MCV and VA Hospitals Continuity of Care Clinics
Description of Rotation or Educational Experience
The VCU Hematology/Oncology Fellowship Program Continuity of Care Clinics at MCVH and the VA Hospitals are designed to enable fellows to be exposed to a wide variety of patients with oncologic malignancies, hematological malignancies, and benign hematologic conditions whom the fellows follow throughout the disease process. The fellows are assigned a clinic at both MCVH and the VA that they maintain through the duration of their training. The continuity clinics consist of one half day per week at each location, with approximately 6-7 follow up patients and 1-2 new patients.
Location:
- VCUHS Massey Cancer Center Dalton Oncology Clinic
- Hunter Holmes McGuire VA Medical Center
- All 3 years of fellowship
Educational Goals
- Gain experience, competence and independence in the outpatient evaluation, staging, prognosis, management, and complications of patients with a wide variety of hematologic and oncologic disorders.
- Gain experience, competence and independence in the ordering, administration, monitoring, and identifying toxicities of chemotherapy
- Gain experience, competence, and independence in the management of hematologic and oncologic emergencies in the outpatient setting, including acute chemotherapy toxicities and reactions.
- Gain experience, competence, and independence in performing the procedures essential to the diagnosis and to the delivery of care of acute hematologic and oncologic disorders, including bone marrow biopsy and aspiration; lumbar puncture with the intrathecal administration of chemotherapy; and the access and administration of chemotherapy via an Omaya reservoir.
- Gain experience, competence, and independence in identifying, discussing, and arranging home care and hospice as they pertain to the patient with hematologic and oncologic disease.
- Gain experience, competence and independence in the management pain and other symptoms in the outpatient setting.
- Gain experience in communication with and the counseling of patients and families regarding their acute hematologic and oncologic medical conditions and in providing the necessary support and ancillary services to effectively meet their medical and psychosocial needs.
- Gain experience, competence in effectively, truthfully, and compassionately discussing end of life issues with patients and their families.
- Gain experience in the management of end-of-life issues, including advanced directives, resuscitation status, surrogate decision-making, and home/inpatient hospice resource utilization.
- Gain experience and proficiency in identifying and understanding the specific barriers posed to patients who are underinsured and/or indigent.
- Gain an appreciation of the value of continuity of care in cancer treatment
- Gain experience in effective communication with patients, caregivers, and other health care providers necessary to effective co-management
- Gain experience and knowledge in the unique aspects of the role of and effective functioning as a subspecialty outpatient consultant
- Gain experience and proficiency in the effective transferring/returning of subspecialty care back to the primary care provider
- Obtaining efficiency in the outpatient setting, review literature critically, and to learn how to plan for and manage clinic days
Progressive Responsibilities by Fellow Year
YEAR 1 / The first year fellow is expected to focus on primary medical knowledge, communication skill and procedural skill development. Medical knowledge acquisition should focus on the routine screening, diagnosis, natural history, staging, prognosis, and first-line management of the hematologic-oncologic conditions. Additionally, the first year fellow should focus on the pharmacologic mechanism of action, dosing considerations, and common toxicities of the medications being employed for the treatment of the hematologic-oncologic condition. Consult recommendations and care plans should be developed independently or in conjunction with attending physician and health care team but reviewed in full with the attending physician in advance of communication to the patient, family, and consulting providers. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling should be done with direct supervision of the attending physician or only after full review of the goals of care and care plan with the attending physician. (The PharmD may provide the direct supervision of chemotherapy counseling and consenting once the care plan has been established with the attending physician).
YEAR 2 / The second year fellow is expected to refine their medical knowledge by focusing on an understanding of the underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment planning; and considerations/options in second-line and beyond. Consult recommendations and care plans should be developed independently with only moderate need for input from the attending physician though reviewed in full with the attending physician in advance of communication to the patient, family, and consulting providers. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling may be done independently but only after full review of the goals of care and care plan with the attending physician.
