Hematology/Oncology Fellowship Overview

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<ul><li>1.Hematology/Oncology Fellowship Overview The University of Wisconsin provides a unique environment for the training of physicians in pediatric hematology/oncology. Our program is designed to train primary careeducated pediatricians to become academic leaders in the care of hematologic/oncologic disorders in children, adolescents, and young adults. Fellowship training will provide the clinical and research experience necessary to treat a wide variety of related problems and will allow the physician to become a teacher, clinician, and researcher as well as to receive board certification in pediatric hematology/oncology. The primary purpose of our program is to prepare trainees for a career in academic pediatrics and to develop their clinical competence in the field of pediatric hematology/oncology. We provide diverse basic scientific training opportunities with an extensive program of clinical investigation. The program has the following goals: General goals: Development of strong, effective interpersonal skills to lead a multidisciplinary care team and interact effectively with patients who are either chronically or acutely ill. These patients come from diverse backgrounds and have different needs. Development of critical skills in the analysis of scientific literature Development of teaching skills Dedication to lifelong self-education Clinical competence in pediatric hematology/oncology: Development of a knowledge base in the pathophysiology of hematologic, immunologic, and oncologic disorders; the pharmacology and use of chemotherapeutic agents; the fundamental principles of radiation oncology; blood banking; coagulation; nutrition and bone marrow transplantation; and the diagnosis and management of infectious complications seen in the immunosuppressed host Development of a systematic, logical approach to clinical decision making. Expert use of the broad databases of history, physical examination, and laboratory evaluation to establish a diagnosis. Inclusion of ethical, socio-economic, and physiological considerations to develop a comprehensive treatment plan appropriate to the unique circumstances of each patient. Development of competence in design and conduct of a research project (clinical or basic): Identification of research/study questions Formulation of testable hypotheses Experimental design, along with identification and use of appropriate controls Analysis of obtained results and application of statistical principles Preparation of a manuscript that reports research results </li></ul><p>2. Clinical Experience The University of Wisconsin Hospital and clinics provide primary multidisciplinary care for approximately two million people in Wisconsin and northwestern Illinois. The division of pediatric hematology/oncology treats approximately 100 new oncology patients and 150 new hematology patients each year. On average, ten children undergo bone marrow transplantation each year. The division participates in pediatric phase I, II, and III trials of cytotoxic and biologic anticancer therapies. The division is responsible for the care of infants, children, and adolescents with primary hematologic or oncologic disorders, and participates in the care of infants, children, and adolescents with hematologic complications of other disorders. The division shares responsibility for the training of medical students, residents, and fellows. Fellows will receive broad clinical experience in the practice of pediatric hematology/oncology in concert with guidelines from the American Board of Pediatrics and Sub-board of Pediatric Hematology/Oncology. Objectives 1. To gain broad clinical experience in the diagnosis and management of pediatric hematology/oncology, including, but not limited to, malignancy of infants, children, adolescents, and young adults, nonmalignant hematology, including bone marrow failure syndromes, autoimmune diseases of the blood, coagulopathies, thrombophilias, hemoglobinopathies, thalassemia syndromes, BMT, and peripheral stem cell transplant 2. To achieve competence in marrow ablative therapy and stem cell rescue, as well as in the safe administration of non-ablative chemotherapy to children with cancer. 