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from a three-year combined hematology/oncology training program followed by a one-year research fellowship), and 4 have withdrawn after one year or less of training to pursue a different career direction; none have been terminated.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.

● 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 faculty and trainees assigned to the VA Consult Service and is encouraged for all trainees.

• Third Tuesday afternoon “Scope Time” conference at the Medical University Hospital — one hour interdisciplinary review at the microscope of exemplary hematopathologic material. This meeting is led by the chief hematopathologist in MUSC’s Department of Pathology and Laboratory Medicine and is conducted around a 10-headed microscope. This conference series follows a prescribed two-year curriculum (less commonly encountered problems are discussed once in the rotation, but more commonly encountered problems are discussed at least annually); at each session, slides from Pathology’s slide library representative of the topic for the session are presented under the microscope by the chief hematopathologist and discussed with the fellows, with clinical correlation as appropriate. Attendance at Scope Time is mandatory for all fellow trainees.

• First Wednesday morning of the month “Meet the Professor” conference series — one hour meeting with a flexible format to permit the fellows to meet as a group with each faculty member in turn (multiple times over the course of the three-year fellowship) to acquire expertise from those faculty in manners appropriate to the subjects being discussed. This conference sometimes will be conducted as a traditional didactic lecture, sometimes as a roundtable, sometimes as a “field trip” to a lab or other relevant venue.

• Second Wednesday morning of the month Division Faculty Meeting — one hour meeting to review and discuss issues pertinent to the Division. Attendance by faculty is required; attendance by fellows is encouraged except when particularly sensitive issues are scheduled to be discussed. As the program encourages its fellows to pursue academic careers, the program feels fellows should gain experience during their fellowship training as to the conduct of a faculty meeting.

• Wednesday morning Oncology Curriculum Conference Series (generally the third and fourth weeks each month) — one hour presentation by an assigned fellow to the Division’s faculty and fellows as well as any interested residents or students. This conference is held twice a month. The full spectrum of the program’s oncology curriculum is divided into approximately 50 areas, with 20 areas assigned per year. (Some areas are rotated only once during the three-year program; others which concern more commonly encountered oncologic problems are rotated as often as once or twice yearly.) A specific fellow and specific faculty mentor are assigned to a given area. The fellow, in consultation with his mentor for this presentation, selects a specific contemporary topic from within the area and develops a full presentation on the topic. Fellows are expected to be reading in their textbooks and the contemporary literature on the broad areas of the curriculum as the Oncology Curriculum Conference Series rotates through all of these areas throughout the course of three years of fellowship training. The Oncology Curriculum Conference presentations themselves provide additional instruction on specific topics within these broad areas. Furthermore, fellows gain valuable experience and improve their skills as speakers as they deliver approximately seven to nine Oncology Curriculum Conference presentations over the course of their training. Fellows’ presentations are evaluated by all the attendees.

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

• Wednesday afternoon GI Tumor Board — one hour interdisciplinary review and discussion of diagnostic and/or therapeutic dilemmas in GI tumor patients. Attendance by interdisciplinary staff. Attendance by trainees is encouraged.

• Thursday morning Hematopathology Lecture Series (generally the first Thursday of each month) — Faculty (e.g., Hematopathology, Transfusion Medicine, Diagnostic Immunology, Molecular Pathology, Cytogenetics, etc.) from the Department of Pathology and Laboratory Medicine lead this one-hour teaching conference, conducted in the Hollings Cancer Center’s primary teaching classroom. A specific written two-year curriculum is followed. Attendance is mandatory for all fellow trainees. A range of advanced microscopic and other multimedia and computing equipment is available to facilitate the learning experience.

• Thursday morning Hematopathology Discussions Conference (generally the first and third Thursdays of each month) — Faculty (e.g., Hematopathology, Transfusion Medicine, Diagnostic Immunology, Molecular Pathology, Cytogenetics, etc.) from the Department of Pathology and Laboratory Medicine join with Division of Hematology/Oncology faculty to lead this interactive conference structured as a hematology tumor board – except the conference is open to discussion of patients with either malignant or benign hematologic problems. The conference is conducted in the Hollings Cancer Center’s primary teaching classroom. Attendance is mandatory for all fellow trainees. A range of advanced microscopic and other multimedia and computing equipment is available to facilitate the learning experience.

• Thursday morning Hematology/Oncology Consult Service Conference (generally the second and fourth weeks each month) — one hour conference in which the trainees assigned to the Division’s two consult services provide (for the other trainees and faculty) reviews and discussions of the patients seen during the week. At a minimum, faculty member attendance at this conference includes the two consult service faculty members. Attendance is mandatory for all trainees. This conference is held in a room with not only two personal computer workstations available for spontaneous clinical, educational, or research reference purposes but also a multi-headed teaching microscope with a television camera attachment; the camera provides a feed to a wall-mounted high-resolution monitor which allows viewing of the microscopic image by all conferees.

• Thursday afternoon Stem Cell Transplantation Planning and Review Conference — one hour interdisciplinary review of all current and pending bone marrow transplant patients: disease status, patient condition, treatment plans, psychosocioeconomic considerations. Attended by interdisciplinary staff and all Division faculty and trainees involved in care for bone marrow transplant patients.

• Friday morning Journal Club (generally the second and fourth weeks each month) — a one-hour conference in which recent articles in the hematology/oncology medical literature are reviewed for the audience by assigned trainees, each of whom also has an assigned Division faculty mentor for the presentation. Although at a minimum the faculty mentors all attend this conference, all Division faculty are strongly encouraged to attend. Attendance is mandatory for all trainees. Fellows’ presentations are evaluated by all the attendees.

• Friday morning Hematology Curriculum Conference Series (generally the first and third weeks each month) — one hour conference in which a designated trainee makes a detailed presentation of a selected case which is then discussed by a hematology-certified Division of Hematology/Oncology faculty member. This conference series follows a specific, written three-year curriculum in which some areas are covered only once in the three-year fellowship program and other areas concerning more commonly encountered problems are covered more frequently. Attendance is mandatory for all fellow trainees. This conference is held in a room with not only two personal computer workstations available for spontaneous clinical, educational, or research reference purposes but also a multi-headed teaching microscope with a television camera attachment; the camera provides a feed to a wall-mounted high-resolution monitor which allows viewing of the microscopic image by all conferees. The TV system also includes a device for capturing viewed images onto floppy disks for permanent archiving (and replaying at later dates for educational purposes).

• Friday noon Hollings Cancer Center Seminar Series — one hour conference in which an invited extramural speaker (or occasionally an intramural speaker) presents a review of a current topic in his/her oncology-related field. The Seminar Series is co-sponsored by the Division. Attendance at the Seminar Series is strongly encouraged for all Division faculty and is mandatory for trainees. This conference is held in a room with extensive multimedia facilities including a well-equipped personal computer workstation; access ports to the campus local area network; a large-screen videoprojector capable of accepting feeds from Macintosh- and IBM-compatible computers, VCRs, and broadcast and cable TV signals; and a multi-headed teaching microscope with a television camera attachment which also provides a feed into the videoprojector.

• Fellows’ Conference the third Friday afternoon of each month — one hour meeting between all fellows, the Fellowship Training Program Director, and the Fellowship Training Program Assistant Director for Research, used by all of these parties for frank discussions of issues affecting the program. Attendance is mandatory for all fellow trainees; no faculty member (except for the Training Program Director and the Assistant Director for Research) is permitted to attend. Minutes are recorded and maintained on file by the program coordinator.

● Distribution (paper-based or electronic) of the Training Program Curriculum and Reading Lists.

● Structured orientation of new fellows to the curriculum, clinical and academic schedules, clinical and academic and research responsibilities, and a review of institutional clinical and academic resources available for their use. Orientation includes a brief “Fundamentals of Hematology and Oncology” lecture series organized and delivered by upper-class fellows, as supervised by the faculty.

• First, it should be noted that the School of Medicine, the Medical University, and the three teaching hospitals are all accredited by their respective accrediting agencies.

• Fellows currently are provided office space which includes two work areas with computers, telephones, and secured personal space for each trainee. A larger space which will accommodate an individual cubicle for each fellow has been secured; plans for renovation of this space are being formulated.

• Multi-head microscopes are provided in the outpatient and inpatient areas to allow simultaneous viewing of microscopic images by a faculty member and up to four trainees. Each microscope is connected to a television camera and high-resolution monitor so that the viewed image can be seen on the monitor by others as well.

• The Medical University Library is also accredited and has an outstanding book and journal collection and an excellent assortment of electronic resources including a complete electronic catalog of its collection, the Ovid software package for providing access to MedLine, CancerLit, a variety of other medical literature databases, electronic access to the full text of dozens of textbooks and hundreds of journals, and access channels to the electronic library resources of several other academic institutions in the area such as the College of Charleston and the Citadel. The MUSC library is able to obtain reprints of articles from journals it does not carry generally within 24-48 hours.

• Personal computer workstations accessible by the fellows are found in abundance in all clinical, educational, and research areas at MUSC. There are approximately 4,000 computers available in the MUSC Medical Center. There are more than 100 computers available to fellows in their primary clinical work areas and office, including a workstation in every exam room in their clinics at MUSC and the VA. Most fellows (and faculty, too) have home computers as well; access logs are available from the dial-in security checkpoints to document the fellows’ frequent use of institutional systems from home.

• Through both on-campus computers as well as their home computers, fellows have access to all major software functions (word processing, database and spreadsheet manipulation, electronic mail, slide presentations, literature searching, access to clinical data and clinical trial protocols, and Internet access).

• A multimedia-equipped classroom is available in the Hollings Cancer Center for didactic presentations to fellows. This room may also be used by fellows wishing to present the results of their research projects. The room’s facilities include a well-equipped personal computer workstation; access ports to the campus local area network; a large-screen videoprojector capable of accepting feeds from Macintosh- and IBM-compatible computers, VCRs, and broadcast and cable TV signals; and a multi-headed teaching microscope with a television camera attachment which also provides a feed into the videoprojector.

● Granting of increased responsibility and independence as increasing competency, knowledge, and skills are demonstrated. This method is implemented in all aspects of the training program as discussed above and below.

● Regular problem-oriented as well as curriculum-structured exposure to medical literature in hematology/oncology:

• With faculty guidance, fellows are required to identify, obtain, and review medical literature relevant to the hematologic and/or oncologic problems of patients they encounter. Fellows are expected to demonstrate their understanding of the literature by providing critical summaries to the faculty and other trainees on the service at hand.

• Through the structure of the Division’s Journal Club and Curriculum Conference Series, and with guidance from assigned faculty members serving as mentors, fellows are expected to perform thorough reviews of the medical literature on their assigned topics. An assigned attending mentor provides a short didactic introduction to the topic selected for Journal Club before the assigned fellow presents the selected journal article(s) and leads the subsequent discussion. At Curriculum Conference, the assigned fellow presents alone, but he typically has had several months of preparation time in which to review the literature and develop a high quality presentation in consultation with his assigned faculty mentor.

• Throughout their training, fellows are expected to participate actively in the Hollings Cancer Center’s Clinical Trials Program and to consider patients for enrollment in clinical trials whenever possible.

• Under supervision from Division faculty, fellows learn how to evaluate patients for trial eligibility, discuss trials with patients, obtain informed consent, coordinate with study managers to register patients, implement treatment plans in accordance with protocols, evaluate for toxicities and adjust treatment plans as necessary, and report data and follow patients as required by protocol.

● Opportunities for participating in existing research or conducting new research projects:

• Fellows are intimately involved with the care of patients enrolled on clinical trials throughout their training and thus become familiar with clinical trial design; assessment of patients for eligibility status; evaluation, treatment, and follow-up of patients by protocol; data reporting requirements. The fellow is expected to cooperate well and coordinate closely with the Hollings Cancer Center’s Clinical Trials Program’s data coordinators.

• Each fellow trainee meets privately each quarter throughout the three years of fellowship training with the Assistant Program Director for Research to review research interests, goals, and plans. Fellows are strongly encouraged throughout the entirety of their training to consider and realize opportunities for knowledge discovery and dissemination. The program commits to providing each trainee all reasonable resources to help each trainee realize his or her full potential for development as a researcher; this includes providing funding for publication and presentation expenses such as graphic arts production costs and travel. The program commits that no trainee who has his work accepted for presentation or publication in a peer-reviewed forum will have to withdraw from that forum for lack of the necessary financial support.

• Second-year fellows are required to make a short presentation to the Division near the end of Year 2 outlining their proposed Year 3 research projects.

• Second-year fellows are allowed to designate (in place of rotating a full four months through the Stem Cell Transplant Service) up to three months for intensive effort on an approved clinical or laboratory research project. The VA Consult Service and certain elective rotations provide additional time for research, too.

• In keeping with the training program’s philosophy of advancing responsibility in concert with advancing competency, the goal of the third year of training is to provide the fellow with sufficient knowledge and skill to conduct an independent research project. Toward this end, the third year is structured as a single intensive twelve-month mentored opportunity. This may be a research project continued from the second year or a newly conceived project. Fellows are expected to approach the Fellowship Program Director by the middle of the second year with several concepts for major research projects. Second-year fellows are required to submit to the Program Director written plans for their major research projects (developed in consultation with his chosen research faculty mentor) prior to beginning the third year.

• Peer-reviewed publication and presentation of all research projects is strongly encouraged and supported by the Division and its Fellowship Training Program. Late in his/her third year, each fellow is required to give a presentation at the Friday noon Hematology/Oncology Seminar Series regarding his/her major research project. Fellows are not eligible to receive their training completion certificates until they have made such a presentation.

