Welcome to New Haven and Yale Pathology! We want this to be a practical guide for a general understanding of the program and New Haven from a resident's perspective. It is based on discussion with many residents, and was put together largely by Tiffani Milless and Naomi Yoo. Photography was by Jarek Jedrych.
Most common route throught the program: AP first two years, CP third year, AP/CP split fourth year for the combined program.
Sinard (residency director), Haines (associate residency director), and Rinder (associate residency director) are your main go-to people for your progress through residency and you meet with one of them every half-year. They guide in updating your CV, what to think about for the next step. Template and other organizational forms provided on the residency web-page under forms and downloads. They are also very useful when it comes time to apply for fellowships because they can give advice, help with your CV, and aid in the application process or link you to someone else who can.
Morning conferences are at 8 AM every morning, except Fridays when you can sleep in a half hour longer or go to the Friday morning dermpath lecture at 7:30 before conference. There is usually an unknowns session with Haines and autopsy conference with Sinard once a week each. Fridays are usually resident-given conferences (you give two your first year and one and a half your second year). Sign-out starts after conference (generally around 9 AM) and typically lasts until lunch time (but is variable depending on what service you're on). This is the time for you to present your cases to the attending and discuss what you thought and figure out any ancillary tests that are needed. Grossing generally takes place in the afternoon. There are four wonderful PA's who help out and specimens can come in until 5 PM. There is sometimes sign-out for biopsies in the afternoon (rotation and attending specific). Previewing takes place in the evenings and you start it all over the next day.
For nights, there is a general hospital resident lounge down the hall from surg path with a fridge that has free sandwiches (not gourmet, but free and is dinner), sodas, and a Keurig coffee machine with K-cups (variably stocked).
Two first-year residents and one senior resident are on the autopsy service at any given time (with a few exceptions). This is the time for first-years to take vacation, so if that occurs then there is just one first-year resident. When a new case comes, it will be alternatively assigned to each of the new first years. Your autopsy senior is there to help you through what to do. Autopsies average about 250 per year.
(Note: You can get Copath from home, so you can work on your reports from the comfort of your couch.)
Heavier service. Keri (PA) will be your savior in the gross room and teaches you how to gross breast and can find any lesion that actually exists. There is a lot of organization involved. Before starting sign-out, try to put slides in order (will have keratin stains with the sentinel lymph nodes, pull previous biopsies, and print out diagrams from grossing.)
You get lumpectomies and mastectomies. (You'll get to know some of the surgeons' characteristics. Grube gives large margins, Lanin gives tiny ones.)
With Tavassoli here, we use the DIN (ductal intraepithelial neoplasia) categorization, not DCIS, as in most other institutions. (Though the equivalent DCIS categorization is still put in the sign-out, so you learn both.)
Tavassoli wrote a book, that is now out of print, but is next to the breast scope. This book is good for looking up pictures (has lots of them) and has lots of detail/depth when you want to learn more. To start, you might want to browse Foundations, the AFIP fascicle, WHO, or another book. (But the pictures are useful to browse during previewing if you have an unknown lesion and are trying to match appearances.)
One of the heavier services b/c the gyn surgeons, especially Rutherford, are pretty productive, but grossing tends to be fairly straightforward. Specimen types you get:
Another one of the heavier services and you will become quite familiar with searching for lymph nodes. The GI fellow is very involved with the resident on this service as well. He/she will come help you with all your livers and Whipple's and is available for questions you might have.
You're day starts about an hour earlier on this rotation, an hour before conference, to look at biopsies that come out in the morning.
Familiarizing yourself with the various types of mucosa before you start is helpful. (ie. Antral versus oxyntic in the stomach, and small bowel versus large.)
Medium/lighter surg path rotation. Lots of thyroids! The head of surgery here is an endocrine guy, so we get lots of thyroids here for head and neck and you'll see a lot of them on cyto as well. (You'll meet Larry the larynx in the gross room.) Composite resections and laryngectomies are the most complicated specimen for grossing.
For thyroids: you'll get to know papillary thyroid caner pretty well; for follicular carcinoma, you have to look for capsular invasion, so if it's called a follicular neoplasm on cytology, you'll need to entirely submit the capsule.
