Curriculum

First-year hematology/oncology fellows have a primarily clinical year that is divided approximately equally between inpatient and outpatient experiences. The clinical services are located at the Hospital of the University of Pennsylvania (HUP), Perelman Center for Advanced Medicine (PCAM), Penn Presbyterian Medical Center (PPMC), and the Philadelphia VA Medical Center (VAMC).

Each rotation will last approximately 10 weeks:

• Outpatient Oncology rotation (PCAM, Outpatient)*
• Classical Hematology (HUP/PCAM, Inpatient/Outpatient)
• Hematologic malignancy and hematopoietic stem cell transplant services (HUP/PCAM, Inpatient)
• Philadelphia VA Medical Center(VAMC, Inpatient/Outpatient)*
• Penn Presbyterian Medical Center (PPMC, Inpatient/Outpatient)

*Combined hematology/oncology track fellows only

For combined hematology/oncology track fellows, about six months per year are dedicated to outpatient training that encompasses solid tumor oncology, hematologic malignancies and transplant, and classical hematology. The other six months include inpatient rotations in hematology and hematologic malignancy/transplant, and the Philadelphia VA Medical Center, with the latter including morning outpatient clinics and afternoon inpatient consults.

Hematology-focused fellows will spend about six months per year dedicated to outpatient training in malignant and classical hematology. The other six months include inpatient rotations in hematology and hematologic malignancy/transplant as well as inpatient and outpatient rotations at the Penn Presbyterian Medical Center.

Throughout the year, fellows are entirely off duty at least one day out of seven; half of the rotations are outpatient based. Penn adheres to the ACGME requirement for an 80-hour work week. There is no in-house overnight call. Penn fellows take four weeks of vacation per year.

Classical hematology

This is a hybrid inpatient/outpatient rotation in classical hematology. Consult fellows see all HUP hematology consult requests, including those from the Departments of Medicine, Surgery, Surgical Subspecialties, Neurology, Obstetrics and Gynecology, and other departments. During this rotation, the outpatient fellows attend clinics and present cases at the weekly hematology case conference. The case discussions include formal literature summaries and management recommendations.

The program's goal is to provide varied and comprehensive experience in consultative hematology

• Principal teaching methods: Teaching rounds, bedside presentation and discussion, conferences, direct supervision of bone marrow aspiration and biopsy procedures, literature review, intensive microscopic review of case materials, participation in hematopathology rounds, and experience in the methodologies and interpretation of laboratory-based testing
• Educational content: Exposure to all aspects of adult hematology, including congenital and acquired coagulation disorders, transfusion medicine, diagnosis and management of cytopenias and elevated blood counts, and evaluation of patients with gammopathies. Detailed study of peripheral blood and bone marrow morphology and laboratory evaluation of coagulation disorders, flow cytometry and cytogenetics are all included
• Mix of diseases: The full range of congenital and acquired adult hematologic disorders
• Patient characteristics: Men and women, adults and adolescents, including geriatric populations
• Types of clinical encounters: Bedside consultations and outpatient evaluations
• Procedures: Bone marrow aspiration and biopsies
• Educational resources: ASH Academy online, multi-headed teaching microscope, as well as the entire collection of the Holman Biotech Commons at the Perelman School of Medicine
• Supervision: All aspects of the fellows' clinical activities and training are supervised by the inpatient attending physician

Hematologic malignancy and hematopoietic stem cell transplant service

This 10-week rotation takes place at the Hospital of the University of Pennsylvania and includes inpatient consultations, management of patients admitted to hematologic malignancy teaching services, and a two-week transplant rotation.

Hematologic malignancy inpatient teaching services consist of one fellow, an attending, a resident, a nurse practitioner, and two interns. Fellows learn to perform diagnostic and therapeutic procedures including bone marrow biopsies and intrathecal chemotherapy administration via lumbar puncture and/or Ommaya reservoir. In addition, fellows are responsible for obtaining consent for chemotherapy and writing all chemotherapy orders on the unit. The fellows continue to follow their patients when they are transferred to other units, such as the intensive care unit (ICU), physical medicine and rehabilitation or surgery.

Fellows also serve as a liaison between hematopathology and the inpatient services, reviewing new cases with the pathologists and reporting results to the team.

