Resident Manual

Program in Clinical Pathology

Introduction

Most pathology residents at the Penn State Hershey Medical Center train in a four-year combined clinical and anatomic pathology program.  With approval, a resident may be accepted for a three-year program in clinical pathology only.

Our overall goal for Clinical Pathology training is to develop pathologists who:

• Can effectively communicate as a medical consultant to other clinicians and to patients.

• Can direct the management of the clinical laboratory enterprise, to assure the quality, clinical appropriateness and usefulness of the laboratory data.

• Understand and effectively consult on methods of diagnostic test utilization, both generally and in the context of patient-specific clinical settings.

• Effectively consult on assay interpretation in acute and chronic clinical management of patients.

• Contribute to development and implementation of informatics and systems that optimize patient care.

• Can consult in these areas at the systems level and in the context of health delivery models.

• Understand the role of research in clinical decision making, test development, knowledge generation and continuing education.

• Gain sufficient knowledge to be able to pass the clinical pathology section of the board examination.

To accomplish these goals, residents must develop specific competencies.  Competencies that are common to all areas of clinical pathology training include:

Patient Care

• Gather essential and accurate information about patients using all relevant available modalities.

• Effectively consult with other clinicians in developing a diagnostic plan based on specific clinical questions and relevant clinical and pathological information (both in patient-specific and systems contexts).

• Effectively consult as part of a multidisciplinary team in developing a therapeutic plan that includes laboratory monitoring of efficacy and toxicity (including laboratory-based therapeutics such as blood transfusion).

• Effectively consult on interpretation or follow-up of unusual or unexpected test results.

• Effectively participate as expert in Laboratory Medicine at multidisciplinary conferences.

Medical Knowledge

• Use all relevant information resources to acquire and evaluate evidence-based information.

• Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in Laboratory Medicine.

• Demonstrate sufficient knowledge to determine clinically optimal yet cost-effective testing and laboratory- based therapeutic strategies, including issues of turnaround time, test menu construction, and in-house versus referral diagnostic testing.

• Recognize the aspects of Laboratory Medicine practice that are affected by patient age and other patient population characteristics.

• Demonstrate understanding of general and test-specific standards for method development, evaluation and implementation.

• Demonstrate awareness and understanding of proficiency programs.

• Understand the various levels of evidence in medicine and their translation into evidence-based practice.

Practice-based learning and improvement

• Demonstrate the ability to critically assess the scientific literature.

• Demonstrate knowledge of evidence-based medicine and apply its principles in practice.

• Use multiple sources, including information technology, to optimize life-long learning and support patient care decisions.  

• Develop personally effective strategies for the identification and remediation of gaps in medical knowledge needed for effective practice.

• Use mathematics and statistics as appropriate to laboratory testing; understand and implement quality control (QC) and quality assurance procedures as required.

• Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety.

• Demonstrate knowledge of how to establish continuing competency assessment for pathologists as well as for laboratory personnel.

• Use proficiency programs to improve laboratory practices.

• Demonstrate knowledge of the principles of clinical research design, implementation, and interpretation.

Interpersonal and communication skills

• Demonstrate the ability to write an articulate, legible, and comprehensive yet concise consultation note; provide a clear and informative report, including when appropriate a precise diagnosis, a differential diagnosis, and recommended follow-up or additional studies.

• Demonstrate the ability to provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a laboratory assay reveals an urgent, critical, or unexpected finding and document this communication in an appropriate fashion.

• Effectively participate and present at multidisciplinary conferences in focused, clear, and concise fashion.

• Demonstrate the ability to work with other clinicians and other health care personnel and administrators to develop clinically advantageous and cost-effective care-delivery strategies.

• Use effective modes and mechanisms of communication.

• Demonstrate skills in obtaining informed consent, including effective communication to patients about procedures, alternative approaches, and possible complications of laboratory-based patient care diagnostic and therapeutic activities such as those related to transfusion medicine and therapeutic apheresis.

• Demonstrate skills in educating colleagues and other health care professionals, including:

  • Helping other residents obtain proficiency in laboratory medicine.

  • Demonstrating the ability to work well with medical technologists and to present Laboratory Medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment.

  • Demonstrating the ability to educate nonpathology clinicians and other health care workers, including pharmacists, nurses, residents, medical students, and others about topics such as the fundamental principles of pathophysiology underlying test design/interpretation and the approach to choosing and interpreting laboratory tests.

  • Demonstrating an understanding of how to educate other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other professional knowledge.

Professionalism

• Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them.

• Interact with others without discriminating based on religious, ethnic, sexual, or educational differences.

• Demonstrate positive work habits, including punctuality, dependability, and professional appearance.

• Demonstrate responsiveness to the needs of patients and society that supersedes self-interest.

• Demonstrate principles of confidentiality with all information transmitted both during and outside a patient encounter.

• Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research.

• Demonstrate a commitment to excellence and ongoing professional development.

• Demonstrate interpersonal skills in functioning as a member of a multidisciplinary health care team.

Systems-based practice

• Demonstrate understanding of the role of the clinical laboratory in the health care system.

• Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians.

• Demonstrate knowledge of basic health care reimbursement methods.

• Demonstrate knowledge of the laboratory regulatory environment.

• Understand and implement policies and systems to continually improve patient safety as they relate to clinical laboratory testing at all levels.

Recognizing that residents have differing backgrounds and career objectives, the clinical pathology training program is designed to be flexible.  This allows us to best meet the needs of each resident and to best prepare each resident for his or her career in pathology.  Residents will have the opportunity to develop more in-depth expertise in one or several areas of laboratory medicine.

