Pediatrics Hematology/Oncology Fellowship Program Manual

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2 I. INTRODUCTION Most hematologic disorders and malignancies occurring during infancy, childhood, and adolescence are uncommon and require a highly sophisticated approach to diagnosis and treatment based on molecular and cellular biology, epidemiology, and other academic disciplines. The rapid and impressive progress in the field in recent decades (and the expected advances in the future) require the specialty to be practiced in a milieu in which teaching and research are actively conducted. The mission of the Pediatric Hematology/Oncology fellowship program at SCHS is to train pediatricians to become highly qualified consultants of Pediatric Hematology-Oncology. The program expects trainees to complete training leading to eligibility for certification in both disciplines. This fellowship program lasts 3 years. It is expected that trainees in these programs will possess excellent clinical skills, deep knowledge of these disciplines and a high standard of professional ethics. II. Goals and Objectives 1. General The Pediatric Hematology/Oncology Fellowship Program provides a structure within which trainees can develop clinical competence in the overall specialty of Pediatric Hematology/Oncology. a. Graduate Pediatric Hematologists/Oncologists with adequate knowledge and skills to manage children with Hematological and malignant diseases. b. Train candidates to become self-disciplined, self-dependent learners and to provide an educational environment that will promote standards of health care. c. Train candidates to perform research and emphasize the research-oriented approach to clinical problems. d. Train candidates to realize the importance of team approach to clinical problems. e. Trainee will rotate between different accredited centers to optimize their training period. f. Graduate trainee at an internationally acceptable standard. g. Graduate trainee with appropriate attitude, medical ethics and scientific caliber. h. Trainee will participate actively in different educational activities during their training and attend symposia and Conferences in Hematology/Oncology. 2. Specific The Pediatric Hematology/Oncology Fellowship Training Program is divided into basic science, clinical science and research. a. Basic Science The Fellow is required to develop competence in disciplines which include: i. Knowledge of the reticulo-endothelial system and hematopoietic organs. ii. Knowledge of biochemical functions and pathological states. iii. Assist in the care of children with hematological/oncological disorders. iv. Physiology: including the renal regulations of water and electrolytes in order to monitor undesirable effects from diseases and from therapy. v. Pharmacology, pharmacokinetics, regulatory mechanisms of drug action, excretion and metabolism in order to avoid irreversible side effects from treatment. Acquaintance with the most commonly used drugs to treat patients with non-malignant and malignant hematological diseases. 2

3 vi. Immunology and microbiology: including immunological mechanisms of hematological and oncological diseases; bone marrow transplantation; the optimal utilization of immunosuppressive agents; and the treatment of bacterial, viral, fungal and protozoal infections utilizing the most effective anti-microbial agents in the immune compromised hosts. vii. Genetics: the mode of inheritance of various hematological and oncological diseases and basic principles of genetics and genetic counseling. viii. Basic knowledge in Molecular Biology of Childhood Malignancies and Blood disorders. ix. Statistics: understanding the proper analyses of clinical and laboratory data and stratification of patients according to risk categories in each disease entity. b. Clinical Science Clinical skills to be acquired include: i. Expanded competence in general pediatrics and pediatric hematology/oncology. ii. Familiarity with the natural history of hematological and oncological diseases including genetics and predisposing factors. iii. Systematization of physical examination and implementation of efficient diagnostic evaluation. iv. Rational expansion of differential diagnoses. v. Correct interpretation of laboratory tests and familiarity with coagulation tests. vi. Performance of procedures, lumbar punctures (diagnostic and therapeutic) and evaluation of the cerebrospinal fluid (CSF), bone marrow aspiration and biopsy and interpretation of clinical tests. vii. Familiarity with blood typing and banking, tissue typing and apheresis techniques. viii. Knowledge and experience in bone marrow transplantation. ix. Familiarity with chemotherapeutic agents and their potential side effects. x. Familiarity with multi-modality therapy including radiotherapy and surgery. xi. Familiarity with recommended symptomatic treatment, supportive therapy, psychological assistance and palliative care. xii. Development of effective interaction with other medical and nursing staff. xiii. Awareness of legal and ethical aspects of the practice of pediatric hematology/oncology and compliance with hospital policies and current rules governing the practice of medicine in the Kingdom. c. Research i. Involvement in research projects (designing and conducting studies). ii. Writing abstracts for presentations at local, national, and international scientific meetings in the field. iii. Drafting manuscripts under the guidance of the Pediatric Hematology/Oncology staff for submission to national and/or international journals. 3

