Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 53
RE: Resident Responsibilities
Revised June 21, 2010
NAME OF ROTATION: Hematopathology
YEAR(S) OF RESIDENCY ROTATION IS TAKEN AND DURATION: Year I-IV;
minimum 6 months.
SITES: University Medical Center (UMC), TTUHSC Anatomic Pathology, Covenant Health
Systems
GOALS: Resident training in hematopathology includes hematology, coagulation, medical
microscopy, flow cytometry, and urinalysis. These are combined into a multifaceted five-month
program designed to prepare residents to successfully manage a clinical laboratory which offers
these types of testing, function as a consultant for clinicians and understand the entire scope of
hematology.
Note that some hematopathology topics are discussed in the context of other rotations:
immunohematology is comprehensively covered during transfusion medicine rotations; lymph
node biopsy interpretation is covered in surgical pathology rotations. Hence, these topics are not
discussed in detail during hematopathology rotations.
OBJECTIVES:
I.
SKILL LEVEL IA: RECOMMEND 1 MONTH
Goal: Develop everyday expertise in basic clinical laboratory medicine as they
apply to hematology, urinalysis, and medical microscopy of body fluids. Gain basic
peripheral smear and bone marrow interpretation skills, especially regarding
proper identification of the various hematopoietic precursors.
A.
Medical knowledge: Demonstrate proper interpretation of basic CBC findings
(anemia, erythrocytosis, thrombocytopenia, thrombocytosis, leukopenia, leukocytosis),
urinalysis findings (both chemical and sediment microscopy), and body fluid microscopy
(benign vs. malignant, cell counts and differential, correlation with associated cytology
specimens). This knowledge will be based upon suggested texts and didactic sessions
with the responsible faculty:
1.
Pathophysiology of hematologic disorders hematopoiesis:
a.
anemia
b.
erythrocytosis
c.
thrombocytopenia
d.
thrombocytosis
e.
leukopenia
f.
leukocytosis
2.
Urine dipstick testing
3.
Urine sediment examination
4.
Body fluid microscopy
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 54
RE: Resident Responsibilities
Hematopathology
Revised June 21, 2010
a.
b.
c.
d.
B.
C.
D.
E.
synovial fluid
cerebrospinal fluid
semen analysis
paracentesis fluids
Patient Care: Demonstrate proficiency in the following techniques:
1.
Administration of the hematopathology laboratory:
a.
quality control
b.
quality assurance
c.
the pathologist as laboratory director
d.
the pathologist as patient care consultant
2.
Specimen collection, transport and processing for hematology and
urinalysis.
3.
Preparation of peripheral blood smears.
4.
Interpretation of hematologic testing other than CBC: ESR, sickle screen,
Kleihauer-Betke test, spun hematocrit and malaria smear.
5.
Proper identification of normal and abnormal peripheral blood elements.
6.
Basic interpretation of peripheral blood smear findings.
a. interpretation of CBC results and histograms
b. normal and abnormal WBC, RBC, and platelet morphology
c. correlation with clinical history
7.
Proper identification of normal bone marrow elements.
a. interpretation of aspirate specimens and special stains
b. interpretation of biopsy specimens and special stains
c. correlation with clinical history, CBC results and peripheral smear
findings.
8.
Proper identification of urinary sediment elements (cells, casts, and
crystals).
9.
Identification and clinical significance of abnormal semen samples
Professionalism: Residents are expected to present themselves as medical
professionals and develop an effective laboratory management style. These
expectations should continue throughout the remainder of the residents’ rotations.
Interpersonal/communication skills: Interpersonal communication is of prime
importance in clinical pathology, and residents must show proficiency in
interpersonal communication with the following members of the health care team:
1.
Medical technologists and medical laboratory technicians
2.
Laboratory supervisors
3.
Attending pathologists
4.
Clinical residents and/or attendings from whom consultations are
requested
Systems based practice: Interface with other services within the hospital and
understand federal regulations as they apply to the hematology laboratory. These
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 55
RE: Resident Responsibilities
Hematopathology
Revised June 21, 2010
expectations should continue throughout the remainder of the residents’ rotations.
1.
Use of the laboratory computer system for order entry, data retrieval
2.
Review of proper safety requirements (OSHA)
3.
Understanding of basic concepts of laboratory medicine as they apply to
hematology (CLIA, JCAHO, CAP, CMS, HIPAA): proficiency testing,
QC, quality management, personnel qualifications, coding, procedures &
policies, confidentiality, etc.
4.
Regular meeting with residents of other departments to gain clinical
insight and teach hematology concepts
II.
SKILL LEVEL IB: RECOMMEND 1 MONTH:
Goal: Develop everyday expertise in more complicated hematology testing, coagulation
laboratory testing, flow cytometry, and hemoglobin electrophoresis.
A.
Medical Knowledge: Demonstrate deep understanding of the following concepts
based on suggested reading and didactic sessions with the responsible faculty.
1.
Coagulation testing
a.
Platelet function disturbances
b.
Intrinsic and extrinsic clotting pathways
c.
Clotting inhibition and thrombolytic pathways
d.
Coagulation factor deficiencies and inhibitors
e.
Lupus anticoagulants and antiphospholipid antibodies
f.
Congenital and acquired thrombophilia syndromes
2.
Flow Cytometry
a.
Laminar flow
b.
Cell population gating
c.
Four color fluorescence
3.
