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The practice of pediatric hematology oncology requires that physicians draw on strong training in general pediatrics and hematologic and oncologic diseases, as well as translating complex information derived from clinical and basic research into optimal care of their patients. Thus training in pediatric hematology oncology in the United States integrates comprehensive clinical training in the basic and clinical aspects of medicine, particularly as relates to hematologic and oncologic disease, with meticulous training in the conduct and analysis of research and other scholarly activities. At the completion of their training, pediatric hematology oncology subspecialists may focus: 1) on the practice or education of clinical medicine in an academic, hospital based or practice setting, 2) on participation in the design and implementation of clinical trials, or 3) on investigation, in a laboratory setting, of the mechanisms underlying hematologic or oncologic disorders. 1 This broad training of specialists in pediatric hematology oncology draws on the expertise and experience of clinicians and researchers in this and a variety of related fields.
In the U.S., physicians generally begin their specialized training in hematology oncology after having already completed 6-7 years of medical training. Following four years of medical school, physicians are trained in general pediatrics at an American Board of Pediatrics accredited 3-year residency program. To enter a residency or fellowship in the United States, International Medical Graduates (IMGs) must receive certification from the Educational Commission for Foreign Medical Graduates (ECFMG). ECGME certifies that IMGs have successfully completed the United States Medical Licensing Examinations (USMLE) Step 1, Step 2 Clinical Knowledge and Step 2 Clinical Skills (or the former VQE, NBME Part I and II, or FMGEMS), as well as providing documentation of completion of medical training. Additionally demonstration of English proficiency through the TOEFL, Test of English as a Foreign Language is often required. Once accepted into a training program, trainees will need to obtain a Visa such as a J-1 or H-1B Visa.2,3 Detailed information for IMGs applying for training in the
U.S. is available through the
ECGME and other groups such as the
International Medical Graduate
Institute.
Upon successful completion of a pediatrics residency, trainees are eligible to enter a
three-year accredited pediatric hematology oncology subspecialty training program. IMGs may have a portion of this training requirement waived by the Board due to prior training credentials. Graduates from pediatric programs approved by the Royal College of Physicians and Surgeons of Canada are also eligible. Most subspecialty training programs are located at the major children’s hospitals and academic medical centers across the United States. Currently there are approximately 60 pediatric hematology oncology subspecialty training programs listed on the American Medical Association (AMA) sponsored Fellowship and Residency Electronic Interactive Database, FREIDA. There, applicants can find contact and general information on graduate medical education programs.4 Most of these pediatric hematology oncology training programs participate in the National Resident Matching Program. The 2007 subspecialty match for pediatric hematology oncology included 54 participating programs. There were 160 applicants for 129 positions to begin training in 2008. Of the 150 applicants who completed the process 118 (79
percent) successfully matched, 44/54 programs filled (81 percent), and 118/129 positions filled (91
percent).5 Positions were filled with both U.S. and foreign applicants. At this time there are approximately 380 pediatric hematology-oncology trainees of which 27
percent are IMGs.
Pediatric hematology oncology training programs are three-year programs designed to teach fellows the evaluation, diagnosis and management of children with oncologic and hematologic diseases through exposure to a broad range of clinical experiences. These programs are also charged with mentoring fellows to develop the necessary skills for the conduct of clinical or laboratory research. This combined focus on clinical medicine and research has been strongly rooted in the specialty of pediatric hematology oncology for many years. Co-operative groups such as the Children’s Oncology Group have demonstrated dramatic successes in improving clinical patient care through careful clinical research. This has led to significant improvements in outcomes in pediatric cancer and provides an example of the importance of linking clinical medicine with ongoing research. The importance of this integrated training of research and clinical medicine is emphasized and defined in the subspecialty training requirements from the American Board of Pediatrics and the Residency Review Committee.
