Exposure of Early Pediatric Trainees to Blood and Marrow Transplantation Leads to Higher Recruitment to the Field

Abstract

The National Marrow Donor Program (NMDP) projects the need for allogeneic unrelated blood and marrow transplants (BMT) in the United States is 10,000 per year. While the NMDP is preparing to facilitate that number by 2015, there are a number of barriers to meeting this need including recruiting additional health care personnel including BMT providers. To learn how best to recruit BMT physicians, we sought to understand why practicing BMT physicians chose to enter BMT, and why others did not. We conducted a web-based survey amongst Pediatric Hematology/Oncology (PHO) and BMT physician providers and trainees to determine the factors influencing their decision to choose or not choose a career in BMT. There were 259 respondents (48% male, 74% of Caucasian origin); 94 identified as BMT physicians, 112 as PHO physicians and 53 as PHO trainees. PHO and BMT providers spent an average of 53% of their time in clinical activities. More than 2/3 of PHO providers stated that they provide BMT services at their institutions, most commonly for inpatient coverage (73%). The proportion of providers exposed to BMT early in their training was significantly higher amongst BMT providers than PHO providers (51% vs. 18% during medical school [p<0.0001] and 70% vs. 50% during residency [p < 0.005]). Exposure during fellowship (94%) did not differ amongst groups. The decision to pursue a career in BMT was made before fellowship (medical school or residency) in 50% of the respondents. A lower proportion of BMT providers reported currently being involved in education of medical students and residents compared to PHO providers (98% vs. 76%, p<0.0001). Of 53 trainees, 64% reported that they were not contemplating a career in BMT. Of these, 68% stated that inadequate exposure to BMT prior to PHO fellowship was the reason. Only 26% reported BMT exposure in medical school and 43% during residency. The two most common reasons for the choice of a BMT career were the degree of intellectual and scientific challenge (89%) and role models/mentors in the field (67%). This survey suggests that early exposure to BMT during medical school and residency results in increased interest in pursuing a career in BMT. BMT physicians and training program directors can foster interest in the BMT field by promoting BMT focused education and clinical inpatient and outpatient rotations during medical school and residency. This early exposure to BMT may aid in a higher recruitment of future transplant providers.

Introduction

The National Marrow Donor Program (NMDP) projects that the need for allogeneic unrelated blood and marrow transplantation (BMT) in the United States will be 10,000 per year by the year 2015. In an effort to facilitate achieving that number the NMDP has established a System Capacity Initiative (SCI) program designed to address human resource, infrastructure (brick and mortar) and care delivery model issues.¹ While some of this growth is in adult BMT, there has been a significant increase in pediatric transplantation as well. In fact, the number of pediatric BMTs increased from 380 overall in 1997 to 730 in 2007 and continues to rise.² This manuscript describes the results of a survey of pediatric providers as part of the human resource working group arm of the SCI.

The need for more BMT physicians is a natural consequence of the growth of bone marrow transplantation. As BMT becomes associated with less morbidity and mortality, and as graft sources increase, there is a trend towards increased acceptance and usage. As a result, there are not only more patients undergoing BMT, but there is also a steadily increasing number of survivors who require follow-up. Indications for BMT have expanded to include more diagnoses and now include a significant number of non-malignant conditions. Inclusion of these non-malignant disorders, such as sickle cell anemia, is resulting in over 30% of transplants for these disorders being performed in children. In fact, survival after unrelated donor (URD) BMT for nonmalignant conditions such as severe aplastic anemia and sickle cell disease has increased from about 40% in the 1990s to over 80% currently, increasing the acceptance of URD BMT for treatment of these conditions.^3,4 The expanding pool of donor sources, as well as a growing number of voluntary donors, contributes to increase the probability of obtaining a suitable HLA match for transplant.² In addition, the feasibility and availability of transplant for all ages ranging from the neonatal period through the seventh decade of life has contributed to the growing BMT market and the increased need for BMT physicians.

Unfortunately, this rise in demand for BMT may well outgrow the ability of the current physician complement to treat all of these patients. A recent survey conducted by the American Society for Blood and Marrow Transplantation (ASBMT) found that most transplant centers are already functioning at maximum personnel and facilities capacity and did not feel they could increase transplant numbers beyond current patient volumes. In fact, the median ratio of annual transplantations to physician is already 25:1.² Another recent study projected that at least 94 new pediatric transplant physicians would be needed by the year 2020 to meet this new demand.⁵

The NMDP has recommended that BMT physician training and recruitment be increased and retention facilitated in order to be able to offer BMT to more patients in need.⁶ In the ASBMT survey referred to above, many respondents urged the organization to help with recruitment of fellows and residents to the field of BMT.² However, the most effective recruitment strategies have not yet been determined. To learn how best to recruit BMT physicians, we sought to understand why practicing BMT physicians chose to enter the field of BMT, and what disincentives and barriers to recruiting and training more physicians into the discipline exist.

