Clinic

In clinic, residents are encouraged to review the medical chart of the upcoming patient and any pertinent imaging. Discuss with your attendings how he/she prefers to organize the day. Some will encourage you to go in and see the patient before them and gather the medical history and formulate an idea of what you think is going on; others may prefer that you see the patient simultaneously with them, as they often have long-term relationships with these patients and know them very well. One of your primary goals should be to learn about the commonly prescribed chemotherapy medications, their most common side effects, and their limitations. Consider the common cancers and metastatic disease to be encountered: neuroendocrine, pancreatic adenocarcinoma, colon cancer, hepatocellular carcinoma.

Diagnostic Imaging

The resident’s core diagnostic radiology skills will be very useful and frequently called upon throughout this rotation. The attendings typically review the imaging and report. However, they may turn to you as an experienced radiologist. In the clinic setting, new patients frequently present to the clinic with only outside imaging available; this is an excellent opportunity for you to showcase your expertise and help the oncologist understand the findings on the CT or MRI. This is a great time to learn and build upon your CT and MRI abdominal imaging knowledge, as these patients often have complicated medical conditions that require advanced imaging. Furthermore, this experience will improve your clinical judgment as you observe how clinicians decide when an imaging study is indicated or needed, how they respond to radiologists interpretations, and how our reports affect patient management and their course in the hospital.

Relevance to Interventional Radiology

This rotation will allow the resident to further develop their clinical knowledge and judgment to progress towards becoming a practicing clinical interventionist. Oncologic patients with advanced disease and those in the immediate postoperative state often require the services of interventional radiology. As a member of the referring team, the IR resident will have an opportunity to learn how our colleagues care for our patients before, during and after IR procedures, which will enhance the resident’s ability to care for these patients themselves in the future. This is also a chance to enhance your knowledge of the indications and limitations of the common interventional radiology procedures this patient population typically requires (see below). Furthermore, you will observe how medical oncologists interact with other clinicians, radiologists, and surgeons.

Frequently requested interventional radiology procedures:

  • TACE and Y-90 radioembolization
  • RF and microwave ablation
  • Percutaneous transhepatic cholangiogram and biliary catheter placement
  • Postoperative abscess drain
  • Mediport and CVC placement
  • IVC filter placement and retrieval
  • G/J-tube exchange
  • Percutaneous nephrostomy tube placement
  • Visceral angiography and embolization for post-op hemorrhage

Specific Rotation Goals and Objectives

  • History Taking and Physical Examination
    • Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
  • Knowledge and Clinical Decision Making
    • Improve medical knowledge regarding the pathophysiology and natural history of a wide range of tumors commonly seen in the outpatient setting and treated with chemotherapy. This includes various types of lung, neuroendocrine, pancreatic adenocarcinoma, colon cancer, hepatocellular carcinoma, and renal cell carcinoma.
    • Develop an appreciation for the clinical presentation of commonly encountered malignancies and imaging findings.
    • Discuss the role of oncogenes in cancer causing mutations (i.e. p16, p53, BRCA 1/2, RAS, HER2, APC).
    • Understand the various tumor-staging systems and utilize these systems in the management of patients. Be able to develop an acceptable treatment regimen for individual patients with cancer based on their disease stage.
    • Expand knowledge base on the selection of each chemotherapeutic agent and how to combine this agent with other components of therapy such as surgery and radiation.
    • Compare and contrast neoadjuvant vs. adjuvant chemotherapy.
    • Identify clinical presentations where combination chemotherapy is recommended.
    • Understand the classification of the chemotherapeutic drugs by mechanism of action:
      • Alkylating agents (i.e. Cyclophosphamide, Temozolomide, Busulfan, Melphalan)
      • Antimetabolite (i.e. Methotrexate, Capecitabine, Mercaptopurine, Fluorouracil, Gemcitabine, Doxorubicin)
      • Nitrosoururea (i.e. Lomustine)
    • List some of the more common chemotherapy regimens (i.e. ABVD, AC, CAV, CHOP).
    • Develop the skills to discuss diagnosis and management of side effects of specific chemotherapeutic agents.
    • Become competent in the appropriate usage of tumor markers (i.e. CEA, CA-125, CA 19-9, AFP, PSA, HCG), tumor excretory metabolites, and diagnostic cytohistologic techniques in the screening and monitoring of disease recurrence/progression.
    • Understand the indications for curative versus palliative treatment and be able to formulate treatment plans for both.
    • Become familiar with currently used radiotherapy and immunotherapy protocols for common cancers.
    • Appreciate the importance of limiting the occupational exposure to anti-neoplastic agents.
    • Discuss the importance of patient and family member education with respect to treatment expectations.
    • Become comfortable with the management and treatment of oncologic pain, including proper dispensing of narcotics.
    • Learn how to diagnose and treat patients presenting with neutropenic fever. Specifically, understand the various classes of antibiotics and know how to prescribe them appropriately.
    • Independently interpret the results of the following laboratory tests:
      • CBC with diff, red cell indices, blood smear, reticulocyte count, serum iron, TIBC, ferritin, UA, electrolytes, BUN/Cr, glucose, hepatic function panel, tumor markers, PT/INR, PTT, and bone marrow aspiration and biopsy.

