Hematology/Oncology Fellowship Training Program
The Hematology/Oncology Fellowship provides three years of training in an ACGME-accredited program that, if successfully completed, will allow the fellow to sit for the examinations for board certification in hematology and medical oncology. The program strives to inculcate the fellows with certain characteristics that we believe will allow them to serve their future patients with the utmost skill and professionalism. As such, the training program aims to develop the fellow’s knowledge base, attitudes and skills that will be needed to provide high quality, state-of-the-art care to patients with hematological and oncological disease, to function effectively and independently as a consultant in hematology and medical oncology, and to develop the ethical and professional traits that value lifelong learning, critical thinking, logical decision-making and a commitment to the philosophy and principles of research and quality improvement.
The inpatient hematology/oncology service varies from 8 to 15 patients that are covered by the hematology/oncology fellow and the internal medicine resident. Each can be responsible for up to 12 patients, which is not expected to exceed the inpatient census. New admissions are seen by either the internal medicine resident or hematology/oncology fellow. Each trainee is limited to a maximum of 5 new admissions daily. If, an unusual circumstances, this number is exceeded, such admissions will be evaluated by a Nurse Practitioner assigned to the inpatient service.
The hematology/oncology fellow is responsible for assigning patients to students and internal medicine residents rotating through the inpatient services. Such patients are evaluated by the student or internal medicine resident and presented to the hematology/oncology fellow for supervisory and teaching activities. Although the hematology/oncology fellow is responsible for evaluating a proportion of patients by himself/herself, the ultimate responsibility for the rounding and teaching service rests with the hematology/oncology fellow. Thus, the hematology/oncology fellow is expected to know all patients on the service, including those evaluated by the internal medicine resident. The hematology/oncology fellow is responsible for teaching internal medicine residents how to obtain and interpret peripheral blood smears, how to perform bone marrow aspirates and biopsies and to interpret the aspirate smears. The hematology/oncology fellow is to screen all consultations throughout the hospital and to assign a number of consults to the internal medicine resident. After evaluation the internal medicine resident is to present the case to hematology/oncology fellow for appropriate supervision and feedback. The hematology/oncology fellow is also responsible for assigning cases for additional reading and discussion by the internal medicine resident in weekly Hematology/Oncology conferences.
Bone Marrow Transplant Service
Hematology/oncology fellows on the Bone Marrow Transplant service evaluate new patients by reviewing the prior history and any smears, slides, pathology reports, bone marrows, x-rays or scans. The hematology/oncology fellow reviews protocols for treatment and writes and reviews all admitting orders, including those for chemotherapy or conditioning therapy for bone marrow transplant. The hematology/oncology fellow makes work rounds each morning and writes orders for any new problems that may have developed. The hematology/oncology fellow reports to the attending physician on both work rounds and teaching rounds. The hematology/oncology fellow makes rounds 6 days a week alternating with the medical resident on the 7th day. The hematology/oncology fellow shares admissions with the medical resident and supervises the medical resident workup and evaluation and reviews and evaluates the medical resident's orders. With progression through the program the hematology/oncology fellow develops a greater supervisory role with the medical resident who is to workup a larger proportion of new admissions. The hematology/oncology fellow reviews the diagnostic studies, smears, bone marrows and scans with the medical resident.
One of the attending physicians (Dr. John Lister, Dr. Robert Kaplan, Dr. James Rossetti, or Dr. Entezam Sahovic) makes work rounds 7 days a week with the hematology/oncology fellow and medical resident. The attending reviews each workup to include history and physical findings and reviews orders and plans for each patient. On a daily basis the attending assesses findings by the medical resident and hematology/oncology fellow and provides input and direction for ongoing patient management. A teaching attending rounds 2 days a week with special emphasis on the initial history and physical and the patient's course prior to transplantation. The teaching attending then deals with the many aspects of care including a review of the various complications of bone marrow transplantation. Such complications to be reviewed include various types of infections, veno-occlusive-disease of the liver, graft-versus-host disease and interstitial pneumonia. The attending physician rounds with fellows on the Bone Marrow Transplant Unit, in Medical Short Stay and in the office as necessary to see the various types of complications. The attending physician provides input for reading and assigns topics for Bone Marrow Transplant Conferences to assure that the hematology/oncology fellow is familiar with the outcomes and complications of bone marrow transplantation. The attending assures that the hematology/oncology fellow becomes familiar with procedures including bone marrow and peripheral blood stem cell harvests and the various types of transplantation.
The hematology/oncology fellow is assigned to an inpatient clinical service which may be either the inpatient oncology service or the inpatient hematology consultation service. In addition, the fellow is assigned to an ongoing outpatient service. The hematology/oncology fellow will evaluate patients assigned to him/her by the pediatric hematology/oncology attending physician. Admissions will be alternated between the pediatric fellow and the hematology/oncology fellow.
