Autopsy Service

Dr. Kisha Mitchell
Arthur Belanger, Manager

The Autopsy Section investigates disease by postmortem study of tissues and the clinical record. It is essential to the closing of a patient's record. It provides verification of diagnosis and therapy, as well as important epidemiological information, and is an important source of teaching material for pre- and post-graduate training. Hospital policy requires that an autopsy be requested on all hospital deaths. Results from autopsy investigation of deaths are directly incorporated into quality assurance programs in the hospital. The case mix reflects the combined general medical and surgical hospital plus tertiary care center that characterizes the Yale New Haven Medical Center. In addition, the residents on the service cover autopsies at Bridgeport Hospital, adding the case mix of a large community hospital to the experience, and cover the VA Connecticut Healthcare System autopsies, providing yet another unique patient population.

Autopsies are performed seven days a week, 365 days a year. A dedicated technical and clerical staff ensures the smooth running of autopsy services. A highly efficient laboratory staff assists residents in the timely evaluation of cases. Tissue sections are returned to house officers within 48 hours and turnaround time for special stains is the same as for surgical specimens.

Autopsies are performed primarily by AP-1 residents. For each patient autopsied, an attending pathologist assumes the responsibility for the diagnostic evaluation and clinical-pathological correlation. Provisional Anatomical Diagnoses are reported within 24 hours of the autopsy. The resident is encouraged to prepare cases for the Final Anatomic Diagnosis as soon as possible so that appropriate information can be given to clinical attendings and the family of the deceased.

Clinical teaching through the autopsy is encouraged. Peer teaching and medical student teaching are opportunities for the pathologist in training to learn teaching skills. House officers are expected to present autopsy findings at interdepartmental conferences. Pathology Assistants in training learn autopsy technique and gross pathology through interaction with the resident staff and technical staff. Appropriate specimens are triaged into the teaching collection.

An important function of an academic autopsy service is to process tissues for research purposes. This activity is coordinated by the Tissue Procurement Module of Yale Pathology Tissue Services. The autopsy service provides tissues to investigators following the approval of the research protocol by the Human Investigations Committee. Not infrequently in a tertiary care center such as Yale-New Haven Hospital, diagnostic evaluation and clinical research are synchronous and complementary.

A detailed manual describing the operation of the autopsy service, including the autopsy process, technical procedures, and the autopsy report, is provided separately to the house staff.

Autopsy Pathology Rotation (AP-1)

Dr. John Sinard and Faculty

Yale New Haven Hospital, as a tertiary care center, Bridgeport Hospital, representing a large community hospital, and the VA afford the opportunity to perform a diverse array of autopsies. This includes a significant number of perinatal/pediatric autopsies as well as adult autopsies. These cases are supplemented by a small number of consult cases from outside the hospital. Historically, this service represents a cornerstone in the Department and intense teaching and numerous conferences revolve around this service. Both junior and senior level residents are integral to the function of this service, beginning with review of the chart and discussions with the clinical team, through the performance of the autopsy, to presentation of the findings and generation of the final anatomic diagnosis.

Each case is presented in conference format to the autopsy attending, residents and students assigned to the service. Clinical staff are encouraged to attend. The initial emphasis is correlation of anatomic diagnoses with clinical diagnoses, problems, and management strategies. Microscopic evaluation and further correlation follow. Three weeks is the expected time for autopsies to be completed. In addition, the autopsy service is an important focus for teaching residents pathology. Autopsy case review conferences (gross), case microscopic reviews, construction of the clinical-pathological summary, resident conferences based on challenging cases, and related reading are the educational components of the autopsy. Intradepartmental consultation is encouraged. Case reporting and clinical investigation are academic exercises available to residents through autopsy services.

Typically, two AP-1 residents and one AP-3 resident staff the autopsy service. These residents cover all autopsies performed on patients from YNHH, Bridgeport Hospital, and the VA (West Haven campus). Patients from Bridgeport Hospital who are to be autopsied are transported to the Yale Autopsy facility for autopsy. VA autopsies are performed at the VA. Each weekend, two AP-1 residents are on call for weekend autopsies. They cover autopsies from all three facilities.

The goal of this rotation is to initially train the AP-1 resident in the techniques of performing an autopsy with evolution to becoming an adroit prosector with synthesis of all clinical and pathological data. The autopsy should be treated as a medical consult. The resident's goal is to perform a thorough examination and then interpret the findings in light of the clinical setting, drawing upon their professional knowledge and experience. The resident is always supervised by a faculty member throughout the course of an autopsy to its completion and this individual continuously evaluates the resident's progress. Each resident will be provided with a detailed manual describing the specifics of the service policies and procedures.

Residents on the autopsy service will be expected to select two of their cases for advanced diagnostic workups. The purpose of this activity is to provide residents a practical exposure to the growing breath of alternate diagnostic modalities such as molecular testing. Details of this are available in the Autopsy Service Manual.

Additional Resident Duties and Responsibilities for the Autopsy AP-1 Rotation

• Check in with the autopsy service immediately after conference and just after 9AM on weekends when on call
• Verify that the autopsy permit is valid before starting the autopsy
• Discuss the case with at least one member of the clinical team prior to performing the autopsy
• Be sure the technician has entered into the computer the names of all of the clinical team members so that they all receive copies of the report.
• Discuss the case with the AP-3 resident and then the pathology attending prior to performing the autopsy. If the brain is to be removed, discuss the case with the neuropathology attending as well.
• Assure that accurate photographic documentation of the case is completed.
• Enter the PAD into the computer following (or ideally, prior to) presentation of the case to the attending.
• Routinely select up to five cassettes for "rush processing" to allow incorporation of these findings into the PAD. If necessary, a limited number of special stains can also be requested rush.
• Contact the members of the clinical team (especially anyone with whom you discussed the case prior to performing it and also the individual who secured the autopsy permission) as soon as possible after the case to provide them with verbal feedback of your findings.
• Expect to be involved in any presentation of your cases at conferences within and/or outside of the department.
• With faculty assistance, identify at least two autopsy cases where an advanced diagnostic workup would be appropriate for the case, and perform that workup
• Do not forget about your autopsy cases or simply "let them sit" until the next time you are on a light rotation. The College of American Pathologists requires that final autopsy reports be mailed within 30 days of the autopsy.
• Although most cases which arrive for autopsy after 3PM are held over until the following day, there are rare occasions when you may be required to perform an autopsy after that point, even perhaps in the middle of the night. Therefore, when you are on the autopsy rotation, you should consider yourself "on-call" 24 hours a day, and be reachable by beeper at all times.
• If you are the one of the residents on-call over a weekend or holiday, be sure to check with the rest of the on-call team, including the attending, before the weekend begins. Make sure you are available by beeper or by phone at all times. If you think you may be out of range, call in every hour or so to make sure there is nothing requiring your attention.

Additional Goals and Objectives for the Autopsy AP-1 Rotation

Patient Care:

• Determining that an autopsy permit is valid, that permission has been given by an appropriate individual, and noting any restrictions
• Recognizing when a particular case falls under the jurisdiction of the medical examiners office
• Adhering to and applying universal precautions in the day-to-day activities in the autopsy room
• Becoming proficient in the standard techniques for the evisceration and dissection of adults, children, and fetuses, preserving anatomic relationships and connections as appropriate, and understanding when it is appropriate and preferable to deviate from standard technique to better demonstrate the pathology in a particular case (first two months)
• Becoming proficient in specialized dissection techniques, performing them without prompting when the details of the case call for a specialized approach (second two months). These would include removal of the brain and spinal cord as a connected unit, preservation of the inferior vena cava and portal vascular systems, removal of the eyes, dissection of the mesenteric vessels, etc.
• Ability to generate appropriate differential diagnoses based upon gross examination of organs and tissues, and perform the appropriate histologic and special studies needed to resolve those differentials
• recognizing patterns of anatomic changes across organ systems as being related to a single underlying disease process
• Completing autopsy provisional and final reports in a timely fashion
• In a graduated fashion over the four months of the rotation, acquiring the ability to perform a complete autopsy examination independently

Medical Knowledge:

• Demonstrating an ability to glean from the medical record the pertinent clinical questions to be addressed during the autopsy examination
• Demonstrating an understanding of the clinical correlates and manifestations of pathology identified at autopsy
• Learning to photographically document an autopsy case, including all abnormal and pertinent normal findings
• Writing a well-organized, thorough, and educational summary which addresses the clinical questions and draws upon recent advances in our understanding of the particular disease processes manifested in the case

Practice-based Learning and Improvement:

• Actively seeking out additional clinical information by consulting patient information systems within the department and hospital
• Using on-line literature searching resources to identify recent advances in our understanding of the disease processes manifested in the autopsy cases
• Monitoring their own case distribution (adults vs fetal) to assure a broad-based exposure to the variations in technical and diagnostic skills based on patient age
• Obtain practical exposure to advanced diagnostic techniques

Interpersonal and Communication Skills:

• Contacting members of the clinical team and/or private primary care providers for the patients prior to beginning the autopsy and eliciting appropriate key information about the patient's medical history and specific questions to be addressed during the autopsy
• Learning to present a concise, organized clinical summary of the patient to the attending pathologist prior to the autopsy and organ review, including pertinent negative information
• Re-contacting members of the clinical team upon completion of the autopsy to discuss findings and, as needed, obtain additional clinical correlation for pathology identified at autopsy
• Learning to draw upon the assistance of technicians, students, and fellow residents during the performance of the case without losing control of the case and with the understanding that the responsibility for all aspects of the case remains with the primary resident
• Writing a well organized, understandable, grammatically correct report which reports findings and educates without being overly critical or inflammatory
• Demonstrating an ability to prepare and present cases at interdepartmental conferences, appropriately summarizing the clinical history and selecting appropriate gross and microscopic photographs for presentation
• Effective teaching of fellow residents (second month on service), pathology assistant students, and medical students in various aspects of autopsy practice and the pathologic evaluation of organs and tissues

Professionalism:

• Responding promptly when on service and/or on call to a case and promoting the efficient, thorough, and expeditious performance of that case so as not to compromise family funeral arrangements
• Interacting with fellow residents, assisting as needed to promote efficient running of the autopsy service
• Demonstrating an ability to view the clinical case from the point of view of the clinicians with the information available to them at the time, and not simply with the full knowledge of the autopsy findings
• Interacting with clinical colleagues in a non-confrontational and professional manner when issues of appropriateness of clinical care are discussed
• Demonstrating an ability to speak to family members about the autopsy in general and about the findings from an autopsy the resident has performed. This includes assisting in obtaining informed consent from family members for performance of an autopsy.

