The Division of Hematology/Oncology generally reports to the office of the Chairman of the Department of Internal Medicine via the office of the Division Director. The Hematology/Oncology Fellowship Training Program Director reports to the Division Director, the Internal Medicine Training Program Director, and the Director of the MUSC Office of Graduate Medical Education.

The Training Program’s first class of fellows matriculated on July 1, 1986. The Division offered both two-year (medical oncology or hematology) and three-year (medical oncology and hematology) training programs until deciding at a faculty retreat in 1997 to phase out its two-year program in view of market forces as well as a desire to train candidates more inclined to pursue an academic career than a private practice. The last two-year fellows graduated on June 30, 1999. The Division’s first fellowship class specifically recruited under the new philosophy matriculated on July 1, 1999.

As of April 8, 2007, in the 20-year history of the Program a total of 56 fellows have matriculated (55 as first-year fellows, 1 as a second-year fellow), 9 are currently in training, 43 have graduated (31 from a three-year combined hematology/oncology training program, 11 from a two-year oncology training program, and 1 from a three-year combined hematology/oncology training program followed by a one-year research fellowship), and 4 have withdrawn after one year or less of training to pursue a different career direction; none have been terminated. To the Program’s knowledge, all graduates have taken and passed the subspecialty certification exams for which they were eligible except for two recent graduates, now overseas, who face considerable logistical barriers to taking the hematology board exam. To the Division’s best knowledge, at this time 36 graduates have active subspecialty-oriented private practices (32 in the United States (including 30 in the Southeast (15 in South Carolina), 3 in the Mid-West, 2 in the Northeast), 1 in Canada), and 7 graduates are pursuing subspecialty-oriented academic careers (5 in the U.S., 1 in Paraguay, 1 in Thailand). Two of the 36 graduates in private practice have also pursued research and/or teaching interests.

The Division’s Training Program was last accredited by ACGME in 2003. The Training Program received full accreditation with no citations.

The Division’s Training Program is accredited to train up to ten fellows simultaneously but typically trains only nine fellows at any given time. As of April 8, 2007, the Division has nine fellows enrolled in its Training Program, including three first-year fellows, three second-year fellows, and three third-year fellows.

As detailed in Section 5, Specific Program Content, the Division conducts a significant amount of basic and/or clinical research in the following areas and more:

The MUSC Division of Hematology/Oncology provides educational experiences for a wide range of consumers including the Division’s fellows, the MUSC Department of Internal Medicine PGY1-PGY3 residents, third and fourth year medical students from both the MUSC School of Medicine and other medical schools, occasional other health professional students and post-graduate trainees at MUSC, and even the lay community. In addition, the Division provides continuing medical educational experiences for its own faculty as well as other professional health care providers in the community. Each of these experiences is tailored to meet the needs of the target consumer and is so discussed below.

The Division’s formal training programs for internal medicine residents and hematology/oncology fellows are structured to provide those trainees with the six essential areas of competency defined by ACGME’s July 2005 “General Program Requirements for Fellowship Education in the Subspecialties of Internal Medicine” document. The “Program Requirements” section of this document contains a more detailed review of how the ACGME competencies are addressed by the Division’s Training Program.

The curriculum for the Division’s fellows is designed to provide the fellows with a thorough grounding in the principles and practice of medical oncology and hematology, from both clinical and research perspectives, over a three year period. The curriculum consists of an integration of the American Society of Clinical Oncology’s Core Curriculum Outline (Muss HB et al., ACCO: ASCO Core Curriculum Outline, J Clin Onc 2005 Mar 20; 23(9):2049-77; http://www.jco.org/cgi/content/full/23/9/2049; copy as of September 10, 2005 included in this document as Appendix 1) and the American Society of Hematology’s Hematology Curriculum (http://www.hematology.org/images/hematology_curriculum.doc; copy as of September 10, 2005 included in this document as Appendix 2). The curriculum is supplemented by the ASCO Syllabus of Classic Oncology References (http://www.asco.org/ac/1,1003,_12-002126-00_18-0012400-00_19-00-00_20-001,00.asp) as well as by the ASH Reading List (http://www.hematology.org/education/training/reading/list.cfm). Highlights of the methods by which the fellows are instructed in this curriculum include the following:

