University of Kansas School of Medicine · Pathology and ABMS certified in Hematopathology. He is...

Hematopathology Fellow Handbook

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TABLE OF CONTENTS

Faculty ………………………………………………………………………………………… 4

Mission ……………………………………………………………………………………..… 5

Overarching Goal…………………………………………….…………………………......... 5

Diversity Statement ……………………………………………...……………………5

Professionalism and Personal Conduct…….. ………….…………...…………………....... 5

Supervision ……………………………………………………...……….........................…… 8

Hematopathology Education ......………...………………….…….………… .......................8

Goals and Objectives Skill Level I.............................................................................. 10

Goals and Objectives Skill Level II............................................................................. 24

Curriculum……………………………….………………........................................... 32

Duties and responsibilities .........................................................................................34

Graded responsibilities................................................................................................ 36

Conferences ...................................................................................................................37

Educational resources ..................................................................................................38

Evaluation..................................................................................................................... 42

Training locations .........................................................................................................45

Duty hours..................................................................................................................... 46

On call............................................................................................................................. 47

Handoff protocol........................................................................................................... 47

Policies and Procedures……………………………………………………....…….... 48

Work environment ........................................................................................................48

Fellow qualifications .....................................................................................................49

Recruitment and selection ............................................................................................49

Nondiscrimination ........................................................................................................49

Moonlighting ..................................................................................................................49

Fatigue ...........................................................................................................................52

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Corrective action ......................................................................................................... 53

Grievance ...................................................................................................................... 54

Searching CoPath ………………………………………………………….………..…61

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FACULTY

Mark T Cunningham, MD Associate Professor, Director of Hematopathology Fellowship e-mail: [email protected] Telephone: 913-588-1187

Wei Cui, MD Assistant Professor e-mail: [email protected] Telephone: 913-588-0094

Diane Persons, MD Professor, Director of Cytogenetics Laboratory e-mail: [email protected] Telephone: 913-588-1728

Janet Woodroof, MD Associate Professor, Medical Director of Clinical Laboratories e-mail: [email protected] Telephone: 913-945-6786

Andrew Godwin, PhD Professor, Director of Molecular Oncology Laboratory e-mail: [email protected] Telephone: 913-945-6373

Da Zhang, MD, MSc Associate Professor e-mail: [email protected] Telephone: 913-588-0388

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mailto:[email protected]






OUR MISSION The mission of the Department of Pathology at the University of Kansas is to provide excellent teaching, research, patient care and community service and to meet the health needs of Kansas and the community at large. Our aim is to provide a supportive work environment so that each individual can excel, and pursue avenues that lead to national and international recognition. We will accomplish this by developing mechanisms that make optimal use of our human and financial resources. Overall goal Hematopathology Fellowship Training Program at the Kansas University Medical Center (KIUMC) is a one year ACGME accredited training program. The overall goal is to provide a comprehensive education in all aspects of Hematopathology The core curriculum consists of supervised training with emphasis on increasing fellow responsibility in service-related work, residents’ education and research activities. At the completion of the training, the fellow is able to function as a competent and independent hematopathologist, effective communicator, respected professional and leader in education and research, capable of practicing in either academic or private practice setting. Diversity statement The University of Kansas School of Medicine is committed to maintaining a diverse and inclusive environment and all that we do will reflect this commitment. Diversity in our classrooms, trainees, faculty, and staff invigorates our efforts to achieve excellence, enhance the quality of life and serve our community and nation. An inclusive environment improves health for all by fostering effective teaching, encouraging the vigorous exchange of ideas, promoting lifelong learning, and supporting high quality scholarship. The University of Kansas School of Medicine is committed to developing culturally proficient physician leaders who are prepared to join the current and future workforce and global economy. Professionalism and personal conduct Fellows are expected to demonstrate conduct consistent with the dignity and integrity of the medical profession at all times. It is expected that fellows will abide by institutional policies that govern conduct including GME, university, hospital, and UKP. Fellows should always strive to reach the highest standards of excellence in their learning, patient-centered clinical practice, teaching and research.

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The components of professionalism, outlined by the University of Kansas School of Medicine’s Professionalism Initiative (found at http://www.kumc.edu/som/professionalism.html ), are:

Altruism, Accountability, Excellence, Duty, Honor and Integrity, Respect, and A Commitment to lifelong learning.

The fellow will, in a timely fashion, fulfill his/her professional responsibilities. Failure to fulfill clinical, academic, and administrative duties, including completion of patient charts and duty hours logging, can result in remediation or disciplinary action, including suspension of any or all privileges. The fellow will strive for personal growth and improvement, and accept criticism with dignity, seek to be aware of his/her own inadequacies, be open to change, accept responsibility for his/her own errors or failures, and stray from displaying a poor attitude under stress. The fellow will maintain appropriate relationships with other individuals, especially those encountered as a result of their clinical training. Each fellow will protect and respect the ethical and legal rights of patient. The fellow will abide by the policies and procedures governing Graduate Medical Education. The fellow will, in a timely fashion, clearly communicate all information relevant to the safe, effective and compassionate care of their patients to their supervising staff. Both fellows and faculty are expected to fulfill their professional responsibility as a physician to appear for duty appropriately rested and fit to provide the services required by their patients. Both program and KUMC leadership will help ensure a culture of professionalism that supports patient safety and personal responsibility. Both fellows and faculty must demonstrate an understanding and acceptance of their personal role in:

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http://www.kumc.edu/som/professionalism.html

Assurance of the safety and welfare of patients entrusted to their care; Provision of patient- and family-centered care; Assurance of their fitness for duty; Management of their time before, during, and after clinical assignments; Recognition of impairment, including illness and fatigue, in themselves and in

their peers; Attention to lifelong learning; The monitoring of their patient care performance improvement indicators; and, Honest and accurate reporting of duty hours, patient outcomes and clinical

experience data. Both fellows and faculty must be responsive to patient needs that supersedes self-interest. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider. The fellow’s personal appearance while on duty, or in areas where contact with patients or their families is possible, shall be neat, clean, professional and in accordance with general University of Kansas Hospital policies. Any fellow may be asked to return home to change clothing on his/her own time. Failure to follow standards may result in disciplinary action up to and including suspension of the fellow from the program. The Medical Center identification badge (or corresponding ID badge of an affiliate institution) and nametag are to be worn visibly whenever the resident is involved in clinical or administrative activities.

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HEMATOPATHOLOGY EDUCATION

SUPERVISION Hematopathology faculty are all board certified by the American Board of Pathology. Program faculty also have added certification in Hematopathology. Supervision of fellows is direct and indirect, but a faculty member is always available, i.e. 24 hours a day, 7 days a week. Fellows and faculty should inform patients of their respective roles in each patient’s care. Methods of Supervision

RESIDENTS IN FINALYEARS OF TRAINING LEVEL of SUPERVISION ACTIVITIES /PROCEDURES(as defined by RRC&

Program) DIRECT N/A

INDIRECT A(with direct supervision immediately available)

N/A

INDIRECT B(with direct supervision available)

Bone marrow pathology and lymph node pathology rotation; laboratory hematology and flow cytometry rotation

OVERSIGHT(with direct supervision available)

N/A

RRC requirements

Per P

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RRC APPROVED LICENSED INDEPENDENT PRACTITIONERSUPERVISOR (PR VI.D.1) Dr. Mark Cunningham, Program Director, is an ABP board certified in Clinical Pathology and ABMS certified in Hematopathology. He is an Associate Professor at the University of Kansas Medical Center, and has current medical licensure in the state of Kansas. Dr. Cunningham has 17+ years of teaching experience in this specialty. OPTIMAL CLINICAL WORKLOAD (PR VI.E.) The program director will make an assessment of the learning environment with input from faculty members and fellows. There will be an adequate clinical workload to develop competency in all areas in diagnostic hematopathology. Clinical workload will include patient labs and patient materials for testing, as well as study sets. MEMBERS OF THE INTERPROFESSIONAL TEAM (PR VI.F.) There are 16 Anatomic and Clinical Pathology residents that will be on rotations with the Hematopathology Fellows. Departments, units, and services working closely with the Hematopathology Fellowship Program:

1. Technical – A total of 22 laboratory technologists are available for the fellowship program, including 12 in the Hematology Lab, 8 in the Cytogenetics Lab, and 2 in the Molecular Pathology Lab.

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2. Clerical – A total of 6 clerical personnel are available for the fellowship program, including 1 Hematopathology Fellowship Program coordinator (for program management), 2 transcriptionists (for test reporting), 1 Cytogenetic Lab administrative assistant (for test reporting), 1 Clinical Lab administrative assistant (for general secretarial functions), and 1 Pathology Office administrative assistant (for general secretarial functions).

3. Histology Laboratory, Department of Pathology, University of Kansas Medical Center – processes and stains bone marrow and lymph node specimens

4. Immunohistochemistry Laboratory, Department of Pathology, University of Kansas Medical Center – stains bone marrow and lymph node specimens

5. Cytogenetics Laboratory, Department of Pathology, University of Kansas Medical Center – fellow rotates for two weeks

6. Molecular Pathology Laboratory, Department of Pathology, University of Kansas Medical Center – fellow rotates for two weeks

7. Hematology-Oncology Division, Department of Medicine, University of Kansas Medical Center – fellow provides pathology consultation to clinicians, and pathology support for the Hematology Case Conference and Lymphoma and Myeloma Conference

COMPETENCIES TO ALLOW PGY1 RESIDENTS TO PROGRESS TO INDIRECT SUPERVISION (PR VI.D.5.a).(1) ) N/A DEFINING RESIDENT LEVELS “INTERMEDIATE LEVEL” & “FINAL YEARS OF TRAINING ” For establishing the minimum rest period between duty periods(PR VI.G.5.b&c) Fellows are in their final year of training. CIRCUMSTANANCES WHEN RESIDENTS IN THEIR FINAL YEARS OF EDUCATION MAY REMAIN OR RETURN IN < 8 HOURS(PRVI.G.5.c).(1)) N/A DEFINED MAXIMUM NUMBER OF CONSECUTIVE WEEKS AND MAXIMUM NUMBER OF MONTHS PER YEAR OF IN-HOUSE NIGHT FLOAT(PR VI.G.6.) Fellows will not be scheduled for more than six consecutive nights of night float. Fellows will be scheduled for in-house call no more frequently than every third night when average over a four week period.

Program-specific guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty (PR VI.D.5)

1. Requests for preliminary diagnoses on patient specimens

Source of specific criteria and/or specific national standards-based criteria used to evaluate each resident’s abilities (PR VI.D.4.a)

N/A

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PROGRAM LEARNING GOALS AND OBJECTIVES

SKILL LEVEL I (Learning of those skills necessary to move from novice to advanced beginner; from basic acquaintance with hematopathology to readiness to commence independent learning of hematopathology.) Months 1-3.

CATEGORY AND OUTCOMES

Legends for Learning Activities and Evaluation Methods

Legend for Learning Activities for Fellows

Didactic lecture DL Faculty sign-out FSO Journal club JC Directly supervised procedure DSP Role modeling RM Lab inspection LI Interdisciplinary conferences IC Unknown slide conference USC Research project RP

Legend for Evaluation Methods for Fellows

Report review RR Direct observation DO Checklist CL Program director and faculty evaluations PDFE Practical slide exam PSE In-house written exam IWE 360 degree evaluations 360

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Goals and Objectives

CORE COMPETENCY: PATIENT CARE Goal: Demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of hematopathology services Objectives: Learning

Activities Evaluation Activities

Gather essential and accurate information about patients using all relevant available modalities.

FSO, DSP, RM, IC

RR, DO, CL, PDFE

Act as a skilled consultant to other clinicians to develop a diagnostic plan based on specific clinical questions and relevant clinical and pathologic information. This should be accomplished both in the patient-specific setting and the broader context of developing appropriate clinical pathway algorithms for diagnosis.

DL, FSO, DSP, RM, IC

RR, DO, PDFE, IWE

Gain knowledge and technical skills to recognize, interpret, and explain pathologic processes in the clinical practice of hematopathology.

DL, FSO, JC, DSP, RM, USC

RR, DO, CL, PDFE, PSE, IWE

Consult as part of a multidisciplinary healthcare team in developing a therapeutic plan that includes laboratory monitoring of efficacy and toxicity.

DL, FSO, JC, DSP, RM, IC

RR, DO, PDFE, IWE

Provide expert consultation on the interpretation and follow-up of unusual or unexpected hematopathology test results.

DL, FSO, JC, DSP, RM, IC

DO, PDFE, IWE

Consult as a clinical expert in hematopathology at multidisciplinary conferences.

DL, FSO, JC, RM, IC

DO, PDFE

CORE COMPETENCY: MEDICAL KNOWLEDGE

Goal: Demonstrate knowledge about established and evolving biomedical, clinical and cognitive (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to hematopathology Objectives: Learning


Be able to use all relevant information resources to acquire and evaluate evidence-based information. Demonstrate proficiency in evaluating and presenting findings from appropriate peer-reviewed journals.

DL, FSO, JC, DSP, RM, IC, USC, RP


Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in hematopathology.

DL, FSO, JC, DSP, IC, USC


Demonstrate sufficient knowledge to determine clinically optimal yet cost-effective hematopathology testing, including issues of turnaround time, test menu construction, and in-house referral diagnostic testing.

