Curriculum

A. Program Demographics

Stanford University
Blood and Marrow Transplantation
300 Pasteur Drive, H101, MC 5623
Stanford, CA 94305

Ph: 650-723-0822
Fx: 650-498-6919
http://bmt.stanford.edu

Program Director:   Wen-Kai Weng, MD, PhD
Email: wkweng@stanford.edu

Alternate Program Contact: Jennifer McGuire, Fellowship Coordinator
Email: jennymcg@stanford.edu

B. Program Introduction

1. History:  The Stanford Blood and Marrow Transplantation Clinical Fellowship Program was started in 1994.
2. Duration: 12 months of clinical training.
3. Prerequisite Training/Selection Criteria: Applicants must have completed a fellowship in Hematology or Oncology and be able to obtain a California medical license. In rare circumstances we may consider an applicant who completed an Internal Medicine Residency Program and not a Hematology or Oncology Fellowship.
4. Goals for Training: The goals of the Stanford BMT Fellowship are to offer an intensive learning experience covering all aspects of clinical and laboratory hematopoietic cell transplantation, and prepare individuals for an academic career in this dynamic field.
   
   This fellowship is designed to provide clinical and investigative training in adult hematopoietic cell transplantation including both autologous and allogeneic (related and unrelated) procedures, as well as non-myeloablative, cord blood stem cell and haploidentical transplants. The aim is to impart a detailed understanding of the principles, rationale, indications, mechanics, complications and results of bone marrow or peripheral progenitor cell transplantation.
   
   Fellows are encouraged to become integrated into a mentored clinical research project, where they will gain experience in data analysis and manuscript writing and submission.
   
   See section D. Clinical Procedures/Objectives for additional objectives.
5. Program Certifications: This program is not eligible for any program certifications.

C. Resources

1. Teaching Staff:  The following BMT attending teach fellows in either the inpatient unit (E1/E ground), Infusion Treatment Area (ITA) or BMT Clinic:
   1. Sally Arai, MD
   2. Janice M. (Wes) Brown, MD
   3. Matthew Frank, MD, PhD
   4. Laura Johnston, MD
   5. Robert Lowsky, MD
   6. Everett Meyer, MD, PhD
   7. David Miklos, MD, PhD
   8. Lori S. Muffly, MD, MS
   9. Robert Negrin, MD
   10. Andrew Rezvani, MD
   11. Parveen Shirez, MD
   12. Judith A. Shizuru, MD, PhD
   13. Surbhi Sidana, MD
   14. Wen-Kai Weng, MD, PhD
2. Facilities: All training takes place at Stanford Hospital and Clinics in the following locations:
   1. E1/E ground Inpatient Unit – Stanford Hospital, 300 Pasteur Drive
   2. Stanford Cancer Center - 875 and 900 Blake Wilbur Drive
      1. Infusion Treatment Area
      2. BMT Clinic

D. Educational Program (Basic Curriculum)

1. Clinical and Research Components
   1. Over Twelve Months, Fellows will participate in the following components: 
      • 3.5 months E-1/E ground inpatient unit
      • 2 months ITA outpatient unit
      • 4 months clinic rotation
        
      • 2.5 months research
      Each required rotation includes 15 hours weekday night on-call shifts and 24 hour weekend day on call shifts throughout the entire year.
   2. The on-call physician is responsible for all patient related issues pertaining to BMT inpatient and out-patient services.  This is a home call arrangement and decisions to return to the hospital are based on clinical needs. On-call coverage is from 5 p.m. to 7:45 a.m. the following morning on weekdays and from 8 a.m. to 8 a.m. on weekends.  
2. Trainee's Supervisory and patient care responsibilities
   1. Ambulatory:   In the ambulatory setting, fellows will evaluate and manage BMT patients in BMT clinic and the Infusion Treatment Area. 
   2. Inpatient: Fellows will receive BMT training primarily in the inpatient setting in the Compromised Host Unit as well as BMT patients in the ICU.  The fellows will be part of a physician team including the Attending physician as well as residents in BMT, Hematology and Medical Oncology and advanced practice providers.
3. Clinical Procedural Requirements/Objectives
   
   By the end of the fellowship, fellows will be expected to have met the following clinical objectives. These objectives are based on the requirements by the Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.
   