In addition, hematology/oncology fellows' attend 4 hours of hematology/oncology conferences at Children's Hospital, with direct interaction with as many as 9 attending physicians on the pediatric service.
There is no formal responsibility for teaching or resident supervision while at Children's Hospital. This is viewed as a time to learn the somewhat unique problems seen in the pediatric population. While at Children's Hospital, the hematology/oncology fellow can participate in the Inpatient Oncology Service or the Hematology/Oncology Consult Service. The former has tertiary care patients such as those undergoing transplantation or receiving high dose chemotherapy for leukemia or other malignancies. The consult service sees a spectrum of pediatric hematologic and oncologic disorders. In addition, the fellow spends time in the ambulatory Hematology/Oncology Clinic throughout the 4 week rotation. In each of these experiences, one half of the patients are assigned to pediatric fellows and the other half are assigned to hematology/oncology fellows. The fellow evaluates each new patient and reviews the prior history and other pathologic material or radiographs that may be available. The fellow reviews protocols for treatment and writes all admitting orders including those for chemotherapy or conditioning therapy for bone marrow transplantation. The hematology/oncology fellow makes work rounds with the pediatric fellow and writes orders and reports to the attending physician on work and teaching rounds. The hematology/oncology fellow is to participate in rounds 6 days a week alternating with the pediatric fellow on the 7th day.
The pediatric hematology/oncology attending makes work rounds and teaching rounds 7 days a week with the hematology/oncology fellow and pediatric fellow to review each workup, including physical findings and to review orders and plans for each patient. On a daily basis the attending pediatrician assesses findings by the hematology/oncology fellow and provides input and direction concerning management of each case. The attending pediatrician provides input for reading and assigns topics for the Pediatric Hematology/Oncology conferences in which the hematology/oncology fellow participates. The attending pediatrician also supervises the performance of procedures such as bone marrow aspirates and biopsies and assures that the fellow becomes skilled in such procedures in the pediatric population. At the conclusion of the rotation, the attending pediatrician completes an evaluation form and reviews the performance by the fellow on this rotation.
Hemostasis and Thrombosis Rotation
During this rotation the hematology/oncology fellow develops increased experience and skills in the diagnosis and management of patients with bleeding disorders and hypercoagulability (thrombophilia). The fellow sees patients in consultation throughout the hospital and in the office in conjunction with Dr. Margaret Kennedy and Dr. Robert Kaplan. He/she spends time in the Hemostasis and Thrombosis laboratory where the fellow performs certain laboratory tests including platelet counts, prothrombin times, an activated partial thromboplastin times. In addition, the fellow reviews the many tests available for bleeding disorders such as DIC screens. He/she also develops experience in ordering and interpreting a panel of tests available for evaluating hypercoagulability or thrombophilia. During this rotation, the fellow assumes responsibility for ordering appropriate laboratory tests and interpreting them in the context of the patient's problems. The attending physician meets each morning and afternoon with the hematology/oncology fellow and reviews the history and physical findings on each new consult seen in the hospital or in the office setting. The attending physician reviews the laboratory work and assures that the fellow has a firm understanding of the reason for ordering such tests and for their proper interpretation. The attending physician also provides appropriate reading and guidance for the fellow, particularly for presentation in Hematology/Oncology Conferences. At the conclusion of the rotation, the attending completes an evaluation form and reviews the performance by the fellow on this rotation.
During this rotation the hematology/oncology fellow is expected to learn the fundamentals of surgical pathology and hematopathology. The fellow will see all new samples obtained in the operating room by frozen section and by permanent section. In addition, the fellow will review all bone marrows submitted during this rotation and will obtain pertinent history and physical findings on each case when necessary to aid in developing a diagnosis. The hematology/oncology fellow is called to the operating room for frozen sections along with the supervising pathologist and is provided with a course of study for review of slides each morning. In the afternoon, the fellow reviews findings on surgical pathology specimens and on bone marrows with the supervising attending pathologist.
The attending pathologist is responsible for assigning each case to the hematology/oncology fellow and assuring that the fellow sees both gross and microscopic samples for evaluation. The attending assures that the fellow develops skills in evaluating slides pathologically and assures that the fellow is capable of achieving a diagnosis. The attending pathologist provides guidance on a daily basis for text and articles to review and assigns certain topics for the fellow to present in the surgical pathology and hematopathology conference. At the conclusion of the rotation, the attending pathologist completes an evaluation form and reviews the performance by the fellow on this rotation.
Blood Bank and Transfusion Medicine
The hematology/oncology fellow attends a series of lectures and laboratory exercises designed to provide a better understanding of blood compatibility, cross-matching and transfusion medicine. This includes didactic and practical experience and a period of time in the laboratory. The fellow reads transfusion texts and reviews any transfusion problems that are seen throughout the hospital during this rotation. The fellow evaluates transfusion reactions and performs appropriate laboratory tests to ascertain the type of reaction.