Systems-based Practice:

• Accurately and appropriately identify and enter Clarifications/Discrepancies from each autopsy case into the clinical information system to allow inclusion in institutional quality assurance programs

Autopsy Senior Resident Rotation (AP-2 and AP-3)

Dr. John Sinard and Faculty

Senior residents rotation on the autopsy service manage the day-to-day medical issues of the service, and should think of the autopsy service as "their" service. Proper handling of autopsy cases, training of residents, and coordinating the dissemination of autopsy findings through communication with clinical teams and presentation of cases at conferences is the responsibility of the senior resident on the service. This is not to say that this resident should actually present each and every case himself or herself. Learning how to properly train and delegate these responsibilities to the junior residents while at the same time assuring the quality and completeness of those tasks is an important part of the senior resident's training while on the service. Issues which the senior resident does not feel qualified to address directly should be referred to the attending pathologist (if it is a case related issue) or to the director of the autopsy service.

Additional Resident Duties and Responsibilities

• This service MUST be covered by a senior resident at all times.
• Keep your beeper on at all times so that you can be contacted. Be available and prepared to address any and all medical issues which arise while assigned to the service. Matters for which you do not have the proper experience should be referred to the attending on the case (for case specific concerns) or the director of the autopsy service.
• Contact autopsy technical staff each morning (usually just after morning conference at 9:00 am) to check on status of cases; keep informed throughout the day of any changes, pending cases, etc.
• Monitor the junior residents to be sure they are progressing at an appropriate pace and fulfilling their responsibilities.
• Assign cases to the residents on the service in an equitable manner.
• Assist junior residents in interpreting clinical record, seeking additional information (e.g. lab, radiology) and contacting clinicians involved. On the basis of information obtained, determine the best approach to each particular autopsy. Pay particular attention to clinical questions to be answered, viral and bacterial cultures to be obtained, and any other special tissue requirements (e.g. fresh tissue for EM, tumor or genetic studies, liver for Carnoy's, lymph nodes for B5).
• Make sure that the attending for the case is appropriately notified (attendings vary in the degree to which they wish to be involved in the autopsy, and this may change on the weekend). It is advisable to discuss this with each attending at the beginning of their rotations on service. Most attendings would like to be called after the clinical information has been gathered but before the autopsy starts. (NB: The attending for weekend autopsies is the attending on service the following Monday.)
• When necessary due to case load or junior resident staffing, the chief resident should assume primary responsibility for cases, including completing all of the paperwork/reports for such cases. Usually, after each junior resident assigned to and present on the service has received two cases on any given day, and there is still another case to do, the chief resident should take a case.
• Supervise any post-sophomore fellows on the service. In some instances, the post-sophomore fellow may be allowed to assume primary responsibility for a case, but the chief resident must supervise the post-sophomore fellow during every aspect of the case.
• Be available to discuss the case with the resident prior to performing the autopsy. Provide advice as to technique and special procedures.
• Make sure the technicians have contacted a member of the Yale Pathology Tissue Services tissue procurement team prior to the beginning of the case. This is particularly important in cases in which neoplasms are suspected. You should be familiar enough with the case to be able to give an initial assessment as to which tissues are likely to be available from the case for research purposes.
• Be available to assist the junior resident(s) during the autopsy, train them in appropriate autopsy techniques, and encourage the use of special procedures such as frozen section and specimen x-ray where indicated.
• Gradually transfer increasing responsibility for the case to the AP-1 resident.
• Act as diagnostic consultant for the junior residents, discussing differential diagnoses for any lesions encountered.
• Make a special effort to teach any medical students or other visitors who may be present in the room during the autopsy.
• Be sure tissue is frozen, where appropriate, for diagnostic and research purposes. This includes all tumors. Tissue should be frozen either by a Yale Pathology Tissue Services representative or by yourself. These tissues must be transported to the -80C freezer the day of the autopsy or left in the cryobath since the cryostat goes through a thaw-refreeze cycle every evening.
• Review the case with the junior resident after he or she has laid out the organs but before the attending arrives to review the case. Be sure everything has been dissected properly and completely, and that the room is in a presentable state for review of the case.
• Assist in the preparation of the PAD. Be sure it is accurate, complete, and in the proper format. Be sure to discuss with the attending what your role in the signout of the PAD will be.
• Be available to review the slides for the case with the junior resident and to assist them in preparing any conference presentations of the case within or outside of the department.
• Review the final report with the resident before it goes to the attending for review. Assure that the report is complete, accurate, and in the proper format. Remember, your name is on this report as well.
• "Encourage" the junior resident, as needed, to have the final autopsy report completed and ready for the attending within 3 weeks of the autopsy.
• If at all possible, the weekend chief-on-call should be present for the Monday morning review of the case with the attending and follow through with assisting the junior resident in preparing the PAD. When responsibilities of another service make this impossible, be sure to "sign-off" on the case with the autopsy chief resident so that they can perform these tasks.
• Coordinate interdepartmental morbidity and mortality conferences as necessary.
• Coordinate the weekly gross conference, including case selection. The Conference may be conducted on autopsy or surgical material on an alternative basis, depending on the availability of cases.
• Be responsible for coordinating Tuesday brain cutting.
• Bring up any issues regarding technical support and facilities with the Manager of the Autopsy Service and/or the Director.
• Give the Surgery Blue and Red Team conferences each Tuesday and Thursday, respectively; slides and reports will be pulled for you and in your box sometime in the morning. If you have any questions about the arrangements for this conference, see the Report Generation Supervisor.

Additional Goals and Objectives for the Autopsy Senior Rotation

Patient Care:

• Training junior residents in the techniques of autopsy evisceration and dissection
• Obtaining experience running a medical service
• Mediating as needed between the attending pathologist and junior residents on the service
• Being fully aware of the details of on-going and pending cases
• Understanding what constitutes a medical examiner reportable case and appropriately bringing such cases to the attention of morgue staff
• Proofreading junior resident write-ups in a timely fashion, providing direction, constructive criticism, and assistance
• As needed due to case load or junior resident staffing, taking primary responsibility for cases, including writing the report for such cases

Practice-Based Learning and Improvement:

• Intervening in complicated cases to assist the coordination of obtaining history and special studies
• Selecting and preparing material for the weekly gross conference

Interpersonal and Communication Skills:

• Coordinating communication with members of the clinical team and/or private primary care providers to provide feedback as to autopsy findings
• Learning to delegate responsibility to junior residents and technical staff without compromising patient care
• Effective teaching of junior residents, pathology assistant students, and medical students in various aspects of autopsy practice and the pathologic evaluation of organs and tissues

Forensic Pathology Rotation (AP-1)

Dr. Jim Gill and Faculty

The educational objectives of this rotation are met by a series of comprehensive lectures designed by the State Medical Examiner's Offices of New York as a didactic element of training. These mandatory lectures are given approximately monthly in the early evening. The lectures are supplemented by a two-week forensic rotation with the New York City Medical Examiner's Office during the anatomic pathology portion of the program, usually in combination with an autopsy rotation. On this rotation, the resident has the opportunity to observe/perform several autopsies daily.

Additional Resident Duties and Responsibilities

• During the rotation, the resident has the opportunity to attend court (to see a medical examiner testify) and to go to crime scenes with the medicolegal investigators to see how the medical examiner's office interacts with the police, crime scene unit, and next of kin.

Additional Goals and Objectives for the Forensic Pathology Rotation

Patient Care:

• Becoming proficient in the standard techniques for the forensic autopsy, paying particular attention to issues of diagnostic and medicolegal significance
• Generating appropriate differential diagnoses based upon gross examination of the specimen and the clinical and medicolegal questions in the case
• Understanding what ancillary studies are needed in particular cases (pediatric deaths, homicides), such as cultures, metabolic screens, radiographs, DNA testing, toxicology
• Demonstrating the ability to suggest appropriate testing (e.g., SIDS work-up) and interpretation of special testing (e.g., toxicology)
• Showing the ability to investigate cases utilizing textbooks and journals
• Demonstrating an understanding of the role that the circumstances of death play in the cause and manner of death

Medical Knowledge:

• Demonstrating an ability to glean from the detective and medicolegal investigators reports, the pertinent clinical and medicolegal questions to be addressed during the autopsy
• Understanding the clinical and medicolegal significance of the diagnoses being made, including implications for family, treating physicians, law enforcement, and district attorneys
• Understanding the data elements which need to be included in the pathology report to provide the treating clinicians, police, family, and district attorney with the information they need for the subsequent medicolegal issues
• Recognizing and describing types of injury (blunt, sharp, burn, gunshot, asphyxia), cause and manner of death definitions and determinations, time of death issues, and interpretation of toxicology results

Interpersonal and Communication Skills:

• Demonstrating an ability to prepare and present cases at agency working conferences
• Being available for court proceeding to observe medical examiner testimony

Professionalism:

• Demonstrating a commitment to ethical principles (e.g., decedent confidentiality) and sensitivity to next of kin interactions
• Understanding religious autopsy objection law and demonstrates sensitivity to family diversity during death investigation

Systems-based Practice:

• Collaborating with other members of the death investigation team to improve patient care, public health, and assist the legal system in relevant medicolegal issues

Cytology Service

Dr. David Chhieng, Co-Director
Kevin Schofield, Manager

The Cytopathology division of the Department of Pathology at Yale-New Haven Hospital provides preparatory and diagnostic services for all fluid, smear and aspiration specimens. The service processes and reads approximately 89,500 specimens per year. Of these, around 4300 are non-gyn specimens, including about 2650 fine needle aspirations (FNAs) and 300 consults. The service also provides a pathologist-performed superficial FNA service at the request of physicians within the hospital. On site adequacy assessment and preliminary interpretation of ultrasound, CT, and EUS fine needle aspirations are provided by cytotechnologists and the cytopathology fellow.