Through their training, Division fellow trainees acquire the skill needed to perform the following subspecialty-related techniques in a competent, independent manner:

● 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.

Fellow trainees also acquire the knowledge and skills attendant to managing the full range of complex chemotherapy regimens used in contemporary hematology/oncology, ranging from the selection of appropriate regimens (and corresponding supportive care) to the ordering and administration of such as well as the follow-up of patients who have received such treatment.

The Division requires each fellow trainee to maintain a log (in the institution’s electronic residency management system) documenting his or her supervised performance of every procedure done throughout the fellowship. Trainee privilege levels (as to the degree of supervision any given trainee must have in place to perform any given procedure) are assigned by the Program Director, recorded in the institution’s electronic residency management system, and appropriately updated as trainees demonstrate increasing proficiency in their various procedures.

The patient populations which patronize MUSC, HCC, CMH, and the VA are of sufficient size and variety that trainees have ample opportunity to acquire all of these skills throughout their 8 months of inpatient responsibilities, 8 months of consultative responsibilities, 4 months of stem cell transplant responsibilities, and 36 months of outpatient responsibilities.

Closeness of supervision of each Division fellow, as previously explained, is continuously graduated according to the task at hand and the level of competency recently demonstrated by the fellow in performing the task.

● In the outpatient arena, faculty members are intimately involved with fellows in approximately the first half of the fellows’ first year in performance of nearly all tasks. Subsequently, faculty members may allow fellows to perform their initial evaluation of patients independently, but a patient’s attending physician always follows the fellow in personally re-obtaining the pertinent history, performing the pertinent parts of the physical exam, and reviewing the pertinent laboratory material. As a fellow clearly becomes more competent in his decision-making skills, the faculty member allows him increasing independence in making and implementing minor treatment decisions. Regardless of level of training, fellows are required to discuss major treatment decisions (such as starting or changing chemotherapy plans, or scheduling the patient for an invasive procedure or admission to the hospital) with faculty members within an appropriate interval.

● Graduated responsibility is handled in the inpatient arena very similarly to how it is handled in the outpatient arena. Note that the attending physician on each inpatient service personally sees each service patient every day (except Saturdays and Sundays, when the weekend covering attending physician is on duty) and personally obtains pertinent history, performs a pertinent physical exam, and reviews pertinent laboratory material.

● The stem cell transplant attending physician is always present in the operating room during a bone marrow harvest procedure for the entire duration of the procedure; the fellow is never left unassisted in the operating room.

The Division requires regular evaluation both of the fellows (by their supervisors, peers, and other co-workers) and by the fellows (of their supervisors and the various components of the training program). A formal process by which the fellows can also be evaluated by their patients is being developed, although such evaluation already occurs informally as faculty seek patients’ opinions of the fellows’ performance during clinical encounters. Frequency of evaluation depends on the activity being evaluated. In general, evaluations of the fellows are structured to assess the fellow’s progress toward mastering the ACGME competencies. First- and second-year non-ambulatory clinical rotations require monthly evaluations; continuity clinic experiences require quarterly evaluations; multidisciplinary clinic experiences require bimonthly evaluations; elective experiences require monthly evaluations; and non-clinical rotations require at least quarterly evaluations. The assistant program director for research meets quarterly with each fellow to mutually evaluate the fellow’s research progress and to discuss research interests, goals, and plans. The program director also prepares a summative performance evaluation on each fellow semiannually and privately discusses each such evaluation with the fellow; the program director and the fellow both sign each summative evaluation. In addition, all fellows are required to evaluate the program and the program director annually; a blinded summary of these evaluations is prepared by the program coordinator (after which the originals are destroyed) and provided to the program director. The program director also files annual fellow performance evaluations with the American Board of Internal Medicine per ABIM requirements. All evaluations are done in accordance with American Board of Internal Medicine, ACGME, and institutional standards where such standards exist. Supervisors are required to discuss each evaluation of a fellow with that fellow, preferably on the last day of their shared experience, or within a reasonable amount of time afterwards. Fellows are encouraged but not required to discuss each evaluation of a supervisor with that supervisor. Fellows are always welcome to discuss their evaluations of supervisors and rotations with the Fellowship Training Program Director as appropriate. All evaluations are kept on file indefinitely and are reviewed semiannually (or more often, as appropriate) by the Fellowship Training Program Director. The semiannual summative evaluations and the annual program/program director/assistant program director for research evaluations are completed on paper; all other evaluations use electronic media. The annual evaluations are summarily transcribed by the program coordinator to ensure anonymity, with the report going directly to the Division Director and the Internal Medicine Program Director, not the Fellowship Training Program Director. The program director also prepares an annual report on the state of the program, distributed to the Department Chair, Division Director, Internal Medicine Program Director, and GME Office Director.

All trainees are permitted to submit anonymous evaluations and other comments with the Training Program Director or Coordinator. All such evaluations are reviewed semiannually (or more often, as appropriate).

The educational environment for the Division of Hematology/Oncology fellowship training program consists of a network of clinical, research, and educational facilities principally centered about the MUSC Medical Center, the Hollings Cancer Center, the Ralph H. Johnson Veterans Affairs Medical Center, and, to a very small extent, Charleston Memorial Hospital.

As of April 8, 2007, the Division of Hematology/Oncology fellowship training program is in full compliance with all 13 of the general programmatic recommendations noted in the current American Society of Hematology’s Model Fellowship Training Program Curriculum (http://www.hematology.org/images/hematology_curriculum.doc).

With regard to clinical activities, Division fellows spend most of their inpatient time on the Medical University Hospital’s 8-West Hematology/Oncology Protective Enviroment (HOPE) Unit (last renovated in the summer of 2002). When this 24-bed unit is full, spillover occurs to other nursing units in the hospital as necessary. The HOPE Unit currently has approximately 15 stationary and mobile personal computer workstations available to fellows and other unit staff for supporting clinical activities, including two workstations in a physicians’ conference room which can also be used in support of research and educational activities. The physicians’ conference room also contains a two-headed Olympus microscope with a television camera adapter; the camera provides a feed to a wall-mounted high-resolution Sony monitor to allow viewing of the microscopic image by all the conferees. The TV system includes a device for capturing viewed images onto floppy disks for permanent archiving (and replaying at later dates for educational purposes). An interface also is provided to allow a feed of a computer image into the monitor (such as when showing a slide presentation to the group). It should be noted that the practice of radiology at MUSC is entirely digital; all radiologic images are viewable from any workstation at MUSC or remotely, and special workstations with ultra-high-resolution displays are available, too, throughout the Medical Center (including the Hollings Cancer Center ambulatory care areas) for times when more careful image review is needed.

Division fellows spend most of their outpatient time at the Hollings Cancer Center’s adult ambulatory care facility, containing more than 60 examination rooms, several procedure rooms, and a Day Treatment suite that can accommodate more than 20 patients simultaneously. Phlebotomy and pharmacy facilities are provided within the HCC ambulatory care areas; samples are sent for processing to the main laboratory in the adjacent Medical University Hospital. A skywalk between the Hospital and the HCC permits comfortable trafficking even during inclement weather. Radiology facilities are available in the Hospital and other locations about the University campus. Also available for the fellows’ use in the HCC are multiple conference rooms and physicians’ workrooms variably equipped with personal computer workstations, multi-headed microscopes, and dictation stations). Specific primary nurses are assigned to each continuity and multidisciplinary clinic so fellows can better coordinate longitudinal care.

Selected Division fellows also attend the Division’s weekly clinic at the Ralph H. Johnson Charleston Veterans Administration Medical Center (see above). This facility is located a seven-minute walk from the Medical University Hospital and the Hollings Cancer Center. The VA Hematology/Oncology Clinic consists of a large physicians’ workroom (containing six computer workstations), 10 examination rooms (each of which contains a computer workstation at the physician’s desk), and a large Day Treatment suite (capable of accommodating up to 12 patients simultaneously).

With regard to consultative care, Division fellows assigned to the MUH Consult Service see patients throughout the 500-bed Medical University Hospital (plus, expected as of November 2007, the 168 bed Medical University Specialty Hospital currently under construction), the MUSC Medical Center’s 1-West Access Center, the 100-bed Institute of Psychiatry, the 30-bed Charleston Memorial Hospital (CMH, which is owned by MUSC and is an integrated facility, not a separate site) and the CMH Emergency Room, and, very occasionally, the 100-bed Children’s Hospital and the 30-bed Storm Eye Institute. MUH, 1-West, the Children’s Hospital, and the Storm Eye Institute are all contiguous with one another; Charleston Memorial Hospital is a 3-4 minute walk from the Medical University Hospital, and the Institute of Psychiatry is a 1-2 minute walk from MUH. The Medical University Specialty Hospital will be a 2-3 minute walk from the Medical University Hospital. The Hollings Cancer Center is adjacent to MUH, and an enclosed second-floor skywalk connecting the Cancer Center and MUH is available for patient transport and protection of staff during inclement weather. When it opens, the Medical University Specialty Hospital will be a 3-4 minute walk from MUH (directly between MUH and the VA).

The clinical environment for all fellows of course extends to the full range of clinical facilities in each institution such as the laboratory and radiology facilities.

The local area networks of all facilities are completely interconnected; data from any MUSC facility’s systems is retrievable from any other MUSC or VA facility’s systems with the appropriate access codes (which all fellows are given). Thus, for example, a fellow at the VA Clinic can retrieve MedLine references from the MUSC Library’s electronic medical literature reference system or can retrieve clinical data from MUSC’s electronic clinical data repository if called about a patient problem. Similarly, a fellow at MUSC can retrieve clinical data from the VA’s electronic medical record if called about a patient problem. There is well-supported remote access to the MUSC campus net (and thus the other facilities as well as the Internet) and to the VA net, so that the fellows can access any data needed from their home or mobile computing platforms; access is platform-independent and will readily accommodate access from IBM-compatible equipment, Macintoshes, and other platforms.

The local research environment available to all fellows extends to the full range of research facilities available at MUSC and the Ralph H. Johnson Veterans Affairs Medical Center. An exhaustive review of these facilities is available from other sources. Principal resources include the research laboratories in the Hollings Cancer Center, Research Building I, Research Building II, Research Building III, the Basic Science Building, and the VA; the MUSC Library (see above for a summary of the library’s resources); the VA Library; and the Hollings Cancer Center’s Clinical Trials Program and Tumor Registry.

With regard to academic (non-clinical, non-research) activities, the environment available to fellows includes the assorted conference rooms mentioned above as well as their personal office space and the Hollings Cancer Center classroom (both also described above). It should be mentioned again that fellows have access to all of the campus’ academic, clinical, and research computing resources from both on-campus workstations and their personal computers at home. It should also be noted that in addition to standard dial-up, the MUSC network supports broadband access via DSL and cable modem connectivity. MUSC’s main connection to the Internet is a triple-T1 connection; MUSC is also an Internet-2 site, enjoying a 45Gbps connection to the regional connection point in Atlanta. Furthermore, an ultra-high-speed fiber “light rail” is being jointly developed to interconnect MUSC with South Carolina’s two other academic medical centers (the University of South Carolina in Columbia and Greenville Memorial Hospital in Greenville).

Duty hours in the first two years of training vary somewhat according to the training rotation, though in general the workday begins at 8:00 a.m. and ends at 5:00-6:00 p.m. After regular business hours, the on-call fellow occasionally has to return to the hospital; this occurs usually no more than twice a month. Hours for call duty extend from 5:00 p.m. to 8:00 a.m. the next morning. Weekend coverage hours extend from 5:00 p.m. Friday to 8:00 a.m. Monday, occasionally extended one or two extra days at times of holidays. It should again be noted that the large majority of the night and weekend coverage by fellows is taken by first year fellows; second year fellows take night and weekend call for only two months; and third year fellows only rarely are called upon to provide night or weekend coverage. The second year SCT fellow participates for about one hour daily on weekends to manage the outpatient SCT service.

Duty hours are more flexible in the third year of training (but still compliant with all ACGME duty hour regulations); subject to approval of the Fellowship Training Program Director, the third year fellow is allowed to independently set his schedule in accordance with the needs of his/her research project.

Leading by example, the Division faculty also educate the fellows with regard to development of professionalism values. Division faculty adhere to the highest ethical standards in their conduct of research and their delivery of medical education and patient care; the Fellowship Training Program and all Division faculty require that all fellows exhibit similar behavior in this regard at all times.

Fellows are shown how to deliver care with a patient-centered approach, continuously adapting to ever-changing patient needs. The faculty also show fellows by example how a professional hematologist/oncologist can impact public health and societal needs (e.g., providing interviews to the media on relevant health matters, or participating in cancer screening fairs).

Fellows are expected to demonstrate their scholarship through citation of relevant medical literature they have reviewed in an independent, unprodded fashion. Fellows are encouraged to develop creative approaches for expanding their knowledge-base and skill-base; again, faculty model this behavior in all clinical environments.

Fellows are required to engage in at least one substantive research project during their training. Commitment to research is another area in which the faculty serve as excellent role models; even the clinically busiest of the Division’s faculty regularly, actively engage in research projects. Fellows have a number of faculty from which to choose to serve as mentors for project design, proposal writing, grant writing, questions of research ethics, etc. Faculty are available to serve as mentors for both laboratory and clinical research projects.

As part of developing their competency in systems-based practice, fellows are required to engage in at least one quality improvement activity during their training. Participation in one or more of the institution’s large number of quality improvement committees and projects is usually the vehicle used by the fellows to satisfy this requirement.