4 I. Structure of the Training Program Total duration of the training will be 3 years. ROTATION 3 YEAR TOTAL First Year Second Year Third Year Oncology Inpatient 6 months 3 3 R Stem Cell Transplantation 2 months 1 1 E Oncology Outpatient 2 months 1 1 S Hematology 6 months 3 3 E Radiation Therapy 1 month 0 1 A Hematopathology 3 months 2 1 R Research 11 months 0 0 C Elective 2 months 1 1 H Leave 3 months TOTALS 36 months 12 months 12 months 12 months II. Description and Objectives of Specific Rotation a. Pediatric Leukemia/Lymphoma Rotation Description and Objectives: The Pediatric Hematology/Oncology Fellow will have the opportunity to take care of pediatric patients with hematological malignancies. Responsibilities will be upgraded as the Fellow advances in his/her training program. It is of paramount importance that the Fellow should achieve the following capabilities: i. To recognize symptoms, signs and differential diagnosis of leukemia and lymphoma in children. ii. To become familiar with the course of treatment of pediatric patients with leukemia and lymphoma. iii. To understand the mechanism of action, route of administration, contra-indications and adverse effects of chemotherapy and management of side effects and treatment of febrile neutropenia. iv. To review the indications for blood component transfusion and its adverse effects as well as its prevention and treatment. v. To acquire the ability to perform the following procedures: a. Bone marrow aspiration and biopsy and requesting the appropriate tests that need to be done on the samples b. Lumbar punctures for diagnostic and therapeutic purposes and evaluation of the cerebrospinal fluid (CSF). vi. Recognition and management of central venous catheter related complications. vii. Participation in multidisciplinary care including effective interaction with the nursing staff and subspecialty medical teams involved. 4

5 b. Pediatric Oncology Rotation Description and Objectives: i. Clinical manifestations of common solid tumors e.g. Wilms tumor, Neuroblastoma, Sarcomas, bone tumors, germ cell, and brain tumors. ii. Diagnostic evaluations and differential diagnosis. iii. Staging for different types of tumors. iv. To be familial with standard guidelines of management. c. Stem Cell Transplantation (SCT) Rotation Fellows will be exposed to a new field where they will be able to follow the Stem Cell Transplant (SCT) patients from the beginning of their treatment till the end. Description and Objectives: i. To Familiarize the Fellows with the indications of: a. HLA typing b. Matched & unmatched related and unrelated SCT (Allogeneic & Autologous) c. Cord blood transplantation d. Donor lymphocyte infusion (DLI) ii. To acquire knowledge of different conditioning regimens including their indications, contraindications, short and long-term regimen related toxicities. iii. To be able to recognize the short and long term complications of SCT and its management including: a. Prophylaxis of graft versus host disease (GVHD) using various immune suppressive therapies b. Manifestations of acute and chronic GVHD c. Management of GVHD Hemorrhagic cystitis Veno-occlusive disease of the liver Bacterial, viral (including CMV) and fungal infections Malnutrition in Stem Cell Transplant (SCT) recipients iv. To understand the principles of immunobiology and immune reconstitution in SCT. v. To attend SCT clinics in order to be familiar with the follow up and outcome of SCT recipients. d. Consultations in Hematology/Oncology Description and Objectives: i. Consults are received daily from other specialties in the hospital. ii. Cases referred include (not limited to) undiagnosed cytopenias, undiagnosed abdominal masses, hemoglobinopathies, hemorrhagic and thrombophilic states, as well as preoperative management of patients with a variety of blood disorders including sickle cell anemia, coagulopathies, and thrombocytopenia. iii. The Fellow will follow all consultations (new and old) and will be responsible in the dayto-day evaluation of patients, tracing results and writing progress notes. e. Outpatient Hematology/Oncology Clinics 5

