Anatomic Pathology Program

Introduction

Goals

The goal of residency training in Anatomic Pathology is to prepare the trainee to successfully pursue a career in which Anatomic Pathology plays a role. Recognizing that our field includes many different types of practices with different responsibilities, we seek to provide broad-based training that exposes residents to each Anatomic Pathology subspecialty, fosters development of diagnostic expertise and confident assumption of the responsibilities of independent practice, educates about laboratory management and quality improvement, and provides opportunities for research and teaching.

Methodology

The residents will participate in the evaluation of a large volume of diverse clinical specimens, which represent a broad spectrum of pathology and include highly complex cases. Current (2012) volumes are projected to be >42,000 surgical, roughly 22,000 cytologies, and 70 autopsies. Selective and elective rotations can be selected to provide greater experience in subspecialty areas of Anatomic Pathology. Residents will have primary responsibility for gross dissection of surgical and autopsy cases and for special procedures performed in the gross room (e.g. frozen sections, medical photography, submitting tissue for molecular analysis). Through this, they will learn techniques and have the opportunity to make independent judgments about their cases. Slides will be previewed by the resident, who then is expected to write or dictate a microscopic report and commit to a diagnosis. This will encourage independence, self-learning, and problem solving, and promotes self-confidence. A system of graded responsibility in surgical pathology will be followed, which should culminate in the resident acting in a manner of near-complete independence prior to graduation. The residents are encouraged to report frozen section diagnoses to the surgeon and handle subsequent communications regarding diagnostic material, which will build communication skills. 

Didactic departmental conferences provide additional exposure to challenging cases and are a forum for discussing differential diagnosis, pathophysiology, epidemiology, and clinical correlation. Interdepartmental patient-care and educational conferences provide for the residents a model of the pathologist as a consultant; residents will have the opportunity to serve as the consultant pathologist for these conferences in the senior portion of their residency. Residents will have access to digital and glass slide study sets, comprehensive and current Pathology and Medical libraries, literature searches, and the Internet. Informatics training is available through the Computer Learning Center and web-based courses. 

Evaluation of the resident's progress will be accomplished via monthly evaluations by faculty, verbal feedback at daily sign-outs, annual 360 degree evaluations, and semi-annual evaluations by the Program Director and Associate Program Directors. The annual RISE examination will provide another source of feedback regarding the resident's medical knowledge base. Residents will evaluate each of the rotations and the teaching performance of each of the members of the Pathology faculty.
Rotations

Training in Anatomic Pathology includes required rotations in each of the organ-based subspecialty systems in Surgical Pathology, with additional Selective rotations in some of these according to the resident's interest, Frozen Section Pathology, Forensic Pathology, Autopsy Pathology, Neuropathology, and Cytopathology. Elective rotations are available in Dermatopathology, Neuropathology, Pulmonary Pathology, Gastrointestinal Pathology, Gynecologic Pathology, Orthopedic Pathology, advanced Surgical Pathology, Cytopathology, and others by special arrangement. Residents may also choose Research as an elective rotation. Elective and Research months must be approved by the supervising attending and must have defined goals.

Required rotations for residents training in Anatomic and Clinical Pathology, in 2-week blocks:

Frozen Section Pathology and Cardiac Pathology
4
Breast Pathology 4
Pediatric Pathology and Gynecologic Pathology
4
Gastrointestinal Pathology
4
Genitourinary Pathology and Neuropathology
3
Head and Neck Pathology and Pulmonary Pathology
3
Dermatopathology and Musculoskeletal Pathology
3
Selectives
5
Total Surgical Pathology
30
Combined Autopsy/Cytopathology
12
Autopsy/Elective
4
Forensic Pathology
2
Elective
4*
TOTAL AP 52

 

*Elective months in Anatomic and Clinical Pathology can be used for rotations in either area (Anatomic or Clinical Pathology).  A strict division of 24 months in AP and CP is not necessary, i.e., completion of 26 months of AP and 22 months of CP is acceptable, or vice versa.
Required rotations for residents training only in Anatomic Pathology, in 2-week blocks:

Frozen Section Pathology and Cardiac Pathology
4
Breast Pathology 4
Pediatric Pathology and Gynecologic Pathology
4
Gastrointestinal Pathology
4
Genitourinary Pathology and Neuropathology
3
Head and Neck Pathology and Pulmonary Pathology
3
Dermatopathology and Musculoskeletal Pathology
3
Selectives
9
Total Surgical Pathology
34
Cytogenetics/Elective
2
Combined Autopsy/Cytopathology
12
Autopsy/Elective
4
Hematology 6
Forensic Pathology
2
Laboratory Management
2
Molecular Pathology 2
Electives
14
TOTAL 78


