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Pediatric Hematology/ Oncology Fellow Handbook For 2007 - 2008

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    Pediatric Hematology/ Oncology Fellow Handbook For 2007 - 2008 Pediatric Hematology/ Oncology Fellow Handbook For 2007 - 2008 Document Transcript

    • Pediatric Hematology/ Oncology Fellow Handbook For 2007 - 2008 University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 1
    • Table of Contents Program Statement Program Requirements Program Description General Description Accreditation Certification Components of the Program Clinical Research Program Features Faculty Facilities and Resources General Curriculum General Program Content Knowledge and Clinical Experience Skills – Clinical, Technical and Procedural Scholarship Research Standard of Conduct Humanistic and Ethical Behavior Summary of Curriculum Goals and Objectives Goals of the Fellowship Continuity Clinic Inpatient Rotation Pathology/Hematopathology/Coagulation Bone Marrow Transplant Adult Hematology Radiation Oncology Transfusion Medicine Conferences University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 2
    • Other Educational Activities Evaluation Procedures First Year Evaluation Second and Subsequent Years Evaluation Evaluation of Fellow Performance Fellow Evaluation of Rotation Fellow Evaluation of Faculty Promotion, Probation, Suspension and Dismissal Important Policies for 2007 – 2008 Supervision Eligibility and Selection Vacation and Leave Moonlighting Work Hours Call Responsibilities Standards of Performance Due Process Evaluation Appendix Form for Fellows to Evaluate Rotations Form for Attendings to Evaluate Fellows Program Director Meeting Form University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 3
    • Program Statement Hematology/Oncology as a Subspecialty of Pediatrics Satisfactory completion of an accredited program in Pediatrics is a requirement for entry into this subspecialty training program. Subspecialty training in Pediatric Hematology/Oncology is a voluntary component of education in Pediatrics. Requirements of the Fellowship Program The primary requirements of the Fellowship program include: Appropriate progress in achieving clinical competence as specified below. Successful completion of all clinically related tasks required on each specific rotation. These include attendance at clinics, performance of consultative history and physical examinations, daily (or more frequent as medically indicated) follow-up of inpatients, and performance of all requested emergency and inpatient consultations. Maintenance of all medical records pertaining to patient care in an accurate and timely fashion. Hospital and Pediatric Hematology/Oncology Division records need to be complete and accurate, legible, and appropriately detailed. Dictations need to be done within 24 hours of the clinic visit and consultation notes placed on the hospital chart within 24 hours of providing the consultation. Regular attendance at all educational activities (journal club, tumor board, clinical and research conferences) of the division. Subspecialty conferences and meetings are mandatory for the Fellow(s) assigned to the specific rotation, and optional for all other Fellows in the program. Familiarity with and comprehension of Pediatric Hematology/Oncology literature. The Fellow is expected to read widely on topics pertaining to patients in whose care the Fellow is currently involved. Fellows will be asked to take part in and present at a number of conferences throughout their training. It is expected that their efforts will reflect an appropriate amount of thought and work in developing the topics. Annually, the Fellow is expected to do at least one 1-hour special conference presentation. The Fellows in the first year will be expected to do a literature search and a presentation of the subject, while in the second and third years will present results of either clinical or basic science research. The Fellows’ presentations will be evaluated and critiqued by the staff, and it is expected that these presentations will be worthy of presentation at a regional or national meeting and comparable to such presentations in terms of scientific quality and use of audiovisual materials. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 4
    • Fellows are expected to maintain a log of procedures performed during their training, including bone marrow aspirates and biopsies, lumbar punctures, paracentesis, thoracentesis, etc. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 5
    • Program Description General Program Description Program Accreditation Certification in Pediatric Hematology/Oncology University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 6
    • General Program Description The University of Utah is the major teaching and research institution in the intermountain west. The University of Utah School of Medicine uses Primary Children's Medical Center (PCMC) as its primary training site for Pediatrics. The University of Utah Health Sciences Center (UUHSC) is also used as a part of Pediatric Hematology/Oncology training program. Major clinical care and clinical and basic research programs are a part of all specialty programs including Pediatrics and Pediatric Hematology/Oncology. The Pediatric Hematology/Oncology Division staff at PCMC and UUHSC is made up of full-time academic faculty members in the University of Utah Department of Pediatrics (see faculty list and appendix for detailed faculty information). Program Accreditation and Relationship to Pediatrics The Hematology/Oncology subspecialty training program at the University of Utah is an integral part of the residency program in Pediatrics, which are together accredited by the Accreditation Council for Graduate Medical Education (ACGME). The Pediatric and subspecialty training programs in the department of Pediatrics are all ACGME accredited programs in the University of Utah’s School of Medicine. These programs include complete and in-depth training in all aspects of Pediatrics, its subspecialties, and in clinical and basic research. The Pediatric Hematology/Oncology training program is offered as a three-year Fellowship. Certification in the Subspecialty of Hematology/Oncology The American Board of Pediatrics offers certification in the subspecialty of Pediatric Hematology/Oncology upon successful completion of the certification examination given by the Board. Specific requirements for certification are given later in this packet. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 7
    • Components of the Program Clinical Research University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 8
    • Components of the Program Clinical Component The Pediatric Hematology/Oncology training program includes 1-6 Fellows who interact on a daily basis with faculty, with each other, and with the general and subspecialty clinical services from Pediatrics and allied medical and surgical specialties. The program consists of structured educational activities including inpatient and outpatient experiences, consultative rotations, technical training, conferences, didactic lectures, teaching experiences, assigned readings, review sessions, and research training. All of these are designed with specific goals, implementation methods, and evaluations so that the Fellow can acquire all of the knowledge, cognitive, technical, interpersonal, humanistic, research, professional and judgment skills necessary to be an academic Pediatric Hematologist/Oncologist and a responsible and contributing part of the medical community and society. The first year of the Fellowship is a clinical year with 5- 6 months of inpatient service and 5-6 months of rotations including Outpatient Clinic and Consultations, BMT (1 month), Pathology and Laboratory Medicine (1 month), Adult Hematology (1 month), Radiation Oncology (I month), and 3 weeks of vacation. Each of the specific educational components is detailed later. Research Component The second and third years of the Fellowship are dedicated to basic science research training. A broad range of research resources and opportunities are available in the division, the department, and the institution. There are tremendous research opportunities available through the University of Utah and the Huntsman Cancer Institute. We recognize that successful research training may not be completed in two years, and are committed to facilitating additional training as appropriate to meet the needs of the Fellow. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 9
    • Program Features Faculty Facilities and Resources University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 10
    • General Features of Training in Pediatric Hematology/Oncology Subspecialty training in Pediatric Hematology/Oncology at the University of Utah provides advanced training to allow the Pediatric Hematology/Oncology Fellow to acquire consultative expertise. All major dimensions of the curriculum (described later) are structured educational experiences with specified goals and objectives, a defined methodology for teaching/learning, and an explicit method for evaluation. The curriculum assures that Fellows will have the opportunity to achieve the cognitive knowledge, psychomotor skills, interpersonal skills, professional attitudes, and practical experience required of a sub-specialist in Pediatric Hematology/Oncology. In addition, Fellows will be expected to maintain in-depth knowledge of Pediatrics, as Hematologist/Oncologists are often called upon to provide primary care to patients. The program at the University of Utah emphasizes scholarship, self-instruction, development of critical analysis of clinical problems, and the ability to make appropriate decisions. The program provides appropriate opportunity for the Fellow to acquire skills in the performance of the techniques required for the practice of the subspecialty. Appropriate supervision is provided during all educational experiences. Faculty The training program is a joint effort between both the Pediatric Hematology and Oncology Divisions of the Department of Pediatrics. Clinical and research faculty is as follows: Division of Pediatric Hematology/Oncology Richard Lemons, MD, PhD Professor of Pediatrics Division Chief, Pediatric Hematology/Oncology Primary Children's Medical Center Phone: 801-662-4733 Pager: 801 914-6360 David Virshup, MD Program Director Willard Snow Hansen Presidential Professor of Cancer Research Professor of Pediatrics Adjunct Professor of Oncological Sciences Investigator, Huntsman Cancer Institute HCI 3245 Phone: 801-585-3408 Pager: 801-914-6512 University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 11
    • Carol Bruggers, MD Professor of Pediatrics PCMC Phone: 801-662-4735 Pager: 801-914-6856 Hassan Yaish, MD Associate Professor of Pediatrics PCMC Phone: 801-662-4701 Pager: 801-914-6993 Zenaib Afify, MD Assistant Professor of Pediatrics PCMC Phone: 801-662-4731 Stephen Lessnick, MD, PhD Assistant Professor of Pediatrics Investigator, Huntsman Cancer Institute Adjunct Assistant Professor of Oncological Sciences HCI 4242 Phone: 801-585-9268 Pager: 801-914-8478 Nikolaus Trede, MD, PhD Assistant Professor of Pediatrics Investigator, Huntsman Cancer Institute HCI 4265 Phone: 801-585-0199 Pager: 801-914-8671 Phillip Barnette, MD, DVM Instructor, Assistant Professor of Pediatrics PCMC Phone: 801-662-4730 J. Kimble Frazer, MD, PhD Instructor, Department of Pediatrics HCI 4263 Phone: 801-587-5599 University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 12
    • Additional Key Faculty Michael Pulsipher, MD Acting Director, Utah Blood and Marrow Transplant Program Assistant Professor of Pediatrics Adjunct Assistant Professor of Medicine PCMC Hem/Onc/BMT Division 5C402 SOM Phone: 801-213-2079 Pager: 801-914-6838 Michael Boyer, MD Assistant Professor Bone Marrow Transplantation Phone: 801-662-4729 John H. Ward, MD Professor of Medicine Division Chief, Oncology Medical Director, Huntsman Cancer Institute 2141 HCI Bldg. Phone: 801-585-0255 Pager: 801-339-5214 George M. Rodgers, MD, PhD Professor of Medicine Adjunct Professor of Pathology (Clinical) 2C110 SOM Phone: 801-585-3229 Pager: 801-339-5208 Robert Blaylock, MD Associate Professor of Pathology Blood Bank Director 5C124 SOM Phone: 801-585-3369 Sherrie Perkins, MD, PhD Associate Professor of Pathology Director, Hematopathology 5C124 SOM Phone: 801-581-5854 University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 13
    • Cheryl Coffin, MD Professor of Pathology Division Head, Pediatric Pathology, PCMC Medical Director, Vice President, Pediatric Pathology ARUP Laboratories Associate Chair, Pathology, University of Utah PCMC, 2nd Floor, Northeast Phone: 801-662-2155 Pager: 801-914-6464 John Thomson, MD Radiation Oncology LDS Hospital Phone: 801-408-1146 Dennis Shrieve, MD Radiation Oncology University of Utah Phone: 801-581-8793 Lynn Smith, MD Radiation Oncology Huntsman Cancer Institute Phone: 801-581-2396 Pager: 801-581-2396 R. Lor Randall, MD, FACS Director, Sarcoma Service Huntsman Cancer Institute HCI 4262 Phone: 801-585-0300 Pager: 888-332-1246 Facilities and Resources The training facilities used by the Hematology/Oncology Fellowship program include inpatient wards and outpatient facilities at PCMC, the UU Health Science Center and the Huntsman Cancer Institute. There are a number of full-time University of Utah faculty members, who provide teaching and direction for the program. The University of Utah, PCMC and Huntsman Cancer Institute are fully accredited and active members of the Children's Oncology Group (COG). COG is a multi-center national clinical investigation cooperative group involved in developing Phase I through Phase III clinical trials for national patient enrollment. Fellows will be expected to take an active role in the recruitment of patients to these trials. Primary Children's Medical Center University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 14
    • PCMC is a pediatric referral center serving five states in the Intermountain West. This 232-bed facility is equipped and staffed to treat children with complex illness and injury. PCMC offers specialized care services including surgery, pathology, laboratory medicine, rehabilitation medicine, diagnostic and interventional radiology, and nuclear medicine. In addition to the general service wards, there are pediatric intensive care, newborn intensive care, and bone marrow transplant units. There is a close working relationship between the Divisions of Hematology and Oncology and the surgical, pediatric, radiology, and pathology staffs. This relationship includes patient care, lectures, and multi-disciplinary conferences. PCMC is part of Intermountain Health Care, a non-profit organization, and is affiliated with the Department of Pediatrics at the University of Utah. There are over 10,000 inpatient admissions and over 130,000 outpatient visits annually (Approximately 7% of these visits are to the Pediatric Hematology/Oncology service.) There is an air transport service that transports over 500 critically ill to PCMC annually. A fully equipped and well-staffed Pediatric Emergency Department at PCMC provides care for nearly 30,000 patients annually. The Pediatric Hematology/Oncology patients are admitted to a newly renovated (as of January, 2004) dedicated medical unit staffed with nurses specifically trained in issues related to Pediatric Hematology/Oncology and bone marrow transplantation. Also, there is a new (as of July 2006) dedicated Pediatric Hematology/Oncology outpatient clinic within PCMC with 10 exam rooms, with an integrated infusion therapy center and multi-bed procedure center. The PCMC inpatient and outpatient experience includes a full consultative Hematology/Oncology service for Pediatrics and Pediatric Surgery, and all their subspecialties. Fellows will rotate through the inpatient service at PCMC, spending 6 months on it during their first year. The vast majority of clinical care for Pediatric Hematology/Oncology patients occurs at PCMC. University of Utah Health Sciences Center The University Hospital is a 365-bed acute care facility offering primary to quaternary care in all specialties of medicine, surgery, pathology, laboratory medicine, family medicine, obstetrics and gynecology (including gynecologic oncology), rehabilitation medicine, diagnostic and interventional radiology, and nuclear medicine. In addition to the general service wards, there are medical, pulmonary and cardiac, surgical, neurological, and newborn intensive care units. There is a close working relationship between the Divisions of Hematology and Oncology and the surgical, medical, pediatric, radiology, and pathology staffs. This relationship includes patient care, lectures, and multi-disciplinary conferences. The University Bone Marrow Transplant Unit, part of the Hematology Division, evaluated 129 new patients in 1998, and performed 55 autologous transplants and 31 allogeneic transplants that year. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 15
    • Fellows will do consults, Adult Hematology and Laboratory Medicine rotations, and parts of their BMT and Pathology rotations at the UUHSC. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 16
    • Huntsman Cancer Institute The Huntsman Cancer Institute (HCI) is affiliated with the University of Utah. Situated east of the main hospital building, the Huntsman Cancer Institute is mandated to be a center of excellence for cancer research. Basic science researchers with the Institute study the molecular and biochemical mechanisms underlying malignant transformation, identify malignant gene rearrangements for use as markers predicting inheritance or targets for gene therapy, and develop new therapeutic agents for the treatment of malignancy. Clinical research staff study patterns of disease inheritance, enroll adult patients in clinical trials to evaluate new therapeutic or preventive agents, and work closely with the basic science researchers in translational research. Pediatric Hematology/Oncology Fellows will spend some part of their Fellowship in this facility attending lectures and providing consults if needed. In addition, a substantial number of Fellows elect to do research with laboratory and clinical researchers housed in HCI. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 17
    • General Curriculum General Program Content Knowledge and Clinical Experience Skills – Clinical, Technical, And Procedural Scholarship Research Judgment Standards of Conduct Humanistic and Ethical Behavior Summary of Curriculum University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 18
    • General Program Content and Curriculum The Pediatric Hematology/Oncology clinical training program is a structured educational experience combining inpatient and ambulatory clinical rotations with interactive conferences and didactic teaching sessions. Fellows will participate in a continuity of care clinic for one day per week for the duration of their Fellowship training. An Attending Physician supervises all clinical activities. Inpatient clinical rotations combine extensive interaction with pediatric residents, as well as Fellows from other specialties with reporting to and instruction from the Attending Physician. All procedural training is supervised by on site Attending Physicians. It should be noted that the educational activities are not only structured to meet all of the goals of Pediatric Hematology/Oncology training, but also to maintain skills in General Pediatrics. Fellows are to do complete evaluations on all inpatient and outpatient consultations. These are reviewed and discussed with Attending Physicians. Fellows are required to attend divisional conferences (the schedule of these is outlined later) and are invited to attend didactic conferences for the pediatric housestaff. Research training is accomplished through both didactic teaching of research principles and through closely supervised research projects. A scientific mentor supervises all research activities. The Fellowship program research training requirements are detailed later. Overall Objectives of Training in Hematology/Oncology The overall objective of the Pediatric Hematology/Oncology training program is to fully instruct Pediatric Hematology/Oncology Fellows in the science and practice of their chosen subspecialty. In addition, our Fellows will acquire expertise in the critical appraisal of medical literature required to maintain a high standard of competence throughout their practice lifetime. Graduates of our program will become board certified, and be highly competent and competitive for academic positions. Knowledge and Clinical Experience The Fellow will receive formal instruction, clinical experience, and opportunities to acquire comprehensive knowledge in the following areas: • Morphology, physiology, and biochemistry of blood, marrow, lymphatic tissue, and the spleen. • Basic molecular and pathophysiologic mechanisms, diagnosis, and therapy of diseases of the blood, including anemias, diseases of white cells, and disorders of hemostasis and thrombosis. • Etiology, epidemiology, natural history, diagnosis, pathology, staging, and management of neoplastic disorders. • Measurement of the complete blood count, including platelets and white cell differential, using automated or manual techniques with appropriate quality control. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 19