During a four-week transplant rotation, fellows will see patients in the outpatient stem cell transplant, myeloma, and lymphoma clinics and attend rounds on the inpatient service.

The purpose of the rotation is to provide a sophisticated and comprehensive experience in the diagnosis and management of hematologic malignancies, the principles and practice of high dose therapies, and autologous and allogeneic hematopoietic stem cell transplantation; to provide experience in the diagnosis and management of oncology emergencies; to gain expertise in the management of pain control and patient and family-centered terminal care

• Principal teaching methods: Teaching rounds, bedside presentation and discussion, literature review, and teaching conferences.
• Educational content: Explication of the pathogenesis and biology of myeloid and lymphoid malignancies and exposure to all aspects of hematologic malignancies requiring hospital-based therapies.
• Mix of diseases: All hematologic malignancies as well as myelodysplastic syndromes and aplastic anemia.
• Patient characteristics: Men and women, adults and adolescents, including geriatric populations.
• Types of clinical encounters: Daily bedside encounters.
• Procedures: Bone marrow aspiration and biopsy, chemotherapy infusion, stem cell and bone marrow infusion, intrathecal/intraventricular chemotherapy administration.
• Educational resources: As previously described.
• Supervision: All aspects of the fellows' clinical activities and training are supervised by the inpatient attending physicians.

Outpatient training in hematology and oncology

During the first year, fellows maintain one clinic session per week with an assigned preceptor in continuity for 6 months. Clinics are selected with attention to fellows’ clinical interests. In addition to the continuity clinics, fellows have full-time (8 sessions per week) outpatient rotations for 5 weeks at the VAMC, 5 weeks at PPMC, and 10 weeks at HUP/PCAM. Fellows are integrated directly into individual attendings' practices. The outpatient clinical experience includes solid tumors, hematologic malignancy/transplant, or additional classical hematology as desired by the fellow.

The fellows are expected to assume primary responsibility for the patients they see, which includes complete H&P, preparation of progress note(s), follow up on laboratory and radiographic data, presentation in conferences, and follow-up management. Fellows follow the patients as necessary, formulate treatment plans, and direct the care of the patients. Fellows continue to be the primary hematology/oncology physician for patients, are available by telephone or pager to patients during the week and see them should an emergency arise.

The program's goal is to provide experience in performing hematology and oncology consultations and second opinions in the outpatient setting, and in devising and carrying out complex treatment plans that include long-term follow-up of the patients

• Principal teaching methods: Outpatient teaching.
• Educational content: Exposure to a wide range of hematologic and oncologic disorders, including hematologic malignancies, leukemias and the full spectrum of solid tumors. Fellows will have the opportunity to teach patients and families about these diseases, and to counsel them, as well as to learn about the side effects of cancer therapy and the management of patients with all stages of disease, including its terminal stages.
• Mix of diseases: See above.
• Patient characteristics: Men and women of all ages and ethnic backgrounds.
• Types of clinical encounters: Interviews and examinations, review of medical records and radiographs.
• Procedures: Bone marrow aspirations and biopsies, lumbar punctures, the supervision of chemotherapy, administration of intrathecal/intraventricular chemotherapy.
• Educational resources: Multi-headed teaching microscope and television, textbooks, computer terminals, including dedicated electronic systems for viewing radiology studies.
• Supervision: Fellows are supervised by faculty in hematology/oncology in each clinic. In addition, nurse navigators and social workers are available for consultation to assist patients with psychological and social problems.

Philadelphia VA Medical Center

This is a hybrid inpatient/outpatient rotation. During outpatient blocks, first-year fellows maintain a continuity panel in which they serve as the primary hematologist/oncologist for veterans. Some fellows choose to maintain their patient panels throughout the second and third years of the fellowship program.

The clinics are staffed by Penn hematologists/oncologists including specialists in malignant hematology, GI malignancies, head and neck cancer and lung cancer. During inpatient VA rotations, the fellow and the consult attending oversee the care of hematology/oncology inpatients.

Several multidisciplinary tumor boards are held at the VAMC, and the fellow and consult attending serve as the medical oncologists for these conferences.

