HEMATOPATHOLOGY (INCLUDING FLOW CYTOMETRY FOR HEMATOPATHOLOGY) – OHSU
(Prepared and Updated June 2006)

Supervisor:
Attending Hematopathology Faculty on Service

Faculty:
Rita Braziel,M.D. Chief, Hematopathology Service
Guang Fan,M.D.,Ph.D. Medical Director, Flow Cytometry Service, Heme. Fellowship Director
Katalin Kelemen, M.D., Ph.D., Medical Director of Hematology
Tony Bakke,Ph.D. Scientific Director, Immunology Lab
Ken Gatter,M.D. Hematopathologist, Vice Chair for Anatomic Pathology
Nicky Leeborg, M.D., Hematopathologist
Marc Loriaux, M.D. Ph.D., Hematopathologist

Location:
Oregon Health & Sciences Verdana, Arial, Helvetica, sans-serifity

Duration:
Total 10 weeks including:
Bone Marrow Pathology Hematology Laboratory / Flow Cytometry: 4 weeks
Lymph Node Pathology /Outside Consultation /Flow Cytometry: 6 weeks

No. Residents:

One to two per rotation

Pre-requisites:

Residents who have completed hematology rotation at Kasier

Evaluation:
Core competencies will be evaluated using the attached evaluation form (see Apendix).

Goals

The goal of the Hematopathology rotation is to provide broadly based training in laboratory hematopathology, and bone marrow pathology, lymph node and other solid tissue Hematopathology, and clinical flow cytometry for hematopathology. The residents training in hematopathology is under the direct supervision of the staff pathologists but the resident is delegated independence and responsibility consistent with his or her ability and level of training.

Hematopathology Objectives

Patient Care

• Evaluate the adequacy of a specimen for evaluation.
• Understand the limitations of sub-optimal or inadequate specimens.
• Timely completion of pathology reports.

• Able to diagnose and sub-classify myeloproliferative disorders and myelodysplastic syndroms
• Able to diagnose and sub-classify acute and chronic leukemias
• Able to diagnose benign lymphoprolifeative disorders and myelodysplastic syndromes
• Able to diagnose and sub-classify lymphoma
• Able to diagnose common hemolytic and non-hemolytic anemias
• Understanding of the principles behind automated CBC analyzers and can analyze CBC and histograms

• Recognizes and corrects problems with specimen labeling, handling and processing
• Understand the indication and utility of ancillary studies based flow cytometry, immunohistochemistry, cytochemical stains, cytogenetics and molecular assays.
• Understand laboratory management and quality improvement, quality control and quality assurance, requirements for hematogy and flow cytometry laboratories to be accredited by CAP and development of new laboratory procedures.

• Working with faculty effectively
• Working with laboratory and administrative support staff effectively
• Working with physician assistants, residents and fellows effectively
• Communicating final diagnoses to clinicians effectively

• Completes assigned duties in a timely fashion
• Effectively share knowledge and skills with others
• Responds promptly and appropriately when paged for clinical calls
• Attends conferences and meetings as expected

• Familiar with programs of quality control and quality assurance
• Familiar with the scientific, legal and ethical issues involved in subspecialty
• Participates in quality management/improvement activities

• Attend didactic teaching sessions in the hematology, Hematopathology and clinical flow cytometry.
• Read articles from resident manual and other texts and journals related to the case material encountered in the lab. Do literature searches when indicated.
• Under the direction of the attending pathologist, examine and interpret all peripheral blood smears and body fluids referred by the medical technologist. Correlate with clinical information and consult with the clinicians on these cases when appropriate. Prepare written reports.
• Triage and select appropriate markers for flow cytometric analysis, immunohistochemical markers, special cytochemical stains, molecular assays based cytological evaluation and clinical indication for the case.
• Examine all peripheral bloods, bone marrow aspirates, body fluids and biopsies assigned to the resident. The resident formulates his or her own interpretation and then reviews and discusses it with the staff pathologist. The resident is responsible for obtaining clinical-pathologic information on each patient studied and prepares written reports.
• Act as a hematopathology consultant to clinical house staff and attending physicians. The degree of independence in this area is dependent on the resident’s experience and ability.
• Attend all conferences in which cases related to hematopathology are discussed and present cases as designated.
• Attend Clinical Pathology Case Conference and present cases when assigned.
• Present articles in Hematopathology journal club when assigned
• Be on-call for Hematopathology Lab, Bone Marrow Lab and clinical flow Cytometry lab with attending staff back-up. The resident is called first for questions involving the laboratory. A staff person is always on call and available for consultation when needed. Being on call may involve coming to the hospital at night or on weekends to review emergency bone marrow aspirates, body fluids, blood smears, etc.
• Participate in CAP inspections as designated.