    • • Immune markers, immunophenotyping, cytochemical studies, and cytogenetic and DNA analysis of neoplastic disorders. • Molecular mechanisms of neoplasia, including the nature of oncogenes and their products. • Systemic chemotherapeutic drugs, biological and immunological response modifiers, and growth factors and their mechanisms of action, pharmacokinetics, clinical indications, routes of administration, and limitations, including their effects, toxicity, and interactions. • The use of multiagent chemotherapy protocols and combined modality therapy in the treatment of neoplastic disorders. • Management and care of indwelling venous access catheters. • Principles and application of surgery and radiation therapy in the treatment of neoplastic disorders. In particular, a basic understanding of the physics involved in the administration of radiation therapy and the complications arising from its use, as well as a comprehensive understanding of potential interactions between systemic therapy and radiation therapy. • Management of the neutropenic and/or the immunocompromised patient. • Rapid identification and treatment of hematologic and oncologic emergencies, including spinal cord compression, hypercalcemia, disseminated intravascular coagulopathy (DIC), thrombotic thrombocytopenia purpura (TTP), & heparin induced thrombocytopenia (HIT). • Effects of systemic disorder, infections, solid tumors, and drugs on the blood, blood-forming organs, and lymphatic tissues. • Allogeneic and autologous bone marrow transplantation and the nature and management of post-transplant complications. • Indications and application of imaging techniques inpatients with blood and neoplastic disorders. • Pathophysiology and patterns of solid tumor metastases. • Pain management in the cancer patient. • Nutrition management for the cancer patient. • Rehabilitation and psycho-social management of patients with hematologic and neoplastic disorders. • Hospice and home care for the cancer patient. • Recognition and management of paraneoplastic disorders. • The etiology of cancer, including predisposing causal factors leading to neoplasia. • Current cancer prevention and screening recommendations, including competency in genetic testing and counseling as they relate to hereditary cancers and hematologic disorders for high- risk individuals. • Participation in a tumor board. • Tests of hemostasis and thrombosis for both congenital and acquired disorders and regulation of anti-thrombotic therapy. • Treatment of patients with disorders of hemostasis and the biochemistry and pharmacology of coagulation factor replacement. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 20
    • • Transfusion medicine, including the evaluation of antibodies, blood compatibility, and the use of blood component therapy and apheresis procedures. • Understand the late effects of cancer therapy. The Fellow will achieve a high level of cognitive knowledge of the following specific disorders, including their risk factors, molecular basis, appropriate treatment options, and prevention strategies, where applicable: • Leukemias, both acute and chronic • Solid tumors of organs, soft tissue, bone, and central nervous system • Lymphomas • Bone marrow failure • Hemoglobinopathies, including the thalassemia syndromes • Inherited and acquired disorders of the red-cell membrane and of red-cell metabolism • Autoimmune hemolytic anemia • Nutritional anemia • Inherited and acquired disorders of white blood cells • Platelet disorders, including ITP and acquired and inherited platelet function defects • Hemophilia, von Willebrand's disease, and other inherited and acquired coagulopathies • Hematologic disorders of the newborn • Transfusion medicine and use of blood products • Congenital and acquired immunodeficiencies In addition to specific hematologic and malignant disorders, the Fellow must develop competency in all aspects of chemotherapy, including treatment protocols and management of complications, diagnosis and treatment of infections in the compromised host, appropriate use of transfusion of blood products, plasma pheresis and bone marrow transplantation. The Fellow is also expected to learn methods of physiologic support of the cancer patient including parenteral nutrition, control of nausea and pain, staging and classifications of tumors, complete knowledge and application of multi-modality therapy, learning to function as a member of an oncology team, and learning the epidemiology of childhood cancer. Skills - Clinical, Technical, and Procedural Fellows will develop the skills needed of a subspecialty consultant in Pediatric Hematology/Oncology. The Fellow will learn the skills of history taking, physical examination, data interpretation, problem synthesis, and proper use of diagnostic and therapeutic procedures. The full spectrum of procedures applicable to the practice of Pediatric Hematology/Oncology will be learned by the Fellow, and will include training in the technical and psychomotor skills required. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 21
    • Clinical Skills: Fellows will be expected to be proficient in the following clinical skills: 1. The performance of a directed but thorough history and physical examination. 2. The ability to serially measure palpable tumor masses. 3. The ability to interpret clinical data, including laboratory data, imaging studies, pathologic specimens, and the microscopic interpretation of blood smears and marrow aspirates and biopsies. 4. The ability to formulate an appropriate differential diagnosis and diagnostic plan based upon the clinical, laboratory, and radiological findings. 5. The ability to communicate clinical data in an organized, succinct, and intelligible fashion. 6. The ability to select appropriate, safe, and cost-effective laboratory and diagnostic studies. 7. The ability to formulate and carry out an appropriate therapeutic plan for Pediatric Hematology/Oncology disorders. 8. The ability to work effectively as part of a multi-disciplinary team. 9. The ability to provide appropriate humanistic, ethical, and conscientious care to the patient. Technical and Procedural Skills: The Fellow will know the indications, contraindications, complications, potential benefits, alternatives, and limitations of the following diagnostic and therapeutic techniques and procedures. The Fellow will be able to appropriately, safely and expeditiously perform or recommend and, where applicable, interpret these procedures based upon knowledge of the history and clinical findings. The Fellow will receive training in each of these areas to accomplish this goal. • Accurately calculate doses, order, administer or supervise the administration of cytotoxic chemotherapeutic agents and biologic response modifiers. Specifically, instruction in the careful, concise, and accurate ordering of these agents will be emphasized. • Ordering and administration of blood products, including factor replacement. This will include instruction in the indications for specific preparation of blood products—filtered, irradiated, and washed. • Recommend and assess tumor imaging studies, including plain films, CT scans, ultrasound (dynamic or static), MRI, and metabolic scanning. • Recommend surgical procedures. • Recommend appropriate insertion of central venous access, including PICC lines, broviac or portacath catheters. • Perform bone marrow aspiration and biopsy, including preparation, staining, examination, and interpretation of blood smears, bone marrow aspirates, and touch preparations. The Fellow will be able to perform the bone marrow aspirate/biopsy by the posterior, and anterior approach. • Recommend apheresis procedures, including therapeutic plasmapheresis or peripheral stem cell harvest for transplantation. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 22
    • • Perform and interpret partial thromboplastin time, prothrombin time, platelet aggregation, bleeding time and other standard coagulation assays. • Perform diagnostic or therapeutic thoracentesis and paracentesis. • Perform lumbar puncture or access Ommaya reservoirs, and, where applicable, instill chemotherapeutic agents directly into the CSF. • Administer sedation for patients undergoing procedures such as bone marrow biopsy. The Fellow will be expected to be able to concisely outline the nature and utility of each procedure, along with its potential complications and benefits, to the patient for the purpose of obtaining informed consent. The Fellow will appropriately document the indications, performance and results of all procedures in the patient chart. In addition, the Fellow will document all procedures in the ABP-approved procedure logbook, and have the supervising Attending Physician sign off on them. The Fellow will be expected to learn to identify his/her own limitations, and identify when to terminate procedures or seek assistance. Scholarship A scholarly approach to learning, practice, research, and teaching will be developed. Pediatric Hematology/Oncology Fellows will utilize educational offerings to their fullest extent. Fellows will also be expected to become independent learners and develop lifelong habits of reading and literature research. They will learn the principles of evidence-based medicine, critical literature review, and clinical application of new knowledge to the clinical and research settings. They will be encouraged to remain active in research throughout their practice careers, in the laboratory setting, in the clinical setting, or both. Pediatric Hematology/Oncology research is required not only for the purpose of learning necessary skills for a possible academic career, but also to gain first-hand experience in the generation of medical knowledge. Like learning, teaching is an integral part of scholarship. As such, the Fellow will be involved in teaching throughout the program. The Division is responsible for teaching medical students about Pediatric Hematology and Oncology. Fellows will participate by directing small groups of medical students in sessions covering topics outlined in the formal lectures. In addition, Fellows will regularly present and discuss patients and therapeutics at multi-disciplinary conferences, give didactic lectures at Friday conferences, present regularly at journal club, and instruct interns and residents from all disciplines during inpatient and consult service rounds. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 23
    • Research Basic science and clinical research are of critical importance to the field of Pediatrics, and to Pediatric Hematology/Oncology in particular. All advances in medical practice are the result of research. Abundant research opportunities exist for our Fellows and include basic laboratory research, translational and clinical research projects. These can be coordinated within the Divisions, the Department of Pediatrics, or any other Department within the University. The HCI investigators and those in the Department of Oncologic Sciences represent a unique opportunity for the development and pursuit of research interests. Fellows in Pediatric Hematology/Oncology will receive instruction in the principles and techniques involved in basic science and clinical research, and will be expected to participate in a research project during their program. Fellows will spend at least two years involved in a research project. By Spring of their first year, Fellows will be expected to have identified a scientific mentor and an area of research interest, and communicate this to the Program Director. Fellows will be encouraged to seek the advice of Faculty members when deciding on a potential research project, and will receive whatever assistance they require. It is hoped that the exposure our Fellows receive to research during their program will foster an interest that will last throughout their career. Judgment The Fellow will develop appropriate clinical judgment in all aspects of the practice of Pediatric Hematology/Oncology. This includes the ability to integrate medical facts and clinical data, weigh alternatives, understand the limitations of knowledge, critically analyze and integrate complex information, develop most appropriate evaluation and management strategies, make appropriate decisions, and incorporate considerations of risks and benefits. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 24
    • Standard of Conduct Fellows will be expected to develop a high degree of standard of conduct. A Fellow must be responsive, reliable, committed, cooperative, and respectful. The Fellow must demonstrate appropriate regard for the opinions and skills of colleagues. Records should be legible, timely, and responsive to the referring physician’s needs and questions. Information should be validated through a personal review of clinical findings, laboratory and radiographic data, and pathology specimens. Communication should be effective and non-judgmental. Interpersonal skills should be highly developed in order to achieve effective, positive, and efficient communication with patients, colleagues, and staff. Standard of conduct includes placing the needs of one’s patients, colleagues and staff ahead of one’s own self-interest, being responsive to the needs of society, having a continuing commitment to scholarship and research, and enhancing the ability of all colleagues in the health professions to discharge their responsibilities optimally. Proper standard of conduct also includes the proper application of judgment, the “art” of medicine, and the values learned from mentors and role-model clinicians. The importance of giving time for teaching, institutional committee work, and community service is a part of the standard of conduct, as is the proper application of the principles of quality assessment, quality improvement, risk management, and cost-effective practice. Humanistic and Ethical Behavior Fellows must exhibit the highest standards of humanistic and ethical behavior. The character traits of integrity, respect, compassion, and empathy should always be demonstrated towards both patients and colleagues. Fellows should establish relationships with patients and all other members of the health care team based on mutual trust and understanding. There should be a primary concern for the welfare of the patient. The Fellow should maintain credibility, rapport with patients and families, and respect the patient’s need for information. The Fellow should always be non- judgmental. There should be appropriate attention to confidentiality, informed consent (both in the clinical and research setting), and to social, cultural, and language barriers. Summary of Training Program Curriculum The overall goals and objectives of the program will be accomplished through the following educational offerings. The objectives, value, teaching methods, educational content, mix of diseases, patient characteristics, types of clinical encounters, procedures and services, educational materials, methods of evaluation, and strengths and weaknesses of these educational offerings are outlined under the section “Details of Each Educational Offering” below. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 25
    • Goals And Objectives Goals of the Fellowship Continuity Clinic Inpatient Rotation Pathology/Hematopathology/Coagulation Bone Marrow Transplant Adult Hematology Radiation Oncology Transfusion Medicine Conferences Other Educational Activities University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 26
    • Goals of the Fellowship It is the intent of this training program to develop physicians clinically competent in the field of Pediatric Hematology/Oncology and also with sufficient knowledge, thought processes and laboratory skills necessary for a potential career as an independent investigator. Physicians completing this training program will be eligible for certification in Pediatric Hematology/Oncology. Clinical competence requires: (1) A solid fund of basic and clinical knowledge, (2) The ability to perform a thorough history and physical examination, (3) The ability to appropriately order and interpret diagnostic tests, (4) Adequate technical skills to carry out selected diagnostic procedures, (5) Clinical judgment to critically apply the above data to individual patients, (6) Attitudes conducive to the practice of Pediatric Hematology/Oncology, including appropriate interpersonal interactions with patients, professional colleagues and supervisory faculty, and all paramedical personnel. These humanistic aspects of medicine are of critical importance, (7) Personal integrity, which includes strict avoidance of substance abuse, theft, and unexcused absences, and (8) Regular, timely attendance at education activities of the Department of Pediatrics and the Division of Pediatric Hematology/Oncology. During the initial year of the training program, each of the above elements of clinical competence will be assessed in writing after every completed rotation (see below) by direct faculty supervisors with at least semi-annual reviews by the Program Director. During subsequent years of the training program, evaluations of clinical competence and acquisition of research skills will be evaluated every six months by the faculty supervisors directly involved with the Fellow. Reappointment and promotion to subsequent years of training will require satisfactory ratings. The Program Director will immediately counsel Fellows concerning any unsatisfactory evaluations and what deficiencies must be corrected. Fellows receiving more than one unsatisfactory evaluation during the year will be subject to specific recommendations by the Program Director and/or the Division Chief, which might include the following: (1) Specific corrective actions required (2) The need to repeat a rotation (3) The need to participate in a special program (4) The need to go into official academic probation for a period of time (5) The need for termination, if prior corrective actions and/or probation have been unsuccessful. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 27
    • Continuity of Care Clinic (1 day/week) On most clinical rotations, Fellows will see new patient consults either in the outpatient or inpatient setting, allowing each Fellow to follow a cohort of patients. Throughout their Fellowship program, each Pediatric Hematology/Oncology Fellow will be assigned a clinic day in the PCMC outpatient clinic. The Fellow will attend this clinic for the duration of the program. The Attending staff are assigned specific clinic days, enabling each Fellow to develop a close rapport with the Attending Physicians who share that clinic day. In addition, throughout the program, the Fellow will become familiar with a cohort of patients who are regularly seen on that day. This will provide the Fellow with valuable continuity of care experience. InPatient Rotation—(5-6 months) Rationale/Value The Inpatient Rotation is one of the core components of the Fellowship Program, providing the opportunity to gain experience managing the complications of malignant diseases that require hospital admission, including oncologic emergencies and complications of therapy. This is also the primary opportunity for the Fellow to diagnose, treat and manage a broad spectrum of pediatric malignancies and hematologic disorders. Principal Teaching Method The Fellow and the on-service Attending work closely together to care for the inpatient hematology/oncology service. Therefore, most teaching occurs via this interaction. Experience: The full range of malignant diseases is seen and cared for on the Hem/Onc inpatient service. As PCMC represents the tertiary referral service for Utah and several surrounding states, the Fellow will encounter many unusual presentations and unusual diseases as well as the more common pediatric diseases. Patients with solid tumors typically are admitted for care of diagnostic evaluations and oncological emergencies (such as spinal cord compression, superior vena cava syndrome and hypercalcemia). The most common malignancy encountered is acute leukemia. Other admissions include those for neutropenic fever, pain control and occasionally end-of-life care. Patient Characteristics: Most patients are from Utah or the surrounding states of Wyoming, Idaho, Nevada and Montana. The population of these states is majority Western European descent, although African-American, Native American, Pacific- islander and Hispanic communities are represented in our patient population as well. Ages of the patients range from newborns to young adult. Types of Clinical Encounters: Fellows participate in the care of all patients on the Hematology/Oncology inpatient service and see inpatient consultations on other services. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 28