DL, FSO, JC, RM, IC

RR, DO, PDFE, IWE

Employ mathematics and statistics as appropriate to hematopathology testing; understand and implement quality control (QC) and quality

DL, JC, RM, LI, RP

DO, CL, PDFE, IWE,

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assurance procedures as required. 360 Recognize the unique aspects of hematopathology practice as modified by patient age and other patient population characteristics, especially aspects of pediatric and geriatric practice.

DL, FSO, JC, DSP, RM, IC, USC

RR, DO, PDFE, IWE

Demonstrate awareness and understanding of general and test-specific standards for method development and evaluation, such as those promoted by the Clinical Laboratory Standards Institute (CLSI; formerly NCCLS), CAP, and similar organizations.

DL, RM, LI, RP

DO, PDFE, IWE, 360

Demonstrate awareness and understanding of proficiency testing programs, such as those provided by CAP and similar organizations.

DL, RM, LI DO, PDFE, IWE

Demonstrate knowledge of the principles of clinical research design, implementation, and interpretation. Understand the various levels of evidence in medicine and their translation into evidence-based practice.

JC, DSP, RM, RP

DO, PDFE, IWE

Be able to design a study that can be used to validate methodologies and parameters of clinical utility for the implementation and continuing use of new evidence-based hematopathology biomarkers in the local setting.

DL, JC, DSP, RM, LI, RP

DO, PDFE, IWE, 360

CORE COMPETENCY: PRACTICE-BASED LEARNING & IMPROVEMENT Goal: Demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices. Objectives: Learning


Demonstrate the ability to critically assess the scientific literature. JC, RM, OT, RP

DO, PDFE

Demonstrate knowledge of evidence-based medicine and apply its principles in practice.

FSO, JC, RM, RP

DO, CL, PDFE

Use multiple sources, including information technology, to optimize lifelong learning and support patient care decisions.

JC, RM DO, PDFE

Develop personally effective strategies for the identification and remediation of gaps in medical knowledge needed for effective practice.

DSP, RM, USC

RR, DO, PDFE, PSE, IWE, 360

Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety.

FSO, RM, IC DO, PDFE, 360

Demonstrate knowledge of how to establish continuing competency assessment for hematopathologists as well as for laboratory personnel.

FSO, RM, LI DO, PDFE, 360

Use proficiency testing programs to improve laboratory practices. RM, LI, RP DO, PDFE, 360

CORE COMPETENCY: INTERPERSONAL & COMMUNICATION SKILLS Goal: Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patients and patients' families. Objectives: Learning


Demonstrate the ability to write articulate, legible, and comprehensive yet concise reports and consultation notes. Provide a clear and

FSO, DSP, RM

RR, DO, CL,

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informative report, including a precise diagnosis whenever possible, a differential diagnosis when appropriate, and recommended follow-up or additional studies as appropriate.

PDFE

Demonstrate the ability to provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a laboratory assay reveals an urgent, critical, or unexpected finding and document this communication in an appropriate fashion.

FSO, DSP, RM

RR, DO, PDFE, 360

Conduct both individual consultations and presentations at multidisciplinary conferences that are focused, clear, and concise.

RM, IC, USC DO, PDFE, PSE

Demonstrate the ability to communicate the vision of the hematopathology service role to other clinicians as well as to other healthcare personnel and administrators to develop clinically advantageous and cost-effective strategies.

FSO, RM, IC DO, PDFE, PSE, 360

Choose effective modes of communication (listening, nonverbal, explanatory, questioning) and mechanisms of communication (face-to-face, telephone, e-mail, written), as appropriate.

FSO, RM, IC, USC

RR, DO, PDFE, PSE, 360

Demonstrate skills in educating colleagues and other healthcare professionals: (1) demonstrate the ability to help pathology residents obtain proficiency in hematopathology; (2) demonstrate the ability to work well with technologists and to present hematopathology concepts to them effectively in continuing education settings and in the day-to-day laboratory environment; (3) demonstrate the ability to educate non-pathology clinicians and other healthcare workers, including pharmacists, nurses, residents, medical students, and others, about topics such as the fundamental principles of pathophysiology underlying test design/ interpretation and the approach to choosing and interpreting laboratory tests; (4) demonstrate an understanding of the principles one must follow when educating other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other cutting-edge professional knowledge.

FSO, JC, RM, IC, USC

DO, PDFE, PSE, 360

CORE COMPETENCY: PROFESSIONALISM Goal: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population. Objectives: Learning


Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them.

FSO, DSP, RM, IC

DO, PDFE, 360

Interact with others without discriminating on the basis of religious, ethnic, sexual, or educational differences.

FSO, DSP, RM, IC

DO, PDFE, 360

Demonstrate positive work habits, including punctuality, dependability, and professional appearance.

FSO, RM DO, PDFE, 360

Demonstrate a responsiveness to the needs of patients and society that supersedes self-interest.

FSO, DSP, RM

DO, PDFE, 360

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Demonstrate principles of confidentiality with all information transmitted both during and outside of a patient encounter.


DO, PDFE, 360

Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research.

DL, RP PDFE

Demonstrate a commitment to excellence and ongoing professional development.

RM DO, PDFE

Demonstrate interpersonal skills in functioning as a member of a multidisciplinary healthcare team

FSO, DSP, RM, IC

DO, PDFE, 360

CORE COMPETENCY: SYSTEM-BASED PRACTICE Goal: Demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide hematopathology services that are of optimal value Objectives: Learning


Demonstrate understanding of the role of the clinical laboratory in the healthcare system.

DL, FSO, LI, IC

DO, PDFE

Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians.

FSO, RM RR, DO, PDFE, IWE, 360

Demonstrate knowledge of basic healthcare reimbursement methods.

DL DO, PDFE, IWE

Demonstrate knowledge of the laboratory regulatory environment, including licensing authorities; federal, state, and local public health rules and regulations; regulatory agencies such as the Centers for Medicare and Medicaid Services and the US Food and Drug Administration; and accrediting agencies such as The Joint Commission (TJC), CAP, and the ACGME.

DL, FSO, LI DO, CL, PDFE, IWE

Understand and implement policies to continually improve patient safety as they relate to hematopathology at all levels.

FSO, RM, LI, RP

DO, PDFE

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Rotation Specific Educational Goals

Bone Marrow and Lymph Node Pathology Rotation

Introduction

The bone marrow and lymph node pathology rotation (26 weeks) is designed to provide fellows the opportunity to acquire comprehensive knowledge, morphologic skills, and consultative skills in those diseases that affect the bone marrow, lymph node, and extra-nodal lymphoid tissue.


See Legends for Learning Activities and Evaluation Methods on Page 2.

CORE COMPETENCY: PATIENT CARE Goal: Demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of bone marrow and lymph node pathology.

Objectives: Learning Activities

Evaluation Activities

Gather essential and accurate information about patients using all relevant available modalities.

FSO,DSP, RM, IC

RR,DO, PDFE



DO, PDFE, SE, IWE

Gain knowledge and technical skills to recognize, interpret, and explain pathologic processes in the clinical practice of hematopathology.

FSO,DL,JC, DSP, RM, USC

DO, PDFE, IWE


DL,JC, DSP, RM, IC

DO, PDFE, IWE

Provide expert consultation on the interpretation and follow-up of unusual or unexpected hematopathology test results.

FSO,DL, DSP, RM, IC

DO, PDFE, IWE

Consult as a clinical expert in hematopathology at multidisciplinary conferences. DSP, RM, IC DO, PDFE

CORE COMPETENCY: MEDICAL KNOWLEDGE Goal: Demonstrate knowledge about established and evolving biomedical, clinical and cognitive (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to bone marrow and lymph node pathology.



Be able to use all relevant information resources to acquire and evaluate evidence-based information. Demonstrate proficiency in evaluating and presenting findings from appropriate peer-reviewed journals.

FSO,DL, JC, DSP, RM, IC, USC, RP

RR, DO, PDFE, IWE

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Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in hematopathology.

DL, JC, DSP, IC

RR, DO, PDFE, IWE

Demonstrate sufficient knowledge to determine clinically optimal yet cost-effective hematopathology testing, including issues of turnaround time, test menu construction, and in-house referral diagnostic testing.

DL, JC, RM, IC,FSO

RR, DO, PDFE, IWE

Employ mathematics and statistics as appropriate to hematopathology testing; understand and implement quality control (QC) and quality assurance procedures as required.

DL, JC, RM DO, CL, PDFE, IWE

Recognize the unique aspects of hematopathology practice as modified by patient age and other patient population characteristics, especially aspects of pediatric and geriatric practice.

DL, JC, DSP, RM, IC

RR, DO, PDFE, IWE

Demonstrate awareness and understanding of general and test-specific standards for method development and evaluation, such as those promulgated by the Clinical Laboratory Standards Institute (CLSI; formerly NCCLS), CAP, and similar organizations.


Demonstrate awareness and understanding of proficiency programs, such as those provided by CAP and similar organizations. DL, RM, LI DO, PDFE,

IWE Demonstrate knowledge of the principles of clinical research design, implementation, and interpretation. Understand the various levels of evidence in medicine and their translation into evidence-based practice.

JC, DSP, RM, RP

DO, PDFE, IWE

Be able to design a study that can be used to validate methodologies and parameters of clinical utility for the implementation and continuing use of new evidence-based hematopathology biomarkers in the local setting.


DO, PDFE, IWE

CORE COMPETENCY: PRACTICE-BASED LEARNING & IMPROVEMENT Goal: Demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices.



Demonstrate the ability to critically assess the scientific literature. JC, RM, RP DO, PDFE Demonstrate knowledge of evidence-based medicine and apply its principles in practice. JC, RM, RP DO, PDFE

Use multiple sources, including information technology, to optimize lifelong learning and support patient care decisions. JC, RM DO, PDFE


DSP, RM, USC

DO, PDFE, IWE, 360

Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety. RM, IC DO, PDFE,

360 Demonstrate knowledge of how to establish continuing competency assessment for hematopathologists as well as for laboratory personnel. RM, LI DO, PDFE,

360

Use proficiency programs to improve laboratory practices. RM, LI, RP DO, PDFE, 360

CORE COMPETENCY: INTERPERSONAL & COMMUNICATION SKILLS Goal: Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patients and patients' families.



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DSP, RM DO, PDFE

Conduct both individual consultations and presentations at multidisciplinary conferences that are focused, clear, and concise. RM, IC DO, PDFE

Demonstrate the ability to communicate the vision of the hematopathology service role to other clinicians as well as to other healthcare personnel and administrators to develop clinically advantageous and cost-effective strategies.

RM, IC DO, PDFE


RM, IC RR, DO, PDFE

Demonstrate skills in obtaining informed consent, including effective communication to patients about procedures, alternative approaches, and possible complications of laboratory-based patient care diagnostic and therapeutic activities, such as those related to hematopathology.

DSP, RM DO, PDFE

Demonstrate skills in educating colleagues and other healthcare professionals: (1) demonstrate the ability to help other residents obtain proficiency in laboratory medicine; (2) demonstrate the ability to work well with technologists and to present laboratory medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment; (3) demonstrate the ability to educate non-pathology clinicians and other healthcare workers, including pharmacists, nurses, residents, medical students, and others, about topics such as the fundamental principles of pathophysiology underlying test design/ interpretation and the approach to choosing and interpreting laboratory tests; (4) demonstrate an understanding of the principles one must follow when educating other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other cutting-edge professional knowledge.

JC, RM, IC DO, PDFE

CORE COMPETENCY: PROFESSIONALISM Goal: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.



Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them. DSP, RM, IC DO, PDFE

Interact with others without discriminating on the basis of religious, ethnic, sexual, or educational differences. DSP, RM, IC DO, PDFE

Demonstrate positive work habits, including punctuality, dependability, and professional appearance. RM DO, PDFE

Demonstrate a responsiveness to the needs of patients and society that supersedes self-interest. DSP, RM DO, PDFE


DL, DSP, RM, IC DO, PDFE

Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research. DL, OT PDFE

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Demonstrate a commitment to excellence and ongoing professional development. RM DO, PDFE

Demonstrate interpersonal skills in functioning as a member of a multidisciplinary healthcare team DSP, RM, IC DO, PDFE

CORE COMPETENCY: SYSTEM-BASED PRACTICE Goal: Demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide bone marrow and lymph node pathology services that are of optimal value



Demonstrate understanding of the role of the hematopathology laboratory in the healthcare system. DL, LI, IC DO, PDFE


RM DO, PDFE, IWE

Demonstrate knowledge of basic healthcare reimbursement methods. DL DO, PDFE, IWE



Understand and implement policies to continually improve patient safety as they relate to the hematopathology laboratory.

FSO, RM, LI, RP DO, PDFE

Additional Specific Objectives

• Understand the clinical indications for bone marrow evaluation. [PC, MK, SBP] • Understand the diagnostic limitations of bone marrow aspirate and biopsy sections. [PC, MK] • Learn technical aspects of performing and analyzing bone marrow aspiration and biopsy.

