Trends and factors affecting the US adult hematology workforce: a mixed methods study

The impact of hematology electronic consultations on the management of iron deficiency

OBJECTIVES

Delays in the evaluation and treatment of iron deficiency can lead to increased disease-related morbidity and mortality. Electronic consultation (e-consult) is a referral modality that allows providers quicker access to recommendations from a specialist based on electronic chart review. While the use of e-consult is expanding in classical hematology, gaps exist in the understanding of patient outcomes related to its use for iron deficiency.

METHODS

We randomly selected 200 e-consults and 200 traditional referrals from 3,336 hematology referrals for iron deficiency at a single center. The primary outcomes of the retrospective analysis were: time to completion of the referral, and time to treatment with intravenous iron. Secondary outcomes included recurrence of iron deficiency, need for repeat e-consult, conversion to in-person evaluation, and assessment of whether the etiology of iron deficiency was addressed.

RESULTS

E-consults significantly reduced the time from referral to intravenous iron repletion (e-consult, 33 days; traditional referral, 68 days; p < .05). Assessment of the underlying etiology occurred in 70.7% of the e-consult encounters compared to 92.5% of traditional referrals (p < .05).

CONCLUSIONS

These findings highlight advantages of e-consults in improving care delivery in iron deficiency, and identifying gaps that can be improved through practice standardization to ensure equitable, high-value care.

Defining the Educational Needs for a Community-Based Hematology/Oncology Career: A National Needs Assessment

PURPOSE

Little is known about the specific needs during training for hematology/oncology providers practicing in community-based settings. We conducted a national survey of hematologists/oncologists employed in community or academic-community hybrid settings to delineate their educational needs.

METHODS

An electronic questionnaire was developed and distributed nationally through professional organizations. We primarily assessed whether survey participants received any specific training during fellowship for community-based practice. Participants were also surveyed regarding training experiences that might have affected their preparation. Relative risk (RR) and 95% CI were calculated using modified Poisson regression to identify factors associated with receiving training specifically for community-based settings.

RESULTS

Of 125 participants from across 25 states, 63% were male and 58% identified as White. Less than half (41.6%, binomial 95% CI, 32.8 to 50.7) received any training in a community-based setting. Participants identified rotations in community settings (47%), direct mentorship from community-based physicians (40%), and longitudinal clinic in a community setting (36%) as experiences that would have been valuable. Specific curricula of interest included medical operations and administration (63%), health policy (35%), and quality improvement (27%). Respondents in clinical practice for <10 years were more likely to have received any training specifically for a community-based career (RR, 2.13 [95% CI, 1.18 to 3.86]).

CONCLUSION

Our study demonstrates substantial unmet needs as they relate to deliberately training fellows destined for community-based careers. Prospective design of clinical training and curricula emphasizing longitudinal exposures to and key aspects of health care delivery in the community setting are paramount to achieving optimal goal-concordant hematology/oncology training during fellowship.

Advanced practice providers in hematology: actionable findings from national paired APP and physician surveys

ABSTRACT

Advanced practice providers (APPs) are critical to the hematology workforce. However, there is limited knowledge about APPs in hematology regarding specialty-specific training, scope of practice, challenges and opportunities in APP-physician interactions, and involvement with the American Society of Hematology (ASH). We conducted APP and physician focus groups to elucidate major themes in these areas and used results to inform development of 2 national surveys, 1 for APPs and 1 for physicians who work with APPs. The APP survey was distributed to members of the Advanced Practitioner Society of Hematology and Oncology, and the physician survey was distributed to physician members of ASH. A total of 841 APPs and 1334 physicians completed the surveys. APPs reported most hematology-specific knowledge was obtained via on-the-job training and felt additional APP-focused training would be helpful (as did physicians). Nearly all APPs and physicians agreed that APPs were an integral part of their organizations and that physician-APP collaborations were generally positive. A total of 42.1% of APPs and 29.3% of physicians reported burnout, and >50% of physicians felt that working with APPs had reduced their burnout. Both physicians and APPs reported interest in additional resources including "best practice" guidelines for APP-physician collaboration, APP access to hematology educational resources (both existing and newly developed resources for physicians and trainees), and greater APP integration into national specialty-specific professional organizations including APP-focused sessions at conferences. Professional organizations such as ASH are well positioned to address these areas.