   a. Patient Care
   1. Demonstrate clinical skills of medical history and physical examination, with specific attention to complications related to immunosuppressed patients.
   2. Demonstrate clinical skill in the diagnosis and management of graft-versus-host disease.
   3. Demonstrate clinical skill in medical management of patients receiving high-dose chemotherapy and immunosuppressive agents. 
   4. Demonstrate competency in performing bone marrow aspirations, biopsies, harvest.
   5. Demonstrate clinical skill in managing patients who receive chimeric antigen receptor (CAR) T-cell therapy.
      
   b. Medical Knowledge
   1. Describe the history and evolution of hematopoietic cell transplantation (HCT) as a therapeutic modality.
   2. Describe the use of HCT for the treatment of and the outcomes for the following diseases:
      • Acute and chronic myeloid leukemias
      • Acute and chronic lymphocytic leukemias
      • Non-Hodgkin’s lymphoma
      • Hodgkin’s disease
      • Multiple myeloma
      • Myelodysplasia and myeloproliferative disorders
      • Aplastic anemia
      • Germ cell tumor
        
   3. Describe the indications for autologous, allogeneic transplantation or CAR T-cell therapy and the differences in patient management, complications and outcomes between them.
   4. Understand the diagnosis and management of complications of HCT including:
      • Short and long term complications of preparative regimen chemotherapy and/or radiotherapy
      • Graft versus host disease: diagnosis, pathophysiology, staging, prophylaxis and treatment
      • Veno-occlusive disease: diagnosis, pathophysiology, prophylaxis and treatment
      • Immunosuppression and infectious disease:
      • Fungal and PCP prophylaxis
      • Empiric antibiotic therapy for prolonged neutropenia
      • Monitoring and treatment of CMV
      • Selected ID, GI, pulmonary and reproductive complications
   5. Describe the definition and biology of hematopoietic stem cells, the sources of hematopoietic cells, modifications of the HCT product and the use of growth factors.  
   c. Practice-based learning and improvement
   
   Fellows will have the opportunity to apply medical literature, research and statistical methods, and data management technology for self-evaluation and improvement.
   1. Formulate and research clinical questions through clinical databases pertinent to patient care as they arise.  Access to the Stanford BMT database is available to assist with clinical decision making.
   2. Select Cases for in depth research, discussion and presentation at the Hematopathology or New Patient conferences as appropriate. 
   d. Interpersonal and communication skills
   1. Develop and demonstrate competence in effective and efficient communication with patients and their families.
   2. Develop and demonstrate competence in effective and efficient communication with physician colleagues on the BMT service, physicians from other services, nursing and support staffs. Since the BMT service involves interactions with multiple ancillary services including social work, dietary, physical therapy, blood bank, nurse coordinators as well as BMT Nurse Practitioners/Physician Assistants, communication is essential for the successful treatment of these patients.
   e. Professionalism
   
   Fellows will have the opportunity to develop and demonstrate an increasing commitment to carrying out professional responsibilities and adherence to ethical principles. An effective therapeutic relationship with patients and families will be demonstrated through listening, narrative and nonverbal skills; education and counseling of patients and families.
   1. Demonstrate respect and compassionate use of medical skills for BMT patients. This includes the treatment of patients and families dealing with life-threatening illnesses undergoing toxic therapies.
   2. Demonstrate respect and compassionate use of medical skills for BMT patients receiving comfort care.
   f. System-based Practice
   
   
   1. Recognize financial issues of HCT including costs of therapy, the prolonged nature of HCT complications and recovery, and the impact of contracts with insurance companies.
   2. Actively participate in the multidisciplinary approach to caring for BMT patients including appropriate recognition of other health professional and paraprofessional’s roles and demonstrate competence in team interactions, including nutritionist, pharmacist, physician’s assistant, nurse practitioner, physical therapist, social worker, nurse coordinator.
4. Didactic and Teaching Methods
   
   The educational content is provided in the following ways:
   • Teaching sessions on the Inpatient Unit (E1/E ground) before and during inpatient rounds by the Attending physician and ancillary staffs
   • Teaching sessions in the BMT Clinic
   • New Patient conference on Tuesdays at 1:00 p.m.
   • Hematology Journal Club on Tuesdays at 12:00 p.m.
   • Hematology Grand Rounds on Wednesdays at 12:00 p.m.
   • Monthly review (M & M) on third Tuesday at 2:30 p.m.
   • Monthly protocol meeting on first Tuesday at 2:30 p.m.
   • Participation in bone marrow aspirations/biopsies in the Infusion Treatment Area (Cancer Center)
   • Reading Materials
     
