Outpatient Rotation

Subspecialty residents will be assigned two blocks in Pediatric Hematology-Oncology clinic in the Outpatient Clinic Rotation during their PGY4 year. Working alongside a full-time faculty member, and with advanced practice providers, medical students, rotating housestaff, nurses, and other health care personnel of the inter-disciplinary team, the fellow will manage outpatients with presumed and established hematological and oncological diagnoses.

During the outpatient rotations, fellows see patients in hematology/oncology clinics organized around hematologic disorders (sickle cell/hemophilia, benign hematology), solid tumors, brain tumors, long-term survivorship, and hematologic malignancies. These blocks will be in addition to the fellow’s continuity care clinic experience. Alternative sites that are administered by the Division of Pediatric Hematology-Oncology, such as satellite clinics, are allowable during this rotation.

Fellows are supervised by one (or multiple) faculty member assigned to the outpatient clinic for each half-day. Fellows see patients in the outpatient clinic with increasing degrees of independence as their knowledge, skills, and experience increases. Supervision and direction will be provided by the attending on duty each day as well as staff that are assigned each day.

The duties that the fellow is to perform include to:

  • see new patients on the schedule that day,
  • maintain clinic flow by seeing routine clinic patients coming for that day,
  • establish relationships with patients that may join their continuity clinic.

The duties are to be maintained in this order.

It is also the responsibility of the fellow to:

  • communicate with the family and the referring physician,
  • make arrangements and communicate with the inpatient team if a patient is to be admitted,
  • work with the staff to coordinate blood draws and procedures that the patient may require,
  • communicate with the supervising attending if all or part of the clinic is to be missed.

It is fine, and expected, for staff to ask a fellow for help to keep patient flow as it is fine, and expected, that a fellow would ask staff for assistance if they have multiple patients waiting. It should be known that the goal to optimize each patient’s experience is to have patients seen within 15 minutes of rooming.

  • The fellow will be assigned one week of FLEX service in conjunction with the Advanced Practice Practitioner when they will be expected to manage the patients on the FLEX service.
  • Notes for each patient encounter are expected to be completed by 2 working days.

The fellow will work with the outpatient clinic coordinators to prepare and write chemotherapy for patients coming to the outpatient clinic.

Objectives

Under the direct supervision with increasing independence through the rotations.

Medical Knowledge

  1. Participate in fellowship core conferences and other conferences designed to provide medical knowledge specific to the discipline.
  2. Apply basic scientific and clinical knowledge of pediatric hematology, oncology, and stem cell transplant.
  3. Use their fund of knowledge and the literature to generate differential diagnoses and treatment plans for patients with hematologic and malignant diseases.
  4. Appropriately prioritize differential diagnoses for children with presumed or proven hematological or oncological disease, both as new presentations or as complications of a known condition

Hematology-Specific Competencies

The fellow will gain clinical experience in management of patients with the following diagnoses:

  1. Hematologic disorders of the newborn
  2. Hemoglobinopathies, including the thalassemia syndromes
  3. Inherited and acquired disorders of the red-blood-cell membrane and of red-blood cell metabolism
  4. Autoimmune disorders, including hemolytic anemia
  5. Nutritional anemia
  6. Inherited and acquired disorders of white blood cells
  7. Hemophilia, von Willebrand’s disease, and other inherited and acquired coagulopathies
  8. Platelet disorders, including idiopathic thrombocytopenic purpura (ITP), and acquired and inherited platelet function defects
  9. Congenital and acquired thrombotic disorders
  10. Bone marrow failure
  11. Transfusion medicine and use of blood products
  12. Management of the patient undergoing long-term transfusion therapy
  13. Vascular malformations and associated tumors

Oncology-Specific Competencies

The fellow will gain clinical experience in management of patients with the following diagnoses:

  1. Leukemias, including acute lymphoblastic leukemia, acute and chronic myeloid leukemia and myelodysplastic syndromes
  2. Solid tumors of organs, soft tissue, bone and central nervous system
  3. Lymphomas
  4. Histiocytosis
  5. Benign tumors that require oncology follow-up