There is a cheat sheet for the common diagnoses. Make sure you get it before starting. This is the "what's left general service" and consists of thoracic, GU, and miscellaneous. The miscellaneous are the "smalls." These are heart valves, DJD joints, degenerative disks...etc.
Thoracic and GU will have the larger specimens. This is what will take up most of your time in the gross room and previewing. The "bigs" (if you get a lot of them, it is more important to preview these over the smalls, especially later on when you get familiar with the small cases.) Urology isn't the most prolific service at YNNH yet, but the volume is increasing.
Lighter rotation and no grossing. There are separate attendings for non-gyn and gyn specimens. Sign-out for non-gyn is throughout the day. They start sometime in the morning and break for lunch. There is then consensus conference at 1 or 1:30, where whichever cyto attendings are around gather and come up with a group diagnosis for the questionable cases of the morning. Sign-out continues in the afternoon. You can get a tray of gyn specimens (PAP smears) from the gyn attending and go through them in the afternoon.
You'll sometimes go to help FNAs.
There are study sets if you want to see a greater diversity of cases. You get lots of thyroids on service. So, if you're motivated, you can grab sets from the filing cabinet and take a look.
Lighter rotation. Dermpath is located upstairs in the department of dermatology and spend part of the time downstairs in surg path and part upstairs.
A.M.: surg path sign out. In surg path, you're in charge of both consults and the in house cases. The consults can be tricky in terms of logistics sometimes, so try to stay organized. In surg path, you get mostly cysts and the resections after biopsies of melanoma. The consults are fairly variable.
P.M.: dermpath sign out upstairs. In the afternoon, you go upstairs to dermpath, where they have their sign-out. If you can get up there early, you can preview some of the cases with the fellow. Upstairs you see mostly biopsies (shave and punch) and they can go somewhat quickly, but they all teach a lot. Some go in a circle, some just ask questions randomly, and some just talk through the specimens themselves. There are usually several people at sign-out (path resident, sometimes derm resident, visiting people, fellow...)
You usually gross the surg path cases in the afternoon. The PA's usually help out with the smaller stuff. Resections you fix overnight and can gross in resections during the day.
Lighter rotation. You have renal in the mornings down in the basement near autopsy. They have a whole system down there and they'll show it to you. Dr. Moeckel does daily teaching sessions when he's on service.
You go to the VA in the afternoons. There is a shuttle that runs every 15 minutes from in front of the med library you can take. The last shuttle from the VA leaves at 6:15, so unless the attending you're with is going to give you a ride, remind them you have to leave by 6 (though sign-out does not usually last that long). You preview as many of the cases as you can when you get there and sign-out afterwards with the respective attending. The sign-out is general, but you do tend to see a lot of skin and GI, while gyn is on the lower side.
We get forensics lectures with dinner the first Wed night of the month. For the rotation, it's at the Bronx ME (Jacobi Medical Center, 1600 Pelham Parkway, South Bronx, New York 10461, 718-829-2030). You get a refund for the travel costs, but you have to ask Dr. Gill for a form that states the dates you were in attendance, so just ask him before you leave.
The CP rotations tend to be a bit more variable. You start out with a "trial month" where you rotate through the various rotations each for one week to get an introduction to what each service is like. This also prepares you for taking night and weekend call. Then, you spend more in-depth time on each rotation. On CP rotations, morning conferences typically start at 8:30 AM. The rest of the day varies based on what service you are on.
Responsible for three different labs. Serum protein electrophoresis (SPEPs), your main job in chemistry, is the most time-consuming (looking at the gels for serum and urine specimens and determining whether you see an abnormal band, usually part of a screening for monoclonal gammopathy). Quick-texts available to help "figure out what to say" but not to worry-- it will become second-nature by the end of the rotation. Also a few times a week you review the urine toxicology GCMS runs. Chemistry 11 AM teaching session (Tuesdays and Fridays) is basically a time for you to get feedback on the SPEPs, learn about lab management issues, or anything else that you might want to know. Dr. McClaskey has a loose schedule/curriculum for these meetings although you can give him input to align the topics with your interests.
Immunofixation electrophoresis (IFE), your main job for immunology, tells you what specific immunoglobulin components comprise the bands you previously identified by SPEP. It can also help confirm an SPEP that was weak or indeterminate. Same as for SPEP, you look at the gels, write up the interpretation, and do the billing.
