• Superb abdominal-pelvic Surgeons facile with the complete range of technical procedures that a Gynecologic Oncology Surgeon may be expected to perform.
  
  
• Scientists committed to Discovery in the broad field of Women's Cancer Prevention, Development, Treatment, and Health Care Delivery who will be performing meaningful investigation for decades after the completion of the Fellowship and the obtaining of Board Certification.
  
  
• Educators, realizing the necessity of assuring that the future generations of Providers of Women's Health Care are skilled and conversant with the essentials of Gynecologic Cancer prevention, screening, and management while developing an appreciation for the value of appropriate and timely referral.
  
  

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• Skilled and mature academic Gynecologic Cancer Surgeons who have a temporally proven commitment to excellence in Patient Care, the Academic Pursuits, and Education that can serve as Mentors
  
  
• The full breadth and depth of expertise of the non-Gynecologic Oncologist fellowship faculty members. These non-Gynecologic Oncologist faculty members include: a Medical Oncologist, Radiation Oncologist, Hepato-biliary Surgical Oncologist, experts in Molecular Biology and Vaccine Research, as well as a World Famous epidemiologist and a individual who is widely recognized as being, if not the pre-eminent Gynecologic Pathologist, one of the leading Gynecologic Pathologists in North America.
  
  
• Faculty members who are full-time NCI scientist/investigators who bring not only a unique vision, but access and exposure to resources to which fellows are rarely exposed.
  
  
• Patient volume and mix, both of disease processes and socio-cultural demographics, such that the Fellow is fully exposed to all diseases that a Gynecologic Oncologist must be expert at managing.
  
  
• An opportunity to spend "discovery" block time in one of numerous disciplines:
  
  
  • Public Health
    • Cancer Control and PreventionAccess to Care
    • Outcomes Research
    • International Women's Cancer Care: focus on Developing Countries
    • Health Care Financing
      
      

• Basic Laboratory Sciences

• Growth factor and bio-marker expression and oncogenesis
• Cancer immunology and vaccine development
  
  
• Unique resources available at the Johns Hopkins Hospital and Medical Institutions:
  • Johns Hopkins University School of Public Health
  • Johns Hopkins Program in International Education in Gyn/Ob (JHPIEGO)
  • Johns Hopkins University School of Accounting and Business Administration
  • Johns Hopkins University School of Medicine
    
    
• Proximity to the NCI
  
  
• NCI designated Comprehensive Cancer Center with all of the anticipated shared core-facilities, which is part of the National Comprehensive Cancer Network.
  

• A new (calendar year 2000) in-patient facility and Cancer Center with the most recent and, in select settings, uniquely available developing technology (Imaging, Interventional Radiology, Surgical Technology,

• Off-Site Real Time Surgery, etc).
  

• Total integration of the Training Program into the Johns Hopkins Hospital and Medical Institutions (JHMI)-Greater Baltimore Medical Center (GBMC) Gynecology and Obstetrics universe. JHMI-GBMC has a completely integrated Residency Review Committee approved, four year Obstetrics and Gynecology post-graduate training program extant.
  

• Minimal distance (9.5 miles) and travel time (20 minutes during peak traffic volume) between facilities.
  

• A relatively inexpensive community in which to live.
  

• The opportunity to participate in a formally structured and funded international health care experience.
  

• The cultural and geographic advantages of the Greater Baltimore-Washington area.
  

• The high-quality of JHMI residents.
  
  

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Weakness

• A new and unproven Fellowship Program.
• Limited options for employment in the surrounding metropolitan area after completing fellowship.
• The physical and psychological rigors of the two clinical years.
• The high level of expectations of fellow's performance, particularly regarding surgical skill and commitment to the academic pursuits
• The weather of the Mid-Atlantic Coast.
• Location of the sponsoring / "mother" Institution in East Baltimore.
  
  

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Educational Program

This fellowship program is totally integrated, building on the successful combining of the JHMI and GBMC Gynecology and Obstetrics Residency Programs that was completed July 1, 1999.

