Hematology and Oncology Consults
The Hematology-Oncology Section is responsible for providing prompt, appropriate, and complete consultation in Hematology and Oncology, 7 days/wk, 24 hrs/day, throughout the medical, surgical, and ancillary clinical services (including E.R., O.R.’s, OB-GYN, and all clinics) at Boston Medical Center with the general but not complete exception of the pediatric services. The consultation services are principal responsibilities of Hem-Onc Fellows during their training. In addition to overall quality of patient care, both the success of Hem-Onc teaching for house officers and students, and the success of identifying and taking productive advantage of clinical research opportunities in Hematology and Oncology are directly dependent upon the level of activity and quality of this service.
The Hematology-Oncology Consult Fellow
The Clinical Hem-Onc Fellow has substantial independent responsibilities in the conduct of the Hematology-Oncology consult service. The Fellow is generally the first to see patients for whom consultation has been requested (together with students and/or residents assigned to the service). The Fellow is also expected to take an active role in identifying potential in-patient and out-patient consults by interacting regularly with housestaff to become aware of new admissions with potential hematologic and oncologic problems, and by serving as a point of contact for the clinical laboratories in following up significantly abnormal hematology lab values. The Fellow should actively solicit in-patient consultations as early in a patient’s hospital course as possible, while taking care not to infringe upon the responsibilities of the house staff to initiate diagnostic and management plans by maintaining a co-management approach with the house staff. It is highly appropriate for Fellows to begin consulting on patients during the course of work up for likely cancer detected as a result of admission to the general medical or surgical service. The Hem-Onc service can often aid the inpatient team in expediting the work up and prioritizing tests. If appropriate the Hem-Onc consult team can suggest Radiation Oncology Consultation or Surgical Oncology consultation to the inpatient team.
Admissions from Hematology or Oncology clinics will generally go directly to the Heme-Onc inpatient service on 7East at the East Newton Street campus. Patients on 7East will be the responsibility of the fellow assigned to that service. It is the responsibility of Fellows or Attendings admitting patients from clinic to contact the Fellow and Attending covering the inpatient service about such patients. However, patients followed by the Hem-Onc service may at times be admitted to other services (e.g. surgical services or Internal Medicine services due to bed availability or desire of primary care MDs to follow the patient). It is the responsibility of the Heme-Onc Fellow and Attending covering the Consult service to follow such patients as consults. When appropriate such patients should be transferred to 7E.
It is the Fellow’s responsibility to make sure that consultation requests are submitted in writing and that specific questions relating to diagnosis and/or management are identified clearly in the consultation request. Since medical students, residents frequently rotate on the Heme-Onc consult service Fellows may also serve an important role in supervising and teaching students and Residents. Residents or students may see patients initially followed by review of such patients by the Fellow and Attending at Heme-Onc rounds. The Fellow should make every effort to see patients for whom consultations are requested on the same day that consult requests are made, even if these requests occur outside of regular working hours. This is a particular requirement if the house officer or attending physician making the request indicates that the reason for the consult is urgent. (Fellows should not second-guess consult requests in this regard; if the urgency of a consult request is either over- or under-stated, it is the Hem-Onc Attending’s responsibility to discuss this issue with the referring staff once the consult is complete.) Although special hematology laboratory evaluations or procedures may be deemed inappropriate by the consulting team, at no time should the Fellow indicate that a consultation request itself is inappropriate unless no specific question(s) is identified in the request.
The Fellow is expected to leave a preliminary note in the patient’s chart on the day that a consultation request is made, whenever possible, and to present the case to the Attending and prepare a written consultation report for placement in the chart within 24 hrs of the request. Responsiveness and promptness are critical determinants of the success of the Hem-Onc consultation service.
Consultation reports should focus upon the Hematologic or Oncologic aspects of a case and should specifically address (but not necessarily be limited to) the question(s) posed by the consult request. Summaries of history, physical exam, and laboratory data should focus on the Hem-Onc issues in question. Assessments and recommendations should provide specific and clear guidance with respect to diagnosis and management, but should also serve to educate. Hence, the consultation report should be dominated by a comprehensive and organized discussion of the case which reflects an appropriate consideration of 1) differential diagnosis, 2) natural history, 3) etiology of the most likely disorders under consideration, 4) additional diagnostic or prognostic evaluations that should be pursued, 5) management options, 6) management recommendations, and 7) specific recommendations for follow-up. Key issues among these considerations should be supported by references, and whenever possible, a printed reference from the literature. The Fellows are encouraged to make use of reference files in the Fellows room and to contact whichever Attending they think will have the most up to date advice on management of the specific problem (regardless of whether that Attending is on service or not). For example, Dr. Hartshorn can be contacted related to Gastrointestinal Cancer management and trial availability, or Drs. Blanchard and Rosenberg can be contacted related to Breast or Gynecological Cancers.
It should be remembered that the timeliness, quality, and substance of the consult report reflects directly upon both the Fellow and upon the Hem-Onc Section as a whole. The Fellow is responsible for assuring that a copy of each final consult report and place this in the files in the Fellows room. The Fellow is also responsible for assuring that each patient is appropriately followed-up on an in-patient or out-patient basis, and that all important laboratory data obtained in follow-up relevant to the initial consultation and all procedures performed by the Fellow on the patient and all follow-up examinations by the Fellow are recorded in the patient’s medical record.
Most Oncology consults (and many Hematology) should be followed up in the outpatient Hem-Onc clinic after discharge. It is vitally important that the fellow identify which clinic session the patient should go to and present the medical team and patient with a clear follow-up plan at the time of discharge. Ideally the Fellow will follow up patients who are new to the Hem-Onc service himself or herself, since such longitudinal care is vital for learning. The consult fellow should confer with outpatient Attendings who would share responsibility for the patient. If the patient has a problem which would generally be followed during a specific clinic session (e.g. lung cancer patients would generally be followed in the multidisciplinary lung cancer clinic; see detailed list of specialized clinics attached) the consult fellow should notify one of the Attendings responsible for that clinic. If the fellow is not regularly attending that clinic session, follow up plans should be discussed with the clinic Attending.