    • Procedures: Fellows perform bone marrow aspirations and biopsies, lumbar punctures, Ommaya taps and instillation of intrathecal chemotherapy, paracentesis, and thoracentesis. Ordering and coordination of chemotherapy administration is emphasized, especially of high dose, inpatient chemotherapy. Services: The Fellow provides three general types of service during this rotation; care of the hematology/oncology inpatients, consultations for other services and telephone call support. The Fellow works with the on-service Attending and resident team to care for about 10- 20 pediatric hematology/oncology patients on a separate ward of the PCMC. Therefore, the Fellow supervises and teaches medical students, interns and residents on rounds and throughout the day as questions arise. He/she is usually the initial person contacted by the housestaff for questions and for supervision of procedures. The Attending is always present during rounds to provide overall education and supervision of the team, and always available to the Fellow and housestaff as needed. The Fellow also will provide hematology and oncology consultations to other inpatient services of PCMC and the University Hospital. There is on average about 3 new patient consultations per week. Typically, the Fellow sees the patient initially, obtains a history, does the physical exam and collects all relevant data. The Fellow formulates a plan, which is then reviewed by the Attending. The patient is seen and a final diagnostic and therapeutic plan devised. Plans for outpatient follow-up are also made. The Fellow is expected to coordinate our recommendations with the primary treating team, and follow the patient with the Attending for the duration of his/her stay. Reading List: The Pediatric Hematology/Oncology Reading List contains key articles on the subjects covered by this rotation. Pathological Material: All bone marrow aspirations and biopsies obtained on the inpatient service are reviewed by the treating team in consultation with staff hematopathologists. Peripheral smears are also reviewed. Any other biopsies obtained on our patients or consult patients are reviewed by the Fellow and Attending with the pathologists as necessary. Other: The Fellow is expected to actively participate in the Tumor Board conferences, typically presenting cases encountered during the inpatient experience. The Fellow presents the details of the case, and representatives of the Pathology and Radiology Departments review and discuss the pathological and radiological materials. The Fellow is expected to review the literature and synthesize the information to provide a cogent, useful presentation. This is an important learning experience for the Fellow. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 29
    • Methods for Evaluating Fellow The Attending Physician provides a written evaluation of the Fellow, describing clinical judgment, clinical skills, medical knowledge, medical care, humanistic qualities, professional attitudes, behavior, and commitment to scholarship. On-going informal feedback is given on a day-to-day basis. Confidential, semi-annual reviews of all the evaluations of each Fellow are provided by the Fellowship Program Director. Methods for Evaluating Program The Fellows provide a written evaluation of the Inpatient Rotation at the end of each month. Fellow’s Responsibilities/Line of Responsibilities As noted previously, the Fellow is part of a team of treating physicians which also includes the on-service Attending, who has ultimate responsibility for the care of the Hematology/Oncology inpatients as well as for the consultations provided for other services. Teaching is another primary responsibility of the Attending Physician. The Fellow is primarily responsible for teaching the housestaff and overseeing the care provided by them, as well as for carefully following patients seen in consultation and ensuring our recommendations are communicated in a timely, understandable manner. The Fellow is also expected to write all chemotherapy orders for inpatients that are not performed by the inpatient nurse practitioner. Pathology/Hematopathology/Coagulation Rotation Rationale/Value The primary focus of this rotation is to: 1) Study the histopathology and pathologic basis of oncologic and hematologic diseases of childhood, 2) Learn diagnostic tools and understand the principles that govern their use, 3) Become proficient in examining bone marrow aspirates and biopsies, 4) Learn the histopathologic classifications of solid tumors, and 5) Gain a working knowledge of hemostatic disorders. Principal Teaching Method The Fellow will learn to prepare peripheral blood and bone marrow specimens and interpret these tests. The Fellow will review teaching file material and discuss didactic cases. Selected readings from “Pediatric Soft Tissue Sarcoma” by Dr. Cheryl Coffin and “Bone Marrow Pathology “ by Dr. Kathryn Foucar are required. A didactic set of clinical cases on hematostatic disorders is covered during the rotation. Rotations through the coagulation laboratory are available for those Fellows desiring to know technical details of hemostasis testing. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 30
    • Educational Content Mix of Diseases: Hematopathologic disorders include malignant and non-malignant disorders, including leukemia, lymphoma, myeloma, myeloproliferative disorders, myelodysplastic disorders, anemias, thrombocytopenias, etc., and staging bone marrows. Bone marrows done pre- and post-bone marrow transplant are also evaluated on the Hematopathology service. A broad range of hemostatic disorders are also seen, including patients with inherited and acquired bleeding disorders, to include hemophilia, von Willebrand's disease, disorders of platelet function, disseminated intravascular coagulation, vitamin K deficiency, etc. The Mountain States Hemophilia Center is located in our institution, and attracts referrals from a seven-state area. University Hospital also has an Anticoagulation Clinic that monitors patients on oral anticoagulation. The Fellows learn appropriate patient instruction in this clinic. Our clinic is also a major referral center for patients with inherited thrombotic disorders, and Fellows learn about the laboratory evaluation and management of their disorders. Patient characteristics: Most patients are from Utah or the Intermountain Western states. Approximately 10% of patients are age 25 or younger. Types of Clinical Encounters: Fellows perform and interpret bone marrows on hospital inpatients and outpatients. They should follow solid tumor from resection to histologic diagnosis. Fellows will attend the Coagulopathy clinic run by Dr. George Rodgers. The Fellow will meet with Dr. George Rodgers at least weekly to review the didactic clinical cases and discuss topics related to coagulation. Procedures: Fellows perform bone marrow aspirations and biopsies, stain blood smears and bone marrows, and interpret peripheral blood smears and bone marrows. Services: Fellows provide the following services on this rotation: performance and interpretation of bone marrows. Principal Ancillary Education Materials Reading list: Read appropriate selections from "“Practice and Principles of Pediatric Oncology” by Paplock and Pizzo, "“Pediatric Soft Tissue Sarcoma” by Dr. Cheryl Coffin and “Bone Marrow Pathology “ by Dr. Kathryn Foucar. Pathological material: During an average one-month rotation on hematopathology, the Fellow performs and interprets 30-50 bone marrows. A comprehensive teaching slide set of peripheral blood smears and bone marrows is also available for Fellow self- teaching. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 31
    • Methods for Evaluating Fellows Each Fellow is evaluated after each Pathology/Hematopathology/Coagulation rotation (written evaluation). Components of the evaluation include technical skills in performing and interpreting bone marrows, clinical skills in evaluating and managing hematologic disorders, their performance in participating in the didactic case discussions, and their month-by-month improvement in fund of knowledge in hematology from independent study. In addition to the written evaluation above, the Fellows receive feedback throughout each month on how they are progressing. Methods for Evaluating Program The Fellow will provide a written evaluation of the Pathology/Hematopathology/Coagulation rotation at the end of the month. Fellow’s Responsibility/Line of Responsibility There are generally no students or residents on this rotation, just the Attending and the Fellow. The Fellow has the primary responsibility for performing and interpreting bone marrows. The Fellow will provide the pager to the Attending pathologists and request to be paged for any solid tumor biopsy. He/she will follow the processing of samples from the OR to final diagnosis for every pediatric solid tumor during the rotation. The Fellow will review all bone marrows obtained during the rotation and attend Hematopathology sign out rounds. He/She should schedule 1-2 days in the flow cytometry lab to learn immunophenotyping (Dr. Sherrie Perkins), 1-2 days in the cytogenetics lab to learn the procedures involved in cytogenetic analysis (Dr. Art Brothman), and 1-2 days in the Coagulation lab at ARUP. Bone Marrow Transplant Rotation (0.5-2 months) Rationale/Value The Bone Marrow Transplant (BMT) Unit rotation at University Hospital and Primary Children’s Hospital will give the Fellow exposure to adult and pediatric patients with a variety of malignancies being treated with autologous or allogeneic transplant. The role of bone marrow transplant in certain diseases is in a state of flux at present, but there are a number of disease processes that are routinely treated with this modality. Whether or not the Fellow plans to perform BMT when in practice, it is extremely important to have an understanding of the indications for BMT, as well as the methods utilized. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 32
    • Principal Teaching Method The Fellow will cover the Pediatric BMT Unit and assist from time to time in covering patients in the Adult BMT unit. The primary teaching method will be by seeing patients in the inpatient or outpatient setting, and discussing those patients with an Attending Physician in detail. In addition, when on the inpatient service, rounds will be done daily in a multi-disciplinary team format, and the Fellow will be expected to participate fully in these. Educational Content The malignant diseases seen on the BMT Unit at University Hospital are both hematologic and solid tumors. The hematologic malignancies seen are primarily leukemias and lymphomas, either in remission or relapsed, as well as occasional patients with myeloma and myelodysplastic syndrome. These diseases may be treated with either myeloablative therapy/stem cell rescue (MAT/SCR) or allogeneic transplant using matched related donors or matched unrelated donors. The most common solid tumor seen is breast cancer, which is generally treated with MAT/SCR. The patients at Primary Children’s Hospital have a wide range of hematologic and solid malignancies, treated either with allogeneic transplant or MAT/SCR. Patient Characteristics: University Hospital and PCMC are the primary BMT referral center for patients in the Intermountain West. Most patients are from Utah, Idaho, Nevada, Montana, or Arizona. The patients seen range from infants to adults; the emphasis in our program is on pediatric transplantation. Types of Clinical Encounters: Patients will be seen in the BMT Unit as inpatients or in the BMT clinic for initial consultation or follow-up evaluation. Procedures: The Fellow will perform supervised lumbar punctures (with and without chemotherapy instillation) and bone marrow aspirates and biopsies. In addition, where indicated, the Fellow will perform skin biopsies on post-BMT patients for evaluation of the presence of graft-vs-host disease (GVHD). Services: The Fellow will generally be assigned to the inpatient BMT service for 0.5-2 months during the first year depending on interest and career goals. The Fellow will be assigned patients from day of admission to date of discharge, and will be responsible for all aspects of day-to-day care, including twice-daily evaluations on stable patients or more frequent evaluations on unstable patients. The Fellow will write all medication and TPN orders, as well as daily progress notes. All patients will be discussed daily in a multi-disciplinary conference, during which the treatment plan for the day will be outlined. The Fellow will be supervised by a BMT Attending Physician, and will work with the physician’s assistants and nurse practitioners assigned to the unit. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 33
    • The Fellow will also see patients who are referred for evaluation for possible transplant, and see patients in follow-up who have already undergone transplant. New patients will have a complete history and physical performed, as well as a review of relevant pathology and scans, following which they will be discussed in detail with the Attending on service. Follow-up patients will be assessed for engraftment, signs of infection, and signs of graft-vs-host disease. Immunosuppressive and anti-infective agents will be adjusted as necessary. These follow-up patients will also be discussed with the Attending on service. Principal Ancillary Educational Materials Reading List: The Bone Marrow Transplant service will provide each Fellow with a comprehensive binder of articles pertaining to all aspects of blood and marrow transplantation. Pathology: The Fellow will have the opportunity to review the pathology slides from biopsies, bone marrows, and other operative procedures with the pathologists. Other: The Fellow will be expected to attend the weekly Multi-Disciplinary Tumor Board, as well as the Wednesday morning Journal Club/Basic Science conference and Monday Fellow lunch conference. In addition, the Fellow will have the opportunity to attend separate Bone Marrow Transplant conferences and lectures when these are held. Methods for Evaluating Fellows The Attending Physician will provide a written evaluation of the Fellow to the Program Director at the end of the rotation, describing clinical skills, clinical judgment, medical knowledge, medical care, humanistic qualities, professional attitudes, behavior, and commitment to scholarship. Methods for Evaluating Program The Fellow will provide a written evaluation of the Bone Marrow Transplant unit rotation at the end of the month. In addition, board scores are monitored for pass/fail as well as for strength/weaknesses in specific areas of hematology and oncology. Fellow’s Responsibility/Line of Responsibility The BMT Unit functions primarily with an Attending Physician and a number of staff physician extenders. The Fellow will be a part of the inpatient or clinic team, and will report to the Attending Physician. The Fellow will be responsible for his/her patients, and be expected to know their current clinical situation. The Fellow will interact with the nursing and ancillary staff on the Unit who are involved with his/her patients, and be expected to provide teaching or clarification to them as needed. The Fellow will have Attending back-up for all areas of responsibility. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 34
    • Should there be medical students or residents on the rotation, the Fellow is encouraged to participate in teaching them whenever possible. Adult Hematology Rotation Rationale/Value During this rotation, the Fellow spends several days each week seeing new and returning patients with selected senior physicians in Adult Hematology/Oncology and Coagulation. The new patient evaluations are comprehensive and provide the Fellow with the opportunity to devise an initial therapeutic plan and to discuss this in detail with both the patient and Attending. Attendings are selected for the relevance of their patient population to the educational mission of the Fellowship. As the Fellow is working with a different Attending, they are exposed to different disease mixes and treatment styles, which serve to broaden their experience from their one day/week continuity clinic. Principal Teaching Method The Fellow and Attending see and discuss each patient in detail, and diagnostic and therapeutic plans are devised together. Relevant papers are provided, and the Fellow is encouraged to research topics in depth as they come up. Therefore, most teaching occurs during the interaction between the Fellow and Attending. Education Content: Mix of Disease: The full range of malignant diseases is seen and cared for in the Outpatient Department, with an emphasis on hematologic malignancies and non- malignant disorders, coagulation disorders and thrombophilia, hemachromatosis and porphyria. Patient Characteristics: Most patients are from Utah or the surrounding states of Wyoming, Idaho, Nevada and Montana. The population of these states is relatively racially homogeneous of Western European descent, although the Native American and Hispanic communities are represented in the patient population as well. Ages range from 18 to quite elderly, the majority tending to be older as is expected for patients with malignancies. Types of Clinical Encounters: All patients are seen in the Hematology/Oncology Outpatient clinic. Procedures: Fellows perform bone marrow aspirations and biopsies, lumbar punctures, Ommaya taps and instillation of intrathecal chemotherapy. Outpatient chemotherapy is also written by the Fellows if needed. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 35
    • Services: The Fellow sees both new patients and those in need of follow-up. The Fellow is expected to obtain a detailed history and performs a physical exam on all new patients. All radiological and pathological materials are reviewed with the Attending, usually with a radiologist and pathologist. A comprehensive, detailed diagnostic work- up and treatment plan is formulated by the Fellow and Attending, and discussed at length by them with the patient and family. The Fellow with the help of the clinic staff coordinates future care. A detailed Initial Visit Note is generated by the Fellow, reviewed with the Fellow by the Attending and provided to the referring physician. The Fellow also sees several follow-up patient visits each day, during which an interval history and physical exam are performed. The Fellow discusses each patient with the Attending, and participates in all decisions, such as initiation or continuation of therapy, and development of diagnostic plans and treatment approaches. All discussions with the patients include the Fellow. The Fellow writes all chemotherapy orders, and the Fellow with Attending supervision typically performs any procedures required in clinic. Principal Ancillary Educational Materials Reading List: The Hematology/Oncology Fellow bibliography contains key articles on the subjects covered by this rotation. Additionally Dr. Rodgers provides hematologic case study problems which require directed reading to decide on appropriate testing, making the diagnoses, and formulating treatment plans. Pathological Material: Pathology slides are usually provided by our new patients for review with our pathologists. This review is done at the time of the initial visit. A similar procedure is followed for review of radiological studies. Most studies obtained for our patients under continuing care are also reviewed the day of clinic. Other: The Fellow is expected to actively participate in the weekly Multi-disciplinary Tumor Board, typically presenting one to two interesting cases encountered during the prior week. The Fellow presents the details of the case, and representatives of the Pathology and Radiology Departments review and discuss the pathological and radiological materials. The Fellow is expected to review the literature and synthesize the information to provide a cogent, useful presentation. This is an important learning experience for the Fellow. The Fellow is also expected to attend weekly Wednesday morning academic conference and Monday Fellow lunch conference. Methods for Evaluating Fellow The Attending Physician provides a written evaluation of the Fellow, describing clinical judgment, clinical skills, medical knowledge, medical care, humanistic qualities, professional attitudes, behavior and commitment to scholarship. On-going informal feedback is given on a day-to-day basis. Confidential, semi-annual reviews of all the evaluations of each Fellow are provided by the Fellowship Director. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 36
    • Methods for Evaluating Program The Fellow will provide a written evaluation of the Outpatient Clinic rotation at the end of the month. In addition, board scores are monitored for pass/fail as well as for strength/weaknesses in specific areas of hematology and oncology. Fellow’s Responsibility/Line of Responsibility While medical students and Internal Medicine residents are often present in the clinic, the Fellow works only with the Attending conducting clinic, as well as the clinic staff. Therefore, the Fellow is responsible for the initial work-up of new patients and ongoing patients. As such, he/she is responsible for ensuring that the diagnostic and therapeutic plans devised by the Fellow, Attending and patient are initiated. The Attending has on- going responsibility for the patients in their clinics, and therefore will receive and review test results, etc. The Fellow is encouraged to follow-up on test results, etc., and communicate them to the patients, but the Attending Physician has ultimate responsibility for this. Fellows are expected to complete all documentation in a timely and complete manner. Radiation Oncology Rotation Rationale/Value The Radiation Oncology rotation at the University Hospital will give the Fellow experience in the use of radiation therapy to treat patients with malignancy. Pediatric Oncologists have always worked with Radiation Oncologists in the treatment of cancer, but this relationship has become closer in recent years. There are now an increasing number of malignancies treated using combinations of chemotherapy and radiation therapy, often given concurrently. It is therefore increasingly important for the Pediatric Oncologist to have a good understanding of the rationale, complications, and logistics behind administering Radiation Therapy. Principal Teaching Method The Fellow will see patients referred to the Radiation Therapy Department for consideration of treatment. Most of the emphasis in this rotation will be on seeing new consults. These patients span a broad range of malignancies, including pediatric sarcomas, brain tumors, and other solid tumors. Also adult patients with breast, prostate, lung, GI, CNS, and hematologic malignancies will be seen. Some of these patients will be receiving radiation therapy only, some will have already received chemotherapy, and some will be receiving concurrent chemotherapy. All patients will be fully reviewed with an Attending Radiation Oncologist after being seen. Scans and pathology will be reviewed where necessary, and a treatment plan will be formulated and discussed. The Fellow will be encouraged to follow those patients seen as new consults through the course of their therapy, although, as a rule, a course of radiation therapy will last longer than the 4-week rotation time. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 37