6 The Fellow will be assigned in the Outpatient Clinics where he/she prepares the initial assessment of the patients, summarize history, physical and laboratory findings and will discuss management of care with the Attending Consultants. f. Hematopathology Lab Rotation Description and Objectives: i. To train the Fellow in all aspects of clinical laboratory medicine and Hematopathology, so that he/she becomes capable of critically evaluating numerical and qualitative data. Training would include demonstration and practice of manual as well as automated procedures, including blood and bone marrow and other body fluid cell morphology relevant to diagnostic hematology. ii. To familiarize Fellows with procedures for the laboratory evaluation and management of patients with hemorrhagic or thrombotic disorders. iii. To prepare the Fellow to use the Blood Transfusion Service (BTS) in a manner most effective for patient management and to develop the clinical and consultation skills in relation to patients requiring blood component therapy. g. Radiation Oncology Rotation Description and Objectives: i. The Fellow will gain experience in the use of radiation therapy to treat patients with malignancies. ii. It is important that he/she has a good understanding of the rationale, complications and logistics behind administering Radiation Therapy. iii. The Fellow will see patients referred to the Radiation Therapy Department for consideration of treatment. Most of the emphasis in this rotation will be on seeing new consults. These patients span a broad range of malignancies, including pediatric sarcomas, brain tumors and other solid tumors and hematologic malignancies. iv. Scans and pathology results will be reviewed where necessary and a treatment plan will be formulated and discussed. The Fellow will be encouraged to follow those patients seen as new consultants through the course of their therapy. v. During the rotation, the Fellow should gain a good understanding of the issues involved in coordinating patient care from the perspective of the Radiation Therapy Department. In addition, the Fellow should become familiar with the common complications arising from radiation therapy, develop a basic understanding of tissue tolerance and understand the rationale behind dose-fractionation. vi. The Fellow will have the opportunity to observe patients being treated or prepared for treatment, but will not have a role in the ordering of Radiation Therapy or determination of doses. vii. The Fellow will have the opportunity to observe simulation techniques and discuss cases with the physician. h. Research Starting from the end of the first year and continuing throughout the Fellowship Training period, the Fellow will be involved in research projects tailored to the Fellow s interest and career path under the supervision of a Research Mentor. During the Fellowship Program at least one study will be expected by each Fellow. 6

7 III. Responsibilities of Fellows Under the supervision of Consultants, Fellows are expected to: Year 1: The 1 st Clinical Year Fellowship (a) (b) (c) (d) (e) (f) (g) (h) (i) Carry out rounds every morning on all patients. Join the consultants rounds. Attend the hand-over rounds. Be responsible for the care of all patients under the supervision of a Consultant. Be responsible for all admissions and should be available to receive report from the referring physician. Supervise Rotating Residents joining the unit. Do on-call duties as appears on the monthly rotation. Provide consultation to other services in the Hospital. Participate in educational activities in the department or in the unit. Year 2: The 2nd Clinical Year Fellowship (a) (b) (c) Participate in upgraded responsibilities and will take a more senior role. Make more appropriate clinical decisions and manage patients efficiently. Conduct daily rounds/sessions with Resident, Assistant and Consultant. Year 3: Research Fellows will be expected to initiate, develop, conduct and complete a research project in Pediatric Hematology/Oncology with supervision, assistance and direction from the consultant members of Pediatric Hematology/Oncology. The Fellow will present his/her progress of the research project on a regular basis. During the third year the Fellow should attend a minimum of 3 clinics of interest per week in addition to on-call duties. IV. Resources a. Universal resources Fellows are expected to know the contents of and use of the following resources: i. Pediatric Hematology/Oncology. ii. Hematology of Infancy and Childhood, DG Nathan and FA Oski. iii. Principles and Practice of Pediatric Oncology, DG Poplack and PA Pizzo iv. Major general and specialized journals: NEJM, Lancet, Science, Nature, Blood, Journal of Clinical Oncology, Pediatric Blood and Cancer, BJH, Cancer Research, BMT, Biology of Blood and Marrow Transplantation. v. Internet resources: Pubmed database, PDQ, Ovid, etc. vi. Computer resources including a word processing program, spreadsheet, database program, statistics program and Endnote b. Institutional resources i. Core Curriculum Lectures ii. Clinical Care Guidelines iii. Grand Rounds/Management conferences iv. Tumor Boards v. Clinic Conferences 7

