Bone Marrow Transplantation Service

Educational Purpose

The objective of this rotation is to provide an experience for fellows to participate in and as their competency improves direct the management of individuals admitted for bone marrow transplantation, complications of bone marrow transplantation and palliation. In addition the fellow will have an experience seeing and providing consultation opinions, care and follow-up on in patients within University Medical Center whose attending physicians request a subspecialty consultation from the Bone Marrow Transplantation Service.

Teaching Methods

  1. Provide, under attending physician supervision including critiquing and feedback, clinical care including the initial assessment and follow-up care to patients admitted to the Bone Marrow Transplantation Service and Consultative Service. .
  2. Perform under attending supervision the following procedures and deductive services:
    1. Bone marrow aspiration and biopsy
    2. Performance of LPs with the administration of chemotherapy
    3. Oral and intravenous ordering and administration of chemotherapy
    4. Management of central venous access devices
    5. Measurement to tumor masses on physical exam and imaging studies
    6. Correlating clinical findings with pathologic information.
    7. Palliation of malignancy related accumulation of fluids within the body.
    8. Performing therapeutic phlebotomies and pheresis 
    9. Preparation and interpretation of blood and bone marrow smears
  3. Present findings to attending physicians for critique and feedback.
  4. Communicate under attending supervision with patients and their families medical information, therapeutic recommendations, and prognosis discussions.
  5. Perform medical literature reviews on the diagnoses and conditions of patients seen and review a summary to the review with the attending physician.
  6. Present cases of interest for education purposes to multi-disciplinary conferences.

Mix of Diseases Seen

Patients seen on this in patient and consultative service represent spectrum of blood and bone marrow disorders together with resistant cancer for whom treatment with high dose chemotherapy followed by bone marrow rescue or treatment with bone marrow transplantation is of proven benefit. Typical patients include those with acute leukemias, chronic leukemias, bone marrow failures, multiple myeloma, and non Hodgkins Lymphoma. The patients seen representative a broad spectrum and social, cultural and economic circumstances thus providing and excellent teaching experience for trainees to enhance their communication skills.

Types of Clinical Encounters


Patients managed on the in-patient Bone Marrow Transplantation Service Hem/Onc service with attending supervision represent the spectrum of individuals requiring bone marrow transplantation, either autologous or allogeneic, as therapy for individuals with blood and bone marrow disorders. As part of providing this service the experience requires definitive diagnostic services, assessment of extent of disease and determining all management options, managing cancer and blood disorder disease complications, and managing bone marrow transplantation treatment related complications. In addition to seeing, assessing, and managing patients under attending supervision, fellows will interact and provide didactic support for other health care providers involved in the care the in patients and patients on the consultative services. Fellows also will arrange continuity of care when patients are transitioned into the out-patient setting. Procedures will be done under supervision as deemed necessary for optimal care under attending physician supervision.

Procedures Anticipated

  1. Bone marrow aspiration and biopsy
  2. Performance of LPs with the administration of chemotherapy
  3. Oral and intravenous ordering and administration of chemotherapy
  4. Management of central venous access devices
  5. Measurement to tumor masses on physical exam and imaging studies
  6. Correlating clinical findings with pathologic information.
  7. Palliation of malignancy related accumulation of fluids within the body utilizing removal or injecting of palliative therapies
  8. Performing therapeutic phlebotomies and pheresis
  9. Preparation and interpretation of blood and bone marrow smears