Opportunities for Teaching and Research

Residents teach informally, "at the bench", to medical students on pathology electives. Residents also have the opportunity to teach in the undergraduate medical curriculum in lecture, laboratory, and case-based learning sessions.  More formal teaching experiences occur in intra- and interdepartmental conferences; the attendees at these include other residents and faculty.  Instruction in educational methods includes observation of faculty and attendance at teaching seminars offered by the College of Medicine (e.g Conversations with Distinguished Educators series).  Feedback on the resident's teaching is included in the semi-annual evaluation.  

Many faculty members would like to include residents in research projects, and will discuss these opportunities with residents. Residents can choose whether to participate or not to participate.  A Research Elective provides an opportunity to learn special research techniques and work on a project.  The project can be a translational or basic research project.  As noted above, this month must be approved by the attending supervising the research, and must have defined goals.  Funding for research project can be requested through the Pathology Research Award Program.  Applications for funding are accepted on a continuous basis. More information can be obtained from Ms. Karen Clabaugh.  The Morphologic and Molecular Pathology Core Research Laboratory provides an excellent resource for the technical support of many research project.  Questions about this laboratory can be directed to Dr. Loren Clarke, Director of this Laboratory.

Supervision

The Pathologist's Assistants or the attending pathologist will closely supervise junior residents in gross dissection. Senior residents are expected to demonstrate sufficient judgment and independence that requires less direct supervision.  Residents nearing graduation should need minimal supervision.  At no time, however, is the resident to feel discouraged from asking for guidance.  Attending pathologists are encouraged to allow the resident as much independence as possible, within the bounds of legal/regulatory responsibility and without compromising patient care.

Anatomic Pathology Conferences

Conferences in Anatomic and Clinical Pathology are an opportunity to enhance diagnostic skills through exposure to rare and difficult cases; to discuss epidemiology, pathogenesis, and molecular biology; and to become skilled and confident in case presentations. Surgical Pathology and Autopsy gross and microscopic conferences and Frozen Section conference are "Unknown case" formats. Cases for these are selected by residents or faculty and usually presented by residents. Didactic conferences include Gynecologic Pathology, Dermatopathology, and Neuropathology. Several of the conferences are mandatory; meaning that resident attendance is expected and residents will be free from service responsibilities during these lectures. Resident must keep their beepers on during all conferences, however, and be available to respond to urgent situations. In addition, residents are strongly encouraged to prepare for and attend the departmental conferences indicated on the following chart, as their responsibilities permit. Interdepartmental conferences, Tumor Boards, Grand Rounds, and other seminars may be attended as time and interest permits.

Mandatory conferences for all residents include:

  • ACGME Core Competency lectures – generally the 1st Thursday of every month
  • Core Curriculum Lectures – generally every Wednesday (7AM and Noon); and Friday (twice per month at 7AM)
  • Surgical Pathology Unknowns conference – every Tuesday
              (exceptions: Resident on the Blood Bank Service, Clinical Pathology only-track residents)
  • Visiting Professor Series lectures – as scheduled
  • Journal Club – as scheduled

Mandatory lectures for residents on Anatomic Pathology services include:

  • Gross Pathology Conference: every Thursday

Mandatory lectures for residents on Clinical Pathology services include:

  • Clinical Pathology Interesting Case Conference: Fourth Tuesday of each block
              (exception: Resident on the Hematopathology service)

Recommended conferences for all residents:

  • Frozen Section conference: as scheduled
  • Lymph Node conference: third Tuesdays
  • Dermatopathology conference: every Wednesday
  • Departmental conferences including QI meetings – as scheduled
  • Tumor Boards/Interdepartmental conferences – as scheduled
  • Grand Rounds – as scheduled

Conference Schedule Chart

Reading List

The body of knowledge in Anatomic Pathology is rapidly expanding as new techniques become available. Reading must go beyond gross and histologic interpretation to include an understanding of pathophysiology, pertinent clinical laboratory tests, treatment, and prognosis. As a consultant the resident must be able to advise the clinicians about a particular pathologic diagnosis and provide guidance for further management. Reading must include textbooks in general pathology and surgical pathology, as well as texts devoted to particular organ systems (see linked list), and regular journal review of the major pathology journals and at least one general medical journal.

