Clinical Pathology Program
Hematology/Hematopathology Core Rotation
Michael H. Creer, M.D.
Goals and Objectives:
The general goal of the Pathology Hematology/Coagulation rotation is to develop competence and expertise that will allow the resident to function as a clinical hematopathologist and a general anatomic pathologist. By the end of the rotation the resident should be capable of assuming the position of Medical Director of the Hematology/Coagulation laboratory in a moderate-sized community hospital. This requires that the resident become proficient in: (1) the morphologic evaluation of peripheral blood smears, body fluids, bone marrow biopsies/aspirates, and lymph node specimens; (2) the interpretation of hematology and coagulation tests; (3) appropriate selection of hematology and coagulation tests; (4) technical evaluation of test methods in hematology and coagulation testing; and, (5) collecting bone marrow biopsies and aspirates. Additionally the resident must gain knowledge of laboratory hematology and coagulation, sufficient for satisfactory performance on the Clinical and Anatomic Pathology Board examinations.
Since the skills necessary to accomplish these goals cross sectional lines, the resident will participate in the activities of both the divisions of Clinical and Anatomic Pathology. Additionally, since bone marrow aspirates and biopsies are not performed by pathologists at the HMC, the resident will also participate in activities of the division of Hematology/Oncology, Department of Medicine. Each resident should perform between five and ten bone marrow aspirate and trephine biopsies on adult patients under appropriate clinical supervision to establish competency. A basic Illustrated Guide to Performing Bone Marrow Aspiration and Biopsy is available for review. The resident learning experience consists of a combination of service responsibilities, self-instruction, technical instruction, formal conferences and informal teaching during rounds with the faculty.
The objectives of the rotation are encompassed by the six core competencies as defined by the ACGME and residents will be evaluated during their training in each of these areas. By the end of the rotation, the resident will be able to:
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.
- 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.
- 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.
- 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.
Duration and Timing of the Rotation
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.
Clinical Pathology faculty:
- Guoli Chen, MD, PhD
- David W. Craft, PhD, D(ABMM)
- Michael Creer, MD
- Ronald Domen, MD
- Melissa George, DO
- Wallace H. Greene, PhD, D(ABMM)
- Mary Beth Miele, PhD, MLS(ASCP)CM, RM(NRCM)
- Hiroko Shike, MD
Anatomic Pathology (Hematopathology) faculty
- Michael Bayerl, MD
- Josef Malysz, MD
- Ronald Livingston MT(ASCP) BHS, Supervisor, Automated Testing Laboratory, Hematology
- Diane Richwine, MT(ASCP)
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. Creer
- Automated hematology: Dr. Creer
- Peripheral Blood module (http://www.medtraining.org/ & Anemia: Dr. Creer
- 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. Creer
- Coagulation (bleeding diatheses): Dr. Creer
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.
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.
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.
Clinical Rotation Elective
Each resident may spend one additional month on a "Clinical" rotation (see separate description).
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.
Technical Instruction in Patient Care & Medical Knowledge Required to Achieve these Competencies
Residents are responsible to arrange training in bone marrow aspirations and biopsies during the first rotation of hematopathology. The resident or fellow will read and view the resources below before contacting the Nurse Practitioners or Physician Assistants in the Day Clinic to arrange notification for performance of bone marrow procedures.
- Chapter 3 "Procurement and Indications for Bone Marrow Examination" in Bone Marrow Pathology, 3rd Edition. Foucar K, et al. ASCP Press, 2010. (Available in 7th Floor Residents' Office)
- VIDEOS IN CLINICAL MEDICINE - http://www.nejm.org/doi/full/10.1056/NEJMvcm0804634
- Bone Marrow Aspiration and Biopsy by Suman Malempati, M.D., Sarita Joshi, M.D., Susanna Lai, M.P.H., Dana A.V. Braner, M.D., and Ken Tegtmeyer, M.D. in N Engl J Med 2009; 361:e28October 8, 2009.
Bone Marrow Aspirate and Biopsy Procedure for Residents and Fellows
The resident or fellow (trainee) contact Susan Rokita, CRNP, at pager 1193 or 531-4627 (or Hoang Dinh, CRNP), to schedule procedures. Ms. Rokita and her staff will familiarize you with their specific procedures. The trainee will observe at least one procedure by the NP or PA (Mid-Level) before performing the procedure. When the Mid-Level is comfortable with the trainee's observation, the trainee will be able to perform procedures under the direct supervision of the NP or PA. The Resident or Fellow will perform a minimum of 5 to 10 procedures under the direct supervision of the Mid-Level until judged as competent. Once the resident is found to be competent, he/she will no longer be required to attend or perform bone biopsy procedures. By the end of the first month of hematopathology, the resident needs to be found competent in performing these biopsies. The "procedure" will include: Review patient's record to determine valid order, indication, absence of contraindication and specimens to be obtained; soliciting informed consent; technical performance of the procedure and post-procedure review with the supervising Mid-Level. The Trainee will never perform a bone marrow procedure without direct supervision by a Mid-Level or Hematology/Oncology attending Physician.