The Program Director (REB) and, in his absence or on his behalf the Associate Program Director (ELT) is directly responsible for the continuous supervision of all the fellows. Throughout the three years of the fellowship, the fellows will be meeting with REB or ELT on a weekly basis immediately following the Gynecologic Oncology Lectures that are held every Friday afternoon. Additionally, fellows will be supervised by the following individuals when the fellows are either on a specific rotation or participating in protected discovery time:

GBMC	Francis Grumbine, M.D.
Franklin Square Hospital	Michael McCollum, M.D.
Breast & Ovarian Cancer Surveillance	Deborah Armstrong, M.D.
Immunology & Vaccine Research	Drew Pardol, M.D., PhD
Growth Factor & Biomarker	Richard Roden, PhD
JHPIEGO	Paul Blumenthal, M.D., MPH
SICU	Tood Dorman, M.D.
Public Health	Keerti Shah, M.D., DrPH

Should there be difficulties that arise or issues that need to be addressed while the fellows are off of the JHMI Clinical Service, these will be resolved by the Program Director or his designee in concert with all involved and concerned parties. The fellow will solely be responsible to the Program Director or his designee, unless otherwise specifically stated and arranged.


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Organization of inpatient and outpatient teaching

All patients that receive care at the two core facilities that are part of this Fellowship are private patients with an identified unique Attending. There are no special "Teaching" or "Service" patients for whom the ultimate and fiduciary responsibility is not the Attending's. Therefore, the fellows will be constantly taught using every patient as a vehicle for education.

JHMI

• 6:30 a.m: Monday-Thursday
  
• 6:00 a.m. Friday
  
• 7:00 a.m. Saturday and Sunday
  

All patients on Service, regardless of who the attending of record (AoR) or admitting physician is, are presented, examined, and a treatment plan for the subsequent 24 hours developed, in person, at the bedside, with AoW. In addition to the AoW and fellow, the three resident physicians on Service, nurse practitioner, and any medical students rotating on Service will be in attendance. Evening rounds with the AoW are held on an as needed basis. Similarly, inpatient consults will be evaluated by the fellow and presented to the AoW. Most commonly, this will occur at the time of scheduled rounds.


Teaching in the Operating Room:
In the Operating Room, there will be intense, one-on-one teaching of the fellows by the Attending Surgeons. The fellow will be either the primary surgeon (with the Attending as first assistant) or the primary assistant for all gynecologic cancer cases and select complex pelvic surgery cases. As the fellow masters the essentials of radical and complex pelvic surgery, he will be allowed to function as the primary oncologic surgeon or assistant with the surgeon "on the other side of the table" being a resident. In these instances, the attending Gynecologic Oncologist will be the second assistant, present for the critical and essential segments of the surgical procedure. The fellow will, in most instances, function as the primary oncologic surgeon only during the last year of training. Even during that time period, there will always be a Gynecologic Oncology attending present to serve as a teacher of surgical skills.

Outpatient Teaching:
All patients seen by the fellow are seen in conjunction with a Gynecologic Oncology attending. Therefore, every patient is a potential source of outpatient teaching. Fellows will be interviewing patients, obtaining histories, and reviewing data prior to presenting the patients to the attending. The patients will then be examined by the fellow and attending in concert. After completion of the examination and after the patient has dressed, the attending and fellow will meet again with the patient to summarize the visit and outline a plan of action.


GBMC

Inpatient Teaching:

Teaching Bedside Rounds with the Attending of Record (AoR) are held Daily

• 5:00 p.m: Monday-Friday
  
• 8:00 a.m. Saturday and Sunday
  

All patients on Service are presented, examined, and a treatment plan for the subsequent 24 hours developed, in person, at the bedside, with the individual AoR. In addition to the AoR and Fellow, the resident physician on Service will be in attendance. Similarly, inpatient consults will be evaluated by the fellow and presented to the AoR. Most commonly, this will occur at the time of scheduled rounds.


