HEMATOLOGY

DEFINITION:Hematology is that branch of medicine which concerns itself with the investigation (clinical and laboratory) and the treatment of diseases of the blood and blood-forming tissues.

GENERAL OBJECTIVES:The intent of a Hematology Training program is to ensure the competence in treating hematological disorders and in the management of hematological laboratories. It is anticipated that additional training during or after the core training period may be required to ensure competence in a specialized laboratory or clinical area.

Only candidates certified in Internal Medicine or Pediatrics may be eligible for the Certificate of Special Competence in Hematology.

The practice of hematology requires that the candidate be a competent clinician understanding the principles and the interpretation of a wide range of laboratory procedures, based upon a sound knowledge of the basic sciences; the relevant aspects of biochemistry, genetics, immunology, pathology, pharmacology, and pathophysiology of hematologic and neoplastic diseases. The candidate should be aware of the hematologic changes that take place in pregnancy, the neonatal period, childhood, and should possess the technical skills for obtaining tissue and fluid samples for diagnostic purposes.

The hematologist should be able to provide consultant advice on the diagnosis and management of patients of all ages. He/she must have an adequate knowledge of the management of general medical problems, such as the diagnosis and treatment of infections, and of disorders of the heart, lungs, liver and kidney. He/she should be skilled in the psychosocial aspects of the management of patients with malignant disease, the use of analgesics in the relief of pain, and in the care of the dying patient. He/she should demonstrate an understanding of biomedical ethics in the investigation and care of patients. He/she should have experience and skills in the application of the principles of quality assurance to clinical care and in the critical appraisal of the medical literature. He/she should be able to contribute to the education of colleagues, students, residents and other health workers, and be able to encourage and sustain a harmonious team approach to patient care. 

The candidates seeking to practice either adult hematology or pediatric hematology/oncology must have an adequate knowledge, and the ability to apply this knowledge to:

1. Basic Science

Knowledge of the physiology and pathophysiology of hematologic and neoplastic cells and diseases.

2. Laboratory Skills and Management

The principles, interpretation and quality control of laboratory tests, with "hands-on" experience in the general hematology laboratory, the coagulation laboratory and the blood bank, including familiarity with common hematological laboratory skills. Management skills in supervising the laboratory should also be acquired.

3. Clinical Skills and Management

The investigation, diagnosis, treatment, and management of patients with hematologic and malignant diseases, including the pharmacology and pharmokinetics of drugs, and the use of blood products, biologic response modifiers, such as growth factors, and chemotherapeutic agents, and the potential response to treatment should be based on consideration of methodologically sound clinical studies, and the rationale and validity of clinical trials in their assessment.

Adult Hematology and/or Pediatric Hematology-Oncology

These three components of the training objectives must be met for the following topics:

1. General Hematology
   1. Hemopoiesis

Basic Science

Cellular and molecular regulation of growth and differentiation, stem cell biology, cytokines, and the use of in vitro cultures.

Laboratory

Assessment of peripheral blood and bone marrow morphology. Developmental hematology and normal values for age. 

Clinical

The hypoproliferative disorders; congenital and acquired.

2. Erythropoiesis, and the function of the erythrocyte

Basic Science

The function of the erythropoietin; genetics and the regulation of hemoglobin synthesis and structure, hemoglobin structure and oxygen affinity and stability, erythrocyte metabolism, the structure and function of the erythrocyte membrane. Iron, vitamin B₁₂, and folate metabolism.

Laboratory

Erythrocyte indices and morphology, inherited and acquired disorders of heme and globin synthesis, including the techniques of DNA amplification and analysis in the diagnosis of disorders of erythropoiesis; hemoglobin structure and function; the recognition of intrinsic and extrinsic causes of hemolysis, including disorders of hemoglobin, altered erythrocyte metabolism, and of the structure and function of the erythrocyte membrane, red cell mass and erythrocyte survival; iron, vitamin B₁₂, and folate absorption and metabolism.

Clinical

The investigation and management of familial and acquired anemia and polysythemia, and the disorders linked to erythropoiesis, such as hemochromatosis and porphyria.

3. Lymphopoiesis and the function of the lymphocytes

Basic Science

The recognition and function of lymphocyte subsets, lymphocyte differentiation, traffic and distribution. The nature and function of lymphokines. The regulation and modification of gene expression, and the structure and function of the gene products as they effect lymphocytes and immunoglobulins.