Fellows also are required to assist in the teaching of lower-level trainees/students during their training. Much of the teaching by the fellows occurs informally in the context of close interaction between fellows and residents/students on the Division’s various clinical services, but there are numerous formal teaching opportunities, too, within the College of Medicine for which fellows are encouraged to serve as instructors (e.g., the sophomore medical students’ Introduction to Clinical Medicine course). The program director regularly, strongly encourages the second- and third-year fellows to serve as instructors in one or more of these courses, and the record clearly attests to a high participation rate (and a high quality of service) by MUSC Hematology/Oncology fellows in these activities.

The Division’s faculty serve as role models to the fellows with regard to community service, particularly with regard to the faculty’s service at community medical center tumor boards and the faculty’s development of educational programs for both the lay community and the extramural professional community. Division faculty also occasionally serve as mentors for local secondary school and undergraduate students seeking to perform research projects in areas of the faculty’s expertise.

Again, through role modelling and didactics, the Division’s faculty educate all its trainees regarding the highest standards of ethics in all the faculty’s activities. It should be particularly noted that, in compliance with existing federal legislation, fellows are prohibited from accepting gifts from commercial organizations in the healthcare industry (e.g., pharmaceutical companies).

Finally, fellows are strongly encouraged to follow the faculty’s lead in joining hematology- and/or oncology-related professional societies and other organizations through which they can effect positive changes on both their profession as well as society in general.

The Division’s fellow trainees have clearly delineated responsibilities in each of their clinical environments.

In the outpatient environment, fellows are charged with serving as the patient’s primary physician for purposes of addressing the patient’s hematologic and/or oncologic problems. Although the patient always has a clear understanding that the attending physician/faculty member has ultimate responsibility for any treatment decisions made and any care delivered, he/she is encouraged to consult with the fellow regarding problems before consulting with the attending. Fellows are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of outpatient care. Fellows are responsible for writing all orders and prescriptions necessary for the treatment of their patients. Fellows are charged with the responsibility for following up on encounters and treatments as appropriate; Division faculty expect the fellows to be at least as informed about the patients’ conditions as the faculty are. Fellows are responsible for assisting faculty in keeping referring health care providers informed of their patients’ progress.

In the consultative environment, the fellow is responsible for assisting the Division faculty consultant in obtaining the patient’s history, performing examinations, obtaining and reviewing laboratory and radiologic data, obtaining and reviewing relevant medical literature, generating required documentation, and communicating assessments and recommendations with the patient’s primary team and with the patient’s other consultants. The fellow is expected to perform a history, physical, and lab data review on each patient and independently formulate an assessment and set of recommendations for review and critique by the faculty consultant; the fellow is expected to independently obtain and review relevant medical literature as needed to optimize his/her understanding of the problem(s) at hand in the patient. The fellow is also responsible for teaching other trainees on the consult team (e.g., residents, students) regarding (a) how to evaluate a consult patient and (b) how to perform bone marrow aspirations and biopsies. Fellows are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of consultative care. If the patient’s primary team requests the consult service to write orders and prescriptions relevant to the consult problem, the consult fellow is responsible for writing all such orders and prescriptions. Fellows are charged with the responsibility for following up on consult encounters and treatments as appropriate; Division faculty expect the fellows to be at least as informed about the consult patients’ conditions as the faculty are.

In the inpatient environment, the fellow is responsible for all the activities noted above for the consultative environment. On the Oncology Service, the fellow is expected to primarily focus his efforts on the subspecialty aspects of the patient’s management, but as a board-certified or board-eligible internist, he/she also is expected to serve as a first-line consultant to the inpatient team’s internal medicine trainees and medical students regarding general internal medicine problems those trainees are facing in the service’s patients. On the Hematology Service, where the only internal medicine trainee handles only a small fraction of the patients, the fellow serves more as noted above in the outpatient environment. On either inpatient service, fellows are charged with writing all chemotherapy and other subspecialty-specific orders (subject to review by the attending); on the Oncology Service, other general internal medicine orders may be written by internal medicine trainees. On each inpatient service, the fellow follows all patients, documenting an admission assessment and daily progress notes for each patient. On the Hematology Service the fellow also dictates discharge summaries for the patients for whom he has direct care responsibilities. As noted above, all documentation is reviewed (and annotated, if necessary) by the appropriate Division faculty supervisor. The Hematology and Oncology Services consist of, on average, 8-14 and 6-10 patients, respectively. If service censuses become grossly lopsided, selected patients can be admitted to the non-traditional service for those diagnoses at the discretion and mutual agreement of the attending physicians.

When the service of another specialist is required, the fellow is expected to assist the attending physician in identifying the specific consultant needed. The fellow is expected to establish a positive relationship with the consultant and convey the consulting need in a clear, concise fashion. The fellow is expected to interact with a consult team’s attending physician and trainees in a professional manner. When faculty and trainees in other Departments and Divisions request the fellow’s assistance in performing (appropriate) clinical tasks, the fellow is charged with providing such assistance as promptly and as completely as possible.

Fellows are expected to seek instruction and supervision as appropriate from faculty in other disciplines such as Radiology/Nuclear Medicine, Radiation Oncology, Surgical Oncology, Nephrology, Gastrointestinal/Hepatobiliary Diseases, Cardiology, Pulmonary/Critical Care Medicine, and Pathology and Laboratory Medicine. When fellows rotate through another department as an elective, they are expected to pursue and complete the elective’s curriculum prepared by that department.

The Division’s Fellowship Training Program constantly strives to achieve and maintain the highest quality in all its educational and clinical activities.

The Training Program has an active Continuous Quality Improvement (CQI) component principally centered around the regular semiannual review of all evaluations filed by trainees and faculty. As problems with existing activities become apparent, proposals for corrections are developed promptly, reviewed with the relevant parties, and implemented as soon as feasible.

As another part of the CQI process, the Training Program is always open to consideration of ideas for new educational activities that may improve the quality of the training. For example, beginning in May 1997, the fellows’ Hollings Cancer Center clinic schedules were adjusted to conflict less with inpatient duties. These schedules were further revised in January 1998 to reduce the number of trainees assigned to each continuity clinic supervisor so that trainees would not have to wait as long to discuss cases with supervisors. And again, in 2001, the structure of the continuity clinics was substantially modified, moving from a 36-month continuity experience at the HCC to a 24-month experience at the HCC and a 12-month experience at the VA to improve the diversity of the patient populations seen by the fellows. Also, throughout 1998-2002, the “menu” of multidisciplinary clinics to which the fellows are exposed has steadily grown. Another substantive CQI initiative in recent times was the first major change in the program’s order of rotations in more than a decade: in response to faculty and fellow input at a fellowship program retreat in February 2002, in July 2003 the inpatient experiences on the Hematology Service and the Oncology Service were split across the first two years, with exclusively second-year fellows being assigned to these experiences in July and August to cushion the stress of matriculation experienced by the first-year fellows. As other examples of its activity in the CQI arena, too, the MUSC Hematology/Oncology Training Program led the institution’s development of an electronic residency management system in 2002-03 and also developed a novel system, based on an innovative biometric device, for improving conference attendance tracking; this system is now used by several other programs, too. Additionally, the Program has the honor currently of one of its fellows being seated on the American Society of Hematology Trainee Council, in which position he is contributing to the development of national hematology training guidelines.

The Division regularly conducts specific QA projects (such as its current chemotherapy order process improvement project at the VA, a current project by the program director to improve handwashing rates, and semiannual reviews of selected charts) to monitor — and identify opportunities for improvement in — various aspects of our process of delivering care.

Furthermore, the Division has a major CQI program in the form of its monthly faculty meetings, where the fellowship program and other programs and projects are routinely discussed, as well as the monthly HCC Management Team meetings, where representatives from throughout the Cancer Center meet to discuss a variety of the Center’s operations.

As another major CQI program, the Division has a monthly one-hour Fellows’ Conference, a mandatory meeting for all fellows and the Fellowship Training Program Director. The purpose of this conference is to provide a “no-holds-barred” forum in which the fellows can raise and discuss with the Training Program Director issues of concern that they have with the training program. The program coordinator also attends the meeting and takes minutes so that appropriate follow-up can be pursued, but these minutes are held strictly confidential and are accessible only to the program director and coordinator.

Fellows participate in various QA projects within the Division and the institution. In this fashion fellows not only have an opportunity to directly observe and participate in the evolution of positive changes in their educational program, but they also learn the principles of QA and CQI.

Risks to both patients and caregivers may be increased in the training environment. The Division faculty take a proactive approach to risk management by careful supervision of all trainees as detailed above. Each trainee is covered by the institution’s group malpractice insurance policy. All trainees supervised by Division faculty (fellows, residents, and students) are educated from the start of their rotations as to their responsibilities and limits. This message is strongly and swiftly reinforced by the faculty if deviations are identified. Though rarely needed, punitive action — up to and including dismissal from the training program — is taken when appropriate. The program complies with all applicable divisional, departmental, and institutional policies and procedures regarding remedial and/or punitive actions.

To further reduce risk and to improve their ability to focus on their education in the crucial first year of training, fellows are strongly discouraged from moonlighting while serving on the Hematology and Oncology inpatient services. Moonlighting while on night or weekend coverage is explicitly forbidden. In accordance with current ACGME requirements and institutional policy, the Fellowship Training Program requires fellows to notify the Program Director of all moonlighting work in which they engage. Moonlighting hours are accounted per ACGME guidelines.

Fellows are educated through the GME Core Curriculum regarding the signs and hazards of fatigue. Faculty are educated on this topic through programs provided by the Department of Medicine. The faculty are required to monitor all trainees/students for excessive fatigue and to promptly take substantive action as appropriate to promptly resolve such situations.

The Training Program is constantly seeking to improve its cost-effectiveness. Current projects in this area are principally focused on investigating the use of the Internet (and the campus intranet) to distribute and collect educational and administrative material on a paper-free, on-demand basis. The Division regularly receives highly positive comments from fellow and faculty candidates regarding the information available from the Division’s web site (http://hcc.musc.edu/hemonc/).

In view of the one-month time limitation, the hematology/oncology subspecialty curriculum for internal medicine trainees rotating through a Division service is necessarily far more limited than the curriculum presented to fellow trainees and focuses on (a) the most common problems encountered by the hematologist/oncologist and (b) broad principles of hematology and oncology (as opposed to the practice of subspecialty hematology and oncology).

Internal medicine trainees (PGY-1 through PGY-3) currently have the opportunity to rotate through the Hematology Service, the Oncology Service, and the MUH/CMH Consult Service. Though the IM trainee’s scope of responsibilities is obviously varies amongst these services, the basic curriculum presented by Division faculty is the same.

● Interpretation of bone marrow aspirate smears, bone marrow biopsy sections, and bone marrow biopsy touch preps

The Division of Hematology/Oncology internal medicine trainee curriculum is taught via the following methods:

● Trainee rotation through either the Hematology Service, the Oncology Service, or the MUH/CMH Consult Service (as described extensively above). Note that trainees on the consult service participate in the weekly VA clinic.

● Division faculty participation in the Department of Internal Medicine residency core lecture series.

● Distribution of reference material and discussions in daily (Monday through Friday) didactic 30-60 minute sessions. More than one curriculum topic may be covered per session.

● 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.

● Trainees are welcome to participate in all conferences described above for fellow trainees. The conferences for which internal medicine trainees are required to attend are as follows:

● Structured orientation of new trainees to the curriculum, clinical and academic schedules, clinical and academic responsibilities, and a review of institutional clinical and academic resources available for their use.

● Provision of extensive ancillary training resources as described above for fellows, except that internal medicine trainees are not provided office space or photocopying privileges by the Division.

● Regular problem-oriented as well as curriculum-structured exposure to medical literature in hematology/oncology:

• With faculty guidance, internal medicine trainees are required to identify, obtain, and review medical literature relevant to the hematologic and/or oncologic problems of patients they encounter. Trainees are expected to demonstrate their understanding of the literature by providing critical summaries to the faculty and other trainees on the service at hand.

• Internal medicine trainees are allowed to participate in the care of patients enrolled in clinical trials and gain insight and appreciation for the principles and practice of clinical research.

● Opportunities for participating in existing research or conducting new research projects:

• Internal medicine trainees are welcome to participate in or develop research projects with Division faculty serving as mentors.

• Peer-reviewed publication and presentation of all research projects is strongly encouraged and supported by the Division and its Fellowship Training Program.

Internal medicine trainees, through their training on Division rotations, acquire the skill needed to perform the following subspecialty-related techniques in a competent, independent manner:

● Bone marrow aspiration and biopsy from the anterior and posterior superior iliac crests, both with and without conscious sedation.

● Interpretation of peripheral blood and bone marrow aspirate smears including integration of findings from automated analytic instruments.

The patient populations which patronize MUSC and the VA are of sufficient size and variety that internal medicine trainees have ample opportunity to acquire these skills during the course of their training.

Due to the brevity of their rotation through the Division’s service(s), internal medicine trainees are directly supervised in the performance of all tasks. Division fellows participate in the supervision and teaching of internal medicine trainees.

The Division requires regular evaluation both of the internal medicine trainees (by their Division faculty supervisors) and by the internal medicine trainees (of their Division faculty supervisors and the specific rotation taken). All personnel evaluations are done in accordance with American Board of Internal Medicine standards for such. Evaluation forms used are those designed by the Department of Internal Medicine. Supervisors are required to discuss their evaluations with the internal medicine trainees; trainees may discuss their evaluations with their Division faculty supervisors and/or with the Fellowship Training Program Director as appropriate.

All trainees are permitted to file by mail anonymous evaluations and other comments with the Training Program Director or Coordinator. All such evaluations are reviewed semiannually (or more often, as appropriate).

