Hematopathology Rotation

Memorial Hermann Hospital – Texas Medical Center


Table of Contents:

I.General Information

II.Goals and Objectives of Rotation


IV.Resident Duties


       I.            General Information


Category:                    Core rotation

Training level:            Introductory to advanced (the first month is taken within the initial
eight months of residency training)

Length of rotation:      Three months, usually taken in one-month increments

Location:                     Hematology Lab, MHH – TMC, 1st floor Robertson Pavilion

Rotation director and contact information:    

Andy Nguyen, M.D. 

Office phone: 713-500-5337

Email: Nghia.D.Nguyen@uth.tmc.edu


MHH Hematology Lab: 713-704-1693



Andy Nguyen, M.D., Professor, Rotation Director

Amer Wahed M.D., Associate Professor

Lei Chen M.D., Associate Professor


    II.            Goals and Objectives of Rotation


A breakdown according to the six ACGME competencies is listed within the section “Goals and Objectives for Rotations Incorporating Hematopathology”. The resident is expected to acquire knowledge and specific skills for the practice of hematopathology and coagulation, such as obtaining hematopoietic tissues (bone marrow procedures), examining hematopoietic specimens/coagulation test results, rendering diagnoses and recommending further diagnostic studies. To accomplish this, the resident must acquire expertise in:


Goals and objectives based on ACGME competencies:


Patient Care

The trainee will demonstrate ability to:

·         Gather appropriate and accurate clinical information with emphasis placed on not missing information essential for the hematopathological diagnosis

·         Understand and correlate findings at clinical, morphological, ancillary studies, cytogenetic and molecular levels

·         Interpret laboratory test results within the clinical context

·         Use clinical decision-making concepts and techniques in interpreting results

·         Advise clinicians on the choice of clinically appropriate, cost-effective tests

·         Advise clinicians on appropriate follow-up for unexpected test results

·         Assess indication for bone marrow biopsy

·         Present the informed consent for bone marrow procedures to patient and family


Medical Knowledge

The trainee will demonstrate:

·         Ability to examine hematopathology specimens (peripheral blood smear, bone marrow aspirate and biopsy, lymph node), render diagnosis using additional techniques as needed, and give appropriate recommendations to clinicians

·         Ability to recommend the use and interpret special studies: flow cytometry, immunohistochemistry, cytogenetics, and molecular studies

·         Know prognostic factors and treatment regimens for major hematologic disorders.

·         Knowledge of common hematology tests; their medical indication and interpretation

·         Knowledge of the effects of anticoagulants, specimen collection techniques of the assays used in the hematology laboratory

·         Ability to collect and evaluate medical evidence regarding the utility of laboratory tests

·         Ability to use a variety of resources to investigate clinical questions

·         Develop and document a personal strategy to maintain and update medical knowledge


Practice-Based Learning and Improvement

The trainee will demonstrate:

·         Ongoing identification and remediation of gaps in personal medical knowledge

·         Ability to utilize non-clinical time for individual study (case review or reading)

·         Understanding of the principles of quality control and quality assurance

·         Ability to evaluate testing methods for analytical performance, clinical utility or cost-effectiveness

·         Use of proficiency-testing results to improve laboratory practice

·         Ability to use laboratory problems and clinical inquiries to identify process improvements in order to minimize the potential for medical errors


Interpersonal and Communication Skills

The trainee will demonstrate:

·         Ability to communicate clearly and effectively with clinicians, medical technologists and other medical personnel

·         Ability to use effectively work as a team member

·         Ability to appropriate modes of communication (direct, telephone, e-mail, written) as needed in accordance with the message content

·         Ability to prepare and deliver effective presentations, including presentation of pathologic findings at interdisciplinary clinical conferences and represent the Hematopathology team



The trainee will demonstrate:

·         Maintenance of confidentiality of patient information

·         Understanding of ethical and privacy issues affecting the clinical laboratory

·         Respectful behavior towards all patients and medical personnel

·         Prompt and courteous response to all pager and telephone calls

·         Regular, punctual attendance and participation in rounds, conferences, meetings and rotation responsibilities

·         Ability to receive and provide feedback in a professional manner


Systems-based practice

The trainee will demonstrate:

·         Understanding of the role of the laboratory in the health care system, and the importance of reliable, cost-effective and timely laboratory results in clinical decision-making

·         Ability to work with clinicians, administrators and others to determine the role of the laboratory in specific situations to optimize patient outcomes

·         Understanding of CLIA, CAP and JCAHO requirements for clinical laboratories

·         Understanding of basic laboratory reimbursement mechanisms and regulatory requirements,including compliance with Medicare/Medicaid “fraud and abuse” avoidance requirements

·         Ability to do cost analysis of laboratory tests


 III.            Curriculum

The curriculum is structured based on the core rotation which includes Hematopathology and Coagulation basics (A). In depth coagulation studies (B) and research activities (C) are encouraged, if core objectives are met or as a separate elective rotations.


