A career in haematologyBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7456.s3-a (Published 03 July 2004) Cite this as: BMJ 2004;329:s3
It's a rapidly changing specialty mixing the best of laboratory and clinical medicine, but it's not much good if you don't like exams. Lise Estcourt and Gail Miflin outline what it entails
“So do you actually see patients then?” is a question many haematologists used to hear, perhaps reflecting a formerly low profile in the eyes of the general public (and doctors). But things are changing: the number of consultant haematologists continues to rise and we generally have a higher profile both within the hospital and in the public eye. Although many people do not think of haematology as being a large specialty, there are now 812 consultant haematology posts in the United Kingdom (Royal College of Pathologists, March 2004, unpublished data)—similar to the number of cardiologists in the country. Departments usually have at least two consultant haematologists and this may rise to 10 or more in large centres.
Haematology is a varied and stimulating discipline, perhaps one of the broadest in the hospital, which includes haemato-oncology, genetic disorders (including sickle cell disease, thalassaemia, haemophilia, and thrombophilic disorders), and transfusion medicine. Because of this most consultants have a subspecialty interest (see box).
What do haematologists do?
Patient care has now become the main focus of most haematologists' workload. Haematologists have direct responsibility for their own patients and are concerned with the management of medical, surgical, obstetric, and paediatric patients within the hospital. Patients are of all ages and have a broad mix of life threatening, acute, chronic, and terminal disorders. Most patients are extremely worried about having to see a haematologist and are grateful for the care we give them.
Clinical haematologists often develop strong relationships with their patients. This may be because the patient has a protracted spell in hospital, in the case of acute leukaemia or bone marrow transplantation, or because he or she has a genetic disorder. Haematologists treat several of the most common genetic diseases in the United Kingdom, such as sickle cell disease, haemophilia, thalassaemia, and lysosomal storage disorders. With these disorders it is not uncommon for patients to have the same haematologist for the lifespan of the patient or until the consultant retires (whichever is shorter). Some subspecialties (such as haemoglobinopathies) may be practised predominantly in certain areas of the country for demographic reasons, while others (such as treatment of haemophilia or bone marrow transplantation) are practised mainly in accredited specialist centres—usually in large teaching hospitals. This may need to be taken into account when deciding on subspecialisation.
Specialist interests within haematology
Bone marrow transplantation
Coagulation and platelet disorders (including haemophilia, thrombophilia, thrombotic thrombocytopenic purpura)
Red cell disorders (including sickle cell disease and thalassaemia)
Lysosomal storage disorders
Laboratory haematology (including diagnostic haemopathology)
Bone marrow failure syndromes
Most consultant haematologists also have considerable responsibility in the laboratory. A hospital always has a routine laboratory, a coagulation laboratory, and a transfusion laboratory (which provide basic haematological tests such as full blood counts, erythrocyte sedimentation rates, or plasma viscosity; coagulation screens; and blood cross matching). Most hospitals also have specialist laboratories providing one or more of the following: haematinics, haemoglobin electrophoresis, and diagnostic bone marrow interpretation. Larger centres are also able to provide specialist coagulation tests (thrombophilia screens and factor levels), specialist red cell tests (erythropoeitin, red cell enzymes, and membrane tests), and specialist diagnostic haemato-oncology (immunophenotyping, cytogenetics). Most specialist transfusion tests are done in the larger centres or blood transfusion centres.⇓
The consultant haematologist is head of the laboratory and must work closely with biomedical scientists to ensure that well qualified staff perform high quality work in a safe laboratory environment. Much of the day to day laboratory management is provided by senior biomedical scientists. However, haematologists must have an understanding of the principles and limits of the tests done as well as an understanding of the meaning of the results. The role of the haematologist is to provide interpretation of the tests within the clinical context and to give advice accordingly.
Some haematologists rarely, if ever, have direct responsibility for patient care. These may include specialists in transfusion medicine based in transfusion centres, laboratory haemopathologists, or academics who decide to work wholly in scientific research.