Teaching in the Operating Room:
In the Operating Room there will be intense, one on one teaching of the fellows by the Attending Surgeons. The fellow will be either the primary surgeon (with the attending as First Assistant) or the primary assistant for all gynecologic cancer cases and select complex pelvic surgery cases. As the fellow master the essentials of radical and complex pelvic surgery, he will be allowed to function as the primary oncologic surgeon or assistant with the surgeon "on the other side of the table" being a resident. In these instances, the faculty Gynecologic Oncologist will be the second assistant, present for the critical and essential segments of the surgical procedure. The fellows will, in most instances, function as the primary oncologic surgeon only during the last year of their training. Even during that time period, there will always be a Gynecologic Oncology attending present to serve as a teacher of surgical skills.


Outpatient Teaching
All patients seen by the fellow are seen in conjunction with a Gynecologic Oncology attending. Therefore, every patient represents a potential source of outpatient teaching. Fellows will be interviewing patients, obtaining histories, and reviewing data prior to presenting the patients to the attending. The patients will then be examined by the fellow and attending in concert. After completion of the examination and after the patient has dressed, the attending and fellow will meet again with the patient to summarize the visit and outline a plan of action.


Supervision in Ambulatory Unit and Operating Room:
JHMI

Ambulatory Unit: Supervision in the Ambulatory Unit has been described above in the section on organization of outpatient teaching. To re-iterate, the fellow will participate in supplying care with the attending, to the latter's private patients. This will be a one-on-one experience with the attending, the focus being on initial consultation and subsequent longitudinal follow-up. The fellow will not be independently staffing a clinic nor be unsupervised on a routine basis.

Operating Room: Supervision in the Operating Room has been described indirectly above in the section on organization of inpatient teaching. To reiterate, the fellow will participate in supplying surgical care with the attending, to the latter's private patients. The fellow will not be performing surgical procedures in the operating room with out the presence and supervision of an attending.

Ambulatory Unit: Supervision in the Ambulatory Unit has been described above in the section on organization of outpatient teaching. To re-iterate, the fellow will participate in supplying care with the attending, to the latter's private patients. This will be a one-on-one experience with the attending, the focus being on initial consultation and subsequent longitudinal follow-up. The fellow will not be independently staffing a clinic nor be unsupervised on a routine basis.

Operating Room: Supervision in the Operating Room has been described indirectly above in the section on organization of inpatient teaching. To reiterate, the fellow will participate in supplying surgical care with the attending, to the latter's private patients. The fellow will not be performing surgical procedures in the operating room without the presence and supervision of an attending.

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JHMI:

Monday	16:00 - 17:00 hrs	Professorial Teaching Rounds
Tuesday	16:30 - 17:30 hrs	Kelly Service Tumor Board
Thursday	07:30 - 08:30 hrs	Departmental Grand Rounds
Friday	07:00 - 0:800 hrs	Case Review & Presentation (Statistics)
	08:00 - 09:00 hrs	Oncology Grand Rounds (Optional)
	13:00 - 14:00 hrs	Gynecologic Oncology Lecture Series
Saturday	08:30 - 09:30 hrs	General Surgery Grand Rounds (Optional)

GBMC:

Wednesday	16:00 - 17:00 hrs	Multi-disciplinary Tumor Board
Friday	08:00 - 09:00 hrs	Departmental Grand Rounds
	13:00 - 14:00 hrs	Gynecologic Oncology Lecture Series (JHMI)

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Seminars and Lectures:

Statistics:

140.611: Statistical Reasoning in Public Health I (3 units)


140.612: Statistical Reasoning in Public Health II (3 units)

Molecular Biology of Cancer:

120.615: Molecular Biology of Carcinogenesis (2 units)

Business:

551.601: Managing Health Services Organizations (4 units)

Basic Clinical Pharmacology:

330.707: Graduate Pharmacology (3 units)

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Scientific Meetings:

• Society of Gynecologic Oncologists: The first year (Research) and third year (Senior) fellow will be expected to attend the annual SGO meeting. The second year fellow will also be allowed to attend if that fellow has an accepted presentation.
  
