Implementing a Military-Specific Hematology/Oncology Curriculum: A Multi-Institutional Assessment of Fellow-Reported Preparedness

More than 800 active‑duty service members (ADSMs) are diagnosed with cancer each year[1], and cancer remains the leading cause of natural deaths among ADSMs and Veterans[2,3]. This burden requires Hematology/Oncology (Heme/Onc) physicians who can deliver high‑quality cancer care while navigating military‑specific responsibilities that influence treatment decisions, survivorship, and return‑to‑duty outcomes.

Military Heme/Onc practice includes competencies not routinely addressed in civilian training, such as applying duty limitations, interpreting retention standards, preparing patients for deployment or medical separation, and managing operational exposures[4-6]. Military oncologists also contribute expertise in transfusion medicine and hematologic support after radiation injury, skills essential in deployed and contingency environments. Despite their relevance to force readiness, these competencies are not standardized across training programs.

The U.S. military operates two Hematology/Oncology fellowship programs at major military medical centers, yet no standardized military‑specific curriculum has previously been implemented or evaluated. To address this gap, we developed a joint virtual curriculum focused on leadership, operational readiness, and military‑relevant clinical responsibilities. The objective of this study was to evaluate whether fellow‑reported preparedness in these military‑specific competencies differed between early‑year and final‑year trainees during the initial implementation of the curriculum, and to identify domains requiring further refinement.

This repeated cross‑sectional descriptive study used quarterly surveys of fellows participating in a joint virtual military‑specific Heme/Onc curriculum delivered at two military training sites from July 2023 to December 2025. All fellows during the study period were eligible and were invited to complete an anonymous, voluntary survey prior to each quarterly session. The curriculum included didactic sessions on leadership, conflict management, operational medicine, massive transfusion protocols, radiation injury, and military retention standards (Table 1). Sessions were delivered virtually, were one hour in duration, and were mandatory at both fellowship programs. Content was developed through faculty consensus and review of operational requirements. Operational requirements refer to military directives and clinical responsibilities that influence patient readiness, including duty‑limiting profiles, retention standards, deployment preparation, and transfusion support in contingency environments. Training year was used as an indirect proxy for curriculum exposure because individual attendance could not be tracked.

The study objective was to compare fellow‑reported preparedness in military‑specific Heme/Onc competencies between early‑year (PGY4–5) and final‑year (PGY6) trainees. Preparedness across 13 domains was measured using a standardized survey instrument (Table 2), which remained unchanged throughout the study. These 13 domains were selected to reflect competencies relevant to military Heme/Onc practice in both routine outpatient care at military treatment facilities and in deployment or contingency environments. The instrument was designed to measure fellow‑reported preparedness across military‑specific competencies. The survey was developed de novo by the program directors and associate program directors at both fellowship programs. Items were generated through faculty consensus to reflect core military‑specific competencies identified during curriculum planning, and content experts in military medical operations, transfusion medicine, and graduate medical education reviewed the items for relevance and clarity. Two response scales were used to align with the underlying constructs: a 0–5 unipolar scale for knowledge‑based and role‑readiness items, and a −2 to +2 bipolar scale for leadership preparedness items. The instrument did not undergo formal pilot testing, cognitive interviewing, or psychometric validation. Survey responses were automatically tagged by training level. PGY4 and PGY5 fellows were combined a priori due to similar clinical exposure. The survey was administered by the chief fellows using a QR code and web link distributed before scheduled curriculum sessions.

Preparedness scores were treated as ordinal variables. Responses were summarized using medians and interquartile ranges (IQR), and differences between early‑year and final‑year fellows were assessed for each question using Wilcoxon tests. Missing data were handled by analyzing all available responses. A two‑sided p < 0.05 was considered statistically significant. Given the descriptive nature of this study, formal nonparametric effect size calculations were not performed. To mitigate the risk of a type 1 error, a False Discovery Rate (FDR) adjustment was implemented. Analyses were performed using SAS version 9.4. This project was reviewed by the institution’s Human Research Protection Program Office and determined to constitute program evaluation under 32 CFR 219.102; therefore, IRB review was not required.