    • During the rotation, the Fellow should gain a good understanding of the issues involved in coordinating patient care from the perspective of the Radiation Therapy Department. In addition, the Fellow should become familiar with the common complications arising from radiation therapy, develop a basic understanding of tissue tolerances, and understand the rationale behind dose-fractionation. Educational Content Mix of Disease: The full range of solid tumors are seen and cared for in the Radiation Oncology department at the University Hospital. In addition, there are some hematologic malignancies seen, primarily Hodgkin’s or Non-Hodgkin’s lymphomas. Patient Characteristics: The University Hospital is a major referral center for patients with malignancies in the Intermountain West. Most patients are from Utah, Idaho, Nevada, Montana, or Arizona. The patients seen range in age from pediatric to the very elderly. Types of Clinical Encounters: Patients will be seen in the Radiation Therapy Outpatient Department for consultation. Patients will also be seen on the Medicine or Surgical wards, if inpatient consults are requested. Procedures: The Fellow will as a rule not be performing procedures while on this rotation, aside from history and physical examinations. Services: The service provided on this rotation is as a consultant to outpatients and inpatients. The Fellow will work with an Attending Radiation Oncologist, who will review all histories and physicals on new patients and follow-up patients with the Fellow. The Fellow will have the opportunity to observe patients being treated or prepared for treatment, but will not have a role in the ordering of Radiation Therapy or determination of doses. Principal Ancillary Educational Materials Reading List: The Fellow bibliography contains some key articles on the subjects covered by this rotation. In addition, the Radiation Oncologists will provide key references pertaining to patients seen while on rotation. Pathology: The Fellow will have the opportunity to review the pathology slides from operative procedures with the pathologists. Conferences: The Fellow will be expected to attend the weekly Adult Multi-Disciplinary Tumor Board. In addition, the Fellow will have the opportunity to attend the separate Radiation Therapy Resident conferences. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 38
    • Methods for Evaluating Fellows The Attending Physician will provide a written evaluation of the Fellow to the Program Director at the end of the rotation, describing clinical skills, clinical judgment, medical knowledge, medical care, humanistic qualities, professional attitudes, behavior, and commitment to scholarship. Methods for Evaluating Program The Fellow will provide a written evaluation of the Radiation Oncology Rotation at the end of the 4 weeks. Fellow Responsibility/Lines of Responsibility While on this rotation, the Fellow will see patients in the Radiation Oncology outpatient department, and occasionally inpatient consults on the wards. The Fellow will be under the supervision of an Attending Radiation Oncologist, who will assume ultimate responsibility for the patients. All histories, physicals, and laboratory or radiographic findings will be discussed with the Attending. All radiation orders will be written by the Attending. The Fellow will have the opportunity to observe simulation techniques and discuss cases with the physicists, but this is not a primary responsibility on the rotation. Transfusion Medicine Rotation (in combination with Pathology rotation) Rationale/Value The Lab Medicine rotation at University Hospital will give the Fellow exposure to the methods utilized in cross-matching blood, and instruction in the management of patients with multiple antibodies, transfusion reactions, or immune-mediated hemolytic processes. Physicians practicing Pediatric Hematology/Oncology frequently utilize blood products. It is therefore extremely important for the Fellow to be aware of issues relating to blood processing and availability, and have a firm understanding of the reasons for using different types of blood products. Principal Teaching Method The primary teaching method on this rotation is by daily lecture. Each lecture discusses a different area of transfusion medicine. In addition, there will be time set aside for hands-on bench-work, during which the Fellow will learn to type blood, and perform antibody screening. The Fellow will have the option of seeing patients on the wards who have multiple antibodies or transfusion reactions, and will also visit the donor center to see patients. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 39
    • Educational Content Mix of Disease: The majority of the patients dealt with on this rotation have autoantibodies, single or multiple alloantibodies, or have had transfusion reactions in the past. There are also occasionally patients with TTP requiring plasmapheresis treatment. All services are represented on this rotation, although the most contact comes from the surgical, obstetrical, and oncology/marrow transplant services. Patient Characteristics: Most patients are from Utah or the surrounding Intermountain Western States. The Lab Medicine service at University Hospital also covers the adjacent Primary Children’s Hospital, so the age range of patients seen is from newborn to the very elderly. Types of Clinical Encounters: Clinical encounters are generally as a consultant to inpatient services. Procedures: The Fellow will be given hands-on teaching in cross-match and antibody screening techniques. These will be performed on teaching samples only, as Fellows are not certified or authorized to perform tests giving official results. Services: The service provided on this rotation is generally as a consultant to inpatients, or as a telephone consultant. There is generally a Pathology resident on the Lab Medicine service who performs most of the consults, and there is a qualified Hematopathologist specializing in blood transfusion medicine on call at all times. Principal Ancillary Educational Materials Reading List: Key articles on the subjects covered by this rotation will be provided. Conferences: The Fellow will attend the blood bank service weekly conference in which difficult cases are presented. Other: There is a folder of practice cases involving antibody screening results. The Fellow is encouraged to complete these. There are generally a number of such cases on the Hematology board examination. Methods for Evaluating Fellows The Attending Physician will provide a written evaluation of the Fellow to the program director at the end of the rotation, describing clinical skills, clinical judgment, medical knowledge, medical care, humanistic qualities, professional attitudes, behavior, and commitment to scholarship. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 40
    • Methods for Evaluating Program The Fellows provide a written evaluation of the Blood Bank Rotation at the end of the month. The subspecialty board scores of the Fellows are monitored, as are the specific strengths and weaknesses as assessed by those tests. Fellow Responsibility/Lines of Responsibility While on this rotation, the Fellow will be expected to attend the didactic lectures, and will have the opportunity to be involved in ward consults. However, since the Blood Bank is under the aegis of Pathology, the Blood Bank attending will have the ultimate responsibility for patient care. There is generally a Pathology resident on the service, who is responsible for doing the consults and deciding patient management in conjunction with the Attending. The Pediatric Hematology/Oncology Fellow will therefore have no order writing responsibility on this service. Conferences Goals and Objectives - Assist the transition from resident to Fellow - Develop teaching, leading and communication skills - Introduce and explore concepts that are essential to the practice of Pediatric Hematology/Oncology • Communication skills and styles • Patient compliance • Difficult situations • Patient experiences • Variations in decision making • Comfort with uncertainty - Increase knowledge of parental and patient resources - Increase knowledge of the six RRC core competencies • Patient Care • Medical Knowledge • Practice-based Learning and Improvement • Interpersonal and Communication Skills • Professionalism • Systems-based Practice - Increase fund of knowledge regarding Pediatric medicine and Pediatric Hematology/Oncology Methods - Case-based discussions - Fellow driven University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 41
    • Monthly Solid Tumor Board (First Friday every Month) This conference is held on a monthly basis year-round, and regular attendance is compulsory for Pediatric Hematology/Oncology Fellows. Staff, Fellows, and residents from Hematology/Oncology, Radiation Oncology, Radiology, Pathology, and various Surgical services attend this conference. Challenging or unique cases of pediatric solid tumors are presented at this conference for the purpose of obtaining opinions on appropriate treatment strategies. Pediatric Hematology/Oncology Fellows are expected to present patients at this conference on a regular basis. This will provide the Fellows with valuable experience in proper medical subspecialty patient case presentation, including case preparation, review of the relevant literature, interaction with a multi- disciplinary audience, and public presentation skills. Monthly Hematopathology Tumor Board (Second Friday every Month) This conference is held on a monthly basis year-round, and regular attendance is compulsory for Pediatric Hematology/Oncology Fellows. This conference is attended by staff, Fellows, and residents from Hematology/Oncology and Hematopathology. Challenging or unique cases of pediatric hematology and hematopoietic malignancies are presented at this conference to review the pathology and for the purpose of obtaining opinions on appropriate treatment strategies. The Fellows are expected to present patients at this conference on a regular basis. This will provide Pediatric Hematology/Oncology Fellows with valuable experience in proper medical subspecialty patient case presentation, including case preparation, review of the relevant literature, interaction with a multi-disciplinary audience, and public presentation skills. Brain Tumor Board. (Third Friday every Month) This conference is held on a monthly basis year-round, and regular attendance is compulsory for Pediatric Hematology/Oncology Fellows. This conference is attended by staff, Fellows, and residents from Hematology/Oncology, Radiation Oncology, Radiology, Pathology, and Neurosurgery. Challenging or unique cases of pediatric brain tumors are presented at this conference to review the pathology and for the purpose of obtaining opinions on appropriate treatment strategies. The Fellows are expected to present patients at this conference on a regular basis. This will provide Pediatric Hematology/Oncology Fellows with valuable experience in proper medical subspecialty patient case presentation, including case preparation, review of the relevant literature, interaction with a multi-disciplinary audience, and public presentation skills. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 42
    • Journal Club/Interesting Case Conference (Fourth Friday every Month) The fourth Friday of each month is the program’s journal club. Each month, a Fellow and an Attending Physician will be assigned to each present one or more recent journal articles that are felt to merit discussion. The choice of the Fellow’s article will be left to the individual Fellow. However, the Attending Physician assigned for that month will be available to act as a resource person. This is particularly important for junior Fellows, who may still be learning the art of critical literature appraisal, and may need some guidance in choosing an appropriate article. Journal club is a valuable experience for Hematology/Oncology Fellows, as it provides important training in critical literature appraisal, and also encourages continuous review of current literature. Other Friday Conferences This conference is held on Fridays when there is not tumor board or journal club and regular attendance is compulsory for Pediatric Hematology/Oncology Fellows. This conference is attended only by Hematology/Oncology Fellows, and is presided over by an Attending from the Hematology/Oncology service. Different topics pertaining to the practice of Pediatric Hematology/Oncology are discussed - management of specific diseases, pain management, ethical, legal and cultural issues are examples. This conference is held in a very informal small group setting, providing an excellent opportunity for the Fellows to benefit from the knowledge and experience of not only the discussion leader but each other as well. Pediatric Research in Progress Conference This conference is held on a weekly basis year round and organized by the Department of Pediatrics. Attendance is not compulsory for Fellows, but they are encouraged to attend whenever time permits. At this conference, all clinical-based and research- based members of the Department of Pediatrics have the opportunity to discuss research projects they are involved in, and what progress has been made in the area being investigated. At this conference, therefore, Pediatric Hematology/Oncology Fellows will be able to learn of different research projects underway in the Department and in associated specialties. This knowledge may help the Fellows decide what area of research they would like to participate. Pediatric Grand Rounds This conference is held on a weekly basis year round and organized by the Department of Pediatrics. Attendance is not compulsory for Pediatric Hematology/Oncology Fellows, but they are encouraged to attend whenever time permits or the topic is of particular interest to the practice of Pediatric Hematology/Oncology. The conference is hosted by the Department of Pediatrics, and features a different speaker and topic each week. All aspects of the practice of Pediatrics and its subspecialties are discussed throughout the year. This conference is an important forum for continuing medical education for the Fellow, and an ancillary to regular review of the medical literature. New therapies and treatment guidelines in other sub-specialties are often discussed, many of which are relevant to the practice of Pediatric Hematology/Oncology. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 43
    • Other Educational Activities Pediatric Fellows Conference This course is mandatory. The course provides instruction on lecture presentation, scientific writing, biostatistics and medical ethics. Fellows from all pediatric disciplines meet on a weekly basis between September and February. National Meetings Attendance at national meetings (ASPHO, AACR, ASCO or ASH) is an important component of subspecialty training. At these meetings, Pediatric Hematology/Oncology Fellows have an opportunity to meet Fellows from other programs and clinical and research experts from all over the world, and to hear presentations on a variety of topics. Frequently, data presented at these meetings result in changes in practice patterns, some of which are profound. Hematology/Oncology Fellows will be given the opportunity to attend one major conference in each year of their Fellowship program. Time off from regular clinical duties is allocated for this (see the Educational Leave section of the Fellow Vacation and Leave Policy segment of this curriculum). Whenever possible, Pediatric Hematology/Oncology Fellows are encouraged to present topics or posters at these meetings. Grant Writing Workshop The Department of Pediatrics offers a semi-annual weekend workshop on grant-writing skills. Fellows are strongly urged to avail themselves of this excellent opportunity. Participants bring the Specific Aims for a small grant, and these are reviewed by senior faculty. In addition, a number of formal didactic sessions review the essential elements of successful grant writing. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 44
    • Evaluation Procedures First Year Evaluation Second and Subsequent Years Evaluations Evaluation of Fellows Performance Fellows Evaluation of Rotations Fellows Evaluation of Faculty Promotion, Probation, Suspension and Dismissal University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 45
    • Evaluation Procedures Assessment of Competence During the First Year of Training During the first year of training in Pediatric Hematology/Oncology, the Fellow will be assessed by the supervisory faculty at least every six months. This information will be stored in the specific Fellow’s file in the Program Director’s office. That assessment will include the following: Fundamentals of clinical diagnosis with special emphasis on history taking and physical examination including the evaluation and management of both inpatients and outpatients who have hematologic and oncologic disorders including: • Leukemias, both acute and chronic • Solid tumors of organs, soft tissue, bone, and central nervous system • Lymphomas • Inherited and acquired bone marrow failure syndromes • Hemoglobinopathies, including sickle cell and thalassemia syndromes • Inherited and acquired disorders of the red cell membrane and of red cell metabolism • Autoimmune hemolytic anemia • Nutritional anemia • Inherited and acquired disorders of white blood cells • Platelet disorders, including ITP and acquired and inherited platelet function defects • Hemophilia, von Willebrand disease, and other inherited and acquired coagulopathies • Hematologic disorders of the newborn • Transfusion medicine and use of blood products • Congenital and acquired immunodeficiencies University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 46
    • In addition to specific hematologic and malignant disorders, the Fellow must develop competency in all aspects of chemotherapy, including treatment protocols and management of complications; diagnosis and treatment of infections in the compromised host; appropriate use of transfusion of blood products, plasmapheresis and bone marrow transplantation. The Fellow is also expected to learn methods of physiologic support of the cancer patient including parenteral nutrition, control of nausea and pain, staging and classifications of tumors, complete knowledge and application of multi-modality therapy, learning to function as a member of a multidisciplinary oncology team, and learning the epidemiology of childhood cancer. Making good observations and keeping accurate patient data are vital aspects of Pediatric Hematology/Oncology and it is expected that the Fellow will acquire these during the first year of this training program. The Fellow is expected also to acquire the necessary skills for the interpretation and performance of procedures and laboratory tests common to the practice of Pediatric Hematology/Oncology. He/she is expected to become skilled in the performance and interpretation of bone marrow aspirations and biopsies, venipunctures, lumbar puncture, clinical microscopy, and interpretation of peripheral blood smears. The Fellow is expected to participate in the entire curriculum for this initial year of training in order to acquire the above detailed skills. That curriculum includes six months on the inpatient Hematology/Oncology service and the attendance of at least one full day’s outpatient clinic per week. In the outpatient clinic, the Fellow will follow a population of patients in continuity during the first and also subsequent years of training. First year Fellows in Pediatric Hematology/Oncology are expected to participate in the conference and lecture schedule of the division which includes weekly patient management conferences, Pediatric Grand Rounds and Pediatric Research in Progress, as well as twice-monthly tumor boards and monthly division journal club. The Fellow is also expected to participate in the Department of Pediatric Fellowship course as offered, which includes the topics of scientific writing and presentations, biostatistics, and medical ethics. Finally the Fellow is expected to participate in the teaching activities of the division including the organization of educational conferences and also the development of skills in medical writing. The first year Fellow is also expected to take home call approximately one out of every 4 weeks. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 47
    • Assessment of Competence During the Second and Subsequent Years of Training The second and subsequent years of training are focused mainly on the development of research skills and experience. Clinical responsibilities are limited to one day in clinic each week, home call approximately only one out of every 5-6 weeks, and the attendance of regular educational conferences of the Division of Pediatric Hematology/Oncology. Under the guidance of a specific mentor, Fellows in the second year of training embark on a structured program of research education designed to develop the knowledge, thought processes and laboratory skills needed for a career as an independent investigator. The specific laboratory work is supplemented by courses within the School of Medicine involving basic science and research methodology important to the development of an investigative career. Trainees in the second and third years of fellowship are required to have a Scholarship Oversight Committee (SOC). This committee should consist of the research mentor and at least two other faculty members who can contribute to the Fellow’s intellectual and career development. This SOC should meet at least semi-annually. During the second and subsequent years of training, the Fellow will meet on a monthly basis with his/her research supervisor and mentor to evaluate progress and receive specific feedback and recommendations. Formal written assessment of performance will be required at six-month intervals by both the research mentor and the other faculty members who have contact with the Fellow in either the clinical or laboratory settings. It is expected during these years that the Fellow will continue to work towards improving his/her teaching and medical writing skills. This can be accomplished by the presentation of lectures within the institution and abstracts of research performed at national meetings, as well as the preparation of manuscripts reporting that research. Fellows are expected to prepare posters, abstracts, manuscripts and/or grant applications with the guidance of their primary research mentor. Members of the Fellow’s Scholarship Oversight Committee are also available to critique and guide the fellow in this process. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 48
    • Evaluation of Fellow Performance The overall performance of each Fellow will be evaluated as follows: 1) The elements of clinical competence described above will be assessed and recorded by the faculty on the Fellow Evaluation Form at the conclusion of every rotation. It is imperative that faculty members responsible for filling out the evaluation form do so critically, utilizing the entire scale from unsatisfactory to outstanding. There should be no hesitation in labeling an unsatisfactory performance as such, since it is crucial that problems be identified as early as possible in a Fellow’s career. Borderline performance that is rated satisfactory is the main reason for Fellows not being placed on probation until their senior years. This evaluation is submitted to the Program Director, who reviews the evaluations quarterly and makes recommendations to the Division Chief, who will review these evaluations with the Fellow annually, at a minimum. If there are substantial deficiencies in the Fellow’s performance (as judged by the Program Director and the Division Chief in consultation with the Division faculty), reviews will be carried out with the Fellow on a more frequent basis. 2) The Program Director, Division Chief and the Division faculty will meet annually to discuss the academic and clinical progress of all the Fellows in the program. Any problems that are identified at this meeting will be reviewed in a meeting between the Division Chief and the Fellow within two weeks of this meeting. Procedure for Fellow Evaluation of Rotations Each Fellow will complete an evaluation form following the completion of each rotation service. Forms will be gathered and reviewed by the Program Director. Possible areas of concern will require review with Division Chief and the Division faculty. Additional information will be gathered and recommendations will be made to the Program Director. A sample of the Fellow Evaluation of Rotation form is included in the Appendix. Procedure for Fellow Evaluation of Faculty Each Fellow will evaluate the faculty members involved in each rotation at the end of each month by filling out the Fellow Evaluation of Rotation Form. In addition, at the end of each year, each Fellow will be given a Faculty Evaluation Form to fill out for each member of the teaching staff. However, the annual Faculty Evaluation Forms will be confidential. The forms will be submitted to the Program Director for review, and then submitted to the Division Chief. The promotion and tenure review committee will use the information obtained from the forms to help guide their decisions. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 49
    • Promotion, Probation, Suspension and Dismissal At the conclusion of each academic year, each Fellow will be promoted to the next year of the Fellowship, provided that he or she has successfully fulfilled the requirements of the program and has received satisfactory (or better) evaluations by each of the two methods described above. Following the successful conclusion of the third year in the program, the Fellow will graduate and will be eligible to sit for the Pediatric Hematology/Oncology certifying examination. Faculty are expected to notify the Division Chief/Program Director of any unsatisfactory performance immediately upon occurrence. The Division Chief will promptly review such situations. If the review confirms that performance is unsatisfactory, the Division Chief will meet with the Fellow to discuss the situation and decide if corrective action is necessary. Unless circumstances are exceptional, the Fellow will have an opportunity to remediate an unsatisfactory performance. Corrective actions required of a resident could include remediation (such as repeating a rotation, participation in a special program, etc), academic probation, suspension, or dismissal. 1) Remediation a) When an evaluation is below that expected for the Fellow’s level of training, the Division Chief must decide on a program of remedial training and must arrange such training. b) The Fellow must be informed of this decision in writing, with details regarding the remediation, including the areas in which, and the time within which, improvement is expected, and the possible outcomes of such remediation. c) At the end of the remedial training, the Division Chief shall inform the Fellow in writing that the weakness has either been corrected or has not been corrected. If it has not been corrected, the Chief shall include written notification that the Fellow will have a further period of remedial training with or without probation, or the Fellow will be placed on probation. 2) Probation A Fellow may be placed on probation by the Division Chief, following approval of the Director of Graduate Medical Education, if: Remedial action outlined in Section 1 fails to correct a recognized deficiency. Or The deficiency is of a nature that is not subject to usual remedial measures; for example, attitudinal or ethical problems. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 50
    • b) Guidelines for the probationary period must be communicated in writing to the Fellow and must include the specific weakness to be corrected, what must be accomplished to correct the weakness, the time period of probation, and the possible outcomes of probation. c) In general, the probationary period will not extend past the end of the current agreement year, unless the agreement year ends within three months, in which case the program has the option of extending the probationary period into the next agreement year, but that extension shall not exceed three months. d) Any houseofficer agreement which may have been issued by a program for a subsequent year will be considered invalid until the Fellow has fulfilled probationary requirements and been removed from probation. e) At the time that the Fellow is removed from probation, the program has the following options: Full reinstatement. An additional probationary period, with or without remediation. Dismissal from the program either immediately or at the conclusion of the current training year. Houseofficer agreements for a subsequent year may contain a written clause stating conditions under which the agreement may be terminated immediately. Usually that clause will refer to continuing problems of the kind that resulted in the first probationary period. 3) Suspension The Division Chief may suspend a Fellow for non-academic reasons, if he or she is of the opinion that the continued presence of the Fellow in a clinical setting would be detrimental to staff or to patient care. This decision to suspend a Fellow must be followed immediately by an evaluation and either probation or dismissal, subject to appeal. Appeals will follow the due process procedures established by the Graduate Medical Education office. 4) Dismissal In general, a Fellow may be dismissed from the program only after going through the process of evaluation and probation with or without remedial training. There are instances, however, in which the Division Chief may find it necessary to dismiss a Fellow for non-academic reasons that are not subject to remediation or probation. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 51
    • The decision to dismiss a Fellow may initially be made by the Division Chief, with the consent of the Program Director and the Division faculty. The Chairman of the Department of Pediatrics and the Dean of the School of Medicine must approve the dismissal. The Fellow must be informed of this decision in writing, which must include the reason(s) for dismissal. Appeals The Fellow may appeal the decision of remedial training, probation, suspension, or dismissal to the School of Medicine. Appeals will follow the due process procedures established by the Graduate Medical Education office. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 52
    • Pediatric Hematology/ Oncology Policies For 2007 - 2008 Supervision Selection and Eligibility Vacation and Leave Moonlighting Work Hours Call Responsibilities Evaluation Standards of Performance Due Process Evaluation University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 53
    • UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION HOUSESTAFF POLICIES AND PROCEDURES _________________________________________________________ RESIDENT SUPERVISION Section 7 No. 10 Rev.2 Review Date: April 2006 Revision Date: January 2006 Chapter: Other I. PURPOSE: To outline guidelines for supervision for postgraduate trainees in the University of Utah Affiliated Training Programs. II. POLICY: Each discipline will be responsible for the development of a policy for its program, which includes the principles stated in this document and outlines specific supervision issues distinctive to their training program. All supervision situations will be specialty specific. Programs are free to adopt these guidelines as appropriate to their specialties. III. PROCEDURE: Resident Supervision Policy -- Summary of Main Points Key principles 1. An Attending Physician must be identified for each episode of patient care involving a resident. 2. The Attending Physician is responsible for the care provided to these assigned patients. 3. The Attending Physician is responsible for determining the level of supervision required to provide appropriate training and to assure quality of patient care. 4. Resident supervision must be documented. 5. Program directors direct and supervise the program. Key supervision issues 1. Attending Physician/staff practitioner responsibilities a. Inpatient i. Attending Physician is identified in the chart. ii. Meet with the patient within 24 hours of admission iii. Document supervision with progress note by the end of the day following admission. iv. Follow local admission guidelines for attending notification. v. Ensures discharge is appropriate. vi. Ensures transfer from one inpatient service to another inpatient service is appropriate. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 54
    • b. Outpatient i. Attending Physician is identified in the chart ii. Discuss patient with resident during initial visit -- Document attending involvement by either an attending note or documentation of attending supervision in the resident progress note. iii. Countersign note c. Emergency Room i. An Attending Physician must always be physically present. d. Consultation i. Discuss with resident doing consultation within 24 hours ii. Document supervision of consultation by the end of the next working day. e. Surgery/Procedures i. Attending Physician is identified ii. Attending meets with the patient before procedure/surgery iii. Documents agreement with surgery/procedures iv. Countersign procedure note f. Sign initial DNR orders and document compliance with local DNR policies 2. Program director/program coordinator a. Establish and write program specific supervision policy b. Orientation for residents c. Education of Attending Physicians d. Implementation and follow--up of policy University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 55
    • POLICY FOR SUPERVISION OF POSTGRADUATE TRAINEES AT THE UNIVERSITY OF UTAH AFFILIATED HOSPITALS Salt Lake City, Utah I. DEFINITIONS: a. Graduate Medical Education. Postgraduate medical education is the process by which clinical and didactic experiences are provided to residents to enable them to acquire those skills, knowledge, and attitudes, which are important in the care of patients. The purpose of graduate medical education is to provide an organized and integrated educational program providing guidance and supervision of the resident, facilitate the resident's professional and personal development, and ensure safe and appropriate care for patients. Graduate medical education programs focus on the development of clinical skills, attitudes, professional competencies, and an acquisition of detailed factual knowledge in a clinical specialty. c. Program Director. The Program Director is responsible for the quality of the overall affiliated education and training program in a given discipline (i.e., medicine, surgery, psychiatry, pediatrics etc.) and for ensuring the program is in compliance with the policies of the respective accrediting and/or certifying body(ies). d. Residents. The term "residents" refers to individuals who are engaged in a postgraduate training program in medicine (which includes all specialties such as internal medicine, surgery, psychiatry, pediatrics, etc.) The term "resident" for the purposes of this policy includes individuals in their first year of training typically referred to as "interns" and individuals in advanced postgraduate education programs who are typically referred to as "fellows." e. Attending Physician. Attending Physician refers to licensed, independent physicians, who have been formally credentialed and privileged at the training site, in accordance with applicable requirements. The Attending Physician may provide care and supervision only for those clinical activities for which they are privileged. This term is synonymous with the "Attending Physician" in medicine. f. Supervision. Supervision refers to the dual responsibility that an Attending Physician has to enhance the knowledge of the resident and to ensure the quality of care delivered to each patient by any resident. Such control is exercised by observation, consultation and direction. It includes the imparting of the practitioner's knowledge, skills, and attitudes by the practitioner to the resident and assuring that the care is delivered in an appropriate, timely, and effective manner. g. Documentation. Documentation is the written or computer--generated medical record evidence of a patient encounter. In terms of resident supervision, documentation is the written or computer--generated medical record evidence of the interaction between a supervising practitioner and a resident concerning a University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 56
    • patient encounter. h. Supervising Practitioner. Supervising Practitioner must provide an appropriate level of supervision. Determination of this level of supervision is a function of the experience and demonstrated competence of the resident and of the complexity of the patients' health care needs. II. POLICY: a. In a health care system where patient care and the training of health care professionals occur together, there must be clear delineation of responsibilities to ensure that qualified practitioners provide patient care, whether they are trainees or full--time staff. It is recognized that as resident trainees acquire the knowledge and judgment that accrue with experience, they will be allowed the privilege of increased authority for patient care. b. The hospital must comply with the institutional requirements and accreditation standards of the Joint Commission of Accreditation of Healthcare organizations (JCAHO) and other health care accreditation bodies. Qualified health care professionals with appropriate credentials and privileges provide patient care and provide supervision of residents. c. The intent of this policy is to ensure that patients will be cared for by clinicians who are qualified to deliver that care and that this care will be documented appropriately and accurately in the patient record. This is fundamental, both for the provision of excellent patient care and for the provision of excellent education and training for future health care professionals d. The quality of patient care, patient safety, and the success of the educational experience are inexorably linked and mutually enhancing. Incumbent on the clinician educator is the appropriate supervision of the residents as they acquire the skills to practice independently. e. The principles of good training and educational supervision are not likely to change radically over time. Rules governing billing and documentation, however, will inevitably evolve. This policy focuses on resident supervision from the educational perspective. f. Institutional Requirements of ACGME state that "[medical] residents must be supervised by teaching staff in such a way that the residents assume progressively increasing responsibility according to their level of education, ability and experience." This process is the underlying University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 57
    • educational principal for all graduate medical education, regardless of specialty or discipline. Clinician educators involved in this process must understand the implications of this principle and its impact on the patient and the resident. g. All programs which include residents within the University of Utah Affiliated Hospital System must be approved by the appropriate the ACGME (Accreditation Council for Graduate Medical Education) or have special approval by the Graduate Medical Education (GME) committee. RESPONSIBILITIES: a. Associate Dean for Graduate Medical Education. The Associate Dean for Graduate medical education is responsible for establishing local policy to fulfill the requirements of this policy and the applicable accrediting and certifying body requirements. b. Residency Program Director. The Residency Program Director is responsible for the quality of the overall education and training program in a given discipline (i.e., medicine, surgery, psychiatry, pediatrics, etc.) and for ensuring that the program is in compliance with the policies of the respective accrediting or certifying bodies. The Residency Program Director defines the levels of responsibilities for each year of training by preparing a description of the types of clinical activities residents may perform and those for which residents may act in a teaching capacity. i. Assess the Attending Physician's discharge of supervisory responsibilities. At a minimum, this includes written evaluations by the residents and interviews with residents, other practitioners and other members of the health care team. ii. Structure training programs consistent with the requirements of the accrediting and certifying bodies (as identified above) and the affiliated sponsoring entity. iii. Arrange for all residents entering their first rotation to participate in an orientation to policies, procedures, and the role of residents within the affiliated training program iv. Ensure that residents are provided the opportunity to contribute to discussions in committees where decisions being made may affect their activities. c. Attending Physician. The Attending Physician is responsible for and must be personally involved in the care provided to individual patients in inpatient and University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 58