Because of the dual clinical and laboratory nature of haematology, consultant haematologists often find themselves and their work split between two or more directorates in the hospital—usually pathology and medicine (or paediatrics, or both). Some find this rather unacceptable as it doubles the number of management meetings and it is not always clear under which directorate business cases should be submitted. Others see this as a good opportunity for influence within the hospital, and in practice most departments split the attendance at different directorate meetings between colleagues.
In a specialty that has so many innovative clinical and laboratory developments, many opportunities exist for research. Haematologists are ideally placed to take full advantage of the rapid advances in molecular and cell biology, both in basic science and translational research. Many new drugs are being introduced, especially in oncology. There is also a long history of Medical Research Council trials in haemato-oncology resulting in some of the best outcome measures in the world for patients with acute leukaemias. Many opportunities exist for teaching: a number of departments now have medical students attached to them, and most consultants also teach biomedical scientists, senior house officers, and specialist registrars.
How to become a haematologist
Potential haematologists have to do at least two years' general professional training in general medicine, including experience in unselected acute medical admissions. Membership of the Royal College of Physicians (MRCP) or the Royal College of Paediatrics and Child Health (MRCPCH) is a prerequisite to obtaining a national training number (NTN). Before applying for an NTN it is useful but not mandatory to gain experience in haematology as a senior house officer, and experience in intensive care medicine is also an advantage.
Higher medical training
Higher medical training takes at least five years, up to two years of which will be spent in district general hospitals. The first two years will be directed towards acquiring a broad, general experience in haematology. This will include training in laboratory aspects of haematology, learning the principles of the laboratory tests, and becoming proficient in reporting blood films, bone marrows, cerebrospinal fluid cytospins, and simple lymph node histology. You'll also gain knowledge of the clinical management of common haematological disorders, with a basic grasp of specialist areas and an understanding of communication and management issues in haematology.
Trainees also learn a variety of practical procedures integral to their specialty. These include bone marrow aspirates and trephines and the administration of intrathecal chemotherapy to both children and adults.
This period of training is followed by the MRCPath (member of the Royal College of Pathologists) part 1 examination. The exam consists of two written papers designed to measure a trainee's knowledge of laboratory and clinical haematology. Successful candidates progress to a three day practical exam, made up of four components: morphology, coagulation, blood transfusion, and a viva. Around 60% of candidates pass the written exam and half then pass the practical, resulting in an overall pass rate of about 30%—similar to MRCP exams. Once candidates have passed the written paper they do not have to take it again if they are not successful in the second part, and some candidates choose to sit the papers separately.
The final years
In subsequent years trainees devote their time to acquiring self sufficiency in clinical and laboratory haematology and also to developing a subspecialty interest. They are encouraged to attend major specialty meetings (such as those organised by the American and British Societies for Haematology). In the final year of training trainees sit the MRCPath part 2 examination. This consists of two 30 minute vivas, and includes one compulsory question about management. One viva may be chosen in a specialist subject. Part 2 is an exit exam which is aimed at ensuring competency to practise as a consultant. The pass rate is about 70%. As with other medical disciplines, completion of training is confirmed by the award of a certificate of completion of specialist training by the Joint Committee for Higher Medical Training. It is rare for trainees to be dually accredited with general medicine, in contrast to most medical specialties.⇓
Research is not a compulsory part of training but is actively encouraged. Many trainees win grants to do research, and a large number of senior academics have also done research abroad, usually in the United States. Currently 23 trainees are on Medical Research Council or Leukaemia Research Foundation clinical scientist fellowships. Up to one year of research can be counted towards the five year training period.
At the moment, getting a haematology consultant post is comparatively easy; around 30 posts in this country are currently vacant. However, getting an NTN is less easy, and personal experience suggests that, certainly in London, the standard of trainees applying for an NTN is excellent and many have locum appointment for training posts before getting their NTN.
Is haematology for me?
Haematology is exceptional as haematologists are concerned with both the clinical management and the laboratory investigation of the patient. Many haematologists say this is why they started a career in haematology. The successful haematologist needs a particular set of personal qualities: this includes the ability to keep a cool head in an emergency, a willingness to accept new ideas as disease management regimens change rapidly, an empathic approach towards patients with chronic and terminal disorders, and an ability to work with other multidisciplinary team members. Haematology also provides a unique forum for interacting with other professionals within the hospital and is great fun.
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