Resident Manual

Surgical Pathology

• Overview
• Revised Surgical Pathology Rotation
• Graded Responsibility in Surgical Pathology
• Senior Resident Semi-Independent Signout Guidelines
• Guidelines for Resident Supervision of Students
• Medical Student Selective in Anatomic Pathology (770)

OVERVIEW
Educational Objectives

1. Develop an understanding of disease processes (benign and malignant) and be able to recognize them in their initial and late stages.
2. Recognize the limitations of tissue diagnosis and maximize the diagnostic information.
3. Recognize your role as a medical consultant and be certain you have the appropriate clinical data before rendering a diagnosis.
4. Learn what diagnostic information is necessary for proper patient care and how to concisely communicate that data to the responsible clinician.

Responsibilities in Surgical Pathology

1. Examine gross specimens and prepare an accurate description of each (see Gross Room Manual). Unusual or complex specimens should be shown to the attending pathologist prior to fixation or sectioning. The attending is responsible for helping you orient the specimen and recommending the proper dissection technique. Residents should review big cases and gross only cases that are dictated by the pathology assistants.
2. Select sections for microscopic examination and trim, decalcify and label appropriately.
3. Select and prepare tissues for special studies including flow cytometry, gene rearrangement studies, and tumor bank.
4. Maintain a log of the sections selected for microscopic study.
5. Photograph all gross specimens that have educational, legal or research potential.
6. Study the microscopic slides from your cases and prepare an appropriate microscopic description and diagnosis.
7. Proofread the clinical history and gross description and make all necessary corrections.
8. Meet with the attending pathologist and prepare a final surgical pathology report. The attending is responsible for reviewing all of the slides and suggesting additional diagnostic techniques.
9. Frozen sections:
   - Consult with the staff pathologist prior to selecting a tissue specimen
      for frozen section diagnosis.
   - Freeze, cut and stain frozen section specimen.
   - Examine the slides and present your diagnosis to the attending pathologist.
   - Review frozen section slides with the staff pathologist.
   - In selected cases communicate your diagnosis to the surgeon.
10. Tissues for research:
    - Give approved tissues to appropriate research technician. Be certain an adequate specimen is maintained for diagnostic purposes.
11. Conferences:
    - Residents on Surgical Pathology rotation will select and prepare at least 3 cases for weekly Surgical Pathology Conference. Review appropriate literature and be able to discuss the differential diagnosis. The attending pathologist should serve as a guide for case selection.
    - Select cases for weekly Gross Surgical Pathology Conference. Be prepared to provide the appropriate clinical history.

Special Techniques

1. Frozen section diagnosis.
2. Tissue preparation for immunofluorescence and electron microscopy.
3. Preparation of specimens for molecular diagnostics.
4. Specimen handling (read Gross Room Procedure Manual).
5. Specimen photography.
6. Immunofluorescence and immunoperoxidase preparation and interpretation.

Evaluation

Your progress in surgical pathology is measured by subjective evaluation of the attending physicians. The yearly in-service examination (May) serves as a method for comparing your progress with that of residents at other institutions. You should review the A.S.C.P. surgical pathology and tumor pathology check samples on a regular basis as an additional means of self-assessment.

REVISED SURGICAL PATHOLOGY ROTATION

Gross Room Activity (day 1)

1. The resident in charge of the gross room will be responsible for all surgical specimens received prior to 5:00 pm. Large specimens received between 4:00 and 5:00 pm that need overnight fixation will be the responsibility of the resident and attending staff covering frozen sections and gross room on the following day.

Sign Out Responsibility (day 2)

1. Residents will review 15 earlies (biopsies) and 25 large specimens per day. Additional cases will be given directly to attending pathologists.
2. Biopsy sign out should begin at 11:00 am and should be concluded by 2:00 pm. If this time is not suitable, the resident and staff should arrange a mutually convenient time. If additional time is needed, the staff pathologist will be available after completion of the cytology sign out at about 3:30 pm. Whenever necessary, the cases should be rewritten and dictated at the multi-headed microscope to avoid further delay in completion.
3. Cases needing additional levels, special stains etc. will be signed out late on the afternoon of day 2 or on day 3, depending on the urgency of the case or the availability of the additional material.
4. Bone marrow biopsies will be the responsibility of the resident on hematopathology. During the occasional months when there is no resident on hematopathology, the bone marrow cases will be given directly to the hematopathologist.