A.    Hematopathology

Residents on Hematopathology rotation need to read the following topics:


Reading Topics for the 1st Month:  


Benign Hematopathology

1.      Peripheral Blood Examination

2.      Microcytic Hypochromic Anemia

3.      Megaloblastic Anemia

4.      Infectious Agents in Peripheral Blood Examination

5.      Autoimmune Hemolytic Anemia

Malignant Hematopathology

6.      Chronic Myelogenous Leukemia and Atypical Chronic Myelogenous Leukemia

7.      Acute Myeloid Leukemia with Recurrent Cytogenetic Abnormalities

8.      Precursor B and T Lymphoid Neoplasm

9.      Plasma Cell Myeloma, Plasmacytoma

10.  Introduction, Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma

11.  Introduction to Lymph Node Pathology

12.  Hodgkin Lymphoma

13.  Diffuse Large B Cell Lymphoma  


14.  Introduction to flow cytometry

15.  Coagulation Essentials

16.  Thromboelastograph

17.  Body fluids


Reading Topics for 2nd Month:


Benign Hematopathology

  1. Benign Lymph Node Pathology

Malignant Hematopathology

2.      Polycythaemia Vera

3.      Essential Thrombocythemia

4.      Chronic Idiopathic Myelofibrosis

5.      Myeloproliferative Disorders-unclassified

6.      Chronic Myelomonocytic Leukemia

7.      Myelodysplastic Syndromes

8.      Acute Myeloid Leukemia, NOS (M0, M1, M2, M4, M5, M6, M7)

9.      Follicular Lymphoma

10.  Mantle Cell Lymphoma

11.  Extranodal Marginal Zone B-Cell Lymphoma (MALT)

12.  Nodal Marginal Zone B-Cell Lymphoma

13.  Burkitt Lymphoma/leukemia

14.  Peripheral T-cell Lymphoma-unspecified


Reading Topics for the 3rd Month:  


Benign Hematopathology

1.      Flow Cytometry Cases

2.      QC and Method Evaluation

Malignant Hematopathology

3.      Adult T-cell leukemia/Lymphoma

4.      Mycosis Fungoides / Sezary Syndrome

5.      Angioimmunoblastic T-cell Lymphoma

6.      T-cell Large Granular Lymphocytic Leukemia

7.      Aggressive NK-cell Leukemia

8.      Extranodal NK/T-cell Lymphoma-Nasal Type

9.      Hepatosplenic T-cell Lymphoma

10.  Anaplastic Large Cell Lymphoma

11.  Post-transplant Lymphoproliferative Disorders

12.  Hairy Cell leukemia

13.  Mastocytosis


B.     Coagulation

Trainees are exposed to principles of instrumentation, testing methodologies and interpretation. Daily conference is held to cover key topics and a series of case studies involving various coagulation disorders.


Case studies:


  1. vWD
  2. DIC
  3. Hemophilia A
  4. Vitamin K deficiency
  5. Thrombophilia, hereditary (FV Leiden, Factor II mutation, AT III def, etc)
  6. Heparin-associated antibody
  7. Platelet storage-pool disease


Coagulation topics:


1.      Coagulation Testing Principles

2.      Coagulation Essentials

3.      Coagulopathy In Surgery Patients

4.      Antiphospholipid Syndrome

5.      Thrombotic Thrombocytopenic Purpura

6.      Molecular Testing for Coagulation

7.      QC and Method Evaluation


Coagulation unknowns:


17 cases to be discussed together in group, facilitated by faculty


C.    Research opportunities:

The resident will have opportunities during this rotation to get exposure to research in hematopathology and coagulation. The scholastic activities will be greatly beneficial to the resident in future clinical practice as well as for credentials in applying for fellowship and job positions. Clinical cases of pathologic interests seen during the rotation can be written up as case reports for presentation in local/national pathology meetings as well as for publication in pathology journals. More elaborate research experience may be explored by talking to the hematopathology staff. This may require extra amount of time to be taken as Clinical Pathology electives. Research activities must not take priority over clinical activities during the 3-month core rotation.


Reference Materials:


1.      Malignant hematopathology:


2.      Benign hematopathology:

3.      Kjeldberg C: Practical Diagnosis of Hematologic Disorders. American Society of Clinical Pathologists

4.      World Health Organization Classification of Tumours: Pathology and Genetics, Tumours of Haematopoietic and Lymphoid Tissue. IARC Press, 2008

5.      Jandl JH: Blood: Textbook of Hematology. Little Brown

6.      Knowles D: Neoplastic Hematopathology. Williams & Wilkins

7.      Foucar K: Bone Marrow Pathology. American Society of Clinical Pathologists

8.      Kjeldberg C and Knight J: Body Fluids. American Society of Clinical Pathologists

9.      Goodnight SH Jr and Hathaway WE: Disorders of Hemostasis & Thrombosis: a Clinical Guide. McGraw-Hill

10.  Kottke-Marchant K (Ed): An Algorithmic Approach to Hemostasis Testing. CAP Press


Supplemental Learning Materials:


1.      Hemepath study sets (15 sets): approximately 1,500 microscopic slides (peripheral blood, bone marrow aspirate and biopsy, body fluids, lymph nodes) covering a wide spectrum of malignant and non-malignant disorders. The study-set slides are also used as unknowns for didactic teaching.

