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Hematopathology Fellowship

This program in hematopathology is intended to provide advanced post-graduate training in diseases affecting the hematopoietic system and includes instruction in lymph node, spleen, blood, body fluid and bone marrow pathology. Under direct staff supervision, the educational goals and objectives for this program are improved proficiency in the examination and interpretation of body fluid, spleen, lymph node, blood and bone marrow cytology, histopathology, cytochemistry, and immunohistochemistry. In addition, the program integrates necessary supporting data from the Immunophenotyping and Flow Cytometry, Cytogenetics, Molecular Diagnostics, and Coagulation Laboratories. The fellow is also responsible for reviewing tissue and other surgical and cytologic pathology specimens that might include an evaluation for or exclusion of a hematopoietic malignancy.

The one-year program consists of six months of blood, body fluid, lymph node, hematopoietic surgical pathology and bone marrow pathology and six months of elective rotations in research, molecular diagnostics, cytogenetics, coagulation, and/or immunopathology. The trainee is responsible for the day-to-day management of the bone marrow laboratory, including supervision of residents and medical students. The trainee is on-call to examine surgical pathology specimens that might require evaluation for hematopoietic pathology. The trainee also serves as a consultant to the routine acute-care hematology laboratory.

For exceptional academically oriented trainees, a potential two-year program may be arranged, which consists of the above rotations with an increased emphasis on lymph node or bone marrow pathology or hematopathology related research project.

Teaching Faculty:

Curriculum

Requirements

In addition to the general Program requirements, three years of approved straight CP or four years of approved combined AP/CP residency training is required at the time of matriculation, including experience in diagnostic bone marrow and lymph node pathology.

Lymph Node Rotation

Lymph Node Biopsies (Ten 4-week rotations integrated with bone marrow, coagulation, molecular pathology and research)

Goals and Objectives.

Throughout the duration of the fellowship the fellow participates in reviewing lymph nodes and other surgical specimens with the possibility of extranodal lymphoma or other hematopathology under the supervision of the surgical pathology or hematopathology staff assigned for lymph node teaching. The fellow independently reviews the histopathology and integrates the immunohistochemistry to generate a surgical pathology report. The fellow and the staff then review the cases together at a multi-headed microscope. The fellows are responsible for integrating data from special laboratories such as flow cytometry, molecular diagnostics and cytogenetics and for the communication of difficult diagnoses to the clinicians and for presentation of interesting cases at the hematology malignancy conference.

What are the responsibilities of the fellow on the lymph node service?
It is the fellow's responsibility to review lymph node biopsies and surgical specimens with possible extranodal lymphomas or other hematopathology seen in surgical pathology, to integrate immunohistochemical, flow cytometric, molecular diagnostic and cytogenetic information and to generate a comprehensive report. Further he /she reviews these cases with designated attending staff. The fellow is responsible for presenting cases to the clinicians at the biweekly Hematology-Malignancy conference. The fellow is also responsible for presentation of cases at the biweekly Cytogenetics/Molecular Diagnostics correlation conference. The fellows may select a theme for this conference and identify historical cases and review the relevant literature.

What are the responsibilities of the attendings on the lymph node service?
The attendings supervise interpretation of lymph node biopsies and the integration of data from special studies. They provide didactic teaching (lectures and unknown conferences) and one-on-one teaching at sign out and at review of outside consult cases.

The attending staff oversees the preparation and presentation of materials at Hematology Malignancy conference, cases of the week and Grand Rounds.

Cytochemistry, Immunochemistry, Flow Cytometry, Molecular Biology

Goals and Objectives.

Cytochemistry: There is no separate rotation for cytochemistry. Interpretation of cytochemical stains such as Chloracetate esterase, leukocyte alkaline phosphatase, terminal deoxynucleotidase, myeloperoxidase, Sudan black, non specific esterase, tartrate resistant acid phosphatase and hemoglobin acid elution are integrated into the bone marrow service.

