COVID-19: A Big Test for Hematology Trainees

When COVID-19 restrictions closed research laboratories across the country, it meant Erik Kimble, M.D.’s hematology and oncology training came to a virtual crawl. Not surprisingly, Kimble, who completed medical school in Mexico at the height of the swine flu pandemic, was overwhelmed yet again with uncertainty.

He spent months preparing for his transition from clinical to research training. He took advanced biology courses and learned scientific techniques used to study the immune system and transplantation. But as the newest member of the laboratory, he had no choice but to wait until on-site work restrictions lifted.

And once they did, “it took me longer to start my project, and no one knew me like they did in the hospital when I was completing clinical training,” said Kimble, who is in his final year of the Hematology-Oncology Fellowship Program at the Fred Hutchinson Cancer Research Center in Seattle, Washington. “It’s been hard to stand out and interact with the local scientific community without in-person conferences or networking events. I’m eagerly waiting for those opportunities.”

Kimble’s concerns come at a critical time for the field of hematology, which is suffering from a dearth of trainees specifically interested in the study of blood diseases that are not cancer, also known as classical hematology. One study found that only 5% of U.S. fellows in hematology and oncology training programs expressed an interest in classical hematology – a number that hasn’t changed in 20 years.

The COVID-19 pandemic has presented a particularly acute demand for these types of hematologists. They observed that some people who had died from COVID-19 formed blood clots throughout their bodies, even in their smallest blood vessels. But the pandemic also has reinforced serious concerns for roughly 620 hematology-oncology trainees about burnout, career and networking opportunities, research funding, salary, family well-being, mental health, and even finding a job.

Fellows frustrations

“The pandemic effectively put a year-long pause on my lab project that was to provide the foundation for a research faculty position,” said Jeremy Allred, M.D., who recently finished the Hematology, Oncology and Transplantation Fellowship at the University of Minnesota Medical School in Minneapolis and joined the faculty there as an instructor focusing on blood cancers.

“When the pandemic started, the research lab was shut down during that time for safety reason,” Allred said. “As a result, I reoriented to focus on other writing projects, grant applications and solidifying my clinical knowledge, before starting as a new faculty member.”

The hit to manpower and laboratory resources, Allred said, meant his own research productivity took a hit. Core labs – centralized laboratories that maintain and support equipment for an entire institution – lost many of their full-time staff. As a result, Allred’s work, heavily dependent on these facilities, came to a screeching halt.

Neither Allred nor many of his peers could access the lab unless they could adapt their existing projects to address questions related to COVID-19. “Some trainees had to completely abandon their projects or take a leave of absence due to the lab closure,” said Gregory Vercellotti, M.D., professor of medicine in the division of hematology, oncology and transplantation at the University of Minnesota Medical School, who also oversees hematology training. “For others, the pandemic markedly altered their timeline and ability to get new data.”

Not only were research projects curtailed; so were clinical trials, added Sean Tracy, M.D., Ph.D., who is also transitioning from the Hematology, Oncology and Transplantation Fellowship to join the faculty at the University of Minnesota Medical School. “Even though some of our support staff who keep our clinical trials going are returning to work, we still have to deal with the backlog of documentation needed to carry out and enroll patients in trials.”

Making way for hematology training in the post-COVID era

Yet, for all the challenges the pandemic has presented to current trainees and programs, it could drive more medical residences to hematology. And while it’s too early to know for sure, said Rakhi P. Naik, M.D., M.H.S., associate director for hematology at Johns Hopkins University in Baltimore, Maryland, “it definitely brings attention to the specialty and makes it look more appealing.”

For example, two of Naik’s third-year single-board hematology fellows, Jennifer Jones, M.D., and Gloria Gerber, M.D., were able to adapt their initial research projects to address questions about COVID.

Jones, who is interested in the intersection of transfusion medicine and sickle cell disease, is studying how exchange transfusion practices changed during the pandemic. Gerber, who is interested in coagulation and disorders involving a part of the immune system called complement, studied the effects of the COVID-19 mRNA vaccine on patients who have a rare acquired, life-threatening disease of the blood called paroxysmal nocturnal hemoglobinuria.

“We know that people who have COVID-19 are prone to clotting, and we have a lot of evidence to suggest that people who have the disease have complement amplification and dysregulation,” Gerber said. “So, for me, being able to study COVID-19 aligns with my overall career interests in the immune system and thrombosis.”

Janis Abkowitz, M.D., head of the division of hematology at the University of Washington School of Medicine, is working to turn challenges highlighted during the pandemic into learning opportunities that could attract the next wave of hematology trainees.

She noted, for example, the growing need for patients to consult with classical hematologists who can answer questions about how to optimize patient care among people with nonmalignant hematologic disorders. This is a particular need at major medical schools like the University of Washington, which often manages patients from surrounding states like Wyoming, Alaska, Montana and Idaho.

“General practitioners may not have the answers to specific questions regarding the duration of anticoagulation, a particular anticoagulant, or how, when, or whether to give iron intravenously, for example,” Abkowitz said. “E-consults are one possibility, especially in the post-COVID era. And it’s important to explore as part of training the next generation of classical hematologists who can answer these questions more broadly in the communities they serve.”

How funding agencies are helping

Needless to say, it’s been tough being a division director, Abkowitz said. The majority of hematology-oncology trainees, like Kimble, are funded by NIH training grants, which funds two years of research. “If the trainee can’t access the lab or learn techniques because they can’t sit next to a person to show it to them, and then they have to write the next grant to be ready for independent funding, that timeline doesn’t work anymore. That’s been a huge concern,” Abkowitz said.

Indeed, the 2020 NIH extramural survey of 45,000 researchers found that early career investigators have the greatest degree of anxiety, in large part because of the pandemic. This prompted NIH to offer no-cost extensions up to two years for young investigators for the sole purpose of completing grant activities. For fiscal year 2022, NIH also will extend a childcare allowance to training grant awardees to help ease the childcare challenges presented by the pandemic.

Additionally, some agencies have accepted late grant applications, and others have allowed young investigators to submit preliminary data for grants up to 30 days before a peer review committee meets – something that NIH never allowed in the past.

For hematology-oncology fellows, the American Society for Hematology (ASH) has created the ASH Research Restart Award to reduce the impact of the pandemic on the research and careers for early-career hematology investigators. And in 2022, the Hematology-Focused Fellowship Training Program will launch an effort to recruit residency graduates and retain them for life-long subspecialty careers focused on classical hematology.

While some hematology-oncology trainees may still steer to more traditional paths, Kimble knows he is determined to become a physician-scientist in hematology.

“Most trainees think twice about the path to becoming a translation scientist, and COVID has made this path much harder,” Kimble said. “Every generation goes through things. I think [the pandemic] is our generation’s struggle. But, for me, I have a strong conviction that this is what I want to do and grateful for mentors who helped me to stay on track despite these challenges.”

NIH Resources

Reminder – Requesting Extensions for Early Career Scientists Whose Career Trajectories Have Been Significantly Impacted by COVID-19: https://grants.nih.gov/grants/guide/notice-files/not-od-21-052.html

Updated Notice of Information: NHLBI Extensions for Career Development Award (K01, K08, K23, K25) Recipients Whose Career Trajectories Have Been Significantly Impacted by COVID-19: https://grants.nih.gov/grants/guide/notice-files/NOT-HL-21-009.html

ASH Resources

COVID-19 Resources: https://www.hematology.org/covid-19

ASH Research Restart Award: https://www.hematology.org/awards/career-enhancement-and-training/restart-award

Hematology-Focused Fellowship Training Program: https://www.hematology.org/hffp