Graduate Medical Education Training Programs

HEMATOLOGY AND COAGULATION

Resident Rotation Summary

Rotation Philosophy and General Purpose Statement:

The Hematology and Coagulation rotation at West Virginia University is designed to instruct trainees in Hematology and Coagulation practice in a tertiary care, academic setting as well as a large community hospital. The major purpose of this rotation is to cover in detail all areas of the Hematology Laboratory not associated directly with Bone Marrow performance and interpretation. These areas include Automated Blood Counts, Peripheral Blood Smear interpretation, Urine analysis and interpretation, and Body Fluid analysis and interpretation. The resident will be exposed to a diverse range of testing modalities, both automated and manual. The resident is expected to become proficient in interpreting these tests and communicating the results to the clinician caring for the patient. Coagulation training covers a broad based experience in coagulation through exposure to a diverse range of testing modalities for both bleeding and clotting disorders. The resident is expected to become proficient in interpreting these tests both individually and collectively.

Teaching Faculty Members

West Virginia University
Patricia M. Canfield, M.D.
Linda L. Cook, M.D.

Charleston Area Medical Center
Oscar Estalilla, M.D.
David A. Hansen, M.D.
Tomislav M. Jelic, M.D.

EDUCATIONAL GOALS AND OBJECTIVES:

The goals and objectives of the Hematology and Coagulation experience is to prepare and enable residents to:

• Demonstrate competency in the performing laboratory procedures involved in the blood and coagulation disorders including the morphology of various anemias, the work-up of bleeding and coagulation disorders, and performance of cell counts/differentials on body fluid specimens and differentiate reactive versus malignant processes in order to be able to practice independently.
• Demonstrate professional behavior regarding patients, other physicians and all clinical laboratory personnel.
• Demonstrate a commitment to reviewing and improving hematology and coagulation practice patterns and to life-long learning. 
• iscuss the scientific basis of hematology and coagulation, such as detailed knowledge of the various nutritional and other anemias, leukemoid reactions and leukemias on peripheral blood smears, their clinical presentation and morphology and the ability to utilize the medical literature and modern techniques to provide optimal patient care. 
• Communicate effectively in verbal and written form with their clinical colleagues, administrative, technical, and clerical personnel.
• Explain the policies and regulations affecting health care (i.e., CAP accreditation, HIPAA, compliance to Medicare and billing regulations, etc.) 

REQUIRED COMPETENCIES, DUTIES AND RESPONSIBILITIES:

PATIENT CARE

Residents gather essential and accurate clinical information about the patients on whom they review slides of fluids or peripheral blood and coagulation assays including:

• Discussion of history with clinical housestaff and/or attendings,
• Preview of laboratory reports of previous pathologic specimens
• Review of the online medical record when applicable.

Residents are able to be actively involved with hematology/coagulation consultations and are able to handle clinical questions with increasing degrees of independence including:

• Researching and reviewing medical information.
• Preparation and interpretation of clinical consults.
• Timely and effective communication with clinicians.

Residents demonstrate competence in the performance of procedures considered essential for hematology practices, including:

• Interpretation of peripheral blood smears.
• Review of body fluids.
• Interpretation of automated hematology tests.
• Review of coagulation testing.

Residents make informed decisions regarding diagnostic workup of clinical consults:

• Consider specialized testing, such as coagulation mixing and factor assays etc. based on patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment. 
• Expected to be able to handle more difficult cases and their approach and diagnoses should more closely correlate the final diagnoses as they progress through their residencies.

Residents make informed decisions regarding diagnostic workup of clinical consults:

• Consider special stains, specialized testing, etc. based on patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment. 
•  Expected to be able to handle more difficult cases and their approach and diagnosis should more closely correlate the final diagnosis as they progress through their residencies.
• Operate available information technology (hospital and laboratory information systems, internet-based literature searches)
• To support workup and diagnosis of hematology and coagulation consults.
• To help educate clinicians by providing relevant literature references.
• Residents work with health care providers, in the generation of accurate and clinically useful clinical pathology reports and effective communication of results to clinicians.

Evaluation:

• Rotation evaluation

  Presentations to medical technologists and clinical consult cases. 

• 360o Global evaluation

MEDICAL KNOWLEDGE

Residents demonstrate an investigative and analytical thinking approach to clinical situations, including:

• Development of reasonable and complete differential diagnoses for peripheral smear, fluid and coagulation cases based on the available clinical information, laboratory tests, and current published information.
• As part of their workup of cases, they suggest appropriate additional testing (special stains, immunohistochemical studies, flow cytometry, and further clinical testing such as serology, etc.) if applicable.
•  Formulation in a comprehensive, cohesive, and coherent fashion the above differential diagnoses and discussion of pathologic findings in the final pathology report.
• Are encouraged to participate in at least one research project, such as clinicopathologic studies, or case reports with literature review.

