Pediatric Hematology Oncology Fellowship Program

Specifically, the trainee should attain clinical skills in the area of Pediatric Hematology/Oncology/BMT, including sickle cell disease, hemophilia, acute and chronic hematological problems, coagulopathies, thrombocytopenias, platelet disorders (both acquired and inherited), hemoglobinopathies including thalassemias, disorders of red cell membrane metabolism, immune and non-immune hemolytic anemias, nutritional anemias, and quantitative and qualitative abnormalities of white blood cells. Additionally, the trainee will become acquainted with and attain skills in the management and diagnosis of specific hematological disorders of the newborn, congenital and acquired immunodeficiencies, bone marrow failure syndromes, and develop expertise in the use of blood products and transfusion medicine. Lastly, the trainee will become competent in all aspects of the diagnosis and management of Pediatric Oncology patients. This includes but is not limited to the development of skills related to the diagnosis of leukemias, including acute lymphoblastic and acute and chronic myeloid leukemias, solid tumors, soft tissue tumors, central nervous system tumors, and lymphomas (Hodgkinsand Non-Hodgkin).

During the three-year Pediatric Hematology/Oncology/BMT Fellowship program, the trainee will become experienced in a number of aspects of therapeutic modalities including, but not limited to, the appropriate use of chemotherapy, biological therapy, surgical therapy, radiotherapy, immunotherapy, and blood and marrow transplantation, including allogeneic and umbilical cord blood transplantation. The trainee will participate in clinical research protocols utilized in the management of childhood malignancies, benign hematological disorders and stem cell transplantation including the initiation of and development of new protocols and the ongoing participation in cooperative group protocols. Patients with a primary immunodeficiency and/or undergoing blood or marrow transplantation will provide the trainee an opportunity to develop skills in the management associated with a severely immunocompromised host. At all times, the trainee will be required to participate as a member representing Pediatric Hematology/Oncology/BMT in the multidisciplinary setting.

Additional educational objectives of the program include developing an experience in other aspects of a Pediatric Hematology/Oncology program, including the management of acute and chronic pain, long term transfusion therapy, acute and chronic complications of blood disorders, management of graft versus host disease, sepsis in immunocompromised patients, enteral and parenteral nutrition, multidisciplinary psychosocial diagnosis and treatment, management of nausea and vomiting, the epidemiology and etiology of childhood cancer, genetic testing and counseling, survivorship and late effects, and the development of a database collection system to monitor responses in clinical and/or basic research studies. The training program also has a structured experience in stem cell transplantation including acquiring the skills in determining the clinical indications for stem cell transplantation, donor selection and processing, stem cell collection and infusion, choosing and administering conditioning regimens, and management of stem cell transplantation complications.

The comprehensive training program will consist of but is not limited to the interpretation of laboratory results including immunology, cytology, microbiology, and pathology. The trainee will be able to perform several procedures including bone marrow harvests, bone marrow aspiration and biopsies, lumbar punctures, reading and interpretation of bone marrow aspirates and peripheral blood smears, and experiences in blood banking and tissue pathology. Additional diagnostic modalities including genetics, nuclear medicine, and radiology are important components of the training during the three-year fellowship.

Pediatric Hematology/Oncology/BMT Fellows perform bone marrow aspirations biopsies and bone marrow harvesting when clinically indicated on patients they are following on both the inpatient and/or outpatient service. These procedures are closely supervised by Pediatric Hematology/Oncology/BMT physicians and the results are reviewed with a faculty member from the Pediatric Hematology/Oncology/BMT division and/or the Hematopathology department.

Lumbar punctures and intrathecal chemotherapy administration, with evaluation of cerebrospinal fluid, are performed routinely by Pediatric Hematology/Oncology/BMT Fellows on patients whose care they are overseeing on both the inpatient and outpatient services. These procedures are directly supervised by attending physicians from the Divisions of Pediatric Hematology, Oncology, and BMT. The results of these procedures are discussed during formal rounds and patient care discussion sessions.

When clinically indicated, relevant peripheral blood smears are reviewed on a daily basis with the attending physician during the Fellow’s rotation on a particular service. Additionally, Fellows spend time in the Hematology laboratory under the direct supervision of faculty in the Pathology department reviewing peripheral blood smears and other pertinent laboratory specimens.

