Program Introduction for Interviewing Hematopathology Fellows

Program information

Mission statement

Our mission is to cultivate independent hematopathology practitioners of the highest quality who contribute to, and advance, our specialty and to nurture well-being through collegial interactions and assist in meeting personal and professional goals.

Program aims

• To provide training based on the diagnosis of hematoplymphoid disorders that span the spectrum of reactive and neoplastic entities.
• To provide training and experience that allows physicians to develop a strong foundation to become successful medical directors and laboratory managers.
• To provide educational opportunities for fellows to teach in a variety of settings to residents, medical technologists, and clinical and pathology providers.
• To provide opportunities for research and training in the application of evidence-based medicine in daily clinical practice.

Program details

This Accreditation Council for Graduate Medical Education-accredited fellowship is designed to provide a wide scope of experience in Hematopathology as regards clinical diagnostics, administration, teaching, and academics.

Hematopathology is an unusual specialty in several respects. It cuts across essentially all divisions in Anatomic and Clinical Pathology. The practice involves proficiency in general surgical pathology to cover the spectrum of hematological neoplasms involving the gastrointestinal, genito-urinary, cutaneous, and central nervous system along with proficiency in cytogenetics, molecular diagnostics and flow cytometry. It is an evolving field incorporating newer molecular genomics and machine learning.

The foremost goal is to train fellows to be proficient in the diagnosis of hematolymphoid disorders that span the spectrum of reactive and neoplastic entities. The fellow will become familiar with the challenges seen in atypical lesions, the pitfalls and diagnosis based on limited specimen; interpretation of newer delineated molecular genetic aberrations in the context of traditionally defined morphologic entities. Fellows are trained to be future consultants in regards to specimen requirements, interpretation of complex tests, and diagnostic implications of the diagnosis. The fellow will be responsive to optimal utilization of resources in the context of personalized medicine.

The second goal is to train future directors and laboratory managers. The training in laboratory management includes didactic sessions in Quality Management Systems, Regulatory Laws and Requirements, Laboratory Trends, Personnel Management, Business Planning, and Laboratory Safety. Didactics and projects in Quality control, quality assurance, and quality improvement are available. Curriculum includes laboratory certifications and regulations under CAP and CLIA. The fellow is encouraged to attend laboratory management meetings and participate in CAP inspections.

The third goal is to train fellows to be future mentors and program directors. A hematopathologist is continuously involved in educating medical technical staff, residents, and clinical providers. The training is directed to meet these requirements.

Finally, fellows will continue their training in evidence-based medicine for application in daily clinical practice. Accordingly, training in research will incorporate participation in the IRB process, investigative research project, and publication in peer-reviewed journals. Our previous trainees have demonstrated success in all aspects of this training with posters or plenary sessions at national level meetings with follow-up publications in peer review journals.

Faculty

Rotation schedule

Hematopathology Rotations: 1 block = 4 weeks

Lymphoma – 0.5 block

The fellow will be involved in Lymphoma diagnosis in Core I, II, and III. The fellow will guide the residents and pathologist assistants who are involved in grossing these specimens. The fellow will competently use ancillary techniques requisite for diagnosis, based on the clinical history, morphologic evaluation and amount of specimen available for evaluation. The fellow will select and order the ancillary techniques to be performed in the evaluation of in-house and consultation cases with support of the attending on service during sign-out.

There is a spectrum of reactive lymphoid hyperplasia and hematolymphoid malignancies encountered in surgical specimens. For each disorder, the fellow will apply the pathologic diagnostic criteria, including optimal ancillary techniques that will support each diagnosis and the associated clinical features. The basic knowledge on each disorder (adequate reading references will be provided) and literature review on the latest issues discussed on the same will be expected. The cases will be discussed with the staff hematopathologist at sign-out and a log of the cases seen will be maintained by the fellow.

The fellow will write accurate, succinct pathology reports that incorporate the results of morphologic evaluation and ancillary techniques with support of the hematopathologist. The fellow will communicate with the clinicians in regards to pertinent clinical information required for diagnosis and provide verbal communication or results, especially of urgent/unexpected findings and the clinical significance of the diagnosis. The fellow will go through study sets that include spectrum of reactive lymphadenopathies and B and T cell lymphomas.

Core I – 2 blocks

In Core I the fellow will learn techniques of bone marrow aspiration and biopsy. Acquisition of bone marrow specimens is under the direction of the Clinical Hematology section of the Department of Medicine, through which the fellow will be provided the opportunity to learn aspiration and biopsy techniques on patients.