Reading List for Residents in Anatomic Pathology


On-call Responsibility (PGY-2 and above)

First-year residents are not permitted to take call.

Residents (PGY-2 levels and above) and attending pathologist are on-call during all nights, weekends, and holidays. Nighttime on-call extends from 5 pm on weekdays until 7:30 am the following day, and on weekends from 5 pm Friday until 7:30 am Monday. Holiday on-call extends from 5 pm the evening preceding the holiday until 7:30 am the day following the holiday. Weekend autopsy shifts are until 3 pm on Saturdays and 11 AM Sundays and holidays (permit, clinical records and body available by this time).Call may be taken from home with the expectation that the resident can be in the hospital within 20 minutes. When called about a frozen section, rush biopsy, etc., the resident should notify the appropriate attending pathologist as soon as all pertinent information has been obtained. It is also helpful for the resident to check into any pending frozen sections around 5pm, and notify his/her attending if a frozen section is expected that evening. Fine needle aspirations should not occur often on call, since typically scheduled between 8 am and 4 pm on weekdays (later requests must be approved by attending cytologist). Requests to perform autopsies after 4 pm on a weekday are also extremely unusual, and must be approved by the attending pathologist on call.

Saturday and holiday cutting

Weekend work shifts are scheduled for PGY-1 level residents. Duties assigned to the PGY-1 resident scheduled for a weekend shift include autopsy and surgical pathology. The PGY-1 resident will cut specimens on Saturday under supervision of the AP (or AP/CP) on call senior resident or attending. The resident will accession, dictate, gross, and submit all surgical pathology cases – except skins and outside cases – that have been submitted to Surgical Pathology (either directly to H2098 or to specimen processing in Clinical Pathology) after 5 pm on Friday evening through noon on Saturday. The PGY-1 is also responsible for any specimens on services not covered by a resident (i.e., Pathologist's Assistant (PA)-covered service). Large cases received before 5 pm on Friday that require overnight fixation will be cut by the resident on that subspecialty service. The resident and/or attending on AP (or AP/CP) call will directly supervise the 1st year resident until the resident has completed their competency checklist for independent grossing. Once the PGY-1 resident has completed their checklist, supervision and guidance by the call resident and/or attending are available for any questions.

When a holiday falls on a Monday-Friday, cutting will be done by the PGY-1 resident scheduled for the Saturday closest to that holiday. The PGY-1 resident is responsible for accessioning, dictating, grossing, and submitting all surgical pathology cases – except skins and outside cases - that have been submitted to Surgical Pathology (either directly to H2098 or to specimen processing in Clinical Pathology) after 5 pm of the weekday preceding the holiday and up to noon on the holiday. They are also responsible for any specimens on services not covered by a resident (i.e., PA-covered service). In the case of a Friday holiday, they cut specimens submitted until from 5pm Thursday to noon on Saturday. In the case of a Monday holiday, they cut specimens submitted from 5pm on Friday until noon on Monday. The call resident and/or attending is available for any questions, and if the resident on AP (or AP/CP) call has no Clinical Pathology duties (apheresis, etc.), they will assist with grossing as needed.

Autopsies will be performed by the PGY-1 for cases received on Saturdays from 8 am to 3 pm, and on Sundays/Holidays from 8 am to 11 am. The resident and/or attending on AP (or AP/CP) call will directly supervise the PGY-1 resident until the resident has been deemed competent by performing and having been "signed off" on at least 3 autopsies. After this, the resident on call is available for any questions and/or assisting with difficult cases. The entire case will be supervised by the attending on call.


Vacation Policy 

  • A maximum of one of the four residents on surgical pathology may be on vacation at a time. If multiple residents request vacation, coverage needs to be arranged for grossing and sign-out responsibilities.
  • Residents are encouraged to take no more than two vacation days during a two week surgical pathology rotation. 
  • Residents should coordinate vacation requests with other residents on surgical pathology and the chief resident(s). 
  • Residents should discuss vacation requests with the service attending(s), preferably a week or more prior to date of leave.   
  • The chief resident(s) will keep a master list of vacation requests to assure adequate coverage of the surgical pathology rotation. Requests will be granted on a first come first serve basis.

Updated: 6/22/2012 JWB