Does hematology rotation impact the interest of internal medicine residents in considering hematology as a career?

BACKGROUND

The ongoing need for hematologists is not met in many parts of the world. The hematology rotation during internal medicine residency is an opportunity to attract more physicians to the hematology field. This study aimed to assess the impact of a hematology rotation on internal medicine residents' interest in considering a hematology career.

METHODS

Internal medicine residents were invited to complete an anonymous questionnaire before and after a mandatory hematology rotation. Their interest in pursuing a hematology career was assessed by asking them to rate "Consider hematology as a career" on a 0 to 10 scale (0 = never, 10 = strongly agree). In addition, viewing the hematology workload as manageable, comfort in dealing with cancer and satisfaction with the hematologist lifestyle were assessed before and after the rotation.

RESULTS

Sixty out of 62 IM residents completed the pre- and post-hematology rotation questionnaire (response rate 97%). 80% were in the age range of 25-29 years and 73% were males. Two-thirds were in the senior level (3rd and 4th year) of their residency program and 40% had a prior rotation in a hematology unit. Rating considering hematology as a career increased significantly from a median of 7 (IQR: 5-9) pre-rotation to 8.5 (IQR: 7-10) post-rotation (p = 0.0018). Subgroup analysis showed a significant increase in interest among subgroups except residents > 29 years of age, those with prior hematology rotation and junior residents (1st and 2nd year residency). The change in viewing hematology workload as manageable, comfort in dealing with cancer patients and perceiving the hematologist lifestyle as satisfactory were strongly positively correlated with the change in considering hematology as a career (p = 0.0014, < 0.0001 and < 0.0001; respectively).

CONCLUSIONS

A hematology rotation is associated with an increase in the interest of internal medicine residents in considering hematology as a career. Further research is needed to Identify factors that may make hematology rotations an effective tool in attracting residents to the hematology field.

Classical Hematology Referrals at an National Cancer Institute-Designated Cancer Center: Lessons Learned

PURPOSE

To understand the spectrum and volume of classical hematology (CH) referrals to hematology clinics at a National Cancer Institute (NCI)-designated cancer center (CC) to plan for the delivery of effective and equitable care for this population.

METHODS

One referral office at the Academic CC located in Bexar County, TX, handles all adult hematology referrals. From October 1, 2021, to September 30, 2022, all nonmalignant hematology (MH) referrals were triaged daily to define the category of CH problem. Declined referrals (confirmed at triage that no CH problem was evident) are included as part of this analysis. Electronic consultation (opinion rendered without patient seen) at our CC is available and is not part of this analysis.

RESULTS

One thousand nine hundred forty-five CH referrals were received in the 12-month period. Seventy-six referrals (3.9%) were declined. During the study period, there were 2,289 medical oncology referrals and 779 referrals for MH. CH referrals therefore comprise 39% of all hematology-oncology referrals and 71% of all hematology referrals at the CC. Anemia and thrombotic disorders were the most common categories of the accepted CH referrals at 487 (26%) and 393 (21%), respectively. Video visits were used for 447 of all CH referrals (23%), and the rest were in person.

CONCLUSION

Nearly 40% of all referrals to hematology and medical oncology at our NCI-designated CC are for CH. Effective management of the CH population of patients will allow ideal care for CH problems and also allow cancer-focused care to improve.

Consensus recommendations on peripheral blood smear review: defining curricular standards and fellow competency

Graduate medical education training in hematology in North America is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees routinely review peripheral blood smears (PBS) in providing clinical care. Competency in PBS review at graduation is required by the ACGME. However, there are no consensus guidelines on best practices surrounding PBS review, education, or competency. We describe the generation of proposed theory and the consensus recommendations developed through a multi-institutional focus group, developed using constructivist grounded theory and a modified nominal group technique. Eight academic hematologists, spanning classical and malignant hematology, enrolled and participated in 2 one-hour focus groups. All routinely worked with fellows and half had formally instructed trainees on PBS interpretation. Focus group data were analyzed using mixed-methods techniques. Tenets of emerging theory were identified through inductive coding. Consensus recommendations (CR) were generated. Participants reviewed CR in an iterative fashion until consensus was reached. Strong consensus was reached on multiple aspects of PBS education. All agreed that trainees should learn PBS review through a systematic approach. Group discussion focused on disorders of red and white blood cells. The diagnoses of acute leukemia and thrombotic microangiopathies were most commonly discussed, with specific emphasis on disorders in which prompt recognition was required to avert significant patient morbidity. These CR offer external validity to future research and curricular development for both PBS review and other visuospatial tasks in medical education.

