Residency training is a mutual commitment between the trainee and the faculty. As such, the resident is expected to approach this relationship with an understanding that they will adhere to policies of the Program, the Departments, and the Institution. The Yale-New Haven Medical Center has a variety of policies related to Graduate Medical Education that apply across all residency programs. The graduate medical education office is updating its web site and these will all be available for download on-line. Some of the Program policies are listed below. Additional policies can be found in the complete Resident Manual.
Pathology residents at Yale must demonstrate a commitment to professional responsibilities and adhere to strict ethical principles throughout their training. Although individual patient contact is less common in pathology than other medical disciplines, residents must be prepared to communicate in a sensitive manner to a diverse patient population. Additionally, residents must be able to communicate and work effectively with team members and other professional associates. Residents are expected to demonstrate respect, integrity, and collegiality when dealing with surgeons, referring physicians, faculty and ancillary healthcare professionals. Patient confidentiality is of the utmost importance, and residents must ensure that they do not leave confidential material (slides, reports, etc.) in public areas, such as conference rooms. Commitment to on-going professional development is stressed at every level of the program, and residents are encouraged to explore and expand their individual goals without sacrificing excellent patient care.
Each of the individual rotations carries with it specific responsibilities and expectations. However, there are a number of general and administrative responsibilities which apply across ALL of the rotations, and to which residents are expected to adhere throughout their training. These include:
Acquisition of technical skills and knowledge are primary focuses of the first year of anatomic pathology training. Responsibilities and goals include:
Residents in their second year of anatomic pathology training are expected to show greater diagnostic proficiency and a broader fund of knowledge than the AP-1 residents. In addition, they should be more adept technically, and at managing their time. Responsibilities include all those for the AP-1 rotations, plus the following:
Senior residents in anatomic pathology have an implicit responsibility for the supervision, assistance, and training of the junior residents. This is not only an important part of your educational experience, but also builds camaraderie within the program. Junior residents will be asked to evaluate how successfully the senior residents fulfill this responsibility.
Senior residents should also voluntarily "step-to-the-plate" to address issues that may arise in the daily clinical care of patients independent of which service they are on. Inquiries by clinicians from other departments should be addressed, investigated, and if necessary referred to the appropriate attending staff. Senior residents are expected to be able to represent the department and its policies to individuals in other departments.
First year residents in clinical pathology focus on learning the details of laboratory diagnostics, including the capabilities and limitations of each laboratory test. Learning appropriate interpretation and utilization of the tests is accomplished through direct clinical consultation. Responsibilities and goals include:
In their second year of clinical pathology training, residents take on greater supervisory and decision making responsibilities in each of the laboratories. Responsibilities include all those for CP-1 rotations, plus:
In addition to their other duties and responsibilities as appropriate for their level of training, individuals selected to serve as the Chief Resident(s) in Anatomic or Clinical Pathology have additional duties.
The Accreditation Council for Graduate Medical Education has defined six areas of competency in which all residents are to be trained and evaluated. These goals and objectives of each of the rotations are based on these competency areas. The areas are listed below, with a number of competencies that are COMMON TO ALL rotations. Additional goals and objectives specific to particular rotations are listed with those rotation descriptions.
Residents must demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation in the context of pathology services. This includes:
Residents must demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and application of this knowledge to pathology. This includes:
Residents must be able to demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence and improve their patient care practices. This includes:
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with other health care providers, patient, and patient's families. This includes:
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. This includes:
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value. Pathologists occupy a unique position within health care delivery. Free from the day-to-day details of direct patient care delivery, pathologists have the opportunity and obligation to analyze and explore human disease. Residents must acquire the ability to assume this role by learning to:
The faculty will evaluate the residents on a monthly basis. This process is crucial for monitoring the resident's progress through their training, and identifying issues which need to be addressed in a timely fashion. The faculty member(s) with whom the resident worked will complete a written or on-line evaluation of the resident's performance and should discuss the resident's performance with him/her at the end of each rotation. The evaluations are based on the goals and objectives of each rotation in each of the competency areas. Residents are provided with a template of the evaluation form, so that performance expectations are fully communicated and understood.
