First Year Experience
First Year Program Details
(13 months, including orientation month) The first-year curriculum includes the following rotations:
- Orientation — 1 month
- Inpatient oncology experience — 3 months
- Inpatient hematology experience – 3 months
- Outpatient oncology experience — 2 months
- Outpatient hematology experience - 6 weeks
- BMT unit — 1 month
- Practicum — 1 month ambulatory subspecialty clinics - 2 weeks
Initially, all new fellows participate in a month long series of subspecialty-focused orientation lectures. A wide range of topics is covered, including in-depth reviews of the diagnosis and management of the major diseases that confront the pediatric hematologist-oncologist, discussion of the principles of experimental design and clinical trial implementation, an overview of epidemiology, and topics related to clinical investigation in pediatric hematology-oncology. In addition to this orientation program, which is organized by our training program faculty, fellows participate in the Fundamentals of Clinical Investigation course sponsored by the Department of Pediatrics. This 32-hour presentation course covers topics on clinical investigation, statistics, ethics, medical literature appraisal, pharmacokinetics, molecular medicine and gene therapy. Fellows are expected to pass a written examination at the end of this course.
The subsequent 12 months of training primarily focus on the clinical aspects of pediatric hematology-oncology. Fellows are trained in the principles of evaluation, diagnosis, and management of pediatric hematologic and oncologic disorders. The clinical experience includes primary patient care in both inpatient and ambulatory settings, consultations in both settings, and participation in teaching pediatric residents. As outlined above, the first year of training includes 12 clinical rotations, both inpatient and outpatient, each one month long. These rotations include three months dedicated to the oncology inpatient unit at Texas Children’s Hospital, three months on the inpatient hematology service, four months in the outpatient clinic, and one month on the 15-bed Bone Marrow Transplantation Unit. The remaining month is spent in a rotation designated the Coursework month. The Coursework month is a learning experience which focuses on coagulation, hematopathology, blood banking, radiation oncology, immunophenotyping, cytogenetics, and DNA diagnostics. Trainees are given a list of specific procedures and learning goals for each activity they encounter. It is important to highlight that the Pediatric Hematology-Oncology Training Program emphasizes one-on-one supervision throughout the trainees’ entire educational experience. During every phase of the clinical training program, the fellows collaborate closely with faculty members to learn and deliver quality patient care.
On the Inpatient Oncology Service (3 months total), first-year fellows oversee the care of 20-25 patients on their team. These patients include new admissions with possible or established oncologic diagnoses, patients on scheduled admissions for therapy or other elective procedures and patients who are unscheduled admissions with disease and/or treatment complications. There are two inpatient oncology teams, each with a fellow and a supervising attending physician. One team is staffed with pediatric interns, residents, and a nurse practitioner. The other team includes two rotating upper-level residents and a full-time clinician. The two teams admit patients on alternating days and are responsible for the care of patients admitted on their call days. Fellows and faculty determine patient distribution daily to help balance their workloads. Night call for fellows on their admission days is taken from home. The service has a full-time faculty nocturnist who remains in house overnight. The fellows participate in daily family-centered, bedside rounds with the attending physicians and house officers, where every patient is reviewed, discussed, and evaluated. The supervising physician is available to the fellow 24 hours a day. Fellows have no other clinical responsibilities during this month so that they can devote all of their time to patient care and teaching.
The Inpatient Hematology Service (3 months total) consists of two first-year fellows and one attending. A first-year house officer and an advanced practice provider are also members of this team on weekdays. The team is responsible for the care of hematology inpatients and consultations on all hematologic problems. There is a high volume of consultations and new referrals for hematologic issues from Texas Children’s Hospital, including the Texas Children’s Hospital Emergency Center. Fellows on the Hematology Service are called to provide the initial Hematology Service encounter with these patients and their families, develop evaluation recommendations, and assist in diagnosis and subsequent management. A recent addition to the service is the availability of a Hemophilia and Thrombosis (HAT) Team. This team offers additional support for evaluating and managing patients with disorders of hemostasis. The fellows take call on alternating days with night call from home.
