During the required 18 months of clinical training, the Hematology/Medical Oncology (Hem/Onc) fellows rotate as part of their core requirements on the Moffitt Inpatient Hematology (1-3 months), Medical Oncology (1-2 months), and Inpatient Hematopoietic Cell Transplantation (1 month) Services. They also rotate through the Hematopoietic Cell Transplantation Outpatient Service (1 month), Transfusion Medicine Service (1 month) and Hematopathology Service (1 month). All fellows have a 2-3 month block of rotations in 4-5 separate disease-specific clinics, which they attend each week for the duration of the rotation. Fellows also rotate on the Tampa General Hospital and Haley VAMC Inpatient Hematology/Medical oncology Consultation Services for a total of approximately 5-6 months.
Hematology and Medical Oncology Inpatient Services: All of the patients on the Hematology and Medical Oncology Inpatient Services are assigned to the Hem/Onc fellows, who participate as members of a team of physicians (1 faculty attending physician, 1 Hem/Onc fellow, 1 PGY 2 or PGY 3 resident, and 2 PGY 1 residents), 1-3 physicians assistants, 1 Pharm.D., and other health care professionals. Although the PGY1-3 residents and physician assistants provide the vast majority of the primary care of all of the inpatients on these services, the Hem/Onc fellows assigned to these services interact directly with patients, particularly providing their expertise in the specific hematologic and oncologic disorders of the patients, but also advising the residents and P.A.'s on general care issues. The fellows also play important roles in coordination of the service with the residents, helping to maintain the desired flow of diagnostic and therapeutic activities, teaching the residents about hematology and oncology issues, educating patients about their diseases and treatments, discharge planning, and taking a central role on daily teaching rounds.
Medical Oncology Inpatient Service is to permit fellows to have a dedicated patient care and education experience with hospitalized patients with oncologic disorders. This service generally has approximately 40-60 admissions per month and 15-20 patients in the hospital each day. As with most Inpatient Medical Oncology Services, the patient mix includes mainly patients with breast, lung, head and neck, and gastrointestinal cancers, melanoma, and sarcomas who are hospitalized for treatment or complications of chemotherapy (primarily cytopenias and mucositis), complications of their cancers, and patients requiring palliation of symptoms related to advancing or near terminal cancer.
Hematology Inpatient Service is to permit fellows to have a dedicated patient care and educational experience with hospitalized patients with hematologic disorders. This service generally has 50-70 admissions per month, and there is an average of 25-30 patients in the hospital each day. As with most Inpatient Hematology Services, about 90-95% of the patients have hematologic malignancies, primarily acute leukemias, a substantial numbers of lymphomas, and fewer patients with myeloma, myeloproliferative neoplasms, myelodysplasia, and less common hematologic malignancies. The other 5-10% of patients consists primarily of those with cytopenias of various etiologies (e.g., bone marrow failure, autoimmune hemolytic anemia, immune thrombocytopenic purpura, thrombotic thrombocytopenic purpura).
Hematopoietic Cell Transplant (HCT) Inpatient Service (1 month): The HCT (also frequently called blood and marrow transplant or BMT) Program is one of the largest in the Southeastern U.S., having performed 355 transplants in 2009. Usually 6-7% of patients on the HCT Inpatient service are assigned primarily to the Hem/Onc fellow (team includes 1 faculty attending physician, 1 H/O fellow, several physician's assistants, and sometimes 1 HCT fellow), although all of the patients are teaching service patients. The fellow provides primary care for assigned active HCT patients and acutely ill pre- and post-transplant patients whose illness requires inpatient care. This responsibility includes performing and writing or dictating admission history and physical examination on all patients admitted to him/her, dictating discharge summary on all patients discharged from his/her care, and writing and signing daily progress notes, orders, procedure notes, etc., as required for patient care. Teaching and patient care rounds are conducted with the entire team, which is similar to that described above for the inpatient Hematology and Medical Oncology services, under the direct supervision of a faculty HCT physician.
Hematopoietic Cell Transplantation Outpatient Service (1 month): We created this rotation for all Hem/Onc fellows several years ago because of the realization by faculty and fellows that there are several critical parts of HCT that are not addressed well in the inpatient setting. These included initial evaluation and screening of patients for suitability as transplant candidates, related donor matching, unrelated donor searches, informing and counseling patients about HCT benefits and risks, chronic graft-versus-host disease management, outpatient transplants, and intensive outpatient management after patients are discharged from the Inpatient HCT service. The fellow is supervised by HCT faculty physicians in all of these activities.
Hematopathology Service (1 month): Hematology/Medical Oncology fellows on the Hematopathology rotation work side-by-side with Pathology residents and with assistance of Hematopathology fellows and under direct supervision of faculty hematopathologists, in interpreting and performing bone marrow aspirations and biopsies, interpreting lymph node biopsies and biopsies of other tissues being assessed for hematologic disorders, and interpreting CBC, peripheral blood smear, flow cytometry, and molecular diagnostic study results. The fellows dictate their own pathology reports on cases assigned to them, and then review (and revise as indicated) their transcribed reports, which are then signed by the supervising faculty pathologists.