In the United States, eligibility for subspecialty certification in pediatric hematology oncology requires that the physician is not only board certified in general pediatrics but also has an unrestricted license to practice medicine in the
U.S., Canada, or the country in which they practice and has successfully completed an accredited pediatric hematology-oncology training program. Successful completion of a pediatric hematology oncology program requires not only that fellows acquire clinical competence in treating children with hematologic and oncologic disorders, but also that they participate in scholarly or research activity beginning in the first year. Lastly, board certification then depends on successful completion of the subspecialty examination, which is offered every two years.6
The pediatric hematology/oncology content outline provided by the American Board of Pediatrics demonstrates the comprehensive nature of training in this subspecialty. Training programs should provide fellows with specific training in clinical hematologic and oncologic diseases in pediatrics. Hematology topics include an understanding of normal hematopoiesis as well as the differential diagnosis and management for anemias, leukopenias, thrombocytopenias, hemaglobinopathies, bone marrow failure syndromes, bleeding disorders, coagulopathies and thrombophilias. Trainees should be educated on the diagnosis and management of the range of malignancies seen in childhood such as leukemias, lymphomas, medulloblastoma, neuroblastoma, Wilms tumor, osteoscarcoma, Ewing’s sarcoma, rhabdomyosarcoma and others. An understanding of related topics such as bone marrow transplant, immunodeficiency syndromes, cancer genetics, pediatric transfusion medicine, principles of chemotherapy and radiation therapy, and supportive care of the immunocompromised patient are also expected. These represent only some examples of the many clinical topics that pediatric hematology oncology trainees are expected to learn during their subspecialty training.7
Most pediatric hematology oncology fellowships are designed that trainees focus primarily on their clinical training during the first year and on their research and other scholarly activities in the subsequent two years. Specific requirements for research in pediatric subspecialty training were changed in 2004 to encompass a broader range of scholarly activities. Current requirements specify that fellows are “expected to engage in projects in which they develop hypotheses or in projects of substantive scholarly exploration and analysis that require critical thinking.” This training includes instruction on study design, methodology, statistical analysis, critical review of medical literature, grant preparation, and preparation of research seminars and reports. Fellows are given adequate protected time during their training for completion of a scholarly project and expected to present their results in a written “work product” to the medical community. Fellowship project examples include participation in hypothesis driven laboratory, translational, or clinical research that leads to a degree, or publication, grant application or clinical trial.6
In summary, through their training in pediatric hematology oncology, fellows develop a range of important skills. They establish through supervised clinical experience, a strong basis in the medical care of children with hematologic and oncologic disorders. They gain required skills in leading a multi-disciplinary team important in the care of children with complex medical problems. And through research or a scholarly project, they develop skills in evaluating, analyzing and implementing research questions. This broad education, allows individuals to further tailor their career in pediatric hematology oncology based on their long-range interests and goals.
About the Authors
Lindsay B. Kilburn, M.D., is an instructor of Pediatrics at Baylor College
of Medicine and recently completed fellowship at the Texas
Children’s Cancer Center, where she served as the chief fellow. She continues
to focus on her research through participation in the NIH-funded K12 Faculty
Fellowship in Pediatric Oncology Clinical Research. Dr. Kilburn’s research
interest is in the area of pharmacology and developmental therapeutics with a
special interest in pharmacogenetics. She studies the role of glutathione
s-transferases
in modulating clinical outcomes in children with neuroblastoma as well as
working toward the study of new therapeutic agents in pediatrics through our
Phase I program.
C. Philip Steuber, M.D., is a
professor of Pediatrics at Baylor College of Medicine. He is chair of the Education Division of the Texas Children’s Cancer Center and is
co-director of the ACGME-accredited Pediatric Hematology-Oncology Fellowship
Training Program. He serves as head of the
Leukemia-Lymphoma Team and has been a member of the Pediatric Hematology-Oncology Service at Texas Children’s Hospital since 1972.
References
- Buchanan G: A Career in Pediatric Hematology Oncology? American Society of Pedictric Hematology Oncology, www.aspho.org
- Educational Commission for Foreign Medical Graduates. www.ecfmg.org
- Residency Guide for the IMG. International Medical Graduate Institute, www.imgi.net
- FREIDA Online Search Results. American Medical Association: www.ama-assn.org/ama/pub/category/2997.html
- Pediatric Hematology/Oncology. National Residency Matching Program, www.nrmp.org
- General Eligibility Criteria for Certification in the Pediatric Subspecialties. American Board of Pediatrics, www.aap.org
- Pediatric Hematology Oncology Content Outline. American Board of Pediatrics, www.aap.org
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