Encourage performance of bone marrow aspiration and biopsy. [PC, MK] • Identify sites for the acquisition of bone marrow in children and adults. [PC, MK] • Learn handling, preparation and interpretation of bone marrow specimens, including special stains

(e.g., silver stain and Prussian blue). [PC, MK] • Correctly quantify bone marrow cellularity and M-E ratio. [PC, MK] • Recognize effects of chemotherapy and growth factor stimulation on blood and bone marrow. [PC,

MK] • Understand common drug effects leading to benign cytopenias. [PC, MK] • Correctly quantify storage iron, sideroblast iron, and ring sideroblasts. [PC, MK] • Understand hematopoiesis and distinguish the stages for cells in each hematopoietic cell series. • Know the major hematopoietic regulatory factors/cytokines. [PC, MK] • Recognize normal WBC, RBC, and platelet maturation as well as cellular dysplasia. [PC, MK]

Understand the pathophysiology, clinical findings, etiology, and expected bone marrow

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morphology for vitamin deficiency anemias, hemoglobinopathies, thalassemias, aplastic anemia, red cell aplasia, leukemias, myeloproliferative disorders, myelodysplastic syndromes, plasma cell dyscrasias, and mast cell diseases. [PC, MK]

• Understand diagnostic principles involved in distinguishing transient myeloproliferative syndromes (such as associated with Down syndrome), transient cytopenias, and transient lymphocytoses from monoclonal disorders. [PC, MK] Understand the pathophysiology, clinical findings, etiology, and expected bone marrow morphology for vitamin deficiency anemias, hemoglobinopathies, thalassemias, aplastic anemia, red cell aplasia, leukemias, myeloproliferative disorders, myelodysplastic syndromes, plasma cell dyscrasias, and mast cell diseases. [PC, MK]

• Integrate morphology, cytochemistry, immunophenotype, and molecular and cytogenetics in the differential diagnosis of acute and chronic leukemia, lymphoma, and myeloproliferative and myelodysplastic diseases. [PC, MK]

• Integrate peripheral blood smear and bone marrow findings and render a preliminary diagnosis. [PC, MK]

• Know the post-therapy findings seen after treatment for leukemia and the temporal relationships to marrow regeneration post therapy. [PC, MK]

• Recognize the bone marrow manifestations of infections (e.g., viral, fungal, and hemophagocytic syndromes). [PC, MK]

• Recognize the bone marrow manifestations of noninfectious systemic diseases (e.g., alcoholism, collagen vascular disease, and nonhematologic malignancies). [PC, MK]

Duties

• Sign-out bone marrow aspirations and biopsies with Pathology staff.

o Prior to sign out: Organize all slides for an individual case (blood smear, marrow aspirate smears,

core biopsy, cell block, special stains) on a single slide tray dedicated for that case Obtain all pertinent information for each case, including previous histologic

material, laboratory data, and clinical data Write-up each case and establish a diagnosis

• Maintain an organized marrow sign-out room • Review with pathology staff all difficult hematopathology cases (lymph nodes, bone marrows, etc.),

as deemed necessary by the fellow or pathology staff, that are scheduled for presentation at the Lymphoma and Myeloma Conference. This applies only to those specific dates that the fellow is scheduled to be present

• Attend and present cases at the weekly Lymphoma and Myeloma Conference that the fellow is scheduled to be present

• Attend and present cases at the weekly Hematology Journal Club that the fellow is scheduled to be present

• Attend the weekly Clinical Pathology Core Conference and Anatomic Pathology Core Conference. This applies only to those lectures that are relevant to hematopathology.

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• Attend the monthly Hematopathology Slide Conference • Function as a consultant to resolve questions asked by lab personnel and clinicians; be available at

all times by pager • Provide training and cross-coverage for the pathology resident and post-sophomore fellow.

References

1. Beutler E, Lichtman M, Collet B, Kipps T, Seligson U, eds. William’s Hematology, 6th ed. New

York: McGraw-Hill, 2001. 2. Carr JH, Rodak BF. Clinical Hematology Atlas. Philadelphia: WB Saunders, 1999. 3. Foucar K. Bone Marrow Pathology, 2nd ed. Chicago, IL: American Society of Clinical Pathology,

2001. 4. Glassy EF, ed. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency

Testing. Chicago, IL: American Society of Clinical Pathology, 1998. 5. Hoffman R, Benz E, Shattil S, Furie B, Cohen H. Hematology: Basic Principles and Practice, 4th

ed. New York: Churchill Livingstone, 2004. 6. Jaffee ES, Harris NL, Stein H, Vardiman JW, eds. World Health Organization Classification of

Tumors. Pathogenesis and Genetics of Tumors of Hematopoietic and Lymphoid Tissues. Lyon, France: IARC Press, 2001.

20

Laboratory Hematology and Flow Cytometry Rotation

Introduction

This rotation (12 weeks) is designed to provide fellows the opportunity to acquire comprehensive knowledge and diagnostic skills in general laboratory hematology and flow cytometry.



CORE COMPETENCY: PATIENT CARE Goal: Demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of laboratory hematology and flow cytometry services



Gather essential and accurate information about patients using all relevant available modalities. DSP, RM, IC DO, PDFE



DO, PDFE, IWE

Gain knowledge and technical skills to recognize, interpret, and explain pathologic processes in the clinical practice of laboratory hematology and flow cytometry..

DL,JC, DSP, RM

DO, PDFE, IWE


DL,JC, DSP, RM, IC

DO, PDFE, IWE

Provide expert consultation on the interpretation and follow-up of unusual or unexpected test results. DL, DSP, RM DO, PDFE,

IWE Consult as a clinical expert in laboratory hematology and flow cytometry at multidisciplinary conferences.


CORE COMPETENCY: MEDICAL KNOWLEDGE Goal: Demonstrate knowledge about established and evolving biomedical, clinical and cognitive (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to wet heme and FCM



Be able to use all relevant information resources to acquire and evaluate evidence-based information. Demonstrate proficiency in

DL, JC, DSP, RM, IC

RR, DO, PDFE, IWE

21

evaluating and presenting findings from appropriate peer-reviewed journals. Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in laboratory hematology and flow cytometry.

DL, JC, DSP, IC

RR, DO, PDFE, IWE

Demonstrate sufficient knowledge to determine clinically optimal yet cost-effective testing and laboratory-based therapeutic strategies, including issues of turnaround time, test menu construction, and in-house referral diagnostic testing.

DL, JC, RM, IC

RR, DO, PDFE, IWE

Employ mathematics and statistics as appropriate to laboratory testing; understand and implement quality control (QC) and quality assurance procedures as required.

DL, JC, RM DO, CL, PDFE, IWE

Recognize the unique aspects of wet heme/FCM practice as modified by patient age and other patient population characteristics, especially aspects of pediatric and geriatric practice.

DL, JC, DSP, RM, IC

RR, DO, PDFE, IWE

Demonstrate awareness and understanding of general and test-specific standards for method development and evaluation, such as those promulgated by the Clinical Laboratory Standards Institute (CLSI; formerly NCCLS), CAP, and similar organizations.


Demonstrate awareness and understanding of proficiency programs, such as those provided by CAP and similar organizations. DL, RM, LI DO, PDFE,

IWE Demonstrate knowledge of the principles of clinical research design, implementation, and interpretation. Understand the various levels of evidence in medicine and their translation into evidence-based practice.

JC, DSP, RM, RP

DO, PDFE, IWE

Be able to design a study that can be used to validate methodologies and parameters of clinical utility for the implementation and continuing use of new evidence-based analytes in the local setting.


DO, PDFE, IWE




Demonstrate the ability to critically assess the scientific literature. JC, RM DO, PDFE Demonstrate knowledge of evidence-based medicine and apply its principles in practice. JC, RM DO, PDFE

Use multiple sources, including information technology, to optimize lifelong learning and support patient care decisions. JC, RM DO, PDFE


DSP, RM DO, PDFE, IWE

Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety. RM, IC DO, PDFE

Demonstrate knowledge of how to establish continuing competency assessment for pathologists as well as for laboratory personnel. RM, LI DO, PDFE

Use proficiency programs to improve laboratory practices. RM, LI DO, PDFE CORE COMPETENCY: INTERPERSONAL & COMMUNICATION SKILLS

22

Goal: Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patients and patients' families.




DSP, RM DO, PDFE


Demonstrate the ability to communicate the vision of the wet heme and FCM service role to other clinicians as well as to other healthcare personnel and administrators to develop clinically advantageous and cost-effective strategies.

RM, IC DO, PDFE


RM, IC RR, DO, PDFE

Demonstrate skills in obtaining informed consent, including effective communication to patients about procedures, alternative approaches, and possible complications of laboratory-based patient care diagnostic and therapeutic activities, such as those related to wet heme/FCM.

DSP, RM DO, PDFE

Demonstrate skills in educating colleagues and other healthcare professionals: (1) demonstrate the ability to help other residents obtain proficiency in laboratory medicine; (2) demonstrate the ability to work well with technologists and to present laboratory medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment; (3) demonstrate the ability to educate non-pathology clinicians and other healthcare workers, including pharmacists, nurses, residents, medical students, and others, about topics such as the fundamental principles of pathophysiology underlying test design/ interpretation and the approach to choosing and interpreting laboratory tests; (4) demonstrate an understanding of the principles one must follow when educating other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other cutting-edge professional knowledge.

JC, RM, IC DO, PDFE




Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them. DSP, RM, IC DO, PDFE

Interact with others without discriminating on the basis of religious, ethnic, sexual, or educational differences. DSP, RM, IC DO, PDFE

Demonstrate positive work habits, including punctuality, dependability, RM DO, PDFE

23

and professional appearance. Demonstrate a responsiveness to the needs of patients and society that supersedes self-interest. DSP, RM DO, PDFE



Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research. DL PDFE


Demonstrate interpersonal skills in functioning as a member of a multidisciplinary healthcare team DSP, RM, IC DO, PDFE

CORE COMPETENCY: SYSTEM-BASED PRACTICE Goal: Demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value



Demonstrate understanding of the role of the hematology and flow cytometry laboratory in the healthcare system. DL, LI, IC DO, PDFE


RM DO, PDFE, IWE

Demonstrate knowledge of basic healthcare reimbursement methods. DL DO, PDFE, IWE



Understand and implement policies to continually improve patient safety as they relate to the hematology and flow cytometry laboratory.

FSO, RM, LI, RP DO, PDFE


Automated Hematology

• Understand clinical indications for peripheral blood cell enumeration and differential analysis. [PC, MK]

• Know the components of a complete blood count and understand the information provided by each. [PC, MK]

• Understand the principles of automated cell counting, including red blood cell (RBC) indices and their derivation. [PC, MK]

• Understand how “absolute values” are determined and how they differ from “relative percent”. [PC, MK]

24

• Identify spurious white blood cell (WBC) RBC, hemoglobin, and platelet determinations and be able to propose a course of action to be followed for reporting results. [PC, MK]

• Understand appropriate WBC correction for the presence of nucleated RBCs. [PC, MK] • Understand automated differential analysis and manual review criteria. [PC, MK, PBL] • Understand the absolute neutrophil count and its clinical utility, as well as problems associated with

band counts. [PC, MK, SBP] • Understand QC procedures specific to cell counters, such as Rumke limits on differential cell

counts and Bull analysis of indices. [PC, MK, PBL] • Understand principles of automated and manual reticulocyte enumeration and their respective

technical limitations. [PC, MK] • Interpret results of automated and manual cell counts and understand the relevant technical

limitations. [PC, MK] • Recommend appropriate steps for abnormal sample processing, analysis, and result reporting. [PC,

MK, PBL] • Review abnormal results and correlate results with peripheral blood smear findings and clinical

history. [PC, MK] Peripheral Blood Smear Analysis

• Know proper preparation and handling of peripheral blood smears, including standard stains and special stains used to identify cellular structures and inclusions. [PC, MK]

• Understand normal RBC, WBC, and platelet morphology. [PC, MK] • Be able to estimate WBC and platelet counts. [PC, MK] • Recognize abnormal RBC, WBC, and platelet morphology; formulate a differential diagnosis; and

suggest appropriate laboratory testing for follow-up. [PC, MK] • Recognize technical artifacts in WBC, RBC, and platelet morphology. [PC, MK] • Recognize infectious disorders that can be diagnosed by blood smear. [PC, MK] • Recognize storage disorders and congenital disorders that have morphologic manifestations in the

peripheral blood smear. [PC, MK] • Correlate peripheral blood smear findings with bone marrow morphology. [PC, MK]

Body Fluid Analysis: CSF, Ascitic/Pleural Fluid, Joint Fluid

• Understand clinical indications for body fluid analysis. [PC, MK] • Understand manual hemocytometer cell counting. [PC, MK] • Understand cytocentrifuge sample preparation and slide staining. [PC, MK] • Identify blood and body fluid cell morphology. [PC, MK] • Interpret results of body fluid analyses in the appropriate clinical context. [PC, MK] • Recognize malignant cells and recommend appropriate confirmatory tests. [PC, MK] • Correlate abnormal body fluid cell morphology with cytology, flow cytometry, and other relevant

diagnostic test results. [PC, MK] • Identify body fluid crystals. Distinguish between urate and calcium pyrophosphate crystals, using

polarized light. [PC, MK]

25

Manual Hematology Methods • Understand principles of microhematocrit determination and its technical limitations. [PC, MK] • Understand the principles of erythrocyte sedimentation rate. [PC, MK] • Understand the principle and utility of supravital stains, including reticulocyte stain, hemoglobin H

preparation, and Heinz body preparation. [PC, MK] RBC Disorders

• Learn the clinical indications for laboratory tests involved in the assessment of intrinsic and extrinsic RBC defects/disorders. [PC, MK]

• Know the pathophysiology and characteristic laboratory findings of the major disorders causing normocytic, microcytic, and macrocytic anemia. [PC, MK]

• Describe iron metabolism and laboratory tests for iron depletion. [PC, MK] • Understand hemoglobin synthesis and degradation. [PC, MK] • Understand the principles of hemoglobin screening by HPLC and electrophoresis at acid and

alkaline pH. [PC, MK] • Understand the principle and clinical utility of screening tests for the presence of hemoglobin S.