Transfusion Medicine Service (1 month): Hem/Onc fellows assigned to the Transfusion Medicine/Blood Banking rotation observe and help to perform such procedures as blood typing, cross matching, direct antiglobulin testing, and workup of possible transfusion reactions. They are supervised by the Director of the Moffitt Cancer Center Transfusion Medicine Service, Dr. Kaaron Benson, who gives laboratory, reading and seminar topics assignments on transfusion medicine topics to each of the Hem/Onc fellows and Pathology residents on the rotation and discusses these transfusion medicine topics with the fellows and residents almost every weekday. She also assigns them to spend time with Dr. German LeParc, Director of Florida Blood Services, which provides all blood products and pheresis services for Moffitt and most other hospitals in this region of Florida. At Florida Blood Services fellows gain more experience with blood donor screening, donation processes, blood safety testing, and plateletpheresis and plasmapheresis procedures.
Multidisciplinary Clinic (MDC) Rotation: This is a very important rotation for all of the Hem/Onc fellows. Most fellows have either a 2 or 3 month rotation, but some have 2 separate 2-month MDC rotations. During this rotation, the fellows select 4 or 5 half-day clinics among the 10 disease type-oriented multidisciplinary programs at the Moffitt Cancer Center (Head and Neck, Breast, Thoracic, Gastrointestinal, Genitourinary, Neurological, Gynecological, Cutaneous, Geriatric Oncology, Sarcoma or Hematologic Malignancies) and the USF (benign) Hematology Clinic, which they attend every week for the 8-16 weeks of this rotation, along with the associated weekly Multidisciplinary Program clinical conferences, when they do not conflict with another of the clinic experiences. These multidisciplinary clinics are distinct from and in addition to the trainees' permanent 6-12 month long continuity clinic assignments that all Hem/Onc fellows have throughout their 36 months of fellowship training (including during their Multidisciplinary Clinic rotation). These shorter duration multidisciplinary subspecialty clinic rotations have a primary goal of providing intensive exposure to multidisciplinary (particularly ambulatory) approaches to the initial evaluation and management of a wide variety of specific cancer types and benign hematologic disorders, but are not designed to be ambulatory continuity clinic experiences.
Moffitt Cancer Center Continuity Clinic Experience: Hem/Onc fellows are assigned 2 separate half-day continuity clinics per week for the full three years of the Hematology/Medical Oncology training, and about half of these clinics are at Moffitt Cancer Center. Most of the sub-sub-specialized, single disease-type clinics that predominate at the Moffitt Cancer Center and USF Clinic sites, are changed at 6-month (and in rare circumstances 3-month) intervals, whereas those at Tampa General Hospital and James A. Haley VA Medical Center are rarely for less than 1 year and usually are for 2 years. The continuity clinics that are located at Moffitt Cancer Center are sub-subspecialty clinics oriented toward specific cancer types as listed above, in which a specific disease type of special interest to a given Hem/Onc fellow is emphasized. In many cases these specialty clinics may be selected because the Hem/Onc fellow's selected area of clinical research interest involves patients with that specific disease type and permits the trainee to screen, enroll, and follow patients on his/her clinical research protocol in a clinic setting under supervision of his/her research and clinical mentor. Each of the Moffitt Cancer Center clinics is run throughout the year by a single faculty member, who is the primary Hem/Onc physician for all of these patients, and who is selected as a mentor based on diversity of his/her patient population, the types of diseases seen in the particular clinic, the needs and requests of the fellows, and the clinical teaching ability of the faculty member. The Hem/Onc fellows work under the direction of the faculty physicians. Their levels of responsibility escalate as their patient management skills in the subspecialty improve. Hem/Onc fellows provide more primary care to and require less supervision for the patients with less complex problems early in their training, and gradually progress to near-independence, even for complex patient problems, by the completion of their fellowship. Patients are evaluated at all stages of their diseases, with management including diagnosis, staging, treatment, follow-up and complications of disease and therapy. Fellows bear a variable responsibility for follow-up of patients depending on the appropriateness of the situation. The fellow's education is best served by seeing combinations of new patients, patients undergoing active treatment, and patients experiencing complications of their disease, but fellows also will learn aspects of natural history of diseases and principles of follow-up in evaluating established patients who are in remission and/or are not involved in active therapy at that particular time. Longitudinal care for a series of patients is strongly encouraged. The Hem/Onc fellow on average sees about 1-3 new patients and 5-8 established patients per clinic, with direct faculty supervision. In particularly high volume clinics, the faculty member assigns the Hem/Onc fellow to see the patients with greater teaching value and patients whom the Hem/Onc fellows have seen previously. The faculty member sees all of the patients in that clinic, either alone or after an initial assessment by the fellow. They discuss together all patients who are seen by the fellow.