The fellow will rotate through the General Hematology Laboratory. Didactic sessions will be given to address the basic principles of cellular hematology, automated hematology analyzers, and automated/manual differential counts. The fellow will review CBC and differential counts in the context of peripheral blood smear and bone marrow specimen evaluation during the course of bone marrow evaluation. As part of general hematology laboratory rotation, the fellow will learn principles of Wright-Giemsa staining and tissue fixation and will become familiar with troubleshooting stain questions (for the optimal evaluation of peripheral blood and bone marrow specimens).

Bone marrow evaluation requires the information of clinical features, diagnostic criteria, and the use of optimal ancillary techniques in arriving at the diagnosis. The fellow is responsible for obtaining clinical history, limited physical examination, clinical consultations in the form of written and telephone follow-ups as appropriate. This will include daily review with clinical hematologists, daily sign-out of cases, presentation at regular conferences, and ad hoc consultations.

The fellow will, with the support of staff hematopathologists, utilize the ancillary techniques of cytochemical stains, flow cytometry, immunohistochemistry, molecular pathology, cytogenetics, fluorescence in-situ hybridization in a diagnostically efficient, cost-effective manner based on morphologic differential diagnosis.

The fellow will become proficient in understanding the clinical features and pathologic features of the main categories of hematologic disease include acute and chronic myeloid disorders, lymphoid disorders, plasma cell proliferative disorders and reactive hematologic conditions. Review of cases will require basic knowledge database (adequate reading references will be provided) and review of literature that discusses the latest pertinent issues relating to the disorder will be expected. The cases will be discussed with the staff hematopathologist at sign-out and a log of the cases seen will be maintained by the fellow.

During the core rotation, the fellow will review a select number of peripheral blood smears each day with the staff hematopathologist. Smear reviews for pathologists are either generated by technologists for review of unexpected findings (“internal”), or if processed due to requests from clinicians (“external”). The fellow will be the primary contact person for the clinical laboratory technologists for questions that arise during the bone marrow rotation.

During the core rotation, the fellow will review body fluid cases each day with the signing out hematopathologist and correlate findings with those that are associated with a concurrent cytology report.

During the core rotation, the fellow will preview hemoglobinopathy evaluations before sign-out with the hematopathologist. Using common electrophoresis techniques such as cellulose acetate electrophoresis and citrate agar electrophoresis, the fellow will become proficient in the diagnosis of common hemoglobin variants such as HbS, HbC, and HbE. The fellow will learn the principles of specialized techniques used in reference labs, such as isoelectric focusing, globin chain electrophoresis, DNA sequencing and their appropriate utilization. The rare variants are sent to reference labs for further evaluation, and the fellow will review these results on their return.

Fellow will apply the use of electrophoresis and immunofixation in the examination of proteins and assessment of monoclonal proteins in plasma cell disorders and lymphoproliferative disorders. Fellow will write up reports in this context.

The fellow will participate in teaching residents the basic principles of hematology. The fellow will present cases in the hematopathology conference/tumor board where clinicians, hematopathologists, cytogeneticists, and molecular pathologists meet to discuss clinical cases.

The fellow, with the support of the attending hematopathologist, will gross specimens received for hematologic malignancies. The fellow will also guide the residents and pathologist assistants who are involved in grossing these specimens. The fellow will competently use ancillary techniques requisite for diagnosis, based on the clinical history, morphologic evaluation, and amount of specimen available for evaluation.

There is a spectrum of reactive lymphoid hyperplasia and hematolymphoid malignancies encountered in surgical specimens. For each disorder, the fellow will apply the pathologic diagnostic criteria, including optimal ancillary techniques that will support each diagnosis and the associated clinical features. The basic knowledge on each disorder (adequate reading references will be provided) and literature review on the latest issues discussed on the same will be expected. The cases will be discussed with the staff hematopathologist at sign-out and a log of the cases seen will be maintained by the fellow. The fellow will be expected to actively participate in the weekly hematopathology conference, explaining the diagnoses of key cases diagnosis and reviewing pertinent current literature.

Core II – 3 blocks

During Core II, the fellow will be expected to build on knowledge and skill levels gained in Core I and take on the added responsibility of flow cytometry. The fellow will receive a general introduction to the instrumentation and theoretical and practical aspects of surface and cytoplasmic phenotyping, DNA content analysis, and CD34 quantitation of stem cell collections during the two-week flow cytometry rotation which will be scheduled before the start of Core II.

Lymphomas and leukemias are routinely analyzed by flow cytometry. Flow results are then discussed in the context of morphology and enzyme cytochemistries during bone marrow and lymph node sign-outs with the hematopathologist. Flow phenotyping is also discussed at weekly hematology/pathology conferences, where most recent hematologic malignancies are presented for review and clinical discussion.