    • outpatient settings as well as long--term care and community settings. When a resident is involved in the care of the patient, the responsible Attending Physician must continue to maintain a personal involvement in the care of the patient. The attending must provide an appropriate level of supervision. Determination of this level of supervision is a function of the experience and demonstrated competence of the resident and of the complexity of the patient's health care needs. The procedures through which the Attending Physician provides and document appropriate supervision is outlined below in section 5. d. Resident. The residents, as individuals, must be aware of their limitations and not attempt to provide clinical services or do procedures for which they are not trained. They must know the graduated level of responsibility described for their level of training and not practice outside of that scope of service. Each resident is responsible for communicating significant patient care issues to the Attending Physician. Such communication must be documented in the record. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible Attending Physician may result in the removal of the resident from patient care activities. III. PROCEDURES: a. Resident Supervision by the Attending Physician. Attending Physicians are responsible for the care provided to each patient, and they must be familiar with each patient for whom they are responsible. Fulfillment of such responsibility requires personal involvement with each patient and each resident who is providing care as part of the training experience. Each patient will be assigned an Attending Physician whose name will be clearly identified in the patient's record. It is recognized that other Attending Physicians may, at times, be delegated responsibility for the care of a patient and provide supervision instead of, or in addition to, the assigned practitioner. It is the responsibility of the Attending Physician to be sure the residents involved in the care of the patient are informed of such delegation and can readily access an Attending Physician at all times. Such a delegation will be documented in the patient's record. The Attending Physician is expected to fulfill this responsibility, at a minimum, in the following manner: i. The Attending Physician will direct the care of the patient and provide the appropriate level of supervision based on the nature of the patient's condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment of the resident being supervised. Medical, surgical or mental health services must be rendered under the supervision of the Attending Physician or be personally furnished by the Attending Physician. Documentation of University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 59
    • this supervision will be by progress notes entered into the record by the Attending Physician or reflected within the resident's progress note at a frequency appropriate to the patient's condition. The medical record must reflect the degree of involvement of the Attending Physician, either by staff physician progress note, or the resident's description of attending involvement. . The resident note shall include the name of the Attending Physician with whom the case was discussed as well as a summary of that discussion. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement and supervision. Pathology and radiology reports must be verified by an Attending Physician. Attending Physicians will be responsible for following the admitting procedures required by the institutions at which they are admitting patients is association with resident physicians. ii. For patients admitted to an inpatient team, the Attending Physician must meet the patient early in the course of care (within 24 hours of admission including weekends and holidays). This supervision must be personally documented in a progress note no later than the day after admission. The Attending Physician's progress note will include findings and concurrence with the resident's initial diagnosis and treatment plan as well as any modifications or additions. The progress note must be properly signed, dated, and timed. Attending Physicians are expected to be personally involved in the ongoing care of the patients assigned to them in a manner consistent with the clinical needs of the patient and the graduated level of responsibility of the trainee. iii. Discharge from Inpatient Status. The Attending Physician, in consultation with the resident, ensures that the discharge of the patient from an inpatient service is appropriate and based on the specific circumstances of the patient's diagnoses and therapeutic regimen; this may include physical activity, medications, diet, functional status and follow--up plans. Evidence of this assurance must be documented by the Attending Physician countersignature of the discharge summary. iv. Transfer from One Inpatient Service to Another, or Transfer to a Different Level of Care. The Attending Physician, in consultation with the resident, ensures that the transfer of the patient from one inpatient service to another or transfer to a different level of care is appropriate and based on the specific circumstances of the patient's diagnoses and condition. The Attending Physician from the transferring service must be involved in the decision to transfer the patient. The Attending Physician from the receiving service must treat the patient as a new admission and write an independent note or an addendum to the resident's transfer acceptance note. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 60
    • v. Intensive Care Units (ICU), including Medical, Cardiac and Surgical ICUs. For patients admitted to, or transferred into an ICU the Attending Physician must physically meet, examine, and evaluate the patient as soon as possible, but no later than2 4 hours after admission or transfer, including weekends and holidays. vi. Night Float Admissions. For patients admitted to an inpatient service of the medical center, a "night float" resident occasionally provides care before the patient is transferred to an inpatient ward team. In these cases, the supervising practitioner must physically meet and examine the patient within 24 hours of admission by the night float to the inpatient service, irrespective of the time the ward team assumes responsibility for the patient. In addition, the supervising practitioner for the night float must be clearly designated by local policy. vii. Outpatient clinic. An Attending Physician must be physically present in the clinic area during clinic hours. All patients to the clinic for which the Attending Physician is responsible should be supervised by the Attending Physician. This supervision must be documented in the chart via a progress note by the Attending Physician or the resident's note and include the name of the Attending Physician and the nature of the discussion. New patients should be supervised as dictated by graduated level of responsibility outlined for each discipline. The supervision for new patients should be documented by either independent Attending Physician note or an addendum to the resident note. Unless otherwise specified in the graduated levels of responsibility, new patients must be seen by and evaluated by the Attending Physician at the time of the patient visit. Return patients should be seen by or discussed with the Attending Physician at such a frequency as to ensure that the course of treatment is effective and appropriate. This supervision must be documented in the record via a note by the Attending Physician or the resident's note that indicates the nature of the discussion with the Attending Physician. The medical record should reflect the degree of involvement of the Attending Physician, either by staff physician progress note or the resident's description of attending involvement. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement. All notes must be signed, dated, and timed by the resident. The Attending's co--signature of the resident's note is an acceptable method for the Attending Physician to document resident supervision. viii. The Attending Physician is responsible for official consultations on each specialty team. When trainees are involved in consultation University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 61
    • services, the Attending Physician will be responsible for supervision of these residents. The supervision of residents performing consultation will be determined by the graduated levels of responsibility for the resident. Unless otherwise stated in the graduated levels of responsibility, the Attending Physician must meet with each patient who received consultation by a resident and perform this personal evaluation in a timely manner based on the patient's condition. The patients seen in consultation by residents must be discussed and/or reviewed with the Attending Physician supervising the consultation within 24 hours of initial consultation by the resident. The Attending Physician must document this official consultation supervision by writing a personal progress note or by writing his/her concurrence with the resident consultation note by the close next working day. The attending may choose to countersign and add an addendum to the resident note detailing his/her involvement. ix. Emergency Department. An emergency department Attending Physician must be physically present in the emergency department. Each new patient to the emergency department must be seen by or discussed with an Attending Physician. The Attending Physician, in consultation with the resident, ensures that the discharge of the patient from the emergency department is appropriate. x. Emergency room consultations. Emergency room consultations by residents may be supervised by a specialty Attending Physician or the emergency room Attending Physician. All emergency room consultations by residents should involve the Attending Physician supervising the resident's discipline specific specialty consultation activities for which the consultation was requested. After discussion of the case with the discipline specific Attending Physician, the resident may receive direct supervision in the emergency room from the emergency room Attending Physician. In such cases where the emergency room Attending Physician is the principal provider of care for the patient's emergency room visit, the specialty specific Attending Physician does not need to meet directly with the patient. However, the specialty specific Attending Physician's supervision of the consultation should be documented in the medical record by co-- signature of the consultation note or be reflected in the resident physician consultation note. xi. Assure all Do Not Resuscitate (DNR) orders are appropriate and assure the supportive documentation for DNR orders are in the patient's medical record. All DNR orders must be signed or countersigned by the Attending Physician. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 62
    • b. Assignment and Availability of Attending Physicians. i. Within the scope of the training program, all residents, without exception, will function under the supervision of Attending Physicians. A responsible Attending Physician must be immediately available to the resident in person or by telephone and able to be present within a reasonable period of time (generally considered to be within 30 minutes of contact), if needed. Each discipline will publish, and make available "call schedules" indicating the responsible Attending Physician(s) to be contacted. ii. In order to ensure patient safety and quality patient care while providing the opportunity for maximizing the educational experience of the resident in the ambulatory setting, it is expected that an appropriately privileged Attending Physician will be available for supervision during clinic hours. Patients followed in more than one clinic will have an identifiable Attending Physician for each clinic. Attending Physicians are responsible for ensuring the coordination of care that is provided to patients. iii. Facilities must ensure that their training programs provide appropriate supervision for all residents as well as a duty hour schedule and a work environment that are consistent with proper patient care, the educational needs of residents, and all applicable program requirements. c. Graduated Levels of Responsibility. i. Each training program will be structured to encourage and permit residents to assume increasing levels of responsibility commensurate with their individual progress in experience, skill, knowledge, and judgment. ii. As part of their training program, residents should be given progressive responsibility for the care of the patient. The determination of a resident's ability to provide care to patients without a supervisor present or to act in a teaching capacity will be based on documented evaluation of the resident's clinical experience, judgment, knowledge, and technical skill. Ultimately, it is the decision of the Attending Physician as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. In general, however, residents are allowed to order laboratory studies, radiology studies, pharmaceuticals, and therapeutic procedures as part of their assigned levels of responsibility. In addition, residents are allowed to certify and re--certify certain treatment plans (e.g., Physical University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 63
    • Therapy, Speech Therapy) as part of their assigned levels of responsibility. These activities are considered part of the normal course of patient care and require no additional documentation on the part of the supervising practitioner over and above standard setting--specific documentation requirements. The overriding consideration must be the safe and effective care of the patient that is the personal responsibility of the Attending Physician. iii. The Residency Program Director will define the levels of responsibilities for each year of training by preparing a description of the types of clinical activities residents may perform and those for which residents may act in a teaching capacity. The documentation of the assignment of graduated levels of responsibility will be made available to other staff as appropriate. These guidelines will include the knowledge, attitudes, and skills which will be evaluated and must be present for a resident to advance in the training program, assume increased responsibilities (such as the supervision of lower level trainees), and be promoted at the time of the annual review. d. Supervision of Procedures. i. Diagnostic or therapeutic procedures require a high level of expertise in their performance and interpretation. Although gaining experience in performing such procedures is an integral part of the education of the resident, such procedures may be performed only by residents with the required knowledge, skill, and judgment and under an appropriate level of supervision by Attending Physicians. Examples include operative procedures performed in the operating suite, angiograms, endoscopy, bronchoscopy, and any other procedures where there is the need for informed consent. Attending Physicians will be responsible for authorizing the performance of such procedures, and such procedures should only be performed with the explicit approval of the Attending Physician. NOTE: Excluded from the requirements of this section are procedures that, although invasive by nature, are considered elements of routine and standard patient care. Examples are the placing of intravenous and arterial lines, thoracentesis, paracentesis, lumbar puncture, routine radiologic studies, wound debridement, and drainage of superficial abscesses. ii. Attending Physicians will provide appropriate supervision for the patient's evaluation, management decisions and procedures. For elective or scheduled procedures, the Attending Physician must evaluate the patient and write a pre--procedural note or addendum to the resident's pre--procedure note describing the findings, University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 64
    • diagnosis, plan for treatment, and/or choice of specific procedure to be performed. This pre--procedural evaluation and note may be done up to 30 days in advance of the surgical procedure. All applicable JCAHO standards concerning documentation must be done. A pre--procedure note may also serve as the admission note if it is written within 1 calendar day of admission by the Attending Physician with responsibility for continuing care of the inpatient, and if the notes meet criteria for both admission and pre--operatives notes. Other services involved in the patient's operative care (e.g., Anesthesiology) must write their own pre--procedure notes (such as for the administration of anesthesia) as required by JCAHO, but such documentation does not replace the pre--operative documentation required by the surgery Attending Physician. iii. During the performance of such procedures, an Attending Physician will provide an appropriate level of supervision. Determination of this level of supervision is generally left to the discretion of the Attending Physician within the context of the previously described levels of responsibility assigned to the individual resident involved. This determination is a function of the experience and competence of the resident and of the complexity of the specific case. e. Emergency Situation. An "emergency" is defined as a situation where immediate care is necessary to preserve the life of, or to prevent serious impairment of the health of a patient. In such situations, any resident, assisted by other clinical personnel as available, shall be permitted to do everything possible to save the life of a patient or to save a patient from serious harm. The appropriate Attending Physician will be contacted and apprized of the situation as soon as possible. The resident will document the nature of that discussion in the patient's record. f. Evaluation of Residents and Supervisors. i. Each resident will be evaluated according to accrediting and certifying body requirements on the basis of clinical judgment, knowledge, technical skills, humanistic qualities, professional attitudes, behavior, and overall ability to manage the care of a patient. Evaluations will occur as indicated by the accrediting or certifying body at the end of the resident's rotation or every six months, whichever is more frequent. Written evaluations will be discussed with the resident. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 65
    • ii. If a resident's performance or conduct is judged to be detrimental to the care of a patient(s) at any time, action will be taken immediately to ensure the safety of the patient(s). iii. At least annually, each resident rotating through the will be given the opportunity to complete a confidential written evaluation of Attending Physicians and of the quality of the resident's training. Such evaluations will include the adequacy of clinical supervision by the Attending Physician. The evaluations will be reviewed by the program director. iv. All written evaluations of residents and Attending Physicians will be kept on file by the Residency Program Director in an appropriate location and for the required time frame according to the guidelines established by the respective ACGME Residency Review Committee or other accrediting and certifying agencies. g. Monitoring Procedures. i. The goal of monitoring resident supervision is to foster a system-- wide environment of peer learning and collaboration among managers, Attending Physicians and residents. The monitoring process involves the use of existing information, the production of a series of evaluative reports, the accompanying process of public review of key findings, and discussion of policy implications. Monitoring will of the compliance with these procedures will be performed by the program director and as part of the scheduled internal program reviews. ii. The basic foundation for resident supervision ultimately resides in the integrity and good judgment of professionals (Attending Physicians and residents) working collaboratively in well--designed health care delivery systems. Approval body: Graduate Medical Education Committee Approval date: April 2002 Policy Owner: Graduate Medical Education Historical Information: Review dates: 2/06 Revision dates 1/06 Approval dates: University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 66
    • Pediatric Hematology/Oncology Fellowship For Academic Year 2007-2008 _____________________________________________________________________ Eligibility and Selection Policy and Procedures _____________________________________________________________________ To be eligible for appointment to Pediatric Hematology/Oncology fellowship at the University of Utah School of Medicine, an applicant must: • Be a graduate of a US or Canadian medical school accredited by the Liaison Committee on Medical Education (LCME) –OR-- • Be a graduate of a college of osteopathic medicine in the United states accredited by the American Osteopathic Association (AOA) –OR— • Be a graduate of a medical school outside of the United Sates who meets one or more of the following qualifications: 1. Has a currently valid ECFMG certificate, –OR— 2. Has a full and unrestricted license to practice medicine in a US licensing jurisdiction, --OR-- 3. Is a graduate of a medical school outside the United Sates who has completed a Fifth Pathway program provided by an LCME-accredited medical school In addition, applicants must have passed Parts I, II, and III of USMLE and be board eligible in Pediatrics prior to the time they will begin training. PROGRAM POLICY/PROCESS We require: Curriculum Vitae, Personal Statement and three letters of recommendation including a letter from current program director for application International Medical Graduates must include the following in addition to the above: • Copy of green card, visa (J-1), or documentation of U.S. citizenship • Valid ECFMG certificate with Clinical Skills Assessment certification • Evidence of previous training in the United Sates (if applicable) Candidates for this program are selected based on their preparedness, ability, academic credentials, communication skills, and personal qualities such as motivation and integrity. Preference is given to candidates that demonstrate interest or achievement in clinical or basic science research. The University of Utah School of Medicine does not discriminate on the basis of sex, race, age, religion, color, national origin, disability, or veterans status. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 67