YEAR 3 / The third year fellow is expected to demonstrate proficiency and independence. The third year fellow is expected to demonstrate full knowledge of the routine screening, diagnosis, natural history, staging, prognosis, and first-line management of the hematologic-oncologic conditions. They should demonstrate a proficient understanding of the underlying pathophysiology, the basis and use of molecular and genetic markers to refine prognostic determinations and treatment planning; and considerations/options in second-line and beyond. Consult recommendations and care plans should be developed independently with minimal input from the attending physician though still reviewed with the attending physician. Initial counseling of the patient and family regarding the goals of care, the care plan, and chemotherapy counseling should be done independently though reviewed with the attending physician.
Patient Care
Goal
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Please refer to overview of the fellowship curriculum for competencies/objectives for patient care.
Specifically, fellows will see patients in all of these clinic settings under the supervision of the appropriate subspecialty faculty member. Fellows will participate in the evaluation and management of acutely and chronically ill oncology outpatients in order to learn the different approaches to subspecialty cancer treatment.
Competencies
Fellows are expected to:
•Gather appropriate clinical information
•Synthesize information into a care plan
•Partner with patients/families in the implementation of the plan
•Coordinate care plans with referring physicians, social workers, and home health agencies
Objectives
Fellows are expected to:
•Develop skills in history/physical examination of the patient with cancer
•Develop skills as an outpatient subspecialty consultant
•Integrate clinical data in the formation of a comprehensive care plan
•Document the encounter in the medical record in sufficient detail to communicate to other physicians and meet billing requirements
•Provide compassionate, appropriate, and comprehensive patient care through:
- Responding to requests for outpatient consultation, evaluation and/or management in a timely and appropriate fashion,
- Providing appropriate follow-up management
Medical Knowledge
Goal
Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.
Competencies
Fellows are expected to demonstrate skills in:
- Acquisition of knowledge
- Analysis of information
- Application of knowledge
All fellows are expected to:
- Demonstrate the ability to perform a comprehensive and accurate physical examination; demonstrate the ability to arrive at an appropriate differential diagnosis; outline a logical plan for specific and targeted investigations pertaining to the patient’s complaints; and formulate a plan for management and follow-up treatment of the patient
- Demonstrate their knowledge by presenting the results of a consultation orally and in writing and by defending the clinical assessment, differential diagnosis, and diagnostic and management plans
Thoracic Oncology
- Demonstrate knowledge of the epidemiology of thoracic cancers including incidence rates and mortality rates
- Demonstrate knowledge of non-small cell histology and biology including adenocarcinoma, bronchoalveolar, squamous cell, and large-cell carcinoma
- Demonstrate knowledge of small cell histology and biology
- Understand the risk factors for lung cancer including lifestyle, active and passive smoking, asbestos and radon exposure
- Understand prevention of lung cancer through smoking cessation
- Demonstrate knowledge of clinical signs and symptoms of lung cancer
- Demonstrate knowledge of diagnosis via sputum cytology, imaging, Imaging-guided biopsy, thoracotomy, bronchoscopy
- Demonstrate knowledge of staging and prognostic factors of non-small cell lung cancer (NSCLC) via the TNM system and small cell lung cancer via the TNM system and/or limited vs. extensive disease
- Demonstrate knowledge of the treatment of non-small cell lung cancer based on stage of NSCLC
- Understand the first-line, second-line, and third line chemotherapy choices and the pharmacotherapy of the common agents administered
- Understand the use of immuno-oncology and biologic agents in the management of lung cancers
- Demonstrate knowledge of the treatment of limited stage small cell lung cancer with combined chemotherapy and radiation therapy, use of prophylactic brain irradiation, and indication for resection of solitary pulmonary nodule
- Demonstrate knowledge of the treatment of extensive disease with first-line chemotherapy, second-line treatment, use of prophylactic brain irradiation, and treatment of brain metastases
- Demonstrate the knowledge of follow-up of Lung cancer according to ASCO and other guidelines
- Demonstrate knowledge of treatment of Pancoast tumors
- Understand how to identify and manage complications of the treatment of thoracic cancers such as radiation pneumonitis, infection, dyspnea, and neuropathy
- Understand the importance of palliation of symptoms including pain and dyspnea in patients with thoracic malignancies.
