Hematopathology Clinical Fellowship Program

General Description of the Hematopathology Educational Experience

The hematopathology fellowship at UPMC Presbyterian is a broad-based experience in all aspects of both clinical and anatomic hematopathology. The program stresses a multiparameter approach to both bone marrow and solid tissue diagnostic hematopathology combining standard morphologic techniques with data obtained from ancillary immunohistologic, in situ hybridization, flow cytometric, molecular and cytogenetic investigations. Bone marrow sign out includes review of peripheral blood and marrow aspirate smears, marrow histologic preparations and other ancillary studies.

The fellowship includes educational experiences in the following specific areas: adult bone marrow sign out, adult clinical bone marrow procedures, lymph node (and related tissue) pathology, flow cytometry, pediatric hematopathology, molecular diagnostics, cytogenetics, laboratory hematology, coagulation, histology and immunohistochemistry, and laboratory management and decision making. The precise duration of each rotation is flexible. Laboratory management and decision making is primarily a component of the laboratory-based rotations.

After the first six months, fellows also participate in the on-call schedule (with faculty back-up). The fellow is expected to actively participate in a variety of hematopathology teaching conferences. The fellow is also expected to participate in the informal and more formal teaching of medical students, pathology and non-pathology residents, hematology/oncology fellows, and medical technologists. He/she will also interact with hematologists, oncologists, and other interested clinicians. Fellows are expected to undertake at least one investigational project and are strongly encouraged to present at national meetings. The nature of the project will depend on the fellow's interest, the amount of time they wish to devote to it and whether they intend to spend one or two years in the division. Fellows are expected to perform marrow aspirates and biopsies in the Internal Medicine Hematology Section.

Conferences include a hematopathology conference (weekly), a Patient Safety and Risk Management conference that alternates with a Journal Club (weekly), a Molecular Diagnostics conference (weekly), a pediatric hematopathology slide conference (approximately 3 weeks per month), a Pediatric Leukemia Tumor Board (monthly), a Leukemia/Lymphoma Tumor Board (bimonthly) and other departmental AP or CP oriented conferences. Fellows will also take advantage of multiple interactive electronic, web-based resources to access information, including laboratory information systems, on-line radiology image resources, and literature searches.

A fellows' Interdisciplinary Conference covers a variety of important topics that are generally scheduled to be presented every two years. However, website access to this series of presentations is available at the following website: http://www.omed.pitt.edu/, Click on "Video Gallery." The topics for Fellows' Interdisciplinary Conference and Checklist can be found in the "Checklist" section of this handbook.

Levels of responsibility (see chart that follows): Because fellows will come to the program with a variable level of experience and because those from outside UPMC will not be familiar with many logistical aspects of our practice, it is expected that fellows will progress through the graded responsibility described for resident trainees, but at a more rapid pace, and progress to a level as indicated in the chart that exceeds that of a senior resident. Fellows may strive to progress to the level expected for those who spend a second year following their fellowship in our division ("second year fellows"). Additional information about the second year fellowship and related instructor experience may be also obtained from the description of the Hematopathology Specialized Instructional Educational Program (Hematopathology SIEP).

The following 6 sections describe the general goals and objectives for the overall fellowship program in relation to the six core competencies as defined by the American Council on Graduate Medical Education (ACGME). Goals and expectations that would be specific to individual rotations are further described in the rotation specific descriptions that follow this section.

Patient Care

Goal
Fellows must develop diagnostic competence to provide for effective patient care.

Competencies (See also specific rotation descriptions.)

  1. Demonstrate diagnostic decision-making skills appropriate to his/her level of training.
  2. Manage appropriate laboratory staff.
  3. Demonstrate ability to triage testing as to importance or urgency in a cost-effective and appropriately time-sensitive manner.

Objectives (See also specific rotation descriptions.)

  1. Construct appropriate written reports in language that other physicians, especially surgeons and oncologists, will understand.
  2. Demonstrate ability to order appropriate ancillary testing through ancillary laboratories and hematopathology staff.
  3. Order testing on a STAT basis when appropriate for patient care and/or limit testing to those studies needed to make the most specific diagnosis by current guidelines.

