Hematopathology Fellowship

Download Brochure(PDF format) or Application Form (PDF format or Word format ). Note that you may also use the standardized CAP fellowship application as a replacement for our application if you prefer. In that case, please be sure to include all the requested information (e.g., statement of your interest in Hematology) on the CAP form, as well as the additional data requested by the CAP form.

Overview.
The ACGME-accredited Hematopathology Fellowship training program at Yale New Haven Hospital and the Veterans Administration Connecticut Medical Center is designed to provide a comprehensive experience in all aspects of hematology/hematopathology including consultative clinical practice, diagnostic testing, multi-level teaching and an understanding of the principles of biomedical research. Instruction and practical experience occurs for all aspects of hematology: lymphoid and myeloid disorders, coagulopathies and red cell disorders. The program takes advantage of the rich environment in both anatomic and clinical pathology at these institutions with a special emphasis on integrating all aspects of clinical practice, teaching and research with the other academic activities in Pathology and Laboratory Medicine at Yale. In addition, the program coordinates on a day to day basis with the extensive clinical and investigative activities of the sections of Medicine Hematology, Medical Oncology and the Yale Cancer Center, and the Pediatric Hematology-Oncology section , which include programs in stem cell transplantation, state-of-the-art immunotherapeutics and therapeutic gene transfer. The program especially highlights the modern need to fully integrate morphology, immunophenotyping, flow cytometry, cytogenetics, molecular diagnostics, functional cellular and protein assays, and longitudinal clinical correlation in providing a complete hematopathology consultation that is maximally useful in both establishing a patient's initial diagnosis/prognosis, and in monitoring the efficacy of therapeutic interventions. The trainee gains hands-on technical experience in all these areas with an emphasis on coordinating the results of different technologies.

The program envisions our trainees, and all hematopathologists, as being the central consultative core of the diagnostic and therapeutic team caring for patients with hematologic disease, both benign and malignant. Close communication with internal medicine, surgery, ob/gyn and pediatric colleagues is emphasized; the fellow provides formal written consultative interpretation not only for lymph node and bone marrow specimens but also for coagulation and hemoglobinopathy testing. Hands-on experience in relevant bedside procedures and patient interviewing is a formal part of the program. Finally, the program accepts as a given that the hematopathologist in clinical practice must also be an excellent teacher and communicator - hence the fellow is given significant responsibility for presenting at multidisciplinary conferences. Moreover, we believe that an hematopathologist should be able to understand and bring to his/her practice cutting edge diagnostic modalities that pass the test of "evidence-based" medical practice. Toward this end, the program provides training in some of the basic principles of state-of-the-art basic, clinical and translational research through active participation in a journal club, by exposure of the fellow to a mentor's research laboratory, by providing for attendance at a national meeting, and by having the trainee carry out at least one significant clinically-oriented research project during their year of clinical training.

There are two "tracks" to the Hematopathology Fellowship. The predominantly clinical track involves a one year integrated clinical experience with an exposure to research as outlined above. The core and elective portions of the curriculum are individualized to take into account the fellow's past experience as well as future career plans. The physician-scientist track is designed on an individual basis as a multiyear clinical and research fellowship designed to provide the fellow with sufficient experience to enable her or him to launch a career as a clinician-scientist. Generally, this involves an initial clinical year during which the fellow begins a substantive research project in the laboratory of a Yale mentor, followed by 2-3 years of additional research training in the same mentor's laboratory. The research component of the fellowship is usually supported under the auspices of an NIH NRSA award, which may allow for participation in attractive financial support options by NIH, including NIH repayment of up to $35,000 per year of past educational loans the fellow may have encumbered.