Interpretations of hematologic laboratory diagnostic tests are reviewed on a daily basis by the Hematology/Oncology/BMT Fellows with the attending physician and other relevant medical personnel during patient and teaching discussions. Tumor Board, patient care team meetings, as well as other formal and informal sessions are routinely conducted to provide accurate interpretation of the diagnostic tests which are performed on patients being followed by the division of Pediatric Hematology, Oncology, and Stem Cell Transplant.

The trainees become familiar with all aspects of chemotherapy during the first year of training. This process involves the development of treatment plans for patients with newly diagnosed or recurrent diseases. The Fellows participate in clinical research protocols, both Investigator derived and/or multi-center trials through cooperative groups such as the Children’s Oncology Group or limited institutional trials. They become familiar with the use of outpatient chemotherapy through their rotations in the outpatient oncology clinics. They additionally consult with the surgeons, including Pediatric Surgery, Urologic surgery, Orthopedic surgery, ENT surgery, Neurosurgery, Gynecologic surgery and Plastic surgery in the daily management of patients.  Fellows also learn about the diagnostic and therapeutic uses of Radiation Oncology, including local radiotherapy and total body radiotherapy. Lastly, both Radiation Oncology and Pediatric surgical physicians actively participate in multi-disciplinary teaching and patient care conferences, including Tumor Board, Pediatric Oncology and BMT team meetings, and Morbidity and Mortality rounds.

The trainees gain experience in the diagnosis and treatment of patients with congenital and/or acquired immunodeficiencies and the diagnosis and treatment of infections associated with those disorders. Additionally, while spending time on the inpatient Hematology, Oncology and Stem Cell Transplant unit, they become familiar with the diagnosis and treatment of immunocompromised patients undergoing chemotherapy and/or blood and marrow transplantation and the development of diagnostic and treatment plans for infections in these patients. In patients with hematologic and/or oncologic disorders, the Fellows become familiar with the use of transfusion of various blood components, including packed red blood cells, whole blood, mobilized granulocyte transfusions, platelet transfusions, specific factor transfusions, cryoprecipitate, fresh frozen plasma, and the management of a variety of hematological disorders. The trainees spend one to two weeks in the Blood Bank learning the discipline of blood typing, blood component isolation and separation, infectious precautions, transfusion complications, etc. The trainees also spend one week in the Apheresis Department and Stem Cell Laboratory developing an understanding of therapeutic apheresis as well as the use of apheresis to isolate single blood components, including stem cell collection, granulocyte collection, plateletpheresis, colony assays, purging, depletions, ex vivo manipulation, and techniques in bone marrow stem cell isolation. Lastly, the Fellow spend two weeks in Hematopathology reviewing blood and marrow smears and flow cytology.

The Fellows actively participate in the Blood and Marrow Transplant Program where they gain experience with patients undergoing autologous bone marrow and peripheral BMT, purged bone marrow transplantation, matched related allogeneic peripheral blood and marrow BMT, related and unrelated cord blood BMT, and unrelated blood and marrow transplantation. The trainees additionally develop an expertise in various purging regimens for autologous transplantation and positive stem cell collection for transplantation and gene therapy. The Stem Cell Transplant Program is a FACT accredited program that participates in the Children’s Oncology Group, the Center for International Bone Marrow Transplant Registry (CIBMTR), and is an approved National Marrow Donor Program (NMDP) unrelated marrow transplant program.

The Pediatric Hematology/Oncology/BMT fellowship program emphasizes the integration of clinical case presentations and didactic lectures to provide a scientific foundation in the phagocytic system, splenic function, cell kinetics, immunology, coagulation, genetics, hemoglobinopathies, nutritional and aplastic anemias, and hematologic manifestations of chronic disease. Specifically, trainees attend a series of lectures where key articles and a bibliography of support literature are provided. This series covers these topics and is repeated throughout the year. In addition, there are weekly clinical patient care rounds where patients are presented that have been seen and evaluated in both the inpatient and outpatient setting the week before. These weekly meetings are multidisciplinary and address in general the differential diagnoses as well as the work-up for anemia, leukopenia, etc. Additionally, a journal review is held quarterly for the trainees to update all physicians in the group and provide a format to teach the basics of critical review of the literature with an emphasis on statistical analysis.

