CORE COMPETENCIES & LEARNING GOALS

The Tulane University Hematology and Medical Oncology Fellowship program is dedicated to training individuals to be competent, humanistic, and scholarly physicians.  Fellows are expected to provide comprehensive care to adults patients presenting with Hematological and Oncologic disease in both the impatient and ambulatory settings.  Specific goals are listed below.

Fellows are expected to read extensively, to use texts only as a base of information and to seek out primary source material in the literature to develop skills in critical analysis of data.  The aim is to prepare fellows for a lifetime of continuing scholarship.

Patient Care

a.  Develop bedside skills important in comforting patients and obtaining clinical data.

b.  Develop skills of obtaining historical and physical examination data

Method of instruction:

• Fellows are trained in the art of bedside care as a part of their ward and ambulatory rotations.

• Teaching rounds are combined with one attending physician conducting both approximately two hours per day. Attending physicians use this time to advance patient care but also to teach residents the art and science of obtaining and processing accurate historical and physical examination data. 

• Didactic lectures are given as part of Various Tumor Boards (Bone Marrow Unit, Multidisciplinary General Tumor Board, Breast Cancer and Head and Neck Tumor Boards, as well as the Benign Hematology Conference and the Didactic Lecture on Fridays). All activities occur on a weekly basis; fellows are also encouraged to attend Internal Medicine Grand Rounds on Wednesdays. As much as possible, the conferences address the core areas of clinical reasoning, diagnostic decision-making, physical examination and procedure techniques.

Method of Evaluation:

• Because attending rounds occur at the bedside, attending physicians are able to evaluate the accuracy of historical data obtained by the resident and to witness each resident’s interaction with the patient. Physicians are also able to demonstrate physical examination techniques and assess residents’ ability to replicate these techniques. Attending and resident evaluations via (www.E-Value.net) have  been redesigned to formalize the evaluation of these skills. 

c.  Develop proficiency in performing and interpreting physical examination maneuvers.

Method of Instruction:

• Fellows are trained in the art of bedside care as a part of their ward and ambulatory rotations.

• Teaching rounds are combined with one attending physician conducting both approximately two hours per day. Attending physicians use this time to advance patient care but also to teach residents the art and science of obtaining and processing accurate historical and physical examination data. 

• Didactic lectures are given as part of Various Tumor Boards (Bone Marrow Unit, Multidisciplinary General Tumor Board, Breast Cancer and Head and Neck Tumor Boards, as well as the Benign Hematology Conference and the Didactic Lecture on Fridays). All activities occur on a weekly basis; fellows are also encouraged to attend Internal Medicine Grand Rounds on Wednesdays. As much as possible, the conferences address the core areas of clinical reasoning, diagnostic decision-making, physical examination and procedure techniques.

Method of evaluation:

• All teaching and management rounds are combined and are conducted at the bedside. This allows the attending physician to both teach and observe the residents’ physical examination techniques. Formal evaluations are conducted via (www.E-Value.net).  Formal feedbacks from students are documented in the resident portfolios.

d.  Develop skills in clinical reasoning and the iterative thought process.

• Use historical data to generate a differential diagnosis.

• Use subsequent questions to assign pre-test probabilities

• Use previously published data from the medical literature (sensitivity, specificity) to calculate likelihood ratios for physical examination and laboratory tests.

• Focus the physical examination to evaluate the diagnoses being considered.

• Use the results of a physical exam test to increase/decrease a diagnosis’ post-test probability.

• Use the results of a laboratory test to increase/decrease a diagnosis’ post-test probability.
  

• Use cost-benefit analysis to establish treatment and testing thresholds
  

Method of Instruction:

• Overall, the conferences have been redesigned to focus less on didactic discussion of disease, and more upon active participation of the fellows in elucidating clinical reasoning techniques.
  

