Resident Manual

Clinical Pathology Resident Hematology/Coagulation Rotation

Introduction

The general goal of the Pathology Hematology/Coagulation rotation is to develop competence and expertise that will allow the resident to function as a clinical hematopathologist or a general anatomic pathologist.  By the end of the rotation the resident should be capable of assuming the position of Medical Director of the Hematology/Coagulation laboratory in a moderate-sized community hospital.  This requires that the resident become proficient in: (1) the morphologic evaluation of peripheral blood smears, body fluids, bone marrow biopsies/aspirates, and lymph node specimens; (2) the interpretation of hematology and coagulation tests; (3) appropriate selection of hematology and coagulation tests; (4) technical evaluation of test methods in hematology and coagulation testing; and, (5) collecting bone marrow biopsies and aspirates.  Additionally, the resident must gain knowledge of laboratory hematology and coagulation, sufficient for satisfactory performance on the Clinical and Anatomic Pathology Board examinations.

Since the skills necessary to accomplish these goals cross sectional lines, the resident will participate in the activities of both the divisions of Clinical and Anatomic Pathology.  Additionally, since bone marrow aspirates and biopsies are not performed by pathologists at the HMC, the resident will also participate in activities of the division of Hematology/Oncology, Department of Medicine.  The resident learning experience consists of a combination of service responsibilities, self-instruction, technical instruction, formal conferences and informal teaching during rounds with the faculty.

The objectives of the rotation are encompassed by the six core competencies as defined by the ACGME and residents will be evaluated during their training in each of these areas.  The above goals will be met through attainment of these six core competencies:

Patient Care that is compassionate, appropriate, and effective for the treatment of health through the following:

• Gather essential and accurate information about patients using all relevant available modalities and incorporate into pathologic interpretations.

• Effectively examine and interpret peripheral blood smears and body fluid slides.

• Effectively analyze and interpret coagulation testing.

• Effectively examine and interpret bone marrow biopsies and aspirates, incorporating flow cytometry and molecular/cytogenetic information.

• Effectively examine and interpret lymph node specimens, incorporating flow cytometry and molecular/cytogenetic information.

• Understand procedural aspects of bone marrow aspiration and biopsy.

• Effectively consult to other clinicians in developing a diagnostic plan, when appropriate, based on specific clinical questions and relevant clinical and pathological information.

• Effectively consult on interpretation or follow-up of unusual or unexpected hematologic test results.

• Effectively participate as expert in Laboratory Hematology and Hematopathology at multidisciplinary conferences.

• Understand the impact of point-of-care testing (POCT) on clinical care.

Medical Knowledge

• Use all relevant information resources to acquire and evaluate evidence-based information.

• Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in Laboratory Hematology and Hematopathology that includes automated hematology testing, peripheral blood and body fluid analysis, flow cytometry analysis, bone marrow biopsy and aspirate analysis, and lymph node specimen analysis as it relates to RBC disorders, platelet disorders, leukemias, lymphoproliferative disorders, inflammatory disorders and coagulation disorders.

• Understand the various levels of evidence in medicine and their translation into evidence-based practice.

Practice-based learning and improvement

• Demonstrate the ability to critically assess the scientific literature.

• Demonstrate knowledge of evidence-based medicine and apply its principles in practice.

• Use multiple sources, including information technology, to optimize life-long learning and support patient care decisions.  

• Develop personally effective strategies for the identification and remediation of gaps in medical knowledge needed for effective practice.

• Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety.

• Demonstrate knowledge of how to establish continuing competency assessment for pathologists as well as for laboratory personnel.

Interpersonal and communication skills

• Demonstrate the ability to write an articulate, legible, and comprehensive yet concise consultation note; provide a clear and informative report, including when appropriate a precise diagnosis, a differential diagnosis, and recommended follow-up or additional studies.

• Demonstrate the ability to provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a laboratory assay reveals an urgent, critical, or unexpected finding and document this communication in an appropriate fashion.

• Effectively participate and present at multidisciplinary conferences in focused, clear, and concise fashion.

• Demonstrate the ability to work with other clinicians and other health care personnel and administrators to develop clinically advantageous and cost-effective care-delivery strategies.

• Use effective modes and mechanisms of communication.

• Demonstrate skills in educating colleagues and other health care professionals, including:

  • Helping other residents obtain proficiency in laboratory medicine

  • Demonstrating the ability to work well with medical technologists and to present Laboratory Medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment.

  • Demonstrating the ability to educate non-pathology clinicians and other health care workers, including pharmacists, nurses, residents, medical students, and others about topics such as the fundamental principles of pathophysiology underlying test design/interpretation and the approach to choosing and interpreting laboratory tests.

