The program is structured to provide all needed core training over a one-year period and to assure that learning of the different subspecialty areas of hematology (morphology, immunohistochemistry, flow cytometry, molecular diagnostics, red cell diagnostics, coagulation, cytogenetics, clinical instrumentation, hematology laboratory management and informatics) is accomplished in a coordinated fashion. The basic structure of all of the rotations is a case-oriented one. We believe that such an approach maximizes the fellow's learning trajectory. The fellowship is also designed to provide graduated responsibility in each area over the course of a year's period of time.
In the beginning of the fellowship, a one week orientation period includes formal lectures in the basics of hematopathology and provides the opportunity for the fellow to meet and interact with the faculty in each of the relevant subsections, to meet with the AP/CP residents with whom the fellow will closely interact during training, and to "learn his/her way around" the institutions. Thereafter, the fellow enters into a series of rotations designed to give the fellow the conceptual and technical underpinnings of each subdiscipline in a relatively concentrated fashion. The schedule is individualized to the past experience of the fellow. However, a typical sequence begins with the "basics":
- Lymph node and bone marrow morphology and histochemistry (LN/BM) for 12 weeks;
- Hematology laboratory and coagulation laboratory for 4 weeks;
- Cytogenetics for 2 weeks;
- Flow cytometry and molecular diagnostics for 4 weeks.
In each rotation, the role of the pathologist as consultant is the focus of learning - trainees communicate results of studies directly to other clinicians, albeit during this initial period of time that communication is often carried out in the presence of the pathology attending. The basic "how-to" of procedures is also taught during this initial set of rotations - this includes doing bone marrow aspirates and biopsies. During this 22 week period of time the fellow is expected to learn all the basic principles and apply these on a case by case basis. It should again be noted that this schedule is individualized depending on the fellow's prior experience. For example, if a fellow has already spent a large amount of time during residency studying flow cytometry and molecular diagnostics but less time reviewing lymph node pathology then that fellow might do 15 weeks on LN/BM and only one week on flow/molecular.
After this initial 22 week training period, the remaining 28 weeks is scheduled on the basis of the fellow's past experience and future career plans. The fellow has had by this time at least one career counseling session with the Program Director. The rest of the year is then tailored to the fellow's needs. A typical schedule might lead off with a 1-2 week partial respite from full time clinical work to carry out dedicated library work for planning and organizing a research project. Then the fellow will assume responsibility for all diagnostic aspects of a given case and will be given joint responsibilities (for example, wet hematology or coagulation combined with lymph node / marrow signouts).
During this set of "second" rotations, the fellow is expected to do significantly more teaching of both AP/CP residents and of fellows from other departments rotating through the services. The fellow consults directly with other clinicians. While on the hematology laboratory rotation the fellow acts as the laboratory director, that is, he/she is the first-call individual to make management decisions (new instrumentation, alterations in informatics, regulatory issues, personnel issues, QC/QA sign-off, and so forth).
It is also during this second part of the fellowship that the fellow is expected to carry out an investigative project with a specified mentor. The nature of that project is determined by consensus of the fellow and the attending group. Depending on the career goals of the fellow, this may involve setting up a new molecular diagnostic assay, carrying out case-review clinical research, or even the commencement of a more translational or basic science project if there are plans for the fellow to spend additional years of research training after the hematopathology fellowship.
It should again be emphasized that all the individual rotations for the fellow are integrated experiences. For example, in the evaluation of lymph nodes and bone marrows (the "LN/BM" rotation), the fellow reviews all the relevant surgical specimens for a given case (LN, BM BX, BM ASP) as well the immunohistochemistry, flow cytometry, molecular diagnostics, special histochemistry, cytogenetic and even, where relevant, IFE, special red cell and special coagulation studies, etc that relate to the case.
The schedule described above refers to the fellow's work at Yale-New Haven Hospital. Twenty percent of the fellow's time is spend at the VA Connecticut Medical Center. This time is organized as an ongoing longitudinal experience. The fellow spends most of his/her time on Mondays at the VA, and the remainder of the week at Yale New Haven Hospital. The VA is a 10 minute shuttle bus ride from YNHH and the shuttle runs continuously. On Mondays, the VA has its weekly major hematopathology conference at which new and relevant old patients are presented at a 10 headed microscope with all their data. The afternoon conference is attended by all hematology and medical oncology clinicians, residents/fellows, an AP/CP resident assigned to the VA, the VA hematopathologist, Dr. Shafi, and on a monthly basis, Dr. Smith from YNHH. The fellow spends the morning reviewing the relevant material with Dr. Shafi and staff and also addressing any ongoing issues in the hematology laboratory at the VA. This experience is somewhat different from that at YNHH because of the more community-hospital but 'integrated health-care network' nature of the institution. The VA is a part of the New England VA integrated health care system (VISN) including major facilities in Boston, Providence, and White River Junction VT.
Both at YNHH and at the VA, an important part of the training program is the fellow's responsibility for presenting cases at multidisciplinary joint conferences. There are three major such conferences held each week at YNHH: (1) YNHH Lymphoma/Stem Cell Transplant Conference, involving medical and surgical oncology, radiation therapy, pathology/laboratory medicine, and diagnostic imaging, is a conference at which all new lymphoma cases and most cases going to transplant are presented; (2) YNHH Hematology Clinical Rounds, involving medical hematology/oncology, pathology/laboratory medicine, and often pediatric hematology/oncology, is a conference at which all new hematology cases (red cell, myeloid, coagulation, hematopoietic malignancy) are presented; (3) YNHH Hematopathology/Hematology Rounds, involving medical hematology and oncology and pathology/laboratory medicine, is a weekly conference at which selected new hematology/hematopathology cases are presented. This latter conference is mirrored at the VA covering VA cases rather than YNHH cases each week - as discussed earlier this conference generally includes all, rather than selected, cases at the VA.
As noted earlier, we believe that teaching is an important part of the hematopathologist's role in medical practice - hence the fellow is also involved in medical student teaching in the second year pathophysiology block at the Yale School of Medicine and on an elective basis is encouraged to assist in teaching medical technologists and physician assistants. Moreover, we believe that it is crucial for the fellow to have the opportunity to go to at least one major national hematopathology meeting a year. Travel funds are provided for attendance at a national meeting.
We should also note several of the unique aspects of the Yale environment that provide interesting elective opportunities. There is a major internationally-recognized program at Yale in the cutaneous lymphomas. Indeed, one of our faculty is joint boarded in Dermatopathology and Hematopathology. The Yale Center of Excellence in Molecular Hematology is one of only four such NIH-sponsored Centers in the country. Yale has had an NCI Comprehensive Cancer Center since the beginnings of that program. A new major addition to the medical center – the Smilow Cancer Hospital – will be occupied beginning in Fall, 2009. The Human Translational Immunology Program concentrates on translational immunotherapeutic research, including in hematopoietic stem cell transplantation. The VA hospital is a Pharmacogenetics center for the national VA.