HEMATOLOGY-MEDICAL ONCOLOGY SUBSPECIALTY CONSULTS/ELECTIVE ROTATION DIVISIONS OF HEMATOLOGY-MEDICAL ONCOLOGY-CELL THERAPY

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1 Department of Medicine Internal Medicine Residency Program HEMATOLOGY-MEDICAL ONCOLOGY SUBSPECIALTY CONSULTS/ELECTIVE ROTATION DIVISIONS OF HEMATOLOGY-MEDICAL ONCOLOGY-CELL THERAPY ROTATION DIRECTORS: Carlos De Castro, MD Hematology/Oncology Fellowship Program Director Thomas Ortel, MD, PhD Clinical Chief, Division of Hematology Michael Kelley, MD Chief, Hematology-Oncology, VA Medical Center ADMINISTRATOR: Sarah J. Overaker Hematology/Oncology Fellowship Program Coordinator OVERVIEW: The Duke Hematology-Medical Oncology Consults Rotation for Junior and Senior assistant Residents (JARs/SARs) consists of an inpatient, consultative experience for the medical house staff, presenting trainees with the opportunity to learn a broad spectrum of non-malignant Hematology at Duke University Hospital and both Hematology and Medical Oncology at the VA Medical Center. The Duke Hematology-Medical Oncology Elective Rotation for medical Interns consists of an inpatient, consultative experience presenting trainees with the opportunity to learn a broad spectrum of Hematology and Medical Oncology at Duke University Hospital and the VA Medical Center. The Interns do not have call duty during this rotation. Required didactic conferences during this rotation are: -Hematology/Oncology Grand : 143 Jones Building, Wednesdays, 7:30 9 a.m. -Hematology Service Case Conference: Room 2993, Duke Clinic (Duke South) in front of Clinic 2B-2C, Tuesdays, 8-9 a.m. -Hematologic Malignancy Grand : Rauch Conference Room, Morris Building, Fridays, 9:15 10:15 a.m. 1

2 GOALS OF THE ROTATION: 1) Develop the ability to perform a medical history, review of systems, and physical examination to adequately evaluate, diagnose and begin to provide therapy and advice for patients with suspected or confirmed Hematologic and Oncologic disorders and their complications 2) Learn how to perform inpatient consultations and become a competent and caring physician in the needs of patients with Hematologic and Oncologic disorders who require hospitalization SPECIFIC OBJECTIVES: 1) Demonstrate the ability to evaluate new patients for the presence of hematologic and oncologic disorders a. Identify characteristics on the review of systems that are consistent with the presence of various hematologic-oncologic disorders and their complications. b. Perform a thorough physical examination with focus on manifestations of hematologic and oncologic disorders c. Order and interpret appropriate diagnostic testing for patients with hematologic and oncologic disorders and their complications d. Learn to function as a consultant for the evaluation and management of patients with hematologic and oncologic disorders 2) Develop skills to evaluate and co-manage, together with the subspecialist, patients with established hematologic and oncologic diseases a. Learn to diagnose and treat complications of hematologic and oncologic disorders b. Manage the complications associated with the treatment of various hematologic and oncologic disorders by chemotherapy and/or radiation therapy 3) Learn and practice Hematology-Oncology procedural skills including: a. Examination of the peripheral blood smear b. Understand the indications for and, if possible, learn to perform bone marrow aspirate and biopsy under the supervision of the attending physician PATIENTS, DISEASE PROFILE and DUTIES The Duke University Hospital Hematology Consult Service Rotation The house staff on the Duke Hematology Consult Service Rotation work closely with a postdoctoral Hematology-Oncology fellow who is responsible, under the supervision of the teaching attending, for the performance of inpatient Hematology and Coagulation consults as requested from all other clinical services at Duke University Medical Center. The medical residents are responsible for seeing consult patients under the supervision of the fellow and attending. As needed, the resident and fellow will also communicate and work with the Special Heme laboratory, the Clinical Coagulation Laboratory, the Transfusion Service, the Apheresis Service, and the Pharmacy to expedite the management of patients on the consult service. The resident will review the cases with the fellow and staff all new consults during rounds with the Attending daily. The required didactic conferences during this rotation are the Clinical Hematology Conference (Tuesday, 8:00 AM) and Hematology-Medical Oncology-Cellular Therapy Divisions Grand (Wednesday, 7:30 9:00 AM). Residents are also welcome at the didactic core curriculum lectures for fellows on each Monday at 11:30 AM in the Rausch conference room in Duke 2