● A structured program of twice-monthly reviews of all the major topics in oncology and hematology and once-monthly “Meet the Professor” sessions

● Intimate, well-supervised participation (with graduated levels of responsibility) in the provision of care to the Division’s outpatients, inpatients, and consult-service patients;

● A structured set of weekly, biweekly, and monthly conferences in different formats (e.g., Consult Service Conference, Case Conference, Journal Club, General and Specialty Tumor Boards, Hematopathology Conference, Scope Time, the Division’s Seminar Series, etc.);

● Basic education in several specialty fields related to medical hematology/oncology (e.g., transfusion medicine, diagnostic immunology, radiation oncology, etc.);

● Detailed exposure to the principles and practices of clinical and basic research;

● Execution of at least one minor research project within the first two years and at least one major research project in the third year, under the supervision of Division faculty members; and

● Plus all the topics in the GME Core Curriculum provided by MUSC’s Office of Graduate Medical Education (http://gme.musc.edu).

● The trainee will have had an opportunity to review current understandings of the following topics and be able to apply this knowledge in clinical, research, educational, and administrative settings:

• Tumors of the nasal cavity and paranasal sinuses, nasopharynx, oral cavity, and oropharynx

● The trainee will be able to competently manage the care of the individual patient with hematologic and/or oncologic disease, including documented abilities to:

• Take both thorough and focused (as appropriate) histories in such a manner as to demonstrate an understanding of differential diagnostic possibilities, the natural history of known diagnoses, and possible treatment outcomes.

• Perform both thorough and focused (as appropriate) physical exams in such a manner as to demonstrate an understanding of differential diagnostic possibilities, the natural history of known diagnoses, and possible treatment outcomes.

• Identify and interpret relevant ancillary data such as laboratory and radiology tests.

• Interpret bone marrow aspirates smears, bone marrow biopsy sections, and bone marrow biopsy touch preps.

• Develop a problem-oriented assessment in such a manner as to demonstrate an understanding of:

• Opportunities and options for treatment based on standards for care as well as a critical appreciation of relevant medical literature; and

• Psychosocioeconomic/environmental factors relevant to the process of prioritizing recommendations for management.

• Develop a comprehensive treatment plan, involving other specialties and ancillary services as appropriate.

• Manage treatment complications and re-formulate treatment plans as appropriate.

• Bone marrow aspiration and biopsy from the anterior and posterior superior iliac crests and sternum, both with and without conscious sedation;

• Administration of subcutaneous, intramuscular, intravenous, intrathecal (including Ommaya reservoir), and intralesional chemotherapy (and related agents), including administration of appropriate pre- and post-medication, fluids, and other supportive care;

• Bone marrow harvest (with assistance from anesthesiology and operating room support staff) for purposes of bone marrow transplantation;

• Preparation of peripheral blood and bone marrow aspirate smears and interpretation of these smears including integration of findings from automated analytic instruments.

• Care for, educate, and counsel patients about their conditions in an attentive, supportive, concerned, caring, empathetic, and ethical manner.

• Document the delivery of care in accordance with not only accepted principles and standards of documentation but also applicable regulatory requirements.

• Maintain appropriate professional communication with referring and other health care providers.

● The trainee will be able to concurrently manage, in an efficient manner, a panel of outpatients and inpatients.

● The trainee will be able to interact with senior and junior colleagues and support staff in a professional manner.

● The trainee will understand the principles of conducting clinical research and will be able to manage the care of a patient enrolled on a clinical trial.

• Trainees who complete a third year of training will be able to independently develop and execute a clinical or laboratory research project.

● The trainee will be able to prepare and deliver discussions of hematology/oncology topics in both interactive as well as didactic settings.

● The trainee will be able to critically evaluate the hematology/oncology medical literature.

