The fellow spends two months in the Department of Radiation Therapy, working under the direction of Dr. Richard Stock, the department director, and his staff, especially Dr. Sheryl Green who is devoted to the radiation therapy for gynecologic oncology. This department is committed to the education of our fellow and since there are few extramural rotators through the department, the staff, including the physicists and radiotherapy technologists, have an opportunity to provide “hands on” preceptorship. This allows participation in the management of all patients with gynecologic cancers. Our fellows’ education can occur by virtue of a supervised “hands on” preceptorial program which will allow participation in the management of all patients with gynecologic cancers, as well as, all patients being planned, localized, and started on radiotherapeutic programs. There are didactics in radiation physics, as well as daily instruction in radiation physics designed to meet the needs of a gynecologic oncologist as outlined by the Division. All patients with gynecologic cancers requiring admission to hospital are admitted on the gynecologic oncology service and their in-hospital care is supervised by the fellow in gynecologic oncology under the direction of the radiation therapist. This applies not only during the fellows’ rotation through radiation therapy but also carries over to all radiation therapy admissions of gynecologic oncology patients. All low-dose brachytherapy procedures are performed by the gynecologic oncology fellow under attending supervision. Because there is a larger cohort of advanced cervical cancer patients requiring brachytherapy at our Queen’s affiliate, the fellows attend the high-dose rate brachytherapy applications for cervical cancer at the Queen’s Hospital Center, during the Radiation Oncology rotation. These sessions are conducted under the supervision of the Radiation Oncology Faculty.

The fellow rotates to the Division of Medical Oncology where for two months, under the supervision of Dr James Holland (Professor Emeritus) and Dr. David Sternberg (Director of the Medical Oncology Fellowship) and with the full time attending staff of medical oncologists, the fellow works as a member of that Division. There are four other fellows in a three year training program and there are approximately 500 new patients treated each year in that division. During this rotation the gynecologic oncology fellow assumes the full responsibilities and duties of a regular trainee, including treatment of patients by Phase II and Phase III chemotherapy and immunotherapy; patients with complications of such therapy, as well as, those with inter-current ailments requiring special attention. There is a didactic program for teaching “cancer medicine” in several weekly seminars. Departmental conferences feature extra-institutional experts, and grand rounds occur weekly. There is no diminution of our fellows’ training because of the presence of other fellows. The work load is such and the supervision is such that this ratio is no problem. During the rotation in the Department of Neoplastic Diseases, each day’s activities are divided into morning work rounds during which the fellow works up and cares for each of the patients assigned in an ongoing fashion; supervised chart rounds for all patients, where dosage, planning, complications and general status are reviewed. The afternoons are devoted to completion of protocol responsibilities for all study patients and bed side rounds with the attending on service during which there is daily active teaching for the entire staff on every patient.

At 7:00 AM each morning there is a teaching conference followed by work rounds, followed by ward rounds with the attending staff, followed by completion of the fellows’ individual clinical assignments, followed by office hours or clinics. We try to arrange the fellows’ rotation to coincide with the presence of Dr. James Holland and both of whom include the fellows in their patient hours and their consultation exercises.

Once weekly there is an ongoing series of seminars in oncology and once weekly there are grand rounds which feature extra departmental speakers, often of national or regional prominence. During this rotation, the fellow not only learns principles of “cancer medicine” but is exposed to a variety of investigators in different cancer disciplines. The fellow acquires the expertise to manage patients who have acquired the adverse effects of chemotherapeutic and immunotherapeutic programs, learns protocol design, interacts with the statistical and data retrieval branch of the institution’s cancer center core activity, and learns about the clinical research efforts of a variety of national collaborators (CALGB, ECOG, SWOG, etc.).

This rotation has invariably been rated very highly by the gynecologic oncology fellows and their performance has been rated highly by the director of the department.

The fellow rotates either through the colorectal service or the vascular service or both, depending on the fellows’ prior training experience.