3 South as well as the Hematologic Malignancy conference on Fridays at 9:15 AM in the Rausch conference room. Some examples of diseases encountered during this rotation include patients with sickle cell syndromes include those with Hgb SS, SC, and a variety of other hemoglobinopathies. Patients with coagulation abnormalities may include those with congenital and acquired bleeding disorders (e.g. hemophilia, von Willebrand s disease, acquired coagulation inhibitors), with acute thrombotic disorders (e.g. pulmonary embolism, thrombotic thrombocytopenic purpura), or with complications of chronic thrombotic disorders. Consults will come from all parts of Duke University Medical Center and present with a wide variety of hematologic problems, both acute and chronic. The Hematology Service will see a variety of disorders related to blood cells as well as thrombotic conditions and hemorrhagic diseases. Hematologic disorders will include anemias and other cytopenias, disorders relating to abnormally high blood cell counts, and bone marrow disorders due to intercurrent diseases and treatments. Consults will also include requests for evaluation and treatment of deep venous thrombosis (including TIA, stroke, acute coronary syndromes, thromboses involving catheters and unusual sites), pulmonary embolism, and the antiphospholipid antibody syndromes. Hemorrhagic disorders will include both surgical complications, patients with hereditary factor and platelet disorders, and acquired disorders of coagulation that develop in patients requiring hospitalization. The Hematology Service may be asked to evaluate the possibility of a malignant hematologic diagnosis; if such as diagnosis is made, the patient will be referred for inpatient or outpatient follow-up to an appropriate Hematology or Medical Oncology physician (attending or fellow), per the attending physician s recommendation. A faculty member will supervise the performance of all initial consults as well as the follow-up of patients after the initial consultation as needed. Faculty will generally be assigned on a 1-week basis. Duties on the Duke University Hospital Inpatient Hematology Consult Service The Hematology/Coagulation functional pagers ( / ) should always be signed over to either the Heme-Onc fellow or rotating medicine resident taking first call for consults. The Hematology Service should provide consultation for in-patients in a timely fashion (generally the same day as the request is received). In addition, the consult service must on occasion provide same-day urgent consultation service, when required, for patients referred from out-patient clinics or patients for whom surgery is planned or emergency room patients with hematologic emergencies such as severe thrombocytopenia or coagulopathy associated with hemorrhage. All consultations must include a written report assessing the patient's problem and providing guidance regarding further care. References from the literature should be included wherever possible. Residents (JARs and SARs) may see 2-3 patients in consultation/day. Interns on Heme-Onc elective typically see 1-2 consults/day. JARs and SARs may be scheduled to take weekend call with the attending and carry the pager. Interns do not take call during this rotation. The house officer will notify the Clinical Coagulation Lab Person-In-Charge ( ) of all consults requiring specialized coagulation laboratory testing, so that this can be expedited on these patients. In complex cases, the house officer will work closely with the laboratory staff and the fellow and attending so that laboratory evaluations will proceed quickly and efficiently. All patients will be presented daily to the Hematology Attending by the assigned resident and the hematology fellow. Curbside consults are discouraged. The fellow and the house officer together will ensure that continuity of care is provided for all patients seen in consultation who have on-going problems that require follow-up. This will include daily 3