[PC, MK] • Know the pathophysiology and laboratory features of intravascular and extravascular hemolysis.

[PC, MK] • Understand the principle and clinical utility of Kleihauer–Betke and/or flow cytometric analysis for

fetal hemoglobin. [PC, MK] • Interpret hemoglobin electrophoretic patterns and ancillary tests for the diagnosis of [PC, MK]

o Major hemoglobinopathies; o Disorders related to enzyme defects; o Hereditary spherocytosis and other RBC membrane/ cytoskeletal defects; o Paroxysmal nocturnal hemoglobinuria; o Hemolytic anemia; o Congenital dyserythropoietic anemias.

Platelet Disorders

• Understand the pathophysiology of thrombocytopenia and thrombocytosis: [PC, MK] • Differentiate between reactive and malignant processes; [PC, MK] • Understand the pathophysiology of immune thrombocytopenia and thrombotic thrombocytopenic

purpura. [PC, MK] • Demonstrate competency in taking a bleeding history. [PC, MK] • Understand the clinical utility of platelet function testing. [PC, MK] • Understand general principles of platelet function testing. [PC, MK] • Understand the pathophysiology of acquired and congenital platelet function disorders. [PC, MK]

26

• Understand the pathophysiology leading to major von Willebrand disease subtypes and expected laboratory results. [PC, MK]

• Recognize acquired platelet function abnormalities associated with antiplatelet therapy. [PC, MK] • Interpret platelet function studies, including screening tests, platelet aggregation, and platelet

secretion studies. [PC, MK] • Interpret studies performed for the evaluation of von Willebrand disease. [PC, MK]

Coagulation

• Understand the clinical utility of coagulation and thrombosis testing. [PC, MK, SBP] • Develop basic understanding of hemostatic and thrombotic disorders: [PC, MK] • Understand the coagulopathy of liver disease; [PC, MK] • Understand the pathophysiology of vitamin K deficiency and antagonism; [PC, MK] • Understand the laboratory evaluation of disseminated intravascular coagulation; [PC, MK] • Understand the pathophysiology of the hemophilias (A, B, and C). [PC, MK] • Understand the pathophysiology of arterial and venous thrombosis. [PC, MK] • Understand the general principles of screening coagulation tests (e.g., prothrombin time, activated

partial thromboplastin time, fibrinogen, and thrombin time). [PC, MK] • Understand the International Normalized Ratio derivation and its clinical significance [PC, MK,

SBP] • Understand the effect of hematocrit and blood-drawing technique on anticoagulation of blood

samples for coagulation testing. [PC, MK] • Demonstrate competency in taking a bleeding and thrombosis history. [PC, MK] • Understand results of mixing studies and factor assays to guide further coagulation testing. [PC,

MK] • Understand the principles of tests involved in the identification of lupus anticoagulant and

antiphospholipid antibody syndromes. [PC, MK] • Recognize the effect of circulating anticoagulants on coagulation testing. [PC, MK] • Understand the monitoring of anticoagulation therapy. [PC, MK] • Understand the method of action of direct thrombin inhibitors and their effect on coagulation

testing. [PC, MK] • Understand the principles of molecular analysis of thrombotic risk factors [e.g., factor V Leiden,

prothrombin G20210A, and methylenetetrahydrofolate reductase (MTHFR)]. [PC, MK] • Understand the principles of functional and antigenic assays for proteins of the anticoagulation and

fibrinolytic systems. [PC, MK]

27

• Interpret results of coagulation and hypercoagulability testing and recommend further studies as needed. [PC, MK]

• Summarize laboratory evidence for hemostatic and thrombotic disorders and be able to assess and explain bleeding and thrombosis risk. [PC, MK]

• Interpret results of Bethesda assays for factor inhibitors. [PC, MK] • Interpret results of coagulation tests in the setting of fibrinolytic therapy. [PC, MK] • Interpret results of heparin-induced thrombocytopenia testing (ELISA tests vs serotonin release

assay/platelet aggregation studies) in the appropriate clinical context. [PC, MK] • Understand monitoring and complications of biologics as drugs (e.g., recombinant activated

protein C and recombinant F VIIa). [PC, MK] Flow Cytometry

• Understand clinical indications for flow cytometric evaluation of blood, marrow, solid tissue, or fluid cells. [PC, MK]

• Understand the physical components and operating principles of a flow cytometer. [PC, MK] • Understand QC procedures unique to flow cytometry assays (e.g., nature of controls and

accounting for all lymphocyte subsets in a blood sample). [PC, MK, PBL] • Understand the principles of routine flow cytometry evaluation of leukocytes, including both

surface and intracellular markers, and recognition of clonal abnormalities. [PC, MK] • Understand principles of tests designed to evaluate DNA content (ploidy) and cell cycle, as used

in the evaluation of products of conception and other tissues. [PC, MK] • Understand platelet antibody testing by flow cytometry and its clinical applications. [PC, MK] • Understand the diagnostic and prognostic information provided by flow cytometry. [PC, MK] • Understand the principles of lymphocyte subset analysis: know the commonly used antigens to

define T-cell subsets, natural killer, and B cells. [PC, MK] • Appreciate the effect of age on lymphocyte subset normal ranges. [PC, MK] • Observe/perform lymphoma/leukemia panel on blood and/or bone marrow. [PC, MK] • Observe/perform lymphoma panel on lymph node or spleen specimens. [PC, MK] • Evaluate and interpret results of flow cytometry in conjunction with cytochemistry,

immunocytochemistry, immunohistochemistry studies, and lymph node pathology as related to hematopoietic and lymphoproliferative diseases [PC, MK, SBP]

• Understand the characteristic clinical, morphologic, immunophenotypic, cytochemical, and cytogenetic/ molecular features of acute myeloid leukemia, acute lymphoid leukemia, myelodysplastic syndromes, paroxysmal nocturnal hemoglobinemia, multiple myeloma, monoclonal gammopathy of undetermined significance, non-Hodgkin and Hodgkin lymphoma, neuroblastoma, chronic lymphoproliferative disorders, lymphomatoid granulomatosis, posttransplant lymphoproliferative disorder, polymorphic and lymphomatoid papulosis, and histiocytic disorders. [PC, MK SBP]

• Interpret specific flow cytometric abnormalities associated with immunodeficiency syndromes. [PC, MK]

• Interpret CD34 counts for stem cell transplantation and for prognostication in myeloproliferative disorders. [PC, MK]

• Understand the principles and interpretation of reticulated platelet analysis. [PC, MK] • Understand the principles of, and interpret analyses for, minimal residual disease. [PC, MK]

28 | P a g e

Duties

• Sign-out of selected hematology tests with Pathology staff: Blood smears Body fluid cytospins Flow cytometry panels Hemoglobin electrophoresis Platelet aggregation Platelet function analyzer Prior to sign-out:

• Obtain all pertinent information about the case, including previous laboratory and clinical data • Review the relevant pathology slides; perform a leukocyte differential count for blood smear and

cytospin evaluations • Write a narrative interpretation • Review bone marrow aspirate smears to approve flow cytometry orders • Review the procedure manual for all hematology tests and flow cytometry tests performed in the

laboratory; perform selected tests under technologist supervision • Attend the weekly Internal Medicine Hematology Conference (each Thurs., 8:30 am) • Attend teaching conferences held by Pathology staff (e.g. CP Core Conference, AP Core

Conference, etc.) • Function as a consultant to resolve questions asked by lab personnel and clinicians; be available

at all times by pager. • Provide training and cross-coverage for the pathology resident and post-sophomore fellow.

References

Also see the Bone Marrow and Lymph Node Pathology Reference Materials in previous section.

1. Beutler E, Lichtman M, Collet B, Kipps T, Seligson U, eds. William’s Hematology, 6th ed. New York: McGraw-Hill, 2001.

2. Carr JH, Rodak BF. Clinical Hematology Atlas. Philadelphia: WB Saunders, 1999. 3. Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN. Hemostasis and Thrombosis: Basic

Principles and Clinical Practice, 4th ed. (5th edition in press). Philadelphia: Lippincott Williams & Wilkins, 2000.

4. Darzynkiewicz Z, Crissman HA, Robinson JP, eds. Methods in Cell Biology, Cytometry, 3rd ed., Part A, Vol. 63. New York: Academic Press, 2000.

5. Foucar K. Bone Marrow Pathology, 2nd ed. Chicago, IL: American Society of Clinical Pathology, 2001.

6. Glassy EF, ed. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing. Chicago, IL: American Society of Clinical Pathology, 1998.

7. Goodnight SH Jr, Hathaway WE. Disorders of Hemostasis and Thrombosis: A Clinical Guide. New York: McGraw-Hill, 2001.

8. Hoffman R, Benz E, Shattil S, Furie B, Cohen H. Hematology: Basic Principles and Practice, 4th ed. New York: Churchill Livingstone, 2004.

9. Hoyer JD, Kroft SH, eds. Color Atlas of Hemoglobin Disorders: A Compendium Based on Proficiency Testing. Chicago, IL: American Society of Clinical Pathology, 2003.

29

10. Jaffee ES, Harris NL, Stein H, Vardiman JW, eds. World Health Organization Classification of Tumors. Pathogenesis and Genetics of Tumors of Hematopoietic and Lymphoid Tissues. Lyon, France: IARC Press, 2001.

11. Keren DF, McCoy JP, Carey JL, eds. Flow Cytometry in Clinical Diagnosis, 3rd edition. Chicago, IL: American Society of Clinical Pathology, 2001.

12. King-Strasinger S, Schaub Di Lorenzo M. Urinalysis and Body Fluids, 4th ed. Philadelphia: FA Davis, 2005.

13. Kjeldsberg C, ed. Practical Diagnosis of Hematologic Disorders, 3rd ed. Chicago, IL: American Society of Clinical Pathology, 2000.

14. Knowles DM. Neoplastic Hematopathology, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000.

15. Loscalzo J, Schafer AI, eds. Thrombosis and Hemorrhage, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

16. Nathan DG, Orkin SH, Ginsburg D, Look TA, Oski FA. Hematology of Infancy and Childhood, 6th ed. Philadelphia: WB Saunders, 2003.

17. Majerus PW, Perlmutter RM, Varmus H, Stamatoyannopoulos G, eds. The Molecular Basis of Blood Diseases, 3rd ed. Philadelphia: WB Saunders, 2001.

18. Stewart CC, Nicholson JKA, eds. Cytometric Cellular Analysis: Immunophenotyping. New York: Wiley-Liss, 2000.

19. Triplett DA, ed. Platelet Function. Laboratory Evaluation and Clinical Application. Chicago, IL: American Society of Clinical Pathologists, 1978.

30

Cytogenetics Rotation

Introduction

The goal of the rotation in the cytogenetics laboratory is to become competent in the interpretation of basic chromosome abnormalities, and to learn consultative skills that aid the clinician in the diagnosis of hematologic diseases that have chromosomal abnormalities.



CORE COMPETENCY: PATIENT CARE Goal: Demonstrate a satisfactory level of interpretive competence in cytogenetics.



Correlate chromosomal abnormalities with specific hematologic disorders such as myelodysplastic syndromes, hematologic malignancies, and myeloproliferative disorders.

FSO, RM, DL DO, PDFE, IWE

Understand the use of fluorescence in situ hybridization (FISH) analysis for common disorders involving aneuploidies, deletions, amplifications, or chromosomal translocations, including hematologic disorders such as acute promyelocytic leukemia and chronic myelogenous leukemia.

FSO, RM, DL

DO, PDFE, IWE

Recognize the major chromosomal abnormalities and their association with hematologic disorders.

FSO, RM, DL

DO, PDFE, IWE


Goal: Demonstrate knowledge about established and evolving biomedical, clinical and cognitive sciences and the application of this knowledge to cytogenetics.



Have awareness of sample types, preparation, and storage conditions for cytogenetic tests. FSO, RM, DL DO, PDFE,

IWE Understand sample preparation from peripheral blood, bone marrow, and lymph nodes for karyotyping. FSO, RM, DL DO, PDFE,

IWE Understand basic cell and tissue culture techniques, harvesting, slide preparation, banding, staining and microscopic analysis for karyotyping.

FSO, RM, DL DO, PDFE, IWE

Have knowledge of different FISH probe strategies (dual fusion, break-apart, etc). FSO, RM, DL DO, PDFE,

IWE CORE COMPETENCY: PRACTICE-BASED LEARNING & IMPROVEMENT

Goal: Demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices. Objectives: Learning Evaluation

31

Activities Activities Demonstrate the ability to critically assess the scientific literature. JC, RM, RP DO, PDFE Demonstrate knowledge of evidence-based medicine and apply its principles in practice.

