Clinical Training

Years two and three of the University Hospitals Gynecologic Oncology Fellowship are devoted to in-depth clinical training. The clinical fellows are involved in all aspects of the care of patients with gynecologic malignancies, including:

Outpatient evaluation and follow-up
Surgery
Chemotherapy and radiation therapy
Post-operative care
Intensive care
Palliative care

Clinical Rotations

Philosophy Graduated responsibility: Our Division embraces the Milestones process as described by ACGME, and progression of clinical responsibility is a central goal for fellowship training programs. These competency-based outcomes serve as a guide to facilitate progressive responsibility of fellows throughout their inpatient and outpatient rotations. Thus, while the physical structure of the rotations for the second and third year fellow are similar, they will differ in very important ways based on a philosophy of progressive responsibility and in a manner outlined by the Gynecologic Oncology Milestones Project. Attending mentors will assess on an ongoing basis each fellow’s progress toward achieving Milestones. When relevant, competency based goals and objectives are distinguished by year of training and align with Milestones metrics. However, the level of responsibility allowed each fellow in each domain and at each stage of training will vary and, by necessity, the process of graduated responsibility needs to be flexible and individualized. Evaluation is competency-based, documented by those having direct observation of the Milestone being assessed, and timely in the event of any observed deficiencies.

Inpatient Gynecologic Oncology Rotation

The Gynecologic Oncology inpatient rotation is centered at University Hospitals Seidman Cancer Center. The rotation provides comprehensive experience on the many aspects of patient care for patients with gynecologic malignancies that require inpatient management. With this experience, the fellow will gain a comprehensive understanding of the oncologic, medical and social issues of patient’s with gynecologic cancers. Fellows participate in relevant surgeries and manage the subsequent postoperative care of the patient. They also participate in the care of all patients admitted to our service for acute problems, for chemotherapy and for palliative care. Fellows also participate in all inpatient consults.

Fellows gain valuable leadership skills on the Gynecologic Oncology inpatient service as they play a pivotal role in directly overseeing the activities of three residents, two nurse practitioners and medical students. They also play a central role in communication with gynecologic oncology faculty, consulting faculty, pharmacy staff, nursing, social work and other ancillary personnel.

Finally, fellows in the outpatient rotation will lead the inpatient and surgery portion of the QA meetings. They will also prepare and participate in discussions at the weekly Tumor Board conferences.

The Inpatient Gynecologic Oncology Team during the week consists of:

One Gynecologic Oncology attending of the day
One second or third year Gynecologic Oncology fellow
One Clinical Nurse Practitioner
Three residents (first, second, and third year resident)
One Acting Intern (variable)

The Gynecologic Oncology Outpatient Rotation

The Gynecologic Oncology outpatient rotation will serve to provide a focused outpatient experience for fellows-in-training. The rotation provides comprehensive experience on the many aspects of patient care for patients with gynecologic malignancies that require outpatient management. With this experience, the fellow will gain a comprehensive understanding of the oncologic, medical and social issues of patient’s with gynecologic cancers.

Fellows on this rotation will participate in clinics at UH Seidman Cancer Center as well as University Hospitals Westlake and Chagrin satellite cancer centers with the four gynecologic oncology faculty. Fellows will see patients independently, gather relevant background information and present them to the attending, who will examine the patient with the fellow. Following examination, fellows will participate in the review of imaging studies and clinical materials and discuss treatment planning for each individual patient with the attending. Fellow will also perform outpatient procedures as needed. These include, but are not limited to colposcopy, diagnostic biopsy, paracentesis, and ultrasound.

Most chemotherapy is administered in an outpatient setting and, importantly, the outpatient fellow will be immersed in the practical application of chemotherapy by participating in continuity care of our patients on active treatment. Through these interactions the fellows will gain an understanding of chemotherapy indications, dosing, administration and toxicity management. Some patients will be considered for clinical trial participation and fellows will also gain an important understanding of the process of informed consent and clinical trial enrollment in this setting. Moreover, the pharmacists at the satellite cancer centers are physically very closely located in the clinic/infusion centers and time the outpatient fellow will work with the pharmacists to gain their perspectives on chemotherapy administration, preparation and cost.

