Benign Hematology Isn’t So Benign

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

As a benign hematologist, I get a lot of questions about what I do and the kind of medicine I practice.

When my parents want to tell their friends what type of doctor I am, they’re usually met with confused questions.

My parents: “She’s a hematologist – you know, a blood doctor.”

Friend: “So she treats leukemia?”

(This is where I lose them.)

My parents: “I think she’s talked about leukemia before …”

That’s when I start getting the questions from my Mom. “Do you cure leukemia?” she asks me. Well, I say, I haven’t ever before, and I’m probably not going to start now – assuming that anyone can ever really “cure” leukemia. (Apologies to all the now-outraged leukemia doctors reading this column.)

Mom: “So, what do you do?”

Me: “I treat blood diseases that aren’t cancer.”

Mom: “Like what?”

Me: “Well, like low blood counts and high blood counts, too much bleeding, abnormal clotting, and ….”

Mom: “I think you should work on leukemia; it sounds more dramatic. Our friends would think it’s more exciting. What do we even tell our friends you do?”

I’m sure my benign hematology colleagues have lived through similar conversations.

For better or worse, benign hematology just doesn’t seem as exciting as malignant hematology. I try to jazz it up when I’m speaking with residents who are weighing their career options and tell me they love hematology, but hate oncology.

“You could totally consider a career in benign hematology,” I say, trying my best to sound persuasive and enticing. “We see clotting disorders, bleeding disorders, anemias, and thrombocytopenias. We figure things out, and our patients mostly don’t die.”

Except when they do – or when they at least give us quite a scare with their attempts to achieve a post-mortem state. As it turns out, benign hematology isn’t always so benign, and the close-call scenarios we encounter sell the “exciting” nature of benign hematology better than I ever could.

Take the case of the young woman with a long history of antiphospholipid syndrome – managed on warfarin without incident for 14 years – who presented with stuttering abdominal pain after three weeks. She then came in with Budd-Chiari syndrome, a clot in her inferior vena cava extending to her right atrium, an international normalized ratio (INR) of 8, and a platelet count of 12. For the record: A platelet count to INR ratio of 1.5 is bad. Oh, and did I mention her history of heparin-induced thrombocytopenia? There was nothing benign about her case.

And then there was the gentleman with wide-open aortic insufficiency and mitral regurgitation with acute heparin-induced thrombocytopenia who needed emergent valve replacement. His end-stage renal failure and dialysis dependence prompted us to use the anticoagulant argatroban – rather than bivalirudin – which unfortunately led to significant thrombosis on the operative field. Despite multiple argatroban boluses and an argatroban drip raised to doses much higher than we initially recommended, when the bypass catheter was removed it was dripping with clot. The surgery was aborted, and the patient was found to have an infinitely prolonged activated partial thromboplastin time and proceeded to bleed 17 units of red cells in the surgical intensive care unit.

Then there are the other patients – at least one per year – who die in the throes of active thrombotic thrombocytopenic purpura. Or the patient with refractory ITP who, insisting he feels fine, refuses splenectomy and subsequently has a head bleed and a platelet count of 2. Or the patients with hemophilia who have developed inhibitors and present to us with refractory hemorrhage.

It’s hard to explain what happened to these patients as being a consequence of “benign” hematologic diseases.

So, what should we call ourselves, since “benign hematology” doesn’t quite convey the seriousness of the conditions we manage? At the University of North Carolina, we’ve settled on “classical hematologists,” a title that evokes an image of stately, somewhat stodgy, Latin-speaking, overly fussy groups of docs – all with beards. That’s not our group at all.

Personally, I’ve decided to call myself a “non-malignant, somewhat benign hematologist.” Maybe it’ll catch on.

The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

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