Hematology/Hematopathology Core Rotation

Rotation Director:

Patient Care that is compassionate, appropriate, and effective for the treatment of health through the following:

• Gather essential and accurate information about patients using all relevant available modalities and incorporate into pathologic interpretations.
• Effectively examine and interpret peripheral blood smears and body fluid slides.
• Effectively analyze and interpret coagulation testing.
• Effectively examine and interpret bone marrow biopsies and aspirates, incorporating flow cytometry and molecular/cytogenetic information.
• Effectively examine and interpret lymph node specimens, incorporating flow cytometry and molecular/cytogenetic information.
• Understand procedural aspects of bone marrow aspiration and biopsy.
• Effectively consult to other clinicians in developing a diagnostic plan, when appropriate, based on specific clinical questions and relevant clinical and pathological information.
• Effectively consult on interpretation or follow-up of unusual or unexpected hematologic test results.
• Effectively participate as expert in Laboratory Hematology and Hematopathology at multidisciplinary conferences.
• Understand the impact of point-of-care testing (POCT) on clinical care.

Medical Knowledge:

• Use all relevant information resources to acquire and evaluate evidence-based information.
• Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in Laboratory Hematology and Hematopathology that includes automated hematology testing, peripheral blood and body fluid analysis, flow cytometry analysis, bone marrow biopsy and aspirate analysis, and lymph node specimen analysis as it relates to RBC disorders, platelet disorders, leukemias, lymphoproliferative disorders, inflammatory disorders and coagulation disorders.
• Understand the various levels of evidence in medicine and their translation into evidence-based practice.

Practice-based Learning and Improvement:

• Demonstrate the ability to critically assess the scientific literature.
• Demonstrate knowledge of evidence-based medicine and apply its principles in practice.
• Use multiple sources, including information technology, to optimize life-long learning and support patient care decisions.  
• Develop personally effective strategies for the identification and remediation of gaps in medical knowledge needed for effective practice.
• Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety.
• Demonstrate knowledge of how to establish continuing competency assessment for pathologists as well as for laboratory personnel.
• Perform 5-10 bone marrow aspirations/biopsies under tutelage of nurse practitioners or mid-level physician's assistant.

Interpersonal and Communication Skills:

• Demonstrate the ability to write an articulate, legible, and comprehensive yet concise consultation note; provide a clear and informative report, including when appropriate a precise diagnosis, a differential diagnosis, and recommended follow-up or additional studies.
• Demonstrate the ability to provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a laboratory assay reveals an urgent, critical, or unexpected finding and document this communication in an appropriate fashion.
• Effectively participate and present at multidisciplinary conferences in focused, clear, and concise fashion.
• Demonstrate the ability to work with other clinicians and other health care personnel and administrators to develop clinically advantageous and cost-effective care-delivery strategies.
• Use effective modes and mechanisms of communication.
• Demonstrate skills in educating colleagues and other health care professionals, including:
  • Helping other residents obtain proficiency in laboratory medicine
  • Demonstrating the ability to work well with medical technologists and to present Laboratory Medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment.
  • Demonstrating the ability to educate non-pathology clinicians and other health care workers, including pharmacists, nurses, residents, medical students, and others about topics such as the fundamental principles of pathophysiology underlying test design/interpretation and the approach to choosing and interpreting laboratory tests.
  • Demonstrating an understanding of how to educate other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other professional knowledge.

Professionalism:

• Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them.
• Interact with others without discriminating based on religious, ethnic, sexual, or educational differences.
• Demonstrate positive work habits, including punctuality, dependability, and professional appearance.
• Demonstrate responsiveness to the needs of patients and society that supersedes self-interest.
• Demonstrate principles of confidentiality with all information transmitted both during and outside a patient encounter.
• Demonstrate a commitment to excellence and ongoing professional development.
• Demonstrate interpersonal skills in functioning as a member of a multidisciplinary health care team.

Systems-based Practice:

• Demonstrate understanding of the role of the clinical laboratory in the health care system.
• Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians.
• Demonstrate knowledge of basic health care reimbursement methods.
• Demonstrate knowledge of the laboratory regulatory environment.
• Understand policies and systems to continually improve patient safety as they relate to clinical laboratory testing at all levels.