General Hematology-Bone Marrow Service

Goals and Objectives.

The fellow provides medical consultation to the hematology laboratory during the months that he/she is on the bone marrow service. All blood and body fluid specimens from the hematology laboratory that require review by a hematopathologist are first examined by the trainee, whose interpretations are then reviewed with a hematopathology attending physician when appropriate.

During the first month of the fellowship the trainee is provided with an orientation to the electronic cell counters, coagulation instruments and laboratory computers by the general hematology laboratory supervisor.

Trainees use computer systems to assist them in tracking their assigned cases. Trainees use computer databases in anatomic pathology to get lists of their pending cases or newly assigned cases. Through these databases, they use word processing software to edit and complete their provisional drafts of surgical pathology, blood smear and bone marrow biopsy reports. They can also use these databases to look up historical results on patients and identify cases with a similar theme for group study. These systems are also used for billing and CPT coding functions. Trainees use laboratory information systems to track specimens and record test results in both a manual and automated manner. They use the computers to assist in data interpretation of testing such as the lupus inhibitor panel. They also use patient care networks to look up results on patients, along with clinical dictations, radiology results, and operative reports. They can also use these databases to look up historical results on patients and identify cases with a similar theme for group study.

Trainees attend quality assurance/control conferences for their assigned clinical services.

Trainees are asked to prepare data for these conferences on issues such as turn-around times, testing parameters and correlation studies and, clinical utilization of various tests.

Immunohistochemistry

Goals and Objectives.

The trainee has the responsibility for QA/QC evaluation of all of the pathologist-ordered immunohistochemical stains, under faculty supervision and prior to the distribution of the slides to the ordering pathologist. The trainee also has the following responsibilities:

  1. Participation in daily laboratory QA/QC, including slide checks, dilution checks, paraffin block checks with documentation of appropriate QA/QC parameters;
  2. Participation in the evaluation of a new antibody including literature review, selection of vendor, appropriate antibody pretreatment with enzyme digestion or antigen retrieval, selection of antibody titer and incubation time and evaluation of reactivity of antibody with a variety of tumors;
  3. Development of a selective "sausage tissue control block".
  4. Researching and presenting a didactic lecture on an antibody of his/her choice.

Flow Cytometry/Immunology/Serology (Integrated with blood, bone marrow and lymph node pathology service)

Goals and Objectives.

Trainees begin by reviewing laboratory instrumentation and techniques with the laboratory technologists. They also analyze a large number of historical teaching cases on a mock flow cytometer and then discuss them with the staff pathologist. After the first week, the trainees become increasingly involved in reviewing current cases in the laboratory and prepare the original draft of the immunophenotyping report, under the supervision of the attending staff.

The trainee is expected to obtain the relevant clinical history and correlating pathology on the cases they review with the attending staff. This involves discussions with the patient care teams and other pathology laboratories, including special hematology, molecular diagnostics, cytogenetics, and surgical pathology. The trainees perform, under the guidance of the laboratory staff, the preparation and testing of a flow cytometry specimen and observe the testing of the other specimens. They participate in the generation of the three reports listed above.

The trainee is expected to answer queries with regard to appropriate testing and patient results. These interactions may include physicians from Medicine Clinic, Hematology/Oncology, HIV Clinic, Bone Marrow and Solid Organ Transplant Services, and others. The trainee is also expected to be able to discuss results with trainees, fellows and staff from the other Special Diagnostics Laboratories.

Molecular Pathology (integrated in Molecular Diagnostics and Cytogenetics-8 weeks)

Goals and Objectives.

Trainees review and assist in the interpretation and preparation of reports on the above list of tests performed in the molecular laboratory. The trainees participate in daily sign-out rounds of current cases in the Molecular Diagnostics Laboratory, T and B cell gene rearrangements, molecular detection of bcr-abl, PML-RAR-a and other leukemia-lymphoma specific translocations, HPV and bone marrow transplant engraftment studies, inherited disorders including Prothrombin G20210A. Each trainee will have a case log of approximately 300-400 cases during their molecular genetics rotation.