Laboratory

The characterization and quantification of lymphocytes and immunoglobulins, including flow cytometry.

Clinical

Investigation and treatment of Lymphoproliferative disorders, EB virus infections, and familial and acquired immune deficiency states. The use of immunosuppressive and immuno-replacement therapy.

4. Granulopoiesis and the function of granulocytes and macrophages

Basic Science

Regulation of growth and differentiation, survival and distribution, cytokines and the responses to bacterial stimuli, and the role of these cells in host resistance.

Laboratory

Structure, function, identification and enumeration of granulocytes and macrophages.

Clinical

Disorders of granulocyte function, agranulocytosis, and the management of the neutropenic patient, and diseases of granulocytes, and of phagocytic cells.

5. Megakaryopoiesis and the function of the platelet

Basic Science

Platelet formation, platelet structure and function, and inhibitors of platelet function.

Platelet receptors, adhesive molecules, and platelet antigens.

Laboratory

Tests of platelet function and tests needed to classify thrombocytopenic disorders including the measurement of platelet survival.

                        Clinical

The investigation and management of thrombocytopenia, thrombocytosis, and congenital and acquired disorders of platelet function.

2. Hemostasis, Thrombosis, Coagulation, and Fibrinolysis

Basic Science

The coagulation and fibrinolytic pathway, their activation, amplification and inhibition, including the role of adhesive molecules, platelets, endothelial cells and the vessel wall, and the mechanism of fibrinolysis. The inheritance of coagulation disorders. The pathophysiology of hemostatis during pregnancy, and in the neonatal period.

Laboratory

Experience with tests of hemostasis, including coagulation factor assays, using functional assays, immunoassays, chromogenic substrates and allied techniques.

Clinical

The investigation and treatment of congenital and acquired disorders of coagulation. The detection and treatment of venous thrombosis and pulmonary embolism. The use of anticoagulants, antiplatelet drugs, and fibrinolytic agents in venous and arterial thrombosis.

3. Transfusion Medicine

Basic Science

The structure and function of cellular antigens and their relevance to immunity and transplantation (including HLA). The clinically relevant blood group antigens. The mechanism of immune clearance of cells. The components of the complement pathway, their activation and function.

            Laboratory

The detection and identification of blood group and HLA antigens and antibodies. Techniques for screening for transfusion of transmitted diseases, and their limitations. The preparation of preservation of blood and blood components for transfusion.

Clinical

The procurement and utilization of blood and blood products. The investigation and treatment of patients requiring blood transfusion and blood component therapy, and of transfusion reactions. The principles and indications for apheresis. The role of iron-chelation therapy in prevention and treatment of iron overload.

4. Autologous and Allogeneic Bone Marrow Transplantation

Basic Sciences

Transplantation immunology, immunosuppression, graft-versus host disease (GVHD), and gene therapy.

Laboratory

Donor-recipient compatibility. 

Clinical

The indications, performance and complications of BMT, and the treatment of GVHD.

5. Hematological Malignancies

Basic Science

The molecular genetic and cytogenetic alterations in hematopoietic malignancies. Oncogenes and factors regulating cell growth. The pharmacology of chemotherapeutic drugs. The fundamentals of radiobiology.

Laboratory

Morphology, cytochemistry, cell-surface markers, and cytogenetics in determination of cell lineage. The histopathology of lymph nodes, the reticuloendothelial system, and bone marrow.

Clinical

The investigation and treatment of hematological malignancies, including chemotherapy and radiotherapy. The prevention and treatment of complications, including infections, immunosuppression, and hormone suppression. The use of biological response modifiers.

Supportive care, including nutrition, pain control, psychiosocial counselling. The late effects on growth, development and intellectual function. The benefits of the team approach to the management of malignancy.

6. Solid Tumors

Basic Science

Oncogenes, cytokinesis, biology of metastasis, principles of drug resistance, the principles governing surgical, radiation and chemotherapeutic treatments, including pharmacology and radiobiology.

Laboratory

Electron microscopy, surface markers and cytochemical methods in histological diagnosis and staging.

Clinical

Design, conduct and interpretation of clinical trials, multi-modality treatment strategies, principles of clinical staging, supportive care and rehabilitation, assessment of performance status, management of the adverse effects of therapy (including the late effects in children) and palliative care.

7. Reticuloendothelial System

Basic Science

The anatomy and physiology of the RE system including the spleen.

Laboratory

The investigation of splenic function. The histology of the RE system and its diseases.