Method of Evaluation:

• Through direct evaluation by the attending on a monthly basis, for the clinical rotations. 

e.  Know how to discern and communicate the relevant features of a clinical case

• Structure the oral presentation to highlight relevant data

• Adapt a presentation to different clinical scenarios

• Structure an admission note to highlight relevant data

• Structure a progress note to highlight relevant data
  

Method of Instruction:

• Taught during internal medicine residency and reinforced during fellowship.

Method of Evaluation:

• Fellows are evaluated in their written and oral communication skills as part of their monthly ward evaluations (www.E-Value.net) and by the feedback received from their students.

f.  Acquire the skills for diagnosis and management of terminal disease.

g.  Understand the emotional, social and financial implications of terminal disease.

Method of Instruction:

• Fellows will be trained on the ability to identify the special aspects of terminal patients such as emotional, social, and financial needs. This is done through the direct interaction with the staff attending that rotation.
  

Method of Evaluation:

• Attending evaluations are used to evaluate residents understanding of chronic and terminal disease.

Medical Knowledge

a.  Develop the knowledge and skills needed for the diagnosis and management of Oncology disease in ambulatory, critical and non-critical inpatient care settings.

Method of Instruction:

• Fellows will attend formal didactic lectures as well as benign Hematology Conference Friday; Bone Marrow Conference every Monday, and multidisciplinary Tumor Boards on Tuesdays.

Method of Evaluation:

• Medical knowledge is evaluated as a part of the In-Service Training Examination, and by ward evaluations from attendings.
  

b.  Develop proficiency in the procedures commonly performed by a Hematologist/Oncologist.

 

Method of Instruction:

• Done by direct supervision of the attending; all procedures are overseen by an attending and methods on how to perform such procedures  are previously discussed and described; the fellowship manual contains a list of procedures and a theoretical description on how to perform these. Once the fellow is considered proficient, he or she can then perform procedures without supervision.

Method of Evaluation:

• Attending evaluations are used to evaluate fellows’ proficiency in performing procedures. Fellows are required to become certified in each procedure with documented supervision of successful completion of the procedure. Procedure completion forms on (www.E-Value.net) document performance of the ABIM required procedures.
  

c.  Acquire the skills necessary to be an effective consultant, and know when to request consultation from other services.

Method of Instruction:

• Fellows are taught the techniques of consultative medicine as part of their core curriculum. This includes the objectives of learning interpersonal and communication skills as well as specific topics of medical consultation.

Method of Evaluation:

• Attending evaluations are used to evaluate the fellows’ consultation abilities with respect to patient care, medical knowledge and interpersonal and communication skills.

Practice-Based Learning & Improvement

a.  Use the medical literature to obtain information necessary to make evidence-based decisions in the management of their patients, including the following specific goals:

• Interpret measures of association between risk factors and disease. (relative risk, odds ratios).

• Interpret measures of disease outcomes – incidence, prevalence 

• Define and interpret null and alternative hypotheses and the role of p-values in statistical decision making.

• Define and compare clinical significance and statistical significance

• Define sampling variation, compute and interpret standard error and confidence intervals.

• Perform a t test; understand how sample size and standard deviation affect power  

• Know how to calculate and interpret a confidence interval
  

Method of Instruction:

• Fellows participate in a monthly Journal Club to consolidate these skills. Peer reviewed clinical studies are presented by the fellows. Discussion that follows includes explanation of statistical methods used, conclusions made, and the effect of the results of the study on the standard management of the disease.

Method of Evaluation:

• As active participants in the journal club, fellows’ skills in evaluating the medical literature are evaluated. Journal club discussions are focused via the Journal Club Guide to ensure that each resident can answer key questions targeting the above objectives.
  

b.  Understand the features of clinical trials

• Know the features of and how to design a descriptive study

• Know the features of and how to design a case-control study 

• Know the features of and how to design a cohort study

• Know the features of and how to design a randomized controlled trial

c.  Critically appraise the medical literature and use it to make evidence-based clinical decisions.

Method of Instruction:

• See the journal club descriptions above. Fellows are encouraged to use NCCN® guidelines as well as Uptodate® to practice evidence-based medicine.