FSO, JC, RM, RP DO, PDFE


DSP, RM, USC DO, PDFE

Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety. FSO, RM, IC DO, PDFE

CORE COMPETENCY: INTERPERSONAL & COMMUNICATION SKILLS

Goal: Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patients and patients' families.




FSO, DSP, RM DO, PDFE


FSO, RM, IC, USC DO, PDFE

Conduct both individual consultations and presentations at multidisciplinary conferences that are focused, clear, and concise. RM, IC, USC DO, PDFE

CORE COMPETENCY: PROFESSIONALISM

Goal: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.




FSO, DSP, RM, IC DO, PDFE



Demonstrate positive work habits, including punctuality, dependability, and professional appearance. FSO, RM DO, PDFE




DL, FSO, DSP, RM, IC DO, PDFE


CORE COMPETENCY: SYSTEM-BASED PRACTICE

Goal: Demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide cytogenetic services that are of optimal value

32



Demonstrate understanding of the role of the laboratory in the healthcare system.

DL, FSO, LI, IC DO, PDFE

Show a working knowledge of the basic principles of quality assurance, quality control, continuous quality improvement, and outcomes analysis, as they apply to cytogenetics.

FSO, RM, LI DO, PDFE

Demonstrate a familiarity with standards set forth by the CAP and TJC for laboratory certification. RM, LI DO, PDFE


(Specific questions to be discussed with the director)

• t(9;22) - What diseases is this associated with? What percentage of cases within each disorder is it present? What is the clinical significance when it is present in each disease? What are the genes that are located at the breakpoints? What is the molecular basis of the abnormality? What is the major breakpoint and what is the minor breakpoint? What is Gleevec? What is the mechanism of action of Gleevec?

• t(15;17) - What disease is this associated with? What gene is located at the breakpoint on chromosome 17? How is this disorder treated? What is the prognosis?

• t(8;14) - What disorder(s) is this associated with? What genes are located at each breakpoint? What alternative translocations are associated with the t(8;14)? What is the molecular basis of the abnormality?

• t(8;21) - What disorder is this associated with? What genes are involved? What is the prognosis? • Inv(16) - What disorder is this associated with? What genes are involved? What is the prognosis? • t(9;11) - Associated disorder? What gene is located at 11q23? What is the prognosis? • Inv(3)(q21q26.2) – prognosis? • t(4;11) - Associated disorders? What is the prognosis? • What is the most common situation in which FLT3, NPM1, and CEBPA mutation assays are

ordered? What is the clinical significance of each mutation? • KIT mutations are clinically significant in AMLs with what cytogenetic abnormalities? How

does the KIT mutation change the prognosis in AML? What other disorders are KIT mutations seen in?

• Describe diseases associated with PDGFRA and PDGFRB abnormalities. • t(2;5) - Associated disorder? What is the important gene? • t(11;14) - Associated disorders? What genes are located at each breakpoint? What are the

functions of the genes? • t(14;18) – What are the associated disorders? What genes are located at each breakpoint? What

are the functions of the genes? • t(11;18) – What is the associated disorder? What is the clinical significance? • t(12;21) – What is the associated disorder? Associated genes? Prognosis? • del(5q) – What is(are) the associated disorder(s)? What are the characteristics of the 5q-

syndrome? Is 5q- found outside of the 5q- syndrome? • -7 – What are the associated disorders? What is the prognosis?

33

• Loss of the Y chromosome - What is the clinical significance when seen in a bone marrow specimen?

• What are the most common additional chromosome abnormalities associated with CML in an accelerated phase or blast crisis?

• What chromosome abnormality is often associated with secondary AML following treatment with topisomerase II inhibitors?

• What chromosome abnormalities are often associated with secondary AML following chemotherapy with alkylating agents?

• What are the cytogenetic and clinical prognostic factors associated with childhood ALL? • What are the cytogenetic prognostic factors associated with multiple myeloma? What makes up a

MM FISH panel? • What are the cytogenetic prognostic factors associated with chronic lymphocytic leukemia? What

makes up a CLL FISH panel? • What is the UroVysion FISH assay used for? • What is high resolution chromosome analysis? • What is comparative genomic hybridization array analysis? How does it complement routine

cytogenetic analysis? • What is a break-apart FISH probe? What is a dual fusion FISH probe?

Duties

• Discuss above questions with director. • Review each hematopathology case coming through the lab during the two weeks. Verify the

correct test has been ordered and the correct procedure is being performed. Anticipate the possible cytogenetic findings. Be prepared to discuss the clinical significance of the findings. Be present to discuss each case when director is signing out.

• Check in Hematology and Surgical Pathology for diagnosis on all hematology cases coming through the lab. Be ready to discuss the relationship between the diagnosis and the cytogenetic result.

• The fellow will be given both a pre-test (first day of rotation) and a post-test (last day of rotation) to determine the increased competency obtained during the rotation.

34

References

1. Gardner RJM, Sutherland GR. Chromosome Abnormalities and Genetic Counseling, 3rd ed. New

York: Oxford University Press, 2004. 2. Gersen S, Keagle M. The Principles of Clinical Cytogenetics. Totowa, NJ: Humana Press, 1999. 3. Heim S, Mitelman F. Cancer Cytogenetics, 2nd ed. New York: Wiley-Liss, 1995. 4. Shaffer LG, Tommerup N, eds. ISCN 2005: An International System for Human Cytogenetic

Nomenclature. Basel, Switzerland: S Karger, 2005. 5. Therman E, Susman M. Human Chromosomes, 4th ed. New York: Springer-Verlag, 2001. 6. Thompson MW, McInnes RR, Willard HF, eds. Thompson & Thompson: Genetics in

Medicine, 6th ed. Philadelphia: WB Saunders, 2004. 7. World Health Organization Classification of Tumors: Pathology & Genetics – Tumors of

Haematopoietic and Lymphoid Tissues, Ed. Jaffe, et al. IARC Press, 2008. 8. World Health Organization Classification of Tumors: Pathology & Genetics – Tumors of

Soft Tissue and Bone, Ed. Fletcher, et al, IARC Press, 2002.

35

Molecular Pathology Rotation

Introduction

The overall goal of this rotation is to become competent in the concepts and interpretation of molecular testing and to learn consultative skills in the areas of molecular hematopathology. One week is spent in the Molecular Diagnostic Laboratory (Dept. of Pathology) to learn the concepts of molecular testing platforms using infectious disease testing as a model, and one week is spent in the Clinical Molecular Oncology Laboratory (Dept. of Pathology) to learn the concepts of molecular hematopathology testing using quantitative BCR/ABL testing by polymerase chain reaction as the model.



CORE COMPETENCY: PATIENT CARE Goal: Demonstrate a satisfactory level of competence in molecular pathology testing



Demonstrate a satisfactory level of competence in interpreting molecular test results (list of example molecular tests is below)

FSO, DSP,JC, RM, DL,IC

DO, PDFE

Demonstrate a satisfactory level of competence in interpreting histocompatibility test results (list of example molecular tests is below)

FSO, DSP, RM, DL DO, PDFE

Demonstrate competence in consultation for appropriate molecular pathology testing based on the clinical presentation

FSO, DSP,JC RM, DL, IC

DO, PDFE

Demonstrate competence in consultation for appropriate histocompatibility testing based on the clinical presentation

FSO, DSP, RM, DL DO, PDFE


Goal: Demonstrate knowledge about established and evolving biomedical, clinical and cognitive sciences and the application of this knowledge to molecular pathology



Demonstrate basic knowledge in molecular testing techniques. DL,JC,FSO, DSP,IC DO, PDFE

Demonstrate knowledge of common hematology-related genetic disorders and molecular tests associated with the disorders

DL,FSO, DSP, IC DO, PDFE

Demonstrate knowledge of the use of appropriate molecular tests for hematologic disorders

DL,JC,FSO, DSP,IC DO, PDFE

Demonstrate knowledge of appropriate specimen handling, storage and use for specific molecular and histocompatibility testing.

DL,JC,FSO, DSP, IC DO, PDFE

Demonstrate knowledge of the use of histocompatibility testing DL,JC,FSO, DO, PDFE

36

for transplant purposes DSP,IC CORE COMPETENCY: PRACTICE-BASED LEARNING & IMPROVEMENT Goal: Demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices.



Demonstrate the ability to critically assess the scientific literature. JC, RM DO, PDFE Demonstrate knowledge of evidence-based medicine and apply its principles in practice.

FSO, JC, RM DO, PDFE


DSP, RM DO, PDFE

Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety. FSO, RM, IC DO, PDFE





FSO, DSP, RM

RR, DO, PDFE


FSO, RM, IC RR, DO, PDFE





Demonstrate knowledge of regulatory and Health Insurance Portability and Accountability Act (HIPAA) issues pertaining to the use of genetic testing in human research and clinical molecular practice.

FSO, DSP, RM

RR, DO, PDFE





Demonstrate positive work habits, including punctuality, dependability, and professional appearance. FSO, RM DO, PDFE





Demonstrate a commitment to excellence and ongoing RM DO, PDFE

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professional development. Demonstrate interpersonal skills in functioning as a member of a multidisciplinary healthcare team





Demonstrate understanding of the role of the laboratory in the healthcare system. DL, FSO, IC DO, PDFE

Show a working knowledge of the basic principles of quality assurance, quality control, continuous quality improvement, and outcomes analysis, as they apply to molecular pathology.

FSO, RM DO, PDFE

Demonstrate a familiarity with standards set forth by the CAP and TJC for laboratory certification. RM DO, PDFE


Acquisition of Knowledge of Specific Tests Using Molecular Biology Methods

• Understand basic molecular biology concepts. • Know molecular testing methods for inherited causes for thrombophilia, such as factor V Leiden,

prothrombin 20210 mutation, MTHFR, and platelet glycoprotein III polymorphisms (PlA 1/2). • Understand molecular testing for hematologic malignancies, including non-Hodgkin lymphomas

(T-and B-cell gene rearrangements) and chronic myelogenous leukemia (bcr-abl detection and quantitation for therapeutic monitoring), and other translocation detection or quantitation assays.

• Be familiar with molecular testing for hereditary hemochromatosis, including the C282Y and H53D polymorphisms.

• Understand the principles behind human identity testing for transplant (see also the Immunology and Immunogenetics section).

Specific Analytical and Technical Training Learning Objectives for Molecular Pathology

• Have awareness of sample types, preparation, and storage for molecular biology tests. • Understand applicability of testing to samples of blood, bone marrow, body fluids (e.g., CSF,

pleural, and peritoneal samples), lymph node, and spleen. • Understand storage media and conditions for cells, DNA, and RNA. • Understand DNA extraction and purification from a variety of biological specimens. • Have knowledge of restriction endonuclease digestion of purified DNA or amplified DNA. • Understand electrophoretic separation of DNA fragments, native DNA gel electrophoresis for

verification of DNA quality, photographic documentation of gels, and capillary electrophoresis methods.

• Have knowledge of total cellular RNA extraction, quantitation, separation of mRNA, and reverse transcription to generate cDNA.

• Understand southern blot DNA hybridization. • Understand DNA sequencing. • Have experience and knowledge of in vitro DNA amplification using the PCR and alternative

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amplification systems, as well as awareness of methods to prevent contamination. • Understand varying means of analyzing PCR products, e.g., electrophoresis, sequencing, and

restriction enzyme digestion. • Understand mutation detection and scanning technologies for single-and multiple-mutation

platforms. • Understand real-time quantitative PCR and reverse-transcription-PCR. • Understand DNA and gene expression microarrays. • Be aware of the legal, ethical, and social implications of genetic testing.

Consultation and Presentation of Cases Using Molecular Techniques/Data

• Understand and use pedigrees for familial genetic assessments. • Interpret and report molecular results in association with pathologic and laboratory findings and

clinical history to reach a final diagnosis. • Assess the sensitivity and specificity of testing for an individual patient’s disease state.

Duties

• Review the procedure manuals for molecular pathology testing. • Complete the assigned handouts covering the facts and concepts of molecular testing. • Observe and perform selected molecular tests including BCR/ABL quantitative PCR. • Review selected hematopathology cases coming through the Clinical Molecular Oncology

Laboratory during the week and discuss the clinical significance of the findings with the lab director.

References

1. Association for Molecular Pathology. Recommendations for in-house development and operation

of molecular diagnostics tests. Am J Clin Pathol 1999;111:449. 2. Burtis CA, Ashwood EA, Bruns DE. Tietz Textbook of Clinical Chemistry and Molecular

Diagnostics, 4th ed. St. Louis, MO: Elsevier Saunders, 2005. 3. Coleman, WB, Tsongalis GJ. Molecular Diagnostics for the Clinical Laboratorian, 2nd ed.

Totowa, NJ: Humana Press, 2002. 4. Killeen AA. Principles of Molecular Pathology. Totowa, NJ:, Humana Press, 2004. 5. Leonard DGB. Diagnostic Molecular Pathology. Philadelphia: WB Saunders, 2003. 6. Persing DH, Tenover FC, Versalovic J, Tang Y-W, Unger ER, Relman DA, White TJ, eds.

Molecular Microbiology: Diagnostic Principles and Practice. Washington: ASM Press, 2003.