The laboratory occupies about 700 sq. ft. on the second floor (EP2-612) of the East Pavilion in Yale New-Haven Hospital, where all non-GYN specimens are processed. About 1/3 of the space is devoted to the preparatory lab, while the remaining space is devoted to specimen review and signout by cytology attendings, fellows, residents and cytotechnolgists.

The lab is equipped with a Cytyc Thin Prep processor and an AutoCyte Prep system for production of thin layer preps. This process facilitates collection of material for routine diagnostic work while saving otherwise discarded material for ancillary tests or research purposes. The lab also maintains all necessary equipment for routine processing and staining cytologic specimens. Additionally, Cytopathology occupies lab space at 430 Congress Avenue, where all GYN specimens are processed. There, we have two FocalPoint Primary Screening Instruments, one Cytyc Imager, two Cytyc ThinPrep processors, and two Autocyte Prep systems.

The laboratory interfaces with immunohistochemistry and the molecular diagnostics lab on a routine basis. Material collected for cytologic analysis may be sent to either of those labs as necessary.

The goals of the service include:

• To maintain excellence in specimen preparation and diagnostic accuracy
• To provide the highest quality consultative services to our clinical colleagues, both within our institution and elsewhere
• To develop and maintain excellent communications with patient care clinicians and consulting pathologists to enhance the reputation and recognition of the Yale Pathology Services
• To train residents, fellows, medical students and cytotechnologists in diagnostic cytopathology
• To support and incorporate advanced diagnostic techniques to improve diagnostic accuracy
• To pioneer new molecular techniques to increase the amount of information obtained from the minimal amounts of tissues received in the routine specimen

Cytology Rotation (AP-1 and AP-2)

Drs. David Chhieng, Diane Kowalski, Constantine Theoharis, Malini Harigopal, Adebowale Adeniran, Gouping Cai, and Angilique Levi

Residents training in anatomic or combined anatomic-clinical pathology will complete a minimum of two months of cytology training. This training is designed to provide a framework upon which to build, leading to possible sub-specialization and expertise as a cytopathologist. Residents are encouraged to do additional elective rotations in cytology if this is aligned with their future career interests.

The service is divided into three units, GYN, non-GYN, and FNA/consults with three attendings on service at all times. As the cytology fellow is an integral part of the cytology service, the resident will work closely with the cytology fellow, under direct supervision of the cytopathology attending, in training and performance of FNA biopsy, triaging of specimens, cytologic preview, case work-up, and communication with clinicians. The attending on service will review all aspects of the cases with the resident at the time of signout.

During the first days of the first rotation, the resident should spend a few hours in the prep lab with a senior cytotechnologist familiarizing themselves with the various laboratory techniques routinely used in preparation of both GYN and non-Gyn specimens. These include ThinPrep, SurePath, cell blocks, cytospins, smears, and routine stains such as Diff Quik.

The resident is responsible for previewing all non-GYN specimens and a portion of the GYN specimens, often in conjunction with the fellow, and will participate in daily signout. Signout for the non-GYN service may occur twice a day.

The resident will be instructed on proper FNA technique by the cytopathology fellow and on-service attending, and will be expected to perform 5 FNA biopsies over the two months of training. Before a resident may perform an FNA on a patient, initial instruction will include practice on a food item, followed by observation at the bedside. The resident will participate with the fellow in adequacy assessment of deep US, CT, and EUS-guided FNAs.

An abundance of teaching material is available in the cytology division including, glass study sets, books, journals, ASCP and CAP workshops, and unknown slides. The resident is expected to utilize these resources to enhance their cytology education. Residents are also expected to attend and participate in regularly scheduled cytology conference, including cytology-histology correlation, weekly consensus conference, and pertinent tumor boards.

Additional Resident Duties and Responsibilities

• Observe routine specimen preparation under the guidance of a senior cytotechnologist during the first week of the first rotation
• Attend daily signout
• Attend all cytopathology conferences
• Practice laboratory preparation of cytology specimens including PAP smears, FNAs, and fluids
• Practice smear techniques
• Practice FNA technique and attend patient FNAs with cytopathology fellow and attending
• Attend image guided, cytology assisted FNAs and observe preliminary assessment process

Additional Goals and Objectives for the Cytology Rotation

Patient Care:

• Understand the techniques used in cytopathology to obtain and preserve specimens, including conventional PAP smears, liquid-based PAP smears, fine needle aspiration, brush specimens, endoscopic ultrasound, bronchial alveolar lavage, and fluids (including urine, CSF, effusions, ascites)
• Understand the preparation of cytology specimens and slides, including PAP smears (Thin Prep and SurePath), HPV typing, touch preps, direct smears, and centrifugation.
• Understand commonly used stains, including, Diff Quik, H and E, PAP stain, special stains, and immunohistochemical stains; their limitations; and how they apply to cytopathology
• Triage the specimen appropriately for optimal diagnostic evaluation

Medical Knowledge:

• At the conclusion of the eight-week rotation, the resident should fully understand the morphologic criteria used to define normal, reactive, atypical, dysplastic, and malignant cells in common cytology specimens, including FNAs and fluids, and GYN specimens (CSF, thyroid, head and neck, breast, GI, GU, lymph nodes, fluids, soft tissue, bone), and GYN specimens
• Specific medical knowledge goals that should be attained at the conclusion of the first four-week rotation include:
• Understand normal GYN, Non-GYN, and Fluid cytology
• Understand and be able to apply the newly revised Bethesda system
• Understand the diagnostic criteria for reactive changes, ASCUS, LGSIL, HGSIL, AGUS, adenocarcinoma, and squamous carcinoma in PAP smears
• Understand the diagnostic criteria for atypical, dysplastic, and malignant non-GYN and fluid specimens
• Understand the purpose of cytology-histology correlation and participate in monthly conference
• Specific medical knowledge goals that should be attained at the conclusion of the second four-week rotation include:
• Accurately diagnose common abnormalities of the cervix, endometrium, vagina and vulva, including reactive processes, dysplasia and malignancy
• Accurately diagnose common abnormalities in FNAs and fluid specimens including reactive processes, dysplasia, and malignancy
• Present cytology teaching cases as necessary, with assistance from the cytopathology fellow, at tumor board and unknown resident conference
• Review cytology consult cases with cytopathology fellow prior to signout with the attending
• Understand the limitations of assessment of a disease process by cytopathology
• Gain exposure to CPT and ICD-9 coding for common cytology specimens

Surgical Pathology Service

Dr. Brian West, Director
Lori Marini, Pathologist Assistant and Gross Room Manager
Keri Stratton, Pathologist Assistant
Christopher Sylvest, Pathologist Assistant

The Surgical Pathology Service renders tissue diagnosis on biopsy samples and studies surgical resection specimens in an accurate and timely fashion. The service is staffed by several attending Pathologists, residents, and fellows. This service entails all facets germane to the evaluation of surgical specimens, including prosection, interpretation, communication, and report generation. As members of a tertiary care center, residents are exposed to a vast spectrum of material. The resident is responsible for each case assigned to him/her and, with supervision by a faculty member, initiates all studies necessary for the completion of a case, including utilization of all available ancillary studies and molecular technologies. Areas of intense sub-specialization include the fields of genitourinary pathology, endocrine pathology, orthopedic tumors, lung pathology, and ENT pathology. As residents accrue experience from the first to second years, they are given increasing responsibilities in this setting. The residents interface with numerous faculty members and experience ongoing evaluation and input that culminates in a formal written evaluation. The ultimate goal for this area is to produce experienced, qualified Surgical Pathologists who will have a solid foundation on which to build their careers and who will appreciate the need for consultation.

Because of the specialized nature of the clinicians who avail themselves of the expertise of the staff, the service is organized in programs that focus on one organ or specialty. Depending on the case load for each individual program, the residents will be assigned to one rotation or a combination of rotations that optimizes the learning experience and the smooth functioning of the service.

Each incoming case is assigned to a resident (AP-1 or AP-2) and an attending who will be responsible for the final report. The average time for a final diagnosis rendered on a biopsy is 24 hours; for resection specimens, it is two to four days. When cases demand a work-up that will prolong the turn around times, a provisional report may be issued and/or the attending will be notified by telephone. The senior resident assigned to the "hot seat" reviews every case and acts as focal point for the communication and exchange of information with the clinical staff.

The medical staff in surgical pathology is supported by the technical group in the gross room, the Histology Laboratory, the Co-Path medical information system, and the transcription pool. Separate summaries are provided in this manual for the histology laboratory and computer services. The gross room group is responsible for the intake of cases and helping the medical staff with the grossing and work-up of the specimens. A manual devoted to gross room procedures is distributed separately. Harmonious cooperation between the Histology Laboratory and the Yale Pathology Tissue Services staff optimizes the collection of samples for scientific purposes without compromising patient care.

After a specimen has been accessioned and subsequently "grossed" by a resident or Pathologist Assistant, a secretary transcribes the gross dictations. The Hot-Seat reviews the paperwork and slides and formulates a preliminary diagnosis. A final diagnosis is generated after further review by the resident and attending. The final reports are electronically signed out by the attendings and copies are sent to attending physicians and medical records.

It is very important for patient care to maintain continuity of knowledge about a specimen. When a resident has grossed in a specimen, that specimen remains the responsibility of that resident until a) it has been signed out, or b) responsibility has been formally transferred to another resident. Transferring responsibility occurs most commonly when one resident is rotating off service and another is rotating on, but also occurs when a specimen is referred to a different specialty service for signout. It is not sufficient to simply "pass on" the slides to the new resident. The resident transferer must organize the case and sit with the resident transferee and clearly communicate how the specimen was grossed in and what workup, if any, has been initiated for the case.