  • Demonstrating an understanding of how to educate other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other professional knowledge.

Professionalism

• Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them.

• Interact with others without discriminating based on religious, ethnic, sexual, or educational differences.

• Demonstrate positive work habits, including punctuality, dependability, and professional appearance.

• Demonstrate responsiveness to the needs of patients and society that supersedes self-interest.

• Demonstrate principles of confidentiality with all information transmitted both during and outside a patient encounter.

• Demonstrate a commitment to excellence and ongoing professional development.

• Demonstrate interpersonal skills in functioning as a member of a multidisciplinary health care team.

Systems-based practice

• Demonstrate understanding of the role of the clinical laboratory in the health care system.

• Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians.

• Demonstrate knowledge of basic health care reimbursement methods.

• Demonstrate knowledge of the laboratory regulatory environment.

• Understand policies and systems to continually improve patient safety as they relate to clinical laboratory testing at all levels.

The amount of time a resident is scheduled for Hematology/Coagulation training depends upon that resident’s progress towards achieving the rotation’s core competencies.  For most residents this will be between four and six months, but can be longer or shorter for a specific resident.  A “typical” resident spends four months in Hematology/ Coagulation rotations.  A resident training in Clinical Pathology only will be required to spend additional time in Hematology/Coagulation.

Advanced rotations can be arranged with the Medical Director’s approval in advance.  The goals, expectations and responsibilities for advanced elective rotations will be defined on an individual basis before approval is granted.

The resident will participate in the medical direction and management of all aspects of the Hematology/Coagulation Laboratory.  Specific responsibilities are outlined under each section below.  The resident is expected to act independently according to the resident’s level of experience and expertise.  A Clinical Pathology attending will be available for consultation and guidance.  The resident is expected to make decisions as a learning experience; resident decisions will be reviewed during daily sign-out sessions.

On the first day of the rotation the resident should meet with the Medical Director to review his or her prior progress and the responsibilities and expectations for the resident on the current rotation.  The resident is expected to have reviewed this description prior to beginning the rotation.

Service Responsibilities

Routine service hours are 8:00 AM to 5:00 PM.  Coverage outside of those hours is provided by the Clinical Pathology resident on call.  On months when there is no resident assigned to “Usual” hematology, or when the assigned resident is absent, service coverage will be provided per the Departmental Policies.  An attending clinical pathologist is available to the resident at all times.

Except during the elective “Clinical” rotation described below, the resident is responsible for daily review and sign-out of peripheral blood smears, body fluid slides and those coagulation tests which require interpretation (primarily mixing studies, lupus anticoagulant testing, and thrombotic panels).  In preparation for sign-out the resident should review the laboratory data, examine smears, and obtain pertinent clinical history.  The resident drafts interpretative reports for review and signature by the attending.

The resident is available to the section supervisors and technologists to assist with resolving patient testing problems.

The resident is responsible for daily sign-out of bone marrows and lymph nodes with the Hematopathologist in Anatomic Pathology in the afternoon.  On months when there is no resident assigned to “usual” hematology, or when the assigned resident is on vacation, the AP resident will be responsible for bone marrow and lymph node sign-outs.

Routine Clinical Pathology sign-out occurs once daily, usually at 11:00 AM.  Occasional test results require urgent review and sign-out.  Anatomic Pathology sign-out should be arranged with the attending Hematopathologist.

The resident on the Hematology service is expected to take Clinical Pathology call unless he/she is being trained for AP only certification.

Clinical Rotation Elective

Each resident may spend one additional month on a “Clinical” rotation. Time during this rotation is spent primarily with the medical Hematology/Oncology service (Department of Medicine).  During this month the resident is relieved of the service responsibilities of “Usual” Hematology/ Coagulation rotations, except for possible coverage of an absence per Departmental Policies.

During this rotation the resident will collect bone marrow aspirates and biopsies and sign-out bone marrow aspirates with clinical hematology attending physicians. 

The resident is expected to attend hematology clinic.  The resident is expected to utilize time spent in the clinic for self-instruction by reviewing peripheral blood smears and laboratory data on clinic patients.  Since all pertinent information and the patients themselves should be available, this represents a unique opportunity for developing skills in clinical-pathologic correlation.  The resident should participate in the laboratory evaluation of hematology/oncology patients, and is expected to function as laboratory consultant to the hematology/oncology service, but is not expected to function as clinical hematology/oncology resident, providing direct patient care. The resident may be called upon to assist in teaching basic blood cell morphology and laboratory hematology/coagulation to medical students during clinic hours.