Trainees are responsible for gathering clinical data from the patient's clinical team and referring institutions, along with other laboratory data and findings. This information is then correlated with the molecular test results to prepare a clinically meaningful interpretation. The trainees also participate/present in the cytogenetics lecture series and the weekly molecular diagnostics journal club.

At the beginning of the rotation, trainees work closely with the teaching staff in interpreting lab test results, correlating them with relevant patient data, and preparing the molecular reports. With more experience, the trainee is given more responsibility for interpreting cases, reviewing the current literature, and preparing the draft reports with a clinical correlation section that considers the clinical history, tissue pathology diagnoses, and current literature. These draft reports are then edited by the molecular laboratory director and discussed with the trainee.

Coagulation (4 weeks)

Goals and Objectives.

At the start of the rotation, the laboratory director shows the trainee how a particular interpretation is done. On the second day, the trainee is expected to do at least some of the interpretations before reviewing the day's cases with the staff. By the end of the first week, the trainee should be able to provisionally interpret all of the test results before staffing them. As the rotation progresses, the trainee should become faster and more proficient in their interpretations. By the end of the rotation, the trainee should be able to do interpretations quickly and with minimal or no editing of their reports by the attending staff.

Trainees generate reports on von Willebrand antigen (VWag) crossed immunoelectrophoresis (CIEP) that include comments on quantitative Factor 8, VWag Ristocetin cofactor (RCF), the probable diagnosis, and recommendations for further testing, if any. Trainees also interpret and generate reports on lupus inhibitor tests and correlate these results with other test results when appropriate. Bethesda assay inhibitor tests, Protein S and Protein C assays, and panels of hypercoagulability tests on individual patients are correlated and interpreted by the trainees. Trainees enter their interpretations into a computer database and then review their interpretations with the coagulation staff before the tests are verified and signed.

Trainees are required to perform, under supervision of the laboratory technologists, common coagulation laboratory tests and to observe some of the more esoteric tests.

Although interviewing patients is not a mandatory part of the rotation, trainees can electively interview patients seen in the hematology thrombosis and hemophilia clinic under the supervision of the attending clinical hematologist.

Hematology

Goals and Objectives.

The fellows are involved in the review of peripheral blood smears of patients with inherited and acquired red cell disorders and in the recommendation of red cell enzyme assays, hemoglobin electrophoresis and other specialized assays and tests including Heinz body preparations, reticulocyte stains and Kleihauer Betke test.

Although the fellows do not interpret Hemoglobin electrophoresis, a comprehensive teaching set is available for self study.

The fellows review peripheral blood smears of patients with the clinical possibility of hemolysis and initiate hemolytic work ups where indicated. They are involved in the interpretation of direct and indirect antiglobulin tests and antibody panels where indicated.

Cytogenetics (integrated in Molecular Diagnostics and Cytogenetics-8 weeks)

Goals and Objectives.

The trainees work closely with the cytogenetics staff to obtain the appropriate clinical and pathologic data on their cases. Trainees are asked to obtain information from the patient's chart, Special Hematology, Immunophenotyping, Molecular Diagnostics and Surgical Pathology Laboratories that may be related to the chromosome findings in each specific case and asked to correlate the findings. In addition, correlation with the medical literature via a literature search is required. The trainees are involved with these activities and the development of the provisional interpretation. The trainee then meets daily with the cytogenetics medical director, during which time background theory and principles are discussed for each individual case and the final report edited.

Trainees also observe tissue culture, banding, special staining and FISH techniques. Trainees also participate in the clinical pathology conference where they prepare a talk on a cytogenetics topic or interesting case from the laboratory that includes a review of the relevant medical literature. Trainees are also required to prepare a similar presentation for the cytogenetics laboratory technicians. Trainees also attend a multi-disciplinary patient care conference and participate in selected lectures in genetics given to the graduate students in the genetics program.