Each academic year, a new lecture series is initiated in the Division of Pediatric Hematology, Oncology, and BMT. These lectures are geared primarily to the Fellows but are also of interest to rotating residents and Hematology/Oncology/BMT nursing personnel. Hematology/Oncology/BMT lectures are held once a week and are frequently given by noted specialists in their fields who come as guest lecturers. The Fellows are also encouraged to participate in all Research Seminars at the medical center. In addition, they also participate in research staff meetings with their respective laboratories or clinical research teams.

Fellows are exposed to a multidisciplinary environment in the management of new and ongoing Hematology, Oncology and SCT patients. Our hospital provides care to a diverse socio­cultural base with large populations of patients from minority groups, including Hispanic, African American, Asian, and other ethnic origins from around the New York metropolitan and Westchester County areas, Mid-Hudon and Western Connecticut. The Fellows are encouraged to assume primary responsibility for new patients under the supervision of the faculty. They are involved in the initial evaluation and discussion with the family regarding diagnosis and projected management. They also coordinate the team, including Social Services and Psychology, to assess the family and provide support, both emotional and logistical.  Due to the large multi-ethnic community served by our hospital, the interpreter services provide not only translation but cultural support, as well, for patients and their families. They provide a cultural link that allows the physician and staff to interact successfully with the patient and their family. Interpretive services are available on call 24 hours a day, seven days a week.

Ongoing contact with primary care physicians is required, by telephone and by letter, providing updates in the management of patients. In the field of Pediatric Hematology/Oncology/BMT, the care of these patients can involve high technology, high-cost care and be a forum for difficult ethical decisions in medicine. The Fellows are encouraged to use the Bioethics Committee as a resource throughout the continuum of providing comprehensive patient care to Hematology/Oncology/BMT patients and their families.

The Pediatric Hematology/Oncology/BMT Fellow participates in the administration of the program by direct participation and presentation at staff meetings, which are organized for the purpose of program definition, development of goals, program planning, and implementation. The Fellows work with the Division Chief to assist in the recruitment process of both faculty and allied health personnel and work within the realm of program development with new personnel. The Fellows are part of the process relative to the quality management of the division and participate with the teams that carry out total quality management and continuous quality improvement.

The trainees have an opportunity to attend lectures and courses in a variety of venues within the Pediatric Hematology/Oncology/BMT training program. The curriculum offered in this clinical oncology research training program allows Pediatric Hematology/Oncology/BMT Fellows to receive education in a variety of areas, including cellular and molecular biology, pharmacology and therapeutics, pathology, virology, infectious diseases, immunology, physiology, epidemiology and behavioral biology. Instruction and experience in other areas, including structure and function of hemoglobin, hemoglobinopathies, iron metabolism and iron-associated diseases, and splenic function are coordinated through the Pediatric and Adult Hematology programs.   Didactic lectures, ward rounds, and invited speakers are additionally utilized to train Pediatric Hematology/Oncology/BMT Fellows in the above-mentioned areas. Lastly, topics of a nutritional nature in Pediatric Hematology/Oncology/BMT are discussed and presented by the Pediatric Hematology/Oncology/BMT faculty and the dietary and nutrition department.

TRAINING YEARS

The Fellowship Training Program in Pediatric Hematology/Oncology/Stem Cell Transplantation is a highly selective, rigorous three-year program designed to prepare pediatricians for an academic and clinical career in Pediatric Hematology/Oncology/Stem Cell Transplantation. As a result, our fellows are very well prepared for the entire spectrum of professional positions available for board certified Pediatric hematologists/oncologist/stem cell transplant physician specialists.

Overview of Year 1:

The first year of training is devoted primarily to the diagnosis and management of inpatients and outpatients with Pediatric Hematologic and Oncologic disorders. Specifically, the Fellows are primarily responsible for all inpatients on the Pediatric Hematology, Oncology, and BMT services. During this first year, the Fellows supervise the initial history and physical examination of patients admitted to these respective areas and the diagnosis and management of their specific disorders. The Fellows spend a minimum of two hours per day in rounds supervised by the Attending Faculty. At all times, the Fellows are supervised by an attending faculty member from the Division of Pediatric Hematology, Oncology, and SCT. Competencies in patient care, medical knowledge, practice-based learning, systems based practices, interpersonal and communication skills, and professionalism are assessed.