The educational environment provided by the Division of Hematology/Oncology for internal medicine trainees consists of a network of clinical, research, and educational facilities principally centered about the MUSC Medical Center, the Ralph H. Johnson Veterans Affairs Medical Center, and, to a very small extent, Charleston Memorial Hospital.

Internal medicine trainees on the Hematology Service or the Oncology Service spend most of their time on the Medical University Hospital’s 8-West Hematology/Oncology Protective Enviroment (HOPE) Unit (described in detail above).

Internal medicine trainees on the MUH/CMH Consult Service spend most of their time throughout the MUSC Medical Center and Charleston Memorial Hospital.

Other aspects of the educational environment are as detailed above for the fellowship training program.

Duty hours for internal medicine trainees in general extend from 8:00 a.m. to 5:00 p.m. Internal medicine trainees on the Hematology Service or the MUH/CMH Consult Service do not have any night or weekend responsibilities. Trainees on the Oncology Service take call in accordance with Department of Internal Medicine policy (currently every sixth night). Average duty hours per week for internal medicine trainees rarely exceed 70 (including hours spent in the hospital on night call) and never exceed 80, and internal medicine trainees are ensured of having at least one duty-free 24-hour period every 7 days regardless of which rotation they are taking. This call arrangement is well within compliance of the ACGME duty hour limits.

Again leading by example, the Division faculty educate the internal medicine trainees just as they do the fellows with regard to development of professionalism values (detailed above).

In the VA clinic (outpatient environment), internal medicine trainees are charged with assisting the Division faculty in obtaining the patient’s history, performing examinations, obtaining and reviewing laboratory and radiologic data, obtaining and reviewing relevant medical literature, generating required documentation, and communicating assessments and recommendations with the patient’s referring physician(s). Internal medicine trainees do not obtain informed consent for chemotherapy, write chemotherapy orders, or deliver chemotherapeutic treatments.

In the consultative environment, the internal medicine trainee is responsible for assisting the Division faculty consultant in obtaining the patient’s history, performing examinations, obtaining and reviewing laboratory and radiologic data, obtaining and reviewing relevant medical literature, generating required documentation, and communicating assessments and recommendations with the patient’s primary team and with the patient’s other consultants. The trainee is expected to perform a history, physical, and lab data review on each patient and independently formulate an assessment and set of recommendations for review and critique by the faculty consultant; the trainee is expected to independently obtain and review relevant medical literature as needed to optimize his/her understanding of the problem(s) at hand in the patient. The trainee performs iliac crest bone marrow aspirations and biopsies under direct supervision of a Division fellow or faculty member. Internal medicine trainees are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of consultative care. If the patient’s primary team requests the consult service to write orders and prescriptions relevant to the consult problem, the internal medicine trainee is allowed to participate in the writing of all such orders and prescriptions, though again such trainees do not obtain informed consent for chemotherapy, write chemotherapy orders, or deliver chemotherapeutic treatments. Internal medicine trainees are charged with the responsibility for following up on consult encounters and treatments as appropriate; Division faculty expect the trainees to be at least as informed about the consult patients’ conditions as the faculty are.

In the inpatient environment (Hematology and Oncology Services), the internal medicine trainee is responsible solely for managing, under supervision, the general internal medicine aspects of the Hematology and Oncology patients. The internal medicine trainee is not expected or asked to be involved in subspecialty-oriented decision-making activities, though such involvement, if desired, is always welcome. Internal medicine trainees are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of inpatient care, though it is expected that their assessments and recommendations will be from a general internal medicine (not subspecialty) perspective. More specifically, internal medicine trainees are charged with documenting admission assessments and daily progress notes and dictating discharge summaries. With regard to procedures, the trainee most directly involved in the performance of a procedure is charged with completing all documentation related to the procedure. Internal medicine trainees are expected to write all orders on Hematology and Oncology patients except for chemotherapy orders; internal medicine trainees may not obtain informed consent for chemotherapy and may not deliver chemotherapeutic treatments. Each PGY-1 internal medicine trainee follows, on average, 3-5 Oncology patients at any given time. PGY-2 and -3 trainees on the Oncology Service follow all patients on the service (average: 6-10 patients); PGY-2 or PGY-3 trainees on the Hematology Service follow the 2-4 patients assigned him or her by the Hematology Service attending or fellow.

When the service of another specialist is required, the internal medicine trainee is expected to assist the attending physician in identifying the specific consultant needed. The trainee is expected to establish a positive relationship with the consultant and convey the consulting need in a clear, concise fashion. The trainee is expected to interact with a consult team’s attending physician and trainees in a professional manner. When faculty and trainees in other Departments and Divisions request the trainee’s assistance in performing (appropriate) clinical tasks, the trainee is charged with providing such assistance as promptly and as completely as possible.

Internal medicine trainees, while rotating through a Division service, are expected to seek instruction and supervision as appropriate from faculty in other disciplines such as Radiology/Nuclear Medicine, Radiation Oncology, Surgical Oncology, Nephrology, Gastrointestinal/Hepatobiliary Diseases, Cardiology, Pulmonary/Critical Care Medicine, and Pathology and Laboratory Medicine.

The Division’s Fellowship Training Program constantly strives to achieve and maintain the highest quality in all its educational activities.

The Training Program has an active Continuous Quality Improvement component principally centered around the regular semiannual review of all evaluations filed by trainees and faculty. As problems with existing activities become apparent, proposals for corrections are developed promptly, reviewed with the relevant parties, and implemented as soon as feasible.

As another part of the CQI process, the Training Program is always open to consideration of ideas that may improve the quality of the training. For example, extensive discussions were held between Division faculty and Department of Internal Medicine training program leaders in Spring 1997 and again in Spring 1998 regarding the redesign of the Division of Hematology/Oncology inpatient service structure to accommodate internal medicine trainees’ desires to focus more on certain problems and less on others. On July 1, 1998, in response to Department of Medicine requests intended to improve resident education, the Division instituted the new Hematology and Oncology Services structure, replacing the former MLT/MST Services structure. Over the next few years the internal medicine trainees’ hematologic education was increasingly judged to have suffered as a result of this arrangement. The Division offered to again redesign its Services to improve the internal medicine trainees’ exposure to hematology, and in 2002 the Department agreed. On July 1, 2002 the Division restructured the Hematology Service and MUH/CMH Consult Service to provide this increased exposure. Follow-up on this matter has shown the objectives have been achieved.

Risks to both patients and caregivers may be increased in the training environment. The Division faculty take a proactive approach to risk management by careful supervision of all trainees as detailed above. Each trainee is covered by the institution’s group malpractice insurance policy. All trainees supervised by Division faculty (fellows, internal medicine residents, and students) are educated from the start of their rotations as to their responsibilities and limits. This message is strongly reinforced by the faculty if deviations are identified. Though rarely needed, remedial/punitive action is taken when appropriate and in accordance with existing divisional, departmental, and institutional policies. Also, the faculty are educated via departmental programs to recognize the signs of fatigue and are required to promptly initiate meaningful corrective action when such a problem is seen in an internal medicine trainee.

Internal medicine trainees are required to stay in the hospital when on call for the Oncology Service. Thus, such trainees are forbidden from moonlighting while on call. The Department of Internal Medicine is responsible for tracking hours spent moonlighting by internal medicine trainees and ensuring such trainees do not exceed the ACGME-required cap of 80 work hours per week.

The Training Program is constantly seeking to improve its cost-effectiveness. As mentioned previously, current projects in this area are principally focused on investigating the use of the Internet (and the campus intranet) to distribute and collect educational and administrative material on a paper-free, on-demand basis.

In view of the short duration of medical student rotations, the hematology/oncology subspecialty curriculum for medical students rotating through a Division service is necessarily far more limited than the curriculum presented to fellow trainees and focuses on (a) the most common problems encountered by the hematologist/oncologist and (b) broad principles of hematology and oncology (as opposed to the practice of subspecialty hematology and oncology).

Third and fourth year medical students (from MUSC’s own medical school as well as other medical schools) currently have the opportunity to rotate through the Hematology Service, Oncology Service, and either of the Division’s consult services. (Other experiences, too, can be custom-designed and provided on request.) Though the student’s scope of responsibilities is obviously different on these two types of services, the basic curriculum presented by Division faculty is the same and parallels the curriculum described above for internal medicine trainees.

The Division of Hematology/Oncology medical student curriculum is taught via the following methods:

● Student rotation through either the Hematology Service, Oncology Service, or either of the Division’s consult services (as described extensively above). Note that students on either consult service participate in the weekly VA clinic.

● Students are not assigned any patient care responsibilities in the HCC clinics, but they are permitted to observe physician-patient encounters in any of the Division’s HCC clinics. Students are encouraged to attend at least one outpatient activity per week to gain some understanding of the significant differences between hematology/oncology inpatients and hematology/oncology outpatients.

● Division faculty participation in the junior medical student “Professor Rounds” series.

● Distribution of reference material and discussions in daily (Monday through Friday) didactic sessions. More than one topic may be covered per session.

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

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

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

● Students are welcome to participate in all conferences described above for fellow trainees. The conferences for which internal medicine trainees are required to attend are as follows:

● Provision of extensive ancillary training resources as described above for fellows, except that medical students are not provided office space or photocopying privileges by the Division.

● Regular problem-oriented as well as curriculum-structured exposure to medical literature in hematology/oncology:

• With faculty guidance, medical students are required to identify, obtain, and review medical literature relevant to the hematologic and/or oncologic problems of patients they encounter. Students are expected to demonstrate their understanding of the literature by providing critical summaries to the faculty and other trainees on the service at hand.

• Medical students are allowed to participate in the care of patients enrolled in clinical trials and gain insight and appreciation for the principles and practice of clinical research.

● Opportunities for participating in existing research or conducting new research projects:

• Medical students are welcome to participate in or develop research projects with Division faculty serving as mentors.

• Peer-reviewed publication and presentation of all research projects is strongly encouraged and supported by the Division and its Fellowship Training Program.

Medical students, through their training on Division rotations, begin to acquire the skill needed to perform the following subspecialty-related techniques in a competent manner:

● Bone marrow aspiration and biopsy from the anterior and posterior superior iliac crests, both with and without conscious sedation (and basic interpretation of these specimens).

● Interpretation of peripheral blood and bone marrow aspirate smears including integration of findings from automated analytic instruments.

The patient populations which patronize MUSC and the VA are of sufficient size and variety that medical students have ample opportunity to acquire these skills during the course of their training.

Due to the brevity of their rotation through the Division’s service(s), medical students are directly supervised in the performance of all tasks. Division fellows and internal medicine trainees participate in the supervision and teaching of medical students.

The Division requires regular evaluation both of the medical students (by their Division faculty supervisors) and by the medical students (of their Division faculty supervisors and the specific rotation taken). Evaluation forms used are those designed by the Department of Internal Medicine and the School of Medicine for this purpose. Supervisors are required to discuss their evaluations with the medical students; medical students may discuss their evaluations with their Division faculty supervisors and/or with the Fellowship Training Program Director as appropriate. All evaluations are kept on file indefinitely and are reviewed semiannually (or more often, as appropriate) by the Fellowship Training Program Director.

All medical students are permitted to file by mail anonymous evaluations and other comments with the Training Program Director or Coordinator. All such evaluations are kept on file indefinitely and are reviewed semiannually (or more often, as appropriate).

The educational environment provided by the Division of Hematology/Oncology for medical students consists of a network of clinical, research, and educational facilities principally centered about the MUSC Medical Center, the Ralph H. Johnson Veterans Affairs Medical Center, and, to a very small extent, Charleston Memorial Hospital.

Medical students on the Hematology and Oncology Services spend most of their time on the Medical University Hospital’s 8-West Hematology/Oncology Protective Enviroment (HOPE) Unit (described in detail above).

Medical students on the MUH/CMH Consult Service spend most of their time throughout the MUSC Medical Center and Charleston Memorial Hospital, while those students on the VA Consult Service spend most of their time at the VA.

Other aspects of the educational environment are as detailed above for the fellowship training program.

Duty hours for medical students in general extend from 8:00 a.m. to 5:00 p.m. Medical students on either of the Division’s consult services do not take call. Medical students on the Hematology and Oncology Services participate in daily rounds and take call in accordance with established School of Medicine policy. The Division complies with the medical school’s policies on medical student work hours (which are very similar to ACGME’s duty hour constraints for residents and fellows).

Again leading by example, the Division faculty educate the medical students just as they do the internal medicine trainees and the fellows with regard to development of professionalism values (detailed above).

In the VA clinic (outpatient environment), medical students are charged with assisting the Division faculty in obtaining the patient’s history, performing examinations, obtaining and reviewing laboratory and radiologic data, obtaining and reviewing relevant medical literature, generating required documentation, and communicating assessments and recommendations with the patient’s referring physician(s). Medical students do not obtain informed consent for chemotherapy, write chemotherapy orders, or deliver chemotherapeutic treatments.

In the consultative environment, the medical student is responsible for assisting the Division faculty consultant in obtaining the patient’s history, performing examinations, obtaining and reviewing laboratory and radiologic data, obtaining and reviewing relevant medical literature, generating required documentation, and communicating assessments and recommendations with the patient’s primary team and with the patient’s other consultants. The student is expected to perform a history, physical, and lab data review on each patient and independently formulate an assessment and set of recommendations for review and critique by the faculty consultant; the student is expected to independently obtain and review relevant medical literature as needed to optimize his/her understanding of the problem(s) at hand in the patient. The student performs iliac crest bone marrow aspirations and biopsies under direct supervision of a Division fellow or faculty member. Medical students are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of consultative care. If the patient’s primary team requests the consult service to write orders and prescriptions relevant to the consult problem, the medical student is allowed to participate in the writing of all such orders and prescriptions, all closely supervised by the Division faculty consultant. Again, medical students do not obtain informed consent for chemotherapy, write chemotherapy orders, or deliver chemotherapeutic treatments. Medical students are charged with the responsibility for following up on consult encounters and treatments as appropriate; Division faculty expect the students to be at least as informed about the consult patients’ conditions as the faculty are.

