Classical Hematology: An Unexpected Destination

By Jacob Cogan, MD , Classical Hematologist, University of Minnesota Medical School

I am an adult classical hematologist.?This was one of the last things I ever thought I would do, but I am very glad that I found my way to this field.?I decided to pursue residency in internal medicine because I love problem-solving and making complex diagnoses.?I ultimately went into fellowship for hematology/oncology with the intention of becoming a medical oncologist and was hoping to minimize my exposure?to hematology because, frankly, I thought having to look at things under a microscope was weird.?After a year of fellowship, I found oncology to be a bit algorithmic, and noticed that I was surprisingly looking forward to my classical hematology rotations more than anything else because they reminded me of how I felt during residency — that I could be a detective and problem-solver, the kind of clinician that I imagined a doctor to be (and, to some extent, who my grandfather was as a physician in the 1940s).?My residency and fellowship?were at Columbia University.?There were numerous oncologists specializing in every tumor subtype, doing research, and running clinical trials.?And then there were these two classical hematologists who were 100% clinical, never did research, and were never listed on the brochures for our cancer center.??

However, having completed all six years of my medical training, it always felt like somehow the entire institution rested on the shoulders of these two individuals working in this relatively obscure field.?They would get calls all the time from panicked surgeons, ER providers, and even oncologists who had also been through hematology training.?There seemed to be something about bleeding, thrombosis, abnormal coagulation tests, anemia, thrombocytopenia, and neutropenia that was terrifying to everyone other than these two guys.?They were never flustered, always available and reassuring to those in need, and the kind of master clinicians that I realized I aspired to become.?There also seems to be something about the uncertainty in classical hematology.?Almost the polar opposite of oncology, where there are tons of clinical trials and everything is protocolized and algorithmicized, nonmalignant hematology has almost no clear answers for anything.?All you are armed with is your experience, your clinical gestalt, and, sometimes, your prayers.?Modern medicine seems to promise an answer to every question, but under the hood we know that is rarely the case.??

I spend my days in the clinic talking about uncertainty with patients, going through risks and benefits, and making decisions that seem to align the patient’s goals with my judgment.?In the hospital, I am reminded of my days as a goalkeeper in soccer — standing around (i.e., dealing with relatively routine hematologic questions) 95% of the time, waiting for the 5% (i.e., shots on goal) where I need to spring into action and be ready to deal with something that will kill the patient if I don’t? identify and treat it right away. Thrombotic thrombocytopenic purpura and hemophagocytic lymphohistiocytosis do not come around often, but when they do, it is thrilling. I will never forget diagnosing catastrophic antiphospholipid syndrome (APS) when a former co-resident called me offhandedly because of an elevated INR lab value in the emergency room. Or managing active cold agglutinin disease in a patient with cardiac arrest who needed to be cooled for therapeutic hypothermia!?I remember when the cardiac ICU had very reasonably started heparin on a patient with lupus and multiple thromboses concerning for catastrophic APS, but my mentor stepped in and said the patient had heparin-induced thrombocytopenia and insisted that they stop heparin in favor of another anticoagulant — and he was right.?Classical hematology is medical mystery-solving at its finest, and a lot of fun for those whose bell it rings.

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