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VCUHS HEMATOLOGY/ONCOLOGY FELLOWSHIP CURRICULUM Description of Educational Experience The VCU Hematology-Oncology fellowship program MCV hospital is a 36-month duration combined training program in hematology and oncology. The curriculum is developed to educate and produce compassionate physicians capable of delivering the highest quality medical care to patients in a variety of settings; to foster physicians capable of contributing to the science of medicine through research and scholarly activity; and to promote lifelong learning in the context of a rapidly changing healthcare environment. The curriculum satisfies the requirements to sit for the ABIM examinations in both hematology and medical oncology. Location: VCUHS MCV Hospital and affiliated clinics McGuire Veterans Affairs Hospital and affiliated clinics Length of Experience: 36 months Educational Goals Gain experience and knowledge in the diagnosis, prognosis, management, and complications of inpatients with acute non-malignant, hematologic problems necessitating hospitalization. Gain experience and knowledge in the diagnosis, prognosis, management, and complications of inpatients with hematologic and solid tumor malignancies Gain experience in the diagnosis, prognosis, and management of acute hematologic and oncologic emergencies Gain experience in the diagnosis, prognosis, and management of complications of advanced malignancy Gain experience in the administration, monitoring, and toxicities of chemotherapy Gain additional experience in performing the procedures essential to the diagnosis and to the delivery of care of acute hematologic and oncologic disorders, including bone marrow biopsy and aspiration; lumbar puncture with the intrathecal administration of chemotherapy; and the access and administration of chemotherapy via an Omaya reservoir. Gain experience in communication with and the counseling of patients and families regarding their acute hematologic and oncologic medical conditions and in providing the necessary support and ancillary services to effectively meet their medical and psychosocial needs. Gain experience and knowledge in effective establishment and communication of goals of care Gain experience and knowledge in the evaluation, grading and management of acute and chronic pain from malignant and non-malignant etiologies Gain experience in the management of end-of-life issues, including advanced directives, resuscitation status, surrogate decision-making, home/inpatient hospice resource utilization, and the resources available to the patient and their families. Gain experience and knowledge of the legal and societal issues as they pertain to the end-of-life management. Gain experience in and respect for the cultural differences in response to severe illness and death Gain experience in recognizing one’s own reaction to grief and stress as a provider Gain experience and knowledge in the role and function of a subspecialty inpatient primary medical providermanager Gain experience in working within and directing the care of a multi-disciplinary team of health professionals in the acute inpatient hospital setting 1 Progressive Responsibilities by Fellow Year YEAR 1 The first year fellow is expected to focus on primary medical knowledge, communication skill and procedural skill development. Medical knowledge acquisition should focus on the routine diagnosis, natural history, staging, prognosis, and first-line management of the hematologic-oncologic conditions. Additionally, the first year fellow should focus on the pharmacologic mechanism of action, dosing considerations, and common toxicities of the medications being employed for the treatment of the hematologic-oncologic condition. Care plans should be developed independently or with conjunction with attending physician and health care team but reviewed in full with the attending physician in advance of communication to the patient and family. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling should be done with direct supervision of the attending physician or only after full review of the goals of care and care plan with the attending physician. (The PharmD may provide the direct supervision of chemotherapy counseling and consenting once the care plan has been established with the attending physician). In a teaching capacity, the first year fellow is expected to provide supervision of the housestaff participating in clinical rotations within the division’s inpatient or ambulatory services. Additionally, the first year fellow is expected to actively participate in educating the housestaff on the same hematology-oncology services. The first year fellow may assist the attending with teaching/work rounds with the resident housestaff under the direct supervision of the attending physician. The fellows may additionally supervise in the procedural training of their peers provided they have themselves achieved independence and competence in the procedure being supervised. In research and scholarship, the first year fellow is expected to focus on primary knowledge acquisition pertaining to the scientific process and the regulatory aspects of conducting clinical investigation. This includes, but is not limited to, mandatory participation by all fellows in the VCUHS GME research course with 100% completion of all related class work. Additionally, the fellow is expected to identify at least one specific scholarly project including an appropriate mentor. By the completion of the first year of training, the project design should be completed and any necessary IRB or other regulatory body approval should be in progress. All fellows are expected to complete annual CITI certification training. YEAR 2 The second year fellow is expected to refine their medical knowledge by focusing on an understanding of the underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment planning; and considerations/options in second-line and beyond. Care plans should be developed independently with only moderate need for input from the attending physician though reviewed in full with the attending physician in advance of communication to the patient and family. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling may be done independently but only after full review of the goals of care and care plan with the attending physician. The second year fellow should assist or even lead teaching/work rounds with the resident housestaff under the direct supervision of the attending physician. In a teaching capacity, the second year fellow is expected to provide supervision of the housestaff participating in clinical rotations within the division’s inpatient or ambulatory services. Additionally, the second year fellow is expected to actively participate in educating the housestaff on the same hematology-oncology services. The second year fellow should assist or even lead teaching/work rounds with the resident housestaff under the direct supervision of the attending physician. The fellow is expected to supervise in the procedural training of their peers provided they have themselves achieved independence and competence in the procedure being supervised. In research and scholarship, the second year fellow is expected work further develop their knowledge of the scientific process and the regulatory aspects of conducting clinical investigation but, additionally, the project specific skills and knowledge acquisition to fully understand the background, rationale, design and conduct of their project(s). The fellow is expected to make initiate the project and make steady progress throughout the year of training toward its completion. The fellow should identify early in the project the targeted venue and method for dissemination of the product of the project. All fellows are expected to complete annual CITI certification training. 2 YEAR 3 The third year fellow is expected to demonstrate proficiency and independence. The third year fellow is expected to demonstrate full knowledge of the routine diagnosis, natural history, staging, prognosis, and first-line management of the hematologic-oncologic conditions. They should demonstrate a proficient understanding of the underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment planning; and considerations/options in second-line and beyond. Care plans should be developed independently with minimal input from the attending physician though still reviewed in full with the attending physician. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling should be done independently though reviewed with the attending physician. The third year fellow should be capable of independently leading teaching/work rounds with the resident housestaff. In a teaching capacity, the third year fellow is expected to provide supervision of the housestaff participating in clinical rotations within the division’s inpatient or ambulatory services. Additionally, the third year fellow is expected to actively participate in educating the housestaff on the same hematology-oncology services. The third year fellow should be capable of independently leading teaching/work rounds with the resident housestaff. The fellow is expected to supervise in the procedural training of their peers provided they have themselves achieved independence and competence in the procedure being supervised. In research and scholarship, the third year fellow is expected to achieve independent proficiency in the project specific skills and knowledge base necessary to develop a scholarly project and to fully understand the background, the rationale and the design of their work develop. Additionally, the fellow is expected to acquire the knowledge and skills needed for the presentation of scholarly work in oral, poster, published, or new-media forms. The fellow is to complete at least one scholarly project and to disseminate the product of the effort at the institutional level and to have submitted the effort to a regional, national or international venue. All fellows are expected to complete annual CITI certification training. Patient Care Goal Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Please refer to overview of the fellowship curriculum for competencies/objectives for patient care. Fellows are expected to learn the practice of health promotion, disease prevention, diagnosis, care, and treatment of both men and women from adolescence to old age, and at all stages of illness. Specifically, fellows will see patients in acute inpatient hospital and ambulatory clinic settings under the supervision of the appropriate subspecialty faculty member(s). Fellows will participate in the evaluation, counseling, and management of acutely and chronically ill hematology-oncology patients. This will provide the opportunity to learn the different approaches to patient management of these conditions. Fellows will additionally work within a multidisciplinary team of health professionals including pharmacists, nurses, physical therapies, occupational therapists, social workers, care coordinators, and junior medical learners. This will provide the fellow experience and feedback in effectively working within and directing the care of a multi-disciplinary team of health professionals in both the inpatient hospital and ambulatory settings. Competency Objectives: Fellows are expected to: Gather appropriate clinical information Synthesize information into a care plan Perform the procedures necessary for the effective diagnosis and management of acute hematologic and oncologic disorders Partner with patients/families in the implementation of the plan Coordinate care plans with the referring physicians, the inpatient multi-disciplinary team of health professionals, and the home health agencies Develop skills in history/physical examination of the patient with hematologic and oncologic disorders Develop skills as an inpatient subspecialty heath care provider and manager 3 Integrate clinical data in the formation of a comprehensive care plan Recognize the common sources of error in the performance and interpretation of hematology laboratory assays Document the encounter in the medical record in sufficient detail to communicate to other physicians and meet billing requirements Provide compassionate, appropriate, and comprehensive patient care Medical Knowledge Goal Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. The fellows are expected to learn the scientific method of problem solving, evidence-based decision making, a commitment to lifelong learning, and an attitude of caring that is derived from humanistic and professional values. Competencies Fellows are expected to demonstrate skills in: Acquisition of knowledge Analysis of information Application of knowledge Objectives All fellows are expected to: Demonstrate the ability to perform a comprehensive and accurate physical examination; demonstrate the ability to arrive at an appropriate differential diagnosis; outline a logical plan for specific and targeted investigations pertaining to the patient’s complaints; and formulate a plan for management and follow-up treatment of the patient Demonstrate their knowledge by presenting the results of a medical assessment orally and in writing and by defending the clinical assessment, differential diagnosis, and diagnostic and management plans First year fellows: Medical knowledge acquisition should focus on the routine diagnosis, natural history, staging, prognosis, and first-line management of the hematologic-oncologic condition. Additionally, the first year fellow should focus on the pharmacologic mechanism of action, dosing considerations, and common toxicities of the medications being employed for the treatment of the hematologic-oncologic condition. Second year fellows: Medical knowledge acquisition should focus on an understanding of the underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment planning; and considerations/options in second-line and beyond. Third year fellows: Medical knowledge acquisition should focus on mastery of the knowledge obtained as a first and second year fellow Content-Specific Objectives The medical conditions experienced during any single block of this rotation can be quite variable. However, in an effort to provide guidance for areas of particular focus during each specific rotation have been outlines within the individual rotation curriculum. 