Preface
Across much of the world, hematology remains a distinct specialty devoted to both malignant and benign blood diseases. In the United States, it has largely disappeared as an independent discipline. What began as a marriage of convenience between hematology and oncology evolved into a quiet absorption. Malignant hematology now lives under oncology’s banner, while benign hematology has been rebranded as “classical.” This essay traces how that happened and how the field, though diminished, continues to adapt and endure.
Before Hematology Had a Name
The story of American hematology begins before the field had a name. Its early figures were internists and pathologists who happened to think through the blood. Richard Cabot, at Massachusetts General Hospital, brought new precision to clinical reasoning through his exhaustive case records. George Minot and William Murphy transformed pernicious anemia from a fatal disease into a curable one through diet and physiology. William Castle, a gifted teacher and investigator, carried this tradition forward, dissecting the mechanisms of absorption and metabolism that lay behind their discoveries.
None of these physicians would have called themselves hematologists; they were generalists who found the blood to be a mirror of the body. Yet their work created the intellectual foundation from which hematology would emerge. By mid-century, a handful of academic divisions devoted to blood disease had taken shape, and the term “hematologist” had entered professional vocabulary. When the American Board of Internal Medicine recognized hematology as a formal subspecialty in 1972, the field had finally achieved official status just as it was about to be absorbed into oncology.
1. The Great Merger
In the mid-twentieth century, hematology stood proudly on its own. The first generation of recognized hematologists—Dameshek, Wintrobe, Ranney, Castle—defined the field through intellectual breadth rather than organ or procedure. They moved fluidly between the microscope and the bedside, grounded in physiology and pattern recognition.
Beginning in the 1970s, that independence began to erode. Oncology was ascendant, propelled by chemotherapy, the National Cancer Act of 1971, and the creation of cancer centers that drew vast new streams of funding and attention. To many, hematology and oncology seemed natural partners: both dealt with proliferating cells, both used cytotoxic drugs, both treated diseases that crossed the boundary between blood and tissue.
By the late 1970s, training programs began merging. The American Board of Internal Medicine created a combined fellowship track. Departments followed, and “hematology/oncology” became a single administrative and cultural entity. The slash mark between them, once a bridge, quietly became a line of erasure.
2. The American Exception
This merger was not inevitable, nor did it occur everywhere. In Europe, hematologists still manage both malignant and benign disorders; oncologists focus mainly on solid tumors. The United States is an exception.
The reasons were structural, not scientific.
- Economics: Oncology brought procedures that generated revenue—infusions, injections, transfusions—while benign hematology remained consultative and time-intensive.
- Policy: The National Cancer Act and the growth of NCI-designated centers created a gravitational pull that drew hematologists into oncology’s orbit.
- Training and certification: The ABIM combined hematology and oncology fellowships into a single three-year program. What began as administrative convenience evolved into identity itself.
By the 1990s, “heme/onc” had become a single word in the American lexicon. Elsewhere, hematologists still traced anemia, thrombosis, and leukemia along one intellectual continuum. In the United States, hematology had been annexed by oncology.
3. The Rebranding
As benign hematology lost visibility, a new term appeared: “classical hematology.” It was intended to dignify what remained—coagulation, anemias, marrow failure syndromes—but its tone looked backward. “Classical” evoked the past: physicians in white coats and bow ties, patriarchal hierarchies, and the austere culture of early twentieth-century medicine. The word carried echoes of classical music—revered, disciplined, and unchanging.
Yet “classical hematology” was also an act of rescue. It gave the field a name again, a foothold in a system that had almost forgotten it. The label sought to preserve identity, even as it risked confining the field to nostalgia. Academic divisions created “classical” tracks to protect benign hematology from total absorption into oncology. The term carried pride and defensiveness in equal measure.
4. The Vanishing Field
Benign hematology is not dying from irrelevance but from diffusion. Its work has become invisible.
- Economics: Consultative, nonprocedural medicine is poorly reimbursed.
- Workforce: Trainees gravitate toward oncology, where salaries and infrastructure are stronger.
- Delegation: Primary care physicians now manage much of what once defined benign hematology—iron deficiency, B12 deficiency, mild thrombocytopenia, anticoagulation. Only the rare or refractory cases reach hematologists.
- Institutional structure: Hospitals fold hematology into cancer service lines, leaving benign hematologists without a clear administrative home.
The paradox is striking: the field’s intellectual vitality endures, yet its clinical footprint shrinks. The common disorders that once sustained hematologists as diagnosticians are increasingly handled elsewhere. What remains are the edge cases and puzzles, the very work that first defined the field, but now without the daily practice that gave it continuity.
5. The Cost of Losing the Generalist of the Blood
Hematology once occupied a special place in medicine. Hematologists were interpreters of complexity, bridging laboratory and clinic, physiology and patient story. They were generalists of the blood, physicians whose diagnostic reach extended across organs and systems.
When hematology becomes indistinguishable from oncology, medicine loses a kind of connective tissue. The discipline that once modeled reasoning from first principles is replaced by protocol and narrow focus. The disappearance of benign hematology is not only professional loss but intellectual loss: a contraction of curiosity, a thinning of the space for thoughtful uncertainty.
6. Signs of Renewal
There are, however, signs of renewal. The American Society of Hematology’s Hematology-Focused Fellowship Training Program (HFFTP) aims to rebuild a pipeline for physicians committed to benign disease. These fellowships pair scientific rigor with mentorship in diagnostic reasoning and clinical judgment, deliberately separate from oncology. The goal is to sustain a culture of inquiry, patience, and interpretive skill that might otherwise vanish.
Still, such efforts face structural headwinds. Without institutional support or sustainable reimbursement, even the best-trained classical hematologists may find few positions that match their expertise. The challenge is not whether the field can train new specialists, but whether medicine can make room for them.
7. The Afterlife of Classical Hematology
To speak of the “afterlife” of classical hematology is not to declare the field dead but to acknowledge its transformation. The label was born out of necessity, not nostalgia. It rescued a fragment of identity from dissolution and gave it language again. The field may have lost its independence, but it has not lost its purpose. Its spirit endures in every careful blood smear, every thoughtful differential, every conversation that links numbers back to patients.
If hematology is to survive, it must keep evolving. The future will not come from defending borders but from reimagining value. The next generation of hematologists will be integrators and educators, physicians who see the blood as a living system that connects disciplines rather than a compartment of the past.
Closing Reflection
From Cabot’s casebooks to Castle’s experiments, from Dameshek’s editorials to today’s molecular diagnostics, hematology has always been defined by interpretation. The merger with oncology was another adaptation in a long tradition of change. “Classical hematology” emerged from that transformation as both a memory and a mission. The label may look backward, but its purpose is forward—to ensure that the field’s way of thinking endures even when its boundaries shift.
The blood has never truly belonged to anyone, yet it has always needed interpreters. The task now is to make sure someone still listens.
Key Takeaways
- The early figures of hematology (Cabot, Minot, Castle) were internists and pathologists before the field had a name.
- Hematology was formally recognized as a subspecialty in 1972, just as it began merging with oncology.
- The hematology–oncology merger was uniquely American, shaped by economics, policy, and certification.
- “Classical hematology” arose as an act of rescue, preserving identity even as it evoked the past.
- Benign hematology’s decline reflects systemic forces and the absorption of common disorders into primary care.
- ASH’s HFFTP and other initiatives represent the field’s afterlife—evidence of renewal, not extinction.
- The survival of hematology depends on reinvention, not nostalgia.