Molecular is basically entering a straightforward interpretation into the computer and doing billing. Examples of tests: chimerism to determine if a bone marrow graft was successful, assessing for mutations as part of a hypercoagulability workup, monitoring leukemic disease progression by measuring abnormal fusion gene products over time, determining EBV infection by measuring gene products of the virus, and assisting in the diagnosis of various hematologic disorders by identifying characteristic mutations. Lots of variability with which tests are done each day (they are usually batched).
BThe most clinically oriented rotation in CP. You will write notes on the patients you round on (don't need a stethoscope!). The clinic in Smilow does therapeutic apheresis (hematologic malignancies, multiple sclerosis, sickle cell), as well as harvest stem cells for bone marrow transplants. Occasionally there is an urgent need for pheresis, which may result in having to come into the clinic if you are on home-call, but this is pretty rare.
You are also the blood product police and you have to approve and oversee usage. Diplomacy skills help. Also need to work up transfusion reactions (which have a way of always happening in the middle of the night) and positive antibody screens. Less daunting than it seems due to lots of back-up (2 fellows, senior resident at first). Rounds are in the late mornings after lecture. You may be asked to "look into something", sometimes to foresee future usage needs other times it is for quality control or curiosity.
Pheresis rounds at 4 to report stem cell collection yields and goals, treatment plans, and any problems there were with the pheresis or gaining peripheral access.
The Veterans Hospital is close to Yale and there's a shuttle. It's practice for how small community labs work and it's very hands-on. Attending are mostly Yale attendings and very teachy. Main duties: cover VA pager (answer clinicians' questions, approve products, handle management issues) and approve "send-out" tests (tests not performed at the VA are sent to Quest for a fee). On Friday, you will give a CME-accredited presentation to the VA attendings called "Test of the Week" about one of your cases that week with a focus on a particular test and its utility and indications.
Rotate through various labs (TB, HIV) and do a project. You choose the project and attendings can help. Good time to get a poster in for a meeting.
Time to read and work on projects. These labs are very self-sufficient and the techs are incredibly knowledgeable and eager to teach you about plating or any of the assays they do. Microbiology fellow leads plate rounds (twice per week with ID). Main responsibility: get cases ready for rounds, carry pager for "issues." There's a worksheet to direct your reading and attendings go over it at the end.
By far the busiest and closest to AP. Get smears before lecture and check with techs about any issues. Write up smear interpretations in morning, go through flows and then attending comes and signs out in early evening. You stay until 6-8 pm usually. Also must do coags and hemoglobin gels. Toward end of month you give Heme Rounds and present interesting cases.
We get $1400 per year for books/journals/membership to professional organizations/some software as well as smartphones. We do have a book lady that visits twice a year that is supposed to be cheaper. (You'll have to do a cost comparison. Do think it is a little cheaper, but Amazon may be comparable.)
Practice of Surgical Pathology is a good starting text that is great for reading the night before you start a service to familiarize yourself with the basic histology and common pathology.
A general overview surg path book is nice to have around. Some people like: Sternberg, Rosai, or Modern Surgical Pathology. Good question book is Lefkowitz Anatomical Pathology Review Book
The Pathology Intranet web-page has a link called Board study material-- that Bart Kenney (attending/former resident/fellow) made. (It's material he made while studying for boards and very comprehensive.) Since it's on the intranet, you can't get to it from outside.
Secure on-site parking in the Air Rights Garage is provided to house staff at a subsidized rate through payroll deductions which costs around $26 per paycheck (~$50 per month). While not indoor, there is a "skywalk" so you can get from your car into the hospital without having to go through an uncovered area, great for days when it is raining. Some people who live near the hospital in downtown New Haven choose to leave their cars in this garage and walk to work due to the significant savings compared to paying full-price for other downtown garages.
You can register your hospital ID at the "food office" in the sub-sub basement to get 20% off your purchases and the money is taken from your paycheck. Your card works on all the hospital cafeterias, including the Atrium Cafe (which has good salads, sandwiches, and personal pizzas.)
Carts make lunch worth living. They line Cedar Street and enable you to get a delicious hot meal from a local restaurant for $3-6 or so. Lots of variety, including Thai, Chinese, Indian, Mexican, Ethiopian, Korean, Japanese, Mediterranean, and Standard American (hotdogs, hamburgers, Philly Cheese Steak). Gelato and ice cream in the summer. Kettle corn. Cupcakes on occasion.