Measuring the Impact of a Pharmacist-Driven Blood Factor Education Program: A Prospective, Single-Center Observational Study

Introduction: Patients with bleeding disorders are best served by multidisciplinary teams. Pharmacists can play a critical role in the optimal management of patients with bleeding disorders through blood factor stewardship strategies and programs. An educational program was developed and implemented wherein a hematology pharmacist provided brief recorded lectures to an entire department of pharmacists in a multi-site health-system with the goal to improve the knowledge base and confidence among this population of general practitioners. Methods: The primary objective of this study was to evaluate the educational outcomes of a blood factor education program for pharmacists. The impact of the educational program was determined by measuring the difference in mean test scores between the pre- and post-program surveys. Results: The final analysis included 214 participants. The primary endpoint of mean competency test score was significantly improved in the post-test compared to pre-test (78.33% vs 52.83%; P < .0001). Any degree of test score improvement was observed in 99% (n = 212) of participants. Pharmacist confidence was significantly improved in all 20 domains of bleeding disorders and blood factor product verification and management. Conclusion: This program identified that most pharmacists in a large multi-site health-system were not familiar with bleeding disorders to a satisfactory degree, commonly because of the relative rare encounters with bleeding disorder-related orders, and that despite systems-based support there was an opportunity to improve practice through education. Such educational programming could be beneficial for the development of pharmacist-provided care and is a measure that could be implemented as part of blood factor stewardship initiatives.

Putting the Heme Back in Heme-Onc: an Evaluation of the Redesigned Hematology Track within the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship

In 2019, the Dana Farber/Mass General Brigham Hematology-Oncology Fellowship redesigned the 6-month Hematology training track/curriculum required for all fellows seeking to double board in hematology and oncology. Responding to both national and local trends suggesting a future shortage of hematologists, the goal of the redesign was to create a new curriculum that would increase fellow interest in hematology, improve fellows' clinical knowledge of hematology, and serve as an example to other Hematology-Oncology programs across the country. The revised track has now been in place for four years, and, in this paper, the authors present the fellow experience with the first four years of the redesigned curriculum. Based on the number of fellows who chose to complete the new curriculum, as well as the fellow evaluations and performance on the Hematology In-Training Exam, the authors conclude that the new curriculum has successfully increased both fellow interest in and knowledge of hematology.

Perceptions of the stressful job search for pediatric hematology/oncology fellows

The pediatric hematology and oncology (PHO) workforce landscape has been evolving over the past decades, with concern for waning interest in the subspecialty. We aimed to evaluate the impact of the initial PHO job search on fellow stress and anxiety, in addition to perceptions of the job search experience and potential areas of improvement. An anonymous survey consisting of demographics, emotional health impacts such as stress and anxiety, and job search experiences was developed and distributed to program leadership at all 74 PHO fellowship programs. At least one representative from 49 (66%) programs responded. Faculty were less likely than fellows to perceive that fellows are struggling to find jobs (p = .0198). However, faculty were more likely than fellows to perceive that fellows are either "extremely stressed" or "stressed" due to job search (p = .0003). By June 2021, 30 of 44 (68%) candidates had been offered a position, and 80% of those had accepted. There were no significant associations between fellow stress level and job offering, proximity to their ideal goals, or change in career type. Common barriers to the job search included geographic constraints and partner employment. Respondents identified centralized job listings, formal training on career development strategies, introduction to various career paths, and more transparency about the search as needed interventions. The perception of difficulty and stress regarding the job search is endorsed by most, identifying a need for more interventions to improve the experience. These data also highlight unmet mentorship and educational needs among PHO fellows in preparing for the job search.

Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: facilitating research through infrastructure, workforce, resources and funding

BACKGROUND

The National Hemophilia Foundation (NHF) conducted extensive, inclusive community consultations to guide prioritization of research in coming decades in alignment with its mission to find cures and address and prevent complications enabling people and families with blood disorders to thrive.