Structure.
The program is structured to provide all needed core training over a one-year period and to assure that learning of the different subspecialty areas of hematology (morphology, immunohistochemistry, flow cytometry, molecular diagnostics, red cell diagnostics, coagulation, cytogenetics, clinical instrumentation, hematology laboratory management and informatics) is accomplished in a coordinated fashion. The basic structure of all of the rotations is a case-oriented one. In each rotation, the fellow has a primary learning responsibility in one area of hematopathology but also coordinates data obtained from other subdisciplines that relate to the primary case. For example, when on the rotation that occupies most of the fellow's time, (lymph node/bone marrow morphology/histochemistry), the fellow spends the majority of his/her time evaluating this aspect of the cases seen and learning the technical, managerial and informatics issues associated with this area. However, for each case identified on that service, the fellow also incorporates data obtained from cytogenetics, flow cytometry, etc in the evaluation of the case and studies the primary data in those other areas as well. Thus the final case interpretation is always a coordinated one for the fellow. We believe that such an approach maximizes the fellow's learning trajectory. The fellowship is also designed to provide graduated responsibility in each area over the course of a year's period of time.

In the beginning of the fellowship, a one week orientation period includes formal lectures in the basics of hematopathology and provides the opportunity for the fellow to meet and interact with the faculty in each of the relevant subsections, to meet with the AP/CP residents with whom the fellow will closely interact during training, and to "learn his/her way around" the institutions. Thereafter, the fellow enters into a series of rotations designed to give the fellow the conceptual and technical underpinnings of each subdiscipline in a relatively concentrated fashion. A typical sequence is as follows: (1) lymph node and bone marrow morphology and histochemistry (LN/BM) for 4 weeks; (2) hematology laboratory and coagulation laboratory for 4 weeks; (3) cytogenetics for 2 weeks; (4) flow cytometry and molecular diagnostics for 4 weeks; (5) immunology and stem cell laboratories for 1 week. In each rotation, the role of the pathologist as consultant is the focus of learning - trainees communicate results of studies directly to other clinicians, albeit during this initial period of time that communication is often carried out in the presence of the pathology attending. The basic "how-to" of procedures is also taught during this initial set of rotations - this includes, for example, doing bone marrow aspirates and biopsies on the floor and interviewing patients with coagulopathies (both during the heme/coag and flow/molecular rotations). The brief sojourn in immunology and stem cell laboratories gives the fellow some exposure to functional (CFU) stem cell assays, hematopathology relevant immunofixation electrophoresis assays, and to stem cell processing, including cell purging and positive selection and cryopreservation. During this 16 week period of time the fellow is expected to learn all the basic principles and apply these on a case by case basis. It should be noted that this schedule is individualized depending on the fellow's prior experience. For example, if a fellow has already spent a large amount of time during residency studying flow cytometry and molecular diagnostics but less time reviewing lymph node pathology then that fellow might do seven weeks on LN/BM and only one week on flow/molecular.

After this initial 16 week training period, the remaining 34 weeks is scheduled on the basis of the fellow's past experience and future career plans. The fellow has had by this time at least one career counseling session with the Program Director. The rest of the year is then tailored to the fellow's needs. A typical schedule might lead off with a 1-2 week partial respite from full time clinical work to carry out dedicated library work for planning a research project. Then there may be the following rotations: (5) LN/BM for 12-14 weeks, (6) hematology/ flow/ coagulation for 6-10 weeks, (7) LN/BM for 10-12 weeks. During this set of "second" rotations, the fellow is expected to do significantly more teaching of both AP/CP residents and of fellows from other departments rotating through the services. The fellow consults directly with other clinicians. While on the hematology laboratory rotation the fellow acts as the laboratory director, that is, he/she is the first-call individual to make management decisions (new instrumentation, alterations in informatics, regulatory issues, personnel issues, QC/QA sign-off, and so forth).

It is also during this second two-thirds of the fellowship that the fellow is expected to carry out an investigative project with a specified mentor. The nature of that project is determined by consensus of the fellow and the attending group. Depending on the career goals of the fellow, this may involve setting up a new molecular diagnostic assay, carrying out case-review clinical research, or even the commencement of a more translational or basic science project if there are plans for the fellow to spend additional years of research training after the hematopathology fellowship. The mentor will usually be selected from hematopathology staff but many other investigators at Yale are also potential mentors.

