Harborview Medical Center

Harborview Hematology-Oncology Consult Service

Faculty Contact
John Harlan, M.D.

Address
Harborview research and Training Building Rm 503C
300 Ninth Avenue
Seattle, WA 98104

Phone: 341-5314
Email: jharlan@uw.edu

Overall Educational Purpose

1. To provide exposure to a broad spectrum of Hematologic and Oncologic disorders and Transfusion Medicine in adults.
2. To develop problem-solving and diagnostic skills related to Hematologic and Oncologic disorders and Transfusion Medicine.
3. To develop treatment skills related to basic Hematologic diseases and Transfusion Medicine problems.

The discipline of hematology-oncology relates to the care of patients with solid tumors and disorders of the blood, bone marrow, and lymphatic systems, including anemias, hematologic malignancies, and other clonal processes, and congenital and acquired disorders of hemostasis, coagulation, and thrombosis.
The general internist should be competent in 1) the detection of abnormal physical, laboratory, and radiologic findings relating to the lymphohematopoietic system; 2) the assessment of the need for bone marrow aspirate and biopsy and lymph node biopsy; 3) the initial diagnostic evaluation and management of the hemostatic and clotting system; 4) the assessment of the indications and procedure for transfusion of blood and its separate components; 5) the management of therapeutic and prophylactic anticoagulation; 6) the diagnosis and management of common anemias; 7) the pharmacology and use of common chemotherapies; and 8) the management of neutropenia/immunosuppression; 8) the diagnosis and general principles of management of common solid tumors
The range of competencies expected for a general internist will vary depending on the availability of a hematologist-oncologist in the primary care setting. For example, in some communities a general internist may be responsible for bone marrow examination and administration of chemotherapy for certain disorders in conjunction with consultative assistance from appropriate hematologist-oncologist and pathologist colleagues.


Team Structure
The Hematology-Oncology consult service at HMC consists of a consult attending and a hematology-oncology fellow.

Principle Teaching Methods
Direct Supervision of Patient Care
The Attending physician on the Hematology-Oncology consult service provides supervision of the consult team (Fellow, resident, and student). In the weekly Hematology-Oncology clinic, the Clinic Attendings provide direct supervision.

Case-Based Discussion
This occurs during attending rounds (3-5 days/week) on the consult team and during post-clinic conferences (once weekly).

Formal Conferences
Conferences include Hematologic Malignancies at Seattle Cancer Care Alliance (SCCA) on the first and third Friday of the month at noon. Tumor Board is held on first and third Mondays at Harborview at 7:00 am. A review of Transfusion Medicine cases occurs at Puget Sound Blood Center on Mondays at 10:00 am.

Didactic lectures include weekly Medicine Grand Rounds (8:00 a.m. on Thursdays), weekly Hematology-Oncology Fellows Conference (7:00 a.m. on Fridays), and Hematology-Oncology Grand Rounds (8:00 a.m. on alternate Fridays) at SCCA.


Educational Content
Mix of Diseases
The Hematology-Oncology Consult Service and Clinic at HMC encompass a broad range of Hematologic-Oncologic disorders and Transfusion Medicine problems including bleeding disorders (e.g., disseminated intravascular coagulation, idiopathic thrombocytopenia purpura), hematologic malignancies (lymphomas, myeloproliferative and myelodysplastic syndromes, chronic leukemias), solid tumors (e.g., lung, heart, colon), and HIV-associated disorders (e.g., Kaposi’s sarcoma, autoimmune thrombocytopenia).

Patient Characteristics
Patients admitted to Harborview Medical Center represent a full socioeconomic spectrum; the ethnic mix reflects the City of Seattle.

Medicaid 47%, Medicare 20%, Managed Care 5%, Self pay 7%, Workmen’s Comp. 5%, Commercial insurance 16%.

Types of Clinical Encounters
Patients seen by the Consult Service include in-patients on Medical, Surgical, and Psychiatric Services as well as the various out-patient clinics. Hematology-Oncology Clinic patients include follow-up from in-patient consults and new referrals. Clinical encounters on the Consult Service generally involve a directed history and physical at the time of initial evaluation, an initial note completed at that time, presentation to the Attending within 24 hrs., and daily follow-up visits and notes as warranted. Clinic patients are presented to the Attending physician during the clinic.

Procedures
Bone marrow aspirate and biopsy are the most frequent procedures. Paracentesis and thoracentesis are sometimes performed in the Hematology-Oncology Clinic.

Services
The Hematology-Oncology Consult Service at HMC provides 24 hour coverage including a Fellow and Attending. A Transfusion Medicine Consult Service with a Blood Center Physician is also available 24 hours daily through the Puget Sound Blood Center.


Rotation Specific Schedule
Monday
Tumor Board at 7:00 a.m. at HMC R&T building on second and fourth Mondays of the month
Transfusion Medicine Conference at Puget Sound Blood Center from 10:00-11:00 am

Tuesday
HIV/Hematology Clinic at HMC from 1-4pm

Wednesday
Hemophilia Clinic at Puget Sound Blood Center from 1-4 p.m.

Thursday
Hematology-Oncology clinic at HMC from 1-5pm

Friday
Hematologic Maligancy Conference at Noon on alternate weeks at SCCA
Core Lecture series at 7:00 a.m. at SCCA


Call and Weekend Responsibilities
The resident is expected to take call on one weekend (Friday evening to Monday morning) during the rotation. This entails phone calls throughout the evenings and days and rounds on Saturday and Sunday mornings.

Principle Educational Materials Used
Recommended Readings
Computers in the HMC library and the Hematology office provide access to internet and literature search computer services. A library of Hematology-Oncology textbooks is available in the Clinic and in the Hematology office. Hoffman’s textbook of Hematology and DeVita’s Textbook of Cancer are considered to be the standard reference texts. Access to the National Comprehensive cancer Network practice guidelines is available through the internet as is the educational program books from the American Society of Hematology and American Society of Clinical Oncology.

Pathologic Materials
Teaching slides for morphology are maintained in the Laboratory Medicine area designated for Hematology.


Methods Used in Evaluating Resident and Program Performance
Residents are evaluated by the Consult Service Attending and the Clinic Attendings based upon case presentations, consult and clinic notes, and interactions during attending rounds and clinic. Comments on the Resident’s performance are also solicited from the Hematology-Oncology Fellows. Attendance at conferences and didactic lectures is considered in evaluation of performance.

At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally by every attending and fellow he or she has interacted with for a significant amount of time. The evaluator rates the resident on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met. The resident also evaluates the teaching competence of each attending and fellow with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibility for Care of Patients on this Service
The Resident on the Consult Service is expected to assume responsibility for the initial evaluation of the consult patient and, after discussion with the Consult Attending, to communicate recommendations of the Consult team for management to the patient’s primary physicians. Although the Hematology-Oncology Fellow may provide input and advice, the Resident is also required to discuss all assessments and recommendations with the Attending prior to communicating with the primary physicians. The Consult or Clinic Attending is solely responsible for all therapeutic decisions. The Resident may arrange the order of routine blood products directly with the Puget Sound Blood Center.

 

Last Revised February 10, 2004 by Virginia Broudy, MD