Record of performance of bone marrow procedures should be documented by completing the located at the following link - Bone Marrow Aspirate/Biopsy Log.
Basic Hematology and Coagulation
The resident is expected to become familiar with the basic hematology and coagulation procedures listed in the table below. The resident should learn the principle, technique, application and interpretation of each procedure. The resident should observe each test performed at the institution; tests not performed at the institution should be discussed with attendings.
The resident is responsible for scheduling technical instruction for these procedures through the section supervisors.
|Complete Blood Count (CBC) by automated cell analyzer||Kleihauer-Betke Test|
|Platelet Count (automated and manual)||Antithrombin III Assay|
|Reticulocyte Count (automated and manual)||Protein C Assay|
|Leukocyte Differential (automated and manual)||Protein S Assay|
|Prothrombin Time (and INR)||Activated Protein C Resistance Assay|
|Partial Thromboplastin Time||Factor V Leiden Assay|
|Fibrinogen Level||D-Dimer Assay|
|Coagulation Factor Assays||Coagulation Factor Inhibitor Assays|
|Hemoglobin Electrophoresis||Hemoglobin Quantitation by HPLC|
|Sickle solubility (Prep)||Anti-Xa Heparin Assay|
|Erythrocyte Sedimentation Rate||Thromboelastograph|
|POCT (INR) in Anticoagulation Clinic||POCT (ACT) in O.R.|
The resident should observe each of the procedures. Although it is not a goal of the rotation that the resident becomes technically expert in laboratory procedures, the resident must gain an understanding of the technical aspects of each procedure.
As with all other Clinical Pathology rotations, self-instruction will form an essential part of the resident's learning experience. Readings and review of patient material will provide the basis for discussions with and instruction by the attendings.
Specific Skills in Patient Care and Medical Knowledge Required to Achieve these Competencies
Red Blood Cells:
- Describe the morphology and physiology of RBC production.
- Understand the principles of laboratory methods used to measure and/or calculate RBC indices including: RBC count, Hb concentration, HCT, MCV, MCH, MCHC.
- Be familiar with the normal ranges for Hb concentration and HCT, and how these vary with: age, gender, hydration status, local elevation, handling and storage of specimen, etc.
- Accurately identify polychromatophilic RBC on a blood smear. Understand the principles of laboratory measurement of reticulocyte counting, physiologic corrections and interpretation of results.
- Identify normal and abnormal RBC morphology on a blood smear and generate differential diagnoses based on common abnormalities such as: hypo/hyperchromatic cells, macro/microcytes, polychromasia, elliptocytes/ ovalocytes, spherocytes, burr/spur cells, dacrocytes, target cells (leptocytes), schistocytes, sickle cells, Howell-Jolly bodies, Pappenheimer bodies, bite cells, normoblasts, etc.
- Describe the laboratory methods, interpretation and limitations of measuring RBC mass.
- Describe the laboratory methods, interpretation and limitations of measuring ESR.
- Compile and synthesize appropriate clinical and laboratory data to generate and resolve differential diagnosis of anemias. Describe the clinical and pathologic features of common forms of anemia.
- Differentiate relative from absolute polycythemia. Compile and synthesize appropriate clinical and laboratory data to generate and resolve differential diagnosis of polycythemia. Describe the clinical and pathologic features of common forms of polycythemia.
Clinicopathologic Entities that you should know about:
- Fe deficiency
- Megaloblastic anemias, B12 and folate deficiency
- Anemia of chronic inflammation / chronic disease
- Anemia of chronic renal insufficiency
- Anemia of liver disease
- Anemia of endocrine disease
- "Anemia" of pregnancy
- Aplastic anemias
- Infection associated
- Congenital / constitutional
- Pure red cell aplasias
- Transient arrest of erythropoiesis
- Transient erythroblastopenia of childhood
- Thymoma associated
- LGL - associated
- Sideroblastic anemias
- Acute / chronic blood loss
- Hemolytic anemias
- Hereditary spherocytosis
- Hereditary elliptocytosis
- Hemoglobin (Hb)
- Hemoglobin structural variants
- HbS, HbC, HbE, HbD, HbO, HbG
- Altered oxygen affinity
- Alpha thalassemias
- Double heterozygotes
- SC, SD, SG, SO
- S beta-thalassemia
- E alpha-thalassemia
- G6PD deficiency
- PK deficiency
- Physical agents - heat, mechanical, MAHA
- Warm antibody-associated
- Cold antibody - associated
- Primary - Polycythemia vera
- Describe the morphology and physiology of myelopoiesis (neutrophilic, monocytic, eosinophilic and basophilic lineages). Describe the concept of the marginated pool of neutrophils and its physiologic/pharmacologic regulation.
