Training is available in three tracks: combined Anatomic and Clinical Pathology (AP/CP), Anatomic Pathology only (AP), and Clinical Pathology only (CP). AP-only and CP-only training are three year programs; combined AP/CP training is four years. All three tracks include similar core rotations with specific responsibilities designed to convey competency in the diagnostic practice of pathology.
Within each year, clinical training is divided into a series of rotations, each typically four weeks in duration. There are, therefore, 13 rotations each academic year (July 1 to June 30). Each level of training is characterized by a particular group of rotations. Together, these rotations provide a broad exposure to diagnostic pathology. The scheduling of residents to the various rotations is the responsibility of the Chief Residents in anatomic and clinical pathology.
The AP/CP training track provides broad training in all of the sub-disciplines of anatomic and clinical pathology. This 48 month program is the most common training track, and prepares residents for broad career options ranging from a small community private practice to a large academic medical center. The majority of AP/CP track residents go on to subspecialty fellowship training following their residency, although some graduates have gone straight into clinical practice or full time research.
Combined Anatomic and Clinical Pathology training includes 24 months of core AP rotations and 18 months of core CP rotations. Core training teaches the principles of gross, microscopic, and analytical evaluation of specimens and laboratory data graduated responsibility tailored to each resident's individual progress. Senior rotations encourage the resident to assume responsibility for the professional supervision of the services, often functioning as a junior attending. Elective opportunities allow for advanced training and/or investigative work with a faculty sponsor.
Residents most commonly do AP or CP rotations in six or twelve month blocks. Because of the flexibility of the program, there can be little correlation between a resident's PGY (post graduate year) status and their rotations. For example, a PGY-1 resident may start their training with clinical pathology rotations alongside PGY-3 residents who have already completed two years of anatomic pathology rotations. The performance expectations of these two residents would be comparable, since they are both just beginning their clinical pathology training. Residents are therefore collectively referred to by the group of rotations that they are currently doing. For example, PGY-3 residents who have completed two years of training in AP and are beginning their training in CP are "CP-1" residents, just as are PGY-1 residents who begin their training in CP. PGY-4 AP/CP residents typically do some combination of CP-2 and AP-3 rotations.
AP/CP training typically begins with 2 years of AP followed by one year of CP followed by a year combining six months of senior CP training and six months of flexible training opportunities, including advanced training and/or basic research (experimental pathology), but past residents have chosen other options:
Communication with the Program Director of your interests and plans early in your training is crucial to designing your training path.
During the first 12 months of anatomic pathology training, AP-1 residents focus on acquiring the technical skills that will form the basis for their careers in pathology. They also must acquire a fund of knowledge to be able to apply these skills intelligently as physicians (not technicians) towards the goal of becoming diagnosticians. The first year of core training in AP includes multiple rotations on the autopsy service. Residents acquire familiarity with a variety of dissection techniques, learn anatomy, and learn how human disease is manifested in anatomic changes throughout the body. Exposure to Forensic Pathology and Neuropathology is integrated into the autopsy experience. Residents also begin their training in Surgical Pathology and Cytopathology during their first year of AP. Rotations through the major surgical pathology services at YNHH (eg breast, GI, GYN) as well as in general surgical pathology at the VA Connecticut introduce residents to the broad scope of surgical pathology material. The subspecialty-focused training at YNHH affords the resident an in-depth exposure to these major areas of surgical pathology practice. Each AP-1 resident also does one rotation in Cytopathology.
Residents in their first year of AP training also do a one-week rotation through Laboratory Medicine as an early exposure to CP training. Understanding the structure and operations in Laboratory Medicine allow the residents to better interact with fellow residents on CP rotations. This exposure also may stimulate residents who find they have a strong affinity for a particular area in CP to consider spending their entire second year of training in CP. This one-week rotation through Lab Medicine is combined with a one-week exposure to the Molecular Diagnostics Lab in Pathology.