Hemoglobin electrophoresis
a.
normal and variant hemoglobin
b.
major hemoglobinopathies
c.
interpretation of hemoglobin electrophoresis
d.
correlation with clinical history and likely significance
B.
Patient Care: Demonstrate proficiency in the following laboratory techniques
following practical demonstration:
1.
Routine coagulation testing including PT (including proper calculation of
the INR), aPTT, thrombin time, DIC panel, platelet function assay
2.
Interpretation of more complex coagulation testing:
a.
PT and PTT mixing studies
b.
Specific factor assays including recognition of factor inhibitors
c.
Lupus anticoagulant profiles
d.
Platelet aggregation studies
e.
Assays for heparin-induced thrombocytopenia
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 56
RE: Resident Responsibilities
Hematopathology
Revised June 21, 2010
3.
III.
Interpretation of immunophenotypic analysis by flow cytometry
a.
Immunodeficiency syndromes
b.
Bone marrow/peripheral stem cell transplantation
c.
Diagnosis of leukemias and lymphomas
SKILL LEVEL II: RECOMMEND 4 MONTHS
Goal: Residents will gain proficiency in bone marrow aspiration and biopsy procedures
and gain increasing independence in the interpretation of peripheral blood smears and
bone marrow specimens. Residents will be expected during these months to conduct
proper correlation between morphologic findings, clinical history, immunophenotypic
analysis and cytogenetic findings.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 57
RE: Resident Responsibilities
Hematopathology
Revised June 21, 2010
A.
Medical Knowledge: Demonstrate deep understanding of various hematopathologic
processes using primarily the 2003 WHO Classification scheme, including the following
areas:
1.
Chronic myeloproliferative syndromes
2.
Myeloproliferative/myelodysplastic diseases
3.
Chronic myelodysplastic syndromes
4.
Acute myeloid leukemias
5.
Precursor B- and T-cell neoplasms
6.
Mature B-cell neoplasms (including plasma cell dyscrasias)
7.
Mature T-cell and NK-cell neoplasms
8.
Hodgkin lymphoma
9.
Immunodeficiency associated lymphoproliferative disorders
10.
Histocytic and dendritic cell neoplasms
11.
Mastocytosis
B.
Patient Care: Develop and demonstrate proficiency in the following areas of
hematopathology with increasing independence:
1.
Procurement of bone marrow aspirate and core biopsy specimens from
posterior iliac crests with patient prone and on their side
2.
Proper interpretation of peripheral blood and bone marrow specimens
including correlation with clinical history, flow cytometry findings, and
cytogenetics
DUTIES AND RESPONSIBILITIES OF RESIDENTS:
Residents will review all peripheral smear, bone marrow, and surgical pathology consult
specimens upon receipt in the laboratory. An immediate evaluation of bone marrow aspirates
will be performed to determine if additional special testing (cytogenetics, flow cytometry,
cultures, special stains, etc.) is indicated. The resident will review the patient’s chart and
investigate pertinent clinical and laboratory findings for correlation with the peripheral smear or
bone marrow findings.
The resident will be notified by and will accompany the assisting medical technologist on bone
marrow procedures. After observing a minimum of two bone marrow procedures, the resident is
expected to ask the attending physician if they may participate in or perform the procedure under
their supervision. Residents are expected to perform a minimum of 10 bone marrow procedures
during their residency training.
Residents will also review results from the Clinical Hematology Laboratories which require
interpretive reports and comments. These include hemoglobin analysis by electrophoresis,
lupus-like anticoagulant profiles, flow cytometry leukemia/lymphoma and immunodeficiency
profiles, malaria smears and abnormal peripheral smears and body fluids.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 58
RE: Resident Responsibilities
Hematopathology
Revised June 21, 2010
Residents will initially perform these reviews with the responsible staff physician. Subsequently,
residents will be expected to independently formulate a differential diagnosis and consider
additional diagnostic studies before reviewing the case with the responsible pathologist. They
will then dictate reports for review and verification by the responsible pathologist.
The resident will also be asked to attend the weekly pediatric hematology conference and to
present any of the cases in which they may have been involved. Residents will be encouraged to
submit appropriate cases for publication.
TEACHING STAFF RESPONSIBLE FOR SUPERVISION:
Safaa Labib, M.D., Assistant Pathology
Irfan Warraich, M.D., Assistant Pathology
SUPERVISION AND EVALUATION:
The responsible staff pathologist will supervise the resident’s activities. Evaluation of resident
performance will be documented in writing at the end of each rotation. The evaluation will be
discussed with the resident, and remedial steps suggested to correct any problems or deficiencies.
Residents will document the number of cases and procedures they were involved in during the
rotation.
SUGGESTED TEXTBOOKS:
World Health Organization Classification of Tumours: Tumours of Haematopoietic and
Lymphoid Tissues, by Jaffe et al
Bone Marrow Pathology, 2nd ed. by Foucar
Practical Diagnosis of Hematologic Disorders, 3rd ed. by Kjeldsberg
Flow Cytometry in Hematopathology: A Visual Approach to Data Analysis and Interpretation,
by Nguyen et al
Wet Urinalysis: Interpretations, Correlations, and Implications, by Schumann & Friedman
Body Fluids, 3rd ed. by Kjeldsberg
Neoplastic Hematopathology, 2nd ed. by Knowles
Wintrobe’s Clinical Hematology, 11th ed. by Greer et al