  
• International Gynecologic Cancer Society: Each fellow will be encouraged to attend the bi-annual IGCS meeting at least once during their 3-year fellowship.
  
  
• Gynecologic Oncology Group: Each fellow will be encouraged to attend the semi-annual GOG meeting at least once during their 3 year fellowship.
  
  
• Society of Gynecologic Investigation: Fellows with a paper accepted for presentation (either plenary, podium, or poster) will be allowed to attend the SGI.
  
  
• Mid-Atlantic Gynecologic Oncology Society: All fellows, whether presenting a paper or not, will be encouraged to attend the annual MAGOS meeting.
  
  
• Western Association of Gynecologic Oncologists: Fellows with a paper accepted for presentation will be allowed to attend the annual WAGO meeting.
  
  

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Research Activities:

During the first year of the fellowship the fellow will have protected time for discovery except during:

• The four weeks immediately before beginning the second year of fellowship, during which time the fellow will be on the SICU Rotation
  
  
• The two, nine-day blocks of personal vacation time.
  
  
• Also during the first year it is expected that the fellow will successfully complete the didactic course work as described above.
  
  

It is our belief that the fellow must participate in meaningful Discovery, but that this Discovery can be in one of numerous fields of oncologic research. We would encourage that the fellow pursue an avenue of Discovery that reflects his or her personal interest. However, though we do offer the fellow a basic science experience, we are particularly attracted to candidates that are interested in the following fields of investigation:

• Health Care Delivery and Access
  
• Outcomes Research
  
• International Health Care Delivery
  
• Health Care Financing
  

Once a specific individual has been selected as the new, first year fellow, a program of discovery that incorporates the fellow into ongoing activities of the Institution will be designed. Specific emphasis will be placed on obtaining a higher academic degree (MPH, MHS, MBA etc) during the protected year of discovery.
We also anticipate that the fellow will be active, as both a primary and secondary researcher, in the ongoing clinical investigations of the Kelly Service.


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Off-Service Rotations:

There will be only one off service rotation during the 3 years of the Fellowship. This rotation is the final block of the first (discovery) year, during which time the fellow will be assigned to the SICU at the Johns Hopkins Hospital. This rotation is an intense 24 hours on, 24 hours off, in-unit rotation, which is jointly administered by the Departments of Anesthesia and Surgery. Every day (Monday to Monday) there is 1.5 hours of bedside group teaching by the SICU Faculty. The fellow's sole responsibility during this four-week block is his/her obligation to the SICU. The fellow is immune from "call back" or vacation coverage.


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Progressive Responsibility:

The fellow will be given progressively more responsibility throughout the Fellowship within the limitations imposed by the fellow's own capacities and skills and the reality of a 100% private patient (no so called "teaching" or "clinic" patients) service as has been described above. The Fellowship is not structured with a built in "hierarchy" of responsibility. However, to a certain extent, such a hierarchy is implied by the inherent surgical inexperience of fellows in their first and early second year. Fellows in the later half of their second and through out the third year will be performing a greater part of the more complex surgeries and will, in many instances be the principal surgeon. There is no formal progression in responsibility of the fellows as regards their pivotal role as Leader of the Inpatient Care Team: this responsibility is the same the first month as it will be the last month that the fellow is on service. However, the amount of micro-management that the AoW/AoR performs will become less as the fellow proves him/herself skillful in inpatient care.


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Responsibilities and Activities of Fellows In:

• Teaching of Residents and Students: Serving as a resident or student educator is not a primary responsibility of the fellow. These obligations are predominantly the responsibility of the attending faculty members. However, because the fellow is the Inpatient Team Leader, it is anticipated and expected that the fellow will serve as a teacher of inpatient management skills for the Residents and Externs (medical students) on the Service as well as impart basic Gynecologic Oncology knowledge. The Fellow will not be presenting medical student or resident lectures.
  
