Hematology and Oncology Clinics
Attendance and participation in Hematology and Oncology out-patient clinics is a central part of clinical training during the Hematology-Oncology Fellowship. Increasingly, the practice of Hematology-Oncology is carried out in the outpatient setting. The wide variety of Hematology and Oncology clinics at Boston Medical Center provide a rich resource for learning and the program places great emphasis on making the most of these resources for satisfying and stimulating training for Fellows. The overall goal is that Fellows will attend two (or occasionally three half-day clinic sessions per week at any given time or more if desired during certain rotations) and that attendance at any given clinic will go on for at least 6 months to provide enough time to follow patients longitudinally. Ideally, Fellows will attend clinics at the hospital center at which they are doing their inpatient rotations (e.g. if they are assigned to Boston Medical Center they will do all clinics there). This will allow the maximal chance for Fellows to follow patients they have picked up on the consult service or to follow clinic patients who are admitted to the hospital.
Clinics at Boston Medical Center have been organized according to disease type in general. In the context of Oncology certain clinics are devoted to breast and gynecological malignancy (under direction of Dr. Rita Blanchard and Dr. Carol Rosenberg). Others are focused on Lung Cancer (under direction of Dr. Ken Zaner), Gastrointestinal Cancer (Dr. Kevan Hartshorn, Ken Zaner), Head and Neck Cancer (Dr. Jochen Lorch), Lymphoid Malignancies, Sarcoma and Melanoma (Dr. Adam Lerner) etc.. Hematology Clinics are less stratified by disease type although the bulk of patients with Leukemias and other malignant hematological problems come to Dr. Lewis Weintraub’s clinics, while the clinic of Drs. Jack Ansell focuses more on coagulation disorders, and other non-malignant hematological disorders. Friday AM clinic with Dr. Adeboye Adewoye, Dr. Lillian McMahon, and Dr. Martin Steinberg is focused on Sickle Cell Disease and Hemoglobinopathies. Dr. Weintraub sees patients a wide spectrum of nonmalignant hematological problems as well, including a special interest in hemachromatosis. Certain clinic sessions deal intensively with patients being evaluated for or undergoing autologous stem cell or bone marrow transplantation (under direction of Drs. Vaishali Sanchorawala and David Seldin). Dr. Sanchorawala also has a clinic focused primarily on patients with Hodgkin’s Disease and Plasma Cell Dyscrasias. Much of the transplantation process occurs in the outpatient setting and involves multidisciplinary care by providers from a variety of subspecialists in addition to Hem-Onc. Fellows will be assigned to cover the Transplant clinics as part of the transplant rotation during the first or second year of fellowship.
The advantage of having clinics which focus on particular disease types within Hematology and Oncology is that such clinics are more easily adapted to the multidisciplinary approach. Such clinics are also popular among patients because they allow patients to interact with others who have similar problems. Disease specific clinics also allow the development of consistent approaches and facilitate application of clinical trials. Having certain Attendings identified with specific Hematology or Oncology problems also makes it easy for Fellows and primary care doctors to know who to call for information and follow up of new patients with specific diseases. By attending specific disease oriented clinics the fellow will obtain a concentrated exposure to management of complex diseases and become familiar in depth with clinical trials in those areas. The only disadvantage of this approach is that Fellows must attend several different clinics to get a broad experience of Hem-Onc. As much as possible we will try to accommodate the desire of Fellows to follow new patients they have picked up on the consult service in clinics they are already attending. Such cases should be discussed with the responsible clinic Attending.
While at Boston Medical Center the Fellows will be assigned to attend certain of these clinics for at least 6 months during the first two years of training. Specific clinic assignments for Fellows will be scheduled at the beginning of the year. There will be regular opportunities for feedback regarding the learning experience in clinics. It is expected that Fellows will come early to all clinics in order to be able to discuss and plan in advance the patients which the Fellow will see. Regular and punctual attendance at clinics is considered a very high priority both for training and for considerate patient care. Clinics will be scheduled with the idea that Fellows will be present. Hence expected absences (e.g. due to vacation) should be planned in advance with the responsible staff and clinic Attendings. Only under extreme circumstances should inpatient events interfere with attendance at clinics. The inpatient services are at all times covered by housestaff and Attendings who are assigned in rotation to cover the Hem-Onc ward and consult service.
Fellows should work closely with the Attending or Attendings in their assigned clinics for patient assignments and supervision. In general, Fellows should be assigned to see new patients whenever possible. Fellows are responsible for writing admission notes and admission orders, with review by the Attending staff, on all patients whom they have seen in the clinics when these patients are admitted to the In-patient Hem-Onc Services. Fellows are also expected to follow these patients as in-patients to the greatest extent possible, and to clearly communicate with the inpatient team (including both the inpatient Hem-Onc fellow and Attending and the housestaff) about such patients. All chemotherapy orders on inpatients, as well as any outpatient chemotherapy orders on patients followed by Fellows, should be written by Fellows and co-signed by Inpatient or Clinic Attendings. Fellows are expected to know the rationale behind the use of specific chemotherapy agents and doses and to provide references for this to housestaff. If the fellow does not understand or agree with the use of specific agents or doses, he(she) should not hesitate to ask responsible Attendings for the rationale and references justifying the chemotherapy plan. This is a valuable training experience as well as important for quality control.
The reference files in the Fellows room should contain up to date references describing clinical trials that define the current standards of care for specific cancers and blood disorders. Clinical trial protocol descriptions are also kept in the clinic, and clinical trial nurses can be called to help evaluate eligibility or explain protocols to patients and Fellows. An additional excellent resource for information about chemotherapy are the Pharmacists who are specialized in this area and are regularly present in the Hem-Onc clinic pharmacy and come on rounds with the inpatient Hem-Onc team. By the end of the second year Fellows should be comfortable with use a wide variety of chemotherapies and other therapeutic modalities and know how to access information readily through computer search, etc. Whenever possible Fellows should participate directly in the consent process for chemotherapy and clinical trial enrollment as this provides another excellent opportunity to learn about chemotherapy through teaching patients.
Fellows are strongly encouraged to write up (with Attending assistance) case reports relating to interesting or instructive cases.