Methods

A web-based anonymous survey was disseminated to all the members of the Pediatric Blood and Marrow Transplant Consortium (PBMTC). In addition, the survey was sent to all the pediatric hematology oncology (PHO) fellowship directors with instructions to distribute it to faculty and fellows in-training. All participants were asked to share the survey with colleagues who might not be included in either of the previous two groups. Prospective respondents were instructed to complete the survey only once independent of how many times they received the survey from different sources. The survey included questions on demographics, physician full-time equivalent (FTE), exposure to BMT at varying training levels through their career, and a request for comments on recruitment of BMT physicians.

The survey was designed to be descriptive. Participants were categorized according to their clinical focus as a primary PHO physician, primary pediatric BMT physician, or a PHO fellow. Though in pediatrics, PHO and BMT physicians may cross cover each other, respondents were asked to choose their primary clinical focus. Data were summarized as frequencies/proportions. Univariate statistical analysis was performed using Stata®, version 11 (StataCorp LP, Texas). In addition, responses were analyzed for major themes amongst respondents. All responses were confidential. Respondents were only allowed to answer the survey once.

Results

Survey Respondents

There were 252 respondents (48% male, 74% of Caucasian origin); 94 identified themselves as pediatric BMT physicians (37%), 105 (42%) as PHO physicians and 53 (21%) as PHO fellows. Since the survey was sent to a select group that was then asked to disseminate, the exact number of people the survey reached is unknown. The demographics for PHO and BMT providers are shown in Table 1. There were no statistical differences amongst the respondents in age, gender, ethnicity and rank for those who chose PHO and those who chose a career in BMT. Though not statistically significant, the number of instructors was higher among the BMT group than the PHO group (11% vs. 2.9%, P=0.059)).

Table 1.

Demographics for Pediatric Hematology-Oncology (PHO) versus Pediatric Blood and Marrow Transplantation (BMT) Providers

	PHO Providers N =105 N (%)	BMT Providers N =94 N (%)	P value
Age (years)
30–40	34 (32)	27 (37)	0.63
40–50	33 (31)	22 (30)	0.99
50–60	28 (27)	20 (27)	1
>60	10 (10)	4 (6)	0.48
Gender
Male	55 (52)	31 (42)	0.25
Female	50 (48)	42 (58)	0.25
Ethnicity
Native American	0 (0)	0 (0)
Asian	12 (11)	13 (18)	0.32
Black or African American	1 (1)	2 (3)	0.75
Hispanic or Latino	4 (4)	1 (1)	0.61
Native Hawaiian or Pacific Islander	0 (0)	1 (1)	0.85
White	86 (82)	53 (73)	0.2
Multi-Racial	2 (2)	3 (4)	0.68
Rank
Instructor	3 (3)	8 (11)	0.059
Assistant Professor	53 (50)	31 (42)	0.37
Associate Professor	21 (20)	18 (25)	0.58
Professor	28 (27)	16 (22)	0.59

Clinical Responsibility

BMT physicians spend most of their time in clinical activities (55%), 28% in research, 9% in teaching, and 13% in administration. PHO physicians similarly reported spending 52%, 30%, 11%, and 14% of their time in clinical activities, research, teaching, and administration, respectively. More than two-thirds of PHO providers stated that they provide some BMT service at their institutions such as pre-BMT consultation, inpatient and/or outpatient care of BMT patients and monitoring and management of BMT late effects. In fact, 67.6% of PHO providers covered the inpatient BMT patients and 42.2% provided outpatient care to BMT patients. A lower proportion of BMT providers reported being involved in the education of medical students and residents compared to PHO providers (98% vs. 76%, p<0.0001).

Critical Importance of Early BMT Exposure

The proportion of providers exposed to BMT early in their training was significantly higher amongst BMT providers than PHO providers. In medical school, 51% of BMT providers were exposed to BMT compared to only 18% of PHO providers [p<0.0001]. During residency, this exposure increased to 70% among BMT providers and was 50% in the PHO providers [p < 0.005]. Exposure during fellowship (94%) did not differ amongst the two groups. However, after removing physicians over the age of 50, the exposure to BMT in medical school and residency was no longer statistically significant between the BMT and PHO providers. The decision to pursue a career in BMT was made prior to accepting PHO fellowship (medical school or residency) in 50% of the BMT providers.

Barriers to BMT Careers

Thirty-nine percent of PHO providers reported having considered a career in BMT at some point. There were 105 responses from PHO on why they did not pursue BMT. These varied factors are listed in Table 2.

Table 2.