The Fellow is only assigned to one of the three independent services at any time. The Fellow is responsible for the clinical assessment of each patient and the development of a treatment program for each individual patient. The multidisciplinary team on the inpatient service consists of medical students, Pediatric residents, nurse practitioners, clinical research nurses, nurse coordinators, dieticians, physical and occupational therapists, psychologists, social workers, and bedside nursing staff. These team members interact with each Fellow to formulate a diagnosis and treatment plan for each individual patient. The Fellow interfaces with consultants in a variety of Pediatric subspecialties for coordination of care, facilitating the development of an accurate diagnosis and follow-up and, in conjunction with the attending physician, devises a specific treatment plan. Additionally, the Fellow supervises the teaching of the Pediatric residents and other allied health professionals participating in the care of these patients. It is the responsibility of the Fellow to conduct and participate in specialty conferences that are designed to develop a treatment program for each patient.

The first year Fellow is always supervised by the Hematology/Oncology/BMT faculty member who is rounding on the inpatient service. Additional consultations done by other physicians within the Division of Pediatric Hematology, Oncology, and BMT in other parts of the hospital are also carried out by the first year Fellow and supervised by the consulting Pediatric Hematologist/Oncologist/BMT physician of the day. Fellows rotating on the inpatient service conduct rounds in the morning with other members of the respective Pediatric Hematology/Oncology/BMT team and the attending faculty. After teaching rounds, the Fellows spend the remainder of their day following up on patient care needs, obtaining results, performing diagnostic procedures, supervising the admission of new patients, attending conferences and seminars, and participating in clinical research. At the end of the day the faculty physician usually makes additional teaching rounds with the Fellows on selected patients who require additional diagnostic and management decisions or require patient/family discussions.

The first year provides the Fellow with the foundation of knowledge and practical experience in the sub-specialty. The Fellow builds on the basis of knowledge that he or she has acquired during the general pediatric residency. The emphasis is on the basic evaluation, diagnosis and day-to-day management of the child with an acute or chronic blood disease, or a child with cancer. Existing skills are focused on the sub-specialty and are refined with a specific emphasis in the sub-specialty. The Fellow should be intellectually curious, sensitive, and caring in the management of patients, while at the same time developing a more organized approach towards the field. The entire year is spent on the clinical service in order to facilitate the acquisition of these skills.

Continuity Clinic

The Fellows are assigned one day a week in the outpatient clinic. Patients of Hematology, Oncology, and BMT services are seen in the same outpatient facility. On average, they are assigned a total of 10-20 patients from the Hematology, Oncology, and BMT services to follow as outpatients during their three years of fellowship training. The Fellows provide continuity of care to a selected group of active patients to maintain a smooth inpatient and outpatient experience for the patient and their families. Assignment of patients to Fellows is prioritized to those patients they have been involved with since diagnosis. The Fellows are encouraged to develop and maintain long-term professional relationships with the children and their families they follow on a regular basis, to be involved in the day-to-day care of patients, and to be a part of the decision-making team. The Fellows are supervised by both the outpatient attending physician and the clinical directors for the three specialty services. The Fellows are responsible for establishing the diagnosis, developing a treatment plan, performing diagnostic procedures, interpreting results, and providing short-and-long term follow up. Fellows will perform diagnostic procedures (LP and BM) and admit patients to the observation unit for various therapeutic procedures, such as radiation therapy. The Fellows gain additional experience in managing patients in an outpatient/day hospital environment and learn about new aspects of cost-effective medical care and managed care clinical pathways.  The Fellows are supervised by the Hematology/Oncology/BMT faculty who are actively involved in the clinical management of these patients. Fellows, however, also interact with other health care providers, including Pediatric nurse practitioners and physician assistants, who are working in similar areas. The Fellows spend time in the infusion center, where outpatient day care is delivered (outpatient chemotherapy, transfusion therapy, stem cell collection and therapeutic apheresis, fluid therapy, nausea, and pain control). Fellows are also involved with and gain experience in the management of hospice patients both in the hospital and at home.