- Understand the interventional options in patients with thoracic malignancies and pleural effusions for palliative purposes such as pleurodesis and pleurovac devices
- Understand the importance of clinical trials in thoracic malignancies
- Demonstrate knowledge of the epidemiology of breast cancer including incidence rates and mortality rates
- Understand the pathogenesis, pathology, and tumor biology of histiopathic subtypes of breast cancer
- Understand the genetic syndromes and recommendations for genetic counseling and testing
- Understand how to assess the risk of breast cancer in a patient based on family history, lifestyle factors, hormone replacement therapy, and use the Gail and Claus models
- Demonstrate knowledge on the prevention of breast cancer including chemoprevention and surgical interventions
- Demonstrate knowledge of screening techniques
- Demonstrate knowledge of the diagnosis of breast cancer by fine-needle aspiration, core biopsy, excision, and needle localization biopsy
- Understand axillary dissection techniques including complete dissection vs. sentinel node dissection
- Understand staging and prognostic factors including TNM system, histologic type, estrogen and progesterone receptors,HER-2 neu, and other biologic and molecular markers
- Demonstrate knowledge of the treatment recommendations based on stage of lobular and ductal cancer including surgery, radiation, preoperative vs. post-operative chemotherapy, endocrine therapy, immuno-oncologic and biologic therapy
- Demonstrate knowledge on estimating the benefits of systemic adjuvant therapy utilizing Oncotype testing and/or Adjuvant online
- Understand treatment of locally advanced and inflammatory breast cancer using multimodal therapy
- Understand the treatment of locally recurrent breast cancer in the breast or chest wall with surgery or radiation therapy. Demonstrate knowledge of therapy for metastatic breast cancer.
- Demonstrate knowledge regarding follow-up of breast cancer based on ASCO and NCCN guidelines
- Supportive care of breast cancer including: psychosocial issues and support groups, lymphedema, bisphosphonates for bone metastases, menopausal symptoms, sexuality and fertility, cognitive dysfunction, surgical reconstruction
- Other/Special issues including male breast cancer, breast cancer in pregnancy, in elderly women, in very young women and recommendations for oophorectomy
- Demonstrate knowledge of the pharmacology of the common chemotherapies used for the treatment of breast cancer
- Understand how to identify and manage complications of the treatment of breast cancers
- Understand the importance of palliation of symptoms in patients with breast malignancies.
- Understand the importance of clinical trials in breast malignancies
- Demonstrate the knowledge of the WHO classifications of Hematologic malignancies
- Demonstrate an understanding of the pathophysiology of the hematologic malignancies including histologic grade, role of infectious agents, and genetic factors
- Demonstrate an understanding of the diagnostic modalities used in differentiating hematologic malignancies such as lymph node biopsy, bone marrow biopsy, flow cytometry, cytogenetics, and molecular diagnostics.
- Demonstrate knowledge of staging and prognostic factors for lymphoma including the Ann Arbor Staging System and the International Prognostic Index.
- Demonstrate knowledge of treatment of Non-Hodgkins lymphoma based on grade (low, intermediate vs. high), as well as aggressive vs. indolent nature and stage of disease
- Demonstrate knowledge of options for treatment of indolent Non-Hodgkins lymphoma including: observation, chemotherapy, radiation therapy, immunotherapy, stem cell transplant, monoclonal antibodies, and combination of aforementioned above
- Demonstrate knowledge of treatment of aggressive Non-Hodgkins Lymphoma including those mentioned above except observation
- Demonstrate knowledge of referral for stem cell transplant in relapsed or refractory lymphomas
- Demonstrate knowledge of the bcr-abl in CML, genetic and molecular abnormalities in CLL
- Demonstrate knowledge of the diagnosis of chronic leukemias based on peripheral blood smear review, PCR or FISH for CML, and flow cytometry for CLL
- Demonstrate knowledge of the chronic, accelerated, and blast phase of CML
- Demonstrate knowledge of the staging systems in CLL
- Demonstrate knowledge of treatment of CML including but not limited to chemotherapy, tyrosine kinase inhibitors, interferon, treatment of blast phase, and the role of stem cell transplantation
- Demonstrate knowledge of treatment options based on stage of CLL including observation, purine analogues, alkylating agents, combination systemic therapy, monoclonal antibodies, stem cell transplant, radiation therapy, splenectomy, steroids
- Demonstrate knowledge of hypogammoglobinemia, infection risk, and autoimmune hemolytic anemia and thrombocytopenia in CLL
- Demonstrate knowledge of treatment of Hodgkin lymphoma at all stages of disease (initial and relapsed) distinguishing the role of radiation therapy, chemotherapy, and stem cell transplant.