Rotation Specific Competency Based Goals and Objectives

  1. Patient Care
    1. With the completion of each rotation on the In-patient Bone Marrow Transplantation Service which occurs each year, a fellow will gain increasing skill, precision, efficiency and accuracy in performing admitting history, physical exams, assessments and formulations of management plans.
    2. With the completion of each rotation the fellow’s skill in providing written accurate, succinct and sophisticated subspecialty evaluations and management plan formulations will increase.
    3. With the completion of each rotation, the fellow will become increasingly proficient and accurate in formulating differential diagnoses in the subspecialty’s patient population.
  2. Medical Knowledge
    1. With the completion of each rotation the fellow will gain an ever increasing knowledge base about each of the diagnoses seen by by the Bone Marrow Transplantation Service.
    2. With the completion of each rotation the fellow will gain an increasing knowledge about the risk benefit of each therapy provided to individuals with the diagnoses seen by the Bone Marrow Transplantation Service.
    3. With the completion of each rotation the fellow will gain an increasing knowledge about the spectrum of palliative intervention and their risk benefit issues.
  3. Interpersonal and Communication Skills
    1. With the completion of each rotation the fellow will gain an increased experience and skill in multidisciplinary treatment planning and how to relate and communicate effectively with the team
    2. With the completion of each rotation the fellow will gain an increased experience and skill in supervising and teaching medical trainees and lower levels and in communicating diagnostic conclusions and management recommendations to teams requesting consultative help.
    3. With the completion of each rotation the fellow will gain an increased experience in creating written documentation of historical details, findings of physical exam, results of diagnostic studies, and describing differential diagnoses, conclusions and management recommendations.
    4. With the completion of each rotation, the fellow will gain an increased experience in communication with patients and their families particularly in discussing clinical assessment and management recommendations.
    5. With the completion of each rotation, the fellow will gain an increased experience and skill in providing emotional support to patient and family with an emphasis on compassion and respectful, professional behavior.
  4. Professionalism
    1. With the completion of each rotation, the fellow will gain an increased experience and serving as a resource to the family for clarifying questions and developing a management plan in which each family member and the patient understands their role.
    2. With the completion of each rotation and with attending physician supervision and feedback a fellow will demonstrate respect, honesty, compassion and integrity in all aspects of the relations with the health care team and the patient and their family.
    3. With the completion of each rotation the fellow will gain an increased understanding of the importance of maintaining strict confidentially and ethics.
  5. Practice Based Learning and Improvement
    1. The fellow will engage in self-directed reading/learning on daily patient assessment and management issues.
    2. As it relates to the patients being managed or consulted on by the Bone Marrow Transplantation Service, a fellow with the completion of each rotation will increasingly be able to find and apply information from the medical literature to the diagnostic plan and management plan.
    3. The fellow with the completion of each rotation will increasing become skilled in the utilization of electronic records, on line medical information resources and be able to provide educational materials to patients and their families.
  6. Competency Goals Based on Year of Training
    1. At the end of the first year of fellowship training, a fellow show have obtained a general knowledge of the blood and bone marrow disorders together with those malignancies for which a bone marrow transplantation is a therapeutic option.
    2. Each year the knowledge should increase so by the end of the third year, the knowledge obtained should be adequate to allow a fellow to successful pass the written certification exams.
    3. By the end of the first year fellows should be experienced in the performance and interpretation of bone marrow aspiration and biopsies and be able to perform the procedures without supervision.
    4. By the end of the first year of fellowship, a fellow should be able to complete chemotherapy orders with therapy ordered with the correct dosages, routes of administration and premedications to minimize the risk of treatment related toxicity.
    5. By the end of the 2nd and 3rd year of fellowships a fellow should be able to correct translate a chemotherapy management plan as it relates to an unusual condition or circumstance from the medical literature to the ordering and administration to a specific patient.
    6. By the end of the 3rd year, a fellow should have acquired the knowledge, skills, and communication abilities to function independently as a subspecialist in the fields of Hematology and Medical Oncology in this case specifically the use of bone marrow transplantation.

Reading List

Please reference the ASCO and ASH national recommended reading lists provided in a separate section in this curriculum.

Pathologic Materials

On all patients who undergoing biopsies, especially bone marrow aspirations and biopsies, a fellow is expected to review the pathologic materials microscopically with the pathology team be it histologies or cytologies.

Educational Resources

Computerized internet access to the Medical Library at the University of Arizona/College of Medicine is available to all trainees both within the facility and at home. In addition the library itself is open 24 hours per day 7 days per week and has an excellent collection of books and journals relating the Hematology and Medical Oncology. In addition the library provides on line internet access to the National Library of Medicine and other subscription medical information services such as “Up to Date” at no charge to trainees.

Competency Emphasis During Rotation (Low, Intermediate or High Emphasis)
Patient Care High
Medical Knowledge High
Practice Based Learning and Improvements High
Interpersonal and Communication Skills High
Professionalism High
System Based Practice  High
 

 

Evaluation Process Tools (Used, Yes or No)
Attending Written Evaluation Yes
360 degree coworker evaluation Yes
Cognitive Testing/In Service Exam Yes
Focused Observation (Mini CEX) No
Certification Examination No
Procedures Yes
Morbidity and Mortality Presentations Yes

Level of Fellow Supervision

Fellows are supervised directly by Hematology and Medical Oncology attending physicians who specialize in Bone Marrow Transplantation. Depending on the situation, this may be direct visual supervision as occurs during procedures and staffing a consultation or it may be verbal supervision of the telephone as occurs when discussing lab results, management plans and after hours consultation. As the fellows knowledge, skills and experience improve, they will be take and ever increasing role in the diagnosis, formulation of management plans, and communication with patients and family so that by the end of the fellowship they are able to function independently. However, throughout all three years of the fellowship, an attending physician is always present and supervision and providing education and critique of a fellow’s performance.