Overview of Year 2:

During the second year, Fellows consolidate the knowledge that they acquired in the first year. The second year is primarily devoted to laboratory or clinical research. They will also assume greater responsibility in the management of their patients as well as the other patients on the service. This will mean some independence in making management decisions depending on their individual progress over the year. At all times supervision from the attending physicians will remain in effect. The initial eight weeks of the second year consist of one-to-two-week selectives in radiation oncology, neuro-oncology, hematopathology, immunogenetics, apheresis and stem cell laboratory, and blood banking that are protected time for the Fellow to spend with each of these subspecialists.

During the second half of year one, the Fellow will meet with the Program Director to identify a research project and research mentor. The Fellow is encouraged to speak with the heads of various laboratories and/or clinical research programs in order to explore the possibility of working with that research team. These research mentors may be within the division of Pediatric Hematology, Oncology, and/or BMT or in another related division at New York Medical College or within the NYC/Westchester county area. The research mentors will provide reading materials specific/relevant to the project/laboratory. Once the research laboratory or clinical research team has been specified, the Fellow will begin the research project in the third month of the second academic year. A Scholarly Oversight Committee (SOC) is established for each Fellow after finalization of the research project. The Fellow, research mentor, program director, and SOC meet every six months or more often as needed to review the progress of the Fellow in their research project.

Overview of Year 3:

The third year of training is devoted almost completely to research. The Fellow continues with their once-a-week outpatient continuity clinic and attends important divisional conferences. The Fellow should generally be able to complete the board requirements at the end of the year. This includes having their research project completed and preparing it for publication. During this time, the Fellows should be planning for the future in terms of job opportunities and career development either in clinical service and/or in basic research.

Evaluation:

Fellows will be evaluated quarterly by the faculty on service, the outpatient faculty member for the Fellow’s designated outpatient clinic day, and their research mentor/laboratory supervisor. The Program Director meets individually with each Fellow quarterly to provide an overview of the evaluations that were submitted and to allow the Fellow to provide feedback on the program. In addition, Fellows will be asked to evaluate the attending physicians and to evaluate the program as a whole.

This training program is designed to encourage trainees to develop an interest in clinical and/or basic research during the first year of training. The first year is almost exclusively devoted to clinical inpatient responsibilities. The second and third years are subsequently devoted to the Fellow’s scholarly research experience. The Fellows are anticipated to be a first author on a presentation of his/her research project at a national or international peer-review meeting and first author peer reviewed publication before they finish their third year of training.

With the exception of their outpatient continuity clinic one day a week and teaching conferences, Fellows concentrate almost all of their training time during the second and third years on laboratory or clinical research. With additional post-doctoral supervision, the Fellow develops his or her own basic laboratory or clinical research project under the direct supervision of the Program Director or his or her faculty designee. The trainee develops the capability of drafting the concept of their project, learns to develop a hypothesis, set of objectives, the background and significance, the development of an experimental design, and to participate in data collection and final analysis. The Fellows attend a research meeting every week at which they are responsible for presenting their research projects to the entire research team and observe additional projects that are ongoing within the department. Once a quarter, the Fellow meets with the Program Director to review the progress of their specific research projects. The Fellow develops abstracts and manuscripts that are completely supervised by either the Program Director or a senior faculty mentor. There is a presentation every six months by the fellow to a Scholarly Oversight Committee (SOC) during their last two research years. The SOC reviews the fellows research proposal, progress and advises the fellow and/or his/her mentor on the progress of the research and any suggestions for improvement, collaboration and educational needs. Most of our fellows go on to present their research projects either locally or nationally. Titles of past and current fellow research projects include:

