Hematology / Oncology

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Hematology / Oncology

  1. 1. Goals and Objectives Hematology/Oncology Outpatient Clinic Elective Rotation OVERVIEW Medical Oncology involves the diagnosis and management of benign and malignant neoplasms. The general internist should have a wide range of competencies in the evaluation and management neoplastic disease. He or she must be able to do the following: (1) identify patients at risk for malignancy and counsel them regarding risk reduction and screening; (2) investigate clinical syndromes suggestive of underlying malignancy; (3) undertake the palliative care of patients with common solid and hematologic malignancies; (4) identify neoplasms with a potential for cure and direct affected patients to the appropriate centers or providers; and (5) participate in the difficult decisions regarding all aspects of management including diagnostic evaluation and screening, treatment, and palliative care. In addition, the general internist must be familiar with the administration, side effects, and drug interactions of therapeutic agents commonly used for the treatment of malignant disease. Hematology relates to the care of patients with disorders of the blood, bone marrow, and lymphatic systems. These disorders include the anemias, hematologic malignancies and other clonal processes, and congenital and acquired disorders of hemostasis, coagulation, and thrombosis. The general internist should be competent in the following: (1) the detection of abnormal physical, laboratory, and radiologic findings relating to the lymphohematopoietic system; (2) the assessment of the need for bone marrow aspirate and biopsy or lymph node biopsy; (3) the initial diagnostic evaluation and management of the hemostatic and clotting system; (4) the assessment of the indications and procedure for transfusion of blood and its separate components; (5) the management of therapeutic and prophylactic anticoagulation; (6) the diagnosis and management of the common anemias; (7) the pharmacology and use of common chemotherapies; and (8) the management of neutropenia/immunosuppression. CURRICULUM During their month on the outpatient Hematology/Oncology service, the medical housestaff will be expected to attend specific weekly lectures within our Division. Please see the attached schedule for and description of these lectures. The cornerstone of patient care in Hematology/Oncology is outpatient care, and the medical housestaff will rotate in clinics of several different faculty members, based in part upon the housestaff interest. The clinics are located in the Lombardi Cancer Center, first floor, and generally occur from 9 AM to 4:30 PM. The housestaff will interview and examine patients, and present their findings to the faculty, and participate in the decision-making and management processes in these patients. The goals of the Hematology/Oncology month should be achieved through the following learning venues and will be evaluated as per the following chart: 1
  2. 2. Competency-based Goals and Objectives Hematology/Oncology Elective Rotation Learning Venues Evaluation Methods 1. Direct Patient Care/Consultation A. Attending Evaluation 2. Attending Rounds B. Direct Observation 3. Residency Core Lecture Series C. Fellow Evaluation 4. Self Study 5. Weekly Heme/Onc Clinical Conferences Competency: Patient Care Learning Venues Evaluation Methods Demonstrate the ability to obtain an accurate patient history regarding risks for cancer / prior malignancy / hematologic abnormalities / bleeding disorders / status of disease / prior treatment 1,2,4,5 A,B,C Demonstrate the ability to perform a thorough physical examination on patients with malignancy and/or hematologic disease 1,2 A,B,C Demonstrate ability to generate differential diagnosis, diagnostic strategy, and to define appropriate therapeutic plan and modifications to ongoing therapy in patients with malignancy 1,2,3,4,5 A,B,C Demonstrate the ability to generate differential diagnosis, diagnostic strategy, and to define appropriate therapeutic plan and modifications to ongoing therapy in patients with a hematologic disorder 1,2,3,4,5 A,B,C 2
  3. 3. Competency: Medical Knowledge Demonstrate the ability to recognize an oncologic or hematologic emergency 1,2,3,4,5 A,B,C Articulate the genetic predisposition to, and the pathophysiology, evaluation, and management of common hematologic disorders 1,2,3,4,5 A,B,C Articulate the genetic predisposition to, and the pathophysiology, evaluation, and management of common malignancies 1,2,3,4,5 A,B,C Demonstrate the ability to monitor a patient’s progress and respond to a change in the patient’s condition during treatment for malignancy (chemotherapy) 1,2,4,5 A,B,C Demonstrate the ability to order and interpret the appropriate diagnostic tests and studies for a given patient with hematologic abnormalities (bleeding/clotting disorders) 1,2,3,4,5 A,B,C Demonstrate the ability to order and interpret the appropriate diagnostic tests and studies for a given patient with malignancy 1,2,3,4,5 A,B,C Demonstrate an understanding of pertinent procedures in the work-up and treatment of hematologic/oncologic disease (bone marrow biopsy, lymph node biopsy, etc.), including indications, risks and 1,2,4,5 A,B,C 3
  4. 4. complications of the procedures Competency: Interpersonal and Communication Skills Interact in an effective way with physicians and nurses participating in the care of patients with hematologic/oncologic diseases (including physicians requesting consultation, fellows, attendings, medical students, and infusion unit personnel) 1,2 A,B,C Show understanding of differing patient preferences in diagnostic evaluation and management of malignancy 1,2 A,B,C Demonstrate the ability to maintain accurate medical records 1,2 A,B,C Demonstrate the ability to serve as a patient advocate 1,2 A,B,C Competency: Professionalism Treat team members, primary care-givers, and patients with respect and empathy 1,2 A,B,C Demonstrate understanding of and adherence to a code of medical ethics 1,2 A,B,C Actively participate in consultations and rounds 1,2 A,B,C Attend and participate in all scheduled conferences 3,5 attendance, A 4
  5. 5. Competency: Practice-Based Learning Identify limitations of medical knowledge in evaluation and management of patients with hematologic and oncologic disorders and use medical literature (primary and reference) to address these gaps in medical knowledge 1,2,4,5 A Competency: Systems-Based Practice Understand need for effective communication between multiple caregivers and sites (eg, hematologists, oncologists, primary care physicians, surgeons, radiation oncologists, chemo nurses, social workers, hospitals, in- and out-patient infusion units) in delivering optimal care to heme/onc patients 1,2,3,4 A Understanding of clinical trial design and the statistical methods for evaluating scientific studies, in cooperation with attendings, fellows and research nurses/personnel 1,2,5 A,B,C 5