Sign Out Responsibility (day 3)

1. The resident and staff will sign out the late cases as in past. The cases should be signed out at the multi-headed microscope and all corrections should be written or dictated at this time to avoid further delay in completion. As noted above, this resident will be responsible for the large cases received in the gross room after 4:00 pm the previous day.

Day 4

1. Complete surgical pathology cases, preview and sign out dermpath, bone path and neuropath

Graded Responsibility in Surgical Pathology

The surgical pathology training consists of 13 months during a 48 month AP/CP residency. A graduated set of responsibilities with respect to the microscopic slide evaluation and preparation of microscopic descriptions, comments and diagnoses is anticipated as follows:

1. First Month – Microscopic slides and gross descriptions reviewed and corrected as necessary, normal histologic elements identified. Brief notes on pathologic abnormalities and probable correct pathologic diagnoses written by resident on working copy of report. Appropriate reading from text and journals should be accomplished prior to sign out with attending
2. Months 2-5 – Additionally, appropriate brief written microscopic descriptions and diagnoses should be prepared on "routine" specimens with gradual inclusion of more complex cases.
3. Months 6-9 – Resident will dictate simple and moderately complex cases and turn in tapes for transcription.  Resident will complete more complex cases in hard copy form for review with attending prior to transcription.
4. Residents who have completed 10 months of surgical pathology rotation are eligible for consideration for advancement to semi-independent signout privileges in surgical pathology (see below).

SURGICAL PATHOLOGY SENIOR RESIDENT SEMI-INDEPENDENT SIGNOUT GUIDELINES

Description:

1. Overview:  The Semi-Independent Signout option provides senior Residents with the opportunity, under the supervision of an Attending Physician, to function semi-independently, with primary responsibility for all aspects of assigned cases. The Attending Physician member will supervise the handling of cases and then review and officially sign out each case.

2. Rotation:  This option, as part of the graduated level of responsibility for Anatomic Pathology Residents, will be available to senior Residents after they have met qualifications for semi-independent sign out (see Qualification for Rotation below). The qualified Resident will then participate in semi-independent sign out whenever she or he is assigned to a surgical pathology rotation.

Objectives and Interests:

1. Patient Care:  Provide accurate, timely diagnosis of cases.

2. Education:  Provide senior Residents with increased responsibility and experience in advanced aspects of diagnosis and sign-out with the goal of preparation for their future career.

3. Regulatory and Financial Compliance:  Follow all regulatory and reimbursement guidelines.

Risks:

1. Inherent in many graduate medical education efforts, the following risks are present:

• Increased turnaround time (delay in sign out) of complex cases

• Increased number of special stains and other special studies ordered

Qualification For Rotation:

1. A Resident will be considered eligible for Semi-Independent sign out after she or he:

• Has completed a minimum of 10 months of surgical pathology rotations

• Is deemed ready by the Anatomic Pathology Attending Physicians, by consensus opinion

Evaluation Process:

1. Evaluation will be carried out by the usual routes:

• Direct verbal feedback by Attending Physician

• Evaluation form. Each Attending Physician who supervises the senior Resident on this rotation will be responsible for evaluation of the performance of the Resident, using the Semi-Annual review form (see below).

Case Load Assignments:

1. Case Assignments and Responsibilities:  The Resident will be assigned cases from a specific cutting day, using the 15/25 case rule. The Resident may select specific cases of interest to enhance the learning experience.

Specific Situations:

1. Triage:  Cases will be triaged into:
   - High Priority (see definition below)
   - Routine Cases, triaged as is appropriate
             -"Early"
             -"Late"

2. High Priority Cases:
   - Definition:  “Rush” cases and other high priority cases (e.g. pediatric tumor cases, breast biopsies) as currently defined.
   - As much as is practical, senior Resident will advise appropriate Attending Physician of  an impending case as early as it is recognized.

3. Routine Cases:  The senior Resident will handle all aspects of the signout of the assigned case, following the existing "early" and "late" designations and protocols, including anticipated turnaround times.

Handling of Cases:

1. Using the above triaging guidelines, the Resident will review cases, develop differential, and, develop a list of special stains to be ordered, if any, as is appropriate (See Special Stains below).