    • Application materials are reviewed via criteria set forth by the ACGME Program Requirements, the Resident Recruitment Committee and this institution. The division members review applicants who meet the criteria. Based on the quality of the application and academic credentials, the applicant is subsequently invited at our expense, if appropriate, for an interview. Applicants interview with members of the faculty, the Program Director and the Division head whenever possible. All applicants also meet with current hematology/oncology fellows and may review potential research opportunities. Following the interview process, all faculty participating will submit their recommendations to the Program Director. These recommendations will be tallied and final decisions made by the fellowship selection committee. Specific criterion for selection are as follows: * Quality of letters of recommendation * Quality of Applicant’s medical school and residency training * Interview evaluation * Potential for an academic career Selected applicants will be admitted, pending receipt and review of USMLE Step III scores. _____________________________________________________________________ J-I VISA ACKNOWLEDGEMENT UNIVERSITY OF UTAH AFFILIATED HOSPITALS I, _________________________________________, am not a citizen of the United States or a permanent resident of the United States. I understand that, as a resident (intern/fellow) of the University of Utah Affiliated Hospitals, I must have a J-1 visa in order to participate in a residency training program (internship/fellowship). I understand that the University of Utah Affiliated Hospitals will not accept any other type of visa. By signing this form, I acknowledge my understanding of the above requirement, and I agree to obtain a J-1 visa prior to beginning my training at University of Utah Affiliated Hospitals. ________________________________________________ Signature of applicant ________________________________________________ Country of citizenship University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 68
    • Pediatric Hematology/Oncology Fellow Vacation and Leave Policy for 2007-2008 Vacation Each Fellow will have 3 weeks vacation per year as outlined in the University of Utah Houseofficer’s Agreement, scheduled in 1 week blocks. Vacation during the first year is scheduled. Vacation during the second and third is to be requested and arranged by the Fellow with approval from the Program Director. Call responsibilities: On-call responsibilities for the first year of training will be approximately 1 week out of every 4 weeks, except during the BMT rotation where call will be arranged by the BMT service (approximately 1:5). During the second and third years of Fellowship, the Fellow is on-call approximately 1 week out of every 5-6 weeks. All call is home based. When on-call, the Fellow will cover the inpatient service and will be available for hematology and oncology consults, outside physician queries, and patient calls. Monday through Thursday, call extends from 1700 to 0800 the next morning. On week- ends, coverage lasts from 1700 on Friday until 0800 on Monday. Call on an official holiday extends from 0800 to 0800 the next day. An Attending will be assigned as backup at all times. All new patients including consults will be discussed with the Attending. Leave Educational Leave: Fellows may be granted up to four days annually of educational leave to attend one regional or national conference. This will generally be the annual meeting of the American Society of Clinical Oncology (ASCO) or the American Society of Hematology (ASH). The request for such leave should be made to the Program Director at least 12 weeks prior to the conference. Sick Leave: Sick leave is arranged on an individual basis. If, however, sick leave is required for longer than 12 days per year, the fellow may have to use vacation time, take unpaid leave, or be required to stay on at the end of the training period to make up for missed training. Family Leave: The family leave policy for Fellows at the University of Utah meets the requirements of the Family Medical Leave Act of 1993, allowing up to 12 weeks of unpaid leave per year. The Fellow should inform the Program Director immediately about any needed leave, so that arrangements for coverage can be made well in advance. Leave for Examinations: Leave to participate in required licensing and other examinations will be granted to all Fellows. A maximum of 4 days leave will be granted for this purpose each year. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 69
    • Procedure for leave application: A request for a change in schedule should be discussed with the Program Director. A written request needs to be submitted to the Graduate Medical Education Office. It must be recognized that the American Board of Pediatrics requires 36 months of training for Board Eligibility in Pediatric Hematology/Oncology. Any leave taken, which exceeds the allotted 27 days per year (15 days vacation leave, 12 days sick leave) must be made up in order to be eligible for board examinations. The schedule for making up this time must be arranged with the Program Director. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 70
    • Pediatric Hematology/Oncology Fellowship Moonlighting and Work Hours Policy For Academic Year 2007-2008 Moonlighting Moonlighting jobs are prohibited in the first year and strongly discouraged in subsequent years, as they may interfere with the Fellow’s commitment to scholarship and produce undue fatigue. Policies on moonlighting conform with current Graduate Medical Education Committee and University of Utah guidelines (Section 5 No. 7 Rev. 8 May 2006). Work Hours The policy on work hours and call duty for Pediatric Hematology/Oncology Fellows has been developed in accordance with the guidelines set forth by the Graduate Medical Education Committee (Section 7 No. 10.1 Rev. 3) at the University of Utah and conforms with current Residency Review Committee guidelines. The intellectual and personal growth of the Fellow and the continuity of care of the patient are the major factors driving the training program. The service needs of the institution are not of paramount importance, but a personal sense of responsibility to the patient overrides any schedule of specific hours. The Fellows shall work no more than 80 hours per week, when averaged over a four- week period, and shall average one full day off per week. There are no in-house call responsibilities. A 10 hour time period for rest and personal activities will be provided between all daily work periods. An Attending Physician is always available for immediate assistance and review of all decisions made by Fellows. Work Hours: Specific Rotations The Pediatric Hematology/Oncology Fellowship is set up on a weekly rotation schedule. All night calls will be home-based. There are no in-house overnight call responsibilities during the Fellowship. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 71
    • Call responsibilities: On-call responsibilities for the first year of training will be approximately 1 week out of every 4 weeks, except during the BMT rotation where call will be arranged by the BMT service (approximately 1:5). During the second and third years of Fellowship, the Fellow is on-call approximately 1 week out of every 5-6 weeks. All call is home based. When on-call, the Fellow will cover the inpatient service and will be available for hematology and oncology consults, outside physician queries, and patient calls. Monday through Thursday, call extends from 1700 to 0800 the next morning. On week- ends, coverage lasts from 1700 on Friday until 0800 on Monday. Call on an official holiday extends from 0800 to 0800 the next day. An Attending will be assigned as backup at all times. All new patients including consults will be discussed with the Attending. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 72
    • Pediatric Hematology/Oncology Standards of Performance 2007-2008 First Year Fellows The Pediatric Hematology/Oncology clinical training program is a structured educational experience combining inpatient and ambulatory clinical rotations with interactive conferences and didactic teaching sessions. Fellows will participate in a continuity of care clinic for one day per week for the duration of their Fellowship training. An Attending Physician supervises all clinical activities. Inpatient clinical rotations combine extensive interaction with pediatric residents, as well as Fellows from other specialties with reporting to and instruction from the Attending Physician. All procedural training is supervised by on site Attending Physicians. It should be noted that the educational activities are not only structured to meet all of the goals of Pediatric Hematology/Oncology training, but also to maintain skills in General Pediatrics. Fellows are to do complete evaluations on all inpatient and outpatient consultations. These are reviewed and discussed with Attending Physicians. Fellows are required to attend divisional conferences and are invited to attend didactic conferences for the pediatric housestaff. Fellows will be expected to be proficient in the following clinical skills: 1. The performance of a directed but thorough history and physical examination. 2. The ability to serially measure palpable tumor masses. 3. The ability to interpret clinical data, including laboratory data, imaging studies, pathologic specimens, and the microscopic interpretation of blood smears and marrow aspirates and biopsies. 4. The ability to formulate an appropriate differential diagnosis and diagnostic plan based upon the clinical, laboratory, and radiological findings. 5. The ability to communicate clinical data in an organized, succinct, and intelligible fashion. 6. The ability to select appropriate, safe, and cost-effective laboratory and diagnostic studies. 7. The ability to formulate and carry out an appropriate therapeutic plan for Pediatric Hematology/Oncology disorders. 8. The ability to work effectively as part of a multi-disciplinary team. 9. The ability to provide appropriate humanistic, ethical, and conscientious care to the patient. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 73
    • In addition to specific hematologic and malignant disorders, the Fellow must develop competency in all aspects of chemotherapy, including treatment protocols and management of complications, diagnosis and treatment of infections in the compromised host, appropriate use of transfusion of blood products, plasmapheresis and bone marrow transplantation. The Fellow is also expected to learn methods of physiologic support of the cancer patient including parenteral nutrition, control of nausea and pain, staging and classifications of tumors, complete knowledge and application of multi-modality therapy, learning to function as a member of an oncology team, and learning the epidemiology of childhood cancer. The Fellow will know the indications, contraindications, complications, potential benefits, alternatives, and limitations of the following diagnostic and therapeutic techniques and procedures. The Fellow will be able to appropriately, safely and expeditiously perform or recommend and, where applicable, interpret these procedures based upon knowledge of the history and clinical findings. The Fellow will receive training in each of these areas to accomplish this goal. • Accurately calculate doses, order, administer or supervise the administration of cytotoxic chemotherapeutic agents and biologic response modifiers. • Ordering and administration of blood products, including factor replacement. This will include indications for specific preparation of blood products—filtered, irradiated, and washed. • Recommend and assess tumor imaging studies, including plain films, CT scans, ultrasound (dynamic or static), MRI, and metabolic scanning. • Recommend surgical procedures and communicate effectively with surgical colleagues. • Recommend appropriate insertion of central venous access devices, including PICC lines, broviac or portacath catheters. • Perform bone marrow aspiration and biopsy, including preparation, staining, examination, and interpretation of blood smears, bone marrow aspirates, and touch preparations. The Fellow will be able to perform the bone marrow aspirate/biopsy by the posterior, and anterior approach. • Recommend apheresis procedures, including therapeutic plasmapheresis or peripheral stem cell harvest for transplantation. • Order and interpret partial thromboplastin time, prothrombin time, platelet aggregation, bleeding time and other standard coagulation assays. • Perform diagnostic or therapeutic thoracentesis and paracentesis. • Perform lumbar puncture or access Ommaya reservoirs, and, where applicable, instill chemotherapeutic agents directly into the CSF. • Administer and monitor sedation for patients undergoing procedures such as bone marrow biopsy. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 74
    • The Fellow will be expected to be able to concisely outline the nature and utility of each procedure, along with its potential complications and benefits, to the patient for the purpose of obtaining informed consent. The Fellow will appropriately document the indications, performance and results of all procedures in the patient chart. In addition, the Fellow will document all procedures in the ABP-approved procedure logbook, and have the supervising Attending Physician sign off on them. The Fellow will be expected to learn to identify his/her own limitations, and identify when to terminate procedures or seek assistance. Second and Subsequent Years Research training is accomplished through both didactic teaching of research principles and through closely supervised research projects. A scientific mentor supervises all research activities. Basic science and clinical research are of critical importance to the field of Pediatrics, and to Pediatric Hematology/Oncology in particular. All advances in medical practice are the result of research. Abundant research opportunities exist for our Fellows and include basic laboratory research, translational and clinical research projects. These can be coordinated within the Divisions, the Department of Pediatrics, or any other Department within the University. The HCI investigators and those in the Department of Oncologic Sciences represent a unique opportunity for the development and pursuit of research interests. Fellows in Pediatric Hematology/Oncology will receive instruction in the principles and techniques involved in basic science and clinical research, and will be expected to participate in a research project during their program. Fellows will spend at least two years involved in a research project. By Spring of their first year, Fellows will be expected to have identified a scientific mentor and an area of research interest, and communicate this to the Program Director. Fellows will be encouraged to seek the advice of Faculty members when deciding on a potential research project, and will receive whatever assistance they require. It is hoped that the exposure our Fellows receive to research during their program will foster an interest that will last throughout their career. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 75
    • Fellows in all Years of the Fellowship A scholarly approach to learning, practice, research, and teaching will be developed. Pediatric Hematology/Oncology Fellows will utilize educational offerings to their fullest extent. Fellows will also be expected to become independent learners and develop lifelong habits of reading and literature research. They will learn the principles of evidence-based medicine, critical literature review, and clinical application of new knowledge to the clinical and research settings. They will be encouraged to remain active in research throughout their practice careers, in the laboratory setting, in the clinical setting, or both. Pediatric Hematology/Oncology research is required not only for the purpose of learning necessary skills for a possible academic career, but also to gain first-hand experience in the generation of medical knowledge. Like learning, teaching is an integral part of scholarship. As such, the Fellow will be involved in teaching throughout the program. The Division is responsible for teaching medical students about Pediatric Hematology and Oncology. Fellows will participate by directing small groups of medical students in sessions covering topics outlined in the formal lectures. In addition, Fellows will regularly present and discuss patients and therapeutics at multi-disciplinary conferences, give didactic lectures at Friday conferences, present regularly at journal club, and instruct interns and residents from all disciplines during inpatient and consult service rounds. Evaluation of Fellow Performance The overall performance of each Fellow will be evaluated as follows: 1) The elements of clinical competence will be assessed and recorded by the faculty on the Fellow Evaluation Form at the conclusion of every rotation. This evaluation is submitted to the Program Director, who reviews the evaluations quarterly and makes recommendations to the Division Chief, who will review these evaluations with the Fellow annually, at a minimum. If there are substantial deficiencies in the Fellow’s performance (as judged by the Program Director and the Division Chief in consultation with the Division faculty), reviews will be carried out with the Fellow on a more frequent basis. 2) The Program Director, Division Chief and the Division faculty will meet annually to discuss the academic and clinical progress of all the Fellows in the program. Any problems that are identified at this meeting will be reviewed in a meeting between the Division Chief and the Fellow within two weeks of this meeting. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 76
    • Promotion, Probation, Suspension and Dismissal At the conclusion of each academic year, each Fellow will be promoted to the next year of the Fellowship, provided that he or she has successfully fulfilled the requirements of the program and has received satisfactory (or better) evaluations. Following the successful conclusion of the third year in the program, the Fellow will graduate and will be eligible to sit for the Pediatric Hematology/Oncology certifying examination. Faculty are expected to notify the Division Chief/Program Director of any unsatisfactory performance immediately upon occurrence. The Division Chief will promptly review such situations. If the review confirms that performance is unsatisfactory, the Division Chief will meet with the Fellow to discuss the situation and decide if corrective action is necessary. Unless circumstances are exceptional, the Fellow will have an opportunity to remediate an unsatisfactory performance. Corrective actions required of a resident could include remediation (such as repeating a rotation, participation in a special program, etc), academic probation, suspension, or dismissal. 3) Remediation c) When an evaluation is below that expected for the Fellow’s level of training, the Division Chief must decide on a program of remedial training and must arrange such training. d) The Fellow must be informed of this decision in writing, with details regarding the remediation, including the areas in which, and the time within which, improvement is expected, and the possible outcomes of such remediation. d) At the end of the remedial training, the Division Chief shall inform the Fellow in writing that the weakness has either been corrected or has not been corrected. If it has not been corrected, the Chief shall include written notification that the Fellow will have a further period of remedial training with or without probation, or the Fellow will be placed on probation. 4) Probation A Fellow may be placed on probation by the Division Chief, following approval of the Director of Graduate Medical Education, if: Remedial action outlined in Section 1 fails to correct a recognized deficiency. Or The deficiency is of a nature that is not subject to usual remedial measures; for example, attitudinal or ethical problems. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 77
    • f) Guidelines for the probationary period must be communicated in writing to the Fellow and must include the specific weakness to be corrected, what must be accomplished to correct the weakness, the time period of probation, and the possible outcomes of probation. g) In general, the probationary period will not extend past the end of the current agreement year, unless the agreement year ends within three months, in which case the program has the option of extending the probationary period into the next agreement year, but that extension shall not exceed three months. h) Any houseofficer agreement which may have been issued by a program for a subsequent year will be considered invalid until the Fellow has fulfilled probationary requirements and been removed from probation. i) At the time that the Fellow is removed from probation, the program has the following options: Full reinstatement. An additional probationary period, with or without remediation. Dismissal from the program either immediately or at the conclusion of the current training year. Houseofficer agreements for a subsequent year may contain a written clause stating conditions under which the agreement may be terminated immediately. Usually that clause will refer to continuing problems of the kind that resulted in the first probationary period. 4) Suspension The Division Chief may suspend a Fellow for non-academic reasons, if he or she is of the opinion that the continued presence of the Fellow in a clinical setting would be detrimental to staff or to patient care. This decision to suspend a Fellow must be followed immediately by an evaluation and either probation or dismissal, subject to appeal. Appeals will follow the due process procedures established by the Graduate Medical Education office. Dismissal In general, a Fellow may be dismissed from the program only after going through the process of evaluation and probation with or without remedial training. There are instances, however, in which the Division Chief may find it necessary to dismiss a Fellow for non-academic reasons that are not subject to remediation or probation. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 78
