ASH Report Carves Out a New Role for Hematologists

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:

• Heparin-induced thrombocytopenia (HIT)—Implementation of care pathways could reduce unnecessary exposure to heparin and direct thrombin inhibitors, and better utilize laboratory testing for suspected HIT.
• Thrombotic thrombocytopenic purpura (TTP)—Improved utilization of the metalloproteinase ADAMTS13 assay as part of a clinical analysis to diagnose TTP in order to better identify patients who need plasma replacement.
• Medical director for hemostasis/thrombosis—Hematologist-led stewardship programs could broadly and systematically address coagulation-related disorders within a medical center or delivery network. This includes handling of cancer-associated thrombosis, which is common in pancreatic and other solid tumors.
• Nonmalignant hematology consultation in an ACO environment—A designated hematologist specializing in nonmalignant conditions could better evaluate and manage the demand for hematology consultations, which is expected to grow as incentives for primary care physicians to handle these patients continue to decline.

Vanderbilt Experience Illustrates the Issues

The ASH concerns in the evolving landscape of hematology care are reflected at Vanderbilt University Medical Center, according to Kevin T. McDonagh, MD, a professor of Medicine and a hematologist/oncologist at the Vanderbilt-Ingram Cancer Center.

In his division, there are about 60 attending physicians, approximately 20 of whom are involved in hematology care. The majority of those hematologists manage patients who have malignant diagnoses such as leukemia, lymphoma, or myeloma, or who are undergoing transplants. Vanderbilt has only three faculty members who practice in both malignant and benign hematology and, until recently, had just one doctor who focused exclusively on nonmalignant hematology, said McDonagh.

That doctor has left for a position elsewhere, leaving the hospital system interviewing for not just one replacement, but two additional nonmalignant hematologists, as Vanderbilt has recognized the need for more. That won’t be easy, McDonagh says. “It is difficult to find people who have really focused in benign hematology during their training. As the report said, this is probably an area that has been somewhat deemphasized in many hematology/oncology programs as the volume of malignant diagnoses and management has increased.”

McDonagh speculated that at large institutions less money has been set aside for hematology salaries and related support staff. “The way that budgeting is done is not perceived that this is something that is as profitable or as valuable to the institution’s bottom line. I think as the report emphasized, it is not hard to take a step back and realize how critical and valuable this expertise is to institutions, particularly at a high level academic institution that does complex surgery and takes care of incredibly sick patients. You need people with this type of expertise,” he said.

In pondering the future of hematology care, Vanderbilt is considering systems-based roles for specialists in the field. “One approach that we are looking at is the impact that somebody in this position has in terms of pharmacy services, because the management of the portfolio of drugs that are used to treat, in particular, hemostasis and thrombosis disorders is very, very large. That has a huge bottom-line impact on the institution.”

He noted that Vanderbilt already has diagnosis management teams comprised of pathologists and hematologists who review coagulation testing ordered by other doctors.

“All of the coagulation testing that is done both in the inpatient as well as the ambulatory setting is reviewed by experts in hemostasis who generate a report and recommendations that flow back within our electronic record to physicians who order those studies,” said McDonagh. “And that might be a hematologist/oncologist who doesn’t have a special expertise in hemostasis/thrombosis, but it might also be a primary care physician or an obstetrician or a neurologist who has even less expertise in that area.”

“It is a very effective model,” he added.

References

1. Wallace P, Connell N, Abkowitz J. the role of hematologists in a changing United States healthcare system [published online March 6, 2015]. Blood. 2015;doi:10.1182/blood-2014-12-615047.
2. The American Society of Clinical Oncology. The State of Cancer Care in America: 2015. Available at: http://goo.gl/XndwW8. Published March 17, 2015. Accessed March 20, 2015.