During the outpatient clinic rotations (4 months total), fellows are involved in evaluating new patients and following established patients in the cancer and hematology outpatient clinic. Fellows obtain the patient’s history, perform a physical examination, and formulate the initial management plan. Duties include ordering and assessing the results of laboratory and imaging studies on patients seen in the clinic. Faculty members review each case with the fellow. Depending upon their experience, fellows are involved in or lead diagnostic and management presentations to the families and patients. They also see established patients, including their continuity clinic patients. The four outpatient months are divided into blocks of focused learning experiences. One month block is devoted to patients with brain tumors and solid tumors. Another concentrates on patients with leukemias and lymphomas. There are 6 weeks devoted to patients with hematologic disorders. The remaining two weeks are focused on learning experiences in long term survivorship, developmental therapeutics, and cancer genetics. During these clinic months, fellows also participate in the Solid Tumor Journal Club and the Hematology Journal Club. While continuity patients comprise less of the clinic experience during the first year of training, they constitute a significant portion of the fellows’ outpatient responsibilities in the second and third years of the Program.
Bone Marrow Transplantation (BMT)
This rotation (1 month/year) involves the care of patients in the state-of-the-art 15-bed BMT unit, with the assistance of an advanced practice provider, a bone marrow transplant fellow, and a supervising physician. The fellows and attending physicians make daily patient rounds. BMT training encompasses one month per year during the fellows’ training (total of three months). The first-year fellow is usually paired with a senior fellow/mentor for the month.
The remaining month is spent in a rotation designated the coursework month. During this month, fellows undergo focused learning experiences in coagulation, hematopathology, blood banking, radiation oncology, immunophenotyping, cytogenetics, and DNA diagnostics. They are specific given learning objectives in each specialty area.
Continuity of Care
Longitudinal patient follow-up is an extremely important aspect of oncology training. When possible, newly diagnosed patients are seen for follow-up care by the same fellow who initially evaluated them in the outpatient or the inpatient setting. During the first-year of the program, fellows have limited opportunities to see patients they initially managed due to the requirements of the inpatient services. However, the electronic medical record system allows fellows to track their patients regardless of their current rotation. During the last quarter of their first year of training, fellows identify a group of patients to become their formal continuity patients. During the second and third years of training, fellows manage their continuity patients with appropriate faculty support. The fellows closely monitor their patients’ course of treatment. Whenever possible, the fellow is involved in major decision-making related to their primary continuity patients.
Scholarship Oversight Committee
Each first year fellow is assigned a scholarship oversight committee (SOC) of four individuals who meet with the fellow early in the first year to provide guidance in their career development and selection of a research mentor. The SOC is comprised of a clinical mentor selected by the fellow, a junior faculty member, and two senior faculty members. At the conclusion of the first year, the SOC membership is revised to include the research mentor and additional experts in the fellow’s chosen research field.
Psychosocial Aspects of Pediatric Hematology-Oncology
Fellows receive training to address psychosocial issues in the care of children and adolescents with life-threatening illnesses. Working with an experienced attending physician in the day-to-day care of patients, fellows learn how to provide optimal psychosocial support to patients and their families. In addition, the service has a full-time psychologist who directs the Psychosocial Support Program and who provides support and advice to fellows. There are also organized multidisciplinary conferences on patient and family management issues, as well as a fellows’ seminar series that focuses on recognizing and dealing with the psychosocial aspects of care (see Fellows' Seminar below).
A prerequisite for success in an academic medical career is leadership ability. An academic physician is expected to guide the patient and family as they adapt to serious illness, supervise the health care team in the care of the patient, direct laboratory and clinical research efforts, teach trainees at all levels and, potentially, lead as the head of a program, department or institution. Leadership is taught implicitly, as in most programs, by a gradual increase in responsibility throughout the fellow's training, and includes the opportunity for a fourth-year fellow to function as an attending. Fellows are routinely invited to participate in formal faculty development activities (e.g.,workshops on grantsmanship, career planning). In addition, the program teaches leadership through a unique Fellows’ Seminar.
This twice-monthly seminar, required for the first-year fellows, and optional thereafter, focuses on reflective practice and leadership. Fellows are encouraged to discuss challenging circumstances they encounter in their care giving role. The diverse topics include issues such as: the difficulty of dealing with a dying patient, the complexities of leading a health care team, and the strain of balancing the family demands with the commitments of an intense academic training program. Selected senior faculty facilitates discussions and frame thought-provoking questions. They may, at times, relate their own experiences as well. This method enhances fellows’ understanding of these complex issues and broadens their experience base through input from colleagues and mentors. There is a systematic effort to help fellows develop skills in analyzing situations and translating reflection into effective action as leaders in academic medicine.