Medical Knowledge

Goal
Fellows must demonstrate knowledge of established and evolving aspects of hematopathology diagnostic testing and state of the art hematopathology diagnosis and classification.

Competencies (See also specific rotation descriptions.)

  1. Demonstrate knowledge of the normal hematopoietic and lymphoid systems.
  2. Demonstrate knowledge of both neoplastic and non-neoplastic disease entities that predominantly affect the hematopoietic/lymphoid systems.
  3. Demonstrate an ability to apply this knowledge in varied clinical settings.

Objectives (See also specific rotation descriptions.)

  1. Obtain an acceptable score on written practical examinations, including those administered within the division (with score of competent) and the ASCP Fellow In-service examination (score above the 25th percentile).
  2. Demonstrate an acceptable level of performance during daily sign-out activities, as assessed by rotation specific evaluations and more broadly within the 360-degree evaluations.
  3. Demonstrate ability to decide what type of testing is needed to limit the differential diagnoses in most cases.

Practice- Based Learning and Improvement

Goal
Fellows must be able to evaluate and adopt new knowledge as changes demand. This includes the development or refinement of skills that will be used long after fellowship training has ceased.

Competencies

  • Identify strengths, deficiencies and limits in one's knowledge and expertise.
  • Systematically analyze practice, using quality improvement methods, and implement changes with the goal of practice improvement
  • Locate, appraise and assimilate evidence from scientific studies related to hematopathology.
  • Use information technology to optimize learning
  • Participate in the education of medical students, residents and other healthcare professionals, as documented by evaluations of a fellow's teaching abilities by faculty and/or learners.

Objectives

  1. Demonstrate ability to search the medical literature to answer medically related questions that arise in daily practice.
  2. Appropriately utilize available texts and self-learning resources, such as study sets, etc.
  3. Construct and complete a quality improvement project with appropriate guidance.
  4. Demonstrate ability to critically evaluate original publications at journal clubs, other conferences, and in the evaluation of diagnostic cases.
  5. Demonstrate progression in skill level, as assessed on bi-annual review with fellowship director
  6. Demonstrate effective and knowledgeable case presentation(s) at divisional conferences.
  7. Demonstrate ability to perform appropriate biomedical literature searches through available electronic tools (example: Pub Med search).
  8. Demonstrate ability to teach residents, students, and fellows from other departments while on-service.
Systems Based Practice

Goal
Fellows must demonstrate an awareness of and responsiveness to the various regulatory bodies (including institution based policies, local and national regulatory agencies) that affect daily practice and laboratory management.

Competencies

  • Incorporate considerations of cost awareness and risk-benefit analysis in diagnostic evaluations.
  • Understand the various administrative and technical functions involved in running a hematopathology division or hematology-oriented laboratory.
  • Understand the need for quality assurance assessments.
  • Participate in laboratory management as appropriate on laboratory based rotations.
  • Know the role of regulatory agencies that affect the practice of hematopathology.

Objectives

  1. Participate in mock or internal College of American Pathologists (CAP) inspections when possible.
  2. Attend rotation specific laboratory management meetings.
  3. Demonstrate ability to choose appropriate immunohistochemistry panels, in situ hybridization studies, and molecular testing appropriate to making a specific diagnosis.
  4. Participate in appropriate faculty-supervised quality improvement projects.
  5. Review the roles of various regulatory organizations (CAP, state, and federal, such as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO) that are involved in regulating laboratory practice and how they can impact laboratory hematology.

Professionalism

Goal
Professional behavior in one of the most basic requirements of any physician, including hematopathologists. This includes demonstrating reliability, punctuality, appropriate demeanor, appearance, completion of work assignments, and ethical behavior.

Competencies

  • Compassion, integrity, and respect for others.
  • Responsiveness to patient needs that supersedes self-interest.
  • Respect for patient privacy.
  • Communicate effectively with hematology-oncology, other physicians and other healthcare professionals.
  • Work effectively as a member of a health care team.
  • Act in a consultative role to other physicians and healthcare professionals.
  • Function as a team player.