Ancillary support staff will also perform evaluations of each house officer every six months. These multi-source evaluations focus primarily on interpersonal communications and ability to work productively with ancillary staff to maximize patient care.
All senior residents have an implicit supervisory role over the junior residents. As such, senior residents will be asked, during discussion with the Program Director, to comment on the performance of the junior residents with whom they have interacted. Likewise, junior residents will be asked to comment on the performance of their senior residents in providing them with the appropriate level of guidance and training.
Intermittently throughout the year, resident performance will be discussed at departmental attending faculty meetings. This affords an opportunity for attendings to share differing experiences that they may have had with each of the residents.
The vast majority of the evaluations are performed electronically using the E*value system. Residents are notified electronically when evaluations are completed on them, and are encouraged to review their evaluations as soon as possible for the most timely feedback. Written summaries of these evaluations are kept in the residents' files maintained by the Residency Coordinator. Residents are allowed to view their file, but files may not be removed from the Residency Coordinator's office and must be reviewed while the Residency Coordinator is in the room. The resident may not make copies of his/her file.
The Director or an Associate Director of the Program reviews all forms of evaluation and meets with each resident on an individual basis every six months to share this information, offer guidance, and seek feedback. A summation of this meeting is produced and is cosigned by the Director and resident.
Each month, the residents are asked to complete an electronic rotation evaluation form and faculty evaluations form(s). This is an anonymous evaluation. Aggregate evaluations of faculty and rotations are prepared approximately every six months and shared with the individual faculty, the rotation directors, and the senior leadership of the departments.
Any resident not performing in a satisfactory manner may be placed on academic remediation. Performance will be considered substandard based on the evaluations received and/or the consensus of the faculty. While on academic remediation, the resident typically does not earn credit for rotations. Also, while on academic remediation, the resident may not participate in away electives. The resident will meet with the Director on a monthly basis to determine if adequate progress is being made and when the resident should be removed from academic remediation status. Residents who consistently (four months or longer) fail to perform at an appropriate level may be subject to dismissal from the Residency Program. All decisions relating to this process are vetted with the institutional GME office.
Residents will be promoted to higher levels of responsibility based on their accomplishments and achievements during the prior year. Simply putting in the time is not sufficient to assure either credit for the year toward Board Certification or advancement to the next year of training. Promotion is based on faculty consensus: the Program Director meets with the clinical faculty each June to discuss resident promotions. However, the ultimate decision lies with the Program Director. Criteria for promotion include:
To achieve an appropriate level of competency during their training, residents must be actively involved in the procedures and interpretations that are part of the care of real patients. However, this involvement must be under an appropriate level of supervision so as not to compromise patient care, and that supervision should be graded to the level of training of the resident. All residents must be aware of their individual limitations and not attempt to provide clinical services or do procedures for which they are not trained and certified to do without supervision, except in instances of extreme urgency where such action may be life-saving.
The ACGME defines four levels of supervision for trainees:
The Pathology Review Committee of the ACGME further goes on to indicate that PGY-1 residents must be directly supervised during performance of, at least, his or her three initial procedures in the following areas: autopsies, gross dissection of surgical pathology specimens by organ system, frozen sections, apheresis, and fine needle aspirations. The Pathology RC also indicates that supervision can be provided by an attending pathologist, senior resident or fellow, or pathology assistant.
The Program has created a number of forms for PGY-1 residents to document their supervision in each of these areas. These are available on the Program's web site. It is the responsibility of each resident to adhere to these restrictions, obtain the proper supervision, and document that supervision on the appropriate forms. These forms should then be provided to the Program Coordinator for inclusion in the resident's file.
Pathology residents at any level of training may, without prior certification, provide preliminary interpretations of pathologic or physiologic tests or data, but any communication of these interpretations to other clinicians or caregivers must clearly identify the interpretation as preliminary and therefore not actionable, and all interpretations must be individually reviewed by an attending pathologist before they are deemed final. Residents may address questions about appropriate usage or interpretation of routine tests and/or special procedures as they feel is supported by their knowledge base, but should clearly identify themselves as a resident and seek appropriate senior resident, fellow, or attending input as needed.
