Rotation: Hematology/Medical Oncology
Site:
- Education Conference Room, Amarillo VA Medical Center
Instructors:
- Dr. Wright, and Dr. Sicola (PhD), Kathleen Whittler RN, chemotherapy nurses.
Makeup of team (responsibility of each team member):
- Resident: Could be PGY 1, 2, or 3.
The resident is expected to attend the Internal Medicine Morning Report from 8:00am to 9:00am from Monday-Friday and then to meet with the hematology/medical oncology staff to discuss patients on the inpatient service. The resident is expected to perform a history and physical examination on new consult patients, to formulate a diagnosis and make a preliminary plan of investigation and management, which is then reviewed with the attending, and to write a daily consult note. The resident is expected to perform a history and physical examination on selected patients of interest in the outpatient hematology/medical oncology clinic from 9:00am to 11:45am on Mondays, Tuesdays and Thursdays. He or she is expected to discuss with his clinic attending each patient on whom he/she has completed a history and physical examination, to write clinic notes, treatment orders (including chemotherapy orders, where appropriate) and plans for follow-up, all of which will be reviewed and co-signed by the attending. Other patients may also be discussed in the clinic depending on interest. The resident is expected to present one or two cases at the weekly Decision Tumor Board Conference on Wednesdays from 8:00am to 9:00am . In the rare instances when patients are admitted into the hospital for chemotherapy, the resident is expected to do a history and physical examination, write chemotherapy and other admission orders and participate on ward rounds with the inpatient Hematology/ Medical Oncology attending physician every day except on weekends and public holidays.
In-patient duty attending:
One attending on inpatient and consult duty each month is primarily responsible for supervising the resident meets daily after Morning Report from Mondays to Fridays to discuss patients, review clinical history and examination findings, discuss appropriate diagnostic tests and the results thereof, carry out didactic teaching on hematology and medical oncology topics, do bench teaching using a multi-headed microscope, teach and supervise the writing of chemotherapy orders. This attending also reviews the cases that should be presented by the resident at the Decision Tumor Board meeting. The attending is expected to teach humanistic attributes and encourage the development of compassionate care for patients with hematologic and oncologic problems. The attending also gives the resident feedback on his performance over the course of the month and, in a formal process, at the end of the month. This attending also participates in clinic teaching.
The attending not on in-patient duty supervises the resident in his outpatient hematology/oncology clinic on the days when the inpatient attending does not have one. He carries out the same didactic, supervisory and mentoring role mentioned above. This attending also gives input to the inpatient attending during the formal evaluation of the resident.
One Ph.D. nurse teaches the residents the proper technique of bone marrow aspiration and biopsy, teaches the management and care of indwelling venous access catheters, teaches ethical, social and compassionate issues related to cancer care, teaches appropriate use of pain medications in cancer patients, and teaches the value of prosthetic devices such as wigs and bra implants to cancer patients. This nurse also teaches humanistic attributes in the care of cancer patients.
One hospice care nurse demonstrates the value of hospice care to terminally ill patients, discusses the indications and demonstrates the practical provision of end of life care to these patients, teaches the management of ethical, emotional and social issues that arise during the terminal stages of illness.
Chemotherapy nurses demonstrate practical issues related to the administration of chemotherapy such as the distinction between drugs that can be administered through peripheral veins and those that have to be administered into large central veins, management of side-effects of chemotherapy, and the compassionate treatment of patients with hematologic and oncologic illnesses.
Days per week (night call):
The team rounds 5 days per week, Mondays to Fridays except on public holidays. There is no night or weekend call.
Usual time of attending rounds (meeting place): 9:15am to 11:45am for established consult patients. New patient consult rounds from 1:00pm to 4:30pm on days when the resident does not have a scheduled clinic at the University (meet in the attending physician's office in Medical Service)
Types of patients encountered: A broad range of patients with benign and malignant hematologic disorders and solid tumor oncology will be encountered. Given the nature of the VA, the majority of patients will be male but there is a small minority of female patients. A significant proportion of the patients will be of geriatric age and have multiple, chronic problems. Residents have great exposure to the management of benign hematologic disorders such as cytopenias of varying etiology, benign myelo- and lymphoproliferative disorders, drug-induced hematologic disorders and auto-immune disorders. There is a wealth of exposure to malignant hematology such as the care of acute and chronic leukemias, malignant lymphoproliferative disorders, myelodysplastic syndromes, and solid tumor oncology such as management of tobacco-related cancers (for example lung, head and neck and bladder cancer) but also prostate cancer, gastro-intestinal malignancy, germ cell tumors, malignant melanoma and numerous other cancers. There is a deficiency of gynecologic and breast cancer, given the overwhelming male preponderance of the veteran population.