The vascular service is directed by Dr Michael Marin who is also Chairman of the Department of Surgery. There are more than 1000 procedures performed annually. There are two fellows in vascular surgery in addition to junior surgical house officers on the service, and the fellow in gynecologic oncology shares the clinical responsibilities with the vascular fellow. Techniques of grafting, anastamosis, embolectomy, thrombectomy and reconstruction are stressed and the gynecologic oncology fellow operates as an assistant for these procedures. The vascular service at Mount Sinai is also recognized for its leadership in the area of endovascular procedures and the fellow gets to appreciate the role of these emerging technologies.

The colorectal service includes Dr. Joel Bauer, a nationally recognized pelvic surgeon, who has had extensive experience in treating inflammatory bowel disease. Dr. Bauer and his colleagues operate daily on a large number of patients with recurrent bowel problems requiring diversions, pouch revisions, creation of continent pouches, and management of inflammatory, adhesive, and oncologic disorders. The gyn oncology fellow does not usually act as surgeon during that rotation, but profits from assisting during such procedures and is thus much more comfortable in the management of the bowel complications seen in our patients with advanced or recurrent diseases. He also gets a unique experience in the management of complex fistulas, such as colo-vesical, and colo-vaginal fistulas.

The fellow rotates for one month to the Intensive Care Unit working under the supervision of its director, Dr. Ernest Benjamin. During this experience, our fellow works with two other rotating fellows. Our fellow has full parity with these rotators and has full exposure and responsibilities of management for all patients in the Surgical Intensive Care Unit. This includes, of course, all techniques of internal and external monitoring, catheter placement, physiologic support for the critically ill patient and understanding of surgical metabolism. Protocols for study in metabolism, renal function, pulmonary physiology and fluid dynamics are ongoing. During this rotation, work rounds are conducted by the staff of the surgical intensive care unit early each morning followed by daily bed side rounds of the entire staff. In the conduct of these rounds, didactic information is dispensed and the faculty comes from the Department of Surgery, Anesthesiology and subdivisions of internal medicine. The remainder of the morning is devoted to special procedures including the placement of lines and catheters, installation of monitoring devices, respiratory intubation, etc. The afternoons are spent receiving patients who are returning from the operating room, completing consultations, stabilizing and initiating therapy for new admissions. There are three weekly didactic exercises: one in critical care medicine, one in interpretation of EKGs and a journal club. These conferences are supervised by faculty. During a portion of the rotation, the fellow spends time as the “nutrition fellow” responsible for total parental nutrition in the intensive care unit. This experience is supervised by the faculty and by the special staff assigned to TPN function including intravenous therapy nurses, nutritionists and pharmacists. The fellow takes call in the unit every third night during the rotation. The purpose of this rotation is to educate the fellow in techniques which can be applied during the remainder of the fellowship and also to give an overview of management of the critically ill patient. While it is understood that one month of such exposure is insufficient to create and expert, the understanding achieved during this rotation has enormously helped each fellow for the remainder of their training and has improved the liaison with the intensive care unit for subsequent consultation.

The fellow rotates through the Department of Pathology working directly in the Division of Gynecologic Pathology with Dr. Liane Deligdisch, Dr. Tamara Kalir, and Dr. Peter Schlosshauer, all of whom are board certified pathologists with special training in gynecologic pathology. See "Gynecologic Pathology" under the Educational Responsibilities heading below for details.