2. Resident will make corrections to gross description on CoPath or on the working draft, dictate a diagnosis and, if appropriate, microscopic description, and turn in paperwork/tape for typing; cases will be turned in for typing in small batches - - e.g. 5 - 10; RUSH/EARLY/PRIORITY cases will be submitted in a GREY FOLDER (See Clerical Support below).

3. Paperwork from case (i.e., the original gross working draft) will be returned by clerical staff to the Resident; the Resident will proofread typing, and make necessary corrections (in CoPath directly), and release case to the appropriate Attending Physician.

4. Once case is released to the Attending Physician, the Resident will then give paperwork and glass slides to the Attending Physician - - (i) preferably taking the materials to the Attending Physician's office or, (ii) as a fallback, notifying the Attending Physician that the cases are ready (e.g., by page, phone call or a note on his/her office door) and putting the case into the Attending Physician's mailbox.

5. Attending Physician will make any necessary changes and officially sign out the case; ALL SIGNIFICANT CHANGES will be relayed to the senior Resident verbally by the Attending Physician.

6. Turnaround times should be, as much as possible, the same as currently defined.

Special Stains:

1. All special stain and recut orders will be ordered by the senior Resident, either independently or as agreed upon by the Resident and Attending Physician, to meet current turnaround time criteria (e.g. as much as possible, "late" case stains will be ordered in time to be available for completion of case by end of Day 2). Resident will need to meet the standard ordering times.

• As much as possible, Resident and Attending Physician will consult about special stains at the time of frozen sectioning or as case is cut in in the gross room.

• Simple stains (e.g. microbiological stains) and recuts - - Resident will place order by COPATH.

• Complex Stains, fewer than 4 (e.g. simple immunoperoxidase panel): Resident will choose block of interest, generate list of special stains, and place order by COPATH if she/he is confident that the panel is the one that is appropriate for the case; if not certain, Resident should consult with Attending Physician.

• Complex Stains, more than 4 stains:  The Resident should review the panel with the Attending Physician (with the goals of Resident education, expediting complex cases, minimizing cost, reducing inefficiency of technologists recutting blocks) prior to ordering.

Pathology-Clinician Interaction:

1. It is anticipated that most interactions with clinicians will be handled by the Resident.

2. Clerical staff and Attending Physician will forward all inquiries to the Resident.

3. Resident will inform Attending Physician of significant issues as they evolve.

Clerical Support:

1. Clerical reports will be handled for the senior Resident cases similar to those of cases for Attending Physicians; clerical staff will make every effort to support and facilitate this rotation.

2. Every effort will be made to expedite the reports of the Resident, recognizing the possibility of delay.

3. Clerical support will be facilitated by the Resident submitting cases (cassette tape and paperwork) in small batches - - e.g. 5 - 10 - - rather than in large batches.

4. A Grey folder will be used by the Resident to indicate to the clerical staff that the case is a Rush/Early/Priority case that is ready for word processing; the submitted cases' paperwork will likewise be returned to the Resident in a Grey folder.

MEDICAL STUDENT SELECTIVE IN ANATOMIC PATHOLOGY (770)

Objectives and Guidelines

Welcome to Anatomic Pathology.  We hope to work with you to make the next 4 weeks an enjoyable and worthwhile part of your undergraduate medical education.  This elective is tailored to best serve each student's individual goals.  For instance, you may:  be considering a career in pathology; desire a review of the pathology of human disease; or you may have chosen a residency already, and want to improve your understanding of the related pathology.  You will meet with the clerkship supervisor on the first day to discuss your goals and determine an appropriate plan for your time here.

General Objectives

Although the types of specimens you see may vary, certain general objectives will apply to all students.

1. You will learn why medical and surgical specimens are submitted for pathologic exam and (for selected specimens) identify what questions are to be resolved by the pathologic examination, devise a plan for answering these questions, carry out this plan, and communicate this information to the submitting clinician through the formulation of a final report.

2. You will learn about basic and specialized ways of processing and examining tissues, when special examinations are useful or necessary, and about any specific procedures that must be followed in the collection or submission of a specimen if special examinations are anticipated.

3. (For selected specimens) you will correlate clinical findings (symptoms, signs, course of disease, treatment) with gross and microscopic alterations in the affected tissue(s).

