Resident Manual

Anatomic Pathology Program

The goals of the training period in Anatomic Pathology are: that the residents develop the following competencies: the technical and diagnostic expertise necessary to confidently interpret common and unusual surgical, cytologic, and autopsy pathology specimens; the ability to not only recognize morphology but also understand the epidemiology, pathogenesis, and biological behavior of disease; articulate written and verbal communication regarding professional material; educational skills to teach others; computer-literacy in, specifically: laboratory information systems, office software, literature searches, and Internet use; the drive and skills necessary to be “life-long learners”; exposure to clinical and basic research and the opportunity to participate in research; preparedness to carry out the administrative functions of the Anatomic Pathology areas in a Pathology Department, including continuous quality improvement; and the professional competence and self-assurance that allows them to practice independently upon graduation from the program. The philosophy that guides training assumes mutual respect among the faculty members and residents; demands commitment, hard work, and a sincere desire to learn from the residents; necessitates close supervision of junior residents by the faculty, but a willingness to allow greater freedom for more senior residents; requires frequent, candid, and as objective as possible feedback from the faculty; and rewards achievement of the above goals with the granting of increasing levels of responsibility, culminating in near-complete independence prior to the completion of training.

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 (2008) volumes are projected to be >42,000 surgicals, roughly 20,000 cytologies, and 100 autopsies, with a resident staff of 12. Special rotations can be selected to provide greater experience in subspecialty areas of Anatomic Pathology. Didactic departmental conferences provide additional exposure to challenging cases and are a forum for discussing pathophysiology; interdepartmental “working” conferences provide for the residents a model of the pathologist as a consultant. Residents will have access to 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. 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 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, cytopathology, and autopsy, with well-defined milestones (see descriptions under separate headings), 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. Learning objectives that cannot be met through the routine patient care work will be accomplished through didactic lectures or special assignments (e.g. membership on administrative committees, participation in research projects). Evaluation of the resident’s progress will be accomplished via annual self-evaluation surveys, verbal feedback at daily sign-outs, monthly evaluations in New Innovations, formal semi-annual evaluations by the Division Chief, evaluations of administrative assignments by the appropriate committee chair, and in-service examinations. Residents will evaluate each of the rotations and the teaching performance of each of the members of the Pathology faculty quarterly. An atmosphere of mutual trust and respect will be maintained in conferences and in all other interactions.

Required Rotations

Training in Anatomic Pathology occurs over 24 months, not necessarily contiguous, and includes required rotations in Surgical Pathology (13 months), Forensic Pathology (1 month), Autopsy Pathology (8 months, combined with other rotations), Neuropathology (1 month, combined with Autopsy) and Cytopathology (6 months, combined with Autopsy). These rotations include exposure to dermatopathology, pediatric pathology, nephropathology, hematopathology, neuropathology, histochemistry and immunohistochemistry, and electron microscopy. Additional selective rotations are available in Dermatopathology, Neuropathology, Pulmonary Pathology, Gastrointestinal Pathology, Gynecologic Pathology, advanced Surgical Pathology, Cytopathology, and others by special arrangement. Residents may also select a Research month, which must be approved by the attending supervising the research, and which must have defined goals and documentation of outcome measures.

Required Rotations For Residents Training Only in Anatomic Pathology:

Residents teach informally, “at the bench”, to medical students on pathology electives. More formal teaching experiences occur in intra- and interdepartmental conferences; the attendees at these include other residents and faculty. Residents also have the opportunity to teach in the undergraduate medical curriculum in lecture, laboratory, and case-based learning sessions. 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. The faculty is encouraged to include residents in research projects. A Research Selective provides an opportunity to learn special research techniques and work on a project. As noted above, this month must be approved by the attending supervising the research, and must have defined goals and documentation of outcome measures.  Faculty mentors may facilitate involvement in educational and investigative activities.

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.