Radiation Oncology (1 month): In addition to extensive interactions with radiation oncology during their inpatient rotations, outpatient clinics, and the weekly case conferences/tumor boards of the individual multidisciplinary oncology programs that they attend, fellows have a 1-month radiation oncology experience, working directly with radiation oncology physicians as they see and treat patients and do simulations/treatment planning. They also receive reading assignments relevant to basic principles of radiation oncology and the specific patient issues encountered during this rotation. The overall supervision of Hem/Onc fellows on this rotation is directed by Dr. Thomas Dilling.
Hematology/Medical Oncology Inpatient Consultation Services at Tampa General Hospital and James A. Haley Veterans Affairs Medical Center: The Hem/Onc fellows round 5 days per week (Mon-Fri) on all of the Hematology and Medical Oncology inpatients, since there is no dedicated Hem/Onc Inpatient service at TGH or Haley VAMC. These patients are assigned to Internal Medicine Inpatient services, although most patients with these diagnoses are located on a single unit staffed by hematology/oncology trained nursing staff. Thus, the fellows follow these patients formally in the role of consultants to the residents and faculty attendings to whom these patients are assigned. However, in reality, since many of these patients have complex hematologic and oncologic problems and many have been admitted to the hospital by one of the Hem/Onc faculty or fellows, the fellows and their supervising attending play a more central role in the care of these patients than they do for other consultation patients. In addition, fellows on these rotations see all of the hematologic and oncologic consultations from other services throughout the hospital. They have formal daily teaching rounds with the assigned supervising Hem/Onc attending faculty member for all of the primarily Hematology/Medical Oncology inpatients and the other consultation patients, usually for 2-3 hours per day. On weekends and holidays at TGH, there are work rounds by the covering on-call fellow and faculty member, but no formal planned teaching activities, although patient-related teaching occurs on these days, as well. The faculty attending physician leads rounds, but often turns over much of the responsibility to Hem/Onc fellows, who are sufficiently advanced that they are capable of a higher degree of responsibility. There is a faculty member assigned as the supervising faculty member 24 hours of every day, who can be called at any time of the day or night. Other faculty members whose expertise may be useful in a particular case also are available to the Hem/Onc fellows on an ad hoc basis at all times. The fellows on Hem/Onc Inpatient Consultation service at TGH generally average seeing about 100-120 cases per month. About 75% of the consultation cases at TGH and 30% of the consultation cases at Haley VAMC are on benign hematology issues and the rest are oncology cases. This is an opportunity for the fellows to learn consulting aspects of hematology and medical oncology practice. The two fellows, and often an internal medicine resident assigned to a month on the Hem/Onc consultation service, see the patients initially, then review and see the patients with the attending faculty member. An emphasis is placed on one-to-one teaching regarding the patient's other medical/surgical problems, reviewing and evaluating microscopic, radiologic, and laboratory material, discussing pathophysiology of the relevant diseases, and establishing an appropriate therapeutic plan. Current knowledge about the diagnosis, pathophysiology and management of the problem is discussed in detail on formal rounds and in numerous separate one-on-one fellow-faculty interactions.
James A Haley VAMC and TGH Outpatient Continuity Clinics: Each year 10 fellows who are in their 2nd and 3rd years of Hem/Onc fellowship training have the opportunity to working at the James A Haley VAMC Medical Oncology or Hematology Clinics and 3 fellows in the TGH 30th Street Hematology/Medical Oncology Clinic as one of their continuity clinics. This clinic assignment is for a minimum of 12 months, but most of the fellows who work in the VA and TGH 30th Street clinics do so for 24 months. These clinics represent unique situations where the fellow has “ownership” over a panel of diverse patients for whom he/she is identified as the primary hematologist/medical oncologist. These clinics are designed to provide a higher level of responsibility for advanced Hem/Onc fellows, who have demonstrated their ability to play a leadership role in management of Hem/Onc patients. Hem/Onc fellows provide more primary care to and require less supervision for the patients with less complex problems early in their training and progress to near-independence, even for complex patient problems, by the completion of their fellowship. This is a key mechanism by which the training program encourages the fellows to take on significant responsibility and near independence for care of their patients. Attending faculty supervision in this clinic is provided, with a greater emphasis on trainee autonomy, supervised decision making, and continuity/longitudinal care. Attending physician supervisors are responsible to review all of the patients with the fellow(s) and facilitate learning through patient-based teaching.
One or two Hem/Onc fellows at any level of training will be assigned at any one time to 6 month long continuity clinics in what is called Moffitt South - a full-service outpatient facility that is owned by and attached to TGH, but is leased and staffed by Moffitt Cancer Center employees and faculty members who work at both TGH and at Moffitt Cancer Center's main facility adjacent to the USF College of Medicine. These clinics operate the same way as the outpatient clinics described above at Moffitt Cancer Center. Some faculty members have Hem/Onc fellows assigned to both their Moffitt and their TGH/Moffitt South continuity clinics, and they are treated identically.
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