Educational goals/competencies:
Patient care:
Residents learn to perform a detailed and thorough history and physical examination, including emphasis on lymph node examination, examination for abdominal organ enlargement, recognition of symptoms and signs of paraneoplastic phenomena, symptoms and signs of severe cytopenias and metastatic cancer, such as the relevance of back pain in patients with cancer. Residents will develop the ability to diagnose the different hematology/medical oncology diseases and understand the etiology, pathogenesis, natural history, usual management, and possible complications of each of these conditions. It is expected that, by the end of the rotation, residents will become comfortable and proficient at examining peripheral blood smears for common hematologic abnormalities and would have learned the techniques of bone marrow aspiration and biopsy.
Medical knowledge:
Residents will develop a thorough knowledge of the differential diagnosis, treatment and long-term management of hematology/medical oncology problems and appreciate the differences between inpatient and outpatient care for patients with these disorders. They will appreciate the value of and recommendations for screening for various disorders; the different goals of therapy in patients with different stages of illness such as the differences between curative and palliative therapy; the availability and benefit of effective treatment for the various disorders, including the potential for long-term survival and cure of otherwise lethal disorders; the role of the different treatment modalities for cancer, such as chemotherapy, radiation therapy, biologic therapy, surgery, stem cell transplantation and immunomodulatory therapy; the phases of clinical drug treatment trials; the value and role of scientifically sound clinical trials in developing treatment; effective treatment options for pain.
Interpersonal/communication skills:
It is expected that residents in the process of interacting with patients and their families will learn the attributes of not only good history taking but also compassionate care. Residents will learn how to handle ethical issues that arise in the care of chronically and severely ill patients and the need to provide comfort to family members of patients with life-threatening illness. Residents will be expected to understand the value, appropriate and judicious use of external and internal medical records including records from other VA and non-VA medical centers. Residents will also learn to communicate effectively with a multi-disciplinary team of physician and non-physician members' health care providers such as radiologists, pathologists, surgeons, pulmonologists, nurses, ethicists, pastoral care providers and laboratory staff.
Professionalism:
Residents will learn the value of politeness, courtesy, punctuality, honesty, frankness and compassion in their interactions with members of the health care team, patients, and patients' families. They will learn the appropriate skills for discussing sensitive issues such as end-of-life discussions for terminally ill patients, discussing bad news with patients and their families, obtaining appropriate consent for risky diagnostic and therapeutic procedures, discussing the need for hospice care with patients and their families, discussing do not resuscitate decisions. They will learn techniques for coping emotionally with these kinds of difficult decisions.
Practice-based learning and improvement:
It is hoped that the experience on this elective will teach residents to manage patients with severe, life-threatening, acute and chronic, curable and incurable illnesses. They will learn that a great deal of comfort can be provided to patients and their families even in the absence of curative therapy. They will learn the ability to listen to patients and find ways to provide beneficial care to patients with acute and chronic illnesses, emotional and psychic distress.
Systems-based practice:
Residents will interact intensively with ancillary healthcare providers such as nurses, ethicists, hospice care providers, and other specialty physicians. They will learn the value of social workers and home health care providers. Residents will understand the use and implications of hospital formularies and the ethical and socioeconomic implications of rationing health care. They will learn to provide cost-effective end-of-life care. The differences between inpatient hospice and domiciliary hospice care will be demonstrated. The role of non-governmental resources such as the American Cancer Society, the various support groups for patients with hematologic and malignant disorders will be revealed. The use of and data entry into a computerized medical records system with be routinely demonstrated; access to and routine use of the on-line medical literature in every day clinical practice will be demonstrated; residents will be taught to use a microscope for examination of pathology samples.
Text/references to be consulted:
For hematology, Williams Hematology (Beutler, et al, McGraw Hill); for Medical Oncology, Cancer Principles and Practice of Oncology (DeVita, et al, Lippincott-Raven) are the major reference textbooks used. Emphasis is laid on review of the journal literature, particularly the journals Blood, Journal of Clinical Oncology, The Lancet and The New England Journal of Medicine. Use is also made of the sub-specialty MKSAP in Hematology and Medical Oncology and also MKSAP XIII.
Methods of evaluation:
Based on daily interaction with the attendings and the input of other members of the team including nurses and hospice care providers, the quality of interaction with patients and their families will be continuously evaluated. Residents are given feedback on multiple aspects of their performance including their knowledge base, level of interest in the rotation, level of professionalism, humanistic attributes, punctuality to conferences and meetings, quality of literature review and presentation of given assignments, use of diagnostic options, consideration of cost of care, quality of documentation and the overall quality of their interaction with their attending. There is a formal interview with the inpatient attending at the end of the rotation, prior to the final evaluation, during which key strengths and weaknesses are discussed and the resident is given opportunity to give feedback on the value, strength and deficiencies of the rotation.