Laboratory Management/Administration

Trainee education in laboratory management and laboratory information systems is on-going throughout the program. This section of a trainee's education is divided between formal didactic teaching and experiences on the individual rotations. Trainees receive didactic teaching through both a course put on three times a year by the Dean's Office for all trainees on global management and financial issues related to the practice of medicine. The Program also has a specific course that cycles every two years on management and health informatics/laboratory information systems. This course meets twice monthly, first for a didactic conference and then later in the month they review a problem set that is distributed via the medical school website.

Trainees are educated in the cost-effective use of the laboratory on each of their service rotations as they complete their cases and decide what additional testing or clinical recommendations are needed. Trainees discuss the rationale for their testing plans and additional recommendations with the members of the clinical teams. Trainees are expected to not only provide the clinical physicians with a diagnosis but also to be able to provide them with the rationale for why additional testing was performed/recommended and how it facilitates patient care in a cost-effective manner.

Trainees are instructed in personnel, budget, and regulatory agencies through both the Dean's Office and the Department's lecture series (see above). As opportunity presents, trainees participate in laboratory inspections, both internal and externally. Trainees are annually instructed in laboratory safety through a required course put on by the Dean's Office and one given by the University's Department of Environmental Health and Safety. These conferences include chemical risk, infectious risks, and blood and body fluid precautions.

The person responsible for ensuring that all trainees participate in laboratory management and administration is the educational program director for the Department of Laboratory Medicine.

Educational

Trainee teaches and monitors the proficient procurement of bone marrow aspirates and trephine biopsies by pathology trainees, post-sophomore fellows, and hematology/oncology/transplantation fellows when they first begin their rotation in hematopathology. During the course of the rotation, trainee also reviews cases with these individuals and teaches them ways to evaluate the specimens in order to arrive at the appropriate diagnosis. Such teaching opportunities are an integral part of trainee's "sign-out" activities.

Trainees also participate as laboratory/small group instructors for the "Blood" section of the Systemic Pathology course (second-year medical students).

Educational Information

Block diagram and concise description of the rotations/assignments for the fellows:

First Year in Program *

Conferences, seminars, and journal clubs in which the fellows participate:

Name of Conference Frequency Department Responsible
Hematology Conference Weekly Unknown slide conference Hematopathology
Clinical Pathology Conference Weekly Laboratory Medicine
Hematologic Malignancy Conference Bi-weekly Hematopathology; Clinical Hematology/Oncology
Laboratory Medicine and Pathology Grand Rounds Weekly (Sept-June) Laboratory Medicine
Resident Lecture Series Weekly Laboratory Medicine
Cytogenetics/Molecular Diagnostics Correlation Conference Bi-weekly Hematopathology; Cytogenetics; Molecular Diagnostics
Didactic Hematopathology Lectures Weekly Hematopathology

Fellow participation in these conferences:

Trainee is required to attend all "unknown slides" conferences (except when away for vacation or other previously arranged time off), at which he/she is called upon to discuss and defend his/her differential diagnoses. These conferences are planned and run by a hematopathology-attending physician. In addition, trainee is also invited to contribute interesting blood, marrow, and/or body fluid specimens and be in charge of at least part of the "unknown slides" conferences.

Trainee is required to attend all didactic hematopathology lectures, except when away for vacation or other previously arranged time off.

For the interdisciplinary Hematologic Malignancies Conference and the Cytogenetic/Molecular Diagnostics Correlation Conference, trainee reviews the relevant pathologic specimens, discusses the cases with the hematopathology-attending physician, reviews the pertinent literature and presents the cases at the conference. He/she also actively contributes to the discussion during the course of the conference.

Trainees also attend and present at the department's Grand Rounds and the Clinical Pathology Conferences.