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Research Rotation

Introduction

The purpose of this rotation (8 weeks) is to acquire expertise in designing, conducting, and disseminating hematopathology-related research. The fellow must identify a specific research project, identify a specific faculty mentor, and follow the guidelines and procedures outlined below for the rotation. The ultimate goal is that the fellow present an abstract of the research project at a national scientific meeting and/or publish the data in a peer reviewed scientific journal.



CORE COMPETENCY: PATIENT CARE Goal: Learn to execute a clinical and/or a basic science research project, including mastering the appropriate technical skills required for completion of the project



Demonstrate competence in development of a clinical and/or basic science research project. RP, JC, RM DO, PDFE

Demonstrate competence in data collection, organization, and analysis for subsequent evaluation. RP, JC, RM DO, PDFE

Submit project data for presentation at a national meeting and/or submission to a peer-reviewed scientific journal. RP, JC, RM DO, PDFE,

RR CORE COMPETENCY: MEDICAL KNOWLEDGE

Goal: Understand how to design a research project, including formulating a hypothesis and designing an experimental strategy to evaluate it.



Demonstrate understanding of basic research methodologies. RP, JC, RM DO, PDFE Demonstrate understanding of statistical analysis of data collected RP, JC, RM DO, PDFE Learn to evaluate results for a given project in the context of other work in the research area RP, JC, RM DO, PDFE




Demonstrate the ability to critically assess the scientific literature. JC, RM, RP DO, PDFE Demonstrate knowledge of evidence-based medicine and apply its principles in practice. JC, RM, RP DO, PDFE

Develop personally effective strategies for the identification and RM DO, PDFE

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remediation of gaps in medical knowledge needed for effective practice. Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety. RM, IC DO, PDFE




Demonstrate the ability to write articulate, legible, and comprehensive yet concise research manuscripts, or posters. RM DO,PDFE

Conduct effective presentations at research conferences or meetings that are focused, clear, and concise. RM, IC DO, PDFE




Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them. RM, IC DO, PDFE

Interact with others without discriminating on the basis of religious, ethnic, sexual, or educational differences. RM, IC DO, PDFE

Demonstrate positive work habits, including punctuality, dependability, and professional appearance. RM DO, PDFE

Demonstrate a responsiveness to the needs of patients and society that supersedes self-interest. RM DO, PDFE

Demonstrate principles of confidentiality with all information transmitted both during and outside of a patient encounter. RM, IC DO, PDFE





Demonstrate understanding of the role of research in the healthcare system.

JC,DL, RM,IC DO, PDFE

Duties

• Follow the "guidelines and procedures" as outlined below. • Perform any specific tasks as determined by the research project and research mentor.

Guidelines and Procedures Definition: Research projects may be composed of a variety of styles including, but not limited to those listed below.

• A case report that demonstrates a new diagnostic entity, or provides new information about an existing diagnostic entity.

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• A case series composed of cases with similar theme or disease process. • A quality assurance project that results in a change in practices in pathology. • Evaluation of new tests or markers when compared to established practice. • A basic science project. • It is understood that a research project may not be completed within 8 weeks and may be

continued part time while the fellow is on other rotations as time allows. Procedure: Listed below are the required procedures for the Research Rotation

• The 8 week research rotation will be divided into two - 4 week rotations. One month prior to the first rotation, the fellow is required to submit a short outline of the project to the hematopathology fellowship program director. This project outline should include a project title, name of the research mentor, hypothesis, specific aim(s), and general strategy to collect and analyze data. The research mentor should sign the project outline.

• The hematopathology fellowship program director will review the project outline and give final approval.

• At the end of both the first and second rotation, the fellow is required to submit to the research mentor and program director a short progress report which will be used as part of the evaluation.

References

1. Daly LE, Bourke GJ, McGilvray J. Interpretation and Uses of Medical Statistics, 4th ed., Blackwell Science Ltd, 1991.

2. Dawson-Saunders B, Trapp RG. Basic and Clinical Biostatistics, 2nd ed., Appleton and Lange, 1994.

3. Day RA. How to Write and Publish a Scientific Paper, 2nd ed., ISI Press, 1983. 4. Friedman GD. Primer of Epidemiology, 4th ed., McGraw-Hill, Inc., 1994. 5. Gehlbach SH. Interpreting the Medical Literature, 5th ed., McGraw-Hill, Inc., 2006. 6. Glass DJ. Experimental Design for Biologists, Cold Spring Harbor Laboratory Press, 2007. 7. Rogers SM. Mastering Scientific and Medical Writing. A Self Help Guide. Springer-Verlag,

2007. 8. Ruxton GD, Colegrave N. Experimental Design for the Life Sciences, 3rd ed., 2011.

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CURRICULUM There is no formal curriculum, but there is ample education material, the opportunity to obtain clinical research training, educational conferences and formative evaluation as delineated below. Apprenticeship model of education Hematopathology training is an apprenticeship. Fellows build their careers by working closely with the pathology faculty together in building the six (6) core competencies, developing technical and diagnostic skills, application of technology and ancillary testing, and appraising the literature, assimilating evidence from scientific studies, among other things. Faculty sign out cases side by side (through a multiheaded microscope) with the fellows at least once every day all year long. Fellows train with a member of the faculty in this fashion at least 2.5-3 hours every day. Fellows train with faculty 30 minutes to 1 hour per procedure daily during procedures. The number of procedures varies daily and range from 1 or 2 to as many as 5 or more faculty assisted encounters. Fellows interact with additional approximately 30 minutes daily on average faculty for quality assurance, second opinions or preliminary screening to determine if ancillary studies will be needed. Faculty spend another 2 hours weekly preparing fellows for multidisciplinary conferences and another 5 hours altogether per week attending these conferences. Core Educational Activities Program objectives will be accomplished by participating in the following rotations, conferences and professional development research projects. ACGME competency-based goals and objectives for each rotation have been outlined before. Program Core Rotations: 12 months combined (13-4 week blocks) The fellow follows a structured daily schedule that provides a systematic approach to learning cytopathology.

I. Bone Marrow/Lymph Node II. Hematology/Flow Cytometry III. Research IV. Cytogenetic/Molecular Pathology

Clinical teaching activities

• Daily Hematopathology sign-out • Supervision by faculty on bone marrow/lymph nodes • Weekly conference preparation with faculty

DUTIES AND RESPONSIBILITIES

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Bone Marrow and Lymph Node Pathology Rotation Pathology residents and medical students will be trained and supervised by the fellow. The fellow will teach them (1) how to perform differential counts on blood smears and bone marrow aspirates, (2) how to enter bone marrow reports into the laboratory information system, and (3) how to prepare and present cases at the Hematology Case Conference. This training will likely take two to three days for each new resident and medical student, after which time they will share with the fellow in the daily bone marrow workload. The fellow will provide ongoing supervision on cell recognition, ancillary studies, clinicopathologic correlation, and clinician consultation. The fellow's involvement will not negatively impact the resident's training, since the average resident will still workup 180 bone marrow biopsies and sign-out 360 bone marrow biopsies during their residency. Laboratory Hematology and Flow Cytometry Rotation Pathology residents and medical students will be trained and supervised by the fellow. The fellow will teach them (1) how to interpret blood smears, body fluid cytospins, hemoglobin electrophoresis, platelet function analysis, and flow cytometry, and (2) how to enter interpretive reports into the laboratory information system. This training will likely take two to three days for each new resident and medical student, after which time they will share with the fellow in the daily workload. The fellow will provide ongoing supervision on test interpretation, ancillary studies, clinicopathologic correlation, and clinician consultation. The fellow's involvement will not negatively impact the resident's training, since the average resident will still workup 323 blood smears, 284 body fluid cytospins, 33 hemoglobin electrophoreses, 9 platelet function analyses, and 127 flow cytometry panels during their residency. In addition they will sign-out 646 blood smears, 568 body fluid cytospins, 66 hemoglobin electrophoreses, 18 platelet function analyses, and 254 flow cytometry panels. Research The fellow has two months of protected time to pursue a clinical or laboratory research project. During this time there is no clinical service or on-call duty. A research mentor will be chosen based on mutual agreement between the fellow and mentor. The fellow will be strongly encouraged to choose a project in the area of hematopathology. The educational goal is to develop a scientific hypothesis, design a research protocol to evaluate the hypothesis, collect the data, analyze the data, and disseminate the results. The results should be disseminated as an abstract presented at a national scientific meeting, or as a peer reviewed publication if sufficient data are collected.

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Fellows as consultants Fellows have many opportunities to serve as consultants:

• Fellows serve as the “first line” consultants on all cytology cases. • Fellows advise clinicians and resident trainees on submission of cytologic

specimens and are primarily responsible for confirming specimen adequacy of both superficial and deep fine needle aspirations performed by radiologists, other clinicians and pathologists themselves. Patient clinical history and clinical suspicions are discussed in conjunction with cytology findings and pathologic differential diagnoses and clinical plans. The fellow, with faculty backup, discusses diagnoses with the clinicians.

• Fellows teach and sign out with residents and medical students • Fellows review fellow-cytotechnologist discrepancies.

Fellows as consultants Fellows have many opportunities to serve as consultants:

• Fellows serve as the “first line” consultants on all cytology cases. • Fellows advise clinicians and resident trainees on submission of cytologic

specimens and are primarily responsible for confirming specimen adequacy of both superficial and deep fine needle aspirations performed by radiologists, other clinicians and pathologists themselves. Patient clinical history and clinical suspicions are discussed in conjunction with cytology findings and pathologic differential diagnoses and clinical plans. The fellow, with faculty backup, discusses diagnoses with the clinicians.

• Fellows teach and sign out with residents and medical students • Fellows review fellow-cytotechnologist discrepancies.

Continuous improvement To learn and eventually practice the best Cytopathology, continuous cytology and histology correlation is necessary. Exposure to some surgical pathology is necessary to maintain essential diagnostic skills. Fellows participate in Surgical Pathology as described below:

• Review and work-up of surgical pathology outside consultation cases on certain rotation as Fellow/Junior Attending.

• Encouraged to review frozen and permanent sections for cases for which they performed prior FNAs.

Graded responsibilities During the first month supervision is direct and very close, with the faculty member being present throughout procedures. In the next 2 to 3 months, depending on the skill level of the fellow supervision of an FNA procedure, for example is more indirect, with faculty available and physically present for the key elements of the procedure. Towards the end of training, fellows are expected to function on the level of a Junior attending with increased independence and self directed learning.

PROGRAM CORE CONFERENCES

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Name of Conference

Frequency Responsible Department

Required? (Yes/No)

Attendance Taken?

(Yes/No) AP Core Wkly Pathology Cytology

lectures only

Yes

Division Mgmt Meeting

Mthly Cytopathology Yes Yes

Multidisciplinary ENT Tumor Board

Wkly ENT Yes* Yes

Multidisciplinary Thyroid Tumor Board

Mthly ENT Yes* Yes

Organ specific slides

Mthly Pathology Yes* No

Grand Rounds Mthly Pathology Yes Yes GSMC 803 – Intro Clin. Research

Mthly for semester

General and Clinical Research Center

Yes Yes

Journal Club Mthly Pathology No Yes Multidisciplinary Breast Tumor Board

3x/mth Hematology/Oncology Yes* Yes

Cytology Unknown

Mthly Cytopathology Yes Yes

Quality Improvement

Mthly Pathology Cytology reviews only

Yes

Multidisciplinary Clinical Pathologic Correlation

Weekly Internal Medicine Yes Yes

Participation in the multidisciplinary patient management conferences are settings in which interdiscipliciplinary clinical quality improvement and patient safety are taught and learned. Additional Learning opportunities

• Attendance and presentation of research projects at national conferences • Participation in Annual Resident Research Day

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• Quarterly review of CAP hematology education program slides • ASCP Conferences • Review and study cases sent for consultation • KUMC and QUEST study sets

Professional Development Research Projects

• Quality Assurance Project • Clinical or Basic Science Research Project

EDUCATIONAL RESOURCES

Journals 1. American Journal of Clinical Pathology 2. Archives of Pathology and Laboratory Medicine 3. Cancer 4. Modern Pathology Textbooks 1. Bain BJ. Blood Cells: A Practical Guide, 1989 2. Bain BJ, et al. Bone Marrow Pathology, 1992 3. Beutler E, et al. Williams Hematology, 6th Ed., 2001 4. Bick RL, et al. Hematology: Clinical and Laboratory Practice, 1993 5. Bunn HF, et al. Hemoglobin: Molecular, Genetic and Clinical Aspects, 1986 6. Carey JL, et al. Flow Cytometry in Clinical Diagnosis, 4th Ed., 2007 7. Foucar K. Bone Marrow Pathology, 2nd Ed., 2001 8. Galagan KA. Color Atlas of Body Fluids: An Illustrated Field Guide Based on Proficiency

Testing, 2006 9. Glassy EF. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency

Testing, 1998 10. Hoyer JD, et al. Color Atlas of Hemoglobin Disorders: A Compendium Based on

Proficiency Testing, 2003 11. Ioachim HL. Lymph Node Pathology, 2nd Ed., 1994 12. Kjeldsberg C, et al. Body Fluids, 3rd Ed., 1993 13. Kjeldsberg CR. Practical Diagnosis of Hematologic Disorders, 4th Ed., 2006 14. Knowles DM. Neoplastic Hematopathology, 2nd Ed., 2001 15. Kottke-Marchant K. An Algorithmic Approach to Hemostasis Testing, 2008 16. McKenna RW, et al. The Handbook of Clinical Pathology, 2nd Ed., 2000 17. McPherson RA, et al. Henry's Clinical Diagnosis and Management by Laboratory

Methods, 21st Ed., 2007 18. Kumar V, et al. Robbins and Cotran Pathologic Basis of Disease, 7th Ed., 2005 19. Nguyen D, et al. Flow Cytometry in Hematopathology: A Visual Approach to Data

Analysis and Interpretation, 2nd Ed., 2007 20. Rogers GM. Case Studies in Hemostasis, 2000 21. Sack U, et al. Cellular Diagnostics. Basic Principles, Methods and Clinical Applications of

Flow Cytometry, 2009

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22. Schwartz E. Hemoglobinopathies in Children, 1980 23. Swerdlow SH, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid

Tissues, 4th Ed., 2008 List of library facilities available at the University of Kansas School of Medicine: Dykes Medical Library - collection of 104,100 books and 2175 periodicals. An extensive online journal collection is available for fellow use from any on site or remote computer. Numerous additional on-line medical databases are available through the library web site, including AccessMedicine and UpToDate. Slides 1. Clinical Material - hematopathology slides (bone marrow, lymph node, extra-nodal

tissues) from clinical cases accessioned by the University of Kansas Medical Center are stored and organized in slide cabinets by accession number and are available to the fellow for self-study. These slides comprise more than 20 years of clinical material. Slides are indexed in the CoPath software system by organ type and final diagnosis, as well as by patient demographics.