Residents may perform postmortem examinations and dissections only after having seen the procedures demonstrated by a trained technician, senior resident, or attending pathologist, and after being directly supervised in the performance of three cases. If, in the performance of a postmortem examination, findings are uncovered which suggest that the death may have been non-natural, the resident should cease the procedure and contact the attending pathologist for further instructions.
Residents in their first year of anatomic pathology training (AP-1) may not order special procedures (immunostains, molecular pathology) during their first six months of training without first discussing this with a senior resident, fellow, or an attending pathologist.
Residents may perform gross examination and dissection of surgically removed specimens only after having had the appropriate dissection techniques for that type of specimen demonstrated to them by a trained technician, senior resident, or attending pathologist, or after having read dissection instructions specific for that type of specimen in the department's grossing manual, and after having been directly supervised in the dissection of three specimens from that organ system. Specific questions should be addressed to a pathologist assistant in the gross room or an attending pathologist.
Residents may perform fine needle aspirations only under the direct supervision of an attending pathologist or the cytology fellow, and only after having observed this procedure. A fellow may act as a supervisor only after that fellow has successfully performed a minimum of five such procedures under direct attending supervision, and has been deemed competent for a supervisory role by the attending cytopathology staff.
Residents may perform bone marrow aspirations and/or biopsy only under the direct supervision of an attending pathologist or the senior hematology fellow and only after they have observed two such procedures.
Residents may supervise apheresis procedures only under the supervision of the blood bank fellow or an attending pathologist.
Residents on overnight coverage should follow all service-specific policies concerning when to contact the on-call pathologist for any patient-care matter. In the absence of a specific policy to the contrary, the resident should contact the appropriate on-all pathologist for ALL patient care matters. All diagnostic procedures performed and evaluated during such call periods are to be reviewed by the attending prior to a definitive diagnosis being rendered.
If questions arise concerning the level of prior experience needed for a particular procedure/interpretation, contact the chief resident, Residency Program Director, one of the Associate Program Directors, or the director of the service for which the procedure/interpretation is being performed.
Duty hours are defined as clinical and academic activities related to the residency program, including patient care, administrative duties related to patient care, time spent in-house during off-hours coverage, and scheduled activities such as conferences. Duty hours do NOT include time reading/studying (regardless of where this is done) or work done away from the duty site.
Per ACGME regulations, duty hours are limited to 80 hours per week, averaged over a four-week period. Since pathology residents do not take in-house overnight call, this is rarely a problem. In addition, residents must have one day in seven free from all required responsibilities, again averaged over a 4-week period. (Therefore, if a resident on weekend coverage has to come in to work on both Saturday and Sunday, but is only covering every other weekend, that does not constitute a violation of the one-day-in-seven off policy.) Finally, residents should routinely get a 10-hour period (and "must" get 8 hours) away from work between non-call obligations. Duty periods for PGY-1 residents are not to exceed 16 hours. See also the section on Laboratory Medicine Overnight Coverage for additional information.
All residents MUST record and document their duty hours. This is important not only for monitoring compliance with the duty hours policy but also to satisfy mandatory reporting requirements to the Center for Medicare and Medicaid Services. Currently, duty hours documentation is done using a paper form (Duty Hours and Handoff Form) available on the department's web site. One form is used for each rotation. The resident starts a new form at the beginning of the rotation, completes the handoff-evaluation portion, and then records duty hours throughout the rotation. At the completion of the rotation, the form should be turned in to the Program Coordinator. At some point during the 2011-2012 academic year, the Hospital is likely to switch to an on-line documentation system, at which point all residents in all programs will be required to use this system.
Any routine "violations" of the duty hours limits set by the ACGME should be reported to the Program Director for review.
Handoffs are defined as transitions of care, when responsibility for care of a patient is transferred from one healthcare provider to another. While handoffs are an inevitable part of any training program where residents rotate from one service to another, patient care must not be compromised during such transitions. In pathology, potential handoffs occur when responsibility for an anatomic pathology specimen transfers from one resident to another, or the laboratory workup of a complex patient transfers from one resident to another.