Conferences in Anatomic 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. All Pathology residents (except residents training in Clinical Pathology only) are required to attend the Tuesday 8 am Surgical Pathology conference and are free from service responsibilities during those hours to do so. All Pathology residents (except residents training in Anatomic Pathology only) are required to attend the Thursday 2 pm Clinical Pathology conference, and are free from service responsibilities during those hours to do so. All Pathology residents are required to attend the Core Resident Curriculum lectures, and are free from service responsibilities during those hours to do so. The interdepartmental conferences (Tumor Boards, Renal, Lymphoma, GI, etc.) are “working” conferences with a focus on current patient management. Pathology is presented by the Pathology attending or a pathology resident with attending supervision. (Specific objectives and methodology for surgical pathology, autopsy, and cytopathology conferences are under separate headings.)

Residents in Anatomic Pathology are strongly encouraged to prepare for and attend the departmental conferences indicated on the Conference Schedule Chart, as their responsibilities permit. Interdepartmental conferences, Tumor Boards, Grand Rounds, and other seminars may be attended as time and interest permits.

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 list below), and regular journal review of the major pathology journals and at least one general medical journal.

A resident and attending pathologist are on-call at all times. 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 on-call is until 3 pm on Saturdays and 12 noon 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, autopsy, etc., the resident should notify the appropriate attending pathologist as soon as all pertinent information has been obtained.

Daily on-call for frozen sections is from 7:30 am to 5 pm.

Daily on-call for fine needle aspirations is from 8 am to 4 pm (later requests must be approved by attending cytologist).

Daily on-call for autopsies is from 8 am to 4 pm.

Vacation Policy

Residents are allowed 4 weeks vacation per year. Vacation may be taken during a surgical pathology, cytology, or autopsy/cytology month, but only if the resident has arranged for autopsy, FNA or frozen section/cutting coverage and informed the attending of this arrangement at least one week prior to the anticipated absence. Extended absences (that is, more than a day or two) are allowed but discouraged during a selective month as the absence would represent a significant proportion of the time on that selective. Vacation requests should be given to the Chief Resident when the schedule for the next 6 months is being determined (typically June and December).

General Surgical Pathology:

• Rosai and Ackerman: Surgical Pathology, 9^th Edition, Mosby, 2004.
• Silverberg, DeLellis, Frable: Principles and Practice of Surgical Pathology and Cytopathology, 3^rd Edition, Churchill Livingstone, 1997.
• A.F.I.P. Fascicles, 3^rd Edition, by organ system.

Pediatric:

• Stocker and Dehner: Pediatric Pathology, 2^nd Edition, JB Lippincott, 2001.
• Enid Gilbert-Barness: Potter’s Pathology of the Fetus and Infant, Mosby.

Hematopathology:

• Kjeldsberg, et xi alia.  Practical Diagnosis of Hematological Disorders, 4th Edition, ASCP Press 2006.

• Jaffe: Tumors of Hematopoietic and Lymphoid Tissues, WHO/IARC Press, 2001. (New edition due August 2008)

• A.F.I.P. Fascicle 9, Tumors of the Bone Marrow.

• A.F.I.P. Fascicle 14, Tumors of the Lymph Nodes and Spleen.

• Foucar: Bone Marrow Pathology, 2nd Edition, ASCP Press.

• Knowles:  Neoplastic Hematopathology, 2nd Edition, Williams & Wilkins.  (New edition coming soon) 

• Williams, Beutler, Erslev, Lichtman:  Hematology, 3^rd Edition, McGraw-Hill.

• Glassy EF, ed:  Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing, CAP 1998.

Pulmonary:

• Dail and Hammar: Pulmonary Pathology, 2nd Edition, Springer-Verlag.

• Colby, Lombard, Yousem, Kitaichi:  Atlas of Pulmonary Surgical Pathology, Saunders.

• Dani S. Zander and Carol F. Farver:  Pulmonary Pathology.  Elsevier, Philadelphia, PA, 2008.