  
• Benign Gynecology: The fellow will not be participating in the care of patients with Benign Gynecologic Diseases except those that are admitted by the Gynecologic Oncology attendings of the Kelly Service at JHMI or the Gynecologic Oncology Service at GBMC. The fellows will not be taking either Benign Gynecology Service or Obstetrics Service Attending Call (either in the hospital or out), will not be staffing clinics or consultation suites, and will be explicitly forbidden from performing similar functions while "moonlighting".
  
  
• Lectures, Etc: As stated above, the fellows will not be giving medical student or resident lectures. The fellow will also not be giving lectures in either Institutional or Industry supported and/or sponsored CME meetings/courses.
  
  

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Diagram of rotation for each month of program:

At full capacity, there will be three fellows in the program, one per year, with the rotation sequence as outlined below.

Block diagram of average workweek on clinical Gynecologic Oncology:

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Oncology research space and research opportunity:

The space available is dependent upon the research opportunity that the Fellow, in discussion with the Program Director, selects. Each basic science research project will have designated research space which will be dependent upon the subject of proposed study and identified mentor for the project. The non-basic science investigations will be performed using core facilities and space, as well as the designated and specific Fellows' Office.


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Integration of the fellowship program with the residency program:

The operational structure of The Kelly Gynecologic Oncology Service and the corollary service at GBMC is pyramidal, with a hierarchy in responsibility and reportability. It is our belief that there needs to be a direct chain of command and responsibility, as this is essential for optimal and efficient patient care and physician-in-training learning. The Gynecologic Oncology fellows will serve an important role in this hierarchy of the care teams at both JHMI and GBMC.

Chain of Command and Responsibility

Chief of Service

Attending Physicians (Including AoW)

Gynecologic Oncology Fellow

Case Manager, Chemotherapy Nurse, PGY 2/3/4

Administrative Office Staff


Clinical Office Staff

The Gynecologic Oncology fellows serve as inpatient Team Leaders, with the senior and junior residents under the direction and guidance of the Fellow. Our desire is to only train Gynecologic Oncologists to stay in the Academic Universe, therefore we must help these "Academics in training" learn how to be educators. To that end, the fellows are integrated into the bedside and didactic educational activities of the Services, not as a replacement for the faculty, but in a gradated manner, in addition to the faculty.


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Relationship with the departments of Surgery, Urology, Medical Oncology, and Radiotherapy:

JHMI
The relationship between the Kelly Gynecologic Oncology Service and the above listed departments is unusual. Our opinion is that Gynecologic Oncologists should be physicians adroit at supplying all levels of Gynecologic Cancer care, serving as the primary surgeons and chemotherapists for women with malignancies of the genital tract. Therefore, we have aggressively integrated all possible care-related activities directly on to the Kelly Service, using extra-service referrals as little as possible and limiting them to Interventional Radiology, Internal Medicine consults, and extra-abdominal/pelvic surgery.

SURGERY: We have, as a faculty member on our Service, a sub-specialty trained hepato-biliary surgical oncologist, who has a secondary appointment in the Department of Gynecology and Obstetrics. His special skill is utilized intermittently when unique procedures are being performed. The Gynecologic Oncology Surgeons on the Kelly Service perform the vast majority of the small and large intestinal procedures necessitated in the care of Service patients.



UROLOGY: We rarely utilize the services of the Department of Urology. All faculty members are facile with the performance of urethral, bladder, ureteral, cystoscopic, urinary diversion, and neo-bladder construction surgery.