● The trainee will develop and execute at least two research projects appropriate for his/her levels of training and prior research experience including the following steps:

• Feasibility exploration, including tentative identification of research supervisor

• Concept review with Fellowship Program Assistant Director for Research and other faculty as appropriate

The research projects must focus on a topic of relevance to hematology/oncology but may involve basic and/or clinical science. Research supervisors may be selected from Division faculty as well as faculty in other Departments and Divisions of MUSC. All research projects must be supervised by a member of the MUSC faculty and are subject to approval by the Fellowship Program Director and Assistant Program Director for Research.

The Division of Hematology/Oncology fellowship activities are summarized in the table below.

Non-Ambulatory

Clinical Activities

Ambulatory

Clinical Activities

Non-Clinical

Activities

Year 1

1. Hem Service (2 or 4 mos.)

2. Onc Service (2 or 4 mos.)

3. MUH Consult Service (4 mos.)

1. HCC Continuity Clinic two afternoons per week (12 mos.)

2. Outpatient SCT Service (2 mos. for one Year 1 fellow, 0 mos. for the other two Year 1 fellows).

3. Multidisciplinary Malignant Hematology Clinic (2 mos. for one Year 1 fellow, 0 mos. for the other two Year 1 fellows)

4. Head & Neck, Gynecologic, and Neurologic Oncology Multidisciplinary Clinics (2 mos. for two Year 1 fellows, 0 mos. for the other Year 1 fellow)

1. Conferences and seminars as detailed elsewhere (required)

2. Minor research project (optional; hours per week are variable but overall minimum one month effort expected)

Year 2

1. Hem Service (0 or 2 mos. as needed for the fellow to have spent a total of 4 mos. on this service across the first two years)

2. Onc Service (0 or 2 mos. as needed for the fellow to have spent a total of 4 mos. on this service across the first two years)

3. VA Consult Service (4 mos.)

4. Electives (typically 2 x 1 mo. each, but can be reduced depending on scope of minor and major research projects)

1. HCC Continuity Clinic two afternoons per week (12 mos.)

2. VA Clinic one morning per week (4 mos.)

3. Outpatient SCT Service (typically 4 mos. (or 2 mos. for the fellow who already spent 2 mos. on this service in Year 1), but can be reduced by up to 3 mos. depending on scope of minor research project)

4. Head & Neck, Gynecologic, and Neurologic Oncology Multidisciplinary Clinics (2 mos. for the Year 2 fellow who did not have this activity in Year 1, 0 mos. for the other two Year 2 fellows)

1. Conferences and seminars as detailed elsewhere (required)

2. Minor research project (required if not done in Year 1; time allocation as described in Year 1 and in Year 2 Outpatient SCT Service)

Year 3

1. Experience customized to research project needs

1. VA Continuity Clinic one morning per week (12 mos.)

2. Other experience customized to research project needs

1. Major research project (required; 12 mos., can be expanded to include some Year 2 time)

2. Conferences and seminars as detailed elsewhere (required)

● Trainee rotation through a wide variety of inpatient, outpatient, consultative, and special services in which the trainee is allowed increasing responsibility and independence in providing patient care as the trainee’s knowledge-base and skill-base demonstrably improve. These services are as follows:

• Inpatient care is taught and learned principally on Medical University Hospital’s 8-West HOPE (Hematology-Oncology Protective Environment) Unit. There are two inpatient services on this 24-bed unit, though beds on other units, too, are occasionally used by these services as needed. Patients are admitted to one service or the other based on their principal hematologic/oncologic diagnosis.

