Oncology

Competency-Based Curriculum

Educational Rationale

The primary goal of this rotation will be to provide the general internist a basis for the diagnostic evaluation and the initial management of patients with oncologic conditions.

The basic pathophysiology of disease principles and the complications of treatment will be highlighted. General internists must have knowledge of patterns of spread and prognoses of common tumor types. They must also know the general treatment options (surgery, radiation therapy, chemotherapy) that are effective in specific clinical situations and they should also be comfortable with palliative methods for these patients. The resident will be involved in discussions with patients and their families with the goal of avoiding aggressive life support methods in patients whose quality of life is no longer satisfactory to them. The resident will participate in discussion of the value of treatments with excessive toxicity where the only reasonable goal is prolongation of life by a few months. Residents will be exposed to information regarding environmental toxins predisposing to other oncological or neoplastic disorders, including chemotherapy and cigarette smoking.

Goals

A. Knowledge

Upon completion of training, we expect our residents to learn the following:

1. Understand the pathophysiology and natural history of commonly encountered oncologic disorders.
2. Understand staging of common cancers.
3. Recognize and manage oncologic emergencies
4. Understand the toxicities of commonly used treatments
5. Understand the role of adjuvant therapies such as radiation therapy
6. Management of a patient presenting with fever and neutropenia.
7. Diagnosis and management of a patient with brain metastases.
8. Evaluation and management of nausea in a cancer patient.

B. Skills

1. Clinical assessment using history, physical examination and appropriate laboratory, radiographic and pathologic evaluation to evaluate oncologic problems.
2. Prompt diagnosis and treatment of a patient with spinal cord compression.
3. Evaluation and treatment of a patient with osseus metastases including pain control and referral for radiation therapy Oncology Curriculum Updated 2015
4. Counseling a young woman with a family history of breast cancer.
5. Participating in a discussion with a patient and family who is, considering "no code" or "palliative care only" status.

C. Attitudes:

Upon completion of training, we expect our residents to appreciate those attitudes valued
and nurtured by hematologists, including:

1. Viewing medicine as humane science.
2. Balancing art with science.
3. Recognizing the limitations of technology and the value of clinical insight.
4. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
5. Balancing intervention with patience.
6. Recognizing limitations of our interventions.
7. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.

Educational Experience

A. General

The monthly oncology elective for residents is presented by division faculty. Residents will be responsible for seeing oncology in-patient consultations and will also participate in the outpatient activities and practices of division staff/faculty.

B. Clinical Activities

1. The Inpatient Experience (IP)

a. Inpatient consultations are called to residents by faculty or their offices. Oncology residents are paged upon receipt of each consultation.
b. All consultations are seen upon the day of their receipt. In each instance, the consultation is discussed with referring housestaff or attending physician, as applicable.
c. Consultations are presented on rounds to the consulting hematologist, at times to be mutually arranged. Usual practice is for the resident to join the consulting physician for hospital rounds each morning and evening, as applicable.
d. It is expected that at the time of presentation to the consulting physician, the residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to knowledgeably discuss the problem at hand. Literature references are available to all residents rotating through the service.

2. The Ambulatory Experience (AM)

a. Residents are expected to attend all sessions, outpatient activities, and practices.
b. Patients are assigned in clinics and offices by the attending physicians. Every effort is made to select patients of "interest". Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permits residents to spend the first few experiences seeing patients together with ttending physicians, so as to better introduce them to the hematologic/oncologic evaluation.
c. New patients and consults undergo a complete history and physical examination with emphasis on their oncological problem(s).
d. Chart notes are pertinent and succinct, and need not restate information already recorded. For certain clinical circumstances, standardized forms may be used for recording information.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

• Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
• Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
• Self-evaluation by In-service training examination scores
• MKSAP study plan (MKSAP)
• Participation and presentations at didactic conferences (DC)
• Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1	Learning Activities*	Assessment
Describe the epidemiology, genetics, natural history, clinical expression of related disorders encountered in the inpatient and outpatient setting.	IP, AM, DC	AE, DC, MKSAP
Describe the screening recommendations for colon, cervical, and breast cancer	IP, AM, DC	AE, DC, MKSAP
Describe the management of patients with neutropenic fever	IP, AM, DC	AE, DC, MKSAP
Describe the epidemiology, genetics, natural history, clinical expression of related disorders encountered in the inpatient and outpatient setting.	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Summarize an approach to the evaluation and staging of common cancers (lung,breast, colon)	IP, AM, DC	AE, DC, MKSAP
List the indications, techniques, contraindications, and complications of bone marrow biopsy	IP, AM, DC	AE, DC, MKSAP
Interpret diagnostic tests used in the staging of malignancies	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatients and inpatients with oncologic disorders.	IP, AM, DC	AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1	Learning Activities*	Assessment
Effectively perform a comprehensive history and complete physical examination in patients with symptoms affecting this system	IP, AM, DC	AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of disorders affecting this system	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Construct a comprehensive treatment plan and assess response to therapy.	IP, AM, DC	AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies.	IP, AM, DC	AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy.	IP, AM, DC	AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1	Learning Activities*	Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases	IP, AM, DC	AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases	IP, AM, DC	AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education.	IP, AM, DC	AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature	IP, AM, DC	AE, DC, MKSAP
Set and assess individualized learning goals	IP, AM, DC	AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement	IP, AM, DC	AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care	IP, AM, DC	AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1	Learning Activities*	Assessment
Apply empathy in all patient encounters	IP, AM, DC	AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team	IP, AM, DC	AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending	IP, AM, DC	AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations	IP, AM, DC	AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate	IP, AM, DC	AE, DC, MKSAP
Teach colleagues effectively	IP, AM, DC	AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1	Learning Activities*	Assessment
Be prompt and prepared for all clinical duties	IP, AM, DC	AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient utonomy, informed consent, and equitable respect and care to all	IP, AM, DC	AE, DC, MKSAP
Respect patients and their families, staff and colleagues	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings	IP, AM, DC	AE, DC, MKSAP
Demonstrate integrity	IP, AM, DC	AE, DC, MKSAP
Respond to phone calls and pages promptly	IP, AM, DC	AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1	Learning Activities*	Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases	IP, AM, DC	AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty.	IP, AM, DC	AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information.	IP, AM, DC	AE, DC, MKSAP

Goals AND Objectives-PGY2/3 (In addition to above)	Learning Activities*	Assessment
Discuss how the health care system affects the management of inpatients with related diseases.	IP, AM, DC	AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions.	IP, AM, DC	AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices	IP, AM, DC	AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized	IP, AM, DC	AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

a. Supervising clinicians-didactic and bedside rounds and concurrent patient care
b. Medical literature including assessment of knowledge using the MKSAP
c. Bedside rounds with team and faculty.
d. Medical Grand Rounds weekly.
e. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
f. Cooperman Barnabas Medical Center library, librarians, and online references/resources.

References

Journal

1. MKSAP 14, Oncology Section, text and questions.
2. Current Literature as assigned by the supervising faculty
3. Chute JP, Chen T, et al. Twenty Years of Phase III Trials for Patients with Extensive Stage Small Cell Lung Cancer: Perceptible Progress. Journal of Clinical Oncology 1998;17:1794-1801.
4. Hainsworth JD, Greco FA. Treatment of Patients with Cancer of Unknown Primary Site. NEJM 1993;329:257.
5. Coblieghm Vogel CL, et al. Multi-Institutional Study of Efficacy and Safety of Humanized Anti-HER2 Monoclonal Antibody in Women with HER2 Overexpressing Metastatic Breast Cancer that has Progressed After Chemotherapy for Metastatic Disease. Journal of Clinical Qncology 1999;12:2639.
6. Theriaultrl Lipton, A, et al. Pamidronate Reduces Skeletal Morbidity in Women with Advanced Breast Cancer and Lytic Bone Lesions. Journal of Clinical Oncology 1999;17: 846-854.
7. Jordan, Craig T., Guzman, Monica L., Noble, Mark Cancer Stem Cells. N Engl J Med 2006 355: 1253-1261
8. Copelan, Edward A. Hematopoietic Stem-Cell Transplantation N Engl J Med 2006 354: 1813-1826
9. Oncologic Emergencies: Diagnosis and Treatment. Mayo Clinic Proceedings. 2006; 81: 835-848.

Texts

1. Cancer: Principles and Practice of Oncology; Vincent De Vita, Samuel Hellman and Steven Rosgenburg.
2. Diseases of the Breast; J.R. Harris, Mark E. Lipman, Monica Morrow and Samuel Hellman

Faculty

Jennifer Wagmiller, M.D, Education Coordinator
Andrew Brown, M.D.
Robert Grossman, M.D.
Stuart P Leitner, M.D.
Richard A Michaelson, M.D.
Maithili Rao, MD
Michael Scoppetuolo, M.D.