Systems Based Practice

  • Take on new patients and consultations with the goal of assigning team resources to address them in an appropriate and timely manner
  • Be able to coordinate care within the team over multiple patients and multiple problems of varying urgency (i.e. be able to triage effectively)
  • Coordinate hospital and physician resources in regards to transferring patients who are critically ill from other institutions
  • Complete full consult notes and progress notes every day on the patients that you are covering in a detailed and accurate format that is easily translatable to other services
  • Be an active, effective and efficient team member by effectively transferring care between duty hours completely and responsibly

Practice-Based Learning and Improvement

  • Shows appropriate use of consultation with medical and non-medical services, including special diagnostic studies
  • Uses evidence from the medical literature to answer clinical questions
  • Identifies areas for potential improvement in personal delivery of care
  • Maintains a positive attitude towards learning, including attendance and participation on patient rounds and conferences, and evidence of reading or other methods of gaining knowledge
  • Participates actively in teaching others, including students, residents, and faculty
  • Serve as a radiology advisor/liaison to the team when called upon
  • Educate the team regarding imaging utilization, radiation concerns and
  • Develop the clinical skills necessary to successfully manage a patient throughout the peri-procedural course, to help facilitate improved non-procedural interventional radiology patient care during your career.

Patient Care

  • Review past and current imaging on all patients you are involved with.
  • Perform procedures within the level of your knowledge under supervision.
  • Assist in the admission and discharge of patients when appropriate.
  • Assist in consults when appropriate.

Interpersonal and Communications Skills

  • Presents a patient effectively and efficiently
  • Communicates with patients and concerned others effectively
  • Writes accurate and complete entries in the medical record
  • Works constructively as part of a team
  • Exchanges information effectively and efficiently during rounds that reflects
  • pertinent issues and problems, current therapeutic plans, and expected
  • complications and issues
  • Establish therapeutic and empathetic relationships with patients and their families

Professionalism

  • Remember you are a guest in another specialties’ practice. Be prompt, present,
  • Take on progressive amounts of responsibilities during your rotation and live up
  • Dress code: White coat and business casual attire is expected in the outpatient clinic. Scrubs under white coat may be acceptable on the floor depending on your attending. Scrubs alone are acceptable during procedures.

Additional Resources

  • Textbooks available on ClinicalKey (Title – Author)
    • Clinical Interventional Oncology – Kee
    • Image-Guided Interventions – Mauro
    • Oncologic Imaging – Silverman
    • Abeloff’s Clinical Oncology – Niederhuber
    • Essentials of Surgical Oncology – Sabel