Patient Care

  1. Demonstrate the ability to obtain a comprehensive history
  2. Demonstrate appropriate diagnostic work-ups relating to hematologic and oncologic issues
  3. Develop skills in managing outpatient hematology and oncology problems.
  4. Develop skills in managing outpatient chemotherapy.
  5. Develop skills in managing the complications of phlebotomy and blood transfusions.
  6. Develop expertise in the management of sickle cell disease, particularly as it pertains to interpreting abnormal newborn screens, phlebotomy and transfusion, iron overload, preventive maintenance, and management of acute complications of sickle cell anemia and post-operative management.
  7. Develop expertise in the management of hemophilia, particularly in terms of workup, prophylaxis, and inhibitors.
  8. Develop expertise in management of other benign hematologic problems such as neutropenia, thrombocytopenia, and anemia.
  9. Review and interpret peripheral smears performed on patients with hematological disorders.
  10. Diagnostic evaluation and staging of new oncology patients and determination of treatment plans.
  11. Staging and reassessment of established patients who have relapsed or recurrent disease.
  12. Develop skills in administration of chemotherapy
  13. Develop expertise in caring for critically ill and palliative patients
  14. Discriminate between patients who may be appropriately treated as an outpatient, and those who require admission to the hospital for escalation of care.
  15. Demonstrate the ability to correctly write outpatient chemotherapy orders
  16. Demonstrate the ability to follow protocol guidelines.

Practice-Based Learning and Improvement.

  1. Appropriately assess gaps in knowledge and skills to enhance learning
  2. Analyze their own practice experience and participate in practice-based improvement activities
  3. Locate, appraise, and assimilate evidence from scientific studies related to patient health problems.
  4. Use data bases such as PubMed, the Cochran Data Base, and Curesearch Website to develop evidence treatment plans for patients.
  5. Lead discussion regarding clinical protocols with faculty supervision.
  6. Fellows will evaluate their clinical performance and generate clinical goals with program director.
  7. Use information technology to optimize learning
  8. Participate in the education of families, students, residents and other health professionals

Interpersonal and Communication Skills:

  1. Effective communication with patient and families across a broad range of socioeconomic and cultural backgrounds
  2. Effective communication with physicians and other health professionals and health related agencies
  3. Maintain comprehensive, timely, and legible medical records
  4. Effectively communicate in a developmentally appropriate manner with patients and families to create and sustain a professional and therapeutic relationship across a broad range of socioeconomic and cultural backgrounds.
  5. Effectively communicate changes in patient status to attending physicians and status of inpatients to community pediatricians and referring physicians.
  6. Lead the discussion with the family of a child with a newly diagnosed malignancy.
  7. Obtain informed consent for fellow performed procedures and protocol-based therapies for malignant disorders.
  8. Present patients effectively to precepting clinical faculty.
  9. Maintain comprehensive, timely and legible medical records on all outpatients, including primary continuity patients.
  10. Ensure all signatures are on the consent form and roadmaps and maintain the roadmaps with frequent updates as necessary.

Professionalism:

  1. Compassion, integrity and respect for others
  2. Responsiveness to patient needs that supersedes self-interest
  3. Respect for patients privacy and autonomy
  4. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation
  5. Develop collegial, constructive relationships with support services.
  6. Manage clinical and personal responsibilities so that patients are seen in a timely fashion.
  7. Demonstrate accountability to all patients and the health care team
  8. Demonstrate a commitment to excellence and ongoing professional development by being prepared, on-time, in appropriate attire and contributing in rounds, teaching conferences and didactic lecture
  9. Recognize and demonstrate an understanding of ethical, cultural, religious, or spiritual values of import to patients and families during communications and care decisions
  10. Demonstrate a commitment to confidentiality, privacy, and respect for patients and families
  11. Demonstrate empathy towards the child and family in negotiating and designing goals of treatment, including relevant medical, legal and psychological issues

Systems Based Practice:

  1. Work in inter-professional teams to enhance patient safety and improve patient care.
  2. Coordinate patient care within the health care system
  3. Incorporate considerations of cost awareness and risk-benefit analysis in patient care
  4. Participate in identifying systems errors and in implementing potential systems solutions
  5. Prioritize the various modes of diagnostic testing and select the most appropriate testing modality, with a goal toward preventing unnecessary laboratory or imaging tests.
  6. Comply with institutional systems that have been developed to prevent errors in the administration of blood transfusion and “high risk” medications, such as immunosuppressive medications, coagulation factor concentrates and anticoagulants.
  7. Acknowledge medical errors in a forthright manner, and report observed medical errors (real or potential) to the appropriate member of the care team, then work with the team to develop a plan for preventing future errors.
  8. Develop an understanding and exposure to clinical research protocols, including issues related to enrollment, and ethical issues in managing patients on institutional and multi-institutional protocols.
  9. Develop skills in working with the research office to integrate clinical research studies into the routine care of patients