As the field of hematology/oncology becomes increasingly specialized, physicians who have completed their fellowships are considering extended fellowships and advanced degrees, which may increase their competitive edge in academic medicine, but come with all the burdens associated with delaying the start of a career.1

“Hematology is becoming increasingly subspecialized; most people are not general hematologists anymore,” said Kevin Kuo, MD, a fourth-year oncology fellow at the University of Toronto, Canada. “If new grads just coming out of fellowship want to survive in the academic environment, they have to develop their own niche.”

Dr. Kuo felt further training in his area of research could provide him with skills that he could then bring to an academic environment.

“Some people may decide to focus on outcomes research, so they use the time to get a master’s degree in public health,” Dr. Kuo said. In his fourth year of training, he will focus his clinical work and research exclusively on heritable red blood cell disorders.

Martin Palmeri, MD, an oncologist with Mountain State Health Alliance in Johnson City, Tennessee, never felt compelled to pursue extended training, but he understands why some would consider it.

“You would be working in an environment where you are academically challenged on a daily basis and you get to move the field forward,” he said. “There is the potential for making a greater contribution to society and the scientific community. If you’re a good researcher and you’re good at getting grants, you could have a very successful and fruitful career in progressing the field of hematology and oncology.”

Paradoxically, however, increased specialization comes with reduced marketability. “It’s a real gamble,” said Dr. Kuo. “If you’re a general practitioner, you can basically go into any small town and hang up your shingle and practice; same thing is true if you’re a general internist.”

A highly specialized hematologist, however, will likely need to be in a larger setting with the capacity for referral, and jobs that sync with his or her specific skills and interests may be scarce. “When you become super subspecialized, there are fewer jobs available,” Dr. Kuo explained.

“If you score, you score big because you get to practice in [the specialty] you love and earn a decent salary. On the other hand, when you finish your extended training, there’s a chance that someone who graduated ahead of you with similar credentials got the job. The saving grace is that you finished your training and wrote your exam so you can go into practice if the plan falls through,” Dr. Kuo said. “But at the same time, it’s like you wasted a year or 2 already.”

Given the age that physicians are likely to be at the point where they would consider further training, that year or 2 can be quite critical, not only for advancing their career, but for social and family reasons. For women in their peak childbearing years, maternity leave could prolong a fellowship.

“Even from a guy’s perspective it’s quite difficult,” said Dr. Kuo, who is 33 years old. “Most doctors are married and have kids already, but I’m still not married and don’t have any kids.”

To some degree, postponing or delaying marriage and children has to do with geographical barriers. “Many people do their third or fourth year in the same institution where they did their first- and second-year fellowships,” Dr. Kuo said. “But if you do it outside of your original institution, it becomes a question of how long you can do your fellowship without straining your relationship.”

Probably the biggest barrier to pursuing extended training, however, is financial. Using data from the Bureau of Labor Statistics, the 2010 MGMA Physician Compensation Survey, the 2010 MGMA Academic Practice Compensation and Production Data, and other sources regarding medical student debt, as well as data on physician reimbursement, home mortgages, retirement planning, cost-of-living expenses, and college savings, Dr. Palmeri and colleagues found academic hematology/oncology careers to be associated with a budget deficit in most scenarios, particularly when fellows extend their training.2

In an abstract presented at the 2010 American Society of Clinical Oncology annual meeting, they concluded the rise in medical student debt and housing costs together with delaying retirement savings can result in substantial budgetary shortfalls for fellows pursuing academic careers in hematology/oncology. 2

“Medical student debt is rising at a phenomenal rate,” Dr. Palmeri said. “In 2005, less than 10% of medical students had debt more than $200,000. Now just over 30% of medical students graduate with debt greater than $200,000, with the average medical student debt rising to approximately $160,000. The interest on those loans just continues to grow, particularly if you do an extended training program and delay paying off your debt.”

The financial problem is exacerbated by the relatively low pay of academic work compared with private practice. “Reimbursement in academic medicine is about half that in private practice in a lot of cases, and a lot of people who are expanding their training to get this extra research to help them get into academic careers are doing themselves a significant financial disservice,” Dr. Palmeri said.

Before committing himself to his fourth year of fellowship training, Dr. Kuo spent a lot of time examining the issue with a mentor. “He is an MD/PhD and is established in stem cell research. We had talked a lot about why I am doing this training, how long I should pursue it, and what time frame I should set to achieve my set goals and objectives,” he said.

He recommends that other fellows pondering an extended training option seek input from others who have done so. “I think the best resource would be to talk to those who have walked the path before,” Dr. Kuo said. “Talk to other fourth-year fellows and mentors who have pursued a similar line of training.”


  1. Kuo K, Palmeri M, Woyach J. The perpetual fellow—extending fellowship training in hematology: the trainee perspective. The Hematologist. Accessed August 15, 2011. 

  2. Palmeri M, et al. Quantifying the personal financial impact of a career choice in academic hematology/oncology (AHO). J Clin Oncol. 2011;29(suppl; abstr 6076).

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