Rotation Redesign to Maximize Teaching

The volume of surgical material being evaluated by most pathology departments has been steadily increasing over the past several years. However, in most programs, the number of residents has not been increasing. As a result, residents are interacting with more and more specimens each year. Although this increased exposure provides new and important learning opportunities, volume overload can ultimately compromise training.

In response to this growing workload, the Resident Education Committee in Anatomic Pathology recommended redesign of each of the surgical pathology rotations to create two paths for specimens through the department: one path involving the residents, and one by-passing the resident, so that resident workloads remain reasonable. This process is currently underway. The Education Committee also developed guidelines for rotation directors to use in the redesign process. They are:

• Residents must be directly and actively involved in all aspects of the real-time evaluation of active cases within the department.
• It is not necessary for a resident to be involved in every case that comes through the department; however, guidelines need to be in place to ensure adequate exposure to neoplastic as well as non-neoplastic lesions specific to each specialty service. Typically, residents should be involved with all malignant resections.
• Residents should be fully responsible for all cases they gross in until they are signed out with the attending. Residents are expected to be able to converse intelligently about their cases with the attending pathologist as well as residents and clinicians in other departments. Therefore, residents must routinely be given time to preview slides on all cases they gross in BEFORE taking them to signout. Residents must accomplish this in a timely fashion to prevent delays in the care of the patients. Previewing should include writing up the case, correcting the paperwork, pulling relevant prior material, and reading about the cases as appropriate. Exceptions may occur at the time of change in rotation, in which case a resident leaving a surgical service may sign-over a case to the resident coming on to the service.
• Decisions about which specimens take a resident path and which take a non-resident path should be determined on a per-service basis and based on the educational value/need for the specimen. These decisions may take into account level (year) of training but should NOT vary based on the interests, efficiency or skill of a particular resident (all residents of equivalent training level should be held to the same standard) or on non-educational factors, such as who the submitting physician is.
• There must be a mechanism to identify unusual and highly educational specimens that take the non-resident pathway to ensure resident exposure.
• Rotations should be designed to provide the resident with a balanced exposure to all stages of the diagnosis, evaluation, and treatment of disease. This should include thorough exposure to primary biopsies (in which a diagnosis has not yet been made), involvement in selection and interpretation of ancillary techniques, evaluation of definitive resections, and participation in multidisciplinary clinical conferences. Opportunities for direct communication with clinicians should be encouraged.

Bone and Soft Tissue (Neoplastic) Pathology Rotation (AP-1 and AP-2)

Drs. Eduardo Zambrano and Jose Costa

The department receives a relatively small number of these specimens compared to other specimens received at Yale, but a relatively large number compared to many other pathology departments. Because of the relative rarity of these lesions, specialty expertise greatly facilitates proper handling, which frequently involves obtaining fresh tissue for cytogenetic or molecular analysis. During this rotation, the resident is exposed to the interpretation of neoplastic bone and soft tissue lesions. Correlation with radiographic and other imaging studies is crucial to making the correct diagnosis.

Additional Resident Duties and Responsibilities

• Review/obtain available imaging studies for cases as needed
• Procure fresh tissue from cases for appropriate ancillary studies
• Attend the Musculoskeletal Tumor Board

Additional Goals and Objectives for the Rotation

Medical Knowledge:

• The resident should demonstrate an appropriate level of understanding of the pathogenesis, clinical significance, treatment and prognostic factors of the major pathologic entities covered on this service, including the role of chromosomal translocations in the etiology of these neoplasm

Breast Pathology Rotation (AP-1 and AP-2)

Drs. Fattaneh Tavassoli, Kenneth Haines, Veerle Bossuyt, Sihem Khelifa, and Ozlen Saglam

The specimens removed from the breast form the basis of a rotation, in which both AP-1 and AP-2 residents participate. The purpose of the rotation is to examine and accurately diagnose these cases, to become acquainted with the processing of specimens derived from the breast, and to understand the diagnostic features and clinical implications of the surgical pathology of the breast.

The resident is guided by the Pathology Grossing Manual, Pathology Assistants, the senior residents, the fellow, and the attendings in learning the processing of specimens. Much of the teaching occurs at the multi-headed microscope, but to help the resident gain an understanding of these features, there is a series of both didactic and case-based conferences held throughout the year dealing with breast pathology. An understanding of the clinical implications is gained by attendance at the weekly Breast Tumor Board, which meets on Wednesdays, and the monthly Breast/GYN Journal Club.

The goals of the resident on this service can be divided into AP-1 and AP-2 levels. The AP-1 resident should be able to describe the grossly observed pathologic changes in relation to the anatomy of the structures in which they are found. The resident should be able to concisely describe the lesion verbally and accurately photograph the pathologic features in relation to the anatomic structures that have been removed. Quality photography is a major element used to evaluate residents' performance. In addition, the resident should be able to demonstrate the pathology efficiently with well-preserved and well-chosen blocks. They should know the pathologic entities that occur and the diagnostic criteria for distinguishing them. The resident should also work up the cases and present the pertinent clinical and previous pathologic material at the time of signout. In addition to these goals, the AP-2 resident is expected to regularly apply the diagnostic criteria and have an understanding of the clinical significance of distinguishing the pathologic entities. Additionally, the AP-2 resident should understand assays and their interpretation as utilized to acquire additional prognostic and therapeutic information such as ER/PR status, Her2/Neu expression, Oncotype DX, and DNA flow cytometry ploidy studies.

Additional Resident Duties and Responsibilities

• Attend Breast Tumor Board and Breast/GYN Journal Club
• Pull slides of prior biopsies for all cancer cases
• Take blocks to Radiology for obtaining X-rays when mammographically detected microcalcifications are not identified on the H&E slides

Additional Goals and Objectives for the Breast Rotation

Patient Care:

• Becoming proficient in the standard techniques for the gross evaluation, dictation, and dissection of breast mastectomy, lumpectomy, reduction mammoplasty, core biopsies, and sentinel & axillary lymph node dissections specimens, paying particular attention to issue of diagnostic and prognostic significance
• appropriately handling implants, implant capsules, titanium clips, handling of cores with microcalcifications, sentinel node processing, touch preps, whole mounts

Medical Knowledge:

• Recognize, understand the diagnostic criteria for, and be able to accurately diagnose the following lesions:
• Normal structure of the mammary duct system
• Physiologic alterations: Gestational Hyperplasia, Lactational changes, Involution
• Benign Lesions:
• Fibrocystic changes, various patterns of Adenosis, Duct ectasia
• Fat Necrosis, various types of mastitis
• Location of and lesion associated with microcalcifications; types of calcifications
• Proliferative/Neoplastic Lesions
• Lobular intraepithelial neoplasia and variants
• Ductal intraepithelial neoplasia (flat type, grades 1-3) / IDH, AIDH, DCIS
• Grading of DIN, tumor extent/size assessment, margin assessment
• Carcinomas
• Microinvasive, Invasive
• Ductal/Lobular/Special types
• ER/PR/HER2, Immunohistochemistry, and FISH
• Lymphovascular invasion
• Margin status
• TNM/staging of carcinomas
• Mesenchymal tumors
• Benign
• Myofibroblastoma/Fibromatosis
• Malignant:
• Angiosarcoma (de novo and post-radiation)
• Other soft tissue sarcomas (liposarcoma, fibrosarcoma, osteogenic sarcoma)
• Biphasic Tumors:
• Fibroadenoma (adult and juvenile)
• Phyllodes Tumor
• Periductal stroma tumors

Dermatopathology Rotation (AP-2)

Dr. Rossitza Lazova and Faculty

Residents are exposed to dermatopathology specimens from two different sources. Specimens resulting from surgery in the YNHH operating rooms come to surgical pathology. This consists mostly of resections of cutaneous malignancies with some additional biopsies mixed in. In addition, residents rotate through the Yale Dermatopathology Laboratory within the Department of Dermatology, where approximately 70,000 specimens per year are interpreted.

Residents' responsibilities include participating in the daily sign-out of dermatopathology specimens, as well as researching interesting cases, gathering cases for teaching purposes, and preparing and presenting occasional talks. In addition, residents are also expected to review teaching sets with examples of different neoplastic and inflammatory conditions.

During a typical morning, the resident handles specimens received in Pathology, and signs out with a dermatopathology faculty member at 12:00 PM each day. Many of these cases may be signed out with other Pathology faculty. In the afternoon, the resident reviews and attends signout of cases in Dermatopathology.

The didactic teaching program in Dermatopathology for the dermatology residents consists of a weekly conference, which throughout the academic year covers major topics in dermatopathology. Three of these conferences are mandatory for pathology residents. However, all of these conferences are open to the pathology residents. Pathology residents should attend these conferences while on Dermatopathology rotation. Reading material is assigned prior to the conference and residents are encouraged to review the slides and be prepared to discuss them during conference. These didactic sessions are conducted largely by Yale's board-certified dermatopathologists, one Yale-affiliated board-certified dermatopathologist from the community, and the dermatopathology fellow. There is also once or twice a month slide review and teaching conducted by the dermpath fellow with review of a variety of interesting cases collected during the preceding month. Additional lectures in Dermatopathology are given throughout the year on a variety of topics in skin pathology, specifically for the pathology residents. Residents also have the opportunity to review two large study sets, often with the guidance of a dermatopathologist or the dermpath fellow.