The attending pathologists present a series of lectures and supervise a wet laboratory in which the fellow performs typing and cross-matching as well as antibody identification. The attending also provides an opportunity for the fellow to become familiar with blood donation techniques and screening tests to prevent any transmissible diseases. The attending pathologist reviews the results of each workup and antibody identification. Thus, the fellow's work is reviewed by the attending pathologist each day with resolution of any transfusion problems that are seen. At the conclusion of the rotation, the attending completes an evaluation form and reviews the performance by the fellow on this rotation.
The hematology/oncology fellow spends a month with the Chairman of the OB/GYN department and her staff in the evaluation and management of patients with gynecologic malignancies. The hematology/oncology fellow performs a complete evaluation including history, physical and pelvic examination on each new referral seen in the hospital or in the office setting. The fellow reviews any pathologic material and presents the case to the attending gynecologist. The hematology/oncology fellow is taught to perform biopsies and to review these in pathology. The fellow also scrubs in the operating room where he/she participates in surgery where techniques are learned for the appropriate staging and management of gynecologic malignancies. The fellow rounds with the attending gynecologist on postoperative patients and writes orders for their continuing care.
The attending gynecologist is responsible for reviewing each new workup and providing comments and input on their content. The attending gynecologist assures that the fellow learns proper techniques for pelvic examinations and for obtaining cervical biopsies. The attending gynecologist assures that the hematology/oncology fellow is involved in the operating room and has an opportunity to observe the techniques for gynecologic surgery. These include appropriate biopsies, D & C procedures as well as staging procedures for the proper management of patients with ovarian carcinoma. At the end of the rotation the attending gynecologist reviews the fellow's performance and provides input and written evaluation of the performance.
The hematology/oncology fellow spends 1 month on the Radiation/Oncology service in which the fellow evaluates a number of new patients referred for radiation therapy. The fellow is expected to learn the indications for radiation therapy and to develop an understanding of the physics involved. The fellow views the mockup for radiation obtained by CT scanning and reviews the physics and treatment planning. The fellow also sees each patient undergoing therapy on a weekly basis and determines potential beneficial effects and any side effects occurring from such therapy.
There are 3 attending radiation oncologists, each of whom have patients seen and evaluated by the hematology/oncology fellow. The attending radiation oncologist reviews each new case with the fellow and provides input for reading about the radiation physics and the potential results of therapy. The radiation oncologist also assigns topics for hematology/oncology fellow to present during tumor board for discussion. The fellow is expected to speak about the indications and expected results of therapy in a variety of different malignant disorders.
There are a number of opportunities available with the various faculty for clinical research. Each hematology/oncology fellow is expected to start a clinical research project within the 2nd year of training and to continue this throughout the 3rd year. This may include basic or bench-top research in which mechanisms of stem cell proliferation and differentiation are under study. One such project includes attempts to increase the proliferation of hematopoietic stem cells in vitro for subsequent transplantation. The hematology/oncology fellow can elect to spend this extensive rotation with the research director and to develop sub-projects within the overall field of cord blood proliferation and transplantation. There are a number of ongoing clinical trials and opportunity for developing a number of new trials. In this instance, the hematology/oncology fellow is assigned to a responsible attending physician and jointly a project is developed for continuing study throughout the year. Once established, the fellow meets with the responsible attending physician 3 afternoons a week for supervision and guidance in the conduct of the particular study.
Ambulatory Care Continuity Clinic
There are 2 major types of ambulatory care rotations for the hematology/oncology fellows. The first type includes a one-half day a week clinic that extends throughout the 3 years of training. To assure a broad range of patient exposures, the hematology/oncology fellow rotates the one-half day clinic amongst the 6 key program faculty members. In this regard, the fellow is to do a complete history and physical examination on new patients and assess each patient on each continuing visit. The fellow is also responsible for the workup and diagnosis of each new patient referred through the outpatient program. For those patients requiring therapy the fellow is expected to write prescriptions and/or orders for therapy such as chemotherapy within the office or the cancer center. The fellow writes a substantive note on each patient, which is then sent to the referring physician.
The attending physician supervises the fellow for a 6 month period in the office setting. This includes a review of the patient, a review of the chart and a review of any orders that are required particularly for office chemotherapy. There is close one-on-one supervision that extends throughout the period of training.
