Flow Cytometry and Immunology (CP-1 and CP-2)
The CP-1 and CP-2 resident rotation in Flow Cytometry is combined with the Hematology rotation while the Immunology rotation is combined with Chemistry. This provides an integrated case-oriented approach to education since it allows flow cytometry studies to be examined in the context of hematopathology morphology and cytogenetic and molecular diagnostic assessment and allows better integration of Immunologic work-ups with serum protein elecrophoresis and other chemical analyses. Virology serologic assays are carried out in the virology laboratory; integration of bacterial serologic assays into the evaluation of the patient is undertaken by the resident rotating through Microbiology/Virology, working with the microbiology fellow and the Immunology resident. This approach, as for all of the resident rotations, allows emphasis to be placed on the acquisition of integrated consultative skills in these disciplines. Similarly, each rotation is characterized by tight integration and participation of the resident in joint Pathology-Medicine-Pediatric-Surgery conferences and rounds.
In Flow Cytometry/Hematology, the resident works closely with the resident rotating on surgical hematopathology and with the Hematopathology fellow, presenting cases at weekly joint Hematopathology Conference with Medicine and Pediatric attendings and housestaff, at weekly joint Lymphoma/Stem Cell Transplant Conference and at weekly Flow Cytometry-Molecular Diagnostic Correlative Rounds. In Immunology, a monthly Laboratory-Clinical Immunology Conference is well attended by adult and pediatric Immunology/Allergy and Rheumatology attendings and house staff and provides an excellent forum both for ongoing clinical diagnostic/therapeutic care and for education. These joint conferences also provide excellent quality assurance functions for all clinical services involved.
In Flow Cytometry, residents are responsible for formal interpretation of all immunophenotyping and DNA ploidy reports including evaluating these in the context of all other relevant morphologic and molecular studies. All immunophenotyping (blood, marrow, lymph node, fluids) is handled in the same laboratory. The total number of flow cytometry studies is more than 7500 per year and growing, including leukemia/lymphoma evaluations, studies for myelodysplasia, transplant/stem cell assessments, and immunodeficiency (including both HIV and congenital immunodeficiencies) evaluations. At the start of the day the resident and attending review the day's upcoming work by looking over the morphology and clinical data for each case and jointly choosing an appropriate 'panel' of tests. Residents later review each flow result independently and record their preliminary interpretation; at afternoon signout rounds this is then reviewed with the attending and a final interpretive report generated. The result is frequently called to the ordering clinician by the resident, under supervision of the attending.
Graduated responsibility occurs both throughout the rotation and between the CP-1 and CP-2 rotations. First year residents initially may handle only a subset of the total daily workload in terms of detailed evaluation and gradually move to handling the entire repertoire; consultation with Medicine/Pediatric/Surgical attendings (by phone or in person) is initially carried out in the presence of the pathology attending but over time, residents take sole responsibility for this. Residents attend joint conferences initially and gradually take responsibility for primary presentation at those conferences. CP-1 residents learn technical aspects of flow cytometry. The Hematopathology fellow, when on a Flow rotation, takes a senior educational role, substituting for the attending in the education of the resident as appropriate and responsible for education of medicine and pediatric housestaff rotating through the service. He/she assumes managerial responsibility, generally not assumed by CP-1 residents.
Consultative interpretive studies in Immunology include: immunofixation electrophoresis, CSF oligoclonal banding, and interpretive analysis for all molecular studies. The latter include many different types of assays for among others: diagnosis of inherited hypercoagulability, gene rearrangements for NHL, diagnosis and treatment of myeloproliferative disorders, quantitative transcript assays (e.g. EBV, BCR-ABL1) for therapeutic response, UGT polymorphisms for predicting complications, and screening for cystic fibrosis risk. Some of these studies are done in support of the approximately 350 stem cell transplants and >500 solid organ transplants performed at YNHH per year. There are also >2,000 ANA, >2,600 quantitative Ig, >10,000 syphillis serologies, and >1,000 mycoplasma/toxoplasma serologies per annum. Graduated responsibility is similar to that outlined above: CP-1 residents take all initial consultative calls to the laboratory but do not carry out managerial responsibility; CP-2 residents assume a junior managerial role, consult and approve serologic studies, and take primary responsibility for education of allergy/immunology housestaff rotating through. QC/QI duties (as an elective) are also gradually assumed based on what other rotations the resident may have had previously.
Additional Resident Duties and Responsibilities on the Flow Cytometry Rotation
- Consult and interpret flow cytometry immunophenotyping and DNA ploidy studies
Additional Resident Duties and Responsibilities on the Immunology Rotation
- Interpret immunofixation electrophoresis and isoelectric oligoclonal banding
- Consult and approve serologic studies
Additional Goals and Objectives for the Flow Cytology / Immunology Rotation
- Become proficient in presenting cases at laboratory rounds and correlation conferences
- Appropriately interpret immunofixation electrophoresis and oligoclonal bands
- Appropriately interpret flow cytometry results