A career in haematology
Authors: David O’Connor, William Townsend
Publication date: 30 Dec 2009
David O’Connor and William Townsend take a look at the road less travelled
For many junior doctors and medical students choosing a career pathway, haematology seems a slightly obscure subject and its perceived complexity means that often it is not considered. In this article we aim to demystify haematology and explain why it is an exciting specialty and an excellent career choice.
Definition of a haematologist
A haematologist is a doctor who specialises in the diagnosis, treatment, prevention, and investigation of disorders of the haematopoietic, haemostatic, and lymphatic systems and disorders of the interaction between blood and blood vessel wall.
—European Hematology Association
Breadth of subject
Haematologists have an enviable role that incorporates laboratory medicine with cutting edge clinical medicine in both the outpatient and the inpatient settings. The integration of clinical and laboratory knowledge makes haematology an almost unique specialty. The opportunity to see a patient in the clinical setting, perform diagnostic tests, interpret the results to make a diagnosis, and start treatment is hugely satisfying.
Haematologists care for patients with a wide range of both malignant and non-malignant diseases. Many consultants subspecialise or develop a special interest in one of a number of different areas within haematology (box 1).
Box 1: Subspecialties in haematology
Haemostasis and thrombosis
Red cell disorders including haemoglobinopathies
Bone marrow transplantation
The management of haematological malignancies—including leukaemias, lymphomas, and myeloma—is both challenging and rewarding. It requires excellent communication skills, teamwork, attention to detail, and astute clinical skills. Although haematology patients are often well for long periods, they can deteriorate rapidly and become extremely unwell, requiring urgent intervention. Such rapid deteriorations may require the haematologist to call on a wide range of general and acute medical skills to manage them appropriately.
Clinical haematology entails much more than the management of haematological malignancies. Conditions that are covered include genetic disorders (for example, sickle cell disease, thalassaemias, and haemophilia), autoimmune disorders (some haemolytic anaemias and idiopathic thrombocytopenic purpura), bone marrow failure syndromes, platelet and red cell disorders, coagulopathies, thrombophilia, and anaemias. As well as managing their own patients, haematologists often provide advice and guidance to other hospital departments and to general practitioners.
Many haematology patients will have been under the care of the haematology unit for a long time, and the opportunity to follow-up patients for prolonged periods, particularly during episodes of severe illness, allows one to build excellent relationships with patients and their families. For many, this is one of the most rewarding aspects of haematology.
Haematologists need to have excellent communication skills. It is not uncommon to have to break bad news—for example, a new diagnosis, disease progression, or the discussion of end of life issues. However, it must be emphasised that it is not all bad news. Haematology is one of the most rapidly developing specialties, with a plethora of new treatments becoming available. Survival rates for haematological malignancies, particularly in the paediatric age group, have dramatically improved in recent years, and often cure is now a realistic possibility.
For many junior doctors considering a career in haematology, the laboratory aspect of the specialty may be off putting, but this should not be the case. All training programmes include a laboratory induction period in which to learn basic laboratory skills. Previous knowledge or experience in the laboratory is not required for entry into a training programme, although an awareness of what is entailed is obviously beneficial.
As a trainee, most laboratory time is spent reviewing blood films and bone marrow aspirates. After a period of training you will soon be reporting films on your own patients as well as other patients in the hospital and the community. Making a diagnosis on the basis of blood film findings alone is an experience most trainees find very satisfying. Laboratory work also includes training in blood transfusion and developing an understanding of coagulation tests, haematinic assays, automated analysers, and other more specialised techniques such as polymerase chain reaction and flow cytometry.
Box 2: Advantages and disadvantages of a career in haematology
Treat a wide range of diseases
Opportunities to develop long term relationships with patients and their relatives
Outstanding academic opportunities
Use specialised techniques like polymerase chain reaction and flow cytometry
Integration of laboratory skills and knowledge in the care of patients
Need to develop extensive skill and knowledge base
Difficult end of life issues
Can be difficult to balance clinical and laboratory commitments
Haematology is particularly attractive for those interested in an academic career. Knowledge of the aetiology of haematological conditions and the development of new treatments is moving at a phenomenal rate, and the United Kingdom is leading the way in a number of areas. Participation in research is actively encouraged and many trainees choose to do a higher degree, usually a doctorate of philosophy (PhD).
