Onc vs. Heme/Onc

[drfunktacular]

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I am really interested in "liquid" tumors and immune neoplasms (i.e., leukemia, lymphoma, etc.), and less so in things like breast, lung, GI. Is there an advantage in doing a Heme/Onc fellowship if you want to focus on these diseases, versus doing just Onc?

Also, is it feasible to focus mainly on them in community/private practice? I know that every question like this is situation-dependent to a degree, but on balance is this a plausible setup in the experience of you experts?

 

[gutonc]

If all you wanted to do was malignant Heme, then Hem only vs Hem/Onc would be the decision. In practice, the number of people who do this is very small and nearly all of them are in academia. Clinical requirements for Heme is 6 mos benign heme, 6 mos malignant heme. Hem/Onc has an extra 6 mos of solid tumor onc and Onc alone is just malignant heme and solid tumor.

In reality, if PP is where you want to go you should probably double board. If you want to then primarily do malignant heme, you should joint a large group where that kind of specialization is possible. In smaller groups (3-7 docs) there's just not enough people to split up like that.

 

[drfunktacular]

If all you wanted to do was malignant Heme, then Hem only vs Hem/Onc would be the decision. In practice, the number of people who do this is very small and nearly all of them are in academia. Clinical requirements for Heme is 6 mos benign heme, 6 mos malignant heme. Hem/Onc has an extra 6 mos of solid tumor onc and Onc alone is just malignant heme and solid tumor.

In reality, if PP is where you want to go you should probably double board. If you want to then primarily do malignant heme, you should joint a large group where that kind of specialization is possible. In smaller groups (3-7 docs) there's just not enough people to split up like that.

Thanks for that info, gutonc. So the difference between onc or heme alone vs. heme/onc is 1yr vs. 1.5yr? I had always heard the difference in program length is 2yr vs. 3yr. Does that include research time?

 

[hsans23]

ya, heme or medical onc is a 2 yr fellowship whereas heme-onc is 3 years; some programs are 1.5 clinical/1.5 research, others I've researched are 2 clinical/1 research so I think there is some variability there.

i think oncology is going the way of outpatient in general. a doc i know says that; he still works half day inpatient half day outpatient 5 days a week but always says it is definitely going more and more outpatient.

 

[drfunktacular]

ya, heme or medical onc is a 2 yr fellowship whereas heme-onc is 3 years; some programs are 1.5 clinical/1.5 research, others I've researched are 2 clinical/1 research so I think there is some variability there.

i think oncology is going the way of outpatient in general. a doc i know says that; he still works half day inpatient half day outpatient 5 days a week but always says it is definitely going more and more outpatient.

Is this something people see as positive/negative/indifferent?

Is it different for heme/onc as opposed to just onc? I would assume malignant heme still has a significant inpatient component with BMT and leukemia patients.

 

[gutonc]

Is this something people see as positive/negative/indifferent?

Is it different for heme/onc as opposed to just onc? I would assume malignant heme still has a significant inpatient component with BMT and leukemia patients.

The answer to your first question is yes.

You will not get a job as a transplanter or hem malignancy guy if you're single boarded in onc. It just won't happen. It's also getting harder to get a BMT job w/o a BMT fellowship (although not impossible since it's not a boarded fellowship yet). I'm also not aware of any community-based transplant centers, I'm pretty sure they're all university. Community oncologists certainly manage post-BMT transplants (after their 100 day f/u when they get to go home) but if anything bad happens and they need hospitalization, they almost always get sent to the transplant center. At least, that's what happens here.

Inpt solid tumor onc is a lot of neutropenic fevers and complications of advanced disease as well as chemo admits, both for toxic continuous infusion stuff than needs frequent monitoring (ifosfamide, HyperCVAD) and for newly dx'd lymphomas and SCLCs in extremis. My current inpt service of 6 has 2 new small cells, two neutropenic fevers, one pt getting ifosfamide and one end-stage pt who refuses hospice and wants to die in the hospital...and I've got an incoming relapsed lymphoma w/ bad disease who needs treatment faster than we can arrange as an outpt.

Just for the record, I am single boarding in onc as part of the research pathway. The primary difference between my rotations and my double-boarded colleagues is that I do no benign hematology.

 

[drfunktacular]

Just for the record, I am single boarding in onc as part of the research pathway. The primary difference between my rotations and my double-boarded colleagues is that I do no benign hematology.

I've heard it said fairly often that many people do only onc expressly to avoid bothering with benign heme (sicklers in particular); is benign heme something you just have to love to do (due to low reimbursement, high hassle factor, a la ID)?

Not to but with your comment in mind, in PP, if you aren't doing benign heme is there any advantage to heme/onc over onc?

 

[orientedtoself]

I'm also not aware of any community-based transplant centers, I'm pretty sure they're all university.

rocky mountain bmt is a university-affiliated heme transplant program. they are based out of presbyterian/ st luke's hospital in denver.

city of hope in la also does hundreds of transplants per year- i don't know if they are considered a university-affiliated program.

 

[gutonc]

rocky mountain bmt is a university-affiliated heme transplant program. they are based out of presbyterian/ st luke's hospital in denver.

city of hope in la also does hundreds of transplants per year- i don't know if they are considered a university-affiliated program.

I wasn't aware of Rocky Mountain. Interesting. CoH is more like MSKCC which is technically university-affiliated and not actually a university program but is very decidedly academic. But your exception more or less proves the rule.

 

[Nerdorama]

I want to offer a different opinion than Gutonc on this issue of Heme vs Onc vs Heme-Onc boards. This is based on the opinions of several attendings/PIs in my fellowship program (a very academic program) and on my own perceptions.

If you are going into private practice, then double boarding is almost essential.

If you are going into academics, then single boarding is fine. In this setting, single boarding in Heme is much less useful than single boarding in Onc, even for people interested in hematologic malignancies. At the institutions where we rotate as heme-onc fellows, everyone who actively does transplant has boarded either in Heme-Onc or in Onc, although the attendings at my program have said that at smaller academic centers, the rare folks who board only in Heme may sometimes do transplant. My impression is this is largely because, as someone else said earlier, Heme boards really benefit those who want to learn non-malignant hematology. If you are interested in transplant, the advice from attendings/PIs in my program would be to double board, but if you were insistent on single boarding, we would say you should do Onc but also do some transplant rotations as would be required for Heme boards.

As for my own experience, my academic and clinical interests are mostly in malignant hematology, and I went through this exact same set of choices at the end of my first year of fellowship as I had hoped to shorten my length of training. In the end I decided to do both Heme and Onc and am very happy with my decision. Feel free to PM me if any of you have add'l questions.