Structure of the Hematology/Oncology Program
The overall structure of the program is broken into two phases. The initial 18 months is an intensive clinical experience encompassing all aspects of Hematology/Oncology. The second phase consists of a focus on structured, mentored research activity while continuing experience in the outpatient continuity clinics.
During the 18 months of training, Hematology/ Oncology fellows rotate through five major clinical services: the 60-bed Feinberg Pavilion Cancer Care Unit of NMH, The Jesse Brown VHA Medical Center, Northwestern Hematology consultation service, Northwestern Oncology Consultation service and Northwestern Palliative Care/Hospice Service. The daily patient census averages 60 oncology patients at NMH and 30 patients at the Jesse Brown VHA Medical Center. These settings give fellows opportunities to care for patients with a broad range of oncologic and hematologic conditions. In addition, each fellow maintains an outpatient, continuity of care clinic(s) at the NMFF or VA site where the trainees have a major role in the diagnosis, initial and ongoing treatment of a group of patients. Fellows also participate on consult services where they participate in the care of patients with a variety of disease states in various stages of clinical presentation and treatment. A formal didactic curriculum accompanies practical experiences and covers all aspects of hematology/oncology and introduces the trainees to aspects of basic cancer biology. The mandatory conferences focused on fellow training include: Journal Club, Core Curriculum Lecture Series, New Patient Case Conference, Symptom Management Conference, Hematology Conference. In addition, Multidisciplinary Management Conferences (Breast, Head & Neck, Thoracic, GI, GU, Sarcoma, Brain, etc) are convened weekly and fellows are encouraged to attend as time allows. In all of these conferences, trainees are strongly encouraged to take an active role in the presentation or in responding to management issues.
The second phase of the fellowship represents an intensive, mentored immersion in clinical or basic/translational investigation in hematology or oncology. Supported by a NIH training grant, fellows have multiple opportunities to work in labs of members of the division or throughout the medical center. Numerous opoprtunties for prospective and restrospective clinical research as well as health outcomes/health services research are available. A rich set of seminars can augment the knowledge of the trainee, including the Cancer Prevention and Control: Health Services Lecture Series and Tumor Cell Biology Seminar Series. Fellows can also obtain a Masters of Science in Clinical Investigation degree through a program offered by the Feinberg School of Medicine of Northwestern University. The coursework in clinical trial design, epidemiology and biostatistics offers formal training in the fundamental skills necessary for the aspiring clinical investigator. 8 units of classroom work and two units comprising a mentored clinical research project are required of all degree candidates, and can be completed over 2 or 3 years. More information about the program can be found at www.clinicalinvestigation.northwestern.edu/index.htm.
Clinical Phase-Inpatient Experience
Feinberg Pavillion Cancer Care Unit
The Feinberg Pavilion Cancer Care Unit, the primary inpatient hematology-oncology unit at NMH, gives fellows experience in managing severely ill patients with a variety of hematologic and solid tumors. As a major tertiary referral center, a large number of patients are referred to faculty who are nationally known for their expertise in clinical cancer research. As such, many patients participate in clinical research projects sponsored through the Eastern Cooperative Oncology Group, the National Cancer Institute, or The Robert H. Lurie Comprehensive Cancer Center of Northwestern University. Patients receiving autologous or allogeneic bone marrow transplantation protocols are treated on this unit at NMH (Transplant census in 2005 was 200 patients). All transplantation protocols are registered with the International Bone Marrow Transplant Registery. A robust cohort of patients are also seen for more typical cancer care, giving the trainee a very well rounded experience in clinical oncology.
Fellows in phase I (1st 18 months) spend 6 months on the Feinberg Pavilion Cancer Care Unit and are responsible for the direction of medical care, implementation of clinical research protocols, collection of research data, supervision of the administration of cancer therapy (chemotherapy, biologic therapy, vaccine therapy, etc) and education of housestaff. Rotations are one month in duration and are divided between Hematology Service, Stem Cell Transplant Service and Medical Oncology Service. On the Hematology and Medical Oncology Services, fellows have a major role in the training of Northwestern University medical residents who serve as primary care physicians for patients on the unit. On other services, fellows work in close collaboration with Nurse Practitioners and Hospitalists, who provide primary care on selected inpatient units. Fellows spend 1-2 months during phase one on the stem cell transplant service where patients undergo allogeneic and autologus transplantation for leukemia, lymphoma, myeloma and marrow failure syndromes. During this time fellows will recieve training in the support of these patients, including the nature of preparative chemotherapy regimens, the use of immunosupressants and prophylactic and therapeutic antibiotics. Fellows are responsible for writing all chemotherapy orders and supervising and reviewing bone marrow aspirations and biopsies. In addition, fellows participate in daily rounds with an attending physician who is a faculty member of the Feinberg School of Medicine who is ultimately responsible for the activities of each unit. Other participants on daily rounds include oncology pharmacists, social work and nursing.
Weekly patient management conferences and seminars held on the Feinberg Pavilion Cancer Care Unit and at the Robert H. Lurie Comprehensive Cancer Center provide background about patient management and research. Organ site directed conferences in lung cancer, head and neck cancer, neuro-oncology, GI malignancy and malignant and benign hematology allow for in depth analysis and debate of critical treatment decisions. Psychosocial issues related to cancer and its treatments are aired in conferences with liaison psychiatry. A lecture series for housestaff is held on the Feinberg Pavilion Cancer Care Unitand focuses on basic principles in hematology/oncology.Fellows play a major role in this educational seris, preparing and delivering many of these lectures. A syllabus is provided to all fellows and Department of Medicine residents rotating through the unit.
Veterans Health Administration Service
The Jesse Brown VHA is a site of patient activity for three months of the clinical phase (I) of training. Fellows have primary responsibility for the management of approximately 20 hematology/oncology patients and are assisted on the consultation services by Northwestern Memorial Hospital (same comment as before re: NMH) and University of Illinois Medical Center residents and medical students. All patients are treated by a primary care team that consists of medical residents in postgraduate years one and two. A faculty member serves as attending physician, makes regular rounds, and ultimately is responsible for management decisions.
While on the Jesse Brown VHA service, fellows encounter patients with a wide variety of common hematologic and oncologic problems including lung, prostate, and head and neck cancers, as well as anemias and coagulopathies. Together with the attending physician and a hematopathologist, fellows review bone marrow aspirates and biopsies.
Northwestern Hematology Consultation Service
Fellows spend 2-3 months on this service, where they see patients with a wide variety of benign hematologic problems including coagulation disorders such as hemophilia, acquired factor deficiencies, hypercoagulable states, postoperative bleeding problems, acquired or inherited platelet disorders, obstetrical emergencies, and hemoglobinopathies. Fellows are part of the consultation team, which includes an attending, residents and medical students. Trainees are given instruction in the ordering and interpretation of specialized laboratory tests in hematology and coagulation and the use of an increasing array of anticoagulants. All peripheral and marrow smears are interpreted under the guidance of attending physicians and formal morphology rounds are conducted under the guidance of senior faculty. The hospital apheresis and stem cell collection unit is staffed by hematology attendings and fellows may gain experience in this specific aspect of hematology, including the use of specialized blood products.
Northwestern Oncology Consultation Service
On this NMH rotation, fellows evaluate new patients who have been referred for consultation as well as those with interesting hematologic or oncologic problems who have not been admitted to the Feinberg Pavilion Cancer Care Unit. This service also consists of patients from the malignant hematology and/or oncology services if these teams have reached maximum census. Hematology/Oncology nurse practitioners or Hospitalists assist fellows on this service. Fellows learn the multidisciplinary approach to oncology and gain experience in the assessment of newly diagnosed oncology patients.
Northwestern Palliative Care Service
The Palliative Care and Home Hospice Program at Northwestern was established in 1982 and includes: (1) an inpatient Palliative Care Unit; (2) a Palliative Care Consultation Service; (3) a Palliative Care Outpatient Clinic; and (4) a Home-based Hospice. The Inpatient Palliative Care Unit is staffed by a palliative care faculty member, the palliative care fellow, a nurse practitioner, a social worker, a medical resident and medical student(s). This rotation offers exposure to complex pain problems and an opportunity for the fellow to participate in multiple interdisciplinary family meetings. Interdisciplinary team rounds occur daily.
The Palliative Care Consultation Service consists of a palliative care attending physician, the fellow, a resident, and/or medical student(s), serving patients and families throughout Northwestern Memorial Hospital and the Rehabilitation Institute of Chicago. The palliative care consult team provides approximately 80 – 100 consults per month; about half of these patients have a diagnosis of cancer. This evidence based service gives the trainee in depth experience in the proper use of analgesics and other palliative medications and strategies, backed by weekly didactic sessions.
The Home Hospice Program serves the city of Chicago and nearby suburbs. While rotating on this service, the fellow attends weekly Hospice Interdisciplinary Team Rounds and makes home visits on patients, initially accompanied by one of the team members and later independently. The trainee will make 12-15 home visits each week and if home patients are admitted, the fellow will round on that patient/family during the duration of the admission.
Trainees will spend one half day a week in the Palliative Care Clinic in the Outpatient Clinical Cancer Center. This Clinic offers assessment, consultation, and treatment for patients and families with symptom management or with issues around advanced care planning. A physician, nurse practitioner, nurse pain specialist, social worker, psychologist, and dietitian, all experienced in palliative care, comprise the outpatient team.
The approximate Distribution of Effort for the Hematology/Oncology Fellowship is as follows:
Hematology Consultation 3 months
Hematological Malignancy Service 3 months
Solid Tumor Oncology Service 3 months
Palliative Care Service 1 month
Stem Cell Transplant Service 1 month
VA Service 3 months
Elective 4 months (Chosen from below)
Clinical Phase-Outpatient Experience
The outpatient experience is divided between the Jesse Brown VHA Medical Center clinics and the division's offices in the Robert H. Lurie Outpatient Cancer Center of NMFF. Each first-year fellow spends three half-days each week treating patients with the goal of establishing a practice that will provide an opportunity for longitudinal follow-up during the three-year program. At Jesse Brown VHA Medical Center, fellows work with medical residents and one or two attending physicians. The clinics are organized into subspecialty areas according to faculty members' research interests. At NMFF, fellows manage patients jointly with a faculty member with the goal of creating and following their own groups of patients. Nurse clinicians administer chemotherapy, which is prepared by a pharmacist on site; a specialized treatment area is designed for prolonged infusion chemotherapy and intravenous fluid administration. Patients are referred to Northwestern both for evaluation for entry into specialized clinical trials and for more routine clinical care. Hence the trainees have a wide opportunity to evaluate and manage a diverse group of patients.
At both The Jesse Brown VHA Westside and NMFF, a data manager attends all outpatient sessions and assists in data collection for patients enrolled in clinical research protocols. All data are accessible for research.