In addition, there are off-site ambulatory rotations available. This includes a 1 month rotation at Butler Regional Cancer Center and a 1 month rotation at the Richard Laube Cancer Center. In each rotation the fellow acts as an attending physician. He/she does a complete history and physical examination and reviews any notes and pathology from the referring physician. The hematology/oncology fellow performs procedures under supervision and is to reach a diagnosis and come up with a plan of management. The fellow also creates an extensive note and writes chemotherapy orders for patients in the office. All evaluations and appropriate therapeutic measures including the use of chemotherapy are reviewed by the attending physician prior to the drugs being mixed by the oncology nurse. Thus, the hematology/oncology fellow has ongoing supervision throughout the ambulatory care experience at both Butler Regional Cancer Center or at the Richard Laube Cancer Center.
Butler Regional Cancer Center
The Butler Regional Cancer Center is a freestanding cancer center located adjacent to Route 422 in Butler, PA, approximately 4 miles from the Butler County Memorial Hospital. The center is open five days a week from 8:30 a.m. until 4:30 p.m. The Butler Regional Cancer Center is approximately 40 miles from The Western Pennsylvania Hospital and is approximately a 1 hour drive. The ambulatory care experience includes monitoring and assisting in the management of chemotherapy treatment protocols, investigating the appropriateness of clinical research and the follow-up of patients on chemotherapy. The new patients are evaluated initially by the hematology/oncology fellow and supervised directly by one of the attending physicians on an ongoing basis. The attending physician provides detailed evaluation of the fellow's performance during the rotation period at the Butler Regional Cancer Center.
One half of the building houses the chemotherapy and medical oncology practice and the other half is for radiation therapy which is staffed by physicians who provide radiation therapy at The Western Pennsylvania Hospital. The Regional Cancer Center services Butler county and parts of the surrounding counties of Armstrong, Allegheny and Beaver. There are approximately eight patients receiving chemotherapy per day on a five day a week basis, with an average of approximately 160-175 treatments per month. New patients are seen for evaluation and consideration for treatment. When appropriate, patients are placed on CALGB and NSABP protocols. Three physicians from the Medical Center Clinic [which is part of the Western Pennsylvania Healthcare System], rotate through the Butler Regional Cancer Center. The fellow meets with the responsible attending physician at 8:30 a.m. where two new patients are assigned for the day. The fellow is also assigned 10 - 15 follow-up patients and 2 - 5 patients who are there to receive chemotherapy.
Each patient seen by the hematology/oncology fellow is reviewed with the attending physician. The fellow is expected to arrive at an accurate diagnosis and to describe plans for potential therapy. For those patients receiving chemotherapy the fellow is to calculate the body surface area and to write orders for the chemotherapeutic agents. These are reviewed by the attending physician before they are given to the oncology nurses for mixture and administration.
Depending upon the fellow's request, the site allows one rotation at a time for as many months as requested.
Richard Laube Cancer Center
Three physicians from the Medical Center Clinic [which is part of the Western Pennsylvania Healthcare System], rotate through the Richard Laube Cancer Center. The fellow meets with the responsible attending physician at 8:30 a.m. where two new patients are assigned for the day. The fellow is also assigned 10 - 15 follow-up patients and 2 - 5 patients who are there to receive chemotherapy.
Each patient seen by the hematology/oncology fellow is reviewed with the attending physician. The fellow is expected to arrive at an accurate diagnosis and to describe plans for potential therapy. For those patients receiving chemotherapy the fellow is to calculate the body surface area and to write orders for the chemotherapeutic agents. These are reviewed by the attending physician before they are given to the oncology nurses for mixture and administration. As noted above, each patient is discussed thoroughly with the attending physician. In essence, the fellow functions one-on-one with the attending physician 5 days a week for the one month rotation. This is expected to provide a good cross section of patients seen in the community setting where direct supervision is provided by the attending physician.
The hematology/oncology fellows are responsible for the Clinical Case Conferences, Journal Clubs, Multidisciplinary Tumor Conferences and the Bone Marrow Transplant Conference. The hematology/oncology fellows assume responsibility for case presentations, for review of the literature and for presentation of patients in the Multidisciplinary Tumor Board and the Bone Marrow Transplant Conference. The hematology/oncology fellow assigns approximately 50% of the patients to the general medical fellows rotating through the respective service. Nonetheless, it is the responsibility of the hematology/oncology fellow to be sure that topics are assigned for review by the fellows based on patients that have been seen within the last week or two on service. The hematology/oncology fellows receive guidance from the respective attending physicians for topics to present at Journal Club. The Basic Science Conference has a list of topics that are to be covered over the course of the curriculum. Each hematology/oncology fellow is responsible for a review and presentation at two conferences a year. During the startup phases of the program, the faculty are responsible for presentations in these conferences.
The monthly Research Conference is directed by the research director. Presentations are made of ongoing research projects within the division with assignments to respective internal medicine fellows who have been conducting research with the faculty, hematology/oncology fellows with presentations of their research, and faculty presentations of ongoing research activities.