Overview
Hematology/Hematopathology training for Wake Forest Baptist Medical Center AP/CP residents is a multifaceted program designed to instruct the resident in the methods used for detection, analysis, and measurement of hematologic specimens, for interpretation and diagnosis of hematopoietic disorders. The overall curriculum consists of three specific educational and training components:
- one month of Basic Hematology
- 3 months of Hematopathology
- comprehensive Hematology/Hematopathology didactic lecture series
A fourth, optional component may be taken as an advanced elective following completion of the required rotations.
Goals and Objectives
Following successful completion of all required Hematology/Hematopathology training, the resident will:
- Understand the basis and diagnostic criteria for the classification scheme of hematopoietic disorders/neoplasms. Formulate differential diagnoses of hematopoietic disorders, through the correlation and interpretation and correlation of morphology, clinical data, and relevant phenotypic/genotypic ancillary studies. [Medical Knowledge]
- Provide detailed morphologic evaluation and interpretation of peripheral blood smears, body fluid preparations and bone marrow, lymph node, spleen and thymic specimens and other extranodal specimens obtained for the evaluation of reactive and neoplastic hematopoietic disorders. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Understand work-up of patients with anemia to include interpretation of hemoglobin electrophoresis, Heinz body stains, hemoglobin H stains, and osmotic fragility, etc., and be able to utilize this information in proposing laboratory test selection to establish diagnoses. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Learn interpretation and diagnosis of immunophenotypic analysis of hematolymphoid malignancies, including immunohistochemistry technology, flow cytometry, and cytochemistry. Correlate data with histologic findings. Describe the decisions involved in antibody selection. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice]
- Learn molecular diagnostic applications and interpretation of hematopoietic lesions, including PCR, in situ hybridization, conventional cytogenetics procedures, and fluorescent in situ hybridization (FISH). Discuss the use of molecular assays in the diagnosis of hematolymphoid malignancies. Correlate data with histologic findings. Describe the decisions involved in test selection. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice]
- Interpret hemoglobin electrophoresis, serum protein electrophoresis, and protein immunofixation assays. Become familiar with other tests, including plasma hemoglobin, serum viscosity, osmotic fragility, sickle solubility, and G6PD [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Understand work-up of patients with coagulopathies, including appropriate specimen collection and interpretation. Obtain proficiency/familiarity in interpretation with various coagulation procedures, including prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen determination, coagulation factor assays, coagulation factor inhibitor studies, fibrin-fibrinogen degradation product determination, bleeding time, platelet aggregation studies, and special molecular assays, etc. To be able to utilize this information in proposing laboratory test selection to establish diagnoses. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Understand the principles, interpret the findings, and know the clinical significance of normal and abnormal results obtained on urine specimens. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Understand importance of gathering and reviewing relevant previous pathologic studies and information
for correlative review [Patient Care, Practice-Based Learning and Improvement] - Make management/triage decisions regarding lymph node and/or extranodal biopsies for possible use in ancillary studies, including flow cytometry, cytogenetics, paraffin immunohistochemistry, molecular/genotypic analysis, and/or tissue culture as indicated [Patient Care, Medical Knowledge, Systems-Based Practice]
- Develop the ability to write concise, informative and comprehensive reports on specimens submitted for examination; to develop communication/liaison skills to discuss pertinent findings with submitting physicians, pathologists, laboratory staff, and serve as an effective consultant with clinicians [Interpersonal and Communication Skills, Professionalism, Medical Knowledge, Systems-Based Practice]
- Obtain current literature or information in the field of hematopathology [Practice-Based Learning and Improvement, Professionalism]
- Discuss issues of quality assurance and lab administration related to hematology laboratories. Be familiar with and participate in Quality Control, Automation/Instrument operation, LIS, and lab management. [Practice-Based Learning and Improvement, Systems-Based Practice]
- Demonstrate competence in the use of microscopic photography, including digital imaging technology through active participation and presentation in conferences. Recognize role as a important member of hematopathology diagnostic team and role as educator [Medical Knowledge, Practice-Based Learning and Improvement, Professionalism, Interpersonal and Communication Skills]
Duration
The required Hematology/Hematopathology training is a minimum of a total of four months, split into a one month of Basic Hematology (first year) and 3 month s of Hematopathology (2nd, 3rd, 4th years) blocks. Additional time for any of the required or elective rotations may be arranged at the approval of both the Residency Program Director and the Rotation Director (or designees).