Coffee in the hospital is plentiful and of varying quality, from BAD to decent. Options include:
There are several clinical applications, but there are a few that tend to be used mostly. Tend to mostly use: Sunrise Clinical Manager (SCM); Centricity; Synapse (Radiology).
You'll develop a love/hate relationship with CoPath in due time. This is how you will submit blocks to histology, order recuts and stains, check on the status of your cases, and perform searches for research projects. Remote access is available.
CAP and ASCP are both free for residents. Sign up at the beginning to have professional societies to put on your CV. Perk-CAP membership also comes with a free subscription to CAP Today and Archives.
Med school gym is free for us and pretty good! There are a number of treadmills with flatscreens at each one, ellipticals, weight machines, and free weights and a small locker room. You just have to register your ID card. The gym is located in Harkness Hall (med school dorms). Entrance is on York street across the street from the hospital on the corner of S. Frontage and York.
Bank of America (BOA) has a small branch within the hospital, as well as a few ATMs, which makes them a convenient choice. In addition, they have a strong presence throughout Connecticut and surrounding states. During orientation there is also an easy way to enroll in automatic direct deposit with Bank of America. It is possible to do so with other banks, but easier to initiate with BOA.
If you are living in downtown New Haven, there are a few grocery stores nearby that are acceptable, but some find it worthwhile to drive a bit. If you need to do a "serious shop," Milford has Whole Foods, Trader Joe's, Costco, and Stop and Shop/ShopRite all within a few miles of each other, in addition to a Target (also with limited groceries) and a Mall.
The closest mall is in Milford (about 15 minutes drive from New Haven). It is an adequate mall built in the traditional 1990s Midwest sense of the word. There is a Macy's, Dick's Sporting Goods, Express, and other mall staples. There is also a Banana Republic and Ann Taylor Loft down the street. There is a more upscale mall near Harford called Westfarms which is more of an outdoor design and includes Nordstrom, Tiffany's, Pottery Barn, Lord & Taylor, Louis Vuitton, and many other stores, as well as many restaurant options. Also, there are two outlet malls within driving distance, Clinton Crossing (in Clinton, CT) and Woodbury Commons (more designer stuff, in Central Valley, NY)
24% discount for Yale with AT&T, plus your book money can go toward a one-time iPhone purchase (or any smart phone).
Go to: www.newhaveneatsit.blogspot.com for some comical and fairly-accurate restaurant reviews of some top spots. There are LOTS of restaurants in New Haven and the surrounding areas; its worth checking them out yourself. Restaurant week, in the spring, is New Haven's attempt to get people out to try new ones with a standard Prix fixe menu. Some favorites:
Check out Yale activities. They have speakers, sports games, movies, etc which are typically associated with a university and available for us too.
Music school is great here and there are many free concerts.
There is a grad student bar, GPSCY (pronounced Gypsy). You need your Yale ID to get in and there are discounted drinks and events, like the annual Halloween Party, trivia night, and karaoke night, etc.
There are a few other trivia nights around town at Playwright (Thursdays) and Anna Liffey's (Tuesdays)
Downtown New Haven has a Bow-tie Criterion Cinema. On Saturday nights they play old movies for cheap and Sunday mornings is Movies and Mimosas.
Link from the intranet site called Yale Travel services (http://www.yale.edu/travel/) has info. On this page there is also a link for discounted airport parking at some airports (under airport parking link) for various airports for Yale people.
Airports near here: NYC ones, Hartford, White Plains, and Tweed New Haven (but New Haven with pretty limited options. Only US Air flies through there and always goes through Philly.) The pros of flying through NYC are that you can get direct flights (unlike New Haven) and it's cheaper than New Haven. To get to the airport, you either take Metro North to Grand Central, and then take an airport shuttle or cab, drive and park at the airport, or take ConnecticutLimo, which is a 15-passenger van that leaves from various stops around New Haven and the shoreline and takes you direct (you can reserve online). Hartford is a nice option too. It's about an hour drive and has cheap parking (as low as $5-6/day). It's also fairly small and easy to navigate, has free wi-fi, and price competitive with New York. White Plains is another smaller airport option that is about an hour away, but warning... the parking is expensive. Some people also like flying out of Newark because the train directly takes you to the airport and it also has more direct flights.