Rotations in Anatomic Pathology are based on three major services within the Department of Pathology at Yale-New Haven Hospital (Autopsy, Cytology, Surgical Pathology), supplemented by exposure to anatomic pathology practice in two different settings (Bridgeport Hospital and the Veterans Administration Medical Center).

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

Additional Goals and Objectives for the Autopsy AP-1 Rotation

Patient Care:
Medical Knowledge:
Practice-based Learning and Improvement:
Interpersonal and Communication Skills:
Professionalism:
Systems-based Practice:

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

Additional Goals and Objectives for the Autopsy Senior Rotation

Patient Care:
Practice-Based Learning and Improvement:
Interpersonal and Communication Skills:

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

Additional Goals and Objectives for the Forensic Pathology Rotation

Patient Care:
Medical Knowledge:
Interpersonal and Communication Skills:
Professionalism:
Systems-based Practice:

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:

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

Additional Goals and Objectives for the Cytology Rotation

Patient Care:
Medical Knowledge:

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:

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

Additional Goals and Objectives for the Rotation

Medical Knowledge:

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

Additional Goals and Objectives for the Breast Rotation

Patient Care:
Medical Knowledge:

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

Additional Goals and Objectives for the Dermatopathology Rotation

Patient Care:
Medical Knowledge:

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

Drs. Manju Prasad, Diane Kowalski, Constantine Theoharis, Adebowale Adeniran

During this rotation, the resident is exposed to the interpretation of endocrine lesions, predominantly thyroid and parathyroid, but also adrenal gland lesion. YNHH has one of the most active endocrine surgery services in the country, so a large variety of lesions are encountered. In addition, lesions of the head and neck, including the sinuses, major salivary glands, oropharynx, and larynx are examined as part of this rotation. Numerous opportunities will be available for correlation with cytologic features revealed in prior fine needle aspirations.

Additional Resident Duties and Responsibilities

Additional Goals and Objectives for the Dermatopathology Rotation

Patient Care:
Medical Knowledge:

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

Drs. Marie Robert, Dhanpat Jain, Zenta Walther, Liming Hao, Kisha Mitchell, and Brian West

During this rotation, the resident is exposed to the interpretation of gastrointestinal and liver pathology and has an opportunity to examine a wide range of biopsy and resection specimens. Emphasis is placed on correlating the clinical findings and endoscopic appearance of the lesion with the histopathology. The importance of a good working relationship and excellent communication with clinicians is vital to giving good patient care on this service.

In addition, residents are encouraged to participate in on-going clinical research with the faculty and to start their own projects under the guidance of faculty. The GI service offers a series of didactic and case based conferences throughout the year, which cover a broad range of aspects of GI and liver diseases. Residents may also participate in the GI Journal Club, which meets on a monthly basis.

Additional Resident Duties and Responsibilities

Additional Goals and Objectives for the Gastrointestinal Pathology Rotation

Patient Care:
Medical Knowledge:

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

Additional Goals and Objectives for the Gynecologic Pathology Rotation

Patient Care:
Medical Knowledge:

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

Additional Goals and Objectives for the Hematopathology Rotation

Patient Care:
Medical Knowledge:

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

Additional Goals and Objectives for the Autopsy/Molecular Rotation

Patient Care:
Practice-based Learning and Improvement:

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

Additional Goals and Objectives for the Neuropathology Rotation

Patient Care:
Medical Knowledge:

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

Additional Goals and Objectives for the Ophthalmic Pathology Rotation

Patient Care:
Medical Knowledge:
Interpersonal and Communication Skills:

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

Additional Goals and Objectives for the Pediatric Pathology Rotation

Patient Care:
Medical Knowledge:
Practice-Based Learning and Improvement:
Interpersonal and Communication Skills:
Systems-based Practice:

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:
Medical Knowledge:

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

Additional Goals and Objectives for the Rotation

Patient Care:
Medical Knowledge:

"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

Additional Goals and Objectives for the Hot-Seat Rotation

Patient Care:
Medical Knowledge:
Interpersonal and Communication Skills:

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

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

Patient Care:
Medical Knowledge:
Interpersonal and Communication Skills:

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

Additional Goals and Objectives for the Bridgeport AP-3 Rotation

Patient Care:
Interpersonal and Communication Skills:
Professionalism:
Systems-based Practice:

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

Additional Goals and Objectives for the VA AP-1 Rotation

Patient Care:
Interpersonal and Communication Skills: