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Rotation Summaries - Clinical Pathology

Hematopathology at Hennepin County Medical Center

This educational experience is designed to provide a broad based experience in hematopathology through exposure to lymph nodes, bone marrow, peripheral blood morphologies, flow cytometry and hemoglobin electrophoreses. The resident is expected to become proficient in performing bone marrow biopsy and aspiration, interpretation of bone marrow aspirate and biopsy material, collection and integration of laboratory data for interpretation of peripheral blood morphologies, interpretation of hemoglobin electrophoreses, interpretation of flow cytometry, and interpretation of various coagulation abnormalities.

Supervisory Guidelines for Patient Care and Specimen Handling

Specimen handling in the laboratories is the direct responsibility of the laboratory technologists. Resident decision making in the laboratory is under the direct supervision of the teaching faculty at their assigned site. The on service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager. No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

For residents who have not performed bone marrows previously, the hematopathology staff will perform the initial bone marrows while instructing the resident during the course of the procedure. During subsequent bone marrow procedures, the resident is expected to learn the technique with the assistance of the teaching faculty. In accordance with HCFA regulations, the teaching staff are present during the critical portions of the bone marrow procedure, during the biopsy and aspiration portions. If the resident is proficient in performing bone marrows, the faculty observes the resident's technique at Hennepin County Medical Center and then allows the resident to proceed with the procedure in a more independent style. The supervising faculty reviews and co-signs all resident procedure notes.

The resident is expected to review bone marrow, peripheral blood and lymph node morphology slides, along with relevant flow cytometry data, formulate an opinion and present that opinion to the assigned staff member in a timely manner. At the initiation of the rotation, the resident and staff should review material prior to the resident entering the case into the computer system. However, as the resident develops proficiency with the material, the expectation is that the resident will enter the case into the computer prior to meeting with staff. The residents will make changes as discussed with staff prior to final review and electronic sign-out by staff.

For coagulation cases, the resident is expected to review clinical data and formulate an opinion regarding the nature of the problem. The problem is then reviewed with staff and the resident is expected to contact the clinical service with appropriate recommendations.

Daily Duties and Responsibilities

  1. The resident is expected to gather clinical information and laboratory data for the morphologies for the day, review slides and then meet formally with staff to discuss the cases. At the initiation of the rotation, the resident should meet with staff prior to entering the case into the computer. As the resident gains familiarity with the material, the resident should formulate an independent interpretation and enter the case into the computer prior to meeting with staff. With peripheral blood morphologies, the resident is encouraged to develop sufficient proficiency so that he/she is able to review and enter the material into the computer without the necessity of formal review with staff. The hematopathology staff then reviews the resident's report, makes changes, and electronically signs-out the case. Staff will notify the resident of major changes and review these changes with the resident. The resident may also review final reports after staff electronic sign-out.
  2. The resident is expected to become proficient in performing bone marrow biopsy and aspiration. In general, bone marrows performed in the clinic are done by hematopathology while those performed in the wards are done by the clinical services. The resident is then expected to perform a differential on bone marrow aspirate material and integrate clinical history/laboratory findings into the assessment of peripheral blood, bone marrow aspirate material and bone marrow biopsy findings to formulate an accurate interpretation of the bone marrow problem being investigated. If ancillary studies, such as immunohistochemistry, flow cytometry, cytogenetic evaluation, or gene rearrangement studies have been pursued, integration of this data into the final assessment is expected. As noted in number 1 (above), the resident should become increasingly independent as the rotation progresses. The final resident report is reviewed by the hematopathology staff, changed if needed, and electronically signed out. Staff will notify the resident of major changes and review these changes with the resident. The resident may also review final reports after staff electronic sign-out.
  3. The resident is expected to review gels for hemoglobin electrophoreses. This is done in tandem with review of the CBC data and a blood smear. As noted in number 1 (above), the resident should become increasingly independent as the rotation progresses. The final resident report is reviewed by the hematopathology staff, changed if needed, and electronically signed out. Staff will notify the resident of major changes and review these changes with the resident. The resident may also review final reports after staff electronic sign-out.
  4. The resident is expected to become proficient in interpreting flow cytometry cases from blood, bone marrow, lymph nodes, as well as other specimens. As noted in number 1 (above), the resident should become increasingly independent as the rotation progresses. The final resident report is reviewed by the hematopathology staff, changed if needed, and electronically signed out. Staff will notify the resident of major changes and review these changes with the resident. The resident may also review final reports after staff electronic sign-out.
  5. The resident is expected to gather clinical information for coagulation abnormalities which are identified by the technical staff. The resident then reviews the clinical information and coagulation abnormality with staff. Subsequent activities may include recommendations for further testing by the technical staff or interaction with the clinical services to correctly define the problem and recommend additional testing.
  6. The resident is expected to perform one 30 minute talk near the end of their rotation for Pathology staff, pathology residents, and relevant technical staff. For this presentation, the resident is expected to choose an interesting hematopathology case, and present the case along with clinical information and review of the literature.
  7. The resident is expected to develop proficiency in reviewing material with the clinical services. This is usually done in the format of slide review at the 10-headed microscope.
  8. The resident is expected to learn appropriate triage of lymph node biopsy material as well as appropriate triage of material for other types of hematologic neoplasms including skin, conjunctival lesions, gut biopsies, mediastinal masses, CNS biopsies, and any other source of material for hematologic neoplasms. The resident should be able to review histologic findings and make appropriate assessments regarding the neoplastic or reactive nature of the material. If ancillary studies are needed, these should be ordered and the results of these studies assessed in final interpretation of the case. As noted in number 1 (above), the resident should become increasingly independent as the rotation progresses. The final resident report is reviewed by the hematopathology staff, changed if needed, and electronically signed out. Staff will notify the resident of major changes and review these changes with the resident. The resident may also review final reports after staff electronic sign-out.