MEDICAL ONCOLOGY: The Gynecologic Oncology members of the Kelly Gynecologic Oncology Service faculty all have joint (i.e secondary) appointments in the Department of Oncology at the JHMI. This allows the utilization of resources that are outside of the Kelly Gynecologic Oncology Service and are core/shared resources of the NCI designated Comprehensive Cancer Center. All first and the majority of second and third line chemotherapy is administered directly under the auspices of the Gynecologic Oncologist members of the Kelly Service faculty. Patients that are participating in certain Gynecologic Oncology Group Trials, Institutional Chemotherapy Trials, or have been directly referred to the Medical Oncologist who is a faculty member of the Kelly Service, will not receive their chemotherapy immediately under the direction of the Gynecologic Oncology faculty members. The joint appointment of the Medical Oncologist at JHMI who is recognized as an expert in Gynecologic Cancers within the Department of Gynecology and Obstetrics and The Kelly Service allows a degree of integration and flow of patients that otherwise would be difficult. There are few, if any difficulties with issues of who is directing patient care, as there is an easy flow of patients with in the faculty membership of the Kelly Service, independent of the Department of primary appointment.



RADIATION ONCOLOGY: The Radiation Oncology Service at the JHMI is part of the Department of Oncology. The Radiation Oncologists at this facility do not have hospital admitting privileges. All patients who have gynecologic malignancies that are being treated with ionizing radiation at JHMI have, as their primary oncologists, a gynecologic oncologist. All inpatient procedures are performed as a joint procedure by a faculty radiation oncologist and a gynecologic oncologist, with the patient being admitted to and cared for by the faculty Gynecologic Oncologists and the residents on the Kelly Service.

GBMC
The utilization of consults in the disciplines of Surgery, Urology, Medical Oncology, and Radiation Oncology is more fluid and less well defined at GBMC than it is at JHMI. The Gynecologic Oncologists at GBMC have the same perspective on the role of the Gynecologic Oncologists as the primary provider and director of oncology care for the woman with a gynecologic malignancy as do the Gynecologic Oncologists on the Kelly Service at JHMI. However, because there has not been a formal integration of a Medical and Radiation Oncologist, or a General or Urologic Surgeon into the Gynecologic Oncology Service at GBMC, the utilization of consults from these four disciplines is more frequent and decided upon on a case by case base. It should be stressed that physicians from these four disciplines are consultants and that the woman with a gynecologic malignancy continues to have her care supplied and, when need be, directed by her Gynecologic Oncologist.

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The type and number of other physician trainees assigned to the gynecologic oncology service and their role in the fellowship program:

JHMI:

Gynecology and Obstetrics Resident PGY 4


Gynecology and Obstetrics Resident PGY 3


Gynecology and Obstetrics Resident PGY 2


Role: The senior resident (PGY 4) and the two junior residents (PGY 2 & 3) that are assigned to the Kelly Gynecologic Oncology Service are completing their 4 to 6-week block rotations in Gynecologic Oncology. These Residents serve as the primary health care providers for all patients admitted to the Kelly Gynecologic Oncology Service and participate in the operative care of such patients at a level appropriate for their training.



4th Year Medical Student performing an externship: JHU Medical students are not routinely assigned to the Kelly Gynecologic Oncology Service. We do offer a four-week Externship elective for Senior Medical students, both from JHU and from other medical schools. There is no more than one medical student on service at a time. The extent of student's activity and responsibility are consistent with their level of training, individual skill, and competency.



Visiting Clinical Scholars: The Kelly Service has an active International Visiting Clinical Scholars Observer Program. This 4 week, by invitation, program is highly selective and is effected in collaboration with the World Health Organization and the International Union Against Cancer (UICC). No more than two visiting scholars are accepted for any four-week program. These clinicians do not participate in patient care and are only granted observer status.

GBMC:

Gynecology and Obstetrics Resident PGY 3
Role: The junior resident that is assigned to the GBMC Gynecologic Oncology Service is completing his or her 6-week block rotation in Gynecologic Oncology. This Resident serves as the primary health care providers for all patients admitted to the GBMC Gynecologic Oncology Service and participates in surgical management of patients to a degree commiserate with the resident's competency. There are no medical students, externs, or observers on the Gynecologic Oncology Service at GBMC.