Key Components

Key components of progression of proficiency and responsibility for both inpatient and outpatient rotations include gaining an understanding of the basic principles of evaluation and management of gynecologic oncology patients as a second year. These include refining an understanding and gaining competency in the mechanisms of carcinogenesis, genetics, disease processes of the gynecologic malignancies, pathophysiology, pharmacology, surgical procedures, chemotherapy management, postoperative care and palliative care. Third year fellows will continue to refine this knowledge base as well as gain further competency in managing unusual presentations and diagnosing and managing complications. They will also be expected to describe the evidence that supports their clinical decision-making and will be afforded a greater degree of latitude for independent decision-making. They will be expected to play a greater role in teaching junior residents, nursing personnel and medical students in varying capacities, formally with didactics and conferences and informally during the course of managing the inpatient service and their outpatient rotation.

The Fellow Service

Third year fellows have an additional clinic of their own. Continuity clinic is structured to prioritize longitudinal relationships for continuous management of all aspects of care for gynecologic cancer patients. It is ½ day per week on Friday afternoon, throughout the fellow’s third year and irrespective of which rotation she/he is on. Comprehensive treatment plans are formulated and executed by the fellow with faculty mentorship using graded autonomy.

Formal Educational Venues Within our Fellowship

Friday Morning Didactic Conference

Takes place every Friday, 6:45 – 8 a.m.
The foundation of our didactic program is our weekly Friday morning conferences. The backbone of this program is case-based learning that highlight disease sites loosely organized according to managing a new diagnosis, surveillance and survivorship, managing recurrent disease, and palliative and end of life care. An integrative learning approach that encompasses each of the Core Competencies throughout is emphasized. Faculty present the majority of didactic sessions. Guest presenters are also invited to address additional topics of interest within their specialty. Moreover, three to four times yearly each fellow will partner with a faculty to co-present a topic of their interest in a mentored experience. Sessions are interactive and slides are filed and available for later access/review. Select sessions will be accompanied by a “take home” test designed to reinforce important concepts.

QA Conference

Discussions at this conference reflect all six ACGME core competencies: medical knowledge, patient care, practice based learning and improvement, professionalism, and systems based practice and encompass all aspects of patient care throughout the spectrum of their cancer care.

Amy Armstrong, MD, coordinates this monthly conference and fellows share responsibility in presenting cases for review.

Interdisciplinary Education Conference

Takes place four times per year.
Interdisciplinary education and quality initiatives increase the success of achieving our common goal of best patient outcomes. We have initiated a regular conference that engages personnel across the disciplines that participate in the care of our Gynecologic Oncology patients on UH Seidman 6. Thus, faculty, nursing, discharge planning, physical therapy, hospice and home care participate in this conference on topics toward that end for our patients on UH Seidman 6. Examples have thus far addressed health literacy, inpatient to outpatient transitions, social determinants of health, patient satisfaction, etc.

Gynecologic Oncology Division Research Conference

Occurs every other month during didactics.
This session provides an opportunity for fellows and faculty to present research updates, receive feedback, and set goals and timelines. It is intended to be a forum that allows an exchange of ideas and enhances collaboration within our division and between fellows and faculty. Fellows who have work accepted at scientific meetings will also formally present during these sessions and receive feedback on their oral presentations.

Tumor Board

Friday Mornings 8 – 10 a.m. in the Radiation Oncology Conference Room
This multidisciplinary conference is attended by a gynecologic pathology specialist, a radiology specialist, a radiation oncology specialist, medical geneticists, all gynecologic oncology faculty, fellows, nursing and residents. Tumor Board is an exceptional educational forum and also a vital step towards learning the importance of good communication practices and systems-based approach to patient care. Fellow share responsibility of preparing for Tumor Board and are expected to undertake independent reading in preparation for their presentations.