• The Hematology Service is staffed by a Division faculty member (ABIM-board-certified in at least Hematology and likely also Medical Oncology), a first-year Division fellow trainee, a certified nurse practitioner, a junior or senior resident from the Department of Internal Medicine, and specifically assigned support staff including a Pharm.D., case manager, social worker, nutrition specialist, etc. Third and fourth year medical students periodically also rotate through the service. This service is intended to manage stem cell transplantation patients who require hospitalization and all other patients with malignant and benign hematologic disorders such as acute and chronic leukemias; plasma cell dyscrasias; high-grade non-Hodgkin’s lymphoma, whose management bears many similarities to the management of acute leukemia; hemoglobinopathies; immune thrombocytopenic purpura; thrombotic thrombocytopenia purpura/hemolytic-uremic syndrome; and other coagulation system disorders. In general, the fellow is expected to assume as much of a leadership role on the service as possible. The fellow has direct care responsibilities for approximately 45% of the patients on the service, supervisory care responsibilities for another 45% of the patients for whom the nurse practitioner has direct care responsibilities, and supervisory care responsibilities for the remaining 10% of the patients for whom the Medicine resident has direct care responsibilities (though the fellow does also have direct responsibility for subspecialty-specific care for this small group of patients (e.g., writing chemotherapy orders, accessing Ommaya reservoirs, etc.)). If a patient becomes critically ill, he/she can be readily transported to the Medical Intensive Care Unit located near the HOPE Unit. The Pulmonary/Critical Care Service then assumes primary responsibility for the patient, but the Hematology Service continues to round on the patient daily (or more often, as necessary), acting in a consulting capacity. Hematology bedside rounds with the attending physician are conducted each day from 10:00 a.m. to 12:00 p.m. (in accordance with Department of Medicine policy) and include — on each patient every day — teaching and discussion focused on subspecialty-oriented issues. Each fellow spends a total of four months (in two non-consecutive two-month blocks) across his/her first two years of training on the Hematology Service. Each fellow is carefully, directly supervised in treatment planning (particularly in the writing of chemotherapy orders and performance of procedures) early in the four-month span; increasing independence is allowed as competency is demonstrated, although the attending physician is always available on site for consultation. Each Hematology Service fellow is required to perform standard delivery-of-care documentation for each patient for whom he has direct care responsibilities; all such documentation is reviewed and critiqued by the Hematology Service attending physician. Each month the Hematology Service fellow and the Oncology Service fellow share night-call and weekend-call responsibilities, alternating 5:00 p.m. to 8:00 a.m. call Monday through Thursday nights, and also alternating each weekend (5:00 p.m. Friday through 8:00 a.m. Monday). Adjustments for holidays are made as necessary. Seven days a week, the on-call fellow is also responsible for remaining on campus as medical back-up for the Hollings Cancer Center’s Chemotherapy Suite until all patients have been cleared from the Suite (an occasional patient’s treatment may run past 5:00 p.m.). It should be noted that the Hematology Service attending physician also serves as the backup attending physician for hematology consults on the MUH/CMH Consult Service should the regular MUH/CMH Consult Service attending physician be unavailable.