In addition, the resident will spend time in the Special Hematology Section of the Medical Laboratory, focusing on flow cytometry and the specialized coagulation tests performed in that area, including platelet aggregation.

Specific Topics and Reading Assignments

The library in the residents’ office contains the standard clinical pathology, hematology and coagulation reference books.  In addition, there are numerous supplementary textbooks, slide sets and other audiovisual materials available.

The basic core reading for the rotation is Henry, JB.  Clinical Diagnosis and Management by Laboratory Methods (20^th Ed.). Philadelphia: Saunders, 2001, Chapters 19 and 24-29. 

During the rotation, the resident should review current laboratory hematology journals and clinical pathology journals, particularly Hemostasis and Thrombosis and the American Journal of Clinical Pathology.

Body Fluids

Assigned Reading:

Chapter 19 "Cerebrospinal, Synovial, and Serous Body Fluids" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

Erythrocytes

Assigned Reading:

Chapter 26 "Erythrocytic Disorders" and related materials from Chapter 24 "Basic Examination of Blood" and Chapter 25 "Hematopoiesis" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

Other Resources:

• Texbooks

  1. Williams Hematology, 6th ed.  Beutler E, et al. McGraw Hill 2001.

  2. Bone Marrow Pathology, 2nd ed. Foucar K.  ASCP Press 2001.

  3. Tumors of Bone Marrow.  AFIP fascicle, 3rd series, Brunning R, et al. 1994.

  4. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing.  Glassy E.  College of American Pathologists.

• Study sets

  1. Peripheral smear study set

• Web resources

  1. Bloodline http://image.bloodline.net   An excellent educational resource for all things hematologic.  Includes image atlas and case studies.

  2. University of Utah Hematopathology Website http://www-medlib.med.utah.edu/
     WebPath/HEMEHTML/HEMEIDX.html  
     An excellent atlas of images.

Granulocytes

Assigned Reading:

Chapter 27 "Leukocytic Disorders" and related materials from Chapter 24 "Basic Examination of Blood" and Chapter 25 "Hematopoiesis" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

Other Resources:

• Texbooks

  1. Williams Hematology, 6th ed.  Beutler E, et al. McGraw Hill 2001.

  2. Bone Marrow Pathology, 2nd ed. Foucar K.  ASCP Press 2001.

  3. Tumors of Bone Marrow.  AFIP fascicle, 3rd series, Brunning R, et al. 1994.

  4. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing.  Glassy E.  College of American Pathologists.

• Study sets (Peripheral smear study set)

• Web resources (See erythrocytes)

Lymphocytes

Assigned Reading:

Chapter 27 "Leukocytic Disorders" and related materials from Chapter 24 "Basic Examination of Blood" and Chapter 25 "Hematopoiesis" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

Other Resources:

• Texbooks

  1. Jaffe ES, et al.  WHO Classification of Tumours:  Pathology and Genetics of Tumors of the Haematopoietic and Lymphoid Tissues.  IARC Press, 2001.

  2. Warnke RA, et al.  Tumors of the Lymph Nodes and Spleen.  AFIP Fasicle, 3rd Series, 1995.

  3. Neiman RS, Orazi A.  Disorder of the Spleen. 2nd Edition.  WB Saunders, 1999.

  4. Keren DF, et al.  Flow Cytometry in Clinical Diagnosis, 3rd Edition.  ASCP Press, 2001.

  5. Beutler E, et al. Williams Hematology, 6th ed.  McGraw Hill, 2001.

  6. Foucar K.  Bone Marrow Pathology, 2nd ed. ASCP Press 2001.

  7. Brunning R, et al. Tumors of Bone Marrow.  AFIP fascicle, 3rd series, 1994.

• Study sets (Lymphoma)

• Web resources

  1. See erythrocytes

  2. Atlas of Genetics and Cytogenetics in Oncology and Haematology:  http://www.infobiogen.fr/services/chromcancer/index.html

Platelets

Assigned Reading:

Chapter 28 "Blood Platelets" and related materials from Chapter 24 "Basic Examination of Blood" and Chapter 25 "Hematopoiesis" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

"Megakaryocytic Cells and Thrombocytes" in Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing.  Glassy EF, ed. CAP Press, 1998.

Other Resources:

• Texbooks

  1. Williams Hematology, 6th ed.  Beutler E, et al. McGraw Hill 2001.

  2. Bone Marrow Pathology, 2nd ed. Foucar K.  ASCP Press 2001.

  3. Tumors of Bone Marrow.  AFIP fascicle, 3rd series, Brunning R, et al. 1994.

  4. Case Studies in Hemostasis.  Rogers GM.  ASCP Press 2000.

• Study sets

  1. Peripheral smear study set

  2. Platelet EM's

• Web resources

  1. See erythrocytes

  2. Platelet related bleeding disorders http://www.cap.org/apps/docs/cap_today/feature_stories/
     platelet_disorders_feature.html A concise summary of bleeding disorders related to platelets on CAP website.