Residents discuss and apply the basic and clinically supportive sciences which are appropriate to the specialty of clinical pathology, including:

• Describe of epidemiology of various infections and neoplastic diseases during discussion of clinical pathology cases, and use of such knowledge to formulate pathologic diagnoses.
• Discuss clinical presentations and manifestations of various diseases during discussion and workup of anemias, coagulopathies, and other hematologic disorders and use this knowledge to formulate pathologic diagnoses.
• Explain basic cytochemical and immunologic stains, including biochemical and immunologic principles, methods, and applications.
• Discuss the principles and practices of automated hematology testing.
• Explain human morphology and physiology during discussions with clinicians. 

Evaluation:

• Rotation evaluation

Hematology score for the in-service examination compared to national means

PRACTICE-BASED LEARNING

Residents show the ability to analyze practice experience and perform practice-based improvement activities using a systematic methodology, including:

• Evaluating their consultative reports for diagnostic and typographical errors, and assessing for suboptimal specimen quality
• Residents are given results of their concordance with staff diagnoses and are expected to apply this information to direct their studying and improve their diagnostic acumen.
• As senior residents, actively participate in monthly Clinical Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, mislabeled/unlabeled specimens, clotted specimens, etc.).
• Residents show ability to locate, appraise, and assimilate evidence from scientific studies related to patients’ health care problems, including:
• Perform literature search and review to find relevant scientific references to aid in the workup of hematology/coagulation problems (computer-based searches).
• Obtain and incorporate information about their patient population (via COPATH and MISYS computer searches and medical records chart review) for clinicopathologic study of selected diseases.

Residents are able to explain study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.

• Perform with information technology to manage information, access on-line medical information, and support their own education, including:
• Accessing of patient clinical information and previous pathology accessions via Medsite and Copath.
• Performance of computer searches of the medical literature.
• Accessing websites pertaining to hematology/coagulation.

Residents actively participate in the teaching of medical students and other health care professionals employed in the clinical pathology section, including:

• Teaching medical students as lecturers (senior residents only), leaders in small groups and laboratory sections.
• Teaching medical technologists and other clinical residents during hematology/coagulations rotations. 

Evaluation:

• Rotation evaluation
• Review of rotation evaluation yearly to assess improvement and discuss self-education

INTERPERSONAL AND COMMUNICATION SKILLS

Residents demonstrate effective communication with other health care providers, patients, and patients’ families by:

• Presenting cases at in-house tumor boards and conferences under direct faculty supervision.
• Interacting with clinicians, patients, and patients’ families during performance of clinical consults and by providing support to clinicians and families during on-call assignments.

Evaluation:

• Rotation evaluation
• 360o Global evaluation

PROFESSIONALISM

• Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
• Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest with prompt response to calls from the hematology lab, faculty and clinicians during their hematology/coagulation and on-call rotations and accountability for this.
• Exhibit a commitment to excellence and on-going professional development by utilizing the study materials within the department including books and journals for their own professional advancement.
• Demonstrate a commitment to ethical principles pertaining to provision of pathology services, confidentiality of patient information, informed consent, and business practices.
• Demonstrate appropriate behavior with the faculty, clinicians, their peers, and the administrative, technical and clerical staff of the hospital.

Evaluation:

• Rotation evaluation
• 360o Global evaluation

SYSTEMS BASED PRACTICE

• Residents must 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.
• Explain how hematology diagnoses affect health care decisions for patients and the health care system.
• Discuss the types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
• Practice cost-effective health care and resource allocation that does not compromise quality of care, understanding the need for and cost of special studies, extended testing, and send-out testing. 
• As senior residents attend the CP QA committee meetings to be able to explain how to partner with the administrative and technical staff to assess, coordinate, and improve health care and know how these activities can affect system performance
• Residents may also inspect the Hematology section during a CAP inspection.

Evaluation:

• 360o Global evaluation

Daily Duties and Responsibilities – Hematology and Coagulation

Hematology

The first week of the rotation will be under the direct supervision of the Director of the Laboratory. During this time, the residents rotating through Clinical Pathology will review the On-Call Laboratory Manual with the director so all call responsibilities are covered adequately. A pre-test in general hematology will be given by the director. The director will instruct the residents, through glass slide review, how to recognize blood cells and urine cells and crystals. Body fluid interpretation will be taught in the same fashion. At the end of this week, the residents will be expected to interpret one peripheral blood smear, one body fluid slide and one urine sample, correctly and without error.