•  The rotation can be completed in any PGY year. 

The rotation is scheduled in 4-week blocks. The total amount of time a resident is scheduled for Hematology/Coagulation training depends upon that resident's progress towards achieving the rotation's core competencies. For most residents this will be between four and six 4-week blocks, but can be longer or shorter for a specific resident. A "typical" resident spends four and a half (4-1/2) months (5 rotations) in Hematology/Coagulation rotations. A resident training in Clinical Pathology only will be required to spend additional time in Hematology/Coagulation.

 

Advanced rotations can be arranged with the Medical Director's approval in advance. The goals, expectations and responsibilities for advanced elective rotations will be defined on an individual basis before approval is granted.

 

The resident will participate in the medical direction and management of all aspects of the Hematology/Coagulation Laboratory. Specific responsibilities are outlined under each section below. The resident is expected to act independently according to the resident's level of experience and expertise. A Clinical Pathology attending will be available for consultation and guidance. The resident is expected to make decisions as a learning experience; resident decisions will be reviewed during daily sign out sessions.

 

On the first day of the rotation the resident should meet with the Medical Director to review his or her prior progress and the responsibilities and expectations for the resident on the current rotation. The resident is expected to have reviewed this description prior to beginning the rotation.

• William Castellani, MD
• Michael Creer, MD
• Ronald Domen, MD
• Keri Donaldson, MD
• Melissa George, DO
• Hiroko Shike, MD

• Michael Bayerl, MD
• Josef Malysz, MD

• Victoria Smalls, MT(ASCP)
• Diane Richwine, MT(ASCP)
• Jeffrey Sanders, MS

Routine service hours are 8:00 AM to 5:00 PM. Coverage outside of those hours is provided by the Clinical Pathology resident on call. On months when there is no resident assigned to "Usual" hematology, or when the assigned resident is absent, service coverage will be provided per the Departmental Policies. An attending clinical pathologist is available to the resident at all times.

 

CP HEMATOLOGY

 

Hematology is divided into benign hematology and hematopathology.

Benign hematology will be three rotations in length. The first two rotations will be benign hematology only, while the last month will be combined with hematopathology.

During all three months of the benign hematology rotation, the resident will be expected to preview, get adequate clinical history and write-up a report on all of the peripheral smears, body fluids, and mixing studies that are submitted for pathology review. These reports should be ready to present to the attending on service at daily rounds starting at 11:00AM Monday through Friday. Any specimen that is sent for pathology review before 10:00AM on the day of rounds should be written-up for the attending to review. Rounds is scheduled for one hour but may be completed early.

During the first two months of the rotation, the resident will also be required to interpret and write up the coagulation work ups. These work ups are available on Friday afternoons and should be completed and ready for sign-out the following Monday afternoon. The resident will not be required to write up the coagulation work ups when on the third month of benign hematology.

During the first two months of benign hematology, the resident will receive a weekly reading assignment with unknown cases to work up. On Friday afternoon of the week, the resident will meet with an attending and to review the topic of the reading assignment or training module (http://medtraining.org)and receive a didactic lecture or review of the cases and quizzes from the training module. During the first month of benign hematology, the resident will cover:

• Coagulation module (http://medtraining.org): Dr. Donaldson
• Automated hematology: Dr. Creer
• Peripheral Blood module (http://www.medtraining.org/ & Anemia: Dr. Donaldson
• Hemoglobinopathies/Thalassemias: Dr. Creer

During the second month of benign hematology, the resident will cover:

• Flow cytometry: Dr. Creer
• Platelet dysfunction: Dr. Creer
• Coagulation (thrombophilia): Dr. Donaldson
• Coagulation (bleeding diatheses): Dr. Donaldson

In addition, the resident will also be responsible for observing hematology associated lab test throughout the first two months. These tests include:

• Tilt tube testing
• Platelet function testing
• Automated coagulation and automated hematologic analyzers

On the final month of the rotation, the resident will not have reading assignments or bench work. 
 