A maximum of two residents per rotation will be allowed.
Clinical Rotations
Urinalysis and medical microscopy training for residents is part of the rotation course in which the residents receive specific hands on training and expertise including urine physical characteristics, urine chemical tests, aminoacidurias, and urine sediment. Practice case studies are used in addition. Other areas of study include standard dip-stick urinalysis testing as well as automated urinalysis instrumentation. Medical microscopy for cellular morphology and crystal and cast identification is studied. Medical microscopy of cerebrospinal, pleural, peritoneal, synovial and bronchoalveolar lavage (BAL) specimens is covered. The resident is expected to be available for consultation during the day for interpretation of morphologic findings, and issue a referral report form. Abnormal and unusual microscopy findings and all BALs are referred to cytology.
Other tests the trainee will become familiar with include plasma hemoglobin, serum viscosity, osmotic fragility, sickle solubility, and G6PD. The resident will help to process patient samples from start to finish using automated cell counters and integrated/interfaced laboratory computer systems, and learns principles of procedure, reagents, equipment, and materials.
Resident Responsibilities
On the first day of the rotation, the resident will meet with the Rotation Instructor to establish a detailed schedule.
Education level specific goals and objectives for first year resident:
- Learning indications, principles, logistics, and general operation procedures for laboratory reagents and equipment in processing hematologic samples [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- List laboratory normal values and state reasons, both technical and biochemical, for abnormal values [Patient Care, Medical Knowledge]
- Preparing of marrow aspirate slides, biopsy touch preps, peripheral blood smears, and body fluids [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Performing bone marrow (500 cell count) and peripheral blood (100 cell count) differentials [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Processing and interpreting other special hematologic work-ups, e.g. serum viscosity, osmotic fragility, sickle solubility, G6PD, etc. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Processing and interpreting urinalysis and medical microscopy of cerebrospinal, pleural, peritoneal, synovial fluid and bronchoalveolar lavage (BAL) specimens. [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Discuss the pathophysiology of various disease states and their associated laboratory findings by evaluating erythrocyte and leukocyte morphology and maturation, identification of abnormal cells in the bone marrow and peripheral blood, hemoglobin electrophoresis results, coagulation theory and testing, urinalysis chemical tests and results, and comparison of cerebral spinal fluid, serous fluid, and synovial fluid
- Evaluate acceptability of patient results based on QC, disease state, and previous values [Practice-Based Learning and Improvement, Systems-Based Practice]
- Follow standard safety precautions at all times in the laboratory [Professionalism, Practice-Based Learning and Improvement, Systems-Based Practice]
- Presenting 15 minute didactic for laboratory staff CE [Medical Knowledge, Practice-Based Learning and Improvement, Professionalism, Interpersonal and Communication Skills]
- Attending specific conferences, including the Hematology/Oncology Case Conferences, Hematopathology Consensus Conference, and Laboratory Quality Assurance/Improvement. See details below for conference descriptions and activities. [Professionalism, Practice-Based Learning and Improvement, Systems-Based Practice]
Satisfactory performance in the Basic Hematology Rotation will be demonstrated by obtaining an average final grade of 86% or better on the tests, quiz, final exam, resident evaluations, laboratory practicals, and resident laboratory grade, otherwise requiring remediation.
Resident Responsibilities
On the first day of the rotation, the resident will meet with the Rotation Instructor, on-service Hematopathology Attending and/or Hematopathology Fellow for orientation and to establish a detailed schedule. A typical rotation will include hands-on performance and interpretation experience in the following areas:
1. Surgical Hematopathology
Over the course of the Hematopathology rotation the resident participates in the evaluation and sign-out of adult and pediatric hematopoietic disorders, which includes correlating peripheral blood data, marrow aspirate smears, trephine core biopsies/clot sections, nodal/extranodal tissues, as well as any/all relevant phenotypic/genotypic ancillary studies, including flow cytometry, cytochemical and immunohistochemical stains, molecular/cytogenetic studies. In addition, the resident is responsible for gathering and reviewing relevant previous pathologic studies and information from patient’s medical record.