   • BMT Didactic Sessions are offered monthly including but not limit to the following topics. Fellows are asked to read 3 articles and be prepared to answer 3 reading questions:
     • Conditioning regimen
     • Common Infectious complications
     • Diagnosis and management of acute GVHD
     • Management of chronic GVHD
     • Management of non-Hodgkin lymphoma
     • Minimal residual disease monitoring and clinical implication
     • Novel non-myeloablative conditioning regimen
     • Therapy for post-transplant relapsed disease
     • Outcome of transplant
     • Long term follow-up of post-transplant patients
     • Chimeric antigen receptor (CAR) T-cell therapy
     • Management of CAR T-cell therapy related side effects/complications
5. Progression in Responsibilities from PGY level: NA

E. Supervision and Evaluation

1. Supervision of BMT Fellows
   1. BMT Fellows will be under the direction and supervision of a BMT faculty member with respect to all inpatient and outpatient care.  Fellows are expected to see and evaluate patients and develop a care plan on their own and present their assessment to a BMT faculty member.  During these presentations the Fellows are provided with one-on-one teaching and guidance.  During night call, Fellows continue to be under the direction and supervision of a BMT faculty member as faculty are on-call and available by page or phone.  All after hour patient care decisions above and beyond the routine (i.e., blood transfusions, correction of low serum potassium or magnesium, etc.) are discussed with a BMT faculty member.
   2. Mentor: In addition to patient care, BMT Fellows are encouraged to seek a primary mentor for the duration of their BMT fellowship.  The primary mentor is a BMT faculty member who formally meets with the Fellow at least every two months.  During these meetings feedback is provided regarding their performance. 
2. Evaluation Process
   1. Rotation Evaluations: Attending physicians provide a written evaluation of fellows following each inpatient and ambulatory rotation via the MedHub system
   2. Mid-Year Milestone Evaluation: BMT attending provide fellows with a 6-month milestone evaluation in November/ December.  Fellows meet with the program director to review their milestone progress.
   3. Final Milestone Evaluation: BMT attending provide fellows with a final milestone evaluation in May. Fellows meet with the program director to review their milestone progress.
   4. BMT Objectives are evaluated in the following ways:
      • Patient Care is evaluated by the attending physicians during the rotation evaluations, and global milestone evaluations with additional information provided from nursing staff. Procedures performed will be documented.
      • Medical Knowledge is evaluated by the attending physicians during the individual rotation evaluations and global milestones evaluations, and peer-reviewed chart audit.
      • Practice-Based Learning and Improvement is evaluated by peer-reviewed chart audit.
      • Interpersonal and Communication Skills is evaluated as part of the individual rotation evaluations and global milestone evaluations provided by the attending physicians with additional information from nursing staff, other ancillary staff, patients and families.
      • Professionalism is evaluated by the attending physicians during the rotation evaluations, global milestone evaluation with information from nursing staff, other ancillary staff, patients and families.
      • System-Based Practice is evaluated by the attending physicians during the rotation evaluations, global milestone evaluation, and peer-reviewed chart audit.

A. Inpatient (E1)

Structure:

E1-A: BMT Attending, BMT Fellow, APPs, Medical resident (half the time)

E1-B: BMT Attending, BMT Fellow (most month), Hem/Onc Fellow, APPs

Patients are distributed evenly between fellows, residents and APPs in each team

Schedule (Monday through Friday):

Pre-round on assigned patients before 8:30

Work-round at 8:30 with all the team members, pharmacist and the nurse. A short presentation (15-20 seconds) on the patient should be given by the primary provider before entering the room. There might be some discussion on the case, followed by seeing the patient togehter. Ideally, we finish work round around11:00-11:30 depending on the census. The BMT fellows are responsible for all transplants or cell infusions. You go to the afternoon clinic on your continuity clinic day. Otherwise, sign out with the on-call person around 5:30 PM.

Expectation:
To learn about indication of transplant for different diseases

To understand the different conditioning regimens

To learn to manage immediate post-transplant complications including organ injuries, infectious complications, acute GVHD, medication toxicities, etc

To learn to manage cytokine release syndrome and neurotoxicity after CART cell therapy

To know how to perform cell infusion

B. Outpatient (ITA)

Structure:

BMT Attending, BMT Fellow, APPs

Patients are distributed evenly among all providers. Depending on the day, you will be assigned to 5-8 patients that day with a mixed group of auto and allo patients.