RESEARCH DESIGN AND METHODS

With the American Thrombosis and Hemostasis Network, NHF recruited multidisciplinary expert working groups (WG) to distill the community-identified priorities into concrete research questions and score their feasibility, impact, and risk. WG6 was charged with identifying the infrastructure, workforce development, and funding and resources to facilitate the prioritized research. Community input on conclusions was gathered at the NHF State of the Science Research Summit.

RESULTS

WG6 detailed a minimal research capacity infrastructure threshold, and opportunities to enable its attainment, for bleeding disorders centers to participate in prospective, multicenter national registries. They identified challenges and opportunities to recruit, retain, and train the diverse multidisciplinary care and research workforce required into the future. Innovative collaborative approaches to trial design, resource networking, and funding to surmount obstacles facing research in rare disorders were elucidated.

CONCLUSIONS

The innovations in infrastructure, workforce development, and resources and funding proposed herein may contribute to facilitating a National Research Blueprint for Inherited Bleeding Disorders.

Training Hematologists/Oncologists for the Academic-Community Hybrid: Creating a Fellowship Framework for the Future

PURPOSE:

Conventional hematology/oncology fellowship training is designed to foster careers in academic practice through intensive exposure to clinical and laboratory research. Even so, a notable proportion of graduating fellows opt to pursue a clinically focused career outside the realm of academic medicine. Given the corresponding shortage of oncologists in nonurban and rural settings, improving the representation of hematologists/oncologists in the community setting is a national priority.

METHODS:

We reviewed current national challenges and changing models of cancer care delivery in the context of the traditional academic training model along with trends in practice patterns for recent hematology/oncology graduates. We defined the Academic-Community hybrid (ACH) and how it supports the evolution in contemporary models of cancer care. We then drew on the authors’ experiences to formulate an innovative goal-concordant training paradigm for fellows seeking careers in the ACH model.

RESULTS:

The ACH hematology/oncology fellowship training pathway emphasizes and optimizes professional development domains including clinical care, patient safety and quality improvement, business and operations, cancer care equity and community access, healthy policy and alignment with professional organizations, and medical education.

CONCLUSION:

This novel hematology/oncology training model provides a paradigm for optimizing preparedness for practice in an increasingly complex cancer care delivery environment while addressing workforce shortages and health disparities.

Pilot Study Characterizing the Hematology-Oncology Fellow Job Search Process: Tools Used and Identification of Potential New Resources

While the search for post-fellowship employment is an essential part of early career development, little is known about the tools and techniques fellows use during their job search and the specific challenges they face during the process. In this pilot survey study of hematology-oncology (HO) fellows at a large academic training program, the majority of 20 respondents (43% of all fellows) reported a plan to specialize in medical oncology, and most planned to practice in an academic setting. Fellows who had started the job search process reported using several tools/techniques including online job centers and email distribution lists, word of mouth, prior connections with other institutions, and their HO fellowship program leadership, and most reported that their current institution provided help for their job search in at least one way. Job search challenges included learning about available positions, lack of mentorship on the process, lack of sufficient time for the process, and lack of preparation for negotiation. Fellows suggested additional resources that could be helpful to future job searchers including access to information about prior HO fellowship graduates, training in negotiation and interviewing, and career development mentorship. We plan to use this information to expand our own Career Development program for fellows enacting many of these suggestions, and we encourage the use of this information as pilot data for the development of larger studies across other medical and surgical specialties.

An evaluation of the content of hematology and medical oncology fellowship websites

Introduction

The growing demand for Hematology and Oncology services has greatly piqued the interest of potential residents towards this specialty. Since the programs' official websites are now becoming the primary source of information that potential residents turn to, we aimed to analyze program websites’ content and availability across parameters that have been used by evaluators of websites.

Methods

& Materials: A list of 181 fellowship programs were identified using The Fellowship and Residency Electronic and Interactive Database (FRIEDA). 160/181 were accessed via a hyperlink or Google search. Content of these websites was evaluated on a 40-point criteria system in 10 distinct domains. Websites without accessible links were excluded from the search.

Results

The 160 programs were divided based on the region with the North-East having the most programs (32.5%) and the West having the least programs (12.4%). Exactly 3/4th of the websites had been updated with the latest available information. “Program overview” (89%) was the most common domain present on the websites while “Alumni” was the least common, present on only (25%) of the websites.