In the inpatient environment (Hematology and Oncology Services), the medical student is responsible solely for assisting in the evaluation and treatment of the inpatients assigned him or her. Medical students on the Hematology and Oncology Services always function under the direct, on-site supervision of either an internal medicine trainee, a Division fellow, or a Division faculty member. The medical student is not expected or asked to be involved in subspecialty-oriented decision-making activities, though such involvement, if desired, is always welcome. Third year medical students are expected to focus their efforts principally on taking histories, performing physical exams, analyzing laboratory data, and developing rudimentary assessments. Fourth year medical students are expected to focus their efforts on taking histories, performing physical exams, analyzing laboratory data, developing more detailed assessments, and developing rudimentary treatment plans for the general internal medicine aspects of each case. Patients followed by third year medical students are always followed by PGY-1 internal medicine trainees (who review and countersign all of the medical students’ orders), whereas patients followed by fourth year medical students may or may not be followed by PGY-1 trainee at the discretion of the PGY-2 or -3 trainee. If the PGY-2 or -3 trainee chooses to have the fourth year medical student’s patients not be followed by a PGY-1 trainee, then the PGY-2 or -3 trainee is charged with responsibility for reviewing and countersigning all orders written by the medical student. Medical students are responsible for adhering to all principles, standards, and regulatory requirements for documenting the delivery of inpatient care, though it is expected that their assessments (and, for fourth year students, their recommendations) will be from a general internal medicine (not subspecialty) perspective. More specifically, medical students are charged with documenting admission assessments and daily progress notes on all their patients. Under close supervision by more senior trainees and Division faculty, medical students are expected to write all orders on their Hematology or Oncology Service patients except for chemotherapy orders; medical students may not deliver chemotherapeutic treatments. Each medical student follows a maximum of four Hematology or Oncology Service patients.

When the service of another specialist is required, the medical student is expected to assist the more senior trainees and the attending physician in identifying the specific consultant needed. The student is expected to establish a positive relationship with the consultant and convey the consulting need in a clear, concise fashion. The student is expected to interact with a consult team’s attending physician and trainees in a professional manner. When faculty and trainees in other Departments and Divisions request the student’s assistance in performing (appropriate) clinical tasks, the student is charged with providing such assistance as promptly and as completely as possible.

Medical students, while rotating through a Division service, are expected to seek instruction and supervision as appropriate from faculty in other disciplines such as Radiology/Nuclear Medicine, Radiation Oncology, Surgical Oncology, Nephrology, Gastrointestinal/Hepatobiliary Diseases, Cardiology, Pulmonary/Critical Care Medicine, and Pathology and Laboratory Medicine.

The Division’s Fellowship Training Program constantly strives to achieve and maintain the highest quality in all its educational activities.

The Training Program has an active Continuous Quality Improvement component principally centered around the regular semiannual review by the Training Program Director of all evaluations filed by trainees and faculty. As problems with existing activities become apparent, proposals for corrections are developed promptly, reviewed with the relevant parties, and implemented as soon as feasible.

Another key CQI vehicle is the Division’s internal monthly faculty meeting, which also serves as a training program review meeting. Both faculty and fellows have the opportunity to participate. See Section 6, Evaluation of the Training Program, for details.

As another part of the CQI process, the Training Program is always open to consideration of ideas that may improve the quality of the training. Examples of current projects which fall under the CQI banner have been noted above.

Risks to both patients and caregivers may be increased in the training environment. The Division faculty take a proactive approach to risk management by careful supervision of all trainees as detailed above. All trainees supervised by Division faculty (fellows, internal medicine residents, and students) are educated from the start of their rotations as to their responsibilities and limits. This message is strongly reinforced by the faculty if deviations are identified. Though rarely needed, remedial/punitive action is taken when appropriate, always in accordance with appropriate divisional, departmental, and institutional policies. The faculty are educated on the signs and hazards of excessive fatigue and are required to take prompt, meaningful, policy-compliant action to correct such problems when seen.

The mission of the faculty of the MUSC Division of Hematology/Oncology parallels that of the MUSC Medical Center:

The MUSC Medical Center's mission is to provide excellence in patient care, teaching and research in an environment that is respectful of others, adaptive to change and accountable for outcomes.

The Training Program Director of the MUSC Division of Hematology/Oncology currently is Lawrence B. Afrin, M.D. Dr. Afrin’s C.V. accompanies this document, and evaluations of his performance are on file in the Division’s main office suite in the MUSC Clinical Science Building, Room 903. Dr. Afrin routinely devotes a minimum of 26 hours each week to the training program in the form of bedside teaching on inpatient rounds (4+ hours every week on average over a year), “bedside” teaching in the outpatient clinic (12+ hours every week), and administrative tasks (10+ hours every week). Dr. Afrin’s office, in the MUSC Clinical Sciences Building Room 906E1, is adjacent to the Division’s main office suite.

The Program Director ensures the Program remains in compliance with the computerized program reporting systems of the ABIM and ACGME (e.g., ACGME’s Accreditation Data System).

◦ Basic aspects in the principles and practice of medical oncology and hematology as outlined in the fellowship curriculum in the Educational Programs section (Section 2).

◦ With assistance from a faculty member, 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.

◦ With assistance from a faculty member, 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.

◦ With assistance from a faculty member, identify and interpret relevant ancillary data such as laboratory and radiology tests.

◦ With assistance from a faculty member, interpret bone marrow aspirate smears, bone marrow biopsy sections, and bone marrow biopsy touch preps.

◦ With assistance from a faculty member, 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.

◦ With assistance from a faculty member, develop a comprehensive treatment plan, involving other specialties and ancillary services as appropriate.

◦ With assistance from and close supervision by a faculty member, execute a comprehensive treatment plan.

◦ With assistance from and close supervision by a faculty member, 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.

◦ With assistance from and direct supervision by a faculty member, 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.

◦ Concurrently manage a panel of up to 100 outpatients and up to 10 inpatients. Optimal efficiency is not yet expected.

◦ Interact with senior and junior colleagues and support staff in a professional manner.

◦ Understand the principles of conducting clinical research and, with assistance from and close supervision by a faculty member, manage the care of a patient enrolled on a clinical trial.

◦ Prepare and deliver intra-divisional discussions of hematology/oncology topics in both interactive as well as didactic settings.

◦ With assistance from faculty, develop a basic understanding of how to critically evaluate the hematology/oncology medical literature.

◦ With close faculty guidance, take at least the first three of the steps toward satisfying the research project requirement:

▪ Feasibility exploration, including tentative identification of research supervisor

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

◦ Clear commitment to absorption and application of didactically received educational material

◦ Clear commitment to self-education (not only independent, internally motivated seeking of knowledge, but also a commitment to learning new methods of learning (e.g., learning how to use new computer-based resources))

◦ Commitment to, participation in, and enthusiasm for furthering the education of colleagues

◦ Commitment to production of new knowledge through good faith efforts to develop a research project

◦ Absolute ethical, moral, and legal integrity in all conduct in the educational, clinical, and research arenas

◦ Sensitivity in relationships to colleagues at all levels and to patients, including spontaneous willingness to assist colleagues in need (e.g., quickly agreeing, when asked, to cover for another fellow during illness or vacation).

◦ Mature acceptance and processing of constructive criticism from supervisors and peers

◦ Advanced aspects in the principles and practice of medical oncology and hematology as outlined in the fellowship curriculum in the Educational Programs section (Section 2).

◦ Independently 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.

◦ Independently 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.

◦ Independently identify and interpret relevant ancillary data such as laboratory and radiology tests.

◦ Independently interpret bone marrow aspirate smears, bone marrow biopsy sections, and bone marrow biopsy touch preps.

◦ Independently 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.

◦ Independently develop a comprehensive treatment plan, involving other specialties and ancillary services as appropriate.

◦ Independently manage treatment complications and re-formulate treatment plans as appropriate.

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

◦ Independently 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.

◦ Concurrently manage a panel of up to 200 outpatients and up to 15 inpatients. Optimal efficiency is expected.

◦ Interact with senior and junior colleagues and support staff in a professional manner.

◦ Informally teach and supervise internal medicine residents and medical students.

◦ Understand the principles of conducting clinical research and independently manage the care of a patient enrolled on a clinical trial.

◦ Independently prepare and deliver intra-divisional discussions of hematology/oncology topics in both interactive as well as didactic settings.

◦ With guidance from faculty, demonstrate the ability to appropriately modify methods of practice in accordance with new developments in the medical literature.

◦ With continuing but more distant faculty guidance, continue on toward satisfying the research project requirement so that, at a minimum, the first five steps are completed:

▪ Feasibility exploration, including tentative identification of research supervisor

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

◦ Improved self-confidence and developing desire for independence, yet still appropriate in consulting faculty for guidance

◦ In-depth understanding of current research in selected medical oncology- and hematology-related topics

◦ Concurrently manage a panel of up to 300 outpatients and up to 20 inpatients with optimal efficiency.

◦ Demonstrated ability to consistently, competently manage all aspects of caring for the medical oncology or hematology patient, with little to no need for faculty guidance in the clinical arena.

◦ Demonstrated ability to appropriately integrate new findings in the medical literature into methods of practice, with little to no faculty guidance.

◦ Ability to independently develop and execute a clinical or laboratory research project.

◦ Sustainable self-confidence and ready access to knowledge base which allows the fellow to define and well defend a plan of care which is medically reasonable but which differs from the faculty member’s proposed plan, i.e., demonstrate a clear understanding of what aspects of care are dictated by existing knowledge and standards and what aspects are subject to stylistic differences.

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ Understanding of health care economic issues such as impacts on patient care of various third-party payer arrangements

◦ Comprehensive understanding of available community-based health care services such as Home Health, home infusion therapy, Hospice, etc.

◦ As discussed above for the outpatient clinical aspects of the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Effective use of clinic resources such as nurses’ time, nurses’ knowledge of patients’ social milieus, social workers, electronic information systems.

◦ Efficient, effective interaction with colleagues in the multidisciplinary organ- and disease-specific clinic environment to rapidly provide comprehensive care to patients requiring multimodality treatment.

◦ Smooth transitioning of patients from outpatient to inpatient environments and vice versa.

◦ Efficient, effective, appropriate adaptation to constraints placed on care decisions by third-party payers.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Maintenance of professionalism in dealing with colleagues of contrary opinion in the multidisciplinary organ- and disease-specific clinic environment.

◦ Consistent respect for, and recognition of value of, co-workers in supportive roles such as nursing, social work, nutrition, financial counseling, scheduling, home health and hospice, etc.

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ Understanding of economic and operational issues in large government-sponsored and -operated health care delivery systems.

◦ Comprehensive understanding of available community-based health care services such as Home Health, home infusion therapy, Hospice, etc.

◦ Appreciation for and comprehensive understanding of the hematologic and oncologic consequences of trauma sequelae, chronic toxin exposure, and chronic substance abuse.

◦ As discussed above for the outpatient clinical aspects of the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Methods of efficient determination of relevant history and laboratory findings in patients returning for follow-up but with whom the fellow is unfamiliar.

◦ Effective use of electronic information systems in large government-sponsored and -operated health care delivery systems.

◦ Smooth transitioning of patients from outpatient to inpatient environments and vice versa.

◦ Efficient, effective, appropriate adaptation to constraints placed on care decisions in large government-sponsored and -operated health care delivery systems.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attribute:

◦ Maintenance of professionalism in dealing with obstacles to efficient delivery of appropriate care in large government-sponsored and -operated health care delivery systems.

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ All aspects of diagnosis and management of acute leukemia (and chronic leukemia or myelodysplastic syndrome in transformation or crisis), high-grade non-Hodgkin’s lymphoma, other advanced and/or aggressive hematologic malignancies and non-malignant hematologic problems (e.g., thrombotic thrombocytopenic purpura, hemoglobinopathies and their complications), high-dose chemotherapy, and stem cell rescue, including short-term complications of high-dose chemotherapy, stem cell rescue, leukemic induction and consolidation therapy, plasmapheresis, leukapheresis, and indications for red cell exchange transfusion.

◦ Basic and intermediate (but not advanced) aspects of care of the critically ill (but potentially salvageable) hematology/oncology patient.

◦ Methods of withdrawal of support in acutely ill hematology/oncology inpatients.

◦ Direct visual appreciation (via observation at autopsies) for the pathophysiology of chronic or acute, severe hematologic and oncologic illness or the chronic or acute, severe complications of such illness.

◦ Precise understanding of the various sorts of advance directives and adjunct legal documents related to advance directives.

◦ Understanding of disposition options for patients ready for discharge but unable to safely return home.

◦ As discussed above for the inpatient clinical aspects of the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Appropriate management of hematologic and oncologic emergencies in patients with diseases as noted above.

◦ Effective, appropriate use of advanced diagnostic and therapeutic services for leukemia and lymphoma patients or patients undergoing high-dose chemotherapy with stem cell rescue.

◦ Development of, and management of patients in accordance with, complex clinical pathways.

◦ Empathetic counseling of patients, and families of patients, acutely struck with life-threatening hematologic or oncologic illness, or the complications of such illness.

◦ Cooperative, coordinated management of critically ill patients with intensivists.