Objectives

  1. Obtain at least satisfactory evaluations of interactions with physician colleagues, attending staff, support personnel, as evidenced by the 360-degree and other evaluations.
  2. Schedule outside activities so as not to interfere with work-related activities, such as on-call responsibilities and service commitments.
  3. Demonstrate an understanding and working knowledge of the Health Insurance Portability and Accountability Act (HIPAA) and sensitivity to protecting the disclosure of patient specific information by completing HIPAA on-line training modules.

Interpersonal and Communication Skills

Goal
Fellows should be able to communicate with a variety of medical center faculty, trainees, and staff. These functions are critical to being a successful hematopathologist. This must also be done with a working knowledge of patient privacy rights.

Competencies

  1. Demonstrate mutual respect for others in communicating with faculty, other trainees, and support personnel.
  2. Convey diagnoses and available diagnostic testing results to other physicians and appropriate support personnel in an accurate manner that reflects the limitations of the currently available findings.

Objectives

  1. Demonstrate ability to convey preliminary diagnoses in verbal and written form that includes appropriate limitations, such as differential diagnoses still to be considered, other information still needed (and/or pending).
  2. Be able to communicate information verbally and in writing in a format and style that is appropriate for the level of the practitioner or support personnel with whom one is interacting.
  3. Accurately convey final diagnoses both orally and in writing to the submitting physician and other appropriate personnel (hematology-oncology fellows, nurse practitioners).
  4. Discuss possible treatment implications of diagnoses with hematology-oncology professionals and other appropriate physicians.
  5. Write complete reports in a timely fashion. Reports must also be accurate, grammatically correct, and easily understood.
  6. Demonstrate ability to seek consultations from other members of the faculty (usually as directed by the attending) and accurately convey the consulting pathologist's impressions to the primary sign-out attending.

Teaching Methods

  1. One-on-one teaching over the microscope during diagnostic case sign-out.
  2. Observation of laboratory procedures and operations.
  3. Attendance at the following conferences:
    1. Hematopathology Journal Club.
    2. Hematopathology Patient Safety and Risk Management in Hematopathology Conference.
    3. Hematopathology Case Conference.
    4. UPMC Presbyterian/Shadyside Leukemia/Lymphoma Tumor Board
    5. Children's Hospital of Pittsburgh Leukemia Tumor Board.
  4. Attendance at didactic lectures.
  5. Reading of textbooks available in the hematopathology division.
  6. Review of available literature in division, either as hard copies or using electronic resources.
  7. Various teaching and virtual study sets.

Assessment Methods

  1. Rotation specific electronic evaluations by attending faculty (based on direct supervision and observation).
  2. Bi-monthly 360-degree evaluations.
  3. Fellow In-Service examinations (administered on-line by ASCP twice per year).
  4. Written practical examinations administered twice per year within the Division of Hematopathology.
  5. Bi-annual evaluations with fellowship director, followed by a written summary.
  6. Final written letter of competency assessment from fellowship director.
  7. Verbal feedback during daily interactions with attendings and teaching faculty.
  8. ASCP CheckPath Examination (quarterly).
  9. See also specific rotations for any rotation specific assessment methods.

Assessment Method (Program Evaluation)

Fellows have periodic written opportunities to evaluate specific rotations.
Trainees complete written evaluations through an on-line web-based system administered by the departmental graduate medical education office and separately through an on-line web-based system administered by the Division of Hematopathology. Faculty periodically also discuss the fellowship program at divisional staff meetings and at the Division of Hematopathology annual fellowship evaluation meeting.

Level of Supervision

See specific rotation descriptions.

Educational Resources

  1. Textbooks in the Division of Hematopathology.
  2. Teaching sets.
  3. Journals available in the Division of Hematopathology and also in the School of Medicine Health Sciences Library (hardcopy and electronic access).
  4. Other electronic resources, including textbooks, hematopathology-related web-sites, UPMC-created educational and research modules.
  5. See also specific rotation descriptions.