Chemotherapy Administration
Historically, the fellowship training at Mount Sinai was recognized for the ability of fellows to provide comprehensive management of all patients including control of chemotherapy administration to all gynecologic oncology patients at the institution. In the last ten years, however, the ability to administer chemotherapy has been challenged by restrictions in reimbursement and institutional support. The outpatient gynecologic oncology infusion fiscally managed by the hospital and incurred a major fiscal deficit. The service was in jeopardy of being discontinued because it was considered to be unprofitable, however the Division took the bold step of assuming total fiscal and administrative control of the chemo-infusion service and has now brought the fiscal operation into the black. In addition, during the last 18 months, the infusion service was successfully relocated to a new home in the Ruttenberg Treatment Center. Under this new paradigm, all of the gyn-oncology chemotherapy infusion is administered with a gyn oncology attending physically present. Over 750 cycles of chemotherapy are administered by the Division annually, and all of the chemotherapy orders are written by the fellows under direct tutelage and supervision of the Faculty.

Daily Chemotherapy Review
On a daily basis, all of the Chemotherapy administration orders are written by the Fellow on service and reviewed with the Director of the Gyn Oncology Chemo-Infusion Service (Dr Rahaman) or another designated Attending. This review allows the fellow the opportunity to discuss the nuances of clinical pharmacology, and review the literature and data justifying the regimens being utilized.

Medical Oncology Rotation
During this rotation, the fellow not only learns principles of “cancer medicine” but is exposed to a variety of investigators in different cancer disciplines. The fellow acquires the expertise to manage patients who have acquired the adverse effects of chemotherapeutic and immunotherapeutic programs, learns protocol design, interacts with the statistical and data retrieval branch of the institution’s cancer center core activity, and learns about the clinical research efforts of a variety of national collaborators. The fellow also attends didactics on clinical pharmacology and non-gynecologic chemotherapy regimens.

Gynecologic Pathology
The fellow rotates through the Department of Pathology working directly in the Division of Gynecologic Pathology with Dr. Liane Deligdisch, Dr. Tamara Kalir, and Dr. Peter Schlosshauer, all of whom are board certified pathologists with special training in gynecologic pathology. While the fellow is on that service there is no other gynecologic trainee. In the mornings, the major pathology “sign-outs” are performed with the fellow reviewing each specimen on the multi-headed microscope. In the afternoon all of the minor cases are similarly diagnosed. The purpose is to ensure expertise in interpreting histologic sections and in acquiring familiarity with research techniques being employed in gynecologic pathology. This initial exposure often results in joint study between the fellow and Dr. Deligdisch for the remainder of the fellowship. This interaction continues on an informal basis because of time constraints; however, the fellow meets with Dr. Deligdisch prior to the Monday afternoon gynecologic oncology conference so as to review all of the specimens collected during the previous week in order to present the conference.

Radiation Therapy
The fellow spends two months in the Department of Radiation Therapy, working under the direction of Dr. Richard Stock, the department director, and his staff, especially Dr. Sheryl Green who is devoted to the radiation therapy for gynecologic oncology. This department is committed to the education of our fellow and since there are few extramural rotators through the department, the staff, including the physicists and radiotherapy technologists, has an opportunity to provide “hands on” preceptorship. This allows participation in the management of all patients with gynecologic cancers. Our fellows’ education can occur by virtue of a supervised “hands on” preceptorial program which will allow participation in the management of all patients with gynecologic cancers, as well as, all patients being planned, localized, and started on radiotherapeutic programs. There are didactics in radiation physics, as well as daily instruction in radiation physics designed to meet the needs of a gynecologic oncologist as outlined by the Division. All patients with gynecologic cancers requiring admission to hospital are admitted on the gynecologic oncology service and their in-hospital care is supervised by the fellow in gynecologic oncology under the direction of the radiation therapist. This applies not only during the fellows’ rotation through radiation therapy but also carries over to all radiation therapy admissions of gynecologic oncology patients. All low-dose brachytherapy procedures are performed by the gynecologic oncology fellow under attending supervision. Because there is a larger cohort of advanced cervical cancer patients requiring brachytherapy at our Queen’s affiliate, the fellows attend the high-dose rate brachytherapy applications for cervical cancer at the Queen’s Hospital Center, during the Radiation Oncology rotation. These sessions are conducted under the supervision of the Radiation Oncology Faculty.