At each quarterly administration, approximately 24 fellows (12 from each site) were eligible to complete the survey. After applying a 20 percent attrition adjustment for clinical duties, leave, and outside rotations, an estimated 19 fellows were available per administration, yielding 192 possible survey opportunities. A total of 92 surveys were completed, corresponding to a 48 percent participation rate. One training site contributed more responses (n=56, 61%) than the other training site (n=36, 39%). Respondents included 61 early-year and 31 final-year fellows. No surveys were excluded. Because the survey was anonymous and individual attendance was not tracked, exact item‑level denominators could not be calculated. All available responses were analyzed for each question.

Preparedness scores reflected the distribution of responses across the 13 survey items. Items assessing understanding of leadership styles (median 4, IQR 3-4) and unique aspects of practicing within the Military Health System (median 4, IQR 3-5) showed the highest mean values within their respective 0–5 scale items. Among the two bipolar preparedness items, implementing change while in a leadership position demonstrated the lowest mean value within that scale (median 1, IQR 0-1).

Final year fellows reported significantly higher preparedness in three questions: operational readiness for conflict (median 3, IQR 2-4 vs. median 3, IQR 3-4, p=0.0326, FDR-adjusted p=0.1523), indications for whole blood versus component therapy (median 3, IQR 2-4 vs. median 4, IQR 3-4, p=0.0290, FDR-adjusted p=0.1523), and adolescent and young adult survivorship (median 3, IQR 2-3 vs. median 4, IQR 3-4, p=0.0010, FDR-adjusted p=0.0135). After FDR adjustment, only adolescent and young adult survivorship remained statistically significant. No significant differences were observed in the remaining ten questions. 

Military Heme/Onc practice requires competencies not routinely addressed in civilian fellowship training, and this study demonstrates that a joint curriculum can begin to fill that gap across two military training sites. In keeping with the study objectives, fellows reported higher preparedness in several domains relevant to military practice, and the curriculum was feasible to deliver in a virtual, joint format. Questions showing the greatest differences between early-year and final-year fellows were those commonly reinforced through clinical encounters. Higher self-reported preparedness among senior fellows in adolescent and young adult oncology likely reflects cumulative clinical exposure rather than curriculum-specific effects. Because the study compared fellows at different training levels rather than measuring individual change over time, observed differences should be interpreted as associations with fellowship progression rather than effects attributable to the curriculum.

Leadership-related competencies showed limited progression. Lecture-based approaches alone may not provide the depth needed to build confidence in conflict resolution, implementing change, or assuming administrative roles[7-9]. Evidence from graduate medical education suggests that mentorship, coached practice, and scenario-based learning may better support leadership skills[10,11]. Additional topics such as massive transfusion protocols, retention standards, duty limiting profiles, and radiation injury may also benefit from simulation or small group exercises.

This study has strengths, including the first implementation of a joint curriculum across two military training facilities and the use of a consistent survey instrument over 2.5 years. Limitations include the small sample size for final-year responses and the voluntary nature of survey participation, which may introduce both response bias and non-response bias. Differential response rates across training sites introduce non‑response bias, and because respondents may differ systematically from non‑respondents, the missing‑data mechanism is likely Missing Not At Random (MNAR). Additionally, the cross-sectional design cannot separate curriculum effects from natural progression through fellowship. Because the survey was anonymous, individual responses could not be linked across administrations, and therefore we could not use repeated‑measures methods (e.g., mixed‑effects models) to account for within‑subject correlation. This may underestimate variance and may inflate statistical significance. Because the survey used both unipolar and bipolar scales, comparisons across items are not appropriate, and the findings should be interpreted within each question rather than across domains. Further, the survey instrument was developed de novo and lacks formal validity and reliability testing, as no validated instruments exist for assessing military-unique Heme/Onc competencies. Preparedness was assessed through self‑reported measures, which may not reflect objective competence. Additionally, curriculum attendance and exposure could not be tracked because surveys were anonymous, and training year served only as an indirect proxy for exposure.

This early evaluation demonstrates that a joint curriculum is feasible to deliver and that fellows reported differing levels of preparedness across military‑specific domains. These findings reflect associations with training level rather than curriculum‑specific effects. Future longitudinal work incorporating direct measures of curriculum exposure is needed to determine educational impact. In particular, targeted development and evaluation of structured leadership training represents an important next step for strengthening military Heme/Onc preparedness. 

Acknowledgements

None

Disclosures

The contents of this presentation are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions, or policies of Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of War (DoW), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Data Availability Statement

Not applicable