In the second year of core anatomic pathology training, AP-2 residents further expand their histopathologic diagnostic skills by focusing on a broader range of specialty areas within pathology, and delving deeper into an understanding of differential diagnoses. They also become more actively involved in interdepartmental interactions, taking on the role of a diagnostic consultant. A second rotation in each of the major surgical pathology subspecialties is incorporated into the AP-2 year, as are rotations in hematopathology, pediatric pathology, neuropathology, dermatopathology, and ophthalmic pathology. AP-2 residents also get their first exposure to a "leadership" role in anatomic pathology by serving as a senior resident on the autopsy service, overseeing the operation of the service and the training of the AP-1 residents. Finally, elective time allows residents to pursue or enhance training in areas of special interest, or to get involved in formal research projects.
Detailed rotation descriptions are available elsewhere on this site. Throughout the core training in anatomic pathology, a series of daily morning conferences provides residents with both formal instruction and a longitudinal exposure to all of the areas of anatomic pathology, regardless of which rotation they are currently on.
During the first 12 months of CP experience, CP-1 residents rotate through each of the sections of the Clinical Laboratories. The first 4-weeks of CP training consists of one-week mini-rotations in each of the major sections of the clinical laboratories. This provides an initial exposure to the breath of the discipline and prepares residents for the responsibilities of covering services after hours. This introductory exposure is then followed by an in depth experience on each of the 6 major rotations (transfusion medicine, microbiology / virology, hematology / flow cytometry, clinical chemistry / immunology, general clinical pathology at the VA, and subspecialty clinical pathology at the VA). All CP-1 residents rotate twice through each service in order to have the opportunity for more senior responsibilities on the second and subsequent rotations. Throughout their training, emphasis is placed upon understanding the basic science and associated biotechnology of Clinical Pathology, becoming familiar and comfortable with modern instrumentation and computers, and upon the interpretation and clinical utilization of laboratory tests. To accomplish this, residents also work on research and/or developmental projects in the laboratories and serve as consultants to hospital and outside physicians. Teaching is another strong area of emphasis during CP training. Residents fully participate in medical student teaching by serving as preceptors in the hematology and microbiology laboratories. Detailed rotation descriptions are available elsewhere on this site.
During their final 6 or 12 months of CP training, CP-2 residents assume a more senior, supervisory role and choose directed clinical responsibilities within each laboratory. We encourage specialization in areas of interest and an in-depth experience as a junior attending.
Integration of the subspecialties is achieved through interdisciplinary teaching and clinical conferences in the Department, through on-call responsibilities, and during rotation at the VA Connecticut Healthcare System. Residents are exposed to all aspects of clinical testing from conceptualization in basic research to practical realization in the clinical laboratory and application to patient care.
Core training leaves six months available to AP/CP residents for additional training, and there are many options available, including research and advanced clinical rotations. The advanced clinical rotations allow the resident to function essentially in the capacity of a clinical fellow, resulting in a mini-fellowship. Experiences are available in both laboratory medicine and pathology. In anatomic pathology, a set of AP-3 rotations provide residents with exposure across all subspecialty areas of pathology to solidify their diagnostic skills. These include the "Hot Seat" rotation, Frozen Sections, Autopsy Senior Resident, and General Signout at Bridgeport Hospital. In clinical pathology, senior CP rotations similarly focus on advanced consultative and diagnostic skills within selected subspecialties. These rotations also further the resident's interactions with clinical teams and allow them to take on greater independent responsibility, gradually transitioning them to independent practice. Elective time is also available. All AP/CP residents must spend at least one month of this period on the frozen section service, to meet ACGME training requirements.
The AP-only and CP-only training tracks provide focused training in all of the sub-disciplines of anatomic or clinical pathology, respectively. Each of these 36-month programs is for residents who have more defined career objectives at the time of applying for residency training. These three-year training programs afford residents a solid foundation in their respective discipline and an opportunity for in-depth subspecialty training and/or a significant research experience. Most commonly, AP-only and CP-only track residents go on to a career in academic pathology, typically at an academic medical center.