4 contacts with primary team physicians including residents and students and follow-up rounds or discussions with the attending, as needed. The house officer should review all peripheral blood smears and bone marrow aspirates and biopsies and all other pathology results pertaining to patients seen by the Hematology Service with the fellow and the attending physician. Durham VA Medical Center Hematology-Oncology Consult Service (JARs/SARs) Residents rotate typically for 4 weeks on Hematology-Oncology during the second or third year of residency. A portion of this time (usually 2 weeks) involves a rotation at the VA Hospital. The goal is to provide exposure to patients with a diversity of hematology and oncology problems in an environment that provides adequate oversight and instruction but also encourages autonomy in clinical decision making. In addition, this rotation will provide training in the interpretation of blood films and to an introduction to the interpretation of bone marrow aspirates. The consult service usually cares for patients at a time. The majority of patients suffer from carcinomas or lymphomas. Leukemias, other general hematologic problems, and coagulation problems constitute approximately 10-20% of all encounters. Duties on the VAMC Hematology-Oncology Inpatient Consult Service- Evaluate inpatients requiring new consultations for hematologic or oncologic problems and discuss new consults with the consult fellow on the same day the consult is received. Act as consultant in the management of patients hospitalized and under continuity care in the outpatient clinics. Interpret all blood films performed on inpatients on the consult service. Patients seen and evaluated by the house officer are discussed and reviewed first with the consult fellow and then with the attending on service. New and relevant literature is presented and discussed. A weekly review of all pathology specimens including bone marrow biopsies is performed with the pathologist on the Surgical Pathology rotation. Weekly multidisciplinary conferences are held for Thoracic Oncology, Gastrointestinal Oncology, and general Hematology/Oncology at the VAMC. The resident is expected to attend the Hematology/Oncology/Cell Therapy Grand Conference on Wednesdays at 7:30 A.M. VA MEDICAL CENTER CYBERSECURITY: The VA strictly prohibits plugging any USB device into a VA computer. This is not limited to but includes flash (thumb) drives, external hard drives, digital cameras, IPODs, MP-3 players, etc. If this is done it will immediately become detected and investigations will ensue. It is considered a serious violation and will be reported as an incident to the VA National Network Security Operations Center. Duties on the Duke and VAMC Hematology-Oncology Outpatient Clinics (Interns) Ambulatory Clinics: Adult patients seen in follow up for confirmed Hematologic-Oncologic conditions and adult outpatients seen in consultation for questions about initial diagnosis or management of suspected or confirmed Hematologic-Oncologic conditions. 4

5 Outpatient clinics 1. Attend Hematology, Medical Oncology or Cell Therapy faculty outpatient clinics at Duke University Hospital whenever not at conference or one s own continuity clinic. In this capacity, the intern will evaluate new and return patients as directed by the faculty member. Interns will be taught to perform a complete history and review of systems and to perform a detailed physical examination. Each patient will be presented to the faculty member, who will repeat the history and physical examination and formulate the assessment and treatment plan with the intern and patient. Depending on the faculty member, the intern may be asked to dictate a note. The intern will not be expected to write prescriptions. The faculty member will be responsible for follow up on testing ordered during the visit, though the intern is encouraged to do so as well for continued learning. 2. Interns on Hematology-Medical Oncology rotation may be assigned to see patients at the Durham VAMC Hematology-Oncology clinics. In this clinic, the intern will evaluate new and follow-up patients under the direct supervision of faculty members. This evaluation will include obtaining a detailed history from the patient, performing a full physical examination and formulating an assessment and plan. Each patient will be fully discussed with an attending who repeats the history and physical examination and formulates an assessment and treatment plan with the intern and patient. The intern will complete a written note and forward it to the attending for signature. The intern is requested to compose a skeleton note immediately after the visit, and to complete all notes after all patients are seen. The intern is expected to follow up on laboratory results obtained after the visit and discuss any abnormalities with the attending. 3. Attend all conferences as detailed above 4. Review literature pertinent to Hematology-Oncology disease processes in patients the intern evaluates ON-CALL DUTIES: The fellow assigned to the Duke Hematology Consult Service will be on-call for emergency consults from Monday 7 A.M. through Friday evening rounds. The Hematology Resident will provide weekend coverage for the Duke Hematology Consult Service and the VAMC Hematology-Oncology Consult Service, according to the online schedule listed at The Fellow of the service whose resident is NOT the on-call resident for the weekend will page the on-call resident at the end of evening rounds on Friday for sign out. Weekend call begins Friday evening, approximately 5 p.m., through Monday 8 A.M. The resident will be responsible for any needed follow ups and for new consults on both services during the weekend. The attending will provide back-up to the resident for both routine follow up and new acute problems and consults throughout the weekend. PROCEDURES: The house staff may perform procedures in which they are properly trained and will be assisted and supervised by the fellow or attending physician as appropriate. These procedures include peripheral blood smear examination and bone marrow aspiration and biopsy. All procedures will be documented by a written note in the chart. Prior to all procedures, patient identification should be accomplished using the TIME-Out process. 5

6 HAND-OFF PROTOCOL: If the resident sees patients on the inpatient consultation service on the weekend during the call duty, the resident should sign out the patients and any follow-up issues with the Hematology fellow at the end of their call duty on Monday AM. The fellow is expected to then take over the pager EDUCATIONAL CONFERENCE ATTENDANCE: House staff will attend the following conferences: -Hematology/Oncology Grand : 143 Jones Building, Wednesdays, 7:30 9 a.m. -Hematology Service Case Conference: Room 2993, Duke Clinic (Duke South) in front of Clinic 2B-2C, Tuesdays, 8-9 a.m. -Hematological Malignancy Grand : Rauch Conference Room, Morris Building, Fridays, 9:15 10:15 a.m. BACK-UP: At no time should house staff feel overwhelmed by either the number of patients to care for on the consult service, amount of work to do or a feeling that there are too many patients that need to be seen. In the event that this does occur, the resident must take responsibility for asking for help and should not feel any pressure to not do so, or that such an action would be viewed as a sign of weakness. Available resources include the fellow on call, the chief resident, and the attending physician on service or on call. EDUCATIONAL METHODS: The house staff rotating on the Hematology-Oncology elective rotation will learn by direct patient encounters performing consults, reading about the problems as s/he sees them, and then presenting this material to the consult attending and then to the patient care service requesting the consultation. All consult notes, in so far as possible, should include appropriate references to current literature. The resident will also have the opportunity to present interesting cases at the Hematology Case Conference on Tuesday mornings. The resident and the fellow should also personally meet with the involved pathologist when histological diagnoses are made. Residents are assigned significant responsibilities for patient evaluation and care in both the inpatient and outpatient settings where teaching and supervision are provided by fellows and attending physicians. These clinical experiences are complemented by didactic conferences which focus on clinic and basic science aspects of Hematology-Oncology as well as an integrated learning experience of basic Hematopathology. Reading list: An online reading list has been compiled by the American Society of Hematology: Clinical Coagulation Laboratory: The Attending and clinical laboratory staff as needed will provide instruction to the residents in the interpretation of laboratory tests useful in the diagnosis of von Willebrand's disease, lupus anticoagulants, factor inhibitors, platelet function abnormalities and heparin-induced thrombocytopenia. The resident should seek opportunities to visit the Coagulation Laboratory to discuss the results of specialized tests. Transfusion Service: Dr. Marilyn Telen has a curriculum of handouts and key references that is available to residents on this service. Supervision of the trainees by faculty is accomplished by: 6