2.      Web-based Pathology Programs at University of Texas-Houston: various self-study programs covering malignant hematopathology, non-malignant hematopathology, coagulation, flow cytometry, hemoglobin electrophoresis, and PDF files of interesting Hemepath cases http://HemePathReview.com

3.      Syllabus of Human Hemoglobin Variants (Titus H.J. Huisman et al, published by The Sickle Cell Anemia Foundation, GA, USA) http://globin.cse.psu.edu/globin/html/huisman/variants/


 IV.            Resident Duties

Working hours: The residents are expected to be on duty from 8:00 am to 5:00 pm.


After hours/weekends: Residents may be scheduled to take night and weekend call as per the global DPALM CP call schedule while being on this rotation as in all other rotations.


Clinical Team: Typically, two pathology residents are on the rotation each month, a senior and a junior level. The clinical team may also include other trainees on the rotation (one fourth-year medical students/week, and a maximum of three per month, one or two MDACC hematology-oncology fellow/month, four or five MDACC hemepath fellows/year, and two TMH hemepath fellows/year).


Conferences: Residents are required to attend the 8-9 am UTHMS teaching conferences. Other conferences, including daily 3 pm CP conferences may be attended with the permission of the attending, if the clinical work is performed.  Residents duties include to present at the Hematopathology journal club (once a month), Hematopathology tumor board (Leukemia, Lymphoma and Multiple Myeloma, also once a month), and hematopathology cases at other Internal Medicine or M&M conferences (occasionally). Resident may also attend or present at the Texas Medical Center Citywide Hematopathology Conferences.


Service duties:

After the morning conference, the residents review pending materials and prioritize work. Learning how to organize and prioritize work is a critical skill required for smooth functioning of the clinical service. By daily organizing cases for review, the residents will also learn to be more efficient and manage their time. The residents will review cases on their own and prepare the reports draft in the Pathnet.  Cases requiring emergent action (such as new/relapsed leukemia and TTP), should be brought to the attending’s attention immediately.


The typical daily workload includes several areas:

I.                    Wet hematology: review of peripheral blood smears and body fluid cytospins

II.                 Bone marrow cases: reading, interpreting and reporting the bone marrow cases in conjunction with the ancillary studies (flow cytometry and immunohistochemistry, if performed); integration of cytogenetics and molecular studies in addendum report.

III.              Interpretation and reporting of coagulation reports.

IV.              Consult cases (lymph node, outside cases etc)


Daily schedule:

For scheduled bone marrow cases, the residents should always review patient’s clinical information, laboratory tests (CBC, coagulation), evaluate the indication for the bone marrow biopsy and discuss it with the attending for appropriate sample triage. All pending cases (see “service duties”) are to be previewed by the residents, then signed-out with the attending within the sign-out sessions, usually taking place throughout the day. The resident is expected to participate in the clinical work by preparing the cases according to his/her level of proficiency and achieve increasing ability to recognize morphology and formulate correct interpretations. Occasionally, different residents may be assigned different tasks depending on level of training, or in order to assess individual skills. The sign-out session is meant to provide direct feedback to the residents’ interpretation. Attendings may choose to edit and release reports at a later time if necessary, while the residents may review unknowns (taken from study sets), complete the reading curriculum or attend afternoon conferences. At the end of the day, the residents will check on all pending cases in the laboratory (hemepath, coagulation cases) and complete entries in the log book (in case of PBS and body fluid cytospins) once they have been signed out.


Lymph node cases referred from Surgical Pathology and UT-Outreach Laboratory for consultation are also reviewed and signed out with the attending as they are brought to the team.


Graduated responsibilities by level of training:

Month 1:

1.      Learn the routine activities

2.      Help the senior resident to prepare cases for sign-out

3.      Learn to complete interpretation drafts for clinical reports to be input into Pathnet

4.      Complete reading topics for the 1st (see curriculum)


Month 2 and 3:

1.      Help junior residents to review clinical cases

2.      Complete interpretation drafts and enter preliminary diagnosis

3.      Complete reading topics for the 2nd or 3rd month, respectively (see curriculum)

4.      Work with the attending on laboratory issues such as QC/QA and correlation studies

5.      Perform safety or quality improvement studies


Additional task (at all levels):

1.      Integrate other team members, especially medical students, to the group activities


Documentation of training:

Residents are responsible for keeping track of their own clinical, teaching and reading activities.