Residents on the AP-only or CP-only tracks who are on the diagnostic practice pathway have an emphasis on clinical science and teaching. This path often leads directly to a post-residency fellowship in such areas as Transfusion Medicine, Neuropathology, Dermatopathology, Medical Microbiology, Hematopathology, or Gastrointestinal Pathology. Other residents on the AP-only and CP-only tracks will pursue two or more years of research following their residency training. Many options exist on this physician-scientist pathway; fellowship experiences can be incorporated into training, and some residents have elected a physician-engineer track in which the research portion is oriented predominantly toward Biomedical Engineering in conjunction with the Yale Dept of Biomedical Engineering. Finally, for individuals without a PhD degree, there is the option of enrollment in the Yale Investigative Medicine Program in which one obtains research training (translational or basic) in the context of a rigorous PhD program.
Residents are encouraged to establish a mentored relationship with a Yale University investigator to oversee their ongoing career development. The philosophy of the Program is to provide all means necessary to assure resident success in becoming a physician-scientist or physician-scholar. To that end, research may be pursued within the Department of Laboratory Medicine or the Department of Pathology, but residents are encouraged to consider mentors in other basic science or clinical departments within the School of Medicine or any other School or department at Yale University. Salary is guaranteed for at least two years of mentored research following residency training (minimum of 5 years of salary support).
Training in AP-only is most commonly for individuals who either have already decided that the focus of their clinical practice will be within some subspecialty area of anatomic pathology, or for individuals who are planning a career which combines on-going basic or applied research and a more limited clinical practice of pathology.
AP-Only training begins with the 24-month core AP curriculum described above for the AP/CP track. The third year of training typically includes at least six months of specifically designed AP-3 rotations: "Hot seat", frozen section, autopsy senior resident, and general surgical pathology signout at Bridgeport Hospital. These cross-specialty rotations carry minimal grossing responsibility and are designed to strengthen the resident's diagnostic skills, further their role as clinical consultants, and transition the resident toward the independent practice of pathology. The remaining six months can be used to spend additional time on these AP-3 rotations as well as for clinical and/or research electives. Alternatively, a full six-month block of protected research time can be arranged.
The specific research strengths in the Department of Pathology are diverse and include basic as well as translational research. Major efforts are centered in cell biology, virology, cancer biology and diagnosis, biotechnology, computational biology, vasculogenesis and vascular disease, mitochondrial biology, and structural biology. Many of the laboratories have overlapping interests and have joined together to build program projects. The department is also home to several core facilities for the institution, folded together into Yale Pathology Tissue Services, which provides tissue procurement and banking, tissue micro-array, and research histology services.
The most common pathway for the CP-only training program is designed to provide residents with: (1) a solid foundation of knowledge in all aspects of Clinical Pathology; (2) an in-depth experience in a subspecialty of particular interest; and (3) a research experience that facilitates development of an independent physician-scientist career pathway.
The 18-month CP core curriculum (see above) is required for CP-only residents to assure familiarity with all aspects of Laboratory Medicine, while still allowing flexibility for sub-specialization within that 18 months and tailoring of CP electives to the individual interests of each resident. Research and/or clinical subspecialty opportunities are then available during the remainder of the 2nd and 3rd years of the CP-only track.
The format for the advanced training is individualized for each resident to assure both relevance to career goals and adherence to the requirements for residency training of the American Board of Pathology. Subspecialty training is handled by giving the residents more senior, graduated responsibilities under the direction of the attending physician. Some residents elect to participate in clinical fellowships in clinical pathology at this stage of their training, while others begin more basic research endeavors. Projects may be in practical areas, such as methods development or outcomes, or they may be in an area of basic research. The broad range of potential research opportunities can be explored in the Yale University medical faculty research database.
The specific research strengths of the Department of Laboratory Medicine are diverse and include R01 and program project funded investigators in immunohematology, molecular immunology and virology, transplantation immunology, molecular diagnostics, hemostasis, hematopoietic stem cells and progenitors, and clinical pharmacology, as well as other areas. The research laboratories (including the Yale Stem Cell Center) are located in close proximity to the clinical laboratories, facilitating ready interaction and transfer of biotechnology.