  6. 6. Hematology-Oncology Conferences The Division of Hematology/Oncology has several weekly conferences focused on both patient care and research interactions. Fellows and residents actively participate in these conferences, which are one of the major activities of the teaching program. The first seven conferences that are listed below are considered to be cornerstones of education, and are mandatory during the rotation. 1. Morning Report: Every Monday morning the entire group of faculty, fellows and residents on service attend a 40 minute case presentation or literature review provided by one of the fellows. The last 15 minutes are for Board Review of multiple choice questions. 2. Hematologic Oncology Pathology Conference: The Hematologic Oncology faculty and the Hematopathology faculty gather once a week, on Tuesday morning, to review the status of complex patients including their pathology, treatment plans and entry to research studies. Pathologists, fellows and residents attend. 3. Breast Cancer Conference: The Multidisciplinary Breast Cancer Conference follows the weekly Breast Clinic, on Tuesdays. The Breast Cancer Conference focuses on patient management issues and includes discussion of relevant literature and ongoing research. The conference is attended by representatives from medical oncology, radiation medicine, radiology (mammography), surgery, pathology, and psychiatry. Patient presentations and literature review are done by fellows. 4. Gastrointestinal Oncology Conference: This is a weekly conference on Monday afternoon, conducted with members of the Departments of Hematology/Oncology, Radiology, Radiation Oncology, Surgery, Pathology, and Gastroenterology to review management of patients who are receiving their therapy at Georgetown. 5. Pathology Conference: The Department of Pathology conducts a weekly slide review for the division, on Friday morning. This conference is also attended by faculty from the Department of Radiation Medicine. The conference is designed to familiarize fellows and residents with histologic patterns typical of malignant diseases and to prepare fellows for the pathology section of the board examination in medical oncology. 6. Thoracic Oncology Conference: Every Wednesday morning, the Divisions of Pulmonary Medicine, Radiation Oncology, Thoracic Surgery, and Hematology/Oncology meet to discuss management issues of patients of common interest. This is a conference that reviews many of the patients with lung cancer. It is also a forum for discussion of the management of metastases to the lungs and pleura. 7. Core Lecture Series: Every Tuesday morning, faculty members deliver lectures in the core lecture series about key topics in Hematology and Oncology, regarding both patient care, and pathophysiology, and the conduct of research.; 8. Cancer Center Research Conference: On Wednesday afternoon, the Cancer Center sponsors a weekly research seminar usually given by a speaker from another institution on a topic relevant to research at the cancer center. 6
  7. 7. 9. Brain Tumor Conference: A biweekly multidisciplinary brain tumor conference held Friday and attended by members of Medical Oncology, Neurosurgery, Radiation Oncology and Radiology departments. 10. Head and Neck Tumor Conference: This is a weekly, multidisciplinary conference on Thursday mornings that is attended by members of the departments of Otolaryngology/Head and Neck Surgery, Radiation Oncology, Radiology, and Medical Oncology, to discuss and review the management of mutual patients, and review recent advances in the field. 11. Urologic Tumor Conference: This is a weekly, multidisciplinary conference on Tuesday afternoons that is attended by members of the departments of Urology, Radiation Oncology, and Medical Oncology, to discuss and review the management of mutual patients, and review recent advances in the field. Progressive Responsibilities: As this is the initial, and usually only outpatient exposure to hematology/medical oncology for the residents, it is difficult to expect significant differences in knowledge level among the different levels of residents. However, based on some inpatient experiences, we would hope for some differentiation on their knowledge bases. PGY-1 Residents: Interns should be experts in gathering information about the patients assigned to them and reporting it to the team. They should demonstrate competence in interpreting basic labs (urinalysis, cultures, complete blood counts, etc) and radiology (chest X-ray, etc). They should have knowledge of malignant disease processes and tests, such as staging and prognosis. They would understand initial management of benign and malignant hematologic and oncologic processes. PGY-2 Residents: Second year residents should be proficient in all the responsibilities listed above for interns. Additionally, they should be experts in interpreting basic labs and radiology. They should demonstrate an in depth understanding of both the initial and ongoing management of benign and malignant hematologic and oncologic diseases, and in particular management of the toxicities of treatments for those processes. PGY-3 Residents: Third year residents should be proficient in all the responsibilities listed above for second year residents. In addition, they should have a greater knowledge of screening and prevention of malignant disease processes, and the genetic processes that may predisponse patients to hematologic and malignant diseases. 7
  8. 8. References: Medical Oncology: DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 8th Edition, 2008. DeVita VT Jr, Lawrence TS, Rosenberg SA et al. Lippincott Williams Wilkins. Abeloff’s Clincal Oncology. 4th Edition, 2008. Abeloff M; Armitage J; Niederhuber J, et al. Churchill Livingstone. National Comprehensive Cancer Center Network (NCCN) guidelines, on www.nccn.org Hematology: Hematology: Basic Principles and Practice. 4th Edition, 2008. Hoffman R; Hoffbrand AV; Furie B, et al. Churchill Livingstone. Wintrobe’s Clinical Hematology. 12th Edition, 2008. Greer JP, Foerrster; Rodgers G, et al. Lippincott Williams Wilkins William’s Hematology. 7th Edition, 2005. Lichtman M; Beutler E; Kaushansky K, et al. McGraw Hill. 8

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