Weeks two through ten will allow the resident to rotate to each station in the Hematology laboratory. The resident will begin by observing the technologist perform a certain function and conclude by actually performing that function at least once. During this time, emphasis will be placed on specimen processing, specimen requirements, and operation of equipment. The resident will familiar him/herself with the operating principle of the equipment and what tests can be performed. Limitations of the equipment will also be stressed. Quality control issues and quality assurance indicators will be explained and discussed with the resident. Participation by the resident in Performance Improvement activities is required.

For each subdivision of the Hematology laboratory, the resident is responsible for teaching the technologists on any new update appropriate for that testing.

All physician call will be directed to the resident. The resident is expected to answer these uestions and investigate problems, if appropriate.

Residents will participate in Hematology Laboratory rounds conducted by Dr. Canfield each week.

During the rotation, the resident is expected to prepare one topic for presentation to the laboratory director and possibly at Pathology Grand Rounds. This subject must be approved by the laboratory director. In addition, a Case of the Month , or similar paper is required before successful completion of the rotation.

During week eleven, the post test will be taken and a make-up test, if necessary. An evaluation of the rotation and director will be prepared by the resident and an evaluation of the resident will be prepared by the director. The rotation paper must be submitted to the director during this week. The presentation for Grand Rounds may be completed before or during this week.

The resident is expected to arrange with the Hematology Manager or Tech Specialist when to do the various activities in the laboratory. The resident is expected to observe as much as possible, ask questions and to capitalize on the opportunity to learn in the laboratory.

The resident will observe tests performed on the Celldyn 4000 automated hematology analyze

The resident will observe urine samples tested on the automated urine analyzer.

The resident will observe and perform body fluid analysis including cell and differential.

The resident will screen and interpret any peripheral blood smears requested by the technologists

The resident will participate in Quality Control, Quality Assurance and performance Improvement Activities.

The resident will review any Proficiency Testing performed by the lab during the rotation.

Goals and Objectives

• Be able to do test interpretations with some supervision by the end of the first week and with minimal direct supervision by the end of the second week.
• Discuss the basis of all automated testing performed in the Hematology Laboratory
• Explain the manual tests performed in the Hematology laboratory.
• Research and present to the technologists at least one new update on laboratory testing in the Hematology Laboratory.
• Discuss the pathophysiologic processes that affect test results in the Hematology laboratory.
• Present to the laboratory director and possibly at Pathology Grand Rounds on an appropriate Hematology subject
• Write a Case of the Month or similar paper for publication on a Hematology patient.
• Successfully pass the post test administered by the director

Coagulation

The major vehicle for instruction of a resident by the course director will be during test result interpretations. During the first few days of the rotation, the resident will observe the laboratory director evaluate the interpretative test results. By the end of the first week, the resident will be expected to do interpretations before presenting them to the faculty. The resident will be expected to review all interpretive tests done in the laboratory and prepare the initial interpretative report for review with the laboratory director. The interpretative reports are done on the laboratory computer database system. The resident is expected to learn to efficiently use this system. It is expected that the resident will do this within 24 hours of the test results being available. During the first week, the resident will also be given a pre-test to help the director evaluate the resident’s preliminary knowledge of coagulation.

At the end of the second week, the resident will be expected to perform autonomously, however, no diagnosis will be given to the clinician without approval by the laboratory director. Each Monday, the resident will meet with the laboratory director to discuss the prior week’s cases and to plan a strategy for the current week.

The resident is expected to be on site at all times (except when specific permission is granted by the laboratory director). All special coagulation tests will be reviewed during that time for appropriateness, timeliness, and results. Attendance at Heme/Onc rounds on Tuesday morning at 8am is required

A specific case – selected by the resident - will be reviewed and worked up for presentation to the laboratory, director and possibly at Pathology Grand Rounds. This case may qualify for the Case of the Month as well.

The resident will be expected to participate in the Clinical pathology resident call schedule.

Demonstrations / Laboratory Testing Participation

• The resident is expected to arrange with the technologists when to do the various activities in the laboratory. The resident is expected to observe as much as possible, ask questions and to make the most of the opportunity to learn in the laboratory.
• The resident will observe tests performed in-house and should run a lupus inhibitor test and a Factor VIII assay.
• The resident will observe platelet aggregation tests done as part of a bleeding workup and platelet screening tests.
• The resident will research the ELISA method, “rocket” immunoelectrophoresis, and crossed immunoelectrophoresis to understand the principles involved.
• The resident should observe chromogenic tests done in-house and be aware of the benefits and shortcomings of the tests.
• The resident will research the genetic tests used in special coagulation and be aware of the indications for use.