All studies are reviewed in detail and final sign-out of cases will be done with the attending hematopathologist at a multi-headed microscope, correlating the relevant clinical and biological features into a final diagnosis. As graduated responsibility, the resident is required for dictation of the final report, with appropriate levels of guidance from the attending physician, and is expected to work nearly independently by the end of rotation. The resident is also responsible for contacting the appropriate submitting clinician, and communicating unexpected or urgent results. The resident will ultimately be able to discuss the pertinent findings with the submitting physician, and to serve as an effective consultant.
Education level specific goals and objectives for the resident:
- Learning/practicing indications, principles, logistics, and general operation procedures for processing/triaging surgical hematopoietic samples [Patient Care, Medical Knowledge, Practice-Based Learning and Improvement]
- Morphologic examination of marrow aspirate slides, biopsy touch preps, peripheral blood smears, and trephine core biopsies [Patient Care, Medical Knowledge]
- Morphologic examination of lymph node biopsies and other lymphoreticular specimens [Patient Care, Medical Knowledge]
- Correlation with clinical presentations/features [Patient Care, Medical Knowledge]
- Diagnostic/interpretation and correlation with phenotypic analyses, including cytochemistry, immunohistochemistry, and flow cytometry [Patient Care, Medical Knowledge]
- Diagnostic/interpretation and correlation with genotypic analyses, including PCR, in situ hybridization, FISH, cytogenetics/karyotypic analysis at daily Cytogenetics Sign-Out [Patient Care, Medical Knowledge]
- Schedule meeting for daily sign-out/rounds with faculty for case reviews [Professionalism, Interpersonal and Communication Skills]
- Formation of final integrative written report, including benign or malignant bone marrow and lymphoid specimens, in a timely manner (to be completed on the day the specimen is received) and pass the completed report to the attending pathologist. All pertinent laboratory data, including CBCs, flow cytometry results and special stains should be used in generating this provisional report. The attending staff pathologist will review each case with the resident via a multi-headed microscope, or give immediate follow-up on any disagreements in the resident’s provisional report and the final report. [Medical Knowledge, Practice-Based Learning and Improvement, Professionalism, Interpersonal and Communication Skills]
- Liaison and consultation with other pathology or clinical services, e.g. Cytopathology, Hematology/Oncology, etc. [Interpersonal and Communication Skills, Professionalism, Medical Knowledge, Patient Care, Systems-Based Practice]
2. Flow Cytometry Laboratory
The resident spends time rotating through the flow cytometry laboratory to learn the basic principles and operation of the flow laboratory. The resident uses the first experience of the rotation to follow at least one specimen of each type from accession, through specimen preparation, cell staining, acquisition on the flow cytometer, results analysis, interpretation of results and report generation. Practical points such as pitfalls vs. advantages, direct versus indirect staining, whole blood lysis vs. gradient separation, quality control, gating practices, and computer analysis are all discussed.
As graduate responsibilities, the resident is expected to review the histograms and slides on all leukemia/lymphoma or other hematologic cases, complete the write-up sheet, and present the case to the attending hematopathologist. The resident will be expected to communicate the results to the submitting physician and correlate the flow cytometry findings with other studies available for review, e.g. paraffin section, cytogenetics, and molecular diagnostics.
Education level specific goals and objectives for the resident:
- Reviewing the histograms and slides on all leukemia and lymphoma cases [Patient Care, Medical Knowledge]
- Completing the write-up sheet and presenting the case to the pathologist. The resident is involved in result reporting under the supervision of the attending physicians and lab directors in each section. The resident will participate in, but is not primarily responsible for, interpretation and sign-out of final patient reports under the supervision of the attending hematopathologist [Medical Knowledge, Patient Care, Practice-Based Learning and Improvement, Professionalism, Interpersonal and Communication Skills]
- Report and communicate the results to the submitting physician, with other pathology or clinical services, e.g. Cytopathology, Hematology/Oncology, etc. [Interpersonal and Communication Skills, Professionalism, Medical Knowledge, Patient Care, Systems-Based Practice]
- In addition to the routine, daily, clinical work research projects are available. [Practice-Based Learning and Improvement]
3. Special Clinical Chemistry/Hematology
The rotation in the Specialty Hematology Section includes instruction in serum and urine protein electrophoresis, immunofixations, and hemoglobin gel electrophoresis, including both acetate and agar
electrophoresis procedures. The resident will learn correlation and integration with CBC data, peripheral blood smear morphology, clinical features, and other relevant laboratory data (direct antiglobulin test, reticulocyte counts, serum heptoglobin, serum bilirubin, etc.) to arrive at a diagnosis.