Clinical

The diagnosis and management of disorders of the spleen, metabolic storage diseases and proliferation of histiocytes.

8. Neonatal Hematology

Basic Science

Maternal-fetal relationships and the function of the placenta as it applies to the hematologic system. Developmental hematology in the fetus. The biology and physiology of the full term and premature infant in terms of hemopoiesis and hemostasis. Bilirubin metabolism in the newborn.

Laboratory

Knowledge of normal values for cellular elements of the blood and coagulation tests in terms of hematopoiesis and hemostatis. The intepretation of abnormal values.

Clinical

The diagnosis and management of disorders of red cells, white cells, platelets and coagulation in the newborn, including the consequences of maternal-fetal incompatibility.

Transfusion practice in the newborn. Prenatal diagnosis and genetic counselling for hematologic disorders.

The resident must be provided with a graduated increase in personal responsibility, appropriate to the level of competence, in both the clinical and laboratory aspects of the specialty. The equivalent of at least one year must be spent in clinical work, during which the resident has supervised responsibility for the care of patients with hematological disease and experience in the laboratory procedures required to manage these patients. There must be at least two qualified hematologists to supervise the residents and provide teaching in the basic and clinical sciences related to hematological diseases.

Through the facilities of the university and the participating institutions, the overall training program must satisfy the following requirements:

1. CLINICAL PROGRAM

Clinical training must be based on adequate resources to ensure full training for each resident in all areas of hematology. The description of the integrated program should specify how the responsibility for each of the components of the program is shared by the participating institutions. The number and variety of patients available for teaching under each of the following headings must be satisfactory:

1. Clinical Hematology. The program must apply the principles basic to the concept of the clinical teaching unit, with special reference to an organized team with graded responsibility under the direction of the head of the service. It is desirable that the unit contain designated beds. However, if there are not designated beds, it is essential that there be adequate numbers of patients in whose management the service participates. Adequate and well-supervised consultant experience must be available.
2. General Pediatric and Newborn Hematology. There should be an adequate number of beds assigned for teaching of residents in hematology, and every resident should have experience in handling consultations in this area.
3. Hematologic Oncology. There must be an adequate number of patients to provide experience for residents in oncology relevant to hematology, including chemotherapy and the role of surgery and radiotherapy. Residents should gain experience in primary consultations on new referrals in an interdisciplinary setting.
4. Intensive Care Units. Units organized for teaching are required within the program to provide experience under appropriate supervision in the care of critically ill patients presenting hematological problems.
5. Emergency Departments. There must be systematic supervision of residents to ensure expertise in the initial management of all types of emergencies involving hematology. Experience in providing a consultative service is an important feature of such training.
6. Ambulatory Care Facilities. In-patient and out-patient teaching units should be integrated so far as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of hematological patients in all categories mentioned above. Special clinics, such as hemophilia or thromboembolism clinics, provide an important part of the training.

2. LABORATORY TRAINING PROGRAM

There must be adequate clinical laboratory facilities, adequately staffed and under qualified medical supervision. The hematological laboratory facilities must be of high standard and capable of providing well supervised studies in those procedures usually associated with a major hematology laboratory. The technical staff and the volume and variety of work must be considered to be adequate for training by the specialty committee. In hospitals in which clinical and laboratory hematology are not supervised by a single person, the Committee must be satisfied that there is the degree of cooperation and liaison between clinical and laboratory hematology that will permit the resources of both divisions to be utilized effectively in the training of residents. Residents must also receive training in the diagnostic applications of radioisotope procedures to hematology, including techniques and interpretation, and become familiar with the principles of and indications for radiotherapy.

1. Laboratory Hematology. Facilities must ensure that each resident gains adequate experience in general laboratory hematology, coagulation, radioisotopes, and the techniques of blood banking. It is desirable that some laboratories participating in the program be engaged in research in addition to their service role.
2. Hematological Pathology. Facilities must provide full training in the interpretation of bone marrow aspirates and biopsies as well as the histopathology of lymph nodes and other areas of the reticuloendothelial system.

3. EDUCATIONAL PROGRAM

A coordinated educational program must be provided in hematology and associated fields. This should include definitive teaching in the basic sciences, and also advanced scientific and clinical knowledge essential to the practice of hematology in those areas outlined in the preceding sections. The program may include didactic lectures and seminars, which may be interdisciplinary in nature, teaching rounds and special conferences, technical demonstrations, and journal clubs.