Role of the Resident

The resident is expected to function fully as a physician member of the leadership and management team of the section to which they are assigned during rotations and of the Division of Clinical Pathology.  Along with the attending faculty, they are fully participating members of the divisional Quality Improvement Committee.  They are expected to be a resource to the laboratory staff and clinical care providers for Laboratory Medicine operational and patient care issues.

There are 12 attending faculty in the Division of Clinical Pathology.

• Michael B. Bongiovanni, MD, Chief, Division of Clinical Pathology and Director, Clinical Laboratory

• Peter C. Appelbaum, MD, PhD, Medical Director of Microbiology

• William J. Castellani, MD, Medical Director of Chemistry

• Laurence M. Demers, PhD (emeritus)

• Ronald E. Domen, MD, Director of Histocompatibility

• M. Elaine Eyster, MD^*, Medical Director of Hemostasis

• Wallace H. Greene, PhD, Scientific Director of Virology

• Roger L. Ladda^†, MD, Medical Director of Cytogenetics

• Mary Beth Miele, PhD, Education & Pathology Residency Coordinator

• Thomas P. Nifong, MD, Medical Director of Hematology and Thrombosis, Medical Director of Molecular Diagnostics

• Hiroko Shike, MD, Associate Director of Histocompatibility

• Witold B. Rybka, MD^*, Medical Director of Hematopoietic Cell Therapy Laboratory

The Clinical Laboratory is organized into the following units based partially on technology (e.g., Automated Testing), partially on discipline (e.g., Virology, Microbiology) and partially on function (e.g., Quality/Compliance, Business Services).

The "standard" rotations in clinical pathology are Blood Bank and Apheresis, Chemistry, Hematology and Coagulation, Microbiology, Virology, and Histocompatibility.  Rotations in Laboratory Management and in Cytogenetics & Molecular Diagnostics can be considered to be either clinical or anatomic pathology rotations.

Each rotation is under the direction and supervision of the faculty member identified with the rotation’s discipline. That faculty member is the rotation director and is responsible for the organization and content of the rotation.  The rotation director is also responsible for resident evaluations for the rotation, but input is solicited from each attending who works with the resident during the rotation.

• Blood Bank and Apheresis: 

• Chemistry:  William J. Castellani, MD

• Cytogenetics & Molecular Diagnostics:  Thomas P. Nifong, MD

• Hematology and Coagulation:  Thomas P. Nifong, MD

• Histocompatibility:  Ronald E. Domen, MD

• Laboratory Management:  Michael B. Bongiovanni, MD

• Microbiology:  Peter C. Appelbaum, MD, PhD

• Virology:  Wallace H. Greene, PhD

“Standard” Core training in Clinical Pathology for combined Anatomic/Clinical Pathology residents consists of a 20 month curriculum.  A curriculum for a “typical” resident would be:

The above table indicates the time a “typical” resident would spend training in each rotation.  As we focus on accomplishing the training goals and objectives of each rotation (and the overall goals of clinical pathology training) rather than the amount of time spent in each rotation (and in overall clinical pathology training), actual time spent in each rotation (and in overall clinical pathology training) may differ from resident to resident.  While most residents can accomplish the rotation and overall goals in 20 months, some residents require up to 24 months of clinical pathology training to achieve basic competence.  The rotation directors and the Chief of Clinical Pathology make determination of a resident’s competence in a rotation and in basic clinical pathology.  Residents training in Clinical Pathology only will be required to spend additional time in Blood Bank and Apheresis and in Hematology and Coagulation.

A wide variety of elective rotations are available in clinical pathology.  Elective rotations must be planned in consultation with appropriate faculty. A description of the elective rotation, with goals and objectives must be generated in advance, and must be approved in advance by the rotation director, program director, and Chief of Clinical Pathology.

When a resident moves from Anatomic to Clinical Pathology, it is expected that on the first day of the Clinical Pathology rotation the resident may spend time in Anatomic Pathology to allow orderly transfer of pending cases to the appropriate resident on the Anatomic Pathology service. It is also expected that after the first day, completion of pending Anatomic Pathology responsibilities will not interfere with the resident’s service and educational responsibilities on Clinical Pathology.  In most cases agreeable arrangements for completion of Anatomic Pathology duties can be made in consultation with the Clinical Pathology attending.  It is also expected that when a resident moves from Clinical to Anatomic Pathology, arrangements will have been made in advance to resolve pending issues.

On-Call Coverage

Scheduling resident on-call coverage is a responsibility of the Chief Resident, and may be delegated to one of the senior residents.  A Clinical Pathology faculty attending is available to the resident at all times. Resident and faculty coverage schedules are available electronically.

The Division Chief holds a monthly On-Call Conference to review on-call issues and problems.

A library of books and teaching materials is maintained in the resident office area. Computer workstations are also available with access to the Clinical Information System, the Laboratory Information System, library resources and the internet.

Didactic conferences are given by the faculty twice weekly.  Numerous other conferences in related disciplines are also available on an ongoing basis.

Each year an orientation program is presented for residents new to Clinical Pathology at the Penn State Hershey Medical Center.  The purposes of this orientation are to:

• Provide an overview of laboratory organization, operations, policies and services.

• Introduce residents to key personnel and resources.

• Prepare the resident for taking call.

The orientation program is revised each year to best prepare residents in a constantly changing environment. Therefore its structure, duration and topics vary. The orientation typically lasts from three days to one week in a concentrated form, with follow-up didactic sessions extending over several weeks.

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