- Demonstrate knowledge of follow up and continued treatment of the acute leukemias after discharge from the inpatient setting, including the evidence regarding use of maintance therapy in APL and ALL
- Demonstrate knowledge of the pathophysiology, staging, prognosis, and therapeutic options for multiple myeloma.
- Demonstrate knowledge of the use of supportive therapies for bony disease including neuororadiologic interventions, radiation therapy, radioactive biologics, medical pain management, and bisphosphonates.
- Understand supportive care related to treatment of hematologic malignancies including fertility and sexuality issues, development of secondary malignancy due to prior chemotherapy +/- radiation exposure, and long term cardiac complications
- Understand the importance of clinical trials in hematologic malignancies
- Demonstrate knowledge of epidemiology of GI cancers including esophageal, gastric, colorectal, gallbladder, hepatocellular, and pancreatic cancers
- Understand the pathophysiology of GI cancers
- Understand the treatment of GI malignancy and its relationship to disease stage
- Understand how to identify and manage complications of the treatment of GI cancers such as pain, mucositis, infection, diarrhea
- Understand the importance of palliation of symptoms in patients with GI malignancies.
- Understand the importance of clinical trials in GI malignancies
Anal Cancer
Demonstrate knowledge of the epidemiology and incidence rates and mortality rates
Demonstrate knowledge of the pathology and histology of anal cancer including premalignant lesions and cloacogenicvssquamous histology
Demonstrate knowledge of the risk factors associated with anal cancer including HPV infection, sexual activity, condyloma, HIV infection
Demonstrate knowledge on diagnosis of anal cancer via physical examination, biopsy, anoscopy/proctoscopy, transrectal ultrasound, FNA of palpable inguinal nodes
Demonstrate knowledge of the TMN Staging System and the treatment based on stage for anal cancer
Demonstrate knowledge of follow-up of anal cancer
Biliary Tree Cancer- Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
- Demonstrate knowledge of the risk factors associated with biliary tree cancer including primary sclerosingcholangitis, gallstones, choledochalcysts
- Demonstrate knowledge related to the diagnosis including clinical signs and symptoms such as obstructive jaundice, imaging, ERCP, and endoscopic biopsy
- Demonstrate knowledge of TMN Staging and histologic grade of the cancer and treatment by stage for bilary tree cancer
- Demonstrate knowledge of supportive care including biliary drainage for biliary tree cancer
- Demonstrate knowledge of the epidemiology, incidence rates, and mortality rates
- Demonstrate knowledge of genetic syndromes,including but not limited to Familial adenomatous polyps and Hereditary nonpolyposis colorectal cancer.
- Understanding of risk factors such as family history, dietary factors, inflammatory bowel disease
- Demonstrate knowledge of screening of colorectal cancer with rectal examination, fecal occult blood test, colonoscopy , virtual colonoscopy in both the general population and high-risk populations
- Demonstrate knowledge of the diagnosis including clinical signs and symptoms, imaging, and endoscopic biopsy
- Demonstrate knowledge of staging and prognostic factors based on TNM Staging system, histology and grade, and genetic and molecular abnormalities
- Demonstrate knowledge of treatment by stage of colorectal cancer
- Demonstrate knowledge of follow-up after curative resection based on ASCO and NCCN guidelines
- Demonstrate knowledge of supportive care of treatment related toxicities such as ostomy care, radiation proctitis, diarrhea, neuropathy