Rotation Goals and Learning Objectives

Goals: The primary goal is to learn morphologic changes associated with neoplastic and non-neoplastic hematologic disorders in peripheral blood, bone marrow, and lymphoid tissues. In addition, the resident will learn to correlate ancillary studies with morphologic findings to arrive at an integrated and complete final diagnosis in hematopathology. The resident will also learn interpretation of hemoglobin electrophoreses and become proficient in evaluating coagulation abnormalities.

Objectives: After the Hematology rotation, the resident should be able to:

  1. Master the ability to competently perform a bone marrow biopsy and aspiration.
  2. Perform peripheral blood and bone marrow morphologic evaluation and differentials.
  3. The resident will understand the principles behind automated CBC analyzers and should be able to analyze CBC histograms.
  4. Interpret flow cytometry studies of blood, bone marrow and lymph node specimens.
  5. Develop a working knowledge of the major causes of microcytic, macrocytic, and normochromic, normocytic anemia.
  6. Identify the morphologic changes associated with nutritional anemias including iron, B12, and folate on peripheral smear and bone marrow specimens.
  7. Know how to distinguish iron deficiency from anemia of chronic disease and thalassemic syndromes utilizing morphology, iron studies, and hemoglobin electrophoresis.
  8. Identify morphologic changes associated with the major hemolytic anemia in the peripheral smear and be able to suggest appropriate ancillary studies for further work-up including:
    1. Autoimmune hemolytic anemia
    2. Heinz body hemolytic anemia
    3. Microangiopathic hemolytic anemia
  9. Develop an understanding of the principles behind the Heinz body preparation, causes of a Heinz body hemolytic anemia, and will be able to interpret a Heinz body preparation.
  10. Understand the principles behind hemoglobin electrophoresis and have the ability to interpret hemoglobin electrophoresis on cellulose acetate and citrate agar gels, and correlate electrophoretic results with CBC data for diagnoses of common hemoglobinopathies and thalassemia syndromes.
  11. Be able to identify common reactive morphologic changes in peripheral blood and bone marrow aspirates and where applicable discuss how to differentiate reactive from malignant processes.
  12. Identify morphologic changes associated with mononucleosis and other mononucleosis- like syndrome and discuss appropriate testing.
  13. Develop a working knowledge of the clinical presentation, morphologic features, and basic immunophenotyping profile of the common lymphoproliferative disorders.
  14. Develop a working knowledge of the clinical presentation, morphologic features, basic immunophenotyping, and cytochemical reactions of acute myelogenous leukemia and acute lymphocytic leukemia. The resident will be able to distinguish AML from ALL utilizing morphology and ancillary studies, as well as distinguish the FAB sub-types for the myeloid and lymphoid leukemias.
  15. Develop a working knowledge of the clinical presentation, morphologic features, and diagnostic criteria for each of the myeloproliferative syndromes including chronic myelogenous leukemia, polycythemia vera, essential thrombocythemia, and agnogenic myeloid metaplasia.
  16. Develop a working knowledge of the clinical presentation and morphologic features of the five major myelodysplastic syndromes including:
    1. Refractory anemia
    2. Refractory anemia with ringed sideroblasts
    3. Refractory anemia with excess blasts
    4. Refractory anemia with excess blasts in transformation
    5. Chronic myelomonocytic leukemia
  17. Have the ability to perform cell counts/differentials on body fluid specimens and differentiate reactive versus malignant processes.
  18. Evaluate Tzanck smears and be capable of identifying morphologic features associated with HSV infection.