◦ Appropriate use of support staff (e.g., nursing, case management, pastoral care) in caring for hematology/oncology inpatients and their families.

◦ Recognition of the appropriate times for advocating for continued aggressive support and the appropriate times for advocating for withdrawal of support.

◦ Management of situations in which the (unresponsive or incapacitated) patient’s advance directives conflict with family directives.

◦ Communication with outpatient staff to help ensure smooth transition of acutely ill outpatients to the inpatient environment and of recovered acutely ill inpatients to the outpatient environment.

▪ Recognition of opportunities for acutely ill hematology/oncology patients to participate in clinical trials.

▪ Similarly, recognition of situations in which it is ethically and/or medicolegally inappropriate to consider such patients for participation in clinical trials.

▪ Counseling of such patients in a balanced manner with regard to potential risks and benefits of trial participation.

▪ Efficient cooperation with clinical trials program staff in enrolling such patients in clinical trials.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Unwavering commitment in word and deed to (appropriately) serving the acutely or critically ill hematology/oncology inpatient’s and inpatient’s family’s needs.

◦ Empathy with patients, and families of patients, acutely struck with life-threatening hematologic or oncologic illness, or the complications of such illness.

◦ Respect for hematology/oncology inpatient support staff (e.g., nursing, case management, pastoral care).

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ All aspects of inpatient management, and complications of such management, of all solid tumors.

◦ All methods of palliative care for the terminal patient, with special emphasis on importance and methods of pain control.

◦ Direct visual appreciation (via observation at autopsies) for the pathophysiology of fatal chronic oncologic illness.

◦ Precise understanding of the various sorts of advance directives and adjunct legal documents related to advance directives.

◦ Understanding of disposition options for solid tumor inpatients ready for discharge but unable to safely return home.

◦ As discussed above for the inpatient clinical aspects of the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Efficiency in inpatient management of solid tumors and routine sickle cell pain crises.

◦ Appropriate management of oncologic emergencies in solid tumor patients and routine sickle cell pain crisis patients.

◦ Compassionate, appropriate care for the dying patient, including empathetic counseling for such patients and their families.

◦ Development of, and management of patients in accordance with, basic clinical pathways.

◦ Cooperative, coordinated multidisciplinary management of terminally ill solid tumor patients requiring a multimodality approach for optimal comfort and palliation.

◦ Appropriate use of support staff (e.g., nursing, case management, pastoral care) in caring for dying solid tumor patients and their families.

◦ Recognition of the appropriate times for advocating for continued aggressive support and the appropriate times for advocating for withdrawal of support.

◦ Management of situations in which the (unresponsive or incapacitated) patient’s advance directives conflict with family directives.

▪ Recognition of opportunities for solid tumor patients to participate in clinical trials.

▪ Similarly, recognition of situations in which it is ethically and/or medicolegally inappropriate to consider such patients for participation in clinical trials.

▪ Counseling of such patients in a balanced manner with regard to potential risks and benefits of trial participation.

▪ Efficient cooperation with clinical trials program staff in enrolling such patients in clinical trials.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Unwavering commitment in word and deed to (appropriately) serving the solid tumor inpatient’s and inpatient’s family’s needs.

◦ Empathy with patients, and families of patients, dealing with chronic hematologic or oncologic illness.

◦ Respect for solid tumor inpatient support staff (e.g., nursing, case management, pastoral care).

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ Consultative hematology and oncology, with heavy emphasis on common consultative problems such as:

▪ Mild to moderate quantitative disorders of red and white blood cells and platelets

▪ Pre-operative management of sickle cell patients and patients with known coagulopathies

▪ Initial diagnostic and therapeutic inpatient management of advanced solid tumors

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Coordination (with staff in other specialties) of consultative care and consult recommendations in complex patients with multiple consults simultaneously in progress.

◦ Recognition of appropriate and inappropriate use of laboratory testing in the consultative setting.

◦ Methods of obtaining information which is needed to perform an adequate consultation but which is not already on the patient’s chart.

◦ Recognition and defense of the appropriate division of consultant’s vs. primary staff’s responsibilities for caring for and communicating with the patient.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Empathy for the patient newly diagnosed with serious hematologic or oncologic illness and such patients’ families.

◦ Commitment in word and deed to making the best possible effort to gather all the information needed to deliver the best possible consultative care.

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ Consultative hematology and oncology, with heavy emphasis on common consultative problems such as:

▪ Substance abuse-related quantitative disorders of red and white blood cells and platelets.

◦ Available resources for assisting with and expediting transference of care of acute leukemic and pre-bone marrow transplant patients to other medical centers authorized to handle such problems.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Use of electronic information systems to obtain consult-relevant information not available from paper records.

◦ Efficient transference of acute leukemic and pre-bone marrow transplant patients to other medical centers authorized to handle such problems.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Maintenance of professionalism in dealing with uncontrollable impediments to the process of providing quality hematology/oncology consultative care in a large government-sponsored and -operated health care delivery system.

◦ Curricular material as discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the acquisition of the following knowledge:

◦ Current standards for use (and non-use) of, and current research into the use of, high-dose chemotherapy with stem-cell rescue.

▪ Pre-treatment evaluation of potential candidates for high-dose chemotherapy.

▪ Pre-operative evaluation of normal bone marrow or peripheral stem cell donors.

▪ Cytokine- and chemotherapy-mediated stem cell mobilization and peripheral stem cell harvesting

▪ Intraoperative and post-operative management of the patient undergoing bone marrow harvest

▪ Management of the post-stem cell rescue patient at all stages of recovery and follow-up, including management of acute and long-term complications of high-dose chemotherapy and stem cell rescue.

▪ Detection and management of minimal residual disease and minimally relapsed disease.

▪ High-dose chemotherapy and stem cell rescue performed totally in the outpatient setting.

▪ Team approach to management of high-dose chemotherapy and stem cell rescue from initial patient evaluation through patient selection through treatment and then follow-up.

▪ Integration of clinical research activities into the process of delivering high-dose chemotherapy and stem cell rescue care.

◦ As discussed above for the inpatient clinical aspects of the different years of fellowship training, with this rotation uniquely or predominantly fostering acquisition of the following skills:

◦ Surgical techniques for operating room-based harvesting of bone marrow from the (posterior and/or anterior) iliac crest.

◦ Ordering of cytokine- and chemotherapy-mediated stem cell mobilization and peripheral stem cell harvesting

◦ Management of the post-stem cell rescue patient at all stages of recovery and follow-up, including management of acute and long-term complications of high-dose chemotherapy and stem cell rescue.

◦ Detection and management of minimal residual disease and minimally relapsed disease.

◦ Appropriate counseling of high-dose chemotherapy patients regarding potential outcomes of and alternatives to high-dose chemotherapy with stem cell rescue.

◦ Provision of high-dose chemotherapy and related care in the context of a clinical trial.

◦ Understanding of social stressors in the high-dose chemotherapy setting, particularly family-related stressors.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Empathy for the patient who needs potentially life-threatening treatment in order to hopefully save his or her life.

◦ Dependent on the particular elective. Specifics for each elective are being developed.

◦ Specific material related to the fellow’s research project. This material may include, for example, advanced principles of molecular biology, methods of genetic engineering, principles of radiation safety, or advanced principles of clinical trial design.

◦ Specific techniques related to the fellow’s research project. These techniques may include, for example, literature searching and review, molecular biology analytical techniques, cell culturing, cytotoxicity assays, recombinant DNA engineering techniques, grant/proposal writing, methods for documentation of research results, development of clinical trial protocols, submission of protocols for IRB review, execution of clinical trial protocols, and clinical trial data analysis.

◦ As discussed above for the different years of fellowship training, with this rotation uniquely or predominantly fostering the maturation of the following attributes:

◦ Interest in determining the answers to significant questions in basic science and/or clinical aspects of hematology/oncology.

◦ Commitment in word and deed to the ethical development and reporting of useful new knowledge in the basic science or clinical arenas of hematology/oncology.

◦ In all research-related work, commitment in word and deed to patient and co-worker safety above all else.

The MUSC Division of Hematology/Oncology’s policy on the selection of fellows is to first provide equal opportunity to all qualified candidates regardless of age, sex, race, national origin, personal beliefs, lifestyle decisions, or physical disability.

A candidate for fellowship is required to be either a Certified Diplomate in Internal Medicine by the American Board of Internal Medicine (ABIM), eligible to take the Internal Medicine ABIM certifying examination, or currently engaged full-time in an accredited internal medicine training program from which the candidate is expected to graduate within two years of submission of the application for a fellowship position. Candidates must pass the USMLE or COMLEX Step 3 examination prior to matriculation. Exceptions to the usual admissions qualifications can be made by the Fellowship Training Program Director for candidates who do not meet these requirements but have otherwise extraordinary qualifications. Without exception, all candidates must meet all applicable state and federal legal requirements for U.S. residency and South Carolina medical licensure. Without exception, all candidates must already have or be able to obtain unrestricted federal Drug Enforcement Administration and South Carolina Department of Health and Environmental Control licenses for prescribing Schedules 2, 2N, 3, 3N, 4 and 5 medications. Without exception, all candidates must be able to obtain a National Cancer Institute investigator’s license. Without exception, all candidates must be able to satisfy any additional requirements (for granting of training privileges) specified by the staff and/or housestaff offices of the MUSC Medical Center, the Ralph H. Johnson Veterans Affairs Medical Center, and Charleston Memorial Hospital. The revocation or expiration of any of these certifications or licenses, or cancellation or limitation of training privileges at any of the above-mentioned medical centers, is sufficient cause for dismissal from the fellowship training program.

Division policy is to accept into the training program those candidates who, in the Division faculty’s collective opinion, are most likely to (1) become highly competent in independently caring for all types of oncology and/or hematology patients (within the limits of available medical resources), (2) continually contribute to the field in some manner (conduct of research, organizational leadership, teaching, etc.) for the duration of his or her career, (3) pursue continuing education in the field for the duration of his or her career, and (4) consistently behave in accordance with the highest ethical and moral standards in every aspect of his or her professional life. The Division of course complies with ACGME/RRC-mandated limits on the number of fellows it is accredited to train simultaneously as well as the limits on the number of fellows who did not receive internal medicine training in the U.S.

Division procedure for selection of fellows is straightforward. Effective with the 2007 recruitment cycle beginning in late 2005, applications will be accepted only via the Association of American Medical College’s Electronic Residency Application System (ERAS). The standard ERAS application form will be used; the program does not require any supplemental application materials not required by ERAS.

Upon ERAS’s release of an application to the training program, the program director conducts a timely review of the application and determines if the candidate’s qualifications are sufficient to merit personal interviews with the faculty. If so, an interview day is arranged. For each interviewee, the Division provides (1) one night of lodging (the night before or the night of the interview day, at the candidate’s discretion) at a facility of the Division’s choosing, (2) breakfast and lunch on the interview day, and (3) transportation between lodging and the medical center. The candidate is responsible for all other expenses incurred.

The bulk of each interview day consists of half-hour interviews of the candidate by a slate of faculty members. The program attempts to have each candidate interviewed by a minimum of four faculty members. Candidates are invited to participate in Division conferences when feasible. Candidates are accorded a private opportunity over lunch to discuss the fellowship program candidly with one or more of the current fellows.

Each faculty member is provided an evaluation form along with the candidate’s application packet. The faculty member must return the completed evaluation within two business days to the program coordinator, who in turn provides the collection of evaluations to the Training Program Director for review. The Training Program Director typically consults further with faculty and fellows and then decides whether or not to offer the candidate a position through the Match (beginning with the 2007 recruitment cycle) or outside the Match. The Training Program Director may also defer a decision as appropriate. Although the faculty are usually extensively solicited for input on fellowship hiring, disciplinary, and termination decisions, the Training Program Director is solely responsible for making and enacting all such decisions.

The process of offering candidates positions through the Match is governed by Match policies. For candidates offered positions outside the Match, the Training Program Director sends a written offer to such candidates. A prompt reply is required. The Training Program Director reserves the right to withdraw at any time a tendered offer to which the candidate has not replied; written and telephoned notice of withdrawal of an offer will be given.

The Division regards a Match-based acceptance, or a candidate’s signature on the program’s written offer of a non-Match-based position, as a contract. Accepted candidates are obligated to complete any remaining pre-fellowship training on schedule and in a satisfactory manner. These candidates are also obligated to attend to all necessary pre-fellowship duties (such as applying for state medical licensure in a timely fashion) and are obligated to serve in the fellowship program for at least one year. Because of the substantial resources invested in its recruiting efforts, the Division warns all candidates who accept an offer that if they later renege on their acceptance, or unilaterally terminate employment prior to the end of the first year, the Division may seek compensation through any channels it deems appropriate; the Division also reserves the right in this situation to inform other programs of the candidate’s decision. Fellows seeking transfer into or out of the program are advised that ACGME requires the “sending” and “receiving” program directors converse regarding the transfer before approving it; all aspects of a fellow’s past performance are potentially subject to discussion.

Continuation in the program beyond the first year is a privilege that is not guaranteed to any fellow. Continuation is considered on an annual basis.

Matriculating fellows are required to attend a comprehensive orientation to the fellowship program either shortly before, or on, their first day in the program. Matriculating fellows (other than those who have just completed their general internal medicine training at MUSC) are also required to attend the MUSC GME orientation program.

