Resident Manual

Autopsy Pathology

Educational Goals and Objectives

Curriculum

During his/her rotation on the autopsy service, each resident:

• should participate in at least 50 autopsies, including forensic and stillbirth cases.

• will receive specialized forensics training under the direction of a forensics pathologist and through exposure to forensics cases and investigations.

• will participate in a variety of cases, which will range from routine to complex and unusual in their pathology.

• will learn various techniques of autopsy evisceration and dissection, fixation, sectioning, and sampling, and special techniques used in diagnosis and documentation, e.g., specimen photography, radiography, special stains, injections, NBT, sampling techniques for molecular studies, EM, cytogenetics.

Attainment of independence:

• By the end of the rotation, each resident will be able to independently perform a complete autopsy, identify normal and abnormal morphology, develop differential diagnoses, appropriately research the case, formulate a complete and coherent written report, and present the findings to colleagues.

• Each resident should advance within a program of graduated independence, from working with an attending or senior resident to complete autonomy and responsibility for the case.  Independent sign-out is a privilege granted to the resident by the pathology faculty depending on prior evaluations and performance level.

• Advancement will be dependent on satisfactory achievement of goals and responsibilities for level.

Attainment of communication skills:

• Residents will learn to formulate and generate an accurate, precise, comprehensive, and timely preliminary and final autopsy report.

• Residents will be able to communicate and discuss autopsy findings and their significance in both formal and informal fashion, to colleagues, students, and patient families.

• Through various types of conferences, residents will gain enough familiarity with clinical and autopsy pathology and techniques to serve as consultants to colleagues and patients.

Become life-long learners:

• Residents will develop good habits of systematic reading.

• Residents will learn how to search and critically evaluate the literature.

• Residents will learn how to analyze data and literature and present coherent summaries.

• Residents will develop and refine teaching skills through formal and informal conferences and sessions with pathology colleagues, medical students, technical staff,  and clinical housestaff and faculty.

• Residents will have opportunities to teach medical students, clinical housestaff and attendings, and junior pathology housestaff during the course of performing autopsy dissections and microscopic evaluation.

• Residents will have opportunities to present data from autopsy research at national meetings.

• Residents will be expected to contribute to teaching material through identification of appropriate specimens.

Other areas to be introduced during autopsy rotation:

• Computer usage/informatics

• Management/administration

• CQI

• Research

• CME

• Special techniques to be acquired

  1. Specimen photography

  2. Microbiologic cultures (tissues and fluids)

  3. Specimen radiography

  4. Nitroblue tetrazolium test (NBT)

  5. Tissue sampling for cytogenetics, molecular techniques, toxicology, EM

  6. Special dissection techniques

     1. CAT scan oriented brain dissection

     2. Dissection for congenital heart disease

     3. Pulmonary inflation

     4. Specimen injection (cardiac)

Duration of Rotation

Beginning with residents starting the program in July 1999, each resident will spend a total of 8 months on a combined autopsy/cytology service.  An additional month is allowed for time spent at the County Coroner's office and/or a dedicated month with a forensic pathologist. 

See guidelines for combined autopsy/cytology rotation.

Duties and Responsibilities of the Pathology Resident

Pathology housestaff are permitted to share as many as 50 autopsies with a maximum of 2 residents/autopsy. Both residents should document their participation in all seven (7) aspects of the autopsy so as to be counted towards their 50 autopsies required by the board of pathology. These aspects include review of the pertinent history, gross examination, gross dissection, review of microscopic and laboratory findings, preparation of written gross and microscopic findings, developing an opinion in cause of death and the review of autopsy report with the staff attending. The resident’s participation in the autopsy service in this teaching institution is designed so that during his/her training period, the resident will have the opportunity to experience a varied number of cases.

In general, each resident participates in a structured reading program, covering basics of pathology and pathophysiology.  The program offers opportunities as well for in-depth reading and research on individual topics as they are encountered in autopsy cases.  Each resident is expected to take an active role in autopsy conferences, both as presenter and as participant.  Resident teaching skills are learned and practiced through formal conferences and interactions with medical students, fellow residents and members of other departments, with appropriate, timely, and constructive feedback and modeling behavior by faculty.

The following is intended to serve as a guideline for insuring that while all residents participate in as many autopsies as possible, sufficient time for reading and studying will be also available.

(For Description of back-up coverage, see Autopsy Manual).