• The Oncology Service is staffed by a Division faculty member (always distinct from the Hematology Service faculty member, and ABIM-board-certified in at least Medical Oncology and possibly also Hematology), a first-year Division fellow trainee (always distinct from the Hematology Service fellow trainee), a junior or senior resident from the Department of Internal Medicine, two interns from the Department of Internal Medicine, and specifically assigned support staff including a Pharm.D., case manager, social worker, nutrition specialist, etc. Third and fourth year medical students periodically also rotate through the service. This service is intended to manage patients with solid tumors and lymphomas (except for high-grade non-Hodgkin’s lymphomas, which are handled by the Hematology Service because of the acute leukemia-like nature of those diseases). In general, the fellow is expected to assume as much of a leadership role on the service as possible. The fellow has supervisory care responsibilities for all patients on the service (for whom the Internal Medicine housestaff have direct care responsibilities), with the exception that all subspecialty-specific care is the direct responsibility of the fellow (e.g., writing chemotherapy orders, accessing Ommaya reservoirs, etc.). If a patient becomes critically ill, he/she can be readily transported to the Medical Intensive Care Unit located near the HOPE Unit. The Pulmonary/Critical Care Service then assumes primary responsibility for the patient, but the Oncology Service continues to round on the patient daily (or more often, as necessary), acting in a consulting capacity. Oncology bedside rounds with the attending physician are conducted each day from 10:00 a.m. to 12:00 p.m. (in accordance with Department of Medicine policy) and include — on each patient every day — teaching and discussion focused on subspecialty-oriented issues. Each fellow spends a total of four months (in two non-consecutive two-month blocks) across his/her first two years of training on the Oncology Service. Each fellow is carefully, directly supervised in treatment planning (particularly in the writing of chemotherapy orders and performance of procedures) early in the four-month span; increasing independence is allowed as competency is demonstrated, although the attending physician is always available on site for consultation. Each Oncology Service fellow is required to perform standard delivery-of-care documentation for each patient for whom he has direct care responsibilities; all such documentation is reviewed and critiqued by the Hematology Service attending physician. Each month the Hematology Service fellow and the Oncology Service fellow share night-call and weekend-call responsibilities, alternating 5:00 p.m. to 8:00 a.m. call Monday through Thursday nights, and also alternating each weekend (5:00 p.m. Friday through 8:00 a.m. Monday). Adjustments for holidays are made as necessary. Seven days a week, the on-call fellow is also responsible for remaining on campus as medical back-up for the Hollings Cancer Center’s Chemotherapy Suite until all patients have been cleared from the Suite (an occasional patient’s treatment may run past 5:00 p.m.). It should be noted that the Oncology Service attending physician also serves as the backup attending physician for oncology consults on the MUH/CMH Consult Service should the regular MUH/CMH Consult Service attending physician be unavailable.

• Outpatient care in the first two years of fellowship is taught and learned principally in the Hollings Cancer Center’s adult ambulatory care area of four suites containing more than 60 examination rooms and an adjacent Day Treatment suite for delivery of outpatient chemotherapy, blood products, and other outpatient treatments. Diagnostic procedures are performed either directly in the examination rooms or in procedure rooms. Nursing and secretarial support staff are provided to assist with delivery of care in the usual manner. Each fellow follows a continuity panel of outpatients on each of two afternoons a week; a given faculty member is assigned to each such clinic and consistently follows along with the fellow and the panel. One of each fellow’s two continuity clinics is generally designed to focus on hematologic issues, the other on oncologic issues. The hematology continuity clinic is a 24-month-long experience; the oncology continuity clinic is divided into four six-month-long experiences, one each in the HCC’s Breast, Thoracic, GI, and GU Multidisciplinary Clinics. Fellows’ continuity clinic attending physician-supervisors (all faculty in the Division of Hematology/Oncology) oversee no more than two fellows in the same clinic session. Each patient is longitudinally followed by a specific fellow and faculty member. The faculty member assigned to one of a fellow’s continuity clinics is different from the faculty member assigned to the other of the same fellow’s continuity clinics so that each fellow is exposed to outpatient teaching from a minimum of 4-5 faculty members. In addition to the above-noted continuity clinics, first- and second-year fellows are assigned to one or more required two-month rotations through the Head & Neck, Gynecologic, and Neurologic Oncology Multidisciplinary clinics in the HCC; first- and second-year fellows also rotate through the HCC’s Malignant Hematology Clinic (one half-day per week) in parallel with their total of four months of experience (across the first two years) on the Stem Cell Transplant Service. Whether in continuity or multidisciplinary clinic, each fellow is carefully, directly supervised in patient evaluation and in treatment planning (particularly in the writing of chemotherapy orders and performance of procedures) in the first six months of training; increasing independence is allowed as competency is demonstrated, although an attending physician is always available on site for consultation. Each fellow is required to perform standard delivery-of-care documentation for each patient he encounters in the HCC; all such documentation is reviewed and critiqued by the patient’s attending physician/Division faculty member.

• Additionally, outpatient care is taught and learned in the Ralph H. Johnson Veterans Affairs Medical Center’s weekly (Wednesday morning) Hematology/Oncology clinic. This facility is located approximately a seven-minute walk from the Medical University Hospital and the Hollings Cancer Center. All third-year fellows engage in a 12-month continuity experience (combined general hematology/oncology) in this VA clinic. Additionally, the second-year fellow rotating on the VA Consult Service participates in this VA clinic, too. Two faculty members are assigned to this clinic. A suite of 10 examination rooms and a nearby Day Treatment suite are available in this clinic. Diagnostic procedures are performed in the examination rooms. Nursing and secretarial support staff are provided to assist with delivery of care in the usual manner. Each fellow is carefully, directly supervised in patient evaluation and in treatment planning (particularly in the writing of chemotherapy orders and performance of procedures); increasing independence is allowed as competency is demonstrated, although an attending physician is always available on site for consultation. Each fellow in the VA clinic is required to perform standard delivery-of-care documentation for each patient he encounters; all such documentation is reviewed and critiqued by one or both of the faculty members assigned to the clinic.

• In addition to the ambulatory experiences noted above that each fellow has in each of the Hollings Cancer Center’s multidisciplinary clinics, additional time may be spent in the multidisciplinary clinics as a third-year fellow upon request.

• Consultative care is taught and learned via the Division’s two consult services:

• Each of the Division’s fellows spends four months (in two non-consecutive two-month blocks) of his/her first year of training on the Division’s Medical University Hospital consult service under the primary supervision of the Division’s Consult Service attending. In certain circumstances the Division faculty member attending on the Oncology Service may also serve as attending on this consult service for oncology consults, and the Division faculty member attending on the Hematology Service may also serve as attending on this consult service for hematology consults. In months where at least one of these attending physicians is board-certified in both Hematology and Medical Oncology, at their discretion the two attendings may mutually agree to have all consults handled by the dual-certified attending. Each fellow is carefully, directly supervised in patient evaluation in the first six months of training; increasing independence is allowed as competency is demonstrated, although an attending physician is always available on site for consultation. Each MUH consult fellow is required to perform standard delivery-of-care documentation for each patient he encounters; all such documentation is reviewed and critiqued by the MUH consult service faculty member.

• Each of the Division’s fellows spends four months (as a single block) of his/her second year of training on the Division’s Ralph H. Johnson Veterans Affairs Medical Center consult service. This facility, located a seven-minute walk from the Medical University Hospital and the Hollings Cancer Center, does not have an inpatient service specifically for hematology/oncology patients and instead accommodates these patients on its three general internal medicine services. Under the direction and supervision of the Division faculty member assigned to this service on a rotating basis, the VA consult fellow is responsible for (a) following the Division’s VA patients while they are on one of the general internal medicine services and providing appropriate subspecialty-oriented management recommendations, and (b) providing consultative services as needed by any of the VA’s services. As the VA consult fellows have all completed at least 12 months of training by the time they begin their VA consult rotation, they may be accorded more responsibility by the faculty member right from the outset of the rotation if prior performance has demonstrated the granting of such privileges to be appropriate. Otherwise, each fellow is carefully, directly supervised in patient evaluation and in treatment planning (particularly in the writing of chemotherapy orders and performance of procedures) as long as necessary, with increasing independence is allowed as competency is demonstrated, although the attending physician is always available on site for consultation. Each VA consult fellow is required to perform standard delivery-of-care documentation for each patient he encounters; all such documentation is reviewed and critiqued by the VA consult service faculty member.

• Care for stem cell transplant patients is taught and learned on both the Hematology Service (as already discussed above) and the Stem Cell Transplant (SCT) Service. The Division’s fellow trainees spend four months on the SCT service (in each class of three fellows, two fellows spend this time as a single block in the second year of training, and one spends it in one two-month block in each of the first and second years of training). The Division’s stem cell transplant faculty attend on this service. The majority of the trainee’s time is spent in the Hollings Cancer Center evaluating new patients referred to the service and participating in the work-up of patients prior to transplant and the follow-up of patients after transplant. Fellows participate in bone marrow harvests in the operating room as well as peripheral stem cell apheresis procedures. Fellows also participate in the Tuesday afternoon SCT conferences (see below). Each fellow is carefully, directly supervised in the first two months on the SCT Service; increasing independence is allowed subsequently as competency is demonstrated, although an attending physician is always available on site for consultation. Each SCT fellow is required to perform standard delivery-of-care documentation for each patient he encounters; all such documentation is reviewed and critiqued by SCT faculty.