AP HEMATOPATHOLOGY

The hematopathology curriculum will be also be three rotations in length. The first two rotations will be hematopathology only, while the last month will be combined with benign hematology.

During the first month of hematopathology, the resident will be required to schedule time to perform bone marrow biopsies as mentioned previously (Please see Bone Marrow Aspirate and Biopsy Procedure for Residents and Fellows). In addition, the resident is required to preview and work up to 5 bone marrow biopsy cases (with accompanying flow cytometry), all the surgical and cytology specimens (with accompanying flow cytometry), and all molecular cases. The resident will do the remaining flow cytometry and FISH studies depending on the circumstances.

The second month of hematopathology, the resident is required to preview and work up all of the cases that come to the hematopathology service. This includes all of the bone marrow biopsy cases (with accompanying flow cytometry), surgical and cytology specimens (with accompanying flow cytometry), molecular cases, flow cytometry only, and FISH studies.

During the third month, the resident will have hematopathology combined with benign hematology. The resident is still required to try working up all the cases that come into the hematopathology service, but it is understood that this may be unreasonable depending on the volume. In these circumstances, the resident should focus on assignments given by the attending.

If the hematopathology fellow is also on the hematopathology rotation with a resident, work-up for the cases should be divided up between the resident and fellow.

Signout will occur at 10:30AM (as needed) and 2:00PM every day. If the resident is performing a bone marrow during the 10:30AM signout or doing the rotation combined with benign hematology, the resident will not be required to attend the 10:30AM signout. The resident is required to attend daily CP rounds.

Residents on hematopathology are NOT required to gross in lymph nodes for lymphoma workup.
 

 

2.  Hemostasis and Thrombosis Rotation (two weeks)

Each resident will spend approximately two weeks on a "Hemostasis and Thrombosis" rotation to further develop competence in the interpretation, appropriate selection, and technical understanding of laboratory based testing for hemostasis and thrombosis. [This rotation is generally done in conjunction with the 2 week Cytogenetics rotation for AP/CP combined residents or CP only residents. AP only residents are not required to complete this two-week rotation.] Time during this rotation is spent in observing specialized coagulation testing in the automated testing (ATL) and special hematology laboratories, interpreting coagulation and thrombosis testing, and reviewing case studies with the Medical Director of Hematology and Thrombosis. During this rotation the resident is relieved of the service responsibilities of "Usual" Hematology/Coagulation rotations, except for possible coverage of an absence per Departmental Policies.

 

The resident is expected to participate in the interpretations for inherited thrombophilia and Lupus Anticoagulant Screening during the rotation. The results and interpretation of these tests will be discussed with the Medical Director on each Friday, along with the case studies described below. 

 

The resident will arrange to spend time in the Special Hematology Laboratory observing platelet aggregation and platelet closure tests. These tests are scheduled in advance so the resident should be able to coordinate time with the Special Hematology supervisor. Additionally, the resident will arrange to spend time in either the ATL or Special Hematology Laboratory observing factor VIII levels and inhibitor assays. 

 

During the first week of this rotation the resident will complete Section 1 (Platelet disorders), Section 2 (Vascular disorders), and Section 3 (Coagulation disorders) of the Case Studies in Hemostasis and be prepared to discuss them with the Medical Director. During the second week the resident will complete Section 4 (Thrombotic disorders) and Section 5 (Preoperative evaluation) of the Case Studies and discuss them with the Medical Director.   

Each resident may spend one additional month on a "Clinical" rotation (see separate description).

 4.  Specific Topics and Reading Assignments

The library in the residents' office contains the standard clinical pathology, hematology and coagulation reference books. In addition, there are numerous supplementary textbooks, slide sets and other audiovisual materials available.  The basic core reading for the rotation is Henry, JB. Clinical Diagnosis and Management by Laboratory Methods (20th Ed.). Philadelphia: Saunders, 2001, Chapters 19 and 24-29.  During the rotation, the resident should also review current laboratory hematology journals and clinical pathology journals, particularly Hemostasis and Thrombosis and the American Journal of Clinical Pathology.