1. The resident is responsible for the autopsy in its entirety, including completion of the final diagnosis and autopsy report, and case presentation at conference. Specifically, the resident should document participation in all seven (7) components outlined in the resident autopsy checklist.

2. The provisional anatomic diagnosis (PAD) must be completed and made part of the medical record within 3 calendar days, and the final anatomic diagnosis (FAD) must be completed within 60 calendar days of the patient's death, according to CAP regulations.

3. Each resident should keep a record of each autopsy, as the American Board of Pathology requires a list of autopsy number, age, sex, primary and secondary diagnoses, and date of autopsy on the application for the Board examination.

4. It is expected that the resident will seek extensive guidance from the attending pathologist during the first few months on the autopsy service, with gradually increasing independence as experience increases.

Weekend and Holiday Call

Autopsies will be performed by the Anatomic Pathology resident and attending on-call.

Graduated Responsibilities

As the resident acquires greater knowledge and experience we offer the opportunity for greater responsibility and autonomy, as follows:

Upon completion of 40 autopsies:

• Resident will be considered by the attending staff for privilege of complete autonomy in the performance of autopsies.

• Upon approval by the attending staff, the resident will be entitled to initiate and complete autopsies independently.

• Cases will be signed by the resident alone.

• If assistance is sought, the attending pathologist will assume final responsibility for the case and co-sign the autopsy report (it is anticipated that there will be, on occasion, cases needing assistance from the attending).

• Cases requiring assistance from the attending pathologist include:  all cases with medical-legal implica­tion and especially complicated cases.

• It is expected that the resident by this point in his/her training will be able to exercise good judgement as to when to ask for involvement by the attending pathologist.  The purpose of graduated responsibilities is to provide an op­portunity for the resident in training to assume greater responsibility, not to overburden him/her.

Responsibilities of the Resident Supervisor

1. Occasionally, a senior resident or fellow will rotate through the autopsy service in a supervisory capacity.

2. These responsibilities and privileges will be granted on an individual basis.

3. In general, the fellow will assist new residents in reviewing the chart, performing the gross dissection, and recording results, but will not have ultimate responsibility for the case - it is still the responsibility of the resident and the attending pathologist.

Teaching Staff

The Anatomic Pathology faculty is responsible for the supervision and instruction of the residents during the rotation.  A faculty member is assigned to each autopsy, even in cases in which the resident has independent sign-out privileges.  Specifically, the attending pathologist should:

1. be available to assist the resident in the performance of each autopsy.

2. perform majority of dissection with the resident for the first several autopsies.

3. guide the resident in the completion of the PAD, the gross description, trimming and submission of blocks, microscopic description, CPC, FAD, photography and assembly of case for conference presentation.

4. be available throughout the post-mortem exam to answer questions, direct further studies, assist in teaching medical students.

5. monitor progress of the write-up of the case.

6. allow increased responsibility and autonomy for the resident.

7. attend the autopsy conference for that case.

8. model good teaching and technical skills and professional behavior.

9. provide timely and appropriate feedback to the resident during the rotation.

10. have the ultimate legal and ethical responsibility for the autopsy. This is achieved by close and complete supervision of the resident in all seven (7) aspects of the autopsy.

Resident Evaluation

In addition to informal constructive feedback provided by the supervising attending pathologist during the rotation, formal evaluation of each resident's progress will be based largely on the subjective evaluations of the attending physicians.  An evaluation form will be completed at the end of each rotation by faculty members who had supervised the resident during that month. The evaluation varies according to the level of practice/experience the resident is at (level 1-3). The resident will be kept informed of his progress by the division chief at six month intervals throughout the years spent in Anatomic Pathology.

Evaluations will be based upon faculty observation of:

• participation in autopsy conferences, both as presenter and as participant.

• interactions with pathology and clinical colleagues, technical staff, clerical staff, medical students, and faculty.

• performance of autopsy dissection, work-up of case, development of report, preparation for conference.

Hours of Operation

Normally, autopsies (including review of chart and evisceration) should be started at 8 am (or earlier).  If the body and the paperwork are received in the autopsy suite before 4 pm on weekdays, or 3 pm Saturdays, and before noon on Sundays and holidays, the autopsy should be started that day.  Otherwise, they will be held until the next day.

N.B.  More detailed information can be found in the Autopsy Policies and Procedures Manual.

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