7 Review by the faculty of the resident s history and physical examination, plan of therapy and evaluation of laboratory and other diagnostic data Direct Observation of Resident s History and Physical Examination Direct Observation of Procedures and Skills Case Review and Discussion at Conferences Assumption of graduated responsibility for the care of patients is monitored by: Review by the faculty of the resident s history and physical examination, plan of therapy and evaluation of laboratory and other diagnostic data Direct Observation of Procedures and Skills Case Review and Discussion at Conferences EVALUATION METHODS: Each resident will be evaluated for his/her ability to formulate a reasonable plan of diagnostic testing and patient management, as well as by his/her performance of collateral reading and medical knowledge, judgment, intellectual honesty, and maturity. The resident s performance in the core competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and system based practices will be evaluated by the various attending physicians with whom s/he works during this rotation and documented using Each resident will also be evaluated by the attending as to his/her potential for academic medicine, insofar as the attending can assess this through observation and interaction in the context of this in-patient and consult service rotation. Residents will also receive individualized verbal feedback from fellows and attendings with whom they work on this rotation. Residents are encouraged to request feedback verbally from supervising fellows and attending physicians during the course of and at the conclusion of the Hematology-Oncology experience. 7

8 CORE ACGME COMPETENCIES in Hematology-Medical Oncology Consults Rotation: Patient Care 1. Gather essential and accurate information about patients with hematologic and oncologic disorders 2. Develop and carry out comprehensive patient evaluation and management plans for patients with benign hematologic disorders as well as patients with complications of cancer. 3. Learn the basic interpretation of peripheral blood smear morphology and the indications for performing a bone marrow aspirate and biopsy for the diagnosis of hematologic disorders 4. Develop clinical skills, experience and competence to serve as a benign hematology and Medical oncology consultant under the supervision if the fellow and attending physician. Medical Knowledge 1. Appropriately use and interpret routine hematology tests as well as basic and specialized tests of hemostasis and thrombosis for congenital and acquired disorders and regulation of antithrombotic therapy. 2. Gain clinical experience and competence in the diagnosis and treatment of benign hematologic disorders and congenital and acquired disorders of hemostasis and thrombosis. 3. Develop clinical experience and competence in transfusion medicine, including the evaluation of antibodies, blood compatibility, and the indications for and complications of blood component therapy and apheresis procedures. 4. Gain clinical experience and competence in the diagnosis and treatment of acquired and congenital disorders of red cells, white cells and platelets as well as hemoglobinopathies and the management of acute complications of sickle cell disease. 5. Develop basic knowledge and evaluation skills of Oncologic disorders and their complications 6. Learn the basic principles and chemotherapy and diagnose and manage complications of chemotherapy Practice Based Learning and Improvement 1. Identify and evaluate evidence from clinical and scientific studies relevant to patients with hematologic and oncologic disorders 2. Present case discussions and literature reviews at the weekly Hematology Case Conference working closely with the Hematology-Oncology fellow. Interpersonal and Communication skills: 1. Work effectively as part of the consult service team consisting of fellows, other residents, medical students and pharmacists. Professionalism: 1. Demonstrate respect, compassion and integrity at all times 2. Demonstrate a commitment to excellence and ongoing professional development 8

9 System Based Practices: 1. Practice cost-effective utilization of laboratory studies, blood products, and coagulation factor concentrates 2. Work effectively with primary health care teams and ancillary care providers to provide appropriate and timely patient care 3. Coordinate outpatient follow-up for consult patients and communicate with clinic physicians 9

10 TYPICAL ROTATION STRUCTURE- Intern/JAR/SAR Hematology-Oncology Elective/Consults WEEK 1 Duke Hematology Consults Monday Tuesday Wednesday Thursday Friday 8:00 AM Sign 8:00 9:00 7:30 9:00 AM out from the Hematology Hematologyweekend Case Oncology Grand resident on conference duty 3PM: Inpatient 8:00-9:00 AM Medicine Grand 9:15-10:15 AM Hematologic Malignancy Grand WEEK 2 Duke Hematology Consults 8:00 AM Sign out from the weekend resident on duty 3PM: Inpatient 8:00 9:00 Hematology Case conference 7:30 9:00 AM Hematology- Oncology Grand 8:00-9:00 AM Medicine Grand 9:15-10:15 AM Hematologic Malignancy Grand WEEK 3 VAMC Hematology- Oncology Consults 8:00 AM Sign out from the weekend resident on duty 3PM: Inpatient 8:00 9:00 Hematology Case conference 7:30 9:00 AM Hematology- Oncology Grand 8:00-9:00 AM Medicine Grand 9:15-10:15 AM Hematologic Malignancy Grand WEEK 4 VAMC Hematology- Oncology Consults 8:00 AM Sign out from the weekend resident on duty 3PM: Inpatient 8:00 9:00 Hematology Case conference 7:30 9:00 AM Hematology- Oncology Grand 8:00-9:00 AM Medicine Grand 9:15-10:15 AM Hematologic Malignancy Grand 10

