Harborview Medical Center
Harborview Hematology-Oncology Consult Service
John Harlan, M.D.
Harborview research and Training Building Rm 503C
300 Ninth Avenue
Seattle, WA 98104
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,
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
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.
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
This occurs during attending rounds (3-5 days/week) on the consult team
and during post-clinic conferences (once weekly).
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.
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).
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.
Bone marrow aspirate and biopsy are the most frequent procedures. Paracentesis
and thoracentesis are sometimes performed in the Hematology-Oncology Clinic.
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
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
HIV/Hematology Clinic at HMC from 1-4pm
Hemophilia Clinic at Puget Sound Blood Center from 1-4 p.m.
Hematology-Oncology clinic at HMC from 1-5pm
Hematologic Maligancy Conference at Noon on alternate weeks at
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
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.
Teaching slides for morphology are maintained in the Laboratory Medicine
area designated for Hematology.
Methods Used in Evaluating Resident and
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
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