3. To achieve competence in the interpretation of peripheral blood smears, bone marrow aspirates, bone marrow biopsies, CSF cytospins, tests of blood clotting and fibrinolysis, platelet function, neutrophil function, hemoglobin electrophoresis, osmotic fragility, RBC enzyme assays, immune function, DNA repair, tissue typing, and blood typing 4. To achieve competence in the performance of bone marrow aspirates and biopsies and lumbar punctures with intrathecal administration of chemotherapy 5. To demonstrate initiative and skill in self-teaching and the use of information to devise sound management strategies for patients with novel or unique problems 6. To demonstrate understanding of the methodologies of clinical research for thoughtful evaluation of results published or presented 3. Summary of Clinical Rotations Inpatient Rotations Goals and Objectives: 1. To develop a broad fund of knowledge regarding the pathophysiology of all childhood malignancies, bone marrow failure syndromes, coagulopathies, thrombophilias, hemoglobinopathies, and thalassemia syndromes 2. To understand and execute the most efficient and cost-effective evaluation processes for the diseases mentioned above 3. To design a treatment plan for all diseases mentioned above 4. To conduct consent for treatment conference with the family 5. To implement changes of therapy, goals, and end-of-life care conferences with families 6. To write chemotherapy orders according to hospital policy 7. To perform lumbar punctures, bone marrow aspirates, and bone marrow biopsies on primary patients and keep a log of such procedures 8. To direct inpatient rounds with residents and students 9. To provide didactic teaching sessions to pediatric residents on inpatient service 10. To be the primary on-call physician at night and on the weekends with attending backup 11. To understand acute and chronic side effects associated with chemotherapy 12. To understand indications for and risks of transfusion therapy 13. To assist in bone-marrow harvesting The first year is largely devoted to clinical training and the development of expertise in procedures, diagnosis, and treatment plans. In addition, fellows gain expertise in terminal care of oncologic patients. Approximately half the year is spent on the inpatient service. Fellows oversee the delivery of pediatric care and take progressively increased responsibility for the diagnosis and management of subspecialty patients. They participate in the supervision and education of the general pediatric house staff, in collaboration with the faculty physician, and gain increased independence as warranted by demonstrated perception, knowledge, judgment, and communication skill. Fellows perform all procedures until they are completely competent, after which time, they teach pediatric residents how to 4. perform the procedures. They write all chemotherapy orders and have them checked by the attending and the pharmacy. The inpatient attending takes primary responsibility for all new inpatients. Whenever the fellow is on the inpatient service, these patients are assigned the fellow as their primary with the faculty attending as the supervisory physician. The inpatient service is composed of the attending, fellow, PGY-2, and two PGY-1. The PGY-1 follows the patients assigned to him or her, writes routine orders (except for chemotherapy), and provides general pediatric care. Fellows and PGY- 2 supervise PGY-1 along with the attending on service. The fellow is responsible for subspecialty diagnosis, performance of procedures, writing chemotherapy orders, and supervising chemotherapy administration. The fellow is continuously supervised, but he or she is expected to assume an increasing role in patient care and teaching of the house staff. Summary of duties of the inpatient fellow: Perform all histories and physicals on new patients and inpatient consults Perform all procedures on patients (lumbar puncture with intrathecal chemotherapy, bone marrow aspirate and biopsy, and bone marrow harvest) Read all peripheral blood smears, bone marrow morphology, CSF cytology, and surgical pathology with pathology faculty Review all imaging studies with radiology faculty Supervise general pediatric workups and management and discharge plans of pediatric residents Write all chemotherapy orders and review with inpatient attending and pharmacy Conduct family conferences regarding diagnosis, management plans, prognosis, and participation in research studies Participate in the teaching sessions for pediatric house staff The fellow is expected to gradually increase his or her role in all these duties and ultimately to act as a team leader. During the third year, fellows spend four to eight weeks pre-tending. They are expected to function as junior faculty, round with pediatric residents without attending, and organize the didactic sessions for the team. After rounds with the team, fellows round alone with the attending on service and help prepare documentation for the attending. This stage serves as the final preparation period to ensure the fellows readiness to assume faculty status the following year. 5. Outpatient Rotations Goals and Objectives: 1. To attend every clinic held by Pediatric Hematology/Oncology faculty 2. To evaluate outpatients who are seen on an urgent basis or for scheduled chemotherapy 3. To communicate promptly and effectively with referring physicians and consultants by phone and dictation of correspondence 4. To perform diagnostic and therapeutic procedures on patients seen 5. To understand policies and procedures regarding chemotherapy and blood- product administration 6. To attend outreach clinics (as schedules allow) dedicated to hematology consults and off-therapy