During Core II, the fellow retrieves and reviews all flow cytometry studies relating to submitted cases and discusses the interpretation with the covering staff. As skills develop, fellows write interpretive reports which are then discussed with senior staff before sign-out. The fellow can assume management of the clinical laboratory, becoming the first line in deciding whether flow cytometry is appropriate to the analysis of new specimens sent to the lab, and which panels should be utilized. The fellow can also serve as consultant to clinicians who call regarding specimen requirements, appropriate studies, or interpretation of results.

Core III – 3 blocks

During Core II, the fellow will be expected to build on knowledge and skill levels gained in Core I and take on the added responsibility of coagulation and consults. The fellow will learn to perform screening tests, factor assays, factor inhibitor assays, platelet aggregation studies during a two-week coagulation rotation which will be scheduled before the beginning of Core III.

The mixing studies (MS) and thrombosis screens (TS) are reviewed by the faculty. The fellow will participate, along with the hematopathologist, in choosing appropriate tests for the MS and TS studies based on the clinical history and will be involved in signing out these cases with the Director, through Core III. The fellow will be encouraged to see patients with bleeding and coagulation disorders. They will also attend the conference dedicated to these disorders (once a month).

Laboratory Genomics I - 0.5 block

The fellow rotates through the cytogenetics section of the CGAT laboratory to learn and obtain practical experience in the processing and analysis of blood, bone marrow, and other tissue samples for acquired chromosomal abnormalities. The fellow will participate in culture setups, harvesting, and slide preparation, staining, and/or hybridization. He/she will participate in scoring of FISH results and their interpretation. FISH exposure will include an overview of the panel testing performed at Dartmouth Hitchcock Medical Center, rationale behind panel design, special processing such as cell enrichment protocols, and interpretive pitfalls.

The fellow will have the opportunity to prepare a karyotype from beginning to finish, and will also review existing prints representing normal and abnormal complements to learn morphology and banding characteristics of each human chromosome. Cases with abnormal karyotypes are used in discussions with the laboratory Director/Supervisor to learn about the significance of abnormal chromosome findings in congenital and acquired diseases. While hematologic neoplasm testing is currently not analyzed by chromosomal microarray at our institution, at least once during part 1 of the rotation, the fellow will be required to observe a complete specimen batch workflow through to sign-out for exposure to this technology.

The fellow reviews the clinical history of patients referred for cytogenetic analysis during the weeks on service and will have discussion/didactic sessions as these cases are signed out. There is a set of articles/chapters on basic genetics, molecular genetics, clinical cytogenetics, and cytogenetic techniques for the fellow to read during the rotation in order to learn/refresh the principles of cytogenetic testing. The fellow will review the CAP checklist for cytogenetic laboratory inspections and the recent challenges in the CAP proficiency surveys.

Laboratory Genomics II - 0.5 block

The fellow rotates through the molecular laboratory for instruction in the basic techniques of DNA isolation and quantification, capillary electrophoresis, traditional and real-time polymerase chain reaction, and DNA sequencing. Prior to rotating through to the wet lab, the fellow will participate in hematopathology-related genetics didactics and case sign-outs with the CGAT molecular faculty member on service. Observation of the technical component of the workflow for any given assay must follow and be within a professional interpretive context.

The testing focus for this block will cover hematopathology-related molecular singleplex assays, though assays for non-hematologic diseases will also be reviewed if the underlying technologic basis for the assay has broad practical application. The broad array of well-characterized pathogenic mutations associated with hematologic illnesses will be covered, as well as established testing methodologies used in the treatment or monitoring of hematologic illness (i.e., chimerism analysis, B- and T-cell clonality analysis, etc). Exposure to massively parallel sequencing and other newer/emerging technologies will be expressly covered in part three of their overall rotation. The fellow will also participate in esoteric molecular genetic testing send-out utilization review with the molecular pathology fellows, attend utilization-review/prior-authorization conference, and become familiarized with specialized software/workflows to help expedite this process. The fellow will also be expected to field and resolve all questions regarding hematologic molecular testing.

An extensive collection of books, manuals, and journal articles are available for study of basic principles and specific diseases. Disease-oriented didactic sessions will be scheduled at the beginning of the block, and sign-out sessions individually scheduled with the faculty member on-service. At the end of this block, the fellow will provide a 30-minute ‘journal club’-style presentation/discussion on a timely/relevant topic for the CGAT technical staff.

Laboratory Genomics III - 0.5 block

The fellow will continue their rotation through the CGAT laboratories, with particular focus on massively parallel sequencing technologies, other newer/emerging technology, test utilization, and exposure to specific resources to aid in the interpretation of new/less-well-established/potentially-pathologic gene variants. If the fellow developed a particular interest or would like additional exposure to topics from the first two blocks, this may also potentially be scheduled on an individual basis. Again, prior to rotating through to the wet lab, the fellow will participate in hematopathology-related genetics didactics and case sign-outs with the CGAT molecular faculty member on service. Observation of the technical component of the workflow for any given assay must follow and be within a professional interpretive context.