8 vi. Medical Library vii. Journal Club viii. Regional and national meetings (ASPH/O, ASH, AACR, ASCO, COG): V. Training Centers Accreditation Participating hospitals should meet the requirements for accreditation detailed in the general accreditation by laws of the Saudi Council for Health Specialties. In addition to the following: a. Personnel i. At least two certified pediatric hematologists/oncologists who should devote sufficient time to the program to ensure adequate teaching and to provide critical evaluation of the progress and competence of fellows. ii. Pediatric oncology nurses who are certified in chemotherapy, knowledgeable about pediatric protocols, and experienced in the management of complications of therapy. iii. Certified radiologists with specific expertise in the diagnostic imaging of infants, children, and adolescents. iv. Certified surgeons with expertise in pediatric general surgery. v. Surgical specialists with pediatric expertise in neurosurgery, urology, orthopedics, ophthalmology, otolaryngology, dentistry, and gynecology. vi. Certified radiation oncologist trained and experienced in the treatment of infants, children, and adolescents. vii. Certified pathologist experienced in pediatric oncology. viii. Certified hematopathologist experienced in pediatric hematological disorders. ix. Certified pediatric sub specialists available to participate actively in all areas of the care of the child with cancer and blood disorders, including anesthesiology, intensive care, infectious diseases, cardiology, neurology, endocrinology and metabolism, genetics, gastroenterology, child and adolescent psychiatry, nephrology, and pulmonology. x. Pediatric nutrition experts with the capability of preparing, administering, and monitoring total parenteral nutrition. xi. A clinical oncology pharmacist in the pediatric hematology/oncology team is recommended. b. Facilities i. An immediately accessible and fully staffed, on-site pediatric intensive care unit. ii. An access to Up-to-date diagnostic imaging facilities to perform radiography, computed tomography, magnetic resonance imaging, ultrasonography, radionuclide imaging, and angiography; positron-emission tomography scanning and other emerging technologies are desirable. iii. An access to Up-to-date radiation-therapy equipment with facilities for treating pediatric patients. iv. A hematopathology laboratory capable of performing cell-phenotype analysis using flow cytometry, immunohistochemistry, molecular diagnosis, and cytogenetics and an access to polymerase chain reaction-based methodology and immunology lab. v. An Access to hemodialysis and/or hemofiltration and apheresis for collection and storage of hematopoietic progenitor cells. c. Capabilities i. A clinical chemistry laboratory with the capability to monitor antibiotic and antineoplastic drug levels. ii. A blood bank capable of providing a full range of products including irradiated, cytomegalovirus-negative, and leucodepleted blood components. 8

9 iii. A pharmacy capable of accurate, well-monitored preparation and dispensing of antineoplastic agents and investigational agents. iv. Capability of providing sufficient isolation of patients from airborne pathogens, which could include high-efficiency particulate air (HEPA) filtration or laminar flow and positive/negative pressure rooms. v. Access to stem cell transplant services and other services including pain management, palliative, and end-of-life care. vi. A regularly scheduled multidisciplinary pediatric tumor board. vii. A long-term multidisciplinary follow-up of successfully treated patients for the potential adverse effects of treatment for childhood cancer. d. Patient Population i. At least 50 pediatric patients with newly-diagnosed oncological diseases each year. ii. At least 50 pediatric patients with newly-diagnosed hematological diseases each year. iii. An inpatient service of Pediatric Hematology/Oncology with a minimum of 15 beds. IX. Training Centers Periodic Evaluation and Management a. The accredited training centers will be reviewed regularly by the Scientific Board/Committee of the Subspecialty and accreditation will be renewed periodically, according to the accreditation by-laws of the Saudi Commission for Health Specialties. b. A structured educational program and academic activities are required by the Scientific Board/Committee of the subspecialty during the accreditation/renewal process. X. Organization of the Program Content: a. There will be a Scientific Committee of the Pediatric Hematology/Oncology Subspecialty at SCHS monitors and improves the professional and educational standards of the training and approve the certification in Pediatric Hematology/Oncology Subspecialty according to the by-laws of SCHS. b. The scientific committee at SCHS will be responsible to appoint the trainees into training center(s) that will assume primary responsibility for monitoring trainees and ensure the completeness and adequacy of the training. c. Primary center: Each Fellow will have Primary Training Center that will be responsible for monitoring and assuring completeness and efficacy of his/her training. The Fellow will spent minimum of 50% of the training period in the Primary Center. The Fellow can do rotations outside the primary center (outside or inside the country) with maximum of 50% of total training duration, this should be arranged between the Fellow, primary centers and visited centers and approved by the scientific board of Pediatric Hematology/Oncology Fellowship. d. During the final year, overseas rotations (6-12 months) are recommended at well recognized centers. XI. Enrollment Criteria: a. Posses a Saudi/Arab Board certification in General Pediatrics (or its equivalent); or had successfully completed the training program for Saudi Specialty Certificate in Pediatrics and passed the final written examination. b. Pass successfully the admission requirements set by the Pediatric Hematology/Oncology Subspecialty Scientific Committee. 9