4 Practice- Based Learning and Improvement Goal Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. The fellow is expected to present primary scientific and medical evidence to support their conclusions and care plans in the diagnosis, prognosis, management, and monitoring of the patients on the service. The fellow is expected to recognize their areas of deficiency. Depending upon the acuity of the care situation, the fellow is expected to be able to effectively utilize their resources to arrive at necessary information and to apply the information to their patient care. Moreover, the fellow is expected to recognize conditions and circumstances requiring escalation. Competency Objectives Fellows are expected to demonstrate skills in: Identifying strengths, deficiencies, and limits in ones knowledge and expertise Setting learning and improvement goals Identifying and performing appropriate learning activities Systematically analyzing their clinical practice, using quality improvement methods, and implementing changes with the goal of practice improvement Incorporating formative evaluation feedback into daily practice Locating, appraising, and assimilating evidence from scientific studies related to their patients’ health problems Using information technology to optimize learning Participating in the education of patients, families, students, fellows, and other health professionals Systems Based Practice Goal Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows will work within a multidisciplinary team of health professionals including pharmacists, nurses, physical therapists, occupational therapists, social workers, and care coordinators. This will provide the fellow experience and feedback in effectively simultaneously both working within and directing the care of a multi-disciplinary team of health professionals in the acute inpatient hospital setting. Additionally, working with the context of a broader health system includes the importance and necessity to recognize conditions and circumstances requiring consultation and/or escalation for the effective and safe delivery of patient-centered medical care. Competency Objectives Fellows are expected to demonstrate skills in: Working effectively in various health care delivery settings and systems relevant to the practice of hematology and medical oncology Coordinating patient care within the health care system relevant to the practice of hematology and medical oncology Incorporating considerations of cost awareness and risk benefit analysis in patient and/or population based care Advocating for quality patient care and optimal patient care systems Working in interprofessional teams to enhance patient safety and improve patient care quality Participating in identifying system errors and implementing potential systems solutions Professionalism Goal Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. The fellow is expected to model professional and courteous behavior in the treatment of the patient and in working with the entire health care team. The fellow is expected to complete documentation of their patient care, of their communications with the patient and health care providers, and of their procedures in a timely fashion within the medical record. The fellow is also 5 expected to recognize the critical importance of their own education and the importance of life-long learning as part of their professional responsibility. As such, it is the obligation of the fellow to themselves, their profession, and their patients to attend and complete in a timely fashion all of fellowship training program’s expected educational activities. Competency Objectives: Fellows are expected to demonstrate: Compassion, integrity, and respect for others Responsiveness to patient needs that supersedes self-interest Respect for patients, society, and the profession Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation Interpersonal and Communication Skills Goal Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Competency Objectives: Fellows are expected to demonstrate skills in: Communicating effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds Communicating effectively with physicians, other health professionals, and health related agencies Working effectively as a member or leader of a health care team or other professional group Acting as a consultative role to other physicians and health professionals Maintaining comprehensive, accurate, timely, and legible medical records Teaching Methods Patient care/clinical experience Modeling of observed behaviors of attending physicians Direct observations of patient encounters Professional patient simulation activities in communication Case-based interactive discussions Didactic and interactive conference sessions Performance feedback Practice performance evaluation and quality assessment Self-directed learning Mentored research/scholarly activities Assessment of Fellow Performance End-of-rotation evaluation of the fellow by the supervising attending physicians 360-evaluation by the medical students, interns, residents, nursing staff, and social worker/care coordination team members Mini-CEX by pharmacy staff, nurse practitioners, and/or supervising attending physicians of a counseling and communication encounter Bone marrow technique evaluations by bone marrow technicians and hematopathology attending physicians Semi-annual self-assessment by the fellow 6 Assessment of Program and Rotations End-of-rotation evaluation of the supervising attending physicians by the fellow Annual program review and survey Discussions with fellows during biannual review Review in-service and ABIM exam results Level of Supervision Varies by rotation. See individual rotation curriculum for details. Educational Resources Devita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology Hoffman Hematology: Basic Principles and Practice UpToDate ASCO University ASCO Practice and Guidelines ASCO-SEP ASH-SEP NCCN Guidelines (www.nccn.org) NCI Common Cancer Types and Clinical Trails by Cancer Type/Disease (www.cancer.gov) The AJCC 7th edition TMN staging of Cancer Common Toxicity Criteria v4.0 (aka Common Terminology Criteria for Adverse Events) GAIL model Claus model Adjuvant! Online Apheresis/Blood bank textbooks (available in TM) ASFA guidelines FIGO staging guidelines VCUHS Hospital Palliative Care Unit patient care set algorithms and procedures manual UNIPAC Self-Study Program EPERC Bonica Management of Pain Bruera Oxford American Handbook of Hospice and Palliative Care Bruera Textbook of Palliative Medicine and Supportive Care 7