The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pathology (ABP) impose a number of specific requirements which pathology training programs must meet to achieve accreditation and which resident trainees must meet to be deemed qualified to sit for the Board examination. Complete information on these requirements can be obtained from the web sites for these two organizations. Selected components of these requirements are listed below:
Informatics is defined as the science of information management. As the amount of medical information that needs to be accessible and assimilated has grown, manual management of this information has become impossible. Therefore, familiarity and proficiency with computers has become an essential component of informatics. The pathologist of the future (and of today), in order to effectively serve his/her role as a diagnostic consultant, must become comfortable with the use of computers to access and manage information. Therefore, training in informatics is an essential part of any modern pathology residency training program. However, unlike many of the subspecialty areas of pathology that have segregated from the mainstream, ALL pathologists must be able to use computers. Therefore, informatics exposure and training at Yale is fully integrated into each and every rotation.
All day-to-day operations in both anatomic and clinical pathology are managed by laboratory information systems (LIS). Each department maintains its own LIS. The anatomic pathology services use CoPath Plus from Cerner/DHT. Yale Pathology is unique among all CoPath users. Extensive in-house expertise and special arrangements with the vendor allow us to customize our system to meet departmental needs. This is managed by the Pathology Informatics Program's Operations Unit. The clinical pathology laboratories have recently installed a new LIS from SCC Soft Computer, which is maintained by Laboratory Medicine's Instrumentation and Data Processing Unit. Each resident interacts with these systems on a daily basis, managing their cases, entering histology information, ordering tests, looking up test results, and printing reports. The systems can also be searched to identify cases for teaching or research purposes (with appropriate approvals). Virtual Private Networking software and accounts allows the residents to access the laboratory information systems from off-site locations, such as home, when on call.
Residents also have electronic access to other hospital information systems, including the radiology PAC system (which allows residents to view not only the reports but the actual images for all plain films, CT, and MRI studies) and the inpatient and outpatient electronic medical record systems. The institution is currently undergoing a massive reorganization of its information technology unit. The three hospital members of the Yale-New Haven Health System (Yale-New Haven Hospital, Bridgeport Hospital, and Greenwich Hospital), together with the Yale University School of Medicine, are uniting their IT support structure and collectively implementing a new Health System-wide medical record (EPIC) over the next two years, which will allow better and more complete access to patient information.
Residents are also exposed to many other informatics tools. All residents are given electronic mail accounts. All resident computers, as well as most workstations throughout both departments, give the residents access to the internet and the world wide web for literature searches and access to other information resources and on-line databases. Departmental conferences and vacation schedules are maintained by the residents in on-line calendars. All residents learn to acquire and use both gross and microscopic digital images. Digital cameras, both copy stand-mounted and microscope-mounted, are available to all residents 24 hours a day. Residents use digital images and presentation software (PowerPoint) in preparing formal conferences which are delivered in conference rooms equipped with digital projection equipment, available in both departments. They also use image editing, word processing, and spreadsheet software.
Finally, residents receive a formal education in informatics through a series of didactic lectures, delivered by faculty in both departments with a special interest in informatics. Topics include desktop computer hardware and software, networking and the internet, databases, interfaces, laboratory information systems, and diagnosis coding.
Opportunities are available for the residents to get involved in system customizations, interface design and deployment, and web page development. Elective time may be spent working on special informatics projects, under the instruction and supervision of faculty.
Laboratory management is one of the most important things that pathologists are called upon to do in their careers. Quality patient care requires accurate lab results, and assuring that accuracy is not a trivial process. To be prepared to effectively manage a clinical laboratory, residents must become familiar with a number of areas not traditionally considered "medical", such as quality control and quality assurance, equipment maintenance, external regulations, human resources, policy development and management, and reagent supply control.
The role of the pathologist in laboratory management is more "transparent" during the clinical pathology training, and thus the focus of training in lab management is during the CP blocks. However, there is a growing national trend toward a more formalized approach to management in the AP labs, and structured workflow analysis techniques well established in CP are being adopted in anatomic pathology, including breaking down laboratory processes into pre-analytic, analytic, and post-analytic phases.
