Section: Bone Marrow

Duration: 3 months

Goals & Objectives

Resident does gross examination under supervision of attendings; attendings give feedback on the gross description of the specimen; resident signs-out cases with attendings; resident attends all the conferences; resident is evaluated during sign-outs and unknown conferences and is given feedback; at the end of the rotation, an evaluation form is filled out by the director with input from all the attendings.

The goal of these rotations is to provide residents with the opportunity to increase their knowledge base and skills in the interpretation of a wide range of hematologic abnormalities. Through regularly scheduled sign-out sessions with the attending pathologists, the residents should gain a great deal of practical experience in how to approach potential diagnoses of hematologic malignancies, systemic disorders affecting bone marrow, lymph nodes and other organs; bleeding abnormalities and thrombotic conditions; hemoglobinopathies, thalassemias, anemias; and a varied array of other hematologic abnormalities presenting in both the inpatient and outpatient populations.

A major goal of the rotation is that the resident gain sophistication in the appropriate choice of laboratory tests for a given clinical situation. While the achievement of technical proficiency in laboratory procedures is not a specific objective of this rotation, sufficient familiarity is required such that the resident can appreciate the intrinsic limitations of the procedures, as well as recognize unlikely individual test results that might reflect technical artifact. During this rotation, the resident should also learn how quality control is maintained for hematologic procedures.

In order to maximize achievement of these objectives, residents on this rotation are strongly advised to establish close working relationships with technologists and supervisors in the laboratories - a number of whom are truly expert in the field.

Duties & Responsiblities:

1. Read bone marrows. Perform differential counts of PB (200 cells, new heme case; 100 cells, repeat on metastatic disease) and BM (500 cells or 300 cells). Review all slides, write up the report of the marrow and blood in detail. Review and sign out the cases with the clinical pathologist on service. Read regularly in the recommended references and current literature about the cases you see and the questions that arise.
2. Be sure the marrow is scanned on the same day it comes in, and that any obvious significant findings are confirmed by the attending pathologist and are reported to the pa-tient's resident or attending physician.
3. The marrow biopsy sections ordinarily will be ready one day after the marrow is obtained. Look at all the sec-tions when they come in. Write a description and incor-porate it in the marrow report for reviewing with the attending.
4. Cytochemistries are performed as a part of the work-up of new patients with acute leukemia. The results should be incorporated in the marrow reported.
5. After signing out the case with the attending pathologist, enter SNOMED codes in the Sunquest computer system.
6. Promptly proofread and sign both preliminary and final reports. Unless special studies entail a delay, the report should go out on the second day after the specimen was obtained.
7. Learn preparation and staining of films, preparation of paraf-fin sections, and touch imprint techniques.
8. Learn and perform bone marrow aspiration and biopsy procedures (at least 3) by arrange-ment with Clinical Hematology Fellow or Attending Clinical Hematologist on service. This is often accomplished during rotations at the VA Hospital and may also be done in an elective clinical rotation at the Regional Oncology Center, but be alert for opportunities during your entire Bone Marrow Rotation.
9. On weekends and holidays (when on-call) and during the week (when on the Bone Marrow Service) look at abnormal or difficult blood films from the Clinical Pathology Core Laboratory in order to check the results of the technologist, as requested. Confirm your impressions with the Hematopathology Fellow, and with the attending pathologist, if necessary. Contact the physician, if appro-priate.
10. Read peripheral blood films (teaching slides or of diagnos-tic importance) that are accessioned with the bone marrow specimens. These reports are written up on a form similar to the bone marrow report and should be treated in the same fashion.
11. When assigned to lymph nodes and immunologic markers, screen incoming cases by reviewing a Wright-Giemsa or H & E stained slide and see that cell counts are performed on blood and cell suspensions. Select the appropriate panel for flow cytometry and/or immunochemistry and assist in selection and gates and blocks. Arrange for molecular and/or cytogenetic studies when appropriate. Review all lymph node consultations and both morphologic and immunologic results of marker cases; write (or amend) description, results and interpretation in the report, and sign out with the at-tending pathologist.
12. Become credentialed in the myeloperoxidase procedure. For the NAP, perform a count of the cells and compare with that of the tech-nolo-gist's. When signing out subsequent NAPs, look at the films to get your impression of the results and validity of procedure.
13. Attend and participate in hematology conferences. For the Tuesday conference, present cases and appropriate review of the topic, as assigned by the attending pathologist in charge of the con-ference. For the Thursday conferences with the clinical hematol-ogists, prepare your cases with the assistance of the attending pathologist, and present them at the conference.
14. Be available for presentation of case studies and lectures to medical technology students and hematology staff.
15. Develop a working knowledge of immunoglobulin and T-cell receptor gene rearrangements and assays for the molecular abnormalities including BCL-2, C-ABL/BCR, and EBV as applic-able to the diagnosis of hematopoietic neoplasms.
16. Develop a working knowledge of cytogenetic abnormalities in leukemias and lymphomas, e.g., t(8;21), t(15;17), t(9;22), t(8;14), t(8;22), t(2;8), t(4;11), t(1;19), t(11;14), inv16, tris12, t(2;5), and t(14;18), etc.

Evaluation

Global Rating of Live or Recorded Performance: A rater judges general categories of ability (patient care skills, medical knowledge, interpersonal and communication skills) and the ratings are completed retrospectively based on general impressions collected over a period of time (end of rotation) derived from multiple sources of information (direct observations or interactions); input from other faculty, lab technicians and residents and review of work products or written materials. Evaluations will be based on the above objectives.

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