Oncology

Educational Purpose and Goal:

Cancer is second leading cause of death in the US. Internists must be familiar with diagnosis and care of cancer patients. This rotation will prepare residents to diagnose, evaluate, stage or treat patients with hematological malignancies, solid tumors, oncological and hematological emergencies, and to provide supportive/palliative care.

Residents (PGY IIs and IIIs) will work in teams under the supervision of an oncology fellow and attending; teaching is divided between one supervising Solid Tumor attending and one supervising Hematologic attending. All patient care is supervised by the responsible faculty.

Competency-based level-specific objectives:

PGY 2

Patient Care

• Recognize the acuity levels of illness

• List the indications, contraindications and risks of common procedures

• Work with all providers to provide patient-focused care

Medical Knowledge

• Utilize literature and reference sources to increase knowledge base

• Demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of basic disease states

• Apply knowledge in the treatment of patients.

• Recognize and manage appropriately oncological emergencies

• Provide adequate symptom control and demonstrate knowledge for control of pain, nausea, and anxiety

Practice-Based Learning and Improvement

• Recognize limitation of knowledge

• Use references and literature to improve practice patterns

• Accept feedback and change behavior

• Ask for help when needed

• Apply evidence-based strategies to prevention, diagnosis, and disease management

Interpersonal and Communications Skills

• Communicate effectively with patients, families, and other members of health team

• Write understandable notes

• Appreciate roles and interaction of the multiple disciplines in the care of oncology patients

Professionalism

• Demonstrate compassion, integrity and altruism in relationships with cancer patients, families and colleagues

• Explain moral and ethical issues encountered in hematology/oncology practice and in conducting clinical trials

Systems-based practice

• Identify the role of ancillarypersonnel including nurses, social worker, hospice personnel, payors and regulatory bodies

• Advocate for quality patient care and assist patients in dealing with system complexities

PGY 3

Patient Care:

• Manage patients with cancer including appropriate diagnostic and therapeutic approaches;

• Explain the safe use of chemotherapy and treatment-related complications;

• List the indications and techniques to safely and effectively perform invasive diagnostic/therapeutic procedures including paracentesis, thoracentesis, and lumbar puncture, bone marrow biopsy

Medical Knowledge

• Practice appropriate management strategies for hematologic/solid tumors;

• Explain the scientific principles underlying recent molecular genetic advances;

• Recognize and manage appropriately oncological emergencies;

• Describe the basic principles of major modalities of cancer treatment including

  1. Chemotherapy

  2. Biological treatment

  3. Surgical treatment

  4. Radiation therapy

  5. Immunotherapy

  6. Targeted therapies-personalized medicine

• Provide adequate symptom control and demonstrate knowledge for control of pain, nausea, and anxiety

Practice-Based Learning and Improvement

• Analyze and interpret clinical trials

• Acquire knowledge to choose diagnostic studies in an orderly and effective way to improve patient care

• Practice evidence-based strategies to prevention, diagnosis, and disease management

Interpersonal and Communications Skills

• Communicate effectively with patients, families, and other members of health team

• Write understandable notes

• Identify roles and interaction of the multiple disciplines in the care of oncology patients

Professionalism

• Demonstrate compassion, integrity and altruism in relationships with cancer patients, families and colleagues

• Work competently with patients regarding advanced care planning, futility, and withholding or withdrawing therapy

• Gain an understanding of moral and ethical issues encountered hematology/oncology practice and in conducting clinical trials

Systems-based practice

• Gain knowledge of the health care delivery system including the role of ancillarypersonnel including nurses, social worker, hospice personnel, payors and regulatory bodies;

• Advocate for quality patient care and assist patients in dealing with system complexities

Educational content:

• Biology and genetics of cancer

• Epidemiology of cancer

• Cancer screening guidelines

• Prevention

• Diagnoses, staging, prognosis, and treatment of common malignancies

• Lung cancer

• Breast cancer

• Prostate cancer

• Colorectal cancer

• Pancreatic cancer

• Esophageal cancer

• Head & Neck cancer

• Pancreatic cancer

• Gastric cancer

• Lymphoma

• Acute and chronic leukemia

• Chronic myeloproliferative disorders

• Ovarian cancer

• Uterine cancer

• Cervical cancer

• Brain tumors

• HIV related malignancies

• VTE in cancer patients

• Paraneoplastic syndromes

• Administration and side effects of Chemotherapy, immunotherapy, and targeted therapies

• Oncological emergencies:

  • 1. Neutropenic fever

    2. Infections in cancer patients

    3. Pericardial effusion/cardiac tamponade

    4. Metabolic emergencies:

       • Hypercalcemia

       • Tumor lysis syndrome

       • Hypoglycemia

       • SIADH

    5. Superior vena cava syndrome

    6. Neurological emergencies

       • Spinal cord compression

       • Seizures

       • Brain metastases

       • Leptomeningeal metastases

• Supportive care

• 1. Symptom control including pain

  2. Giving patients bad news

• Radiation therapy

• 1. Indications

  2. Mechanisms of radiation therapy

• Diagnostic procedures: Indications, and limitations as well as technical aspects of common diagnostic procedures

• 1. Bronchoscopy/ Mediastinoscopy

  2. Bone marrow aspiration and biopsy

  3. PET scan

Principal Teaching Methods/Learning Venues

There are 2 separate oncology services: NW2 (“liquid”) and NW8 (“solid”). IM housestaff are assigned to both NW2 and NW8 and are in charge of routine patient care (not chemotherapy regimens). There is a separate 24-hr PA service that takes care of half of the patients on NW2 (including the BM transplant patients).

There are 2 Montefiore residents assigned to each service, and 1 Wakefield resident assigned to the liquid service only (most of the time).

Schedule/Shifts/Sign-out:

1. Sign out occurs at 7 AM from the overnight PA, on your respective floors.

2. There are four types of shifts. Every day, there is one resident on call on each floor, and he/she is responsible for admitting patients that day. Please make sure to look at New Innovations prior to the start of the rotation, and note when you are on call (short/long), and when you have clinic/wellness half-days.

   1. • The Short Call resident stays until 5 PM and admits any patients that come to the floor until 4 PM.

      • The Long Call resident stays until 7 PM and admits patients up until 6 PM. The short call resident signs out to the long call resident at 5 PM, and the long call resident cross-covers both services between 5-7 PM and admits to both services. The Wakefield resident on NW2 is admitting on all days until 5 PM (but does not work on the weekends).

      • Half Days are non-admitting shifts which are followed by clinic, wellness half-day, or board review. You are expected to stay until at least 12 PM, participate in rounds, and write your progress notes. After 12 PM, you will sign out to the on-call resident and leave.

      • Onc-No Adm days are also non-admitting shifts. You will stay until approximately 4 PM but do not do any admissions (unless it is a particularly busy day and help is needed, but this should not happen often).

3. Sign-out between the long call resident and night PAs for both services takes place on NW2.

Floor splits/Floor cross covering policies:

1. On NW2, the oncology attending/fellow will triage patients to the appropriate service, i.e. PA vs. housestaff (there is no geographic split within the floor itself). The housestaff service is to cap at 17 patients.

2. During the cross-coverage period (5-7 PM), the "team" dynamics are to change, so that (when needed) the resident is the senior member of the team who can delegate responsibilities to the 2 PAs. This is mainly intended for when there are too many urgent matters for one resident to handle. During these times, the PAs can and should help out, even on NW8.

3. The on-call fellow is expected to stay in house until 6 PM everyday (except weekends/holidays).