PATIENT CARE
PROCEDURAL SKILLS
A. Objective
1. What procedural skills must be acquired on this rotation?
a. Level I
1. Grossing and triaging lymph node or hematolymphoid
tissue biopsies for histopathology as well as any
appropriate ancillary studies at Parkland and University
Hospitals.
b. Level II
1. Demonstrate mastery of all of the objectives from the
Level I rotation.
2. Gain exposure to bone marrow aspiration and biopsy
procedures for histopathology as well as any appropriate
ancillary studies.
3. Understand the basic procedures for bone marrow
processing, including factors that may compromise
specimen adequacy, and the advantages and
disadvantages of the various preparations.
B. Plan
1. How are the procedural skills taught and by whom?
a. Level I
1. Lymph node and tissue procedural skills are taught by
observation and actual performance under the supervision
of senior residents (a resident having completed at least
one two-month rotation in hematopathology),
hematopathology fellows, and hematopathology faculty.
Detailed written instructions for submitting tissue for a
hematolymphoid workup are provided during the rotation
orientation. During the procedure, the residents will make
touch preparations of the nodes and examine the "diffquick" stained slides. Based on the morphologic
impression, they will select ancillary tests for which
dissected tissue will be submitted (flow cytometry,
cytogenetics, molecular diagnosis, or culture).
b. Level II
1. Senior residents are expected to observe one bone
marrow biopsy at Parkland Hospital to become familiar
with this procedure. A senior resident may, if he or she
chooses, perform a bone marrow under the supervision of
hematology/oncology personnel.
2. Senior residents are expected to participate in a “bench
rotation” in the bone marrow processing laboratory where
they will learn preparation and routine staining of bone
marrow aspirates, touch preparations and special staining
of bone marrow aspirates including iron, myeloperoxidase,
and non-specific esterase stains.
C. Supervision/Assessment
1. How and by whom are the procedures supervised and the skills
assessed, and how are these documented?
a. Level I
1. Junior residents will be supervised directly by senior level
residents, hematopathology fellows, and hematopathology
faculty at the beginning of the rotation.
2. Junior residents are responsible for maintaining a log of
the first three grossing or triage procedures they perform.
Once proficiency in grossing and triaging at least three
lymph node or other hematolymphoid specimens has been
verified, junior residents may perform these procedures
without direct supervision. However, fellows and attendings
will be available in-house to assist, if necessary, during
business hours (8 a.m. to 5 p.m.). After hours,
hematopathology fellows and attendings are available to
assist on call, if necessary.
3. Performance in grossing and triaging specimens will be
assessed through direct observation of at least three
procedures by hematopathology faculty, fellows, and
senior residents. Faculty will provide direct verbal feedback
regarding grossing technique for each case at the time of
sign-out.
4. The rotation director will discuss verbal and written
assessments provided by faculty, fellows, supporting staff,
and clinicians at both the midpoint and endpoint of the
rotation.
b. Level II
1. Senior residents may gross and triage specimens with
indirect supervision (hematopathology fellows and faculty
on call to assist, if necessary). Bone marrow biopsy
procedures are performed under the supervision of
hematology/oncology faculty and fellows. Bone marrow
processing and staining skills are learned under the
supervision of laboratory technologists at Parkland
Hospital.
2. Resident performance will be assessed through direct
observation by hematopathology faculty, fellows,
laboratory technologists and clinicians. Faculty will provide
direct verbal feedback regarding grossing technique for
each case at the time of sign-out.
3. Residents will complete and submit to the rotation director
a checklist documenting they have observed at least one
bone marrow biopsy and have participated in the bench
rotation at the bone marrow laboratory.
4. The rotation director will discuss verbal and written
assessments provided by faculty, fellows, supporting staff,
and clinicians at both the midpoint and endpoint of the
rotation.