10 c. The candidate must provide written permission from his/her sponsoring institution allowing him/her to participate in the program on a full-time basis. Trainees shall be enrolled in continuous full-time training for the whole period of the program. d. The candidate has to provide 3 letters of recommendations from consultants with whom he/she had recently worked with them. e. The candidate must register annually for the program at the Saudi Commission for Health Specialties. XII. Ethical issues Goal: Acquisition of knowledge and skills to deal with arising ethical issues during work. The trainee should be familiar with the health worker code of ethics in their center and should consult with colleagues and Islamic scholars when faced with medical ethical dilemma. He/she should be familiar with decisions related to CPR status/terminal care; of treatment, no further need for tertiary care services (discharge from clinic) and be able to counsel parents regarding child loss or life threatening events. XIII. Leaves Regulations governing holidays are as per Saudi Commission for Health Specialties. Holidays are to be scheduled by the institution in such a way that it will not interfere with the quality of the training and with patient care. XIV. Fellow Evaluation and Promotion: Pediatric Hematology/Oncology Fellows will be evaluated continuously for intellectual abilities, technical skills, professional attitudes and inter-personal relationships, as well as specific tasks of patient management, decision-making skills and critical analysis of clinical observations. Fellows will also be evaluated with respect to their knowledge in Pediatrics and also in literature review. There is a provision for appropriate feedback of this information to the Fellow for guidance. On the other hand, Fellows are given the opportunity to evaluate the staff performance with appropriate feedback to the staff members concerned to resolve any problems. The Fellows performance will be assessed by: a. Formal evaluation forms from each faculty member on each rotation. b. Annual examinations held at the end of the first and second year. Pediatric Hematology/Oncology Fellows will be advanced and promoted contingent upon successful performance, personal intellectual growth and satisfactory completion of the annual examinations. 10

11 XV. Evaluation of Rotations by Fellows The Pediatric Hematology Oncology Fellow is encouraged to complete this questionnaire at the end of each rotation and to forward it to the Director of the PHO Fellowship Training Program. A. Were the objectives of rotation fulfilled? 1. Yes 2. No B. How would you rate your interaction with the consultant? 1. Excellent 2. Average 3. Poor C. Was there a regularly allocated time for educating the PHO Fellow? 1. Yes 2. No D. Was there a provision of educational material/ references? 1. Yes 2. No E. How would you rate the overall yield you got from the rotation? 1. Excellent 2. Average 3. Poor Suggestions to improve rotation Fellow s Name: Signature: Date: XVI. Final Examination The trainees can set for the final examination only after fulfilling the following prerequisites: a. Successful performance and satisfactory completion of the annual examinations. b. Have completed a research study in the field which has been published or accepted for publication in a peer review journal. XVII. Certification A certificate of completion of the Pediatric Hematology/Oncology Subspecialty SCHS will be awarded upon satisfactory completion of the requirements of the program, which includes passing the required examinations. 11

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