Additional Resident Duties and Responsibilities

• Attend Dermatology Grand Rounds
• Attend all of the weekly dermatopathology conferences

Additional Goals and Objectives for the Dermatopathology Rotation

Patient Care:

• Mastering skills needed to correctly orient and gross skin specimens:
• Proper fixation and dissection
• Appropriate usage of cassettes and an understanding of tissue processing
• Ability to know limitations, seek help from the fellow or attending prior to grossing

Medical Knowledge:

• Expected fund of knowledge:
• Inflammatory conditions
• Know criteria for psoriasis and eczematous dermatitides
• Know criteria for Graft vs Host disease and differential diagnosis with drug eruption and erythema multiforme
• Know histologic features for Lupus erythematosus and Dermatomyositis
• Know how to differentiate toxic epidermal necrolysis from staph scalded skin syndrome on frozen and permanent sections
• Recognize common inflammatory patterns of cutaneous infection on routine and specially stained sections
• Neoplastic conditions: Know the characteristic histologic features of...
• melanocytic nevi and malignant melanoma
• basal cell carcinoma and distinction from benign tumors of the hair follicle
• squamous cell carcinoma, and distinction from pseudoepitheliomatous hyperplasia
• common benign conditions such as epidermoid cysts, hemangiomas, acrochordons and dermatofibromas

Endocrine and Head & Neck Pathology Rotation (AP-1 and AP-2)

Gastrointestinal and Liver Pathology Rotation (AP-1 and AP-2)

Gynecologic Pathology Rotations (AP-1 and AP-2)

Drs. Fattaneh Tavassoli, Kenneth Haines, Pei Hui, Veerle Bossuyt, Sihem Khelifa, and Ozlen Saglam

The experience in this rotation encompasses reproductive and gestational pathology and the pathology of gynecologic disease. Emphasis is placed on recognition of common gynecologic tumors, and the pathologist's role in the management of these tumors. A major clinical program in gynecologic oncology provides the setting for the development of the residents as consultants for the gynecological surgeon.

Residents do two rotations in gynecologic pathology during their AP-1 and AP-2 years. A large variety of gynecological specimens consisting of surgical specimens and biopsies comprise the surgical material. Most of the in-house specimens will be grossed in by the resident on the service. Most of the biopsies will be grossed in by technicians.

For those residents interested, they can do an additional elective rotation in "outreach GYN", reviewing biopsy specimens received by the department from physicians' offices.

Gestational pathology specimens such as products of conception are shared between the GYN service and the pediatric service. For cases in which a termination is done for suspected or known genetic abnormalities, the specimens go to the pediatric pathology service. Always read and understand the clinical questions first before grossing the specimens. If the clinical information is not clear, call the physician and clarify.

As with all the surgical pathology services, residents are expected to have previewed their slides prior to bringing them to signout, to have formulated a preliminary impression/diagnosis for the case, and to have all the paperwork in order, with appropriate previous material available for review.

Additional Resident Duties and Responsibilities

• Attend the weekly GYN-Oncology Tumor Board Conference.
• Use standardized forms/synoptic reports for signing out all tumor cases. They are stored in the signout area and in the copy room.
• Fee codes and ICD-9 codes should be entered before signout.
• In cases of Pap smear discrepancy, the resident should inform the attending at signout. These cases should be brought to the attention of the cytopathologist for review. The attending on service will decide if the cases should be included for cytology-histology correlation conference.
• The resident will maintain a log of all special stains and studies for each case. A copy of the report should be attached to all special stains when presented for review. Follow up on POC specimens for which flow cytometry has been ordered and check back on a regular basis and report on the results with special reference to discrepancies if any.
• Photograph ALL carcinomas and unusual tumors
• Attend gyn/Breast Journal Club
• Pull slides of prior biopsies for all cancer cases

Additional Goals and Objectives for the Gynecologic Pathology Rotation

Patient Care:

• Become proficient in the standard techniques for the gross evaluation, dictation, and dissection of conization specimen; hysterectomy specimen for benign and malignant epithelial and/or mesenchymal tumors; oophorectomy specimen for benign and malignant lesions; cancer staging procedures; partial and complete vulvectomy samples; biopsies and curettings, paying particular attention to issues of diagnostic and prognostic significance (e.g., complete distortion of uteri or vulvar specimen by massive benign or malignant lesions).

Medical Knowledge:

• Recognize, understand the diagnostic criteria for, and be able to accurately diagnose the following lesions:
• Cervix:
• Reactive changes, intraepithelial, neoplasia and a variety of invasive carcinomas
• Human papilloma virus changes
• Endometrium
• Normal cyclic changes
• Dating of the endocmetrium
• Physiologic and functional changes
• Polyps
• Gestational changes, normal and abnorma
• Partial mole, complete mole, choriocarcinoma
• Metaplasias, hyperplasias and carcinomas
• Myometrium
• Adenomyosis
• Leiomyomas and leiomyosarcomas
• Stromal nodules and low grade sarcomas
• Fallopian tubes
• Inflammatory and neoplastic changes
• Ovaries
• Physiologic and functional changes
• Benign, borderline and malignant neoplasms
• Serous, mucinous, endometrioid, transitional
• Sex-cord stromal tumors, benign and malignant
• Germ cell tumors, benign and malignant
• Metastatic carcinoma
• Vulva
• Benign and malignant (intraepithelial and invasive) lesions
• Vagina
• Benign and malignant (intraepithelial and invasive) lesions
• Peritoneum: Primary and metastatic peritoneal carcinomas
• Mesothelioma: cystic, papillary
• TNM staging for all malignant tumors of the female genital tract

Hematopathology Rotation (AP-2)

Drs. David Hudnall and Demetrios Braddock

The resident is crucial to this service, organizing all information regarding wet hematologic cases and initiating phenotyping and genotyping studies on lymphomas. A wide spectrum of material, both in-house and consultative, is available due to the variety of patients attracted to YNHH. Thus, residents experience diverse exposure to histologic material and become conversant in the rapidly evolving field of molecular hematopathology. Residents also have access to a vast teaching collection. Evaluation and constant guidance are ongoing. The goal of this rotation is to assure adequate exposure in hematopathology for general surgical pathologists as well as to afford a very strong foundation for those residents wishing to specialize in this field.

Ancillary studies are integral to the workup of most hematopathology cases. The resident will be expected to participate in the evaluation of all components of a case, including those portions performed in Laboratory Medicine. This rotation, thus, routinely bridges the AP and CP training experiences.

Additional Resident Duties and Responsibilities

• Attend the weekly hematology/oncology conference
• When not handling cases in surgical pathology, participate in the evaluation of other parts of these cases in Laboratory Medicine

Additional Goals and Objectives for the Hematopathology Rotation

Patient Care:

• Become proficient in the standard techniques for the gross evaluation, dictation, and dissection of lymph node/spleen specimens, paying particular attention to issues of diagnostic and prognostic significance.
• Understand techniques commonly used in working up hematopathology cases such as classic morphology, immunohistochemistry, flow cytometry, FISH, cytogenetics, EM, frozen section, smears, and touch preparations.

Medical Knowledge:

• Understand the clinical and pathologic criteria used to distinguish reactive from malignant lymph nodes, phenotype and genotype lymphomas, apply cytogenetic results to diagnoses, stage lymphomas, diagnose etiologies for anemia, understand myelodysplastic syndromes and leukemias, and evaluate the effects of treatment and therapy on lymph node, splenic, and bone marrow pathology

Molecular Pathology Rotation (AP-1)

Drs. Jeffrey Sklar and Pei Hui

During their rotation on the autopsy service, AP-1 residents will also be assigned additional responsibilities in either Neuropathology or Molecular Diagnostics. These responsibilities need to be balanced with the needs of the autopsy service, and that allocation is the decision of the senior resident on the service. In general, autopsy responsibilities will take precedence over the molecular pathology responsibilities.

As part of a program to introduce trainees to the evolving and expanding diagnostic repertoire available in the practice of pathology, residents on the autopsy service will shadow activities in the anatomic pathology molecular diagnostics laboratory. A specific two week period is assigned for each resident to engage in this experience. However, this is designed to be a flexible experience, and "time missed" because of responsibilities on the autopsy service should be made up during other autopsy time.

Additional Resident Duties and Responsibilities

• Shadow the daily activities in the clinical molecular diagnostics laboratory
• Read papers as assigned
• Attend the Friday afternoon molecular signout

Additional Goals and Objectives for the Autopsy/Molecular Rotation

Patient Care:

• understand the scope of molecular tests available in the molecular diagnostics lab
• understand how to interpret the data resulting from these tests
• appreciate the limitations of the techniques and pitfalls of the interpretations

Practice-based Learning and Improvement:

• Begin to appreciate the value of ancillary testing beyond the traditional gross and histologic examination of the specimen

Neuropathology Rotation (AP-1 and AP-2)

Drs. Alex Vortmeyer and Anita Huttner

Training in neuropathology includes both classical and surgical neuropathology. For surgical neuropathology, the neuropathology resident has the opportunity to see many interesting and unusual in-house neurosurgical cases. In addition, the neuropathology faculty receives numerous extramural consultation cases, which are often diagnostically challenging and highly educational. The neuropathology resident receives training in the special handling of certain neurosurgical cases, including the peripheral nerve and skeletal muscle.

Classical neuropathology is learned at the weekly "Brain Cutting" gross conference, where the resident describes the gross findings of postmortem brains and takes sections of the brain for histological evaluation. The neuropathology resident learns the normal CNS histology as well as pathological changes in various neurological disorders when he/she signs out postmortem cases.

The neuropathology resident is responsible for cases for conferences, particularly the Neuro-oncology Tumor Board and neurosurgical morbidity and mortality conferences. For the neurosurgical M&M conference, the neuropathology resident prepares a PowerPoint presentation with photomicrographs.

Handling of specimens for neuropathology is not, in general, different from those for other subspecialties. However, there are some specimens (peripheral nerve, skeletal muscle) that need to be treated differently. Details of these specimens are described in the Grossing Manual, and the resident is expected to be familiar with the special handling these specimens require.

When a case is presented at the brain cutting conference, Neuropathology resident will be responsible for the gross description of the brain, trimming tissue blocks and logging them into the computer, and bringing the tissue blocks to histology. He/she will signout the cases with one of neuropathology attendings, and shall complete the report on the brain. For brain only cases, the neuropathology resident is also responsible for FAD and CPC.

