Community Practice Training During Fellowship Often Falls Short

Although most hematology/oncology fellows will treat patients in the community setting over the course of their careers, adequate preparation for outpatient care often falls short during fellowship, prompting instructors to reevaluate their training approach in this area, according to Shubham Agrawal, MD.

“Currently, most fellowship training programs are based in major academic centers, and few, if any, offer specific pathways tailored to community-based hematology/oncology,” Agrawal, a hematology fellow at the University of Minnesota Medical School in Minneapolis, said in a statement to Oncology Fellows. “As a result, fellows interested in community-based careers often need to independently seek opportunities to gain relevant experience. This highlights a growing need for specialized training pathways that align with the goals of trainees aiming for careers in community hematology and oncology. [Because] 80% to 85% of patients with cancer receive treatment in community settings, high-quality and efficient community oncology models are essential to ensuring equitable cancer care. Hence, it is crucial to provide training experiences to equip trainees for their future careers as community-based hematology/oncology providers.”

Agrawal was the first author of a national assessment published in JCO Oncology Practice, which sought to identify the training needs of hematology/oncology providers practicing in community- or academic-community hybrid-based settings.1 To conduct their study, Agrawal et al developed a cross-sectional online survey study and distributed it to practicing hematologists/oncologists in community-based and academic-community hybrid settings across the United States from March 2022 to February 2023.

The survey included 14 multiple-choice items covering 3 primary domains: current practice setting and satisfaction, opportunities for community-based training during fellowship, and additional clinical/didactic experiences desired during fellowship that could better prepare respondents for community-based careers. It also included 2 open-ended questions: What would better equip a hematologist/oncologist in training to work effectively in your current clinical practice setting? What comments or suggestions do you have regarding a professional development pathway for hematology/oncology trainees with a planned focus in community-based hematology/oncology?

Respondents were also asked to provide information regarding their sex, years in clinical practice, and location of fellowship training. The primary outcome of the study was whether hematologists/oncologists based in community or academic-community hybrid practices felt that they had received adequate training during fellowship to prepare them for their current roles and in their current mode of practice.

“Given that a large percentage of hematology/oncology care is delivered through community-based models, our study aimed to assess the perspectives of fellowship training leadership on preparing fellows for careers in community-based hematology/oncology,” Agrawal said. “The survey’s goals include evaluating directors’ attitudes on the inclusion of community-based training within fellowship programs, the presence of clinical or nonclinical experiences designed to build skills specific to community practice, and their opinions on motivating fellows to pursue community-based career paths.”

Most survey respondents were men (63.2%), White (57.6%), board certified in both hematology and oncology (64.0%), and very satisfied in their current work setting (63.2%). Respondents’ current work responsibilities included outpatient clinical practice (93.6%), training fellows (29.6%), administrative responsibilities (16.8%), engagement with clinical trials (11.2%), inpatient clinical practice (8.0%), research (8.0%), medical education (6.4%), and quality improvement (5.6%). The most common reasons for choosing their current work setting for respondents included location (59.2%), work-life balance (53.6%), desire to be a primary clinician (47.2%), compensation (39.2%), and mentor-directed experience (20.0%).

Findings from the study demonstrated that survey respondents (n = 125) received specific training for a community-based career during fellowship at a rate of 41.8%; rotations in the community clinic/setting (44.8%), community-based clinical trials (20.8%), quality improvement (12%), business and operations (10.4%), and health care delivery research (7.2%) were cited as high-impact experiences during their time as fellows, and nearly all respondents were satisfied with their training during fellowship (98%). Being in practice for less than 10 years was the only factor that was significantly associated with an increased likelihood of receiving community-based training during fellowship (relative risk, 2.13; 95% CI, 1.18-3.86).

In terms of clinical experiences during fellowship that would best equip trainees for future careers in community-based hematology/oncology, respondents indicated rotations in community-based settings (47.2%), direct mentorship from a community-based physician/provider (40.0%), longitudinal clinic for a minimum of 2 years (36.0%), improved education regarding palliative/supportive care or end-of-life discussion (28.0%), engagement with a higher volume of patients (28.0%), and additional clinical trial exposure (20.0%). Extra clinical experiences that respondents suggested to enhance community practice training included clinical/hospital administration, clinical operations, or business/financial aspects of health care delivery (63.2%); health policy issues in hematology/oncology (35.2%); quality improvement/patient safety initiatives (27.2%); health care disparities, diversity, equity, and inclusion (23.2%); research during training (13.6%); and medical education (9.6%).

“Given the changing landscape of community-based hematology/oncology care models, it is imperative to incorporate these experiences in fellowship training to adequately prepare current trainees for their future roles,” Agrawal said.

Agrawal also coauthored a national survey of hematology/oncology fellowship program directors to further elucidate areas of unmet need in terms of preparation during fellowship for community-based careers.2 Agrawal et al conducted a cross-sectional survey of 185 fellowship program directors in the United States via email. The primary outcome was to assess the attitudes of program directors regarding the inclusion of community-based training during hematology/oncology fellowship. Secondary outcomes included assessing whether programs currently have clinical and/or nonclinical training experiences specifically addressing skills relevant to community practice. The survey also included items that evaluated program directors’ attitudes toward the motivations of fellows to pursue careers in community practice.

Survey respondents (n = 53) were mostly from programs in academic tertiary care hospitals (76%), and they had a median of 5 trainees per class. Most program directors had been in clinical practice for at least 10 years (68.0%), were in their program leadership position for 10 years or less (83.0%), and had graduates from their program who pursued careers in community-based settings (96.0%).

“Our program directors’ survey is currently ongoing, but preliminary findings revealed that most program directors reported having graduates who pursued community-based careers, with financial compensation cited as the primary motivation in that decision,” Agrawal said. “However, training opportunities specifically for community-based careers highly varied across programs. The most frequently cited clinical training is rotation in a community setting, [whereas] the most common nonclinical experience is training in quality improvement and patient safety.”

Initial findings from the study, which were presented in a poster session during the 2024 American Society of Clinical Oncology Annual Meeting, showed that among survey respondents, 83% indicated that training experiences in community-based hematology/oncology should be available for fellows during training. Most programs offered clinical community-based experiences (74.0%); however, only 32.0% offered nonclinical experiences in this setting. The most common clinical experience was a rotation in a community-based setting (80.0%), and the most common nonclinical experience was training in quality improvement/patient safety (88.0%).

“Building on the findings from both projects, we have evaluated the current perspectives of practicing community-based hematologists/oncologists and fellowship program leaders,” Agrawal said. “The next steps for this research involve using the findings from our projects to prospectively design and develop evidence-driven training pathways for trainees who are interested in pursuing careers in community-based hematology/oncology, thereby equipping them with essential skills for their future roles.”

References

1. Agrawal S, Patell R, Dodge LE, et al. Defining the educational needs for a community-based hematology/oncology career: a national needs assessment. JCO Oncol Pract. 2024;20(6):861-868. doi:10.1200/OP.23.00698
2. Iacoviello A, Agrawal S, Berry JL, et al. Fortifying the workforce: a national survey of hematology/oncology fellowship program directors and training fellows for community-based careers. J Clin Oncol. 2024;42(suppl 16):9028. doi:10.1200/JCO.2024.42.16_suppl.9028