A call for subspecialty training programmes in women's thrombosis and haemostasis

Multidisciplinary collaboration to create formal education/training programmes in women's thrombosis and haemostasis will ideally lead to improved knowledge and health equity and potentially improve patient outcomes. Women's health has previously been characterized by some as a 'niche' issue in healthcare and therefore has not been considered an essential part of subspecialty medical training in most specialties outside of obstetrics–gynaecology. However, given that women's health simply represents 'health' for half the world's population, I believe it is an essential component of healthcare in general and deserves additional attention with regard to training in a broad variety of additional medical specialties. In haematology, women's health issues in thrombosis and haemostasis are extremely common, but at present time, there are no training programmes specifically dedicated to the education of physicians interested in this area. I believe that the development of such training programmes as a subspecialty fellowship for physicians from multiple disciplines (e.g. haematologists, obstetricians and gynaecologists and obstetric anaesthetists) would be an asset both to physicians and to their future patients. There are multiple conditions, disease states and life situations that particularly affect women with regard to thrombosis and haemostasis. Iron deficiency and iron deficiency anaemia are incredibly prevalent in all women (often due to menstrual blood loss),1 and pregnant women are at particular risk of iron deficiency which can be caused/exacerbated by postpartum haemorrhage.2 Postpartum haemorrhage is a major source of pregnancy-related morbidity and mortality worldwide.3 Pregnancy and the postpartum period are times of increased risk of venous thrombosis.4 Additional aspects of women's health—ranging from contraception to assisted reproductive technologies to menopause—also share close associations with several aspects of thrombosis and haemostasis. In addition to these conditions that may affect all women, women with specific disorders of thrombosis and haemostasis require specialized management during several gender-specific life situations. For example, women with bleeding disorders (von Willebrand disease, mild haemophilia, platelet function disorders and immune thrombocytopenia) are at high risk of menorrhagia and postpartum haemorrhage (often complicated by iron deficiency anaemia)5, 6 and also require specific care during pregnancy to manage analgesia for delivery safely.7 Conversely, women with thrombotic disorders (inherited thrombophilias and antiphospholipid syndrome) are at increased risk of thrombosis with the use of combined oral contraceptives, during pregnancy/postpartum period, and with oral oestrogen used for menopausal hormonal therapy (MHT) and require specific care to minimize the risk of thrombosis while also providing safe and effective interventions for contraception and MHT.8, 9 Women with haemoglobinopathies such as sickle cell disease and thalassaemia also require extremely specialized care for multiple aspects of reproductive health.10, 11 The field of haematology has recognized the importance of targeted training in subfields of haematology, leading to the development of training programmes such as the American Society of Haematology Hematology-Focused Fellowship Training Program (HFFTP) focused on classical haematology,12 as well as individual subspecialty training programmes in areas of malignant haematology such as lymphoma, multiple myeloma and stem cell transplantation. However, while the need for specialized training in women's thrombosis and haemostasis is clear, there is not yet a defined path or programme for education of physicians who wish to provide this type of specialized care. I believe that subspecialty training programmes in the specific aspects of care related to women's health in haemostasis and thrombosis hold promise in advancing medical education and patient care in this essential field. Physicians in several specialties have knowledge that can be shared with colleagues to create a mutually beneficial educational experience in women's thrombosis and haemostasis. For example, haematology fellows could rotate on the inpatient obstetric service and outpatient high-risk obstetrics/maternal fetal medicine clinic, while obstetrics–gynaecology residents and fellows could rotate in the thrombosis–haemostasis clinic. Physicians of each specialty could provide education to both trainees and practicing physicians in other specialties via multidisciplinary rounds, case-based teaching and journal clubs. Some such resources are already available via societies such as the Foundation for Women and Girls with Blood Disorders (FWGBD)13 and these online resources could also serve as starting points for additional multidisciplinary teaching and discussion within institutions. Ultimately, I envision coalescing these individual learning experiences to develop a full subspecialty fellowship programme where physicians from a wide range of specialties could apply after completion of their primary residency/fellowship training programmes. While the programme would be 'hosted' under the umbrella of a specific specialty—likely haematology–oncology or obstetrics–gynaecology—for logistic and regulatory purposes, programme faculty (programme directors, associate programme directors and core clinical faculty) would ideally be from a range of specialties to provide depth and breadth of knowledge. The curriculum would be standardized across institutions to ensure adequate training in many aspects of women's health. For example, month-long blocks could include inpatient rotations on the classical haematology consult service, labour/delivery ward and with the obstetric anaesthesia team and outpatient rotations in the clinics of both specialties as well as coagulation and transfusion medicine laboratories. Additional clinical electives (medical genetics, haemoglobinopathy clinic, etc.) may also be an option depending on the facilities of each participating institution. Fellows could also be given an opportunity to participate in multidisciplinary meetings with all involved specialties and conduct or participate in research related to women's health in thrombosis/haemostasis. Overall, such subspecialty training would offer physicians from a variety of specialties a path towards leadership in the clinical care of women with disorders of thrombosis and haemostasis. Additionally, both the training fellows would receive as well as the multidisciplinary contacts they would make would offer further opportunities for collaborative research in this area. Subspecialty training in women's thrombosis and haemostasis would also offer an opportunity to further the principles of diversity, equity and inclusion (DEI) in the haematology workforce, a topic of particular importance to myself and many of my colleagues.14 Expansion of clinical education in this fundamental aspect of women's health would improve awareness of specific aspects essential to the care of women throughout their lives. From the research perspective, improved knowledge of the specific unmet needs of women with disorders of haemostasis and thrombosis could spur expansion of clinical trials designed specifically to answer questions related to women's haematological needs, including study of management of these conditions in pregnancy (a vastly understudied area at present time). Additionally, training could include attention to the current inequities and DEI-related challenges in specific populations (e.g. the increased pregnancy-related thrombosis mortality seen in Black women in the United States)15 and specific areas of the world (e.g. inadequate access to medications and blood transfusions for postpartum haemorrhage in low- and middle-income countries).16 As our knowledge of the unique healthcare needs of women expands, so too must the educational opportunities available to those who wish to have a positive impact on women's health. Formal educational programmes could further open the path for improving advocacy, clinical care and research and creating a more equitable health system for women with haematological needs across the globe. The author (Dr. Marshall) developed the concept, wrote the manuscript and revised the manuscript per reviewer/editor request. No funding received for this study. The author has no relevant conflicts of interest to disclose. 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