The purpose of the program is to provide sophisticated and comprehensive experience in the diagnosis and management of hematologic and oncologic diseases

• Principal teaching methods: Outpatient teaching, inpatient consults, clinical conferences and case reviews, literature reviews
• Educational content: Exposure to the diagnosis, treatment, and prevention of a variety of hematologic problems and liquid and solid tumors, particularly aerodigestive cancers, GI cancers, head and neck malignancies, and prostate cancer
• Mix of diseases: As above
• Patient characteristics: Largely men, including a high representation of the geriatric population
• Types of clinical encounters: Interviews and examinations in the outpatient office and on inpatient services
• Procedures: Bone marrow aspiration and biopsies, supervision of chemotherapy infusion, intrathecal/intraventricular chemotherapy administration.
• Educational resources: As previously noted
• Supervision: Fellows are supervised by members of the Penn faculty who serve primarily at the VAMC or at HUP

Penn Presbyterian Medical Center

At Penn Presbyterian Medical Center, fellows benefit from unique training opportunities and are exposed to the socioeconomically and demographically diverse patient population of an urban safety net hospital. In contrast to the tertiary care oncology clinics based at PCAM, where most patients are seeking second opinions or clinical trial enrollment, the majority of cases seen in the PPMC clinic constitute “bread and butter” hematology-oncology. In this setting, fellows learn to manage common treatment-related toxicities, chemotherapy dosing and modification, and will be better poised to own patient care in a longitudinal manner.

Clinical experiences exclusive to PPMC include a multi-disciplinary Mesothelioma and Pleural Disease Program and a novel Cancer Diagnostics clinic. The latter serves as a much-needed point of access for West Philadelphia community members who present to the emergency department with suspected malignancy.

The purpose of the rotation is to provide comprehensive training in the diagnosis and management of hematologic and oncologic diseases in an academic urban safety net setting

• Principal teaching methods: Outpatient teaching, inpatient consults, clinical conferences and case reviews, literature reviews
• Educational content: Exposure to diagnosis, treatment, and prevention of a variety of hematologic problems and liquid and solid tumors, and well as classical hematology
• Mix of diseases: As above
• Patient characteristics: Diverse patient population reflective of West Philadelphia
• Types of clinical encounters: Interviews and examinations in the outpatient office and on inpatient services
• Procedures: Bone marrow aspiration and biopsies, supervision of chemotherapy infusion, intrathecal/intraventricular chemotherapy administration
• Educational resources: As previously noted
• Supervision: Fellows are supervised by members of the Penn faculty

Second and third year curriculum

The upper years of hematology-oncology fellowship education at HUP are tailored to the career goals of the individual trainee. Our curriculum is specifically designed to permit our fellows to identify and pursue a specific investigative path, whether in the traditional laboratory-based sciences, or in population science, health services, epidemiology, or developmental therapeutics. There are some ongoing limited clinical responsibilities expected during these years of training to ensure that our fellows also become expert physician sub-specialists.

Oncology consults (combined hematology/oncology track)

On this rotation, the fellows focus on the evaluation and management of hospitalized patients with new cancer diagnoses (or patients with unknown diagnoses in whom a malignancy is part of the differential diagnosis). The aims are for the fellow to gain an understanding of disease processes, the interactions of cancer and its treatment with co-morbid medical conditions, and the selection of chemotherapy regimens. Consults are staffed by a dedicated oncology consult attending physician who is also responsible for daily rounds and teaching

• Principal teaching methods: Inpatient management, consultation, teaching, clinical conferences and case reviews, literature reviews.
• Educational content: Explication of the biology and pathogenesis of a variety of cancers and participation in the diagnosis and treatment of these diseases and their complications, including lymphoma, myeloma, breast, GI, GU, and aero-digestive cancers, melanoma and sarcoma, and brain tumors.
• Mix of diseases: A wide array of oncologic problems, as well as new lymphadenopathy, hypercalcemia, workup of new masses and lytic bony lesions.
• Patient characteristics: Men and women, adults and adolescents, including geriatric populations.
• Types of clinical encounters: Interviews and examinations in the inpatient setting.
• Procedures: Bone marrow aspiration and biopsies, chemotherapy infusion, intrathecal/intraventricular chemotherapy administration.
• Educational resources: As previously described.