Schedule (Monday through Friday):

The usual hours are 8:30-5:00 depending on the patient number. The fellows talk to, exam the patients, gather the lab work and discuss the case with the attending. They may go back to see the patients together, or make additional plan for such as new onset GVHD, relapse or new infection. The ITA fellow will also do bone marrow biopsy for the month. The BMT fellows are responsible for all transplants or cell infusions.

Expectation:
To learn to manage post-transplant complications such as viral re-activation, acute GVHD, medication toxicities, etc

To learn to interpret donor cell chimerism

To learn to manage early relapsed diseases

To learn the process of non-myeloablative allogeneic transplant

C. Clinic

Clinic month

Structure:

Attend clinics of different attending daily

Schedule (Monday through Friday):

Most attending has half-day clinic in the afternoon. The fellows are expected to go to different attending’s clinic throughout the weekdays expect the continuity clinic day. We expect the fellows see the new patient(s) and a few follow-up patients per clinic. The fellows will present the new patient(s) he/she saw the week before at the Tuesday New Patient Meeting.

Expectation:
To learn how to evaluate a new patient including the indication, the candidacy for transplant and the transplant plan for individual patient

To learn the sign of chronic GVHD and the management

To learn to manage late relapsed disease

Continuity clinic

Structure:
Each fellow will be assigned to TWO 6-month blocks with one attending at a time.

Schedule:

The fellows will attend weekly half-day clinic of the assigned attending throughout the year even on post-call days since the clinic usually starts at 1:00 PM

Expectation:
To gain experience in manage patients in a longitudinal way

D. Research

Structure:

Fellows are expected to find a mentor and project(s) early on during the fellowship. Most of the projects are collecting data for ongoing clinical trials, retrospective review of Stanford experience on specific disease(s) or regimens using BMT database, or helping the clinical samples collection for specific study.

Expectation:
There will be a report or manuscript to be generated during the fellowship.

E. Apheresis

Structure:

During one or two of the clinical months, fellows will supervise the apheresis unit in the morning while having clinic in the afternoon. There will be no attending assigned in apheresis unit.

Schedule:

Apheresis unit collects ~800 peripheral blood hematopoietic cells for transplant and perform ~400 photopheresis (ECP) for patients with chronic GVHD per year. Fellows are expected to go through patients’ chart, check on these patients when they are in the unit, and contact attending if there is an issue. The ITA attending or the attending of specific patient will be the one to contact.

Expectation:
To learn the basic principle of peripheral blood hematopoietic cell mobilization

To understand the operating principle of apheresis machine

To get an idea about the management of chronic GVHD especially for patients receiving photopheresis

On-Call

Structure:

Fellows take turn to cover the inpatient unit at night during the weeknight and cover the inpatient team on weekend.

Schedule:

On average, each fellow takes 4 calls per month (2-3 weeknight calls and 1-2 weekend call). For weeknight call, go to E1 around 5:00-5:30 to sign out with the inpatient teams. For weekend call, the fellow will do round with Attending and APPs in the morning like weekday and cover the night time.

Expectation:
While the call night can be managed from home, staying in the hospital is recommended. On average, ~1 patient will be admitted via ED at night. We also expect the fellows to stay on site in the unit until 8:30 PM if they chose to leave the hospital for the night. In this way, most of the patient issues will be taken care of by that time. This is a attending driven service so always feel free to call the attending any time when need help.

Education

New Patient Meeting:

Every Tuesday 1:00-2:30 PM

Discuss previous week’s new patients, patients on both E1-A and E1-B teams, and interesting cases in ITA.

Protocol Meeting:

Every FIRST Tuesday 2:30-3:30 PM

New protocols related to transplant will be presented and discussed.

Monthly M & M:

Every THIRD Tuesday 2:30-3:30 PM
Discuss all mortality from pervious month in details including pathology, and other interesting cases.

CCT Meeting:

Every FOURTH Tuesday 2:30-3:30 PM

New protocols related to cellular therapy such as CART will be presented and discussed.

Monthly Attending Lecture:

One attending will give a one-hour lecture on topics of his/her choosing. It is usually held on a weeknight with dinner provided.