surveillance visits for oncology patients 7. To be the primary on-call physician one weekend per month. During outpatient rotations, fellows attend eight half-day clinics under the direct supervision of faculty physicians. The fellows time is divided between hematology and oncology clinics, which meet simultaneously. Outpatient fellows are responsible for answering telephone calls from patients, seeing drop-in patients, and working with nurses to coordinate clinics. The outpatient fellow also attends monthly neuro-oncology clinic and long-term follow-up clinic of oncology patients who have completed their therapies. During outpatient rotation, the fellow attends weekly half-day hematology/hemophilia clinic, which includes patients with hemoglobinopathies, disorders of coagulation/hemostasis, white blood cell disorders, etc. This clinic is supervised by Dr. Carol Diamond. 6. Palliative and End-of-Life Care Rotation (Supervised by Dr. Margo Hoover-Regan) We recognize that most of our fellows have had very little exposure to this important part of medicine in their previous training. Palliative and end-of-life care comprise an integral part of pediatric hematology/oncology clinical work. For these reasons, fellows are required to do a palliative and end-of-life care rotation during the first (clinical) year of fellowship. Dr. Margo Hoover-Regan supervises this rotation. Palliative Care and End-of-Life Care Curriculum (Curriculum organized and conducted by Dr. Margo Hoover-Regan) Objectives: 1. To understand the basic philosophy of palliative care as it applies to children who live with life-threatening illnesses 2. To learn to effectively manage pain and other symptoms common to children with cancer (nausea, vomiting, fatigue, etc.) 3. To learn principles of effective communication with cancer patients and their families, especially in regard to difficult conversations about prognosis, transitions in goals of therapy, limitation or withdrawal of life-sustaining therapy, etc. 4. To be aware of some of the key ethical issues in pediatric palliative care 5. To learn to care for a child dying of cancer or complications of cancer treatment Objectives will be achieved by attending rounds with the palliative care team an average of once a week for four weeks and by attending didactic sessions. The fellow will attend rounds, which will last two to four hours each. This will involve attending scheduled, multidisciplinary UWHC Palliative Care service rounds as well as bedside rounds to current inpatients about whom the Palliative Care team has been consulted. Typically, one to six patients are seen or discussed in either of these scenarios. Once during the rotation, the fellow will also make rounds with a hospice physician at HospiceCare in Madison (to be confirmed with HospiceCare). Didactic sessions with Dr. Hoover-Regan will cover the following topics: 1. Management of pain and other symptoms 2. Advance care planning 3. Optimal communication with patients and families, including delivery of bad news and collaborative decision making (attention will be given to cultural sensitivity) 4. Ethical issues in palliative care 5. Care of pediatric oncology patients at the end of life 7. Format for these topics may be one-on-one teaching sessions, case presentations and discussion, lectures presented for Palliative Care rounds, pediatric hematology/oncology educational conferences, etc. 8. Introduction to Biomedical Research (Supervised by Dr. Sinisa Dovat) One of the most difficult decisions that a fellow has to make during the fellowship is how to choose a research project and mentor. Most of our fellows have had limited exposure to research in the past. The purpose of this rotation is to help fellows decide what kind of research they are interested in, who would be the best mentor for a particular project, and how much time they would like to dedicate to research. We would like to emphasize that the research component of the fellowship is individually tailored. Some of our fellows are very clinically oriented, some want to become physician-scientists with more bench-type basic research, and others prefer translational research. We respect each fellows choice, and we try to provide the best guidance to achieve research goals. For example, if a fellows major interest is in palliative and end- of-life care, we would provide extensive clinical experience in this field during the second and third years of fellowship, but we would also offer several projects (clinical, translational, or basic science) that are relevant to this topic to provide the fellow with an extra edge for the future academic career. We want to stress that research projects are not designed to interfere with the clinical experience of our trainees but rather to provide a different perspective to the clinical problem and to enhance the academic potential of our fellows. We are very committed to the education of our fellows, and we believe that the strength of our program is best measured by...</p>