2. Lymph Node and Related Organs Teaching Set, 2002 Fall AP Slide Seminar, American Society of Clinical Pathology – 18 slides

3. Blood, Lymph Node, and Lymphoid Tissues Teaching Set, American Society of Clinical Pathology – 147 slides

4. Blood, Bone Marrow, Lymphoid Tissue Teaching Set, Mark Cunningham, MD – 54 slides

5. Body Fluid Teaching Set, Mark Cunningham, MD – 34 slides Photographs 1. Bone Marrow Pathology Teaching Set, Kathryn Foucar, MD, American Society of

Clinical Pathology – 250 photographs 2. Hematopathology Teaching Set, Armed Forces Institute of Pathology – 148

photographs Clinical Pathology Teaching Set, Alvin Ring, MD – 250 photographs Other Resources Space – A total of 60,591 square feet of space is available for educational purposes within the Department of Pathology, including 41,191 square feet of diagnostic lab space, 1200 square feet of office space, and 18,200 square feet of research space. Facilities – A pathology library with books and journals is accessible at all times within the Department of Pathology. Dykes Medical Library and History of Medicine Library are accessible during regular working hours.

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Equipment – A personal microscope with dry and oil objectives (2x, 4x, 10x, 50x, and 100x), personal computer with software (Word, Excel, PowerPoint), and digital camera is accessible at all times. Laboratory Information System (LIS) The lab system and the CoPath system are currently operating on a Veritas Cluster managed High Availability system running on Dual IBM 520 UNIX (version 5.3) servers for both the Lab and CoPath applications. The database for the lab system is Cache, VERSION 2007. The database for the CoPath system is Sybase, VERSION 12.5. Both applications utilize standard Microsoft Windows based workstations for access to each system. The current configuration is Windows 7. There are over 175 workstations in use for the Lab and CoPath applications. There are a variety of document printers and label printers installed for both application environments. All results from both the lab and CoPath systems are interfaced to the hospital information system, EPIC and ChartMaxx as the primary electronic medical record central results repository for the entire institution. Quality assurance/improvement education CoPath is used for various quality assurance indicators/measures. Fellows have access to CoPath, EPIC and ChartMAXX as they formulate their hematologic interpretations, and correlate histologic, laboratory and clinical data. Introduction to Clinical Research Fellows participate in the Introduction to Clinical Research course offered the General Clinical Research Center (GCRC) and now the Heartland Institute for Clinical and Translational Research. The following topics are covered:

• Who/What/Why/Where of Clinical Research • Developing Clinical Research Questions/Hypothesis • Types of Clinical Research Designs • Ethics of Clinical Research • Designing a Clinical Research Protocol • Research subjects • Study organization and management/Forms • Measures/Instruments • Outcomes, covariates, sample size, analytic plans • Critically Appraising Research-A Consumer’s Perspective • Grantsmanship / RI Funding • Writing a Clinical Research Paper and Submitting to a Journal • Effective Data Presentation: Platforms and Posters • From Bench to Bedside • Putting it all together: How I got my research off the ground at KUMC • Conduct of First-IN-Man Trials

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Fellows are also encouraged to present their research at the annual Residents, Postdocs and Fellows Research Day. Research resources http://www.kumc.edu/som/facdev/researchresources.html Board preparation Faculty provide board preparation and question sessions at the end of the academic year. Formal preparation for the Hematopathology Specialty Boards can be arranged with the Program Director, three months prior to administration of the test and with documentation of registration. Fellows also receive $1,000 for purchase of educational books. Counseling and Educational Support services The KUMC Division of student services provides comprehensive educational support, psychological and psychiatric services to students, residents and fellows. The approach they describe is proactive, collaborative, confidential and respectful. All psychological and educational services are provided at no cost to students, residents, and fellows. There are 3 learning specialists and 3 Ph.D.-level psychologists. Psychiatric services (i.e., medication evaluation and follow-up appointments are available for a reasonable fee. Electronic resources

A. Institutional resources • Graduate Medical Education: http://gme.kumc.edu/ • KUMC Information Resources: Online Clinical Resources

http://library.kumc.edu/clinicalreference.html • KUMC Chalk online training modules (go to myKUMC log on) • Information for Faculty and Staff http://www.kumc.edu/faculty.html • Hospital: https://access.kumed.com/vpn/index.html

EVALUATION Evaluation of fellows is accomplished by a variety of methods as follows:

• Direct observation • Review of patient reports • Global rating assessments • Projects • Procedure and case logs • Practical Examinations • Written examinations

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http://www.kumc.edu/som/facdev/researchresources.html

http://www.kumc.edu/studentcenter/scess/cost_eligibility.html

http://gme.kumc.edu/

http://library.kumc.edu/clinicalreference.html

http://www.kumc.edu/faculty.html

https://access.kumed.com/vpn/index.html

• 360° evaluations • Semi annual (formative and summative) evaluation by program director

Faculty perform direct observation and review of patient reports on a daily basis. Procedure and case logs are reviewed at the time of formative and summative evaluation. Other specific examples are: Objective third party evaluation (written examination) The department also participates in the Progressive Evaluation of Competency (PEC), and online examination program offered by the American Society of Pathology (ASC). There are a series of three tests (pre-exam, mid-exam and final-exam) designed to track fellows progress through the year and overall competency in Cytopathology. The results are returned to the program director who reviews these results with the fellows. If particular weaknesses are noted, the Program Director and/or individual faculty spend extra time with the fellows, recommend readings and/or review study sets with the fellows. Individual Faculty evaluation (global assessment) Program faculty completes electronic evaluations the fellows quarterly through the e-Value online evaluation tool. Fellows are evaluated based on the core competencies. Program Director evaluation (global assessment.) Cytology Fellows receive formative (at six months) and summative written evaluations (year end) from the Program Director. These are formal written evaluations which are given to the Fellows and discussed one-on-one with the Program Director. A copy is placed in the Fellow’s file and a copy is retained by the Director. In addition to the competencies outlined above, fellows are evaluated in the following areas: technical skills, morphologic skills, clinical judgment, teaching and research efforts. Fellows have the opportunity to discuss their training by evaluation of the Fellowship Program and the Program Director on an ongoing basis. 360 evaluations 360 degree evaluation of the fellows is utilized. Residents, the laboratory prep technician, a peer (Surgical Pathology Fellow), clinician and/or nurse will contribute to these evaluations. Projects Fellows perform a mock CAP inspection of the laboratory and report findings to the program director and/or co-director. Fellows are evaluated on the understanding of rules and regulations in place for hematopathology laboratories and their thoroughness with the project. Fellows perform research and QA/QC projects that are evaluated by program faculty.

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American Society of Cytopathology Progressive Evaluation of Competency (ASC-PEC) (written and practical examination: Fellows participates in the ASC-PEC. The PEC includes three online exams over the fellowship year that track a fellow’s baseline, mid-year and final level of knowledge and overall competency in cytopathology. Topics covered include: gynecologic, non-gynecologic, FNA, ancillary tests and laboratory operations. Each exam is available for a specified period of time during which the registered fellow will take the exam online. The results will be returned to the director to be reviewed with the fellow. The Pre-Exam is in the middle of July, the Mid-Exam is in the middle of January and the Post-Exam is at the end of May. Evaluation documents Permanent records are kept on file in the Residency Coordinator’s office and are accessible to the fellow. The final evaluation contains the following language: "The trainee has successfully completed the Hematopathology Fellowship training program, having demonstrated sufficient professional ability to practice competently and independently. In addition, the trainee has demonstrated sufficient competence to enter practice without direct supervision." Evaluation of Faculty and Program Since hematopathology training is an apprenticeship, there is frequent, close interaction between the faculty and trainee. Trainee input is solicited on a daily basis. Trainee input is also encouraged at monthly division management meetings. Fellows are required to complete electronic evaluations of the Hematopathology Faculty on a quarterly basis. Fellow confidentiality is maintained. All evaluations are reviewed and discussed with the Program Director and Department Chair. The fellows and faculty are required to complete a program evaluation annually. At the end of the year fellows meet with the program director, program co-director and program coordinator to review evaluations and give fellows the opportunity to provide input relative to program effectiveness. An action plan is developed for any concerns and there is always fellow input in that plan. The action plan is implemented over the next academic year and is reviewed and revised annually. Fellow Training location Main Campus The KUMC main campus is located at 39th and Rainbow in Kansas City, Kansas. The University of Kansas Hospital, University of Kansas Physicians outpatient clinics, the Heart Center, the soon to open Multispecialty Office Building, the Hemenway Kansas Life Sciences Innovation Center, and the academic units (School of Medicine, Schools of

52

Allied Health, Nursing and Graduate Studies) are located on the main campus. The hospital is staffed by UKP physicians and the MidAmerican Cardiology physician practice. Fellows spend the most of their training time at this site. Didactic lectures, journal club, research and most conference are located on the main campus. In addition to the excellent and wide range of clinical material available, the division of hematology has a wealth of teaching materials available for the training fellows and residents within the division and the department. Within the department there are greater than 100 texts and reference books. There are 5000 cases in study sets encompassing all organ systems and cytology specimen types. Duty Hours The program adheres to institutional GME requirements for duty hours and call policies. Please refer to the online Graduate Medical Education Policy and Procedure Manual @ http://www.kumc.edu/Documents/gme/GMEManual.pdf Briefly, duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care; time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. Training occurs within the context of the 80 hours per week, maximum duty period length and one day off in seven standards. Fellows work a maximum of 80 hours .averaged over a four-week period, inclusive of all in-house call activities. Fellows must be provided with one day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call. Adequate time for rest and personal activities must be provided. This should ideally consist of a 10-hour time period provided between all daily duty periods; 8 hours between duty periods is required. Fellows are in their final year of training and may stay on duty or return to the hospital to perform bone marrow or lymph node biopsies. At-home call (or pager call): The frequency of at-home call is not subject to the 8 hours between duty periods rule. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each fellow. Monitoring of duty hours Duty hours are monitored electronically through the MedHub system, which is an institution-wide system managed by the Graduate Medical Education office to ensure compliance. The program coordinator reviews fellow hours on a weekly basis. If irregularities occur, this information is immediately reported to the program director. Violation of duty hours

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http://www.kumc.edu/Documents/gme/GMEManual.pdf

A violation of duty hours would be reported to and addressed immediately by the program director. The program director would determine why the violation occurred and would take steps to ensure no future violations would occur in the future. On call duty Fellows are on call for preparation and immediate evaluation of stat hematology every 3rd week of the month. All call is supervised by faculty members. Fellows are given increased responsibility which will include more time on each procedure or task being indirectly supervised (immediate availability) by the faculty member. Hematopathology fellows are in their final years of training. Hematopathology fellows do not have overnight call or “night float”. Handoff Protocol Transfer of Care To provide safe and effective patient care in pathology, transitions of care hematopathology and consult specimens/cases) will use effective and structured hand-off procedures including the following:

End of Month Handoff Departing and arriving fellow MUST meet face to face to discuss incomplete cases and what each case needs to be signed out. The status of each incomplete case MUST be indicated on the paperwork for the case (ex awaiting immunohistochemistry or special stains, needs Q/A, history etc). All incomplete cases MUST have available clinical history, corrected procedure notes topography, and preliminary diagnosis entered as much as HUMANLY possible.

• The departing fellows are to make themselves available for questions as needed during the first week of the next month.

For on call fellow, if called in during the night or on the weekend • Write the details regarding the call (e.g. patient information, physician

information, results) on the paperwork. The will always be direct or indirect supervision by faculty.