Reasons given by PHO physicians (105 responses) and fellows (34 responses) for not pursuing a career in BMT

Pediatric Hematology/Oncology Physicians: Reasons for not Specializing in BMT
Too narrow of a focus
Patients are too sick
Too intense
No available jobs
Stressful lifestyle
Difficult personalities
Poor outcomes
Needed elsewhere in division
Not interested in the field
Not enough exposure during training
Pediatric Hematology/Oncology Fellows: Reasons for not Specializing in BMT
Reason
Poor compensation
Dismal outcomes
Long work hours
No available jobs
Too emotional/too intense
Do not want extra training
Too narrow of a focus
Too scary
Not interested in the field
Not enough exposure during training

Of 53 trainees, 64% reported that they were not considering a career in BMT. Of these, 68% stated that inadequate exposure to BMT prior to and/or during PHO fellowship was the reason. Only 26% reported BMT exposure in medical school and 43% during residency. Table 2 lists the reasons given by the 64% of trainees not pursuing a career in BMT. Respondents were allowed to give as many reasons as they saw fit and all 34 of these fellows responded at least once. Table 2 demonstrates that issues related to perceptions of workload, intensity, and quality of life all impact a trainee’s decision to pursue BMT. Both the PHO physicians and fellows stated lifestyle and work/life balance as reasons for not choosing a career in BMT. This demonstrates the importance of these factors to people no matter their age.

The two most common reasons for the choice of a career in BMT were the degree of intellectual and scientific challenge (89%) and role models/mentors in the field (67%).

Discussion

The results of this survey of pediatric providers suggest that early exposure to BMT leads to higher recruitment to the field. Though the exposure to BMT was not statistically significant between current BMT and PHO providers less than 50 years old, from the fellow surveys, it appear that lack of exposure played a role in not choosing BMT as a primary clinical focus.

Of particular note, our study also found that at a time when BMT education for medical students and residents seems to be vital for recruiting necessary practitioners into the field, fewer BMT providers are involved with education of these groups compared to their PHO peers. Possible reasons for this include limited time for teaching, clinical workload, and current training models for medical and pediatric residencies which may be limiting exposure to highly-specialized fields such as BMT. The results of our survey imply that continuation of trends toward less exposure of early trainees to BMT physicians will result in even fewer physicians entering the field. Without adequate BMT role models to generate interest, the perceived barriers to BMT as a career will continue to deter trainees from entering the field. To correct this, it is imperative for BMT providers to: 1) convince training program leadership of the importance of early exposure to BMT, 2) become reengaged in education and 3) act as role models for early learners and trainees.

One limitation to the study is that the results are restricted to survey respondents and may not adequately represent the field as a whole. Although target leaders at centers were requested to disseminate the survey at their institutions, the uniformity of this dissemination was not tracked. However, a recent study identified 156 pediatric BMT physicians in the US.⁵ If our survey did, in fact, reach every pediatric BMT provider, given that 94 people identified as pediatric BMT, the response rate for BMT providers was about 60%. Therefore, the responses we collected likely reflect the majority attitude within the field of BMT. Also, while we do note that there are BMT physicians that have left the field, we had no way of targeting these physicians with this survey. It would be useful to survey them directly to determine causes for them leaving the field and how retention could be improved.

Similarly, we do not know the response rate for the PHO fellows and PHO providers. However, there are approximately 150 PHO fellowship positions in the United States (personal communication with the National Residency Matching Program®). Since we received responses from 53 fellows at worse, our response rate for fellows would be 35%. According to the American Board of Pediatrics, there are 2500 diplomates ever certified in pediatric hematology/oncology. It is not known how many of these diplomats are currently practicing clinical medicine. At worse, our response rate for PHO is 4%, but is likely much higher than that.

As the need for BMT increases, more people without formal training in BMT are providing service as evidenced by the high number of non-BMT physicians performing BMT duties. If patient volume continues to increase without a concomitant increase in BMT physician training, this trend might worsen. Although non-BMT physicians providing BMT services part time may help programs with staffing, for accreditation purposes and for best practice it makes sense that each center should have at a minimum, a core of dedicated trained BMT specialists.

One finding in our study was that no matter the age of respondent, PHO physicians and PHO fellows both felt the lifestyle and work hours in BMT were not suitable for good work/life balance. This topic of work/life balance has become increasingly more public as people have become more vocal on the subject and its importance. In fact, in a recent article by Lanie Francis, she illustrates how physicians can strive for better work life balance.⁷ There is not yet enough data to support that BMT as a field cannot offer a suitable work/life balance; therefore this will be addressed in a future study.

Conclusion

This survey suggests that early exposure to BMT during medical school and residency is a crucial factor that increases interest and helps trainees choose to pursue a career in BMT. BMT physicians and training program directors can foster interest in the field by promoting focused education and clinical inpatient and outpatient rotations during medical school and residency. This early exposure to BMT may aid in a higher recruitment of future transplant providers. Research opportunities in BMT seem to be an attractive feature to early learners. Perhaps expanding these opportunities for medical students and residents may also contribute to higher recruitment and future advancements in our field.

Figure 1.

Exposure to BMT by level of training for pediatric BMT physicians versus PHO physicians