The fellow will be exposed to the workflow for both the wet- and dry-bench portions of next-generation sequencing (NGS). While multiple NGS assays are offered at Dartmouth Hitchcock Medical Center, the trainee’s contact will be focused mostly on hematopathology-related gene sequencing panels as the prototype for didactics. Time will also be scheduled with the CGAT faculty member on-service for sign-outs and/or technical observation as they pertain to new/emerging technologies. The fellow will also participate in esoteric molecular genetic testing send-out utilization review with the molecular pathology fellows, attend utilization-review/prior-authorization conference, and becoming more familiar with this process. The fellow will also be expected to field and resolve all questions regarding hematologic molecular testing.

An extensive collection of books, manuals, and journal articles are available for study of basic principles and specific diseases. ACMG/CAP guidelines for molecular diagnostic testing will also be reviewed. Disease-oriented didactic sessions will be scheduled at the beginning of the block, and sign-out sessions individually scheduled with the faculty member on-service. No presentation/discussion will be required at the conclusion of this block, however the fellow may be asked to participate in a small molecular genetic testing workflow-improvement project for the hematopathology section.

Coagulation – 0.5 block

The coagulation rotation will include a two-week rotation through the coagulation section of the hematology laboratory. The fellow will learn to perform screening tests, factor assays, factor inhibitor assays, platelet aggregation studies.

Flow Cytometry – 0.5 block

This experience in flow cytometry includes a general introduction to the instrumentation and theoretical and practical aspects of surface and cytoplasmic phenotyping, DNA content analysis, and CD34 quantitation of stem cell collections. Lymphomas and leukemias are routinely analyzed by flow cytometry. Flow results are then discussed in the context of morphology and enzyme cytochemistries during bone marrow and lymph node sign-outs with the hematopathologist. Flow phenotyping is also discussed at weekly hematology/pathology conferences, where most recent hematologic malignancies are presented for review and clinical discussion. During the two week rotation in flow cytometry, the fellow reviews with the supervisor/technologists the instruments in the lab, and, for each type of assay, the mechanics of specimen preparation, the actual running of specimens, and their preliminary analysis.

The fellow subsequently observes the second level of analysis performed on list mode data, utilizing the offline workstations within the flow laboratory. He/she then discusses the interpretation of results and final report with the laboratory director or covering staff physician. A syllabus of learning objectives and relevant articles on the theory and practice of clinical flow cytometry is available in the lab for review, in addition to the laboratory manual.

Research – 1 block

Fellows will develop academic skills by completing at least one clinicopathologic study. All fellows are expected to conceive, plan, execute, analyze, and write up an original research project. These are projects of the fellows’ development, not just participation in ongoing faculty projects. These projects are expected to result in both an abstract submission for presentation at a national meeting, as well as manuscript submission for publication.

Sample block schedule (PDF)

Conferences

The Dermatopathology Fellow participates in regularly scheduled lectures, tutorials, seminars, and conferences.

Conference	Frequency
Hematopathology Conference	Weekly
Cutaneous Lymphoma Tumor Board	Monthly
Lymphoma Tumor Board	Weekly
Clinical Pathology Seminar	Weekly
CP Call Rounds/Quiz/Chalk	Weekly
Coagulation Conference	Monthly
Laboratory Management Seminar	One-day seminar
Pathology & Laboratory Medicine Grand Rounds	Monthly
Pathology Journal Club	Bi-monthly
Anatomic Pathology Didactic Conference	Weekly
Cytology Conference	Weekly
Molecular Conference	Weekly

Leadership Preventive Medicine Residency (LPMR)

• Builds on TDI strengths in outcomes research, improvement, population health, and institutional commitment to quality, safety, and value
• MPH degree from TDI – tuition paid by program!
• Opportunity to lead change and improvement at Dartmouth Hitchcock Medical Center
• Two-month governmental public health experience
• Dedicated faculty coach; teaching opportunities; unique multi-specialty resident/fellow/faculty group
• May incorporate research in one year of program (3 + 1)
  • continue clinical work
  • moonlighting allowed
• Graduates are in demand and employers are very interested in their mix of clinical skills plus improvement and change knowledge and experience
• Visit the LPMR web page, email tina.c.foster@hitchcock.org or contact an alum to learn more!

Contact us

elaine.r.danyew@hitchcock.org, Program Coordinator
prabhjot.kaur@hitchcock.org, Program Director