INTERPRETIVE SKILLS
A. Objectives
1. What interpretive skills are important to acquire on this rotation?
i. Level I
1. Be able to evaluate and interpret peripheral blood and
body fluid smears, bone marrow aspirates and core
biopsies, and a variety of hematology tests including CBC,
reticulocyte counts, hemoglobin electrophoresis.
2. Demonstrate proficiency in bone marrow differentials.
ii. Level II
1. Demonstrate mastery of all of the objectives from the Level
I rotation.
2. Be able to evaluate and interpret lymph node biopsies, any
hematolymphoid infiltrate in other organ/systems and flow
cytometric analysis.
B. Plan
1. Level I
i. In the first week of the rotation, residents will participate in
scheduled morning sessions with the rotation director. These
sessions will include basic blood and bone marrow cell
morphology at a multi-headed microscope.
ii. Perform bone marrow and peripheral differential counts at the
beginning of the rotation under the supervision of
hematopathology faculty, fellows and senior residents.
iii. The residents will be expected to prepare the assigned cases,
including gathering appropriate clinical and laboratory data,
reviewing the morphology, performing differential counts when
applicable, and formulate their own impressions and diagnoses
prior to reviewing the cases with the attending hematopathologist.
The hematopathologists will discuss the cases with the residents
during sign-out and finalize the diagnosis.
iv. Residents are assigned to Children's Medical Center on a rotating
basis to prepare morphologic reports on pediatric bone marrow
and body fluids. Generally there is sufficient time for the CMC
resident to sit in on the sign-out at Parkland and vice versa.
v. The resident will act as a first line resource for hematology wet lab
problems during business hours (8 a.m. to 5 p.m.)
vi. The resident will attend and actively participate in weekly HPLC
sign-out at CMC.
2. Level II
i. Demonstrate mastery of all of the objectives from the Level I
rotation.
ii. Demonstrate the progressive mastery of lymph node/lymphoid
tissue based diseases.
iii. The senior resident may assist in supervising junior residents
when performing bone marrow and peripheral blood differential
counts at the beginning of the rotation.
iv. The resident will take responsibility for some interdivisional consult
cases at the discretion of the hematopathology faculty and fellows.
These cases may be more complex than routine cases and
require a greater level of involvement with regard to obtaining
clinical history, interpreting ancillary tests, generating reports, and
communicating with consulting pathologists and/or clinicians.
C. Supervision/Assessment
1. How are the interpretive skills assessed and by whom?
i. Level I
1. Junior residents performing bone marrow differential
counts will be supervised directly by senior level residents,
hematopathology fellows, and hematopathology faculty at
the beginning of the rotation. Junior residents are
responsible for maintaining a log of the first three bone
marrow differential counts they perform. Once proficiency
in performing bone marrow differential counts in three
separate cases has been verified, junior residents may
perform these procedures without direct supervision.
However, fellows and attendings will be available in-house
to assist, if necessary, during business hours (8 a.m. to 5
p.m.). After hours, hematopathology fellows and attendings
are available to assist on call, if necessary.
2. Performance will be assessed through direct observation
by hematopathology faculty, fellows, and senior residents,
as well as through oral quizzes during daily sign-out,
weekly flow cytometry conference, and unknown
conferences. Faculty will provide direct verbal feedback for
each case at the time of sign-out. The rotation director will
administer a bone marrow differential quiz to junior
residents after the first week of the rotation. The rotation
director will discuss verbal and written assessments
provided by faculty, fellows, supporting staff, and clinicians
at both the midpoint and endpoint of the rotation.
ii. Level II
1. The resident's performance will be assessed through direct
observation by hematopathology faculty and fellows, as
well as through oral quizzes during daily sign-out, weekly
flow cytometry conference and unknown conferences.
Faculty will provide direct verbal feedback for each case at
the time of sign-out.
2. The rotation director will discuss verbal and written
assessments provided by faculty, fellows, supporting staff,
and clinicians at both the midpoint and endpoint of the
rotation.