Additional Resident Duties and Responsibilities

• Prepare PowerPoint presentations for cases at neurosurgery morbidity and mortality conference
• Cut in and evaluate brains from the autopsy service; reviews these at neuropathology signout and prepare neuropathology addendums for the autopsy reports
• For "Brain Only" autopsies, the neuropathology resident is the primary prosector. This means he/she is responsible for the entire autopsy report, including the FAD and CPC.

Additional Goals and Objectives for the Neuropathology Rotation

Patient Care:

• Understand uniqueness of neuropathological evaluation in CNS disorders that are often serious in nature.
• Determine what types of cases need appropriate history or other laboratory data, including imaging, and be able to acquire information from charts, clinicians, or other related personnel before signing out cases with an attending.
• Be able to technically handle different types of tissue (muscle, nerve, CNS and PNS, for example) proficiently so that there may be no delay in rendering appropriate patient care based on the final findings of the specimen.

Medical Knowledge:

• Demonstrate appropriate knowledge of normal anatomy, histology and biology of the nervous system, and skeletal muscle.
• Understand the basic principle behind routine and immunohistochemical stains that are commonly used in neuropathology.
• Be able to describe succinctly and accurately the postmortem brain grossly and microscopically.
• Be able to render clinicopathological correlation on postmortem brains.
• Be able to prepare the muscle and peripheral nerve for histochemistry, electron microscopy and routine histology without assistance.
• Understand the reason why various routine histochemical and enzyme histochemical stains are needed for the evaluation of the skeletal muscle.
• Develop knowledge on histological and biological differences among common brain tumors, and on the principle of histological grading, if applicable.
• Be able to describe salient neuropathological features in various neurological disorders including neurodegenerative and metabolic disorders.

Ophthalmic Pathology Rotation (AP-1 and AP-2)

Dr. John Sinard and attending staff

Ophthalmic pathology represents a subspecialty area both because of the number of entities which occur uniquely in the area and because of the somewhat esoteric vocabulary associated with the discipline. Since the specimen volume is small, these specimens are handled by one of the residents on the "General" surgical pathology rotation. Many of the cases, such as eyelid biopsies and temporal artery biopsies, can be signed out directly with the General attending. Other cases more unique to the eye, such as corneas, some conjunctival biopsies, and most lesions of the globe are routinely signed out with Dr. John Sinard, who is also happy to look at any other peri-orbital specimens.

The resident is exposed to a wide array of neoplastic and non-neoplastic pathology with study sets supplementing this material. The goal of this rotation is to assure some exposure to the field of ophthalmic pathology, which may be enhanced with additional training.

Additional Resident Duties and Responsibilities

• For specimens which will not be signed out by the attending pathologist on the General rotation, contact Dr. Sinard and arrange for timely signout of the material.

Additional Goals and Objectives for the Ophthalmic Pathology Rotation

Patient Care:

• Becoming proficient grossing specimens from the eye and peri-orbital region

Medical Knowledge:

• Learning ophthalmologic terminology and abbreviations

Interpersonal and Communication Skills:

• Working with the ophthalmology resident assigned to the service to interpret clinical histories and clinical differential diagnoses

Pediatric and Placental Pathology Rotation (AP-2)

Dr. Eduardo Zambrano

The resident has responsibilities similar to those on the other surgical pathology services. In addition, the resident assists with molecular studies and participation with national study groups (POG, NWTSG, etc.) for the array of neoplasms seen. The goals of this rotation are to become acquainted with the spectrum of material in this field and to be exposed to the critical role that molecular pathology plays in this particular area. Daily evaluation and supervision occurs in the gross room and at the time of signing out.

The experience in Pediatric surgical pathology complements the pediatric autopsy experience obtained during the Autopsy pathology rotations, building a strong exposure to pediatric and neonatal pathology.

Additional Resident Duties and Responsibilities

• Attending and present intra- and interdepartmental conferences, such as monthly M&M perinatal and pediatric ICU sessions, weekly pediatric tumor board, monthly pediatric surgical pathology session, ad hoc pediatric pulmonary and pediatric cardiology sessions, etc. Most of these conferences (in particular those related to autopsy cases) require PowerPoint presentations, including gross and microscopic features of each case, ancillary test reslts, and clinicopathological correlations with with appropriate and updated literature support.

Additional Goals and Objectives for the Pediatric Pathology Rotation

Patient Care:

• Becoming proficient in the standard techniques for the gross evaluation, dictation, and dissection of pediatric, perinatal, and placental specimens, paying particular attention to issues of diagnostic and prognostic significance. Pediatric specimens differ significantly from adult ones, and also among themselves, depending on the specific age group. Residents need to keep in mind that the key word in this rotation is DEVELOPMENT. Therefore, pediatric specimens are always uniquely characterized according to their age. Preservation of visceral relationships is essential in order to recognize deviations from the normal anatomy (vide infra re: malformations).
• Knowing special techniques to dissect and submit sections for complex developmental disorders (including Hirschsprung disease, dysmorphic fetuses and abnromal placental vascular anastomoses) and pediatric tumors. Although most rules applicable to adult pathology are useful for pediatric specimens, there are specific needs to take into account. Extensive sectioning and special techniques are required to study certain developmental disorders and pediatric tumors. Frozen section analysis may also be required in some cases.
• Recognizing when to submit specimens for special molecular techniques required in pediatric specimens (cytogenetics, flow cytometry, electron microscopy, molecular studies, tissue cultures and microbiology studies). Chromosomal and molecular genetic analyses are extremely important in the diagnosis and treatment of many pediatric neoplasms and other pediatric disorders. Chromosomopathies, detected by routine and high-resolution cytogenetic analysis, are frequently diagnostic and prognostically significant in pediatric oncology. Complete and partial moles require flow cytometry and/or molecular analysis, and the same may be true for other placental anomalies (e.g. confined placental mosaicism). Molecular studies for gene rearrangements and other genetic abnormalities (FISH, PCR-based studies, etc), are also frequently required in the analysis of solid tumors.
• Looking up, prior to grossing and/or signout, any clinical terms, unusual syndromes, or abbreviations used on the requisition form. This is particularly important in pediatrics, since many relatively rare syndromes are part of our daily routine.
• Reviewing and understanding, prior to grossing and/or signout, key points of the patient's clinical history that may be required for the appropriate interpretation of gross and/or microscopic findings. This may be done by utilizing any of the available electronic clinical information systems (i.e. Sunrise, Centricity, Synapse, etc.) and/or by contacting the clinician(s) in charge of the patient's care.
• One particularly sensitive issue in pediatric pathology is the proper handling of fetuses. In the state of CT, examination of fetuses >20 weeks of gestation requires an autopsy request signed by a parent, and a death certificate. The autopsy examination is then performed at the morgue by one of the residents in the Autopsy Pathology rotation. The residents rotating in the Pediatric Pathology service need to familiarize themselves with the proper handling of fetuses algorithms, and should contact the Pediatric Pathology attending whenever necessary.

Medical Knowledge:

• Understanding the clinical significance of the diagnoses being made, including implications for the subsequent treatment and prognosis of the patient. Genetic implications are extremely important in pediatric disease.
• Understanding the basic principles of congenital/developmental diseases (malformations, deformations, sequences, field defects, dysmorphologic syndromes, pediatric cancer-predisposition syndromes, and the like), pediatric tumors, inborn errors of metabolism, pediatric age-related infections, placental pathology, and disorders related to twining and multiple gestations.

Practice-Based Learning and Improvement:

• Using online literature and online searching resources (such as Online Mendelian Inheritance in Man-OMIM) to identify recent advances in our understanding of the disease processes manifested in the cases

Interpersonal and Communication Skills:

• When indicated, contacting the surgeons and/or other members of the clinical team (particularly radiologists) and eliciting appropriate key information about the patient's medical history and specific questions to be addressed during evaluation of the specimen (e.g., imaging files in bone-related cases, etc.)
• Always be aware of the increased sensitivity that parents may have in regards to their children's diseases. This sometimes introduces a different level of anxiety, and information needs to be delivered to clinicians timely and efficiently. This approach should be kept at the level of individual communications with pediatric surgeons and all other pediatric specialists, as well as in interdepartmental conferences such as tumor board, and other sessions. The residents should not get in touch with family members of pediatric patients without previous consultation with the faculty member in charge of the case.

Systems-based Practice:

• Be aware and able to make adequate use of the multi-institutional consortia that collaborate gathering information and biological reagents such as the Children’s Oncology Group and its affiliates. This requires the ability to get and provide adequate information and sample collection, storage and submission to the specific centers involved. Special techniques such as karyotyping of tumors and other tissues, oncogene amplification (e.g. MYC-N), chromosomal translocation studies, and other analyses are examples.

Renal and Ultrastructural Pathology Rotation (AP-1)

Drs. Gilbert Moeckel and Jan Czyzyk

This integrated rotation incorporates the histopathology, ultrastructure, and immunofluorescence of a diverse spectrum of renal pathology, including transplant pathology. The resident learns all of the techniques relevant to this specialty. In addition, all other diagnostic electron microscopy performed for the institution is reviewed by the resident. This includes ultrastructural evaluation of tumors, peripheral nerve and muscle diseases, identification of virus, and evaluation of cilia. The goal of this rotation is to assure some exposure to the plethora of renal diseases and the role that ultrastructural studies play in diagnostic pathology.