Throughout the program, the trainee is responsible for direct communications with the clinical services to discuss the diagnostic laboratory results and to participate in patient management, thus fulfilling his/her role as a laboratory consultant. To foster trainee's sense of independence while assuring appropriate supervision it is required that trainee review with the attending hematopathologist(s) his/her interpretations before communicating with the clinical services, or to request that additional discussion with the attending hematopathologist(s) be sought for follow-up.

For the interdisciplinary Hematologic Malignancies Conference, the trainee is the primary liaison between the clinical physicians and the hematopathology attending physician for selection of the patient cases for review. The trainee prepares and presents the cases at the conference. He/she also actively contributes to the discussion during the course of the conference.

Trainee performance is evaluated and the trainee evaluates the program as follows:

Using the E*Value electronic evaluation form, trainees are evaluated on their knowledge, skills and professional growth at the end of each rotation (every one - three months). Written evaluations are also obtained/prepared after rotations outside of the program's affiliated institutions and elective trainee-tailored specialty rotations. The trainees are provided with continuous feedback on their performance during each rotation. In general, only deficiencies are noted in writing and a midpoint written evaluation is only done on a rotation in which a trainee is performing sub optimally. During the last days of each rotation, the coordinating teaching faculty member personally discusses their written evaluation with the trainee. Trainees are evaluated on their performance and attainment of the rotation's goals and objectives, demonstrated ability to provide informative consultation to the clinical service teams, their medical knowledge, their application of this knowledge to efficient/quality patient care, their technical and observational skills, the effectiveness of their teaching skills, and their attendance and participation in conferences. Trainees are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their appropriate use of initiative in fostering quality patient care and use of the medical literature. Their timely completion of assigned interpretive reports is another component of the evaluation. Trainees on probation receive a written mid-rotation evaluation. In addition to the E*Value form, the trainees are asked to distribute twelve "360 degree" evaluation forms during the fellowship period to either laboratory technologists, laboratory technicians, residents, medical students, clinical attending staff, clerical staff, nursing staff or patients that they have had direct contact with. Each of these categories must be represented at least once during the training period. The 360 degree evaluations are returned to the Pathology Residency Program office and place in the trainee's file. The 360 degree evaluation is recommended by the Accreditation Council for Graduate Medical Education (www.acgme.org) as one of the instruments for evaluating core competencies.

Trainee evaluations are immediately and continuously available to them via the on-line E*Value system at all times. If an evaluation cannot be personally discussed with the trainee due to unavoidable time conflicts at the end of a rotation, a copy of the evaluation is sent to the trainee for their review. Trainees acknowledge that their evaluation was discussed with them on their E*Value evaluation of the rotation. At minimum, the Program Director in Hematopathology meets with the trainee at the end of the bone marrow block to discuss issues that they may have or anticipate with their training and/or the overall Program. In order to facilitate improvements in the quality of our training programs, the Program also requires the trainee to regularly complete confidential surveys on the Program, its teaching faculty, and its individual rotations. The Program assures trainees of an educational environment in which they may raise and resolve issues without fear of intimidation or retaliation.

A permanent individual training file is maintained in the Department's GME office on each trainee. This file contains their application to the Program, human resource/contract/payroll documents, written evaluations, resume, vacation/leave forms, and copies of all Program correspondence and copies of case or conference presentations given by the trainee during the fellowship. In order to preserve the integrity of the training files, a trainee or authorized faculty member can review their training file by making an appointment with the Program Director or Program Coordinator in the Director's absence.

At the end of a trainee's program, the Program Director meets with the graduating trainee to discuss their overall program performance, especially focusing on the final aspects of their training. The Director issues each graduating trainee an overall written summary that indicates that the trainee has the skills necessary to practice competently and independently in the area of hematopathology and demonstrates professional and personal attributes dedicated to the life long learning associated with the practice of medicine. A copy of this final evaluation is maintained in the trainee's permanent file.