Conclusion

When compared with previous similar research, there have been a few significant improvements across the programs' websites, however many still lack important information regarding certain domains. The content and availability of the program's website can encourage or deter an applicant, in their decision to apply to the program, hence making it necessary for programs to augment their websites.

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Assessing the quality of content of fellowship programs using a 40-point criteria system for 10 distinct domains.

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Aim is to help optimise applicant virtual experience when they're searching through fellowship websites.

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The most prevalent domain mentioned by 89% of fellowship websites was ‘Program Overview’.

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The least common domain reported was ‘Alumni information’ by only 23% fellowship programs.

Impact of Hematology Electronic Consultations on Utilization of Referrals and Patient Outcomes in an Integrated Health Care System

INTRODUCTION

Electronic consultations (e-consults) may be a valuable tool in the current era of increased demand for hematologists. Despite the increasing use of e-consults in hematology, their optimal utilization and impact on patient outcomes and workload are largely unknown.

METHODS

In this retrospective cohort study, we studied the hematology consult experience at Veterans Affairs Connecticut from 2006 to 2018. We included 7,664 hematology consults (3,240 e-consults and 4,424 face-to-face [FTF] consults) requested by 1,089 unique clinicians.

RESULTS

We found that e-consults were rapidly adopted and used equally among physicians of different degrees of experience. The number of FTF consults did not decrease after the introduction of e-consult services. E-consults were preferentially used for milder laboratory abnormalities that had been less likely to result in a consult before their availability. Referring clinicians used e-consults preferentially for periprocedural management, anemia, leukopenia, and anticoagulation questions. Eighty-three percent of e-consults were resolved without needing an FTF visit in the year after the consult. Consults for pancytopenia, gammopathy, leukocytosis, and for patients with known malignancy were less likely to be resolved by e-consult. Among patients who were diagnosed with a new hematologic malignancy after their consult, having an e-consult before an FTF visit did not adversely affect survival.

CONCLUSION

In summary, e-consults safely expanded delivery of hematology services in our health care system but increased total consult volume. We report novel data on what types of consults may be best suited to the electronic modality, the impact of e-consults on workload, and their optimal use and implementation.

Results of a Time and Motion Survey Regarding Subcutaneous versus Intravenous Administration of Daratumumab in Patients with Relapsed or Refractory Multiple Myeloma

Purpose

Daratumumab (DARA) is a humanized anti-CD38 monoclonal antibody and approved as monotherapy or in combination with standard of care regimens for the treatment of multiple myeloma (MM). DARA intravenous (IV) administration is time-consuming; availability of DARA subcutaneous (SC) is expected to reduce this burden. A time and motion survey was undertaken to elicit healthcare providers’ (HCPs’) understanding of the workflow and time estimates for administration of DARA IV and SC (beyond treatment time) in patients with relapsed/refractory MM.

Patients and Methods

This web-based, prospective survey collected data from HCPs at sites that actively enrolled patients in the phase 3 COLUMBA trial, a multicenter, noninferiority study of DARA IV versus DARA SC. Data collection included time actively spent on pre-specified drug preparation and drug administration/patient care activities; active HCP and chair time were extrapolated for first and subsequent treatments.

Results

Compared with DARA IV, DARA SC reduced median total active HCP time by 63.8% (from 265.9 to 96.3 minutes) and 49.5% (from 179.2 to 90.4 minutes) for first and subsequent treatments, respectively. When extrapolated to the anticipated number of treatments per year (23 in Year 1 and 13 in Year 2, per label), estimated active HCP time per patient was reduced by 50% in Years 1 (from 70.1 to 34.8 hours) and 2 (from 38.8 to 19.6 hours) for DARA SC versus DARA IV. Estimated chair time for DARA SC was decreased by 97% versus DARA IV for first (from 456.9 to 13.3 minutes) and subsequent treatments (from 238.0 to 8.1 minutes).

Conclusion

These results suggest that DARA SC is associated with less active HCP involvement during drug preparation and drug administration/patient care compared with DARA IV, potentially reducing burdens on patients and caregivers and creating efficiencies for HCPs and healthcare facilities, allowing more patients access to care.

Systems-based hematology: highlighting successes and next steps

Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.