Gynecologic oncology (combined hematology/oncology track)

All fellows spend two weeks attending the outpatient clinics in gynecologic oncology under the direction of the obstetrics and gynecology surgery service at Penn, and a medical oncology attending physician with special expertise and interest in gynecologic medical oncology, including clinical trials for this patient population.

Classical hematology electives

Fellows on the hematology-focused tracks and any fellows planning to board in hematology, will do additional classical hematology electives in the second and third year. Options include rotations in the special coagulation laboratory, apheresis and transfusion medicine, and/or hematopathology.

Laboratory-based research

Those individuals planning careers in basic research spend the remainder of their fellowship either:

• As a mentored trainee with one of the many physician-scientists in the Division or with another scientist at the Abramson Cancer Center, the Abramson Family Cancer Research Institute, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, or the Wistar Institute. Investigators across our campus work on all aspects of hematology and cancer, including genetics and genomics, proteomics, cell and developmental biology, signal transduction, stem cell biology, structural biology, computational biology, immunobiology, vaccine and cellular therapy, gene therapy and virology.

The laboratory experience is structured to provide the fellow with training to establish the foundation for a successful career as an independent investigator.

First-year fellows are encouraged to attend a variety of formal and informal research venues to become aware of potential laboratory mentors. The scientific mentor is chosen in the spring of the first year just prior to the start of the 2^nd fellowship year.

Clinical/translational research

Fellows who wish to pursue careers in clinical research undertake a structured clinical research program that formally begins with the second year of fellowship training. This includes the following:

• In-Depth Methodological Research training that may include:
  • A year-long course led by Emma Meagher, MD, (Center for Experimental Therapeutics), "Patient Oriented Research," that culminates in the fellow generating a grant proposal
  • Summer courses offered by the ASBMT, AACR/ASCO and ASH. A good example is the AACR/ASCO Methods in Clinical Cancer Research annual workshop in Vail, CO, in which many of our fellows have participated
  • A master's degree in clinical epidemiology (MSCE) offered through the Department of Biostatistics and Epidemiology
  • A master's degree in experimental medicine and translational research (MTR) offered through the Institute for Translational Medicine and Therapeutics
  • For those already prepared with master's degrees, the School of Medicine offers certificate programs in both clinical epidemiology and translational research through the sites listed above.

Each fellow interested in a career as a clinical investigator is expected to develop, write, submit to the IRB, and begin one or more clinical research protocols.

Formal mentoring

Formal mentoring consists of the fellow working closely with one or more of the many basic, clinical, or translational investigators in the Hematology/Oncology Division or the Abramson Cancer Center. The fellow finds a mentor(s) after consultation with the Program Director, one of the Fellowship Program Associate or Assistant Directors and other members of the faculty. The process of identifying and meeting with potential mentors culminates with formal selection of a mentor(s) in the spring of the first year of fellowship. The Division is proud of the strong tradition and culture of mentoring our fellows and junior faculty.

Clinical experience

Whether participating in bench research or the clinical/translational research pathway, each fellow maintains a weekly half-day continuity clinic throughout his or her fellowship. This allows fellows to deepen their experience in clinical hematology/oncology.

As in the first year, each fellow is supervised in the continuity practice by the clinical faculty with whom they see patients. All patients are seen with and under the direct supervision of an attending physician. The fellows' educational experience is further enhanced by continuing to attend clinical case conferences in hematology and oncology throughout the upper years.

In addition, fellows are encouraged to participate in one of the many multidisciplinary subspecialty tumor boards, particularly those related to their research projects and clinical interests.

The fellows' training during this individualized, senior research phase is designed to prepare the fellows to begin independent investigative careers as faculty members at an academic institution, in the pharmaceutical industry, or in government. Integral to this training process, along with specific research activities, is training in scientific writing and presentation.

In the spring of the second and third years, fellows are expected to make formal presentations of their research to the Division, and they are encouraged and supported to present mature work at regional and national meetings of scholarly societies.

All fellows are mentored sufficiently to apply for and compete successfully for career development awards. Many opportunities exist for fellows who successfully obtain such awards to continue their professional careers following completion of their formal fellowship training as senior research fellows or instructors in the Division.