Following consultation with the faculty as a whole, the senior leadership of the Program met to develop methods of minimizing the impact handoffs within the program. Rotations are designed in multi-week blocks (typically four), where possible, to minimize handoffs. Autopsy cases are not handed off; responsibility for the case remains with the resident who performed the autopsy. For surgical pathology and cytology cases, transfers primarily occur when one resident is rotating off a service and another is rotating on, but can also occur when a case is transferred from one subspecialty service to another. Residents may elect to follow through on their cases until signed out, depending on the demands of the service onto which they are rotating. If they do elect to handoff incomplete cases, it is not sufficient to simply hand over the slides. The process is: a) print out (from CoPath) a list of all of your active cases (unless only one case is being transferred), b) organize the cases, c) sit with the incoming resident (or a fellow or attending if there is no incoming resident) and go through each case, discussing the status of the case, particularly any pending studies, and handing over any paperwork / slides for the cases, and d) identify which attending (outgoing or incoming) will be responsible for the case.
In Laboratory Medicine, patients undergoing complex laboratory workups can be transitioned at the end of the rotation by a verbal handoff that identifies key aspects of the workup, including: a) patient names and identifiers, b) clinical context, including any pertinent diagnoses, specific laboratories that have been involved in the management of the patients, and clinicians/clinical teams who are involved in the care of the patient, c) laboratory studies that have been performed prior to the transition, and d) pending studies and issues that are likely to require follow up. Handoffs following weekend coverage are formalized as a Monday Morning Report to include printouts of laboratory consults encountered by the laboratory medicine resident throughout the weekend, as well as discussion among residents of the clinical context of each consult, laboratory involvement in the care of the patient, results of the consult, and any issues that may require follow up by the resident covering the pertinent laboratory service. Handoffs after a single night of coverage occur on a one-on-one basis in which the covering resident verbally signs out consults to the resident covering the pertinent laboratory service.
The ACGME also requires us to monitor the effectiveness of the handoff of cases. The effectiveness is best assessed by the person receiving the cases - did any issues arise for which they were not prepared because they did not know the status of a case? Monitoring the mechanism and effectiveness of handoffs is done using the Duty Hours and Handoff Tracking Form. The resident receiving cases should complete this portion of the form when starting a new rotation, and then continue to record their duty hours on the form. Specific problems with handoffs should also be reported verbally or by email to the Program Director or an Associate Program Director. Additionally, to monitor the effectiveness of post-weekend handoffs, during the first three nights and first weekend of coverage by incoming CP-1 residents, backup is provided by a CP-2 resident in the event of a challenging consult, and to monitor the effectiveness of the CP-1 resident at handling consults. Evaluations of the CP-1 resident will be completed by the backup CP-2 resident to ensure the CP-1 residents understand their duties and responsibilities during these coverage periods, and they show they can effectively hand off pertinent consults.
Evening and holiday call is from 5:00 PM until 8:00 AM and weekend call is 24 hours a day, from 5:00 PM Friday until 8:00 AM Monday. All evening call in anatomic and clinical pathology is at-home call by beeper. Residents or fellows on call must be reachable either at home or by assigned beeper at all times. It is not necessary for the resident to remain in the hospital all night when they are on call. However, residents assigned to cover some services on weekends are expected to be in-house during certain hours and to come into the hospital whenever an issue requires on-site attention. Any time spent in the hospital should be recorded on the Duty Hours and Handoff Tracking Form.
All on-call residents are expected to verify that their pagers are working by paging themselves. It is also the responsibility of the on-call residents to assure that they are properly trained in any on-call responsibilities BEFORE their first day/evening of call.
Residents on-call are expected to know who the attending(s) on-call is/are, and how to reach him/her.
During the last week of each month, the page operator will be provided with a call schedule for the following month including beeper numbers and home phone numbers. It is important that any changes in call be arranged prior to this time so that an accurate schedule can be provided.
The details of resident responsibilities when covering services off-hours are listed below:
Two residents, typically AP-1 residents, are scheduled to cover the autopsy service each weekend. They cover autopsies performed at Yale-New Haven Hospital (includes both YNHH autopsies and Bridgeport Hospital autopsies) and at the VA Connecticut Healthcare System's West Haven campus. Prior to the weekend, the covering resident should contact both the attending on-call for surgical pathology and the attending(s) on call for autopsies and reach an understanding as to how events over the weekend should be handled.