Resident Opportunities to Function as a Consultant to Other Physicians

The resident is expected on a day-to-day basis to integrate laboratory findings with interpretive results of lymph nodes, bone marrows, peripheral blood morphologies and hemoglobin electrophoreses. This is an integrated, ongoing daily activity that is required of the resident on this service. The Residents' Room at Hennepin County Medical Center is equipped with computer access to clinical laboratory, anatomic path, and patient medical record data to ensure efficient acquisition of this information.

Residents have the responsibility, under faculty supervision, of discussing the interpretive consultative reports with appropriate members of the clinical/surgical teams. Through their discussions with the clinical team members, the residents have the opportunity to directly impact patient care. Other departments with ACGME approved post graduate training programs include, but are not limited to the following: Pediatrics, Internal Medicine, Obstetrics and Surgical Services. The resident is expected to review laboratory data and slide material with a variety of clinical services that request this type of interaction. The resident is expected to interact on a daily ongoing basis with the clinical hematology service in gathering important clinical history, reviewing slide material with the clinical services, performing bone marrow biopsies and aspirations and making recommendations for further assessment of coagulation issues.

The resident is expected to review material with the clinical services daily. During these interactive sessions, the hematopathology personnel review cases of interest with the hematology resident group and staff.

The resident is expected to correlate fine needle aspirate material with interpretation of lymph node biopsies. In addition, the resident is expected to integrate flow cytometry, cytogenetic, and gene rearrangement data into lymph node interpretations. Similarly, flow cytometric, cytogenetic and gene rearrangement data, when performed, must be integrated into the interpretation of bone marrow reports. Peripheral blood morphologies that show evidence of neoplasia may also require incorporation of ancillary studies, such as flow cytometry, cytogenetics, or gene rearrangement data into the appropriate report. As noted earlier, the resident is expected to review CBC data and blood smear as part of the interpretation of hemoglobin electrophoreses. The resident is also expected to correlate information gathered from referred bench material with interpretation of various body fluids in Cytology.

On-Call Duties

The resident at Hennepin County Medical Center are provided with a pager and are expected to be available for questions which arise on the Hematology Service by a variety of clinical services. The hematopathology staff person on-call is available at all times for review of questions and recommendations for further action. During this rotation, the residents will on average have one out of every seven days free of hospital duties. Due to the at-home nature of call and the limited number of emergencies, the call duties are constructed in the following fashion. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday. While on-call, residents are supervised by a teaching faculty member, who is available at all times, either via their office phone, pager, or home phone. The resident is expected to be available for weekend procedures as they arise. In general, a resident might encounter one or two instances during the course of a two-month rotation when he/she might be expected to perform a bone marrow on a weekend. Any interaction with the clinical services regarding hematopathology issues is to be reviewed with the appropriate hematopathology staff on-call, prior to interaction with the clinical services.

The hematology resident shares on-call duties with the anatomic pathology services, including surgical, autopsy, and cytopathology on a rotating basis. In addition to hospital autopsies, the resident is required to provide weekend on-call autopsy coverage for the Hennepin County Medical Examiner's office, provided such coverage does not conflict with on-call coverage of the hospital services. Assignment of Hennepin County Medical Examiner's office cases is at the co-discretion of the Hennepin County Medical Examiner and Medical Center Teaching Faculty. During the on-call period, the resident is responsible for handling clinical requests that arise during off hours, emergent operating room consultations, emergency off-hour autopsies with the approval of the on-call staff pathologist, and autopsies which present before 2:00 P.M. on the weekends.