- Describe the laboratory methods, limitations and interpretation of counting leukocytes in the blood and generating a leukocyte differential. Explain why our clinical laboratory does not report "bands."
- Generate a differential diagnosis for quantitative leukocyte disorders (neutrophilic leukocytosis/neutropenia, monocytosis/monocytopenia, etc.) Specifically define neutropenia, degrees of severity and clinical consequences. Know the major hereditary neutropenic disorders (cyclic, familial, Kostman, etc).
- Identify the major, qualitative, disorders of neutrophils: toxic granulation/Dohle bodies, (pseudo)Pelger-Huet, May-Hegglin, Alder-Reily, Chediak-Higashi. Correlate the clinical syndromes associated with these disorders.
- Differentiate neoplastic from non-neoplastic myeloid disorders. Synthesize clinical information, clinical laboratory results, blood and bone marrow morphology, cytochemistry, immunophenotype and genetic data to accurately diagnose acute myeloid leukemias, myelodysplastic syndromes, chronic myeloproliferative disorders and myelodysplastic/myeloproliferative diseases. Use this synthesis to compose pathology reports including accurate diagnosis, subclassification and prognostic data.
- Correctly triage tissue and other samples received in the laboratory to maximize the diagnostic yield.
- Be able to identify the morphology of the normal lymphoid immune system and physiologic responses, specifically lymph nodes, spleen, thymus and bone marrow.
- Understand the normal immunology of the B-, T- and NK- cell response, and apply these principles for diagnosis of nodal and extranodal lymphoid proliferations.
- Correctly request and interpret flow cytometric and immunoperoxidase immunophenotyping for diagnosis and prognosis as related to lymphoproliferative disorders.
- Correctly request and interpret molecular and cytogenetic testing prognosis as related to lymphoproliferative disorders.
- Apply 1. through 6. to differentiate physiologic from neoplastic lymphoid proliferations.
- Recognize non-neoplastic lymphoid patterns with specific clinical correlates. Correctly classify lymphoid neoplasm based on the WHO 2001 classification, including clinical, morphologic, immunologic and molecular correlates.
- Describe normal megakaryopoiesis, physiologic control and morphology.
- Describe normal platelet functions.
- Develop a differential diagnosis for thrombocytopenia and an algorithm for diagnosing specific etiologies.
- Develop a differential diagnosis for thrombocytosis and an algorithm for diagnosing specific etiologies.
- Describe the pathophysiology of specific platelet function disorders: Glanzmann thrombasthenia, Bernard-Soulier, platelet type vWD, collagen receptor defect, Scott syndrome, alpha and or dense granule deficiency and acquired platelet function disorders. Synthesize clinical and laboratory data to diagnose disorders of platelet function.
- Describe the underlying principles, interpretation and limitations of specific platelet tests:
- Platelet / Megakaryocyte morphology
- Platelet morphology in blood film
- Platelet granules by EM
- Platelet counting
- Visual platelet estimate
- Hemocytometer phase contrast
- Platelet function testing
- Bleeding time
- Platelet aggregation and release
- Antiplatelet antibody testing
|Laboratory Methods in Hematology||Dr. Creer|
|Basic Work-up of Anemia||Dr. Donaldson|
|Hemolysis - Membrane, Metabolic and Immune||Dr. Domen|
|The Erythron||Dr. Ballard|
|Basic Flow Cytometry||Dr. Malysz|
|CMPD and MDS/MPD||Dr. Bayerl|
|Reactive Lymphoid Hyperplasias||Dr. Malysz|
|Hodgkin Lymphoma||Dr. Bayerl|
|Small Cell, B-Cell Lymphomas||Dr. Bayerl|
|DLBCL and Burkitt Lymphomas||Dr. Bayerl|
|T-Cell Lymphomas||Dr. Bayerl|
|Coagulation Overview||Dr. Donaldson|
|Disorders of the "Intrinsic Pathway"||Dr. Donaldson|
|Disorders of the "Extrinsic Pathway"||Dr. Donaldson|
|Hypercoagulable States||Dr. Donaldson|
Conferences and Case Material
- Benign Hematology Conference, 1st and 3rd Thursdays at Noon, T2500
- Hematology/Oncology Grand Rounds, each Thursday at 7:45 AM, T2500
- Lymphoma/Leukemia Conference, each Wednesday at 5:00 PM, T4007
- Lymph Node Conference, last Tuesday of each month at 2:00 PM, C7702
Method(s) of Evaluation
- Residents will be evaluated based on direct observation by faculty
- After each rotation, residents will be evaluated by faculty in New Innovations