Additional Goals and Objectives for the Renal/EM Rotation

Patient Care:

• Becoming proficient in the standard techniques for the submission of specimens for electron microscopy and immunofluorescence, paying particular attention to issues of diagnostic and prognostic significance
• Understanding the differences in processing of specimens for these special procedures
• Becoming proficient in immunofluorescence imaging
• Keeping cases moving along: preview slides, IF, and EM, and bring cases to signout in a timely fashion

Medical Knowledge:

• Demonstrating a knowledge of the contribution and utility of electron microscopy and immunofluorescence microscopy to surgical pathology diagnosis
• Demonstrating a knowledge of the indications for diagnostic electron microscopy and immunofluorescence microscopy
• Understanding the contribution of electron and immunofluorescence microscopy to resolving a differential diagnosis
• Demonstrate an understanding of cellular ultrastructure
• Demonstrate an understanding of normal histology of the kidney in biopsy specimens
• Demonstrate an understanding of the types of inflammatory changes involving glomeruli and interstitium
• Understanding the criteria for the diagnosis of acute and chronic rejection in renal transplantation
• Understanding the criteria for ultrastructural identification of viruses and other pathogens
• Understanding the contribution of ultrastructural features of tumors and other tissues to diagnosis

Thoracic/Genitourinary/Misc Surgical Pathology Rotation (AP-1 and AP-2)

Drs. Ken Haines, Rob Homer, and Faculty

This rotation/service includes all of the specimens from surgical specialties with insufficient volume to support an independent specialty service. This includes cardiothoracic pathology (including pulmonary pathology), genito-urinary pathology, ophthalmic pathology and non-neoplastic bone and soft tissue pathology.

Since the variety of specimens received on this service is broader than that of the other specialty services, a broader range of grossing skills needs to be acquired. This service must also adapt to the changing needs for ancillary evaluation of tissue, especially with pulmonary neoplasms. Since this service includes specimens from a variety of surgical subspecialties, in some cases it may be necessary for the resident to coordinate showing the case, and perhaps signing out the case, with a different pathologist than the one on service who may have specialty expertise in a pertinent area. The attending on service will make the determination as to when this is necessary.

Additional Resident Duties and Responsibilities

• As directed by the attending pathologist on service, seek consultation from other pathologists with subspecialty expertise pertinent to a particular specimen

Additional Goals and Objectives for the Rotation

Patient Care:

• Become proficient in the standard techniques for the gross evaluation, dictation, and dissection of specimens from:
  • GU: Prostate, Bladder, Kidney, Ureter, Testis
  • Pulmonary: Approaches to biopsy and resections of neoplasms; inflammatory lung pathology
  • Bone and Soft Tissue: Benign versus Sarcoma
  Emphasis is placed on issues of diagnostic and prognostic significance
• Understand commonly used techniques, including safe use of the band saw, inflation/dissection, seeds (radioactive), cytogenetics, electron microscopy

Medical Knowledge:

• The resident should demonstrate an appropriate level of understanding of the pathogenesis, clinical significance, treatment and prognostic factors of the major pathologic entities covered on the multi-specialty service

"Hot-Seat" General Surgical Pathology Rotation (AP-3)

The "Hot-Seat" rotation is one of the busiest rotations in surgical pathology, yet is one of the most popular. The senior resident/fellow on this rotation previews the vast majority of the cases that pass through surgical pathology before the slides go to the resident who grossed in the case. This affords the resident exposure to a vast array of surgical pathology, crossing all subspecialties.

In addition to rendering preliminary diagnoses on all cases, the Hot-Seat functions as a hub of communication between clinicians and residents/attendings. Hot-Seat should attempt to remain aware of the status of high priority cases, anticipate potential problems, and alert those involved to important issues. He/she may also use his/her judgment to facilitate the movement of cases through signout and transcription.

Another important role of the Hot Seat resident is to facilitate the interactions between the Department and clinicians from other departments. The Hot-Seat resident is responsible for troubleshooting cases for clinicians, showing cases to clinical teams, and generally being a collegial liaison on behalf of the department. As such, the Hot-Seat resident is expected to be available at the Hot-Seat desk at all times. In the Hot-Seat, one is an ambassador for the Department; professionalism must be demonstrated at all times.

Additional Resident Duties and Responsibilities

• Review the slides for all cases that come to the Hot-Seat, recording provisional diagnoses in the HS log. If appropriate, order necessary special stains to facilitate the handling of the case. Make notations for any stains you have ordered or any other information you become aware of through your contact with clinicians. Communicate any relevant information to the appropriate junior resident and/or signout team.
• If you come across a case which you feel needs immediate clinical action, act. DO NOT CALL PRELIMINARY DIAGNOSES TO CLINICIANS without first discussing the case with the attending, except in response to specific inquiries. When rendering a preliminary diagnosis, it is IMPERATIVE that the clinician understands that you are a resident and that the diagnosis is preliminary. Feel free to communicate your level of confidence, but remember that your diagnosis is still preliminary. Give the clinician some idea of when the signout attending pathologist will see the case and offer to call back with the final diagnosis. Use Post-Its or some other system of organization to make sure you can do this. Communicate to the signout team that the clinician/clinical team has inquired about the case, so the signout team may prioritize its review if indicated.
• Check for cases with mislabeled slides, missing slides, parts, or entire missing cases. It is your responsibility to assure that each case is optimally ready for signout or, if issues arise, that these issues are communicated to the signout team expeditiously.
• Biopsies should be read and in the residents' boxes by 8 AM. To facilitate this, you can work cooperatively in the morning with the GI, GYN and "general" residents, or begin earlier in the morning. (Biopsies are out the evening before at 10-11 PM; some Hot-Seat residents prefer to review the slides at night to avoid the morning rush.) Remember that the AP-1 and AP-2 residents are expected to have their biopsies ready for 9 AM signout.
• Late biopsies usually arrive after 9 AM. Read these and give them to the appropriate resident ASAP.
• In all cases, flag important cases (unsuspected malignancy, cases requiring immediate treatment) to the resident's attention, so that he/she can alert the attending and prioritize signout.
• Try not to bypass the resident on service in your enthusiasm to discuss cases with the attending, unless it is urgent. However, if, in your professional judgment, immediate review by an attending is necessary, please respond accordingly.
• After the AP-1 and AP-2 residents have signed out their cases with their attendings, they should report the diagnoses back to you. Record cases as "signed out" in the Hot-Seat log by noting the date to the left of the case number, amending your preliminary diagnosis as necessary. All residents should report every case final diagnoses back to you after signout; they should alert you as well to the status of cases pending so that you can function effectively in your communications with clinicians. This signout communication is MANDATORY and no exception is valid.
• In those cases in which you find a significant disagreement between your preliminary interpretation and the case final diagnosis, you are encouraged to discuss your discrepancy with the signout attending. This should be done in a respectful, non-confrontational manner, keeping in mind that the purpose of such discussion is not only educational, but also a reflection of your involvement in patient care. Not infrequently, the Hot Seat resident picks up on something which the attending may have missed.
• CALL FINAL DIAGNOSIS on cases where the final diagnosis shows an unexpected malignancy or a significant change in diagnosis from that made at the time of frozen section, unless the junior resident, fellow, or signout attending has already done so.
• The Hot-Seat resident is expected to remain at their "post" until at least 5:00 PM on weekdays, even if all slides have been reviewed. Hot-Seat is responsible for the organization of the "unknown" resident microscopic conference.

Additional Goals and Objectives for the Hot-Seat Rotation

Patient Care:

• Increase your confidence and your ability to diagnoses a wide variety of specimens.
• Make critical decisions regarding the workup of cases, ordering appropriate stains and ancillary tests, which may he crucial for the final diagnosis.
• Report critical results to clinicians on a timely fashion, when appropriate.

Medical Knowledge:

• Understand the key therapeutic consequences of the pathologic diagnosis and facilitate communication of diagnoses which require rapid treatment action.
• Become proficient in multiple areas of surgical pathology through the daily review of a large number of cases spanning many different subspecialties.

Interpersonal and Communication Skills:

• Learn to communicate effectively with clinical teams, providing preliminary diagnoses and following up on clinical issues.
• Learn to communicate effectively with staff members of the Department of Pathology, making sure that cases are complete and ready for signout.
• Learn to communicate effectively with colleagues and faculty members in the Department of Pathology, providing accurate and appropriate clinical information to signout teams, and discussing case workups and final diagnoses.

Frozen Section / Gross Room Rotation (AP-3)

Surgical Pathology Staff

Senior residents in their third year of anatomic pathology training participate in intraoperative clinical care by serving as the front-line contact for frozen section consultations. During this rotation, all frozen section intraoperative consultations are the primary responsibility of the frozen section resident. These are evaluated under the direct supervision of an attending surgical pathologist, who is assigned to the service on a daily rotational basis. The frozen section resident is the default on-call resident for all weeknights Monday through Thursday, just as the frozen section attending each day is the on-call attending that evening.

The frozen section resident is also the resident in charge of the gross room. The resident should remain available to assist junior residents grossing specimens with which they may be unfamiliar and provide guidance with special techniques. Junior residents who have questions about how best to handle a specimen should seek advice from the frozen section / gross room resident.