The Tumor Board list is distributed every Wednesday afternoon. Some of them will have pathology and/or radiology for review and some may only be treatment discussions. Fellows are expected to consider their treatment recommendations ahead of the conference and prepare with reading to support their recommendations.

NOTE: The radiologists, pathologists, medical geneticists and radiation oncologists that attend this meeting are an important resource for fellow education and the fellow is expected to focus on their presentations and discussions during this conference. Asking questions for the purposes of achieving a deeper understanding with regards to any aspect of their portion of the discussion/presentation are explicitly encouraged.

Surgical Conference

Weekly, after Tumor Board conference
Every Friday, after the Tumor Board cases are reviewed, we proceed to a brief Surgical Conference. The scheduled surgery schedule for the upcoming week is presented by the R2, who has reviewed and prepared all of the H&Ps for the upcoming surgeries should be completed. Attendings weigh in to describe any concerns they may have or potential challenges they anticipate on their cases. Note fellow responsibilities:

The fellow on service is responsible for making case assignments for the members of the team according to appropriateness for their level of training. By assigning cases early, we expect both fellows and residents to be prepared each surgical cases.

Second assisting is a vital learning opportunity for resident growth in the OR and should be considered education, not service. All major surgeries should have a second assistant to optimize resident growth and preparedness. Interns and second year fellows are to be second assist on OR cases in preference to students whenever possible and particularly on high priority cases needed for their case logs.

It is not always obvious to early learners that surgery requires preparation. The fellow is encouraged to explicitly instruct residents how to prepare for their upcoming cases (i.e., through reading H&Ps, reviewing and understanding indications for surgery, surgical anatomy and surgical atlases or by any means available to them).

Note: The OR schedule can get busy and sometimes many rooms are running simultaneously. It is policy that the benign GYN service can be called upon as a resource if there are surgical cases that cannot be covered by the residents and fellows on the oncology service.

We often do combined surgeries with other teams, particularly urology and colorectal surgery. The fellow is expected to participate in all aspects of combined surgical cases.

Journal Club

Every other month, held in the evening
Faculty, fellows and CNPs attend. Faculty choose topics with fellow input. Articles chosen will be related and often address a controversial topic or newly published research in the context of existing evidence. Fellows are each assigned a scientific article to review, critique and present. When relevant to the topic, we engaged other specialties for a multidisciplinary journal club.

Professional Development Seminars

Monthly, Monday 5 – 6 p.m.
This monthly session is attended by all fellows and junior faculty within the department. Topics within the curriculum are relevant to faculty development and include managing your office, negotiating, teaching and feedback skills, professionalism, networking, preparing for board exams, promotions and tenure, etc. Sessions are organized by Margie Greenfield, MD, and Vice Chair for Faculty Development.

Also included in faculty development curriculum is a focus toward academic growth and productivity. Research updates among fellows are discussed as well as workshops on scientific writing, managing research teams, grant writing, etc. This portion of the curriculum is organized by Sam Mesiano, PhD, and Professor of Reproductive Biology.

Departmental Grand Rounds

Take place Wednesday mornings, 7 – 8 a.m.
On Wednesdays, surgery does not start until 8 a.m. Topics are varied and published well in advance. Dr. Armstrong is our Grand Rounds coordinator. The Gynecologic Oncology fellow is only required to attend those directly relevant to their subspecialty or patient care interests.

Health System Science Curriculum

“To fully serve patients today and into the future, physicians need to know more than biomedical and clinical sciences. They need to understand the content of health systems science. This new discipline includes understanding how to:

Improve healthcare quality
Increase the value of care provided
Enhance patient safety
Deliver population-based medical care
Work collaboratively in teams

Physicians need to learn how to advocate for their patients and communities and understand the socio-ecological determinants of health, healthcare policy and healthcare economics.”

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