• Bryan Corrin and Andrew G. Nicholson:  Pathology of the Lungs, Churchill Livingstone (Elsevier), 2005.

• Kevin O. Leslie and Mark R. Wick:  Practical Pulmonary Pathology: A Diagnostic Approach, Churchill Livingstone, 2004.

• William Travis WD, et al:  Non-Neoplastic Disorders of the Lower Respiratory Tract, American Registry of Pathology, 2002.

• William D. Travis, Elizabeth Brambilla, H. Konrad Müller-Hermelink and Curtis C. Harris:  WHO Classification of Tumours: Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart, IARC Press, 2004.

• Anna-Luise A. Katzenstein:  Katzenstein and Askin's Surgical Pathology of Non-Neoplastic Lung Disease, Saunders, 2006.

ENT:

• Barnes: Surgical Pathology of the Head and Neck, 2^nd Edition (revised and expanded), Marcel Dekker, 2001.

• Thompson:  Head and Neck Pathology, Elsevier, 2006.

Cardiovascular:

• Moss and Adams: Heart Disease in Infants, Children, and Adolescents Including the Fetus and Young Adult, 5^th Edition, Williams and Wilkins, 1995.
• Virmani, Atkinson, Fenoglio: Cardiovascular Pathology, Vol. 23 in the Series, Major Problems in Pathology, Saunders, 1991.

Bone and Soft Tissue:

• Bullough and Vigorita: Atlas of Orthopaedic Pathology with Clinical and Radiologic Correlations, University Park Press - Gower Medical Publishing - JB Lippincott Company (distributors as of 1985).
• Huvos: Bone Tumors: Diagnosis, Treatment, and Prognosis, 2^nd Edition, Saunders, 1991.
• Weiss and Goldblum: Enzinger and Weiss’ Soft Tissue Tumors, 4^th Edition, Mosby, June 2001.

Gastrointestinal:

• Ming and Goldman: Pathology of the Gastrointestinal Tract, Saunders.
• MacSween: Pathology of the Liver, 4^th Edition, Churchill Livingstone, 2002.

Breast:

• Rosen:  Breast Pathology, 2^nd Edition, Lippincott, Williams and Wilkins, 2001.

Cytopathology:

• DeMay: The Art & Science of Cytopathology, ASCP Press.

Neuropathology:

• Gray, De Girolami and Poirier: Escourolle & Poirier Manual of Basic Neuropathology, 4th Edition B/H, 2004.

• Louis, Ohgaki, Wiestler and Cavenee:  WHO Classification of Tumours of the Central Nervous System, 4th Edition, IARC, 2007.

• AFIP Fascicle 7, Tumors of the Central Nervous System, 2007.

Dermatopathology:

• Philip McKee: Pathology of the Skin with Clinical Correlations, 3rd Edition, Elsevier Mosby, 2005.

Female Reproductive:

• Kurman: Blaustein’s Pathology of the Female Genital Tract, 5^th Edition, Springer, 2002.

• Robboy, Russell and Anderson: Pathology of the Female Reproductive Tract, Churchill Livingstone, 2001.

Urologic:

• Murphy: Urological Pathology, 2^nd Edition, Saunders.

Renal:

• Tisher and Brenner: Renal Pathology With Clinical and Functional Correlations, 2^nd Edition, JB Lippincott.

Placenta:

• Richard Naeye: Disorders of the Placenta, Fetus, and Neonate: Diagnosis and Clinical Significance, Mosby.

• AFIP Fascicle 3, Placental Pathology, 2004, atlas on non-tumor pathology.

Autopsy Pathology:

• Werner Spitz:  Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation.

• M.D., Vincent J.M. DiMaio and Dominick DiMaio:  Forensic Pathology, Second Edition (Practical Aspects of Criminal and Forensic Investigations), CRC Press LLC, 2001.

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