Method of Evaluation: 

• Direct supervision and evaluation from the attending is done by the Program Director/Associate Program Director at the end of the presentation.  The results are shared with the fellow at the end of each session.
  

d.  Accurately document patient care and treatment plans.

Method of Instruction:

• Direct interaction with the supervising faculty.

Method of Evaluation:

• Once per ward month, each fellow has two charts reviewed by the attending for the month. In addition, in all ambulatory rotations, fellows dictate a note, which is forward for review and signature by the appropriate attending, thus giving an opportunity for additional evaluation.

Interpersonal and communication skills

a.  Develop the fundamentals of leadership. Successfully lead a health care team comprised of members of nurses, physician assistants, and social workers.

Method of Instruction:

• Fellows acquire leadership, teamwork and educational skills while rotating in the comprehensive care clinics. They also learn systems-issues related to team and leadership on the job as the key team leader for the inpatient consultation service.

Method of Evaluation:

• Residents are evaluated as part of their monthly ward rotations by attending physicians. Other personnel (nurses, PA and medical students) provide feedback and point out potential problems and solutions.

b.  Develop the fundamentals of medical education.

Method of Instruction:

• Each fellow is required to engage in multiple teaching activities each year; including journal club, benign hematology conference, formal and informal lectures to the members of the team while in the inpatient  or consult service. Fellows also receive training in teaching students and Medical Residents how to give oral case presentations.

Method of Evaluation:

• Fellows are evaluated by the students that they teach. These evaluation forms that target interpersonal skills and communication are filed in the resident’s portfolio. There is also direct attending supervision during these activities
  

c.  Develop skills in interpersonal relationships.

Method of Instruction:

• Residents are taught the principles of interpersonal relationships through all of their training. 

Method of Evaluation:

• Patients and nurses evaluations (one per year for each resident- also called 360 evaluations) are designed to assess the resident’s interpersonal skills. One patient will be surveyed per fellow frequently.
  
• One patient will be surveyed per fellow frequently.  The fellow is responsible for picking up two forms from the fellowship coordinator’s office.  The form should be filled out by the patient, returned to the office in the envelope provided.  This is in addition to the attending physician, other resident, and student evaluations that are collected.
  

d.  Identify signs of emotional distress and substance abuse in colleagues.

Method of Instruction:

• Fellows are required to attend a Sleep-Deprivation course and pass an in-service.  Fellows also participate in school (Tulane) and hospital (MCLNO) Housestaff Forums on Impaired Physicians and dealing with death and dying.
  

Method of Evaluation:

• Residents work as supervisors and preceptors for medical students. In this capacity, they are called upon to exercise these skills.

Professionalism

a.  Develop habits for life-long self-education and personal growth.

Method of Instruction:

• Each year, fellows are taught how to develop reading strategies and methods of preventing skills decline as they continue to acquire new knowledge.

Method of Evaluation:

• Done on a monthly basis with the supervising staff, also during tumor board presentations as well as journal club.

b.  Develop an understanding of the principles of ethical care.

Method of Instruction:

• Each year, fellows are taught how to develop reading strategies and methods of preventing skills decline as they continue to acquire new knowledge.
  

Method of Evaluation:

• Ethical practice of medicine is evaluated as part of the monthly ward evaluation form. Attending physicians evaluate each fellow on a monthly basis.
  

Systems-based practice

a.  Understand the systems of medical care. This includes familiarity with medical economics, regulations and types of health care and health delivery.

• Medicaid regulations, standards of care and billing requirements

• Medicare regulations, standards of care and billing requirements

• Uncompensated care provisions

• Third-party insurance regulations, standards of care and billing requirements
  

b.  Understand the principles of medical economics.

c.  Gain proficiency in accurate diagnostic coding and billing.

Method of instruction:

• Fellows are required to attend a lecture on “Documentation exceeding standards of care” supplied by the department of medicine.