Additional Resident Duties and Responsibilities

• Keep your beeper on for 24-hour availability, from 7:30 AM Monday to 5 PM Friday.
• The frozen section coverage on the last day of the rotation is performed by the person finishing the frozen section month who is on call until 8:00 AM of the morning when the new frozen section resident starts.
• Obtain the OR schedule on the afternoon before a day of coverage, look up previous material, and pull relevant slides for cases likely to generate frozen sections.
• Arrive no later than 7:30 AM (ORs start at 7:00 AM) to be available for specimens/questions from the OR. Inform the staff that you are present and where you can be found.
• When specimens arrive for frozen section (FS), label containers with case number, examine tissue, select tissue to freeze and orient on chuck. Ask for assistance from the FS attending if you have any questions on how to process the specimen.
• Provide a written description of the specimen for the resident who will be responsible for the final prosection, including weight, size, etc., attached to protocol.
• Photograph interesting specimens before freezing, if sectioning will destroy the integrity of the specimen, and after sectioning, and ensure that the images are loaded into the ImageDrop folder for filing.
• Help technicians freeze, cut, and stain when appropriate.
• Look at slides immediately when ready (verifying case and part numbers, size of tissue and number of pieces).
• Review slides with the FS signout attending, providing relevant history and previous material when available (remember that prior material for GYN-ONC cases are often found in conference boxes, rather than in the slide files).
• Record diagnoses on the FS sheet precisely as communicated with the surgeon, call OR/surgeon with the diagnosis and stamp time on FS form when THE DIAGNOSIS IS COMMUNICATED; record on frozen sheet the number of tissue blocks frozen for diagnosis; consult with the signout to determine which of the frozen blocks should "count" for billing purposes.
• Photocopy diagnosis and separate the paperwork:
• original to originals box behind FS desk
• yellow and pink copies to residents' slide box
• xerox with yellow protocol sheet, description, original containers, frozen controls and original specimen in formalin on resident's FS shelf
• Before putting specimen in formalin, take fresh tissue as needed for special studies (e.g. DMSO for ploidy, glutaraldehyde for EM, adipose tissue for breast study, fresh tumor and normal tissue for the Yale Pathology Tissue Service). Be sure to accurately document what you have done for the grossing resident. If frozens are busy and you are unable to take care of this within a reasonable amount of time, alert the ultimate grossing resident who may be able to help.
• Make sure that grossing residents understand how specimens were handled at FS. For difficult cases, go over the specimen with the grossing resident at the time the frozen section is performed. Such communication is expected and essential for optimal patient care.
• If there is an AP-2 resident also rotating on the frozen section service, work with that resident to provide appropriate frozen section experience while retaining responsibility for smooth operation of the service. Although the AP-2 resident may cover the service alone during the AP-3's lunch or teaching/conference responsibility, the AP-3 resident should otherwise be present for all frozen sections. Difficult cases should be handled by the AP-3 resident.
• When not doing frozens, circulate in the gross room to supervise grossing residents, with particular attention to AP-1 residents. Help AP-1 residents triage cases on their shelf and review all specimens with them at the beginning of their rotations. Do not leave at the end of the day until you are comfortable that the grossing residents are in control of their specimens for the day.
• Retain good gross specimens on the conference shelf for use at future gross conferences.
• Supervise gross room technical staff to assure a clean, properly equipped working environment. This includes making sure that each cutting station is clean and appropriately stocked, that clean and sharp cutting instruments are readily available, that frozen section, band saw and photographic stations are clean and stocked, and that all shelved supplies are stocked.
• Be responsible for any rushes (kidney, heart, biopsy, etc.) that come out after 5:00 PM.

Additional Goals and Objectives for the Frozen Section / Gross Room Rotation

Patient Care:

• Become proficient in quickly and accurately evaluating a specimen received for intraoperative consultation, selecting sections appropriate to answer the surgeons questions.

Medical Knowledge:

• Understand the key decision points for surgery and how information obtained at frozen section can direct the source of the surgery.

Interpersonal and Communication Skills:

• Learn how to communicate diagnoses clearly and succinctly to surgeons, providing the information they need without providing more information than is appropriate for the material examined.
• Learn how to supervise junior residents in the gross room, providing them with needed assistance without simply assuming their duties.

Bridgeport Hospital Pathology Service

Dr. Young Choi, Chairman and Director of Laboratories
Dr. Vinita Parkash, Director of Surgical Pathology
Brian Jameson, Pathologist Assistant

The Pathology department at Bridgeport Hospital is staffed by the Department of Pathology at the Yale School of Medicine. Autopsies on Bridgeport Hospital patients are performed at Yale. Surgical pathology services are provided by on-site pathologists, one fellow, and one AP-3 level resident.

Bridgeport Hospital Rotation (AP-3)

Drs. Vinita Parkash, Paul Cohen, Liming Hao, Marguerite Pinto

The rotation in Bridgeport Hospital Pathology Department allows an opportunity for AP-3 residents to begin to function as a practicing pathologist in a community hospital setting. This includes taking an active role in case management, technician and pathologist assistant supervision, and clinical consultation by preparing and presenting cases at multiple clinical conferences.

The AP-3 resident will cover the biopsy service 1-2 days each week. The final report bears the name of the resident as co-signout pathologist and it is expected that the resident will produce a report for which they are willing to take such a responsibility. Sign out requires that the resident review the case in its entirety, order the appropriate stains in the computer, and write up the final diagnosis. Ideally, they should edit and correct the diagnosis in the computer. This activity should resemble sign-out in real practice and the resident is expected to do everything short of signing out the case. In most cases, the AP-3 resident should take a complete transcribed and corrected case for sign-out to the attending pathologist. In occasional cases, where additional stains may be necessary, the AP-3 resident should still have the entire case submitted for transcription but should consider a quick discussion with the attending to determine if the additional work-up being considered by the AP-3 resident is in line with the norm at the institution. Cases that have been signed out with the AP-3 resident will undergo a rapid signout with the attending. At least one day a week the senior resident will be responsible for signing out Frozen Section cases. The proposed method of functioning in this setting is that the senior resident discuss with the PA what sections they want taken and cut. They will read the slide and form an independent diagnosis and ought to be ready and willing to call in the report within 15 minutes of receipt of the frozen. The attending pathologist will then review the material with them and may choose to allow the resident to call in the frozen or call in the frozen section themselves. The volume of frozen sections is sufficiently low to allow the resident to independently preview the frozen section and form an opinion. They will perform a similar function for on site FNA adequacy evaluations. 1-2 days a week, the resident will sign large cases and will have similar responsibilities. The fellow will have a similar schedule, and they will share equally in their responsibilities.

Preparation and presentation of cases at conferences is also a high priority. This includes Tumor Board (every Friday), Pulmonary Conference (once a month), and GI Conference (every Tuesday). Preparation for these conferences requires review of all slides and gross pictures if available, taking microscopic pictures using digital camera, literature review if dealing with an unusual entity, and creating a PowerPoint presentation. Emphasis should be on relevant clinicopathologic issues pertinent to patient management rather than pure histologic criteria, keeping in mind that the target audience consists of clinicians and residents from several specialties as well as nursing, medical, and PA students. The designated pathologist will provide back up and answer the more complex questions that may arise at the meeting.

The AP-3 resident will be required to choose one article of interest in a current pathology journal and present that article at a journal club. A second article will be presented by the fellow.

The resident will be given an intake examination of up to 10 slides covering various areas of pathology to determine their level of knowledge and to identify any areas of weakness that we might help address during this rotation. A similar examination will be given at the end of the rotation, so that the resident may objectively evaluate their performance and identify areas that they need to focus on in subsequent rotations.

Additional Resident Duties and Responsibilities

• Residents will be expected to be in the department by 8AM except when the resident is attending a grand rounds speaker conference at YNHH. Some clinical conferences at Bridgeport Hospital occur at 7:00 AM, and residents are required to attend these conferences (for example, the biweekly GYN Tumor Board). On frozen section days, the resident is expected to be on site by 7:30 AM.
• Residents will perform all frozen sections on their assigned day, under supervision of a pathologist.
• Residents may be required to assist in the cutting schedule in extremely rare circumstances. In the event this happened, the resident will complete these cases through to signout.
• Residents will attend all conferences at Bridgeport hospital which have pathology participation.
• Residents will signout additional biopsies, cytology, and outreach cases as assigned to them.

Additional Goals and Objectives for the Bridgeport AP-3 Rotation

Patient Care:

• Becoming proficient in the standard techniques for the gross evaluation, dictation, and dissection of a wide variety of specimens received in a large community Hospital, paying particular attention to issue of diagnostic and prognostic significance

Interpersonal and Communication Skills:

• Enhancing skills in writing concise, accurate reports in Anatomic Pathology
• Developing skills in communicating with community physicians while seeking additional clinical information, explaining the diagnosis, and answering other clinical questions that the physicians may have
• Enhancing and developing communication and presentation skills while preparing for tumor board and other multidisciplinary conferences

Professionalism:

• Learning to interact with a small, tightly knit group of PA/PA students, histotechnologists, technicians, pathologists, and other clinicians in a professional and collegial manner

Systems-based Practice:

• Understanding the differences between the practice models for anatomic pathology in academic and community hospital settings

Veteran’s Administration Connecticut Medical Center

Dr. Gary Stack, Director of Pathology and Laboratory Medicine, VA Connecticut Healthcare System
Dr. Robert Homer, Director of Anatomic Pathology
Dr. Sheldon Campbell, Director of Laboratories

The Pathology department at the West Haven campus of the Veterans Administration Connecticut Healthcare System is staffed, in part, by members of Yale’s Departments of Pathology and Laboratory Medicine. Residents rotate in both Anatomic and Clinical Pathology rotations at the VA.

Frozen section coverage is provided primarily by the signout Pathologist, thus allowing the residents flexibility in their time commitment. Autopsy coverage is provided by the residents on the autopsy service at YNHH. Off hours laboratory medicine issues are handled by the Yale CP resident on-call. Familiarity with the VA system is necessary from the beginning of the academic year for all residents and fellows taking call.

Veteran’s Administration Connecticut Healthcare System (AP-1)

Drs. Robert Homer, Nelafar Shafi, Antonio Galvao Neto, and Susan Gobel

The rotation at the West Haven campus of the VA Connecticut Healthcare System allows the resident to function in an environment where the clinical material and the problems that challenge the Pathologist are different from those encountered at YNHH. Because the team of residents is small, exchange among the housestaff and contact with the signouts is enhanced.

The VA has its own hospital-wide computer system, and residents are expected to become familiar with its use. One major feature of the VA is the availability of a complete electronic medical record which allows comprehensive clinical and laboratory correlation with all diagnostic specimens. The VA is a major site for the pathologist assistant program so that ability to learn to work with PAÕs early in each of the residents/PA training is a feature of the rotation.

Additional Resident Duties and Responsibilities

• Residents will be expected to be on-site at the VA at least five hours each day they are assigned to that rotation
• Residents will preview all slides on surgical and cytology cases and sign them out with a pathologist.

Additional Goals and Objectives for the VA AP-1 Rotation

Patient Care:

• Becoming proficient in supervising pathology assistant students in the standard techniques for the gross evaluation, dictation, and dissection of resection specimens, paying particular attention to issue of diagnostic and prognostic significance
• Looking up, prior to signout, relevant history on CPRS electronic medical record
• Taking responsibility in assisting with obtaining consultations from affiliated academic institutions

Interpersonal and Communication Skills:

• Attending GI, GU Hematopathology and General Tumor Boards and being able to discuss the key features of their cases