Goals and Objectives

• Test interpretation with some supervision by the end of the first week and with minimal direct supervision by the end of the second week.
• Explain the basis of all clotting based tests, which are primarily done on instruments.
• Discuss the rare manual tests, including thrombin time.
• Discuss in detail the general methods for factor assays, lupus inhibitors, and platelet aggregation tests by the end of the first week.
• Explain the method for at least one ELISA test, one rocket immunoassay, and one crossed immunoelectrophoresis test by the middle of the second week.
•  By the end of the second week, the resident should be able to explain the pathophysiologic processes that affect interpretation of test results for both bleeding and clotting tendencies.
• By the end of the second week, the resident will also be expected to discuss anti-phospholipid antibodies and lupus inhibitors.
•  By the end of the rotation the resident will be expected to successfully complete the post-test indicating a sound understanding of coagulation

Supervisory Guidelines for Patient Care and Specimen Handling

Specimen handling in the laboratories is the direct responsibility of the Specimen Processing people and the technologists. Resident decision making in the laboratory is under the direct supervision of the teaching faculty at their assigned site. The on-service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager. No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

Opportunities for Residents to Act as Consultant to Other Physicians

Residents play an important part in the daily activities of the Hematology Laboratory, not only in the knowledge they share with the technologists, but also in their ability to interact with clinicians referring specimens to the laboratory. The resident may speak with these physicians, who may be from UML outreach areas, as well as from other institutions. Residents may discuss relevant clinical information about the patient and may also convey information to them about the status of testing.

On-Call Duties:

The resident is expected to be available in the laboratory throughout the working day from 8am until 5pm. Each night a resident rotating on Clinical Pathology Services will take call from home via telephone or pager. The resident is the first-line call and it is the resident’s position to call the attending pathologist when necessary.

During clinical pathology call the resident provides first call consultation and problem solving. During this period, the residents will on average have at least one out of every seven days free of hospital duties. The resident is directly supervised by the CP faculty member on-call. While on-call, residents are supervised by a Faculty Member, who is available at all times, either via their office phone, pager, or home phone. During the WVU rotation, all calls are reviewed daily with a faculty member and at a weekly CP on-call conference. 

The resident is expected to be available to laboratory personnel, either in person or by pager, throughout the working day. Due to the at-home nature of call, the call duties are constructed in the following fashion. The residents are on at-home/pager call every other week. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday.

Charleston Area Medical Center

Same as WVUH except that there is no weekend on-call rotation.

Communication with On-Duty Faculty

Teaching faculty members on service are physically present during standard operating hours (8am – 5pm); specific faculty members when not physically present in the laboratory are available by phone or pager. At all times, a supervising faculty member is on call for evening and week-end questions. No diagnosis is communicated to clinicians before a faculty member has evaluated the case.

Required Conferences / Seminars

Clinical Pathology Conference: (day and time to be announced) weekly, residents and faculty present and discuss interesting clinical pathology cases, recent advancements in clinical pathology, and the interpretation of laboratory values in terms of a clinical setting. This conference provides a weekly forum for trainee and faculty discussion of difficult and unusual cases. The conference is composed of both a 30 minute resident and a 30 minute faculty presentation. Residents develop their presentation under the guidance of a faculty member with whom they are currently rotating.

Pathology Grand Rounds: Friday, 12:30 pm. Residents attend and are expected to present at this conference on a variety of basic science and clinical topics.

Hematology Laboratory Rounds: (day and time to be decided) weekly, residents and technologists attend while director presents an interesting case of the week. Case is discussed with literature to support diagnosis

Director’s Hour: Monday 8am, weekly. Each Monday morning all Clinical Pathology residents will meet with the Laboratory Director to discuss the previous week’s cases and the plans for the new week.

In addition many of you will be assigned to teach sophomore medical student pathology small group discussions on Wednesday and Thursday from 10am until 12noon.

Scholarly Activities / research Activities During and After Rotation

During the rotation, residents are expected to perform literature searches with regard to difficult/unusual cases.

Basis, Method and Criteria for Resident Evaluation

Residents will be evaluated on performance of daily activities (described previously) participation in required meetings and conferences, and presentations to the staff on assigned cases. The residents are provided with continuous feedback on their performance during the rotation. In general, only deficiencies are noted in writing. Residents are evaluated on their demonstrated ability to provide informative consultation to the Patient Care teams, their medical knowledge, their application of this knowledge to efficient/quality patient care, and their diagnostic, technical and observational skills. Residents are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretative reports is another component of the evaluation. Residents on probation receive a written mid-rotation evaluation.

Educational Resources Available:

Rappaport, Introduction to Hematology.

Goodnight & Hathaway, Disorders of Hemostasis & Thrombosis