• “Combination Immunotherapy Against Neuroblastoma with Novel CAR in Expanded PBNK Cells and Bispecific NK Engagers”
• “Engineering Dendritic Cell Based Vaccines as Targeted Immunotherapy Against Ewing Sarcoma”
• “Investigation on the potential therapeutic effects of human umbilical cord blood derived unrestricted somatic stem cells on Acute Graft versus Host Disease”
• “Mechanism and Efficacy of PD-L1 blockade in PMBL and GBM”
• “Targeted Immunotherapy in Combination with Checkpoint Blockade in Burkitt Lymphoma”
• “Safety and Tolerability of Chronic Erythrocytapheresis in Children, Adolescent and Young Adult (CAYA) Patients Receiving Chronic RBC Transfusions”
• “Targeting AML with Anti-CD123 Chimeric Antigen Receptor Modified NK cells”
• “Unrestricted somatic stem cells and INF-γ inhibitors therapy for acquired severe aplastic anemia”
• “Allogeneic Stem Cell Transplantation for Malignant and Non-malignant Hematologic Diseases Utilizing alpha/beta T cell and CD19+ B Cell Depletion”
• “The Use of Dose Dense Rituximab for High Risk Patients with Newly Diagnosed Acute Immune Thrombocytopenic Purpura”

The Pediatric Hematology/Oncology/Stem Cell Transplantation division has a seven physician faculty with a very wide range of clinical and research interests. Additionally, fellows will be provided with a list of several faculty outside the division that will serve as mentors for the fellows’ research. This assures each trainee of the opportunity to be exposed to all facets of our field. Our faculty is currently involved in dozens of research projects, ranging from cell and molecular biology, clinical trials and epidemiological research. Fellows may choose any of the faculty as mentors in research.

There are numerous clinical and educational resources available to the fellow during training. Clinical resources include exposure to approximately 20 inpatients on a daily basis with primary diagnoses of Pediatric Hematology or Oncology or Stem Cell Transplantation. Additionally, each day the fellow participates in one to three consults within the inpatient hospital. The outpatient program has an ambulatory clinic and infusion center with an average daily visit of 20 patients in total for the fellows to participate in their care. Educational resources include a fellow’s library with availability of common Pediatric, Pediatric Hematology, Oncology, and Stem Cell textbooks. Additionally New York Medical College has an outstanding Health Sciences Library consisting of 20,000 square feet, room for 225 seats, two computer labs, four multipurpose conference rooms, and a 20-person classroom. The library has access to 16,543 journal titles and participates in NNLM and OCLC. The fellow also has their own PC and internet access to all search engines to obtain educational material. Lastly, all related policies and procedures and research protocols are available on the hospital intranet site.

New York Medical College

New York Medical College, which has been training physicians since 1860, is one of the largest medical schools in the United States. The main campus moved to Westchester from New York City over 15 years ago, and this move has sparked an extraordinary growth in both the research and patient care roles of the medical school. The Department of Pediatrics has likewise grown at a fantastic rate, with all subspecialists very well represented. There are huge opportunities for each fellow to interact with basic scientists and clinical scientists in all fields of medicine.

The Graduate School of Basic Medical Sciences at New York Medical College offers a unique opportunity for trainees in this program to obtain a PhD degree in one of six basic medical sciences programs – Biochemistry and Molecular Biology, Cell Biology, Microbiology and Immunology, Experimental Pathology, Pharmacology, or Physiology.

The School of Health Sciences and Practice (School of Public Health) of New York Medical College is another vital resource for our training program. In addition to strong statistical and epidemiological support, the faculty of the Institute for Public Health Health and our division faculty collaborate closely in our newly developed Children’s Environmental Health Center of the Hudson Valley. Trainees are strongly urged to consider obtaining either a Master’s or PhD degree in Public Health while they are completing their fellowship in pediatric Hematology/Oncology/Stem Cell Transplantation.

Maria Fareri Children’s Hospital

The Maria Fareri Children’s Hospital at Westchester Medical Center is a major teaching hospital of New York Medical College. It serves as the only major referral center for the seven counties in the lower Hudson Valley, and has the highest “case-mix index,” which is a measure of acuity, in the state. Our helicopters bring children in daily from a very expansive geographic region. The focus is on tertiary and critical care. We are always at or above 100% census with transports of critically ill children occurring daily. In 2004, the magnificent Maria Fareri Children’s Hospital at Westchester Medical Center opened, and continues to expand in size and scope of programs offered. MFCH is dedicated to family-centered care and is a truly beautiful facility. All patients have private rooms and parents are encouraged to stay 24 hours a day. Learn more.