11 TEACHING ATTENDINGS ON DUH INPATIENT HEMATOLOGY CONSULTS ROTATION Attending Office Home Pager Murat Arcasoy, M.D Gowthami Arepally, M.D Philip Blatt, M.D. Laura De Castro, M.D Regina Crawford M.D Ara Metjian, M.D Thomas Ortel, M.D., Ph.D Nirmish Shah, M.D.. Marilyn Telen, M.D

12 DURHAM VAMC PHONE/PAGER LIST FOR HEMATOLOGY ONCOLOGY Arcasoy, Murat Asheville VA Arepally, Gow Charlotte OPC Bone Marrow Room 7214, 7568 Danville OPC fax Cates, Vicky (marrows) 7214, 7568 page 0565 Durham VAMC or Chemo Unit 7043, 7163, 7044, 7203 Marvis, Kia, Karen, Karen F ville VA or Cunningham, Stephanie SW 5068 or page 0229 or SWS 6974 FVAMC alpha x 5160 fax Fax Machine D Greenville OPC fax Fax Machine 1D Hillandale OPC ; fax J ville OPC fax Finch, Anne (marrows) 7212 or cell Morehead OPC fax Goforth, Harry 6083/ Raleigh OPC Graves, Ester Page 0753 Wilmington OPC Iden, Deborah 7563/ Salisb VA or Kendall, DiSean W-S OPC Kinser, Michaelene OCNS 7213 or page 0173 Greenville OPC fax Kelley, Mike 7326, 7331/ Gillmer, Barb or x 6168 Kelley, Pat Overaker, Sarah Lowery, Jill--Psychology 7064,6934 or page GSU FVAMC x McCormack, Meg (PA) 7251 or STEPS (Thal/Rev) Celgene Celgene Fax Microscope Room 7546, 7547, 7557, 5131 BMT Coord Mikki Peoples x 5258/ Parker, Shirley (H/O sec) 7590 IRM computer 5812 Ramiah, Veshana IRU 5114 Simmons, Alice (H/O 6944 Medical Records 6217 or 6222 sec) Weinberg, Brice 6833 or Microbiology 6689 Williamson, Kristen (NP) 5520 or MRI 5818 or 5092 York, Sally MUGA 7359 Yost, Becky (PA) 7180 or Nuclear Med 6952 or 7349 or C Phlebotomy 7215, 7591 Nursing Svc 6131 (Felecita & Edna) 1C RNs (James, Jennifer, et al) 7087, 5601 Pathology 6535 or 6537 (histology) 12

13 1C Clinic Mgr. (Sloan, 7082, 5246 Pathology FNA page 0365 Letitia) Admissions/Util. 6244/ Patient Regis 5034 Review AOD/Bed Control 6250 or page 0346 Duke , Fax Blood Drawing 1st Floor 6233 Pharmacy, Page 0696 Chemo Blood Bank 6532 Pharmacy, OP 6232 Chemistry Lab 6999 Pharmacy, Inpt Chromosome Lab x 4060 Pharmacy, IV 6069 (Labcorp) CT 6611 or 7387 Pharm Ron L Page 0689 DUMC Pharm Vault 7396 Echocardiogram (Roger) 7257 or page 0528 Police 6230 ECRC 7700/7710 Pul or page 0227 Function/Resp E-R 6304 Radiation Onc 6996 or 6007 Escort 7811/706 Radiology Sched 5976 Flow Cytometry Ultrasound 6607/report 6622 Heme Lab 6529 or 6530 Vascular Rad 6620 or