Education level specific goals and objectives for the resident:
- Interpretation of procedures for hemoglobin electrophoresis, and serum/urine protein electrophoresis/immunofixation assays [Patient Care, Medical Knowledge]
- Written/result reporting under the supervision of the attending physicians. The resident will participate in, but is not primarily responsible for, interpretation and sign-out of final patient reports under the supervision of the attending hematopathologist [Interpersonal and Communication Skills, Professionalism, Medical Knowledge, Patient Care, Systems-Based Practice]
- The resident will be expected to report and communicate the results to the submitting physician. [Interpersonal and Communication Skills, Professionalism, Medical Knowledge, Patient Care, Systems-Based Practice]
This rotation will be arranged at the approval of both the Residency Program Director and the Rotation Director (or designees).
Conferences and Didactics
- Bone Marrow Rounds - daily.
During the Hematopathology and Advanced rotations, the resident attends these daily clinicopathologic correlation conferences. Marrow Rounds are a primary didactic specialty-specific conference performed at a multi-headed microscope, held in conjunction with the Clinical Hematology team to review all current bone marrow specimens. The rounds allow the resident to interact with the Clinical Hematology team on a daily basis. Topics include case-relevant pathobiologic features, treatment and therapeutic options, prognostic factors, etc., with both Attending Hematopathologist and Attending Clinical Hematologist. The resident participates in teaching of fellows, junior residents, medical students, in morphologic evaluation and interpretation of peripheral blood smears and bone marrow specimens.
- Cytogenetics Sign-Out - daily.
During the Hematopathology and Advanced rotations, the resident attends and participates in the daily cytogenetics and molecular genetics sign-out of current hematopoietic malignancies, including acute/chronic leukemia, myeloproliferative neoplasms, myelodysplastic disorders, and lymphoproliferative disorders. Topics of discussion principally relate to correlating cytogenetic and molecular data with all case work-ups as part of a multi-modality diagnostic approach.
- Hematology/Oncology Case Conference – 2nd, 4th Wednesday of month.
Residents on all rotations (Basic Hematology, Hematopathology, Advanced) attend and participate in this bi-monthly case-based interdisciplinary conference held in conjunction with the Section on Hematology/Oncology, Department of Internal Medicine, in which the residents/fellows present and discuss morphologic features, pertinent laboratory findings, and diagnostic interpretations of cases. As a graduated responsibility, case presentations (one or more) are assigned by the Hematopathology Fellow or Attending, as the resident acquires more experience, typically during the second rotation. The resident is responsible for review of appropriate diagnostic materials, digital photography, and presenting cases using digital presentation formats.
- Hematopathology Consensus Conference – 1st, 3rd, 5th Wednesday of month.
Residents on all rotations (Basic Hematology, Hematopathology, Advanced) attend and participate in this monthly intradepartmental case conference held by Attending Hematopathologists, and involving the entire Hematopathology Section, other AP/CP Attendings/Fellows/Residents. Discussion involves presentation of cases posing problematic or difficult diagnosis, cases representing particularly atypical or typical pathologic characteristics, and/or any case of interest. Relevant journal articles are also presented for discussion. Residents may present current cases, with varying degrees of difficulty depending on level of training/experience in advance of the conference. The resident is responsible for higher-level contributions in case discussions, including review of relevant/current literature on the topic, review of pertinent pathology materials, including previous pathology and ancillary studies, be knowledgeable about clinical and laboratory findings, and be able to discuss diagnostic interpretations.
- Clinical Pathology Case Conferences – 2nd and 4th Thursday of month
Residents on all rotations (Basic Hematology, Hematopathology, Advanced) attend and participate in this bi-monthly case-based interdisciplinary conference held in conjunction with the Sections of Clinical Pathology. Residents present and discuss specific hematologic cases, including morphologic features, pertinent laboratory findings, and diagnostic interpretations of cases. The resident is responsible for review
of appropriate diagnostic materials, digital photography, and presenting cases using digital presentation formats, if appropriate.