The "first call" resident is responsible for the first case EACH DAY. The "second call" resident is called in only if there is more than one case on a given day. Subsequent cases are assigned alternately to the two residents. Residents are not assigned to cover the autopsy service more than two weekends a month to assure that they have the one day in seven, averaged over the month, free from service obligations.
Residents are expected to be available to be in at work by 9:30 AM when they are covering the service. Residents should call the morgue shortly after 9:00 AM to see if there are any cases and to verify with morgue staff how they can be reached. If there is no case going on early in the morning, assigned covering residents are expected to remain available to arrive expeditiously at the hospital until 2:00 PM that afternoon. Cases for which all of the necessary paperwork is not available by 2:00 PM are routinely held over until the next day. However, in rare instances, an autopsy may need to be performed even after this "cut-off" time. The attending on call or the Director of the autopsy service will make this decision.
On a rotating basis, AP-1 and AP-2 residents serve as the "weekend cutter". Some of the surgeries on Friday run late, past the time of the last specimen delivery to pathology. These specimens are brought to pathology on Saturday morning. Additional specimens from Saturday surgeries may also arrive on Saturday. Finally, specimens may be dropped off from physician offices on Saturday morning. These specimens cannot be allowed to simply sit around until Monday. The same rules apply for holidays. The weekend cutter is responsible for taking care of these cases.
The weekend cutter is responsible for fully grossing in all of these specimens, to the extent to which they do not require extended fixation. In the vast majority of cases, these specimens will all be accessioned before 8AM, but may include an occasional Saturday morning case. The weekend cutter should be in by 8AM and gross specimens as long as is needed to complete the work. If they complete the grossing before the 12 noon cut-off time, they should call the OR to make sure there are no cases about to send down specimens for cutting. If there are none, the weekend cutter can leave as early as 11AM, but not earlier. It is not necessary to remain around past 12:00 noon on the "outside" chance that something else might show up.
One of the histotechnologists in from 7-11 AM will be assigned to wait until the weekend cutter finishes grossing in the specimens received before noon, and will take responsibility for loading those cassettes on the processor. On many occasions, this may all be completed by 11AM, so no additional time will be needed. However, there will typically be the need for this person to stay until about 12 or even 1 when the resident finishes cutting. As a courtesy, the weekend cutter should be conscious of the fact that they are keeping someone from going home. The weekend cutter should cut continuously until the cutting is complete, and not wander off for lunch with the plan to come back and finish later, all the while keeping the histotech from going home.
Any specimens which arrive after 12 noon or which arrive after the weekend cutter has appropriately discharged his/her duties and has left become the responsibility of the senior on call resident. This responsibility involves "stabilizing" the specimen (placing in formalin, perhaps pinning out) but not fully grossing in the specimen unless there is a medical indication which requires special handling.
On official YNHH holidays, the clinics, physician offices, and ORs are closed, so there is no regular specimen drop-off. Also, on those days, no histology staff is available to accession the cases or load the cassettes into the processor. Therefore, if the holiday day is contiguous with a weekend, the resident on weekend cutter duty will only have to come in on the Saturday, not the contiguous holiday.
The AP-3 resident on the frozen section rotation is automatically the resident on call Monday through Thursday evening. The on-call resident should check with the operating room before going home to see if there are any surgeries still in progress which may require a frozen section. Any rush biopsies which come out after 5:00 PM, or other pending clinical issues, are also the responsibility of the resident/fellow on-call.
Any emergency specimens or other "new" specimens which arrive after hours MUST be accessioned into CoPath before they are processed. The CAP specifically requires that all specimens must be given a unique accession number when received in the lab. Failure to do so could result in the tissue or slides being later associated with the wrong case.
Weekend call begins at 5:00 PM on Friday and continues until 8:00 AM Monday. After 5:00 PM Friday, all on-going and add-on surgery cases, rush biopsies, or other pending clinical issues are the responsibility of the on-call resident or fellow, recognizing there may be professional-based reasons for patient care issues in which it is appropriate for the day frozen section resident to continue a case past 5:00 pm.