Coagulation

Assigned Reading:

Chapter 29 "Blood Coagulation and Fibrinolysis" in Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Henry JB, ed. 2001.

Technical Instruction in Patient Care and Medical Knowledge Required to Achieve These Competencies

During the Hematology rotation the resident will collect bone marrow aspirates and biopsies.  This may be accomplished by arranging time with attendings and/or fellows on the clinical Hematology/Oncology service as available or through the elective “Clinical” rotation (see above).  Bone marrow aspirates should be formally counted with either the clinical Hematologist or the Hematopathologist. 

The resident is expected to become familiar with the basic hematology and coagulation procedures listed in the table below.  The resident should learn the principle, technique, application and interpretation of each procedure.  The resident should observe each test performed at the institution; tests not performed at the institution should be discussed with attendings.

The resident is responsible for scheduling technical instruction for these procedures through the section supervisors.

The resident should observe each of the procedures.  Although it is not a goal of the rotation that the resident becomes technically expert in laboratory procedures, the resident must gain an understanding of the technical aspects of each procedure.

As with all other Clinical Pathology rotations, self-instruction will form an essential part of the resident’s learning experience.  Readings and review of patient material will provide the basis for discussions with and instruction by the attendings.

Specific Skills in Patient Care and Medical Knowledge Required to Achieve These Competencies

Red Blood Cells

1. Describe the morphology and physiology of RBC production.

2. Understand the principles of laboratory methods used to measure and/or calculate RBC indices including:  RBC count, Hb concentration, HCT, MCV, MCH, MCHC.

3. Be familiar with the normal ranges for Hb concentration and HCT, and how these vary with:  age, gender, hydration status, local elevation, handling and storage of specimen, etc.

4. Accurately identify polychromatophilic RBC on a blood smear.  Understand the principles of laboratory measurement of reticulocyte counting, physiologic corrections and interpretation of results.

5. Identify normal and abnormal RBC morphology on a blood smear and generate differential diagnoses based on common abnormalities such as:  hypo/hyperchromatic cells, macro/microcytes, polychromasia, elliptocytes/ ovalocytes, spherocytes, burr/spur cells, dacrocytes, target cells (leptocytes), schistocytes, sickle cells, Howell-Jolly bodies, Pappenheimer bodies, bite cells, normoblasts, etc.

6. Describe the laboratory methods, interpretation and limitations of measuring RBC mass.

7. Describe the laboratory methods, interpretation and limitations of measuring ESR.

8. Compile and synthesize appropriate clinical and laboratory data to generate and resolve differential diagnosis of anemias.  Describe the clinical and pathologic features of common forms of anemia.

9. Differentiate relative from absolute polycythemia.  Compile and synthesize appropriate clinical and laboratory data to generate and resolve differential diagnosis of polycythemia.  Describe the clinical and pathologic features of common forms of polycythemia.

Clinicopathologic Entities that you should know about:

1. Fe deficiency

2. Megaloblastic anemias, B12 and folate deficiency

3. Anemia of chronic inflammation / chronic disease

4. Anemia of chronic renal insufficiency

5. Anemia of liver disease

6. Anemia of endocrine disease

7. Myelophthisis

8. PNH

9. "Anemia" of pregnancy

10. Aplastic anemias

    1. Idiopathic

    2. Toxin

    3. Radiation

    4. Hypersensitivity

    5. Infection associated

    6. Pregnancy

    7. Congenital / constitutional

       • Fanconi

       • Familial

    8. Pure red cell aplasias

       • Transient arrest of erythropoiesis

       • Transient erythroblastopenia of childhood

       • Diamond-Blackfan

       • Thymoma associated

       • LGL-associated

11. Sideroblastic anemias

    1. Acquired

    2. Congenital

12. Acute / chronic blood loss

13. Hemolytic anemias

    1. Membrane

       • Hereditary spherocytosis

       • Hereditary elliptocytosis

       • PNH

    2. Hemoglobin

       • Hemoglobin structural variants

         • HbS, HbC, HbE, HbD, HbO, HbG

         • Unstable

         • Altered oxygen affinity

         • Methhemoglobinemia

         • Lepore

       • Thalassemias

         • Alpha thalassemias

         • Beta-thalassemias

         • Lepore

       • Double heterozygotes

         • SC, SD, SG, SO

         • S beta-thalassemia

         • E alpha-thalassemia

    3. Metabolic

       • G6PD deficiency

       • PK deficiency

    4. Physical agents - heat, mechanical, MAHA

    5. Infectious

    6. Immune

       • Warm antibody-associated

       • Cold antibody - associated

       • Mixed

       • Isoimmune

       • Drug

14. Polycythemias

    1. Primary - Polycythemia vera

    2. Secondary

       • Physiologic

       • Inappropriate

Granulocytes

1. Describe the morphology and physiology of myelopoiesis (neutrophilic, monocytic, eosinophilic and basophilic lineages).  Describe the concept of the marginated pool of neutrophils and its physiologic/pharmacologic regulation.