- Clinical Pathology Core Laboratories QA Meeting – 4th Thursday of month
During the Hematopathology and Advanced rotations, the resident attends the monthly QA Hematology Administration meeting to gain further experience in managing a Hematology Laboratory, including instrument maintenance, quality control problems, technical staffing issues, capital equipment procurement, and triaging of performance of high-cost/low volume tests, appropriate record keeping, etc. The resident may be involved in the screening and implementation of new techniques or methods introduced into the surgical hematopathology service for diagnostic or research purposes.
Evaluations and Milestones
Resident
The resident will be evaluated by the rotation faculty/staff and Hematopathology Fellows. Methods of evaluation will include direct observations by attending faculty, 360 evaluations by clinical laboratory staff, "on-the-fly" spot evaluations, oral/written/unknown case work-ups, and written documentation of activities including procedure/case log and conference presentations. Resident assessment will be based on performance in the following areas:
- Daily morphology sign-out/rounds
- Daily review of written provisional reports
- Assistance and availability to the attending Hematopathologists
Faculty/Rotation
At the completion of each rotation, the resident will be given the opportunity to evaluate the rotation and the faculty.
Milestones
Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. Evaluation of Milestones will be made in consultation with Residency Program Director for the semi-annual reviews of resident performance. As part of the overall Hematology/Hematopathology training, residents will work in achieving the target milestones designated as level 3 and 4. Examples of milestones include, but are not limited to:
- Preparing full consultative reports with comprehensive review of medical records on common and uncommon hematologic diseases [Patient Care]
- Prioritizing and presenting patient care issues for report after call, applying standardized procedures for failed critical value call-backs, and appropriate specimen triaging protocols [Patient Care]
- Effectively communicating preliminary results on cases in progress, including clinically significant or unexpected values and critical values [Patient Care, Interpersonal and Communication Skills, Professionalism]
- Understanding analytic issues and quality control for advanced precision diagnostics, including understanding potential confounding factors that may contribute to erroneous results [Patient Care]
- Preparing and leading discussion on developing a focused differential diagnosis based upon clinical information and/or abnormal laboratory results [Medical Knowledge, Patient Care, Interpersonal and Communication Skills]
- Interfacing with clinical team to recommend tests, based upon current literature, and suggests evidence-based management, prognosis, and therapeutic recommendations based on the consultation, and prudently applying justification for approval of costly testing [Patient Care, Systems-Based Practice]
- Interpreting ancillary phenotypic (flow cytometry, immunohistochemistry) and genotypic (molecular, cytogenetics, FISH) testing results in clinical context with full integration into comprehensive report [Medical Knowledge, Patient Care]
- Performing scientific literature review and investigation of clinical cases to inform patient care (evidence-based medicine) and improve diagnostic knowledge of pathology [Medical Knowledge, Practice Based Learning and Improvement]
- Teaching across departments and at all levels, including to clinicians, patients, and families [Medical Knowledge]
- Preparing, presenting, and leading case discussions at multidisciplinary conferences [Interpersonal and Communication Skills]
- Developing a portfolio of clinical consultation experience and scholarly activities, which may include manuscript preparation, abstract presentation at a local, regional or national meeting, or other scientific presentation [Professionalism, Practice Based Learning and Improvement]
- Anticipating team needs and takes leadership role to independently implement solutions [Professionalism]
- Participating in new instrument and test selection, verification, implementation, and validation (including reference range analysis) and maintaining a portfolio of participation of these experiences [Systems-Based Practice]
- Able to correctly use Current Procedural Terminology (CPT) and ICD9 (ICD10) codes for billing purposes [Systems-Based Practice]
- Demonstrating knowledge of proficiency testing and its consequences [Systems-Based Practice]
Absences
Given the curriculum and laboratory work flow requirements, scheduled time off for the Basic Hematology rotation will not generally be granted. Activities missed from unscheduled time off, e.g. sick time, will need to be made up. Excessive time off from the rotation will require remedial work as determined by the Rotation Instructor, Residency Program Director and Rotation Director.
A maximum of one week’s scheduled absence (vacation or locum tenens time) may be taken during the Hematopathology rotation. Such time is to be approved by both the Residency Program Director and Rotation Director (or designees) prior to beginning the rotation.