4. You will learn the role of the pathologist as part of the patient care team.

5. You will learn the importance of communication among all members of the patient care team in optimizing health care delivery.

6. You will learn the various responsibilities of and contributions by all members of the patient care team in arriving at a diagnosis as promptly as possible.

7. You will progress along a scale of graded responsibility, from close supervision at the beginning of the rotation to near independence at the end.
   
   Responsibility for your education is shared among the resident with whom you are working (particularly for gross pathology), the attending staff (selection of appropriate cases, gross dissection of complex cases, microscopic interpretation and general concepts), and yourself (attendance, initiative, reading).

Schedule

You will work with a pathology resident during your elective.  Below is an outline of a typical Surgical Pathology rotation (which is 4 days long, so you will have approximately 4-5 of these during your month with us).

Day 1: 
Surgical Pathology cutting room ("Gross room").  2nd floor near OR suite.  Specimens from operating rooms, procedure rooms, and clinics received, accessioned, described, and sections taken for microscopic examination.  Includes OR consultations and frozen section diagnosis.

Day 2:
Early morning:  Slides for "early" cases (diagnostic biopsies, rapid turnaround time required) available for review.  Look at slides, do necessary reading, write microscopic description and preliminary diagnosis.
Late morning:  Sign-out "earlies" with attending staff (i.e. sit at microscope with attending/resident to generate a pathology report).
Afternoon/evening:  Finish review of late cases.

Day 3:
Sign-out "lates" (i.e. large cases requiring more dissection and fixation) with attending staff (8:00 am or after morning conference).

Day 4:
Flexible “catch-up” day:  Specialty sign-out day (Dermpath, placenta, bones, hemepath); observation of autopsies, attendance at Fine-needle aspirations, cytology sign-out; possibly observe a day in Clinical Pathology.

Specific Requirements

1. Daily Schedule - Responsibilities in the gross room begin at 8:00 a.m. (day 1).  Expect to be here until 5-5:30 p.m. on sign-out days.  You may need to be here later on day 2 if you have a lot of "late" cases.  You will have no weekend, holiday or on-call duties (although if you are interested in observing a post-mortem examination these may be the best opportunities).
    
2. Case Load - You will be responsible for 10-15 surgical specimens per cutting rotation (this is roughly one-third the load of a pathology resident).  Early on, the resident with whom you are working will do most of the cutting of your cases; you will do progressively more as you get more comfortable with grossing procedures.  You will be expected to have reviewed your slides, done the appropriate reading, made some notes on the microscopic findings, and formulated a preliminary diagnosis by the time of sign-out.
   
   Texts - Reference texts are available in the Pathology Library. There are both general Path textbooks and books in specific subspecialties, e.g. Liver Pathology.  There are also clinical texts available and manuals to help with surgical dissection and staging of neoplasms.
   
   Case presentation - Each student will present at least one case at the Surgical Pathology Unknowns Conference before the completion of the rotation.  Typically done during the last week.  Conference is usually Tuesday 8 am in C7602 (Path conf room).
   
   Attendance - You may, if necessary, be excused for up to 3 days for illness or interviews.  If you will need more time than this off, you may consider taking this elective on a not-for-credit basis.
    
3. Conferences - Attendance is required at the Surgical Microscopic (Tuesday, 8 a.m.) and Gross (Wednesday, 9 a.m.) conferences.  You are welcome to attend any other conference of interest to you.  You will be provided a copy of the week's conferences.  (See Conference Schedule)
    
4. Cytopathology - You should observe sign-out of cytologic specimens at least 3 times during this elective.  This sign-out is in the afternoon, but check with the attending assigned to that day.  Reading on the basics of cytologic interpretation (Keebler's Manual of Cytotechnology, available in Cytology Laboratory) would be useful preparation but is not required.

Evaluation

The clerkship supervisor will assign you a grade based on your overall performance, your case presentation, evaluation by the residents with whom you work, and input from other attending staff.

The evaluation is based on both

1.     performance on rotation:  numbers and complexity of cases, thoroughness of work-ups, quality of interactions with resident and attending

2.     presentation: (content, level of difficulty, presentation style, ability to discuss)

Pass = doing the minimum

High Pass = more in-depth effort, doing the extra workups

Honors = working on the level of a junior Path resident (consider the student's year - i.e. MS III vs. MS IV)

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