For on call fellow, if the fellow receives a phone call not requiring coming in:

• Communicate this information in person or by email (prior to 8:30 am) with the call details to the pertinent fellow and attending. There will always be direct or indirect supervision by faculty.

POLICIES AND PROCEDURES

Fellows are expected to become familiar with the General Policies and Procedures listed in The Department of Pathology and Laboratory Medicine Resident Manual, as well as

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the Graduate Medical Education Policy and Procedure Manual (http://www.kumc.edu/Documents/gme/GMEManual.pdf) The Graduate Medical Education Policies and Procedures manual represents the institutional guidelines, policies and procedures governing the residents at the University of Kansas School of Medicine and Medical Center. Should material conflict between the institutional policies outlined in the Graduate Medical Education Policies and Procedures manual and those adopted by a program, i.e. the Department of Pathology and Laboratory Medicine Resident’s Manual, the Graduate Medical Education Policies and Procedures manual will take precedence. Work Environment The program will maintain an environment that is conducive to the health and well-being of the fellows. We will provide fellows with an educational and work environment in which fellows may raise and resolve issues without fear of intimidation or retaliation. Fellow qualifications Candidates must be Board eligible or certified in clinical pathology or anatomic and clinical pathology and must have or be eligible for an unrestricted license to practice medicine in Kansas. Recruitment and selection The Fellowship Training Program in Hematopathology is listed in the Directory of Pathology Training Programs published by the Intersociety Committee on Pathology Information, Inc. as well as on the institutional website. The program selects fellows from among eligible candidates on the basis of program related criteria such as their preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. Nondiscrimination The Hematopathology program will not discriminate with regard to sex, race, age, religion, color, national origin, disability, or any other applicable legally protected status as required by the ACGME Moonlighting Moonlighting is strongly discouraged. However, if a fellow should desire to moonlight, the following parameters must be followed. 1. All moonlighting must be approved, prior to the onset, by the Chair of the

department, Program Director and the Designated Institutional Official. 2. The description of the moonlighting functions must be on record in the office of the

Chair of the department. 3. The practice must not compromise the educational time or function of the resident in

the program and it must be during "off" hours. If the resident’s performance is

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compromised, the Program Director and/or department Chair may suspend the resident’s moonlighting privileges. (Graduate Medical Education Policy and Procedure Manual)

4. Kansas University Medical Center has no malpractice liability responsibility for activities covered under this section. Therefore, it is mandatory that the resident maintain personal malpractice coverage, at a level no less than that provided by the State of Kansas for activities related to our resident program. The carrier and policy number must be recorded on the approval form.

5. The fellow must have a permanent license to practice medicine in the state in which the moonlighting is to take place.

6. All moonlighting hours must be logged into the E*Value system, and must be approved by the Designated Institutional Official.

Vacations Each fellow is entitled to a fifteen days of vacation annually. The vacation period is to be scheduled through the Program Director, faculty for that month and other fellow(s) and must be acceptable to the fellow’s scheduled service. This vacation must be used in the fiscal year (July thru June) in which it is earned. Because of the many problems relating to the influx of new residents and termination of training of old residents on or around July 1, the following vacation policy pertains: In general, no vacation will be permitted for any resident from June 15 to July 15. When leaving town for any reason, whether on scheduled vacation or holiday or to attend a meeting, leave your complete temporary address with the Program Coordinator and notify the Program Director, faculty of that month and other fellow(s) of any necessary or anticipated change in call schedule. This requirement is largely for your benefit so that in the event of personal emergency you can be reached. Allotted time off during monthly rotations – Only one week per month may be taken off (vacation, sick leave, coverage for another resident, or other) on any given rotation. Additional time off will have to be made up during elective time. Until the excess time off has been made up, the resident will not receive credit for that rotation. Scheduling of vacation is restricted to certain rotations. Vacation times are scheduled by mutual agreement between the fellows. It is encouraged that fellows coordinate scheduling with the main program Chief Residents prior to the start of the academic year. Any changes in the vacation schedule after the start of the year must be approved by the Program Director. Reporting of Absences Unscheduled absences must be reported to Fellowship Coordinator as early as possible on the day of absence. The resident must also contact the service to which they are assigned. Fatigue

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All new residents must complete the Fatigue Training Module during the institutional orientation. All faculty members are also educated to recognize the signs of fatigue and sleep deprivation and must adopt and apply policies to prevent and counteract its potential negative effects on patient care and learning. A “swing” call room (Room 2901 Heart hospital) and/or travel vouchers are available for fellows who might experience fatigue. Personal problems There are a variety of resources available including mental or emotional conditions inhibiting performance or learning. These are:

The Department of Psychiatry A full range of inpatient, outpatient, and emergency services are offered for the diagnosis and treatment of personal problems, including chemical dependency. The department is professionally staffed by psychiatrists, psychologists, and social workers and appointments may be made through the Psychiatry Clinic or individually through the private practices of these faculty members. Kansas State Medical Advocacy Program A Kansas medical license may be revoked, suspended or limited if a health care provider becomes unable to practice with reasonable skill and safety due to physical or mental disabilities, including deterioration through the aging process, loss of motor skills or abuse of drugs or alcohol. Kansas law does provide a Medical Advocacy Program which providers can contact in lieu of contacting the Kansas State Board of Healing Arts. The goal of the Medical Advocacy Program of the Kansas Medical Society is to confidentially rehabilitate and support the provider whenever possible. Under the Impaired Practice provisions of the program, confidential assistance is offered to residents who suffer from chemical dependency or other forms of impairment. Also available to fellows is the counseling and educational support center which offers the following:

• Training Exam coaching • USMLE Step 3 Preparation • Specialty Board Exam Assistance • Educational and Performance Excellence Coaching • Manage Stress/Time • Residency Demands • Personal Life Demands • Relationships / Marital / Family Concerns • Personal Counseling • Psychiatric Counseling

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• Consultation and Referrals • Crisis Intervention • Lending Library- in training and board exams

These facilities are staffed by professional-level or practicum counselors. All services are provided in the strictest of confidence.

State of Kansas HealthQuest An additional source of assistance for residents needing confidential counseling, medical, and psychological support services is the State of Kansas HealthQuest, 24- hour, toll-free assistance line; if referred through the HealthQuest, the first counseling session is paid by the State. All contacts are kept in strict confidence. Residents may also contact or be referred to off-campus resources as appropriate.

Corrective action If there is a problem with the performance of any Fellow identified during any month or in the formative evaluation, the Program Director will immediately meet with the Fellow to discuss the issues and develop a plan of action. If there are no problems with performance, then the Fellows will review and sign their evaluations at six month intervals and at the end of the program. Grievance Procedure Should a fellow have a grievance or be dissatisfied with any aspect of the program, he/she is encouraged to initially discuss the issue with his/her attending. If the results are felt by the fellow to be inappropriate or the issue is not satisfactorily resolved, the fellow should bring the issue to the program director for discussion. If the fellow continues to feel that the issue or issues have not been adequately addressed, he/she should approach the department chair. If resolution cannot be attained the fellow may present the grievance in writing directly the Office of Graduate Medical Education as per GME policy. Miscellaneous Policies Medical Student Teaching Responsibilities Fellows participate in the teaching program as junior instructors. You will be involved with teaching residents and medical student histopathology labs. This is a valuable part of your experience. Your teaching responsibilities may also include substituting for senior staff in small group problem-based learning sessions. Occasionally, a fellow may be asked to give a lecture, if they have developed a special area of expertise, or express a desire to lecture. Pagers The Department will provide a pager for each fellow. If the pager is lost or damaged, the resident is responsible for the cost of the replacement.

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Procedures and Logbooks The ACGME requires Pathology residents to list the following procedures on the ACGME web-based logbook: autopsies, bone marrow aspirates/biopsies and fine needle aspirates. It is the responsibility of each resident to maintain updated ACGME logs. Hospital and Departmental Services Consult the main program Chief Residents or Fellowship Coordinator regarding uniforms, laundry, and necessary keys. Keys, protocols, slides, sections, and blocks must be obtained from and returned to the appropriate departmental offices. Assignment of individual offices, microscopes, and other equipment will be made by through Program Director. Conferences Fellows are required to attend hematology lectures in the Department's Clinical Pathology core curriculum, hematology conferences, hematology division management meetings, and the lectures in the Department's Clinical Pathology core curriculum. Fellows are also encouraged to attend the residents' AP/CP case presentations. Conference attendance will be recorded by the hematology laboratory supervisor respectively and reviewed on a quarterly basis by the program director. Failure to achieve the required attendance level (75%) will result in disciplinary action. Fellows are expected to attend monthly departmental quality improvement conferences, especially if hematology is being discussed. Participation in the multidisciplinary patient management conferences are settings in which interdiscipliciplinary clinical quality improved and patient safety are taught. All other policies including appointment of residents, resident agreements, resident standing, and program completion, remediation and probation, dismissals, appeal and fair hearing, , other forms of severance of the resident agreement, policy on prevention of illegal drug and alcohol use, personal leave (including maternity leave), and leave of absence, professional liability and risk management policies and procedures, policy on resident stipends and supplements, equal opportunity and harassment policies, policies related to loan deferment and financial counseling, policies regarding residents with disabilities, physical examination, immunization and post-exposure prophylaxis policies, policies relating to DEA registration, policy on resident transfers, and policies regarding overseas travel are all located within the GRADUATE MEDICAL EDUCATION POLICY AND PROCEDURE MANUAL (GME Manual) that is distributed to each resident during orientation. The GME manual is also located online at http://www.kumc.edu/Documents/gme/GMEManual.pdf Please Note: The Graduate Medical Education Policies and Procedures manual represents the institutional guidelines, policies and procedures governing the residents at the University of Kansas School of Medicine and Medical Center. Should material conflict between the institutional policies outlined in the Graduate Medical Education Policies and Procedures manual and those adopted by a program, i.e. the Department of

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Pathology and Laboratory Medicine Resident Manual, the Graduate Medical Education Policies and Procedures Manual will take precedence.

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Hematology turnaround time policy We expect over 80% of all of our specimens to meet the following expected parameters. All times, days and hours, are working days from delivery of the specimen.

• Uncomplicated specimens will be completed within 24 hours from delivery to the laboratory.

• Complicated specimens will be completed within 48 hours.

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Searching CoPath

How to search perform a natural language search 1. Click on the “Reports” button

2. Double click “Case Diagnostic Reports”

3. Double click “Nat Lang II Search No Race”. It is the only option that shows up.

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4. Now you will see a screen that looks like this.

5. For our sample search, I’ve arbitrarily decided that we want to find all cases of gastrointestinal leiomyomas in the past year. So, for accession date and sign out date, we will choose 1/01/2010 as the starting date, and 12/31/2010 as the end

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date. Just choose “User-selected date” for each date and type in the date you want, like so:

6. Now we will choose the specimen class. We are doing this for Dr. Al-

Kasspooles, who is only interested in KU surgeries and not outside cases or autopsy cases, so we will choose “surgical routine.” By not choosing “all” you will also make the search go faster. Select surgical routine by clicking “individual items,” then scrolling down to “surgical routine” and clicking “add”:

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7. Now we continue to “text search”, the most important and variable part of the search. Obviously we will want to search for “leiomyoma” in the final diagnosis line, which we can set up easily enough, like so:

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a. However, this will give us an obnoxious amount of uterine tumors that we are not interested in to sift through. To make our search more specific, we can have the case exclude words that are likely to be associated with uterine leiomyomata, such as “hysterectomy.” The odds of seeing the word “hysterectomy” in the final diagnosis line of a GI

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leiomyoma are slim to none, so we won’t lose any sensitivity by doing this.

b. Note: pay careful attention to the “ANY/ALL” buttons – if you are looking

to search for “invasive ductal carcinoma”, for example, you must make sure you have selected “ALL”. “ANY” will return every case that has “invasive” plus every case that has “ductal” plus every case that has “carcinoma” – which means your search will never end, never ever, until you force quit CoPath. In our example, we only have 1 search criterion for each box so we are not worried about this.

c. Note also that by choosing the “And/Or” button you can set up complex

logic statements to further refine your search.

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8. Now we will move down to “text type to print.” The more things we select, the

longer and more obnoxious our report will be to read. However, if you need to glean certain information from the gross, for example, having the gross description print out can save you the trouble of having to go back in to CoPath and look at each one of those cases individually. In our example, we will choose “Final Diagnosis” only.

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9. The last three options, “age”, “gender”, and “part type”, are things that I rarely

use in these searches. Gender can be useful if you want to reduce the search time for a search on prostate cancers, for example, or cervical cancer. For our example, we will leave these unmodified. So, now we are done and ready to see our search results. Click “OK”.

10. This step may take some time.

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11. As you can see, we got 31 cases in our search results. Looking at the first case that comes up, we see that at least one of these is still a female gyn case – doh! (In fact, most of them are.) This often happens, and you have to adjust your search criteria accordingly – for example, going back to exclude ANY of the following: “salpingo-oophorectomy”, “myomectomy”, “uterine” as well would make the search more specific. No big deal – just start relatively broad and then narrow it according to what you’re seeing – this is better than being too specific and missing cases that you would include in your study. To go back and modify your original criteria – DON’T close out your search – just choose “select criteria”.

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12. When you have the criteria fine-tuned, click print.

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University of Kansas School of Medicine · Pathology and ABMS certified in Hematopathology. He is...

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