Resident training and exposure to laboratory management at Yale occurs in many ways. There are several lectures given each year focusing on issues related to lab management and quality assurance, (e.g. overview, financial management, personnel management, billing and external regulations), comprising a core curriculum. More importantly, however, the residents are integrated into the weekly management meetings that occur in each lab, as well as participate in daily management decision. This occurs in a graded fashion, with CP-2 residents playing a greater role than CP-1 residents. Residents participate in annual internal mock inspections of the various labs, and some even join faculty in the department inspecting external laboratories as part of the College of American Pathologists Laboratory Accreditation Program. During the VA rotation in CP, residents delve deeply into the details of laboratory test workflow and test validation for a particular test, reporting their findings at the "test-of-the-week" conference. Residents are encouraged to participate in the actual process of bringing a new test on-line and making it available to the medical staff.
Finally, a new rotation in Laboratory Management has been created for CP-2 residents to provide a focused and dedicated practical exposure to laboratory management issues. This rotation is described in greater detail elsewhere in this manual.
As our understanding of the links between genetic alterations and disease increases, the use of a wide range of techniques to look for genetic alterations in patient material is expanding. Nowhere is this happening faster than in the evaluation of neoplastic disease. These genetic alterations can be used to help classify a tumor into a particular diagnostic category (molecular diagnostics), to predict the behavior of a tumor (molecular prognostics), or to suggest potential treatment options (tumor profiling).
The modern practice of Pathology requires pathologists to understand the relationship between genetic changes and disease, to know when molecular testing techniques are warranted, and to understand how to interpret the test results in the context of the specimen and patient. With the proliferation of new companies aggressively marketing new molecular tests to surgeons and other physicians, as well as patients themselves, the pathologist is often called upon to be the voice of reason, applying sound scientific principles and our understanding of quality assurance issues in assessing the appropriateness of a particular test or the value of the result of that test.
While "Molecular Pathology" exists as a subspecialty in pathology, all pathologists of all subspecialties must develop a level of proficiency in the use of molecular testing, as has already become the case with immunohistochemistry and information management tools. In the Yale Pathology Residency Program, residents are exposed to a wide range of molecular techniques through a multi-facetted approach. First and perhaps most important is the use of molecular studies in the daily evaluation of cases. However, in addition to this, more formal approaches to training in molecular pathology have been established.
This series of lectures in morning conference slots provide a broad exposure to the fundamentals of genomic testing, including the architecture of the genome, functional genomics, epigenetics, methods of genomic analysis, and genomic alterations in disease.
This one-week rotation gives PGY-1 residents in AP an early "hands-on" exposure to practical aspects of the performance of molecular testing in the Molecular Diagnostics Lab in Pathology and the Tumor Profiling Lab in the Smilow Cancer Center.
Through the presentation and discussion of recent papers using molecular techniques, residents (working with the Molecular Genetics Fellow) see and critically evaluate the use and application of molecular pathology in the evaluation of patient material. Each paper presented in the Journal Club focuses on particular techniques and how the results of those tests can be used in clinical medicine.
Under the direction of Dr. Jeff Sklar, first year residents in Pathology will work together on a project to get direct exposure to genomic pathology, designing and then building a real-time RT-PCR array to determine the tissue of origin for cancers with unknown primaries.
Funds are available for residents to explore further a disease process manifesting in one of the autopsy patients. The autopsy can be a comparatively limitless source of material for molecular testing, and many analysis remain possible even on post-mortem material.
During the CP-2 year, residents take a rotation in the Molecular Pathology lab in Laboratory Medicine. Here they are exposed to a large number of tests, including screening for genetic disorders such as hemochromatosis and cystic fibrosis, minimal residual disease detection, and molecular techniques to identify a wide variety of infectious agents.
Residents may use their elective time to schedule more advanced rotations in molecular pathology in either the Department of Pathology or the Department of Laboratory Medicine