How do fellows participate in the evaluation of the training program (facilities, teaching staff, organizational structure, etc.)? Are written evaluations of the program by the fellows reviewed and comments/suggestions acted upon by the department? (Please attach copy of evaluation form, if appropriate.)

Rotations and Teaching Faculty Evaluation - Trainees are required to regularly complete electronic E*Value evaluations of their individual rotations and teaching faculty experiences, which reflects upon the rotation's effectiveness in meeting the written curriculum guidelines and facilitating their attainment of the educational goals and objectives. The E*Value system ensures that all trainees participate in the evaluation process and their anonymity.

Trainees complete a survey that reflects upon their past year of training and limit responses to rotations personally completed within the year. When completing the survey, trainees are asked to keep the following in mind:

  1. The purpose of graduate medical education is to provide an organized educational program with faculty guidance and supervision of trainees that facilitates the trainee's professional development, while ensuring safe and appropriate care for patients.
  2. Trainees are to be incorporated into an educational environment that is scholarly, committed to excellence in education and medical care, and fosters ethical professional development.
  3. Trainees are first and foremost students, rather than employees, and all Program activities must reflect this distinction. Trainees are to be protected, as students, with respect to their educational environment and the clinical settings in which they learn.
  4. Trainees are to be assured of an educational environment in which they may raise and resolve issues without fear of intimidation or retaliation.
  5. Trainees are required to complete for Program review confidential written evaluations of the Program's educational content and the teaching staff.

Periodically, discussions are held among the hematopathology attending physicians and also with the laboratory technical support staff to assess the following: proficiency of trainees with the marrow aspiration and biopsy procedure, appropriateness and effectiveness in interactions with patients and clinical colleagues, degree of preparedness at the "unknown slides" conferences and didactic lectures, accuracy and efficiency at sign-out responsibilities quality of judgment and problem solving abilities with call responsibilities. From these discussions, "gaps" in trainees' knowledge as well as gaps in the breadth and depth of educational activities and supervision are identified for correction. For example, based on these discussions lectures on hematology laboratory instrumentation and on anemia work-up have been added to the core curriculum.

Library Facilities:

The University has a major academic library on the same campus as University of Minnesota Medical Center, Fairview, which is open from 7 a.m. to midnight Monday-Saturday and noon to midnight on Sunday. This library provides trainees with librarians who assist in performing literature searches and in obtaining journal articles and other materials not found in their holdings. A reference book collection, teaching glass and 35mm slide sets, and CD ROMs are available within the trainee office area. Trainees may also borrow books from faculty members.

Research:

The fellows are encouraged to work on clinical research project with a view to present the data at a National meeting. Travel expenses are covered for trainees who are presenting a research paper or an abstract at a national meeting. Fellows are given academic leave to attend local meetings such as the Minnesota Society of Pathologists and the Bell symposium.

Computers and Informatics:

On each rotation, trainees are instructed in the use of computer information systems that track specimens, provide results, and assist in quality assurance. Trainees are also instructed in and frequently perform on-line literature searches. In addition to textbook reading, trainees are expected to locate recent articles and reviews on their assigned cases.

Daily, trainees use computer systems to assist them in tracking their assigned cases. Trainees use computer databases in anatomic pathology to get lists of their pending cases or newly assigned cases.

Through these databases, they use word processing software to edit and complete their provisional drafts of surgical and autopsy reports. In cytology, they use computer systems that facilitate report generation through the use of standardized/coded text comments. They can also use these databases to look up historical results on patients and identify cases with a similar theme for group study. These systems are also used for billing and CPT coding functions. On clinical services, trainees use laboratory information systems to track specimens and record test results in both a manual and automated manner. They use the computers to assist in data interpretation of testing such as the lupus inhibitor panel. They also use patient care networks to look up results on patients, along with clinical dictations, radiology results, and operative reports. They can also use these databases to look up historical results on patients and identify cases with a similar them for group study.