1. Initial Level of Responsibility: Trainees lacking skills in identification of different normal hematopoietic progenitors, and lacking basic knowledge about hematologic diseases will play a very limited role in bone marrow signout initially. The trainee will perform an initial review of the daily marrows, attempting to identify significant abnormalities and generate a preliminary differential diagnosis prior to signout with Hematopathology faculty. This initial review should not interfere with timely review of marrows with faculty. As the trainee gains skills in identification of cell types, he/she will be responsible for performing differential marrow aspirate counts during their initial case review, prior to case signout with faculty.
2. Intermediate Level of Responsibility: Trainees who have acquired adequate skills in the recognition of basic hematopoietic progenitor cells and hematologic disorders will still perform initial review of daily marrows, including differential counts where appropriate, but will also dictate bone marrow reports in selected cases after signout with faculty. Case review and dictation at this level will also include adjunctive flow cytometric or paraffin section immunophenotyping studies. The trainee will also be responsible for appropriate billing of the dictated cases, and will phone report results to clinicians as required.
3. Advanced Level of Responsibility: Trainees who have acquired sufficient knowledge of hematopoietic disorders, expertise in morphologic evaluation of bone marrow, and efficiency in dictating, editing, and billing of bone marrow reports will be allowed to review selected bone marrow cases independently and generate reports integrating all relevant information prior to signout with faculty. All paperwork (including a printout of the proposed report and any flow cytohistograms) and all slides (including immunohistochemical and cytochemical stains) should be given to the attending faculty as soon as the trainee has completed his/her review of the case. The faculty will review the trainee’s reports independently, and will only review the cases again with the trainee if significant corrections are needed. When operating at this level, the trainee must adhere to the following policy: No final diagnosis can be provided to clinicians until the case has been reviewed and the trainee’s diagnosis confirmed by the attending faculty. Trainees wishing to operate at this level of responsibility must have approval from each individual faculty member to do so. Additionally, the trainee must be able to perform his/her review in a timely fashion; they must not introduce significant delay into the handling and diagnosis of the cases.

1. Initial Level of Responsibility: Trainees beginning on this rotation will play a very limited role. Initially, the trainee will perform the first review of the case in conjunction with attending hematopathology faculty, and assist with ordering of immunophenotyping studies and/or molecular analyses, as necessary. The trainee will not have the responsibility of report generation at this stage, but will review all of the combined histologic findings and flow cytometric studies. immunophenotypic, and molecular data on a case with the hematopathology faculty. As the trainee gains experience in case handling, he/she should perform an initial evaluation of the case review prior to case review with attending hematopathology faculty. The trainee should be ready to provide a differential diagnosis to the attending faculty. This initial review should not interfere with timely review of cases with faculty, and the trainee will not provide any information to clinicians or other pathologists about the case until it has been reviewed with his/her attending.
2. Intermediate Level of Responsibility: As the trainee gains skills in the handling of lymph node biopsies and outside consultations, he/she will independently triage cases and select ancillary studies to be run. In cases with a high clinical priority or limited specimen for special studies, case triage and selection of appropriate ancillary studies will still only be performed with attending faculty. At this level, the trainee will have the responsibility for dictation of selected cases after signout of cases with faculty. No results should be provided to clinicians until the attending staff has confirmed the trainee’s interpretations. The trainee will also be responsible for editing and billing the cases, and will communicate results to clinicians after case signout when appropriate.
3. Advanced Level of Responsibility: Trainees who have acquired adequate skills in the evaluation of lymph node biopsies and other outside consultation cases, including the knowledge of phenotypes of the various hematopoietic malignancies and efficiency in dictating, editing, and billing of case reports will be allowed to review selected cases independently and will be allowed to generate reports integrating all relevant information prior to signout with faculty. Case review and dictation at this level will also include adjunctive studies. All paperwork (including a printout of the proposed report, any flow cytohistograms, and any outside paperwork/reports) and all slides (including immunostains, cytochemical stains, and any submitted outside slides) should be given to the attending faculty as soon as the trainee has completed his/her report on the case. The faculty will review the trainee’s reports/slides independently; the trainee will only be required to review the case again with the faculty if significant corrections are needed. When operating at this level, the trainee must adhere to the following policy: No final diagnosis can be provided to clinicians until the case has been reviewed and the trainee’s diagnosis confirmed by the attending faculty. Trainees wishing to operate at this level of responsibility must have approval from each individual faculty member to do so. Additionally, the trainee must be able to perform his/her review in a timely fashion; they must not introduce significant delay into the handling and diagnosis of the cases.