Communication with On-Duty Faculty

The hematopathology staff person on service during routine hours is available in his/her office or by pager throughout the course of the day. A formal call schedule is generated for hematopathology and is available through the hospital operator. The resident is provided with a copy of this call schedule. The hematopathology staff person covering the service is available either by telephone (at home) or by pager at all times.

Education in Laboratory Management

The resident is provided with checklists for JCAHO and CAP inspections and asked to review this material. The resident is then expected to attend staff meetings in which review the checklist material and discussion of the recommendations for implementing corrections occurs. If a formal JCAHO or CAP review occurs during the resident's rotation, the resident is asked to attend the meeting in order to familiarize him or herself with appropriate interactions with the reviewing body. Residents are expected to review materials for CAP accreditation surveys in flow cytometry and hemoglobin electrophoresis and to complete the exercises in the survey.

Opportunities for involvement in development of new testing protocols are relatively limited, given the community trend toward centralization of esoteric testing. However, in those instances where new testing is being considered, the resident is asked to review the testing protocols as well as the data which is generated during the evaluation process. This material is then reviewed with staff and recommendations formulated as to whether to proceed with integration of the proposed test into the current hospital test menu.

Required Conferences/Seminars

Scholarly Activities/Research Available During and After Rotation

The resident is encouraged to investigate unusual clinical and pathologic cases which arise during the course of the rotation.

Basis, Method and Criteria for Resident Evaluation

Residents will be evaluated on performance of daily activities (described previously), participation in required meetings and conferences, and presentations to the staff on assigned cases. The residents are provided with continuous feedback on their performance during the rotation. In general, only deficiencies are noted in writing. Residents are evaluated on their demonstrated ability to provide informative consultation to the clinical service teams, their medical knowledge, their application of this knowledge to efficient/quality patient care, and their diagnostic, technical and observational skills. Residents 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 initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretive reports is another component of the evaluation. The resident is informally reviewed at mid-point during the rotation. If deficiencies are identified at this time, these are formally documented. A formal written review of the resident's performance is completed at the end of the two-month rotation. Residents on probation receive a written mid-rotation evaluation.

Description of Educational Resources Available

Paraffin section immunohistochemistry, flow cytometry and cytogenetic evaluation are routinely performed during the course of evaluation of a hematologic malignancy. This type of testing is done on site and the resident is expected to incorporate this information into the final assessment of a case. Immunoglobulin gene rearrangement studies are referred to a reference laboratory for testing. If this type of testing is performed, the case is generally held until these results are available. The resident is expected to integrate this information into the final interpretation of the disorder when the results become available.

Reference materials made available to the resident include general hematology reference texts (William's Hematology, Wintrobe's Clinical Hematology, Hoffman's Hematology, and Nathan and Oski's Hematology of Infancy and Childhood). Residents have access to Tumors of the Bone Marrow by Brunning and McKenna as well as Tumors of Lymph Nodes and Spleen by Waernke, et al. A variety of other lymph node diagnostic texts are available including Surgical Pathology of the Lymph Nodes and Related Organs by Jaffee, Pathology of Lymph Nodes by Weiss, and Lymph Node Biopsy Interpretation by Stansfeld and D'Ardenne. Disorders of the Spleen by Neimann and Orazi is also available. The resident is expected to utilize these references as needed in review and interpretation of cases.

The resident has computer access to the Clinical Laboratory, Anatomic Pathology, and EPIC electronic medical record in addition to computer access to programs for searching the medical literature. The Library at HCMC has an extensive collection of books and journals. Search capabilities are also readily available to the resident through the Library. An extensive Hematopathology teaching file is available for use by the resident. This includes red cell disorders, reactive and neoplastic peripheral blood cases, interesting neoplastic and reactive bone marrow cases, and an extensive collection of reactive and neoplastic lymph node cases. For much of this teaching file, the clinical history and laboratory data as well the pathology report are available with the case.

Computer Information Systems Available for Resident Education and Service Duties

The resident is provided with a password in order to access both the Clinical Laboratory and electronic Medical record data bases. This computer is located in the Clinical Laboratory Residents' Office and is available for resident use at all times.