Even if you do not do formal research, haematology remains an academic specialty. With improvements in genetic techniques there is now a much greater understanding of an individual patient’s disease and with it the ability to tailor treatment. An interest in basic science and the willingness to keep up to date with new developments are, therefore, vital to a career in haematology.
Entry to a training programme
Entry to a haematology training programme is possible by a number of routes.
Entrants to specialist training in haematology must have completed specialty training (ST) year 2 competencies, either core medical training or acute care common stem (medicine), and passed the part 1 membership exam of the Royal College of Physicians. Full membership of the Royal College of Physicians is required for progression beyond ST3 and for the award of a certificate of completion of training. Trainees entering via the paediatric route must have achieved ST2 basic paediatric competencies and have membership of the Royal College of Paediatrics and Child Health.
When you apply it is helpful, but not essential, to have had some haematology experience. If you have not had this opportunity it would be beneficial to attend some haematology clinics, ward rounds, and the laboratory before submitting your application. Although most junior doctors’ experience of haematology will be in the management of haematological malignancies in inpatients, it is important to remember that there is a lot more to haematology than this when completing application forms and answering interview questions.
It may come as a pleasant surprise that haematology trainees do not do general medical takes. On-call commitments vary from hospital to hospital, but in most centres you are not required to be resident on-call and you are always supported by a consultant. Responsibilities include management of your own patients as well as giving advice to other teams in the hospital.
Training and exams
The training programme is competency based and takes around five years to complete after entry at ST3. Training takes place in a range of different settings including tertiary referral, academic, district general hospitals, and paediatric haematology and blood transfusion units. As with all medical training programmes, haematology training now comprises a system of continuous work based assessments. Progress is reviewed at annual reviews of competence progression, and an online portfolio and curriculum have recently been launched.
The joys of not taking part in the general medical take are countered by the extra hurdle that faces the haematology trainee in the form of the fellowship of the Royal College of Pathologists (FRCPath (Haematology)) exams, which must be passed to gain a certificate of completion of training. This takes the form of two exams testing your knowledge in all areas of haematology: transfusion medicine; general haematology (including laboratory management); haematological oncology; and haemostasis and thrombosis. Part 1 is a written exam usually taken in the first two years of training; part 2 includes a written paper, a practical paper, and a viva, usually taken near the completion of training.
A note on paediatric training
Until recently most consultant paediatric haematologists began in adult medicine. However, it is now more common for paediatric trainees to enter haematology training with the aim of becoming consultant paediatric haematologists. To achieve all competencies in paediatric haematology, an attachment to a paediatric haematology unit is usually required. Those wishing to pursue a career in paediatric haematology who have achieved core competencies in paediatrics will normally spend around two years of their specialty training in haematology in a specialist paediatric centre to achieve the appropriate range of experience. Those wanting to pursue a career in paediatric haematology whose core competencies were achieved in adult medicine will be required to train in general paediatrics for around one year to achieve paediatric core competencies. Not all deaneries can offer comprehensive training to become a specialist in paediatric haematology and so it is best to discuss this with the paediatric haematologists in your deanery if you are interested in this career option.
Haematology is a hugely enjoyable and rewarding specialty. You should consider a career in haematology if you want to work in an area that is moving forwards at a fast rate and want to treat a wide range of conditions. You don’t need to be a genius, but you do need to have an inquiring mind and the ability to work hard and communicate well with patients. Haematology’s position at the interface between the laboratory and the patient is a unique aspect to this fascinating specialty.
We are grateful for the advice and assistance of Paul Harrison, chair of the National Haematology Specialty Advisory Committee, in preparing this article.
Competing interests: None declared.
David O’Connor year 4 specialist trainee in haematology
West Midlands rotation
William Townsend year 3 specialist trainee in haematology North London rotation