On Friday afternoon, the on-call resident/fellow should contact the AP-1 on-call residents for autopsy, the attending(s) for autopsy (to determine whether or not they want to be called for every case), the Saturday grossing resident (who might need supervision), and the on-call attending for surgical pathology (beeper number, home phone number, type of cases for which he should be called). The on-call resident/fellow should also determine who the histotechnologist on call is and how they can be reached. If there have been any changes in the posted monthly on-call schedule, contact the hospital page operator (203 688-3111) to be sure they know you are on-call and have your correct beeper number.
On Saturday, the person on-call is expected to cover the Hot-Seat phone from 9:00 AM until 1:00 PM, during which time all biopsies from the previous day should be read and necessary phone calls made.
On both Saturday and Sunday, the person on-call should be available, as needed, to provide advice and/or technical assistance to the residents on-call for autopsies. This includes autopsies at the VA hospital. Call the morgue at approximately 9:15 AM each day to check on the status of that service.
As with late specimens which arrive late on weekdays, any emergency specimens or other "new" specimens which arrive on weekends MUST be accessioned into CoPath before they are processed.
On Monday morning, any case related issues from the weekend have to be followed up or appropriately transferred to another resident/fellow. If current service duties permit, the on-call person should attend the presentation of weekend autopsy cases. Otherwise, contact the AP-3 resident on the autopsy service and discuss any pertinent issues with them so that they can properly follow up on the case.
Residents are strongly encouraged to develop their skills as a CP consultant and thus have certain responsibilities besides the laboratory rotations. The most important of these is handling general evening and weekend issues for all of the laboratories and blood bank, which is rotated among all residents currently on CP rotations. This results in coverage approximately one night each 7-9 weekdays, and approximately one weekend each month. The covering resident is responsible for emergency consultations and problem-solving for all of the labs at Yale, the VA Hospital, and the Shoreline Medical Center from 5 PM to 8 AM on weekdays and from 5 PM on Friday to 8 AM on Monday during weekends. This usually entails staying in the laboratories until 6-7PM on weekdays or from about 8 AM to 3 PM on weekends, after which coverage of the laboratories is accomplished from home. Nearly all problems are handled by telephone, but we encourage, if applicable, our residents be visible on the wards to facilitate their training and their comfort level as consultants. Backup is available at all times from the chief resident, laboratory medicine fellows, and the laboratory medical directors, as well as initially from an assigned CP-2 resident (as described above).
A pool of on-call pagers is located in the resident room in laboratory medicine. It is the responsibility of the covering resident to acquire one of these pagers and have it on at all times during the period when they are covering the clinical laboratories. You must also carry your own personal beeper (the one assigned to you at the beginning of the year). The reason for this is that if the coverage beeper malfunctions or is lost, an alternate means exists for someone to get in touch with you. The program has provided a coverage laptop with complete system access so that all information may be obtained while offsite in a HIPAA compliant mode.
Between 5 - 6 PM, all of the residents in the core lab rotations should contact the covering resident to signout any active or problematic cases. This is particularly true for the Blood Bank and VA rotations, which often have patients that require attention after the regular work day has ended.
After covering the laboratories during the evening/night period, if there are any active cases remaining, it is your responsibility to sign them out to the resident covering that laboratory during the regular work day. This is normally done between 8:00-8:30 AM, prior to the morning's didactic session. In the event that evening/night coverage was very taxing and did not allow the resident an appropriate period of rest and reasonable personal time, especially if the resident was required to return to the hospital for a significant time as part of a consult, that resident is excused from their clinical responsibilities during the following work day, or they can elect to have their schedule adjusted (late arrival, early dismissal, etc.) such that they are able to achieve an appropriate rest period. This will be expedited by the chief resident who will communicate to the appropriate labs and to the Associate Program Director, Dr. Rinder. However, sign-out of cases is expected to occur after every evening/night coverage period, regardless of whether that resident is excused from their other work duties. Following weekend coverage, the resident is responsible for presenting cases at the Monday Morning Report.