• Specialty areas and special techniques are learned in elective rotations taken by Division fellow trainees in their first two years of training. Two months are reserved for rotations through two or more of the following areas: general and subspecialty surgical oncology, radiation oncology, pediatric hematology/oncology, subspecialty radiology, nuclear medicine, dermatologic oncology, pathology, hematopathology, coagulation laboratory, clinical flow cytometry, cytogenetics, immunopathology, blood banking, and apheresis.

● Assignment of trainee responsibility for handling business-hour and after-hour urgent and emergent clinical problems:

• First year fellows are generally not allowed to provide care for urgent and emergent problems of their outpatients from 8:00 a.m. to noon so as not to dilute the educational experience of morning conferences and rounds during the first crucial formative year of training. If a first year fellow’s patient presents (by phone or in person) with a problem during these hours, ancillary staff are instructed to contact the patient’s attending physician.

• First year fellows are expected to care for their outpatients’ urgent and emergent problems (with direct supervision by the patients’ attending physicians) when such problems present in the afternoon (unless concurrent inpatient problems require the fellows’ presence on the inpatient unit).

• In keeping with the training program’s philosophy of advancing responsibility in concert with advancing competency, second and third year fellows are expected to care for their patients’ urgent and emergent problems (with graduated supervision by the patients’ attending physicians) throughout business hours.

• Virtually all night and weekend coverage is handled from the covering fellow’s home. Covering fellows are liable to receive contacts from (a) in-house Internal Medicine residents and nursing and ancillary staff covering the Hematology and Oncology services, (b) staff on other services with consult-type questions, (c) any of the Division’s outpatients, and (d) any extramural health care professional. It should be noted that the in-house Internal Medicine housestaff provide first-line coverage for all inpatients on the Hematology and Oncology Services. Covering fellows are required to return to the hospital immediately if the clinical situation so indicates, though in an immediately life-threatening situation, the in-house Internal Medicine housestaff still provide first-line coverage for these patients. Problems encountered during coverage rarely (typically twice a month or less) require the fellow to return to the hospital. Typical problems requiring return to the hospital are admissions of patients with new diagnoses of acute leukemia or thrombotic thrombocytopenic purpura. The management of after-hours admissions of lower-acuity patients is typically directed by the fellow via telephone conversation with the in-house Internal Medicine housestaff; the fellow for the appropriate inpatient service first sees such a patient the following morning.

• Night coverage: First- and second-year fellows assigned to the Hematology Service and the Oncology Service alternate night coverage every other night during weeknights for Hematology Service and Oncology Service inpatient problems, consultative problems at MUH and the VA, and problem calls from the Division’s outpatients (both HCC and VA). The Hematology Service and Oncology Service attending physicians alternate supervision of first year fellows providing night coverage; in general, the Hematology Service attending takes call with the Oncology Service fellow and the Oncology Service attending takes call with the Hematology Service fellow. This is done so that there is a subspecialist or subspecialist trainee on call at night who is familiar with all of the inpatients on both the Hematology and Oncology Services. Seven days a week, the on-call fellow is responsible for remaining on campus until all patients have been cleared from the Hollings Cancer Center’s Chemotherapy Suite (occasionally, a patient’s treatment may run past 5:00 p.m.).

• Weekend coverage: First- and second-year fellows assigned to the Hematology Service and the Oncology Service alternate weekend coverage (defined as continuous coverage from Friday 5:00 p.m through Monday 8:00 a.m.), with scope of service as defined above for night coverage. The Hematology Service attending physician and Oncology Service attending physician generally alternate weekend coverage in the manner described above for night coverage. The on-call attending and on-call fellow conduct rounds each weekend morning, first on one service and then the other. On the Hematology Service, the nurse practitioner is off-duty on weekends. Therefore, the on-call fellow provides direct patient care for the nurse practitioner’s patients, too, on the Hematology Service on the weekends. On the Oncology Service, the Internal Medicine housestaff continue to bear all their direct patient care responsibilities on the weekend, subject to the ACGME requirement for “one day off in seven.” It should again be noted that, seven days a week, the on-call fellow is responsible for remaining on campus until all patients have been cleared from the Hollings Cancer Center’s Chemotherapy Suite (on the weekends, the Suite is usually cleared no later than 12:00 noon).