2. Describe the laboratory methods, limitations and interpretation of counting leukocytes in the blood and generating a leukocyte differential.  Explain why our clinical laboratory does not report "bands."

3. Generate a differential diagnosis for quantitative leukocyte disorders (neutrophilic leukocytosis/neutropenia, monocytosis/monocytopenia, etc.)  Specifically define neutropenia, degrees of severity and clinical consequences.  Know the major hereditary neutropenic disorders (cyclic, familial, Kostman, etc).

4. Identify the major, qualitative, disorders of neutrophils: toxic granulation/Dohle bodies, (pseudo)Pelger-Huet, May-Hegglin, Alder-Reily, Chediak-Higashi.  Correlate the clinical syndromes associated with these disorders.

5. Differentiate neoplastic from non-neoplastic myeloid disorders.  Synthesize clinical information, clinical laboratory results, blood and bone marrow morphology, cytochemistry, immunophenotype and genetic data to accurately diagnose acute myeloid leukemias, myelodysplastic syndromes, chronic myeloproliferative disorders and myelodysplastic/myeloproliferative diseases.  Use this synthesis to compose pathology reports including accurate diagnosis, subclassification and prognostic data.

Lymphocytes

1. Correctly triage tissue and other samples received in the laboratory to maximize the diagnostic yield.

2. Be able to identify the morphology of the normal lymphoid immune system and physiologic responses, specifically lymph nodes, spleen, thymus and bone marrow. 

3. Understand the normal immunology of the B-, T- and NK- cell response, and apply these principles for diagnosis of nodal and extranodal lymphoid proliferations.

4. Correctly request and interpret flow cytometric and immunoperoxidase immunophenotyping for diagnosis and prognosis as related to lymphoproliferative disorders.

5. Correctly request and interpret molecular and cytogenetic testing prognosis as related to lymphoproliferative disorders.

6. Apply 1. through 6. to differentiate physiologic from neoplastic lymphoid proliferations.

7. Recognize non-neoplastic lymphoid patterns with specific clinical correlates.  Correctly classify lymphoid neoplasm based on the WHO 2001 classification, including clinical, morphologic, immunologic and molecular correlates.

Platelets

1. Describe normal megakaryopoiesis, physiologic control and morphology.

2. Describe normal platelet functions.

3. Develop a differential diagnosis for thrombocytopenia and an algorithm for diagnosing specific etiologies.

4. Develop a differential diagnosis for thrombocytosis and an algorithm for diagnosing specific etiologies.

5. Describe the pathophysiology of specific platelet function disorders:  Glanzmann thrombasthenia, Bernard-Soulier, platelet type vWD, collagen receptor defect, Scott syndrome, alpha and or dense granule deficiency and acquired platelet function disorders.  Synthesize clinical and laboratory data to diagnose disorders of platelet function.

6. Describe the underlying principles, interpretation and limitations of specific platelet tests:

1. Platelet / Megakaryocyte morphology

   • Platelet morphology in blood film

   • Platelet granules by EM

2. Platelet counting

   • Visual platelet estimate

   • Hemocytometer phase contrast

   • Automated

3. Platelet function testing

4. Bleeding time

5. Platelet aggregation and release

6. Antiplatelet antibody testing

Didactic Series

Conferences

Residents on the Hematology/Coagulation rotation are strongly encouraged to attend:

1. Hematology/Oncology Grand Rounds, each Thursday at 8:00 AM

2. Lymphoma/Leukemia Conference, each Wednesday at 5:00 PM

Residents may be asked to present at these conferences.

Resident Evaluation

Residents will be evaluated at the end of the rotation in accordance with departmental policies.  The resident’s evaluation will be submitted to be incorporated into periodic summary evaluations.

It is expected that the resident will critically evaluate the rotation.  If at any time the resident feels that there is a problem or deficiency with the rotation, the resident should immediately consult with the medical director, the division chief or the program director.  Most problems can be resolved between the resident and the medical director.

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