It should again be emphasized that all the individual rotations for the fellow are integrated experiences. For example, in the evaluation of lymph nodes and bone marrows (the "LN/BM" rotation), the fellow reviews all the relevant surgical specimens for a given case (LN, BM BX, BM ASP) as well the immunohistochemistry, flow cytometry, molecular diagnostics, special histochemistry, cytogenetic and even, where relevant, IFE, special red cell and special coagulation studies, etc that relate to the case.

The schedule described above refers to the fellow's work at Yale-New Haven Hospital. Twenty percent of the fellow's time is spend at the VA Connecticut Medical Center. This time is organized as an ongoing longitudinal experience. The fellow spends most of his/her time on Mondays at the VA, and the remainder of the week at Yale New Haven Hospital. The VA is a 10 minute shuttle bus ride from YNHH and the shuttle runs continuously. On Mondays, the VA has its weekly major hematopathology conference at which new and relevant old patients are presented at a 10 headed microscope with all their data. The afternoon conference is attended by all hematology and medical oncology clinicians, residents/fellows, an AP/CP resident assigned to the VA, the VA hematopathologist, Dr. Shafi, and on a monthly basis, Dr. Smith from YNHH. The fellow spends the morning reviewing the relevant material with Dr. Shafi and staff and also addressing any ongoing issues in the hematology laboratory at the VA. This experience is somewhat different from that at YNHH because of the more community-hospital but 'integrated health-care network' nature of the institution. The VA is a part of the New England VA integrated health care system (VISN) including major facilities in Boston, Providence, White River Junction VT and Togus ME. The hematologist pathologists from all these facilities meet several times during the year to discuss issues of hematopathology that span the network. The fellow is expected to join in these meetings. This provides a broader, modern-day experience for the fellow.

Both at YNHH and at the VA, an important part of the training program is the fellow's responsibility for presenting cases at multidisciplinary joint conferences. There are three major such conferences held each week at YNHH: (1) YNHH Lymphoma/Stem Cell Transplant Conference, involving medical and surgical oncology, radiation therapy, pathology/laboratory medicine, and diagnostic imaging, is a conference at which all new lymphoma cases and most cases going to transplant are presented; (2) YNHH Hematology Clinical Rounds, involving medical hematology/oncology, pathology/laboratory medicine, and often pediatric hematology/oncology, is a conference at which all new hematology cases (red cell, myeloid, coagulation, hematopoietic malignancy) are presented; (3) YNHH Hematopathology/Hematology Rounds, involving medical hematology and oncology and pathology/laboratory medicine, is a weekly conference at which selected new hematology/hematopathology cases are presented. This latter conference is mirrored at the VA covering VA cases rather than YNHH cases each week - as discussed earlier this conference generally includes all, rather than selected, cases at the VA.

As noted earlier, we believe that teaching is an important part of the hematopathologist's role in medical practice - hence the fellow is also involved in medical student teaching in the second year pathophysiology block at the Yale School of Medicine and on an elective basis is encouraged to assist in teaching medical technologists and physician assistants. Moreover, we believe that it is crucial for the fellow to have the opportunity to go to at least one major national hematopathology meeting a year. Travel funds are provided for attendence at a national meeting.

Stipends.
Stipends are commensurate with the fellow's years of post-graduate training on the same scale as that received by Yale New Haven Hospital resident staff and also include family-plan-level health insurance and individual disability insurance benefits. Funds are also provided for educational materials ("book allowance") and for attendance at at least one national meeting. Details of the current stipend scale are provided upon application.