For the MUSC-based inpatient and consultative rotations, teaching staff are selected from amongst the Division’s complement of ABIM-certified medical oncologists and hematologists. Staff rotate amongst the various inpatient and consultative services. Each month one faculty member is assigned to the Hematology Service, and a separate faculty member is assigned to the Oncology Service. These attendings also serve as backup attendings on the MUH/CMH Consult Service (the Hematology Service attending handles hematology consults; the Oncology Service attending handles oncology consults; by mutual agreement between the two attendings on service in any particular month, a dual-boarded attending can handle all consults). A third faculty member is assigned to the MUH/CMH Consult Service, and a fourth faculty member is assigned to the VA Consult Service.

There are no particular criteria for selection of teaching staff for the general medical oncology and hematology clinics at the Hollings Cancer Center and the VA because nearly all of the Division’s faculty staff these clinics. However, the teaching staff for the organ- or disease-specific multidisciplinary clinics are carefully selected for their expertise in those areas. For example, the Genitourinary Oncology Clinic is staffed by Dr. Chaudhary, whose research is well focused in this area. The teaching staff, or “mentors,” for the Journal Clubs are similarly selected for their expertise in the topic to be discussed at each Journal Club meeting.

Selection of teaching staff for elective rotations is a task for which the involved Departments are responsible.

The principal mechanism by which teaching staff are supervised is review of trainees’ evaluations of teachers by the Training Program Director. Trainees are required to evaluate their teachers at the end of every month. Trainees may discuss their evaluations with their teachers but are not obligated to do so. Trainees are obligated to discuss their evaluations with the Training Program Director if the Director so requests. Trainees’ evaluations of their teachers are kept on file in the teachers’ respective files maintained by the Training Program; a teacher may review his or her file on demand during business hours.

A second method by which teaching staff are supervised is the annual performance evaluation by the Division Director.

Finally, each teacher’s continuing medical education (CME) credit file is reviewed annually by the Training Program Director. Teachers are expected to pursue at least 20 hours per year of CME relevant to their clinical and research pursuits, inasmuch as they must maintain a state-of-the-art knowledge (and skill) base in order to provide state-of-the-art education and clinical and research supervision to the trainees. The Training Program Director notifies the Division Director of those teachers who fall below the 20 CME hours per year mark.

The Training Program Director is responsible for addressing problems with teaching staff as they are identified. Teachers who may benefit from a refinement in teaching style are initially counseled by the Training Program Director and/or the Division Director.

Problems in which the knowledge base or teaching skills of the teacher are in question are handled on a case-by-case basis.

The Training Program Director is responsible for informing the Division Director (or the Chairman of the relevant elective Department) of persistent problems.

The Division has a “zero tolerance” policy for substance abuse and sexual and other forms of harassment in line with MUSC policies on these subjects. Teachers determined to be in violation of these policies are subject to immediate probation and/or termination from their involvement in the Training Program at the discretion of the Training Program Director.

All fellows are supervised by faculty in performance of all professional tasks, including all provision of patient care by fellows. The supervisor determines the acceptable degree of physical proximity between supervisor and supervisee in accordance with the nature of the task at hand and the supervisor’s estimate of the fellow’s ability to independently perform the task in an acceptable manner. Especially in matters of patient care, all faculty are keenly aware that they are responsible for all actions taken in the professional environment by the trainees serving under them.

Faculty generally supervise fellows most closely for the first six months of their fellowship. Thereafter, greater degrees of independence are permitted of each fellow by faculty the fellow demonstrates increasing competence.

Fellows are directly supervised by faculty in the performance of all procedures until they have demonstrated competency. Fellows who appear competent to perform procedures independently are explicitly instructed to summon faculty immediately for assistance if difficulties develop; all faculty are aware of their responsibility to respond immediately to such summons.

Although supervision of clinical care delivered after regular business hours is largely the responsibility of the on-call faculty member, all faculty are aware of their responsibility to respond to a fellow’s call for assistance to them any time. (For example, a fellow facing a difficult situation in a patient with a rare disease may decide to contact the faculty member known to have the greatest amount of experience with the disease rather than the on-call faculty member or the patient’s principal attending physician in the Division. The contacted faculty member has an obligation to respond to the fellow’s call in a professional manner.)

In preparation for Journal Club meetings, an assigned faculty member serves as a mentor to the assigned trainee and supervises the trainee’s selection and development of material to be presented at the Journal Club. A similar approach is taken with Curriculum Conferences.

Faculty members of course closely supervise fellows in their research projects as they learn new techniques.

Division faculty all are keenly aware of the responsibilities of the fellows, the demands on their time, the stress that may ensue, and the need to provide a supportive environment in which the professional growth of the fellow can proceed at a due pace. It is Division policy that all faculty are to be available (within reason) to the fellows for purposes of counseling and support. All MUSC counseling and support resources are available to each fellow. The Training Program Director also uses the monthly Fellows’ Conference as a forum in which to provide group-wide counseling and support to the fellows.

The Division has a “zero tolerance” policy for substance abuse and sexual and other forms of harassment in line with MUSC policies on these subjects. Fellows determined to be in violation of these policies or otherwise demonstrating unacceptable behavior are subject to immediate probation and/or termination at the discretion of the Training Program Director.

As of May 1, 2007, the Division enjoys the membership of 17 distinguished faculty. Their names, positions, research interests, and board certifications are summarized below. Their full C.V.s are attached to this document. Division faculty not routinely involved with the Fellowship Training Program are indicated by an asterisk.

Name	Position(s)	Research Interests	ABIM Board Certification
Harry A. Drabkin, M.D.	Professor of Medicine; Division Director	Acute leukemia; genitourinary malignancies	Internal Medicine; Medical Oncology
Lawrence B. Afrin, M.D.	Associate Professor of Medicine; Director of the Division’s Fellowship Training Program; Director of Information Technology for the MUSC Office of Graduate Medical Education; Director of Medical Informatics and Senior Physician-IT Liaison for the Medical University Hospital Authority	Medical informatics; clinical trials	Internal Medicine (exp. 2001); Medical Oncology; Hematology
Chris Y. Brunson, M.D.*	Associate Professor of Medicine; Director, Adult Sickle Cell Program	Hemoglobinopathies, esp. sickle cell anemia	Internal Medicine; Medical Oncology; Hematology
Uzair Chaudhary, M.D.	Assistant Professor of Medicine	Genitourinary oncology	Internal Medicine; Medical Oncology; Hematology
Robert Fenning, M.D.	Professor of Medicine	Consultative hematology/oncology	Internal Medicine; Medical Oncology; Hematology
Debra A. Frei-Lahr, M.D.	Associate Professor of Medicine; Acting Director, Bone Marrow Transplant Program	Bone marrow transplantation	Internal Medicine; Medical Oncology; Hematology
Mark R. Green, M.D.*	Professor of Medicine	Lung cancer; Phase I/II clinical trials	Internal Medicine; Medical Oncology
Rayna K. Hall, M.D.	Associate Professor of Medicine	Breast cancer; antiemetic therapy	Internal Medicine; Medical Oncology
Andrew S. Kraft, M.D.	Professor of Medicine; Director, Hollings Cancer Center	Genitourinary malignancies; sarcoma	Internal Medicine; Medical Oncology
Amanda C. LaRue, Ph.D.	Assistant Professor of Medicine, Division of Experimental Hematology	Physiologic mechanisms of hematopoietic stem cells
Alberto F. Montero, M.D.	Assistant Professor of Medicine; Fellowship Program Assistant Director for Research	Breast cancer	Internal Medicine; Medical Oncology; Hematology
Paul E. O’Brien, Jr., M.D.	Instructor of Medicine	Breast cancer, gastrointestinal and head & neck cancer	Internal Medicine; board-eligible in Medical Oncology and Hematology
Makio Ogawa, M.D.*	Professor of Medicine; Director, Division of Experimental Hematology; Director of Biomedical Research at the Ralph H. Johnson Veterans Affairs Medical Center	Stem cell biology (full-time research)
Clifford W. Schweinfest, Ph.D.*	Professor; Research Scientist in the Center for Molecular and Structural Biology	Molecular genetics of colorectal tumorigenesis, prostate cancer and pancreatic cancer
Carol A. Sherman, M.D.	Associate Professor of Medicine; Medical Director for the Hollings Cancer Center	Thoracic malignancies	Internal Medicine; Medical Oncology
Robert K. Stuart, M.D.	Professor of Medicine; Medical Director of MUH 8-West	Malignant hematology; stem cell transplantation; clinical trials; head and neck cancer	Internal Medicine; Medical Oncology; Hematology
M. Rita I. Young, Ph.D.*	Professor; Associate Chief of Staff for Research and Development, Charleston VAMC	Head and neck cancer biology; dendritic and stem cell biology

The Division’s Fellowship Training Program makes use of the following special resources in the training of its fellows:

● The matrix-oriented multidisciplinary environment of the Hollings Cancer Center, a seven-story facility adjacent to the main inpatient facility and main Division office suite, featuring a complete adult and pediatric, medical and surgical ambulatory care facility, conference and educational meeting space, and clinical and basic research resources all focusing on oncology.

● Three medical centers (MUSC, CMH, and the VA), all within two blocks of each other, each used by inpatients and outpatients drawn from distinct populations.

● The MUSC Hematology/Oncology Protective Environment (HOPE) Unit, a specially constructed 24-bed inpatient unit on the 8-West wing of Medical University Hospital (MUH), for bringing together physicians, trainees, and specially trained support personnel with hematology and medical oncology inpatients.

● Multimedia teaching facilities in the HOPE Unit, the Cancer Center’s ambulatory care facility, and the Cancer Center classroom including multi-headed teaching microscopes and a large array of multimedia equipment for image capture and presentation display.

● A highly experienced faculty member (Dr. Afrin) available for assistance with information technology issues.

● An internationally recognized faculty member (Dr. Brescia) available for guidance regarding ethics and palliative and end-of-life care issues.

● An internationally recognized faculty member (Dr. Ogawa) available for guidance regarding basic research into stem cell biology.

● Additional faculty as noted in the previous section with clinical and research expertise in a wide array of hematologic and oncologic topics.

● South Carolina itself, where relatively uncommon esophageal and cervical cancers, among other cancers, are epidemic in certain large minority populations, providing fellows with great learning opportunities not available at most other training programs.

● The MUSC Stem Cell Transplant Program, which performs every type of stem-cell rescue procedure currently being done.

● The MUSC Apheresis Unit, which performs every type of pheresis procedure currently being done, including plasmapheresis, leukapheresis, stem-cell pheresis, plateletpheresis, and pheresis with the staphylococcal protein A immunoadsorption column.

● Good relationships with community-based hematologists and oncologists throughout the state and other professionals in hematology- and medical oncology-related disciplines within MUSC, so as to provide training grounds for its fellows at community tumor boards as well as elective second-year rotations through various hematology- and medical oncology-related disciplines.

The primary training site for the Division’s Fellowship Training Program is the Medical University Hospital for inpatient care training (principally on the HOPE Unit on 8-West); the MUSC Medical Center, the Ralph H. Johnson Veterans Affairs Medical Center, and, to a very small extent, Charleston Memorial Hospital (wholly owned by MUSC and located on the MUSC campus) for inpatient consultative training; and the Hollings Cancer Center and the Ralph H. Johnson Veterans Affairs Medical Center for ambulatory care training. The Ralph H. Johnson Veterans Affairs Medical Center also serves as a secondary site for inpatient training, but this Center is not authorized to treat acute leukemia or to perform stem cell transplantation. The Division’s Fellowship Training Program has on file a current Letter of Agreement with the Ralph H. Johnson Veterans Affairs Medical Center regarding the educational experiences provided in that facility.

The Division employs 1.5 FTEs in administrative support of its Fellowship Training Program. This figures includes Program Coordinator Ms. Sherrel Wilcox (1.0 FTE), Ms. Laura Aycock (0.25 FTE), and Ms. Debbie Collins (0.25 FTE).

Using data drawn from encounter billing databases for the Hollings Cancer Center and the Medical University Hospital, along with data drawn from the master Ralph H. Johnson Veterans Affairs Medical Center database, Tables A1-A14 characterize the mix of patients seen by trainees in the Division of Hematology/Oncology.

1. Medical University Hospital and Hollings Cancer Center data obtained from billing databases, which identify attending physicians but not trainees who participate in providing care. Patient financial class information not available from the Ralph H. Johnson VA Medical Center; this Center also does not require collection of patient racial information, accounting for the high percentage of patients with “Unknown” race.

Total number of encounters by Hematology/Oncology attendings in the Hollings Cancer Center, July 1, 2003 through June 30, 2005: 20,070

Total number of encounters by Hematology/Oncology attendings in the Medical University Hospital, July 1, 2003 through June 30, 2005: 4,098

Total number of encounters in Hematology/Oncology Clinic (including junior fellow clinic and all senior fellow continuity clinics) at the Ralph H. Johnson Veterans Affairs Medical Center, July 1, 2003 through June 30, 2005: 359

Total number of discharges of inpatients with hematology/oncology diagnoses from the Ralph H. Johnson Veterans Affairs Medical Center, July 1, 2003 through June 30, 2005: 631

3. Standard Query Language (SQL) queries used on Microsoft Access databases to produce these tables are available from Dr. Afrin.

Inpatient and outpatient care experiences provided to trainees by the Division’s Fellowship Training Program are described in detailed fashion in Section 2, Educational Programs.

In addition, the Training Program’s structure requires the trainee to maintain general internal medicine skills. In recognition of the value of the primary care model of care, fellows who encounter patients who do not have a primary care physician are obligated to attempt to locate such physicians for these patients to optimize their long-term care, but the Program also encourages fellows to personally attend to routine, minor primary care problems not only as a method of maintaining fellows’ general internal medicine skills but also as a matter of convenience for the patients. Still, fellows are cautioned that their principal role during their training is to learn about hematology and medical oncology, and non hematology/oncology-related primary care problems that become too time-consuming need to be referred to the primary care physician for management. Fellows are frequently reminded of the importance of keeping the patients’ primary care physicians informed of progress; part of the fellows’ evaluations hinges on the consistency with which they do this.

