Due to the overwhelming success of the rotation as judged by residents, staff and the Training Program Director, the rotation became a mandatory component of the training program in the 2012 academic year. This has attracted electives from other programs. To date, twenty-eight residents from nine Canadian universities have experienced the rich learning environment as an elective. In collaboration with colleagues, an e-learning module on hemoglobinopathies was implemented for hematology residents. We also delivered a new hemoglobinopathy workshop at the national hematology trainees' retreat in 2011, and repeated in 2015. Alongside this, beginning in 2010, there has been further diversity of the learners exposed to hemoglobinopathies across the Faculty of Medicine. This is in recognition of the cross-disciplinary nature of these disorders. Tailored educational resource packages were implemented for core internal medicine residents, endocrinology, and cardiology residents and fellows. This includes development of an e-learning module on sickle cell disease for core medicine. A redesign of hemoglobinopathy learning experience took place for the MSc Genetic Counseling Program, and subsequently invited to provide teaching for Medical Genetics residents. Educational outreach events in hemoglobinopathies have been held for Maternal-Fetal Medicine and Heart Failure fellows. The Fellowship Program is now well established and is on track to meet its overriding goal of training a core of hematologists to establish an adult Hemoglobinopathy program in each major population center in Canada. Additionally, due to the cross-disciplinary nature of hemoglobinopathies, trainees in other disciplines have benefited from the fellowship curriculum. It is hoped that these physicians will form of a community network of clinical care and scholarly activities in hemoglobinopathies. In the future, the Program hopes to train more North American and overseas trainees, achieving global impact. Described here is the design, implementation and multifaceted impact of Canada's first-ever curriculum in adult hemoglobinopathies. This peer-reviewed advanced fellowship has demonstrated knowledge translation to the clinic and a broad impact on trainees in allied specialties. The fellowship's successful curriculum design has subsequently lead to the development of further advanced training programs in nonmalignant hematology at the University: Thrombosis and Hemostasis, Consultative Hematology, and Maternal-Fetal Hematology. This work was supported by the American Society of Hematology's Medical Educators Institute.