• Due to the alternating nature of the coverage scheme, together with the fact that only Hematology Service or Oncology Service fellows take night or weekend call, average on-site duty hours per week for all fellows in all years of training rarely exceed 60 and never exceed 80. Average on-site duty hours per week for Year 1 fellows is 65; average on-site duty hours per week for Year 2 fellows is 50; average on-site duty hours per week for Year 3 fellows is 45. The Hematology Service fellow, the Oncology Service fellow, and the SCT Service fellow are ensured of having at least two duty-free 24-hour periods every fourteen days (i.e., one duty-free 24-hour period in every seven days as averaged over a two-week period); all other fellows have at least two duty-free 24-hour periods every seven days. Additionally, because Division fellows do not take call in the hospital, they are not at risk for violating the “24 plus 6” duty hour rule. And, because all Division fellows across all years have planned duty hours that run only from 8:00 a.m. to 5:00 p.m., they are not at risk for violating the “10 hours of break between planned duty periods” rule. These duty hour arrangements are 100% compliant with the ACGME and AMA requirements and standards. Furthermore, in keeping with MUSC GME policy, all Division fellows are required to log their duty hours in the institution’s electronic residency management system. The system immediately alerts the program director if any fellow is delinquent in logging his hours or if any fellow violates any of the ACGME duty hour requirements.

• The SCT Service fellow continues to cover the outpatient SCT service on alternating weekends. Patients are seen with either the SCT attending physician or the on-call inpatient service attending physician for approximately one hour each weekend morning in the Hollings Cancer Center’s Day Treatment Area. Decisions regarding the medical care and appropriateness of outpatient management are made.

• Fellows not on the Hematology Service or the Oncology Service are needed only rarely to provide backup coverage, and there is an effort to use the first and second year fellows more than the third year fellows so as to minimize interference with the third year fellows’ research work.

● Direct faculty supervision of trainees’ delivery of care in all outpatient, inpatient, and consultative settings.

● Faculty review (and annotation, as appropriate) of all delivery-of-care documentation by trainees.

● Regular provision of constructive criticism by faculty to trainees regarding their techniques of knowledge and skill acquisition, delivery of care, and documentation of delivery of care. (See Section 6, “Evaluation.”)

● Regularly scheduled conferences as follows (attendance logs of each conference are maintained):

• Monday afternoon Breast Tumor Board — one hour interdisciplinary review, discussion, and treatment planning of all breast tumor patients. Attended by interdisciplinary staff. Attendance by trainees is encouraged.

• Monday afternoon Head & Neck Tumor Board — one hour interdisciplinary review, discussion, and treatment planning of all head and neck tumor patients. Attended by interdisciplinary staff. Attendance by trainees is encouraged. Note this tumor board immediately follows the Breast Tumor Board in the same location to facilitate attendance at both tumor boards by trainees.

• Tuesday morning Department of Internal Medicine Grand Rounds — grand rounds in the traditional one-hour format: Divisions in the Department have a rotating responsibility for arranging for didactic presentations by intra- or extramural speakers on current topics in their fields. Live patient presentations are occasionally integrated into Grand Rounds presented by the Division of Hematology/Oncology. Attended by all Division faculty and trainees as regularly as possible; trainees are strongly encouraged to attend Grand Rounds as part of their continuing general internal medicine education.

• Every other Tuesday afternoon General Tumor Board at the VA Medical Center — one hour interdisciplinary review and discussion of diagnostic and/or therapeutic dilemmas in selected VA cancer patients. Attendance at General Tumor Board is mandatory for Division fa