The inpatient and outpatient populations seen by the Division’s fellow trainees at the different training sites are themselves quite different. A detailed listing of diagnoses seen in the various settings in the last two years is provided below, but in summary (and not surprisingly), the veteran population is afflicted with multiple common geriatric medical problems (e.g., hypertension, coronary artery disease, diabetes, arthritis/gout) as well as aerodigestive tract cancers borne out of a lifelong history of tobacco and alcohol abuse. These cancers are commonly metastatic at presentation. The population seen at MUSC and the Hollings Cancer Center, on the other hand, tend to be a combination of a classic tertiary referral population as well as a primary/secondary population of patients who are somewhat less likely to have abused substances, somewhat more likely to have attended to their health, and somewhat more likely to present with diseases at less than advanced stages.

Specific diagnoses determined and/or treated by our Division at the various facilities in the recent past are listed below in Tables B1-B4.

Standard Query Language (SQL) queries used on Microsoft Access databases to produce these tables are available from Dr. Afrin.

Oncologic and Hematologic Diagnoses Encountered in the Hollings Cancer Center by Hematology/Oncology Attending Physicians July 1, 2003 through June 30, 2005
ICD-9 Code	Diagnosis	No. of Encounters	Pct. of All Encounters
174.9	MALIGN NEOPL BREAST NOS	3466	17
162.9	MAL NEO BRONCH/LUNG NOS	2027	10
202.8	OTH LYMPH,UN ST,XNOD&SOLD	1478	7
203	MULTIPLE MYELOMA WO REMIS	1279	6
205	AC MYELOID LEUK WO REMIS	1192	6
153.9	MALIGNANT NEO COLON NOS	722	4
205.1	CH MYELOID LEUK WO REMISS	707	4
185	MALIGN NEOPL PROSTATE	695	3
282.61	Hb-SS DISEASE W/O CRISIS	564	3
201.9	HODGKINS UNS STE XNDL&SOL	490	2
285.9	ANEMIA NOS	442	2
204	AC LYMPHOID LEUK WO REMIS	440	2
157.9	MALIG NEO PANCREAS NOS	388	2
204.1	CHR LYMPHOID LEUK WO REM	369	2
150.9	MAL NEO ESOPHAGUS NOS	318	2
238.7	LYMPHOPROLIFERAT DIS NOS	288	1
189	MALIG NEOPL KIDNEY	252	1
188.9	MALIG NEO BLADDER NOS	239	1
280.9	IRON DEFIC ANEMIA NOS	232	1
195	MAL NEO HEAD/FACE/NECK	212	1
198.81	SECOND MALIG NEO BREAST	209	1
172.9	MALIG MELANOMA SKIN NOS	201	1
154.1	MALIGNANT NEOPL RECTUM	193	1
282.6	SICKLE-CELL DISEASE, UNSP	192	1
287.3	PRIMARY THROMBOCYTOPENIA	177	1
287.5	THROMBOCYTOPENIA NOS	151	1
284.9	APLASTIC ANEMIA NOS	143	1
155	MAL NEO LIVER, PRIMARY	129	1
151.9	MALIG NEOPL STOMACH NOS	123	1
288	AGRANULOCYTOSIS	120	1
238.4	POLYCYTHEMIA VERA	111	1
199.1	MALIGNANT NEOPLASM NOS	96	0
161.9	MALIGNANT NEO LARYNX NOS	88	0
202.1	MYCOSIS FUNG UNS ST,XNODL	80	0
202.4	LEUK RETICULOENDOTHELIOSI	76	0
186.9	MALIG NEO TESTIS NEC	73	0
284.8	APLASTIC ANEMIAS NEC	71	0
171.9	MAL NEO SOFT TISSUE NOS	70	0
146	MALIGNANT NEOPL TONSIL	65	0
286.9	COAGULAT DEFECT NEC/NOS	61	0
282.61	HB-S DISEASE W/O CRISIS	57	0
289.9	BLOOD DISEASE NOS	57	0
288.8	WBC DISEASE NEC	51	0
154	MAL NEO RECTOSIGMOID JCT	46	0
191.9	MALIG NEO BRAIN NOS	46	0
146.9	MALIG NEO OROPHARYNX NOS	41	0
239	DIGESTIVE NEOPLASM NOS	41	0
147.9	MAL NEO NASOPHARYNX NOS	37	0
233	CA IN SITU BREAST	36	0
238.9	UNCERT BEHAVIOR NEO NOS	34	0
289.89	OTH SPEC DIS BLD/BLD-FORM	34	0
283.9	ACQ HEMOLYTIC ANEMIA NOS	33	0
148.9	MAL NEO HYPOPHARYNX NOS	32	0
289	SECONDARY POLYCYTHEMIA	31	0
141	MAL NEO TONGUE BASE	30	0
183	MALIGN NEOPL OVARY	28	0
141.9	MALIG NEO TONGUE NOS	27	0
283	AUTOIMMUN HEMOLYTIC ANEM	27	0
153.5	MALIGNANT NEO APPENDIX	26	0
197	SECONDARY MALIG NEO LUNG	26	0
197.7	SECOND MALIG NEO LIVER	25	0
200.8	OTH VAR,UNSP XNOD&SOL SIT	25	0
175.9	MAL NEO MALE BREAST NEC	24	0
189.3	MALIGN NEOPL URETHRA	23	0
164	MALIGNANT NEOPL THYMUS	22	0
198.5	SECONDARY MALIG NEO BONE	21	0
282.62	Hb-SS DISEASE WITH CRISIS	21	0
282.63	SICKLE-CELL/Hb-C DIS W/CR	20	0
162.3	MAL NEO UPPER LOBE LUNG	19	0
187.4	MALIG NEO PENIS NOS	19	0
281.3	MEGALOBLASTIC ANEMIA NEC	19	0
281.9	DEFICIENCY ANEMIA NOS	18	0
282.6	SICKLE-CELL ANEMIA NOS	18	0
198.3	SEC MAL NEO BRAIN/SPINE	17	0
154.3	MALIGNANT NEO ANUS NOS	15	0
182	MALIG NEO CORPUS UTERI	15	0
211.3	BENIGN NEOPLASM LG BOWEL	15	0
288.3	EOSINOPHILIA	15	0
145.9	MALIG NEOPLASM MOUTH NOS	14	0
156.2	MAL NEO AMPULLA OF VATER	14	0
173.9	MALIG NEO SKIN NOS	14	0
183.2	MAL NEO FALLOPIAN TUBE	14	0
170.9	MALIG NEOPL BONE NOS	13	0
176.9	KAPOSI'S SARCOMA,UNSPEC	13	0
239.7	ENDOCRINE/NERV NEO NOS	13	0
202.9	OTH&UNS MAL OF LYMPH&HIST	12	0
212.6	BENIGN NEOPLASM THYMUS	12	0
286	CONG FACTOR VIII DIORD	12	0
202.81	LYMPHOMAS NEC HEAD	11	0
283.2	HEMOLYTIC HEMOGLOBINURIA	11	0
152	MALIGNANT NEOPL DUODENUM	10	0
156	MALIG NEO GALLBLADDER	10	0
202	NOD LYMPHOMA,UNS-STE,XNOD	10	0
237.5	UNC BEH NEO BRAIN/SPINAL	10	0
144.9	MAL NEO MOUTH FLOOR NOS	9	0
164.9	MAL NEO MEDIASTINUM NOS	9	0
208.9	UNSPEC LEUK WO MEN REMISS	9	0
238.6	PLASMACYTOMA NOS	9	0
239.6	BRAIN NEOPLASM NOS	9	0
151	MAL NEO STOMACH CARDIA	8	0
156.1	MAL NEO EXTRAHEPAT DUCTS	8	0
179	MALIG NEOPL UTERUS NOS	8	0
282.41	SCKL CEL THALASS W/O CRIS	8	0
285.29	ANEMIA, OTHER CHRONIC ILL	8	0
193	MALIGN NEOPL THYROID	7	0
198.89	SECONDARY MALIG NEO NEC	7	0
200.2	BURKITT'S,UNSP,XNOD&SOLID	7	0
205.01	AC MYELOID LEUK IN REMIS	7	0
235.5	UNC BEHAV NEO GI NEC	7	0
286.3	CONG DEF CLOT FACTOR NEC	7	0
289.6	FAMILIAL POLYCYTHEMIA	7	0
289.8	BLOOD DISEASES NEC	7	0
155.2	MALIGNANT NEO LIVER NOS	6	0
157	MAL NEO PANCREAS HEAD	6	0
160.9	MAL NEO ACCESS SINUS NOS	6	0
162.4	MAL NEO MIDDLE LOBE LUNG	6	0
162.5	MAL NEO LOWER LOBE LUNG	6	0
174.8	MALIGN NEOPL BREAST NEC	6	0
189.1	MALIG NEO RENAL PELVIS	6	0
202.83	LYMPHOMAS NEC ABDOM	6	0
238.1	UNC BEHAV NEO SOFT TISSU	6	0
239.5	OTHER GU NEOPLASM NOS	6	0
289.81	PRIM HYPRCOAGULABLE STATE	6	0
156.9	MALIG NEO BILIARY NOS	5	0
171	MAL NEO SOFT TISSUE HEAD	5	0
173.3	MAL NEO SKIN FACE NEC	5	0
191	MALIGN NEOPL CEREBRUM	5	0
192.1	MAL NEO CEREBRAL MENING

Age Spectrum of Patients with Oncologic and Hematologic Diagnoses Encountered in the Hollings Cancer Center by Hematology/Oncology Attending Physicians July 1, 2003 through June 30, 2005
Age Range	No. of Patients in this Range	Pct. of Patients in this Range
10-19	91	0
20-29	994	5
30-39	1,704	8
40-49	3,543	18
50-59	5,202	26
60-69	5,074	25
70-79	2,769	14
80-89	664	3
90-99	29	0

Sex Breakdown of Patients with Oncologic and Hematologic Diagnoses Encountered in the Hollings Cancer Center by Hematology/Oncology Attending Physicians July 1, 2003 through June 30, 2005
Sex	No. of Patients of this Sex	Pct. of Patients of this Sex
Female	11,314	56
Male	8,756	44

Racial Breakdown of Patients with Oncologic and Hematologic Diagnoses Encountered in the Hollings Cancer Center by Hematology/Oncology Attending Physicians July 1, 2003 through June 30, 2005
Race	No. of Patients of this Race	Pct. of Patients of this Race
Caucasian	13,256	66
African/African-American	6,422	32
Asian/Asian-American	206	1
Latino/Hispanic-American	129	1
Unknown/Other	57	0

Financial Class Breakdown of Patients with Oncologic and Hematologic Diagnoses Encountered in the Hollings Cancer Center by Hematology/Oncology Attending Physicians July 1, 1996 through June 30, 1997
Financial Class Description	No. of Patients of this Class	Pct. of Patients of this Class
Medicare	7148	36
Blue Cross	5136	26
HMO	3567	18
Medicaid	1994	10
Self-Pay	918	5
Commercial	764	4
Indigent	178	1
CHAMPUS	165	1
Other Sponsors	130	1
State Agency	67	0
Medically Indigent Assistance Fund	2	0
Workmen’s Compensation	1	0

Age Spectrum of Patients with Oncologic and Hematologic Diagnoses Encountered in the Medical University Hospital by Hematology/Oncology Attending Physicians July 1, 2003 through June 30, 2005
Age Range	No. of Patients in this Range	Pct. of Patients in this Range
0-9	0	0
10-19	76	2
20-29	333	8
30-39	371	9
40-49	734	18
50-59	949	23
60-69	875	21
70-79	585	14
80-89	159	4
90-99	16	0

Age Spectrum of Inpatients with Hematology/Oncology Diagnoses Discharged from the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Age Range	No. of Patients in this Range	Pct. of Patients in this Range
20-29	4	1
30-39	5	1
40-49	31	7
50-59	22	5
60-69	180	38
70-79	154	33
80-89	69	15
90-99	6	1

Sex Breakdown of Inpatients with Hematology/Oncology Diagnoses Discharged from the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Sex	No. of Patients of this Sex	Pct. of Patients of this Sex
Male	600	95
Female	31	5

Racial Breakdown of Inpatients with Hematology/Oncology Diagnoses Discharged from the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Race	No. of Patients of this Race	Pct. of Patients of this Race
White, not of Hispanic Origin	275	44
Unknown	203	32
Black, not of Hispanic Origin	151	24
American Indian/Alaskan	1	0
Hispanic, White	1	0

Age Spectrum of Outpatients with Hematology/Oncology Diagnoses Seen at the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Age Range	No. of Patients in this Range	Pct. of Patients in this Range
20-29	1	0
30-39	10	3
40-49	33	9
50-59	77	21
60-69	108	30
70-79	91	25
80-89	38	11
90-99	1	0

Sex Breakdown of Outpatients with Hematology/Oncology Diagnoses Seen at the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Sex	No. of Patients of this Sex	Pct. of Patients of this Sex
Male	331	92
Female	28	8

Racial Breakdown of Outpatients with Hematology/Oncology Diagnoses Seen at the Ralph H. Johnson Veterans Affairs Medical Center July 1, 2003 through June 30, 2005
Race	No. of Patients of this Race	Pct. of Patients of this Race
White, not of Hispanic Origin	170	47
Unknown	104	29
Black, not of Hispanic Origin	84	23
Hispanic, Black	1	0