    • The decision to dismiss a Fellow may initially be made by the Division Chief, with the consent of the Program Director and the Division faculty. The Chairman of the Department of Pediatrics and the Dean of the School of Medicine must approve the dismissal. The Fellow must be informed of this decision in writing, which must include the reason(s) for dismissal. 5) Appeals The Fellow may appeal the decision of remedial training, probation, suspension, or dismissal to the School of Medicine. Appeals will follow the due process procedures established by the Graduate Medical Education office. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 79
    • UNIVERSITY HEALTH CARE HOSPITALS AND CLINICS GRADUATE MEDICAL EDUCATION HOUSESTAFF POLICIES AND PROCEDURES _____________________________________________________________________ SCHOOL OF MEDICINE HOUSESTAFF DUE PROCESS POLICY Section 7 No. 5 Rev. 2 Review Date: January 2006 Revision Date: February 1, 1992 Chapter: Other _____________________________________________________________________ I. PURPOSE To assure fairness in all evaluations the Graduate Medical Education Committee has adopted Standards of Review for actions that may affect the status of the resident. All residents will receive a copy in the orientation packet of the institution's Standards of Review at the start of training, as well as in the Housestaff Manual. Any resident being disciplined or put on probation, or otherwise affected by the policy will receive a second copy of the policy in the mail, from the Director of Graduate Medical Education (DGME). The policy will be sent with a cover letter as soon as the DGME is notified of the problem by the program director. II. POLICY A. All programs will follow the University of Utah School of Medicine Resident Evaluation Policy. Standards (as spelled out by the institution and each individual program) not met will be considered to be academic problems. No resident will be dismissed for academic problems without a probationary period, unless extraordinary circumstances exist. No resident will be dismissed without consultation with the Director of Graduate Medical Education to make sure that appropriate evaluation, documentation, and probationary procedures have been followed. B. A resident's pay will stop at the time of termination by the program. If the decision is later reversed by the appeals process, back pay may be awarded as part of that decision. C. An appeal of any decision in this process must be made in writing to the DGME within one week of receipt of the written decision, unless other arrangements have been made. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 80
    • III. THE RESIDENT: A. Will be notified in writing by the program director of any negative evaluations which may affect his or her standing or progress in the training program. B. Has a right to appeal the evaluation if the resident feels he/she has been evaluated unfairly. The resident is allowed to appropriately address the questions of performance before various committees within the department or School of Medicine as specified by the policy below. Academic evaluations during a rotation and the assignment of a rating at the conclusion of a rotation are provided by the course director(s) and will be sustained unless found to be arbitrary, capricious, or not based on established criteria. The unsatisfactory rating may result in interruption of the normal sequence of rotations. C. Has a right to provide additional or explanatory information to the body considering an appeal, as that body is receiving information. If the appeals body has requested the resident to provide or expand upon that information in person, he/she will be excused from committee deliberations after presenting his/her information. D. Has a right to be accompanied by a faculty member or another resident to act as advocate during any personal appearance at an appeal procedure. A summary of proceedings will be made available to the resident. The resident may take notes at the meeting. E. The resident will be informed, by the program director or the DGME: 1. of the decision of each committee or appeals body. This will be followed by written notification of the decision, at which time the time starts for the next level of appeal. Notification should contain information on the next level of appeal, if the resident is so inclined. The department will be sent a copy of the decision of each committee as well. 2. that at each level of appeal, the party making the appeal, whether it be the resident, program director, or hospital, is responsible for providing evidence to convince the committee or appeals body to reverse the decision being appealed. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 81
    • IV. THE PROGRAM: May appeal any decision made by any body subsequent to the decision of the program Grievance Committee, by filing a written appeal with the DGME, as per the above resident procedures, substituting the word "program" for "resident". University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 82
    • INSTITUTIONAL DUE PROCESS PROCEDURES I. Informal The Office of Graduate Medical Education will try to facilitate informal discussions to resolve differences. II. Formal Any houseofficer, or any party dissatisfied with a decision of the program evaluation committee, may appeal for: A. review by the Program Grievance Committee, comprised equally of housestaff and faculty. Members of the committee should be broadly representative of the program faculty and residents. Appeals may be for any action considered to be arbitrary, capricious, or not in keeping with previously announced criteria. The resident may appear before this committee to testify on his/her behalf, with an advocate, as previously specified. This committee will take into consideration the resident's overall performance when arriving at a decision. This committee will reach a decision no longer than 30 days after receiving an appeal. Any party dissatisfied with the decision of this committee may appeal for: B. review by the School of Medicine Housestaff Grievance Committee, which shall be made up of a program director, two faculty members, and one resident. No member of the committee shall be a member of the resident's department, and if that is the case, that individual shall be replaced for purposes of this particular appeal. They may ratify, reverse, or make a new decision. This committee will reach a decision no longer than 30 days after receiving an appeal. Any party dissatisfied with the decision of this committee may appeal for: C. review by the Dean, School of Medicine, who will review to be sure procedures have been followed. Usually, he/she will not rule on a case but merely pass it on to the Vice President after review. However, the Dean may ratify, reverse, or make a new decision. The Dean will make a decision no longer than 14 days after receiving an appeal. Any party dissatisfied with the decision of the Dean may appeal for: D. review by the Vice President of Health Sciences who may ratify, reverse, or make a new decision. The Vice President will make a decision no longer than 14 days after receiving an appeal. This will be the final step in the appeal process. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 83
    • III. Time limits as established above may be extended by mutual agreement between the DGME and the aggrieved party. Time limits refer to working days. IV. Appeals at every level may result in hearings where the parties will be afforded ample opportunity to present their case and to introduce relevant information. V. Violations of law and other such behavior which do not bear directly on performance or suitability as a physician are considered disciplinary problems, and will be referred to the civil authorities where appropriate. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 84
    • DEPARTMENTAL DUE PROCESS CHECKLIST FOR HOUSESTAFF 1. Establish program criteria pursuant to the University of Utah School of Medicine Resident Evaluation Policy. 2. Set up a Program Grievance Committee, comprised equally of housestaff and faculty and broadly representative of faculty and residents. 3. Notify a resident in writing of any negative evaluations which might affect his or her standing or progress in the program. 4. The resident has a right to appeal any evaluation on the basis that it is arbitrary, capricious, or not based on an established criteria. 5. The resident has a right to provide additional or explanatory information to the Program Grievance Committee. 6. The resident has a right to be accompanied by a faculty member or another resident to act as advocate during any appeal procedure. The resident may take notes at the meeting. 7. No resident may be dismissed without a period of corrective action, or probation. 8. The resident will be informed by the program director, or Director of Graduate Medical Education, of the decision of each committee or appeals body. 9. All the above steps must be followed, as outlined in the School of Medicine Housestaff Due Process Policy (Section 7, No. 5, Rev. 2) before the resident may appeal to the School of Medicine Housestaff Grievance Committee. Approval body: Graduate Medical Education Committee Approval date: 1/192 Policy Owner: Graduate Medical Education Historical Information: Review dates: 1/06 Revision dates Approval dates: University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 85
    • Pediatric Hematology/Oncology Fellowship Evaluation Policy Academic Year 2007-2008 Assessment of Competence During the First Year of Training During the first year of training in Pediatric Hematology/Oncology, the Fellow will be assessed by the supervisory faculty at least every six months. This information will be stored in the specific Fellow’s file in the Program Director’s office. That assessment will include the following: Fundamentals of clinical diagnosis with special emphasis on history taking and physical examination including the evaluation and management of both inpatients and outpatients who have hematologic and oncologic disorders including: • Leukemias, both acute and chronic • Solid tumors of organs, soft tissue, bone, and central nervous system • Lymphomas • Inherited and acquired bone marrow failure syndromes • Hemoglobinopathies, including sickle cell and thalassemia syndromes • Inherited and acquired disorders of the red cell membrane and of red cell metabolism • Autoimmune hemolytic anemia • Nutritional anemia • Inherited and acquired disorders of white blood cells • Platelet disorders, including ITP and acquired and inherited platelet function defects • Hemophilia, von Willebrand disease, and other inherited and acquired coagulopathies • Hematologic disorders of the newborn • Transfusion medicine and use of blood products • Congenital and acquired immunodeficiencies University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 86
    • In addition to specific hematologic and malignant disorders, the Fellow must develop competency in all aspects of chemotherapy, including treatment protocols and management of complications; diagnosis and treatment of infections in the compromised host; appropriate use of transfusion of blood products, plasmapheresis and bone marrow transplantation. The Fellow is also expected to learn methods of physiologic support of the cancer patient including parenteral nutrition, control of nausea and pain, staging and classifications of tumors, complete knowledge and application of multi-modality therapy, learning to function as a member of a multidisciplinary oncology team, learning the epidemiology of childhood cancer. Making good observations and keeping accurate patient data are vital aspects of Pediatric Hematology/Oncology and it is expected that the Fellow will acquire these during his first year of this training program. The Fellow is expected also to acquire the necessary skills for the interpretation and performance of procedures and laboratory tests common to the practice of Pediatric Hematology/Oncology. He/she is expected to become skilled in the performance and interpretation of bone marrow aspirations and biopsies, venipunctures, lumbar puncture, clinical microscopy, and interpretation of peripheral blood smears. The Fellow is expected to participate in the entire curriculum for this initial year of training in order to acquire the above detailed skills. That curriculum includes six months on the inpatient Hematology/Oncology service and the attendance of at least one full day’s outpatient clinic per week. In the outpatient clinic, the Fellow will follow a population of patients in continuity during the first and also subsequent years of training. First year Fellows in Pediatric Hematology/Oncology are expected to participate in the conference and lecture schedule of the division which includes weekly patient management conferences, Pediatric Grand Rounds and Pediatric Research in Progress, as well as twice-monthly tumor boards and monthly division journal club. The Fellow is also expected to participate in the Department of Pediatric Fellowship course as offered, which includes the topics of scientific writing and presentations, biostatistics, and medical ethics. Finally the Fellow is expected to participate in the teaching activities of the division including the organization of educational conferences and also the development of skills in medical writing. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 87
    • Assessment of Competence During the Second and Subsequent Years of Training Clinical responsibilities are limited to one day in clinic each week, home call approximately only one out of every 5-6 weeks, and the attendance of regular educational conferences of the Division of Pediatric Hematology/Oncology. Fellows in the second year of training embark on a structured program of research education designed to develop the knowledge, thought processes and laboratory skills needed for a career as an independent investigator. The specific laboratory work is supplemented by courses within the School of Medicine involving basic science and research methodology important to the development of an investigative career. The Fellow will be evaluated twice a year on their progress in the lab as their research progresses. These evaluations will be stored in the Fellow’s file in the Program Director’s office. Trainees in the second and subsequent years of the fellowship are required to have a Scholarship Oversight Committee (SOC). This committee should consist of the research mentor and at least two other faculty members who can contribute to the Fellow’s intellectual and career development. This SOC should meet at least semi-annually. It is this committee’s responsibility to evaluate the progress of the Fellow at least twice a year. These evaluations will be sent to the Program Director. The Program Director will discuss the evaluations with the Fellow and have the Fellow sign and date them before they are put in the Fellows permanent record. University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 88
    • Appendix Form For Fellows to Evaluate Rotations Form For Attendings to Evaluate Fellows Program Director Meeting Form University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 89
    • Appendix 1. Form for Fellows to Evaluate Rotations 2. Form for Attendings to Evaluate Fellows 3. Program Director Meeting Form University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 90
    • Division of Pediatric Hematology/Oncology Primary Children’s Medical Center University of Utah Form for fellows to evaluate rotations Fellow’s Name__________________________________Rotation__________________ Dates: ______________________________ Please comment specifically on the following areas, when applicable: 1. Patient Population. (volume, variety, acute, etc.) 2. Responsibility for patient management: 3. Opportunity to acquire experience with patients and laboratory procedures: (Bone marrows; lumbar punctures; blood, marrow and CSF morphology; etc.) Give approximate number of bone marrow aspirates and biopsies, and lumbar punctures you performed during this rotation. 4. Teaching experience: (Comment specifically on the formal and information teaching received on this rotation, including an appraisal of the responsible attending(s) teaching interest, effort and ability.) Name of Attending(s):________________________, _____________________ University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 91
    • ATTENDING Pediatric Hem/Onc fellow evaluation RETURN FORM TO: Trainee: David Virshup Evaluator: Huntsman Cancer Institute Dates: University of Utah Salt Lake City, UT 84112 COMPETENT: Performance within expectations for current level of training. MARGINAL: Performance not unacceptable, but must improve to meet the experience of the level of training. UNACCEPTABLE: Deficient performance for level of training. *Comment required on reverse side for any unacceptable or marginal ratings Please put a checkmark for each area of evaluation to indicate the level of performance. You may add either a “+” or "-" to any area to indicate the high or low side of C, M, or U. _________________________________________________________________________________ U M C Don't Know A. PATIENT ASSESSMENT 1. Gathering data by history ___ ___ ___ ___ 2. Gathering data by physical exam ___ ___ ___ ___ 3. Generating a differential diagnosis ___ ___ ___ ___ 4. Rationality of diagnostic plan ___ ___ ___ ___ 5. Assessing data and arriving at diagnosis ___ ___ ___ ___ 6. Knowledge base ___ ___ ___ ___ _________________________________________________________________________________ B. PATIENT CARE 7. Establishing priorities in treatment plan ___ ___ ___ ___ 8. Relationship with patients/families ___ ___ ___ ___ 9. Recognition and management of emergencies ___ ___ ___ ___ 10. Maintenance of complete and orderly records ___ ___ ___ ___ 11. Takes personal responsibility for patient care ___ ___ ___ ___ _________________________________________________________________________________ C. PERSONAL CHARACTERISTICS 12. Confidence level appropriate for knowledge base/experience ___ ___ ___ ___ 13. Honesty and integrity ___ ___ ___ ___ 14. Acceptance of direction or criticism ___ ___ ___ ___ 15. Relationship with other team members ___ ___ ___ ___ 16. Organized and efficient work habits ___ ___ ___ ___ 17. Professional demeanor ___ ___ ___ ___ _________________________________________________________________________________ D. CLINICAL COMPETENCE 18. Overall clinical competence based on this service/rotation (check one): ____ Unable to manage many pediatric problems including most routine ____ Able to manage only the most routine problems in pediatrics ____ Able to manage the common problems of pediatrics adequately ____ Able to manage most pediatric problems in an effective way University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 92
    • ____ Able to manage almost any pediatric problem highly effectively 19. Is this rating consistent with this resident's level of training? ____ Yes ____ No - OVER - Please use this portion of the evaluation for specific comments, which may address issues of patient assessment or care, personal characteristics, progress made during rotation, teaching or supervisory skills. These comments should: 1) Suggest one or more improvements the resident could make to help on future rotations: 2) Comment on resident's performance, including exceptional performance, using specific examples whenever possible; and 3) Elaborate on any Unacceptable or Marginal ratings using specific examples or episodes. Disease entities seen during this rotation: Procedures performed during this rotation: Trainee’s strongest points: Sugestions for areas that trainee could improve in: OVERALL RATING FOR THE ROTATION: A. ____ Satisfactory Performance B. ____ Marginal Performance C. ____ Unsatisfactory Performance Have there been any events or incidents that would lead you to question the moral and ethical integrity of this houseofficer? _____ Yes _____ No Faculty Signature__________________________________________________Date________________ Resident's response to evaluation: (optional) University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 93
    • Resident Signature______________________________________________________Date____________ Pediatric Hem/Onc fellows Program Director meeting Date: Research Program: Goals and achievements Six month goal: One year goal: Funding sources: Publications: Mentor Feedback: Program Feedback: Supervisory Committee: Last Meeting: Next Meeting: University of Utah Department of Pediatrics Hematology/Oncology Fellow Handbook Revised January, 2007 Page 94