Facilities.
Yale New Haven Hospital (YNHH), a combined tertiary care and community-based medical center and the main teaching hospital for Yale School of Medicine (YSM), is the primary training location for the fellow. In addition to serving the greater New Haven metropolitan area, YNHH is also part of the Yale New Haven Health System which includes Bridgeport, Greenwich, and Westerly Hospitals. YNHH serves as a major reference pathology center (especially hematopathology samples and advanced technology procedures) from other system hospitals and also from many other hospitals and medical center/physician offices in New England and New York. YNHH/YSM (collectively referred to as the Yale New Haven Medical Center) is an extensive tertiary hematology-oncology facility serving as an NIH Comprehensive Cancer Center and including stem cell transplantation, gene therapy and immunotherapy units. The medical center also has major referral populations in red cell diseases (especially hemoglobinopathies and membrane disorders) and coagulopathies. It includes a large obstetrical population and a major integrated Children's Hospital. Hematology patients are cared for by a multidisciplinary team including internal medicine hematologist-oncologists, surgeons, radiation therapists, and, prominently, hematopathologists. Advanced diagnostic procedures (complex molecular diagnostics, flow cytometry, image analysis, cytogenetics) are routinely well-integrated into patient care.

The VA Connecticut Healthcare System (VA-CT), primarily based in West Haven, CT but also providing all anatomic and clinical pathology services for major additional facilities in Newington, CT and for series of outpatient clinics located around the state and into Massachusetts, provides 20% of the training to the fellow. The VA-CT, a major teaching hospital of YSM, has a very active hematology-oncology service and a consequent active hematopathology service led by a board-certified hematopathologist. The VA experience provides the fellow, not only with additional material for study, but also with important additional management experience in a smaller laboratory setting and in a setting of more extensive AP/CP integration into a regional (New England) coordinated government health care system (the New England "VISN"). The VA provides some services for all the other hospitals in the system and receives services from other facilities in the system. Furthermore, the centralized VA West Haven laboratory is responsible for providing optimal service to clinics located across the state and determining the proper mix of on-site vs referral testing for those outpatient facilities. Extensive communication between pathologists in this regional network is routine and provides an important additional perspective on community and integrated health system models of medical care. Thus the two institutions together provide comprehensive training in all aspects of modern hematopathology and represent a synergistic pair of teaching hospitals.

Staff.
The primary clinical teachers in the program include:

Brian R. Smith, MD
Stuart Flynn, MD
Henry Rinder, MD
Mazin Qumsiyeh, PhD
Nelofar Shafi, MD
Gary Stack, MD, PhD
J Gregory Howe, PhD
Diane Krause, MD, PhD
Mark Shlomchik, MD, PhD
Jeffrey Sklar, MD, PhD
Carlo Bifulco, MD

Physician-Scientist Training
For individuals with an interest in a longer term commitment to research work and to a physician-scientist career path, there is opportunity to have an extended research experience in the laboratory of faculty from the departments of laboratory medicine and pathology but also in the laboratories of other Yale University Faculty as part of the fellowship. A three to four year program of combined clinical training and research training in hematopathology and immunohematology is available as outlined earlier. For more information on some of the mentors that participate in this program and some of the opportunities available, please see the section on Research Fellowships for more details.

Past Fellows.
Past fellows in the program have gone on to research and clinical academic positions at major institutions. Representative publications and history can be found in the sections Where are our past residents and fellows now?, Our Current Residents and Fellows, and Recent Resident and Fellow Publications.

Applications.
Applicants should, in general, be board eligible in CP, AP or AP/CP by the time of their fellowship. Since the American Board of Pathology will also certify individuals in Hematopathology who have previously been certified in the Internal Medicine/Hematology subspecialty by the American Board of Internal Medicine, such individuals are also encouraged to apply to this Hematopathology program. To apply to the program, please complete the application form front page, available either as a Microsoft Word document (click here) or in PDF format (click here). In addition, please send a CV, statement of your interest in hematopathology and have letters of reference forwarded by three individuals - one of those letters should be from the Chair or the residency director of your prior training program. The fellowship is filled for academic 2007-2008 and 2008-09 but applications are now being considered for 2009-10 and beyond. We encourage those interested to apply up to several years in advance. Inquiries should be addressed to the Fellowship Director, Dr. Brian Smith, at:

Brian R. Smith, MD
Hematopathology Fellowship Director
Department of Laboratory Medicine
Yale School of Medicine
333 Cedar Street
PO Box 208035
New Haven, CT 06520-8035
E-mail: HemePathFellowship