ST. LUKE S-ROOSEVELT HOSPITAL CENTER 1000 TENTH AVENUE NEW YORK, NY 10019 PATHOLOGY TRAINING PROGRAM SURGICAL PATOHLOGY ROTATION Faculty Staff: Refer to the St. Luke s-roosevelt Pathology Program Description 1
SURGICAL ANATOMIC PATHOLOGY ROTATION COURSE OUTLINE OBJECTIVE: To understand basic concepts in surgical pathology. I. During the rotation the resident will be involved with: 1. The gross dissection and description of varied specimens which come through the anatomic pathology department. 2. Previewing and the write up of all large cases to include the appropriate cancer reporting protocols where necessary and the ordering of appropriate immunohistochemical stains. Prior ordering special studies consultation with senior residents and or attending pathologists required. 3. The resident must not come to sign out without awareness of patient clinical/surgical history. 4. For difficult cases the generation of a differential diagnosis list is necessary and appropriate special studies for resolve. See recommended literature list below. 5. Follow up of cases is to include submission of additional tissue where necessary, attending and non attending initiated. For example on review of ones sections if there is an insufficient number of lymph nodes one must submit additional nodes that night in order not to delay case. Follow up of case is also to include evaluation of special studies ordered prior finalizing cases with attendings and contacting residents/attendings of cases for specimen orientation and additional clinical/surgical history. 6. All cases must be followed through with respective attendings until case is finalized unless end of month with rotation at different site. 7. All residents on AP rotations must attend QC review of first time malignant diagnosis and review of challenging cases and monthly QA/QC meetings. 8. All residents must attend all intradepartmental teaching conferences. All residents assigned for intradepartmental conferences must attend and be prepared. This means reading on respective topics, knowing their differential diagnosis and foreseeing possible questions to be asked by clinicians. All conferences must be reviewed with an attending prior presentation II. After completion of the rotation, the resident should: 1. Know the gross dissection and handling of the varied specimens which come into surgical pathology. This is to include preparation for electron microscopay, flow 2
cytometry and various oncological sensitivity testing assays. Learn the use of the frozen section cryostat and staining. 2. Gain competence of a satisfactory level in gross and microscopic diagnosis both at sign out and during intraoperative procedures. 3. Be able to utilize information technology to support patient care decisions pertaining to past medical and surgical history 4. Educate and works with other health care professionals to provide patient-focused care via one on one interactions for specific patient issues, in inter and intradepartmental conferences to include necropsy. 5. Build a strong diagnostic base and means to keep current with evolving knowledge. Develop an investigative and analytic approach to diagnostic problems; consults appropriately in complicated problems; is familiar with the pathology literature; 6. Becomes knowledgeable of laboratory management including implementation of all applicable safety regulations and sound management; 7. Participates in quality assurance and quality improvement procedures; appraises 8. Assimilates evidence from scientific studies; applies knowledge of study design and statistical methods to appraisal of clinical and pathologic studies 9. Learn skills that result in effective information exchange and team building with professional associates and support staff. is objective, frank, and concise; is an effective listener; works effectively with other members of the health care team; gives clearly defined orders and administrative directives 10. Expresses ideas and positions clearly both orally and in writing; ensuring that reports are complete and up to date. 11. Learns and appreciates the importance of organization keeping thorough and accurate records. 12. Be objective, frank, and concise; an effective listener; works effectively with other members of the health care team; gives clearly defined orders and administrative directives. 13. Demonstrates a commitment to carrying out professional responsibilities, adherence to ethical principles, carries out duties with dispatch and thoroughness; is prompt and wellprepared for conferences and teaching assignments; assumes delegated responsibility; demonstrates stability in critical situations; demonstrates respect, compassion and integrity is committed to excellence and on-going professional development. 14. Demonstrates awareness of the role of pathology in large medical systems and public health; is able to call on system resources to provide pathology services that are of optimal value; understands the reciprocal interaction of pathology practice with that of other health care professionals, health care organizations, and the larger society; demonstrates knowledge of different types of health care delivery systems including federal, state, and local laboratory regulations, billing and compliance issues; practices cost-effective health care and resource allocation without compromising quality. 3
SURGICAL ANATOMIC PATHOLOGY ROTATION III. Competency-Based Goals and Objectives by Education Level PGY 1/FIRST YEAR RESIDENTS The resident will be able to: Medical Knowledge 1. Identify specific areas of the surgical pathology laboratory: grossing, cryostat, histology and operating rooms. 2. Characterize the stains used in general surgical pathology: H&E and a variety of special stains used daily (iron, amyloid, collegen, etc) and immunohistochemical stains. 3. Review anatomy and normal histology and identify these when reviewing cases. 4. Learn the basic proper grossing techniques for surgical specimens and submit sections appropriately. Patient Care 1. Review the operating room schedule and locate any prior specimens and reports for signout. (Professionalism) 2. Prepare a frozen section and learn how to identify anatomic structures and processing the tissue. (Knowledge) Professionalism 1. Review all histologic slides prior to sign-out and identify normal and abnormal. (Patient care, knowledge) Communication and Interpersonal Skills 1. Speak clearly and succinctly when generating a gross description. 2. Communicate and ask questions regarding surgical specimens with the surgeon and pathology attending. 3. Communicate all results in a timely and professional manner. (Patient care) Practice-Based Learning 1. Begin to make a pathologic diagnosis; read appropriately for assigned cases. 2. Attend the autopsy conferences, multidisciplinary tumor board conferences where cases are discussed Systems-Based Learning 1. Use the computer system to obtain pertinent clinical and radiographic information regarding the patient. RESPONSIBILITIES The resident is responsible for: Intraoperative Consultation/Frozen Sections 1. Reviewing the operating room schedule for that day. 2. Arriving to surgical pathology by 7:30AM to be ready for frozen section duties. 3. Confirming the appropriate paperwork, patient s name and specimen type before handling the frozen section. 4. Communicating discrepancies in tissue, tissue labeling or patient information with the pathology attending. 4
5. Properly identifying tissues, margins, sutures, or inking on specimens sent for intraoperative consultation (when needed). 6. Communicating with the pathology attending as soon as the specimen is received. 7. Preparing frozen sections and smears for designated cases. 8. Asking for help when numerous frozen sections are accessioned simultaneously, if needed. 9. Going into the operating room when asked to retrieve tissue with appropriate instruction and/or with senior resident. 10. Communicating/documenting frozen section results to the surgeon and within pathology 11. Reviewing the frozen section or smear. Grossing 1. Starting to prepare the specimen for grossing the day before (fixation, cassettes, etc). 2. Beginning to gross UNDER DIRECT SUPERVISION from a senior resident or an attending no later than 9am (and earlier if needed). 3. Following the grossing manual/guide book (present in the grossing room) and having a senior resident, PA or attending for direct supervision on large specimens (for at least the 1 st three cases). (with log into New Innovations) 4. Properly identifying tissue and confirmation of labeling/patient information. 5. Making and correctly labeling cassettes for all assigned cases. 6. Dictating the gross section of the surgical pathology report with appropriate ICD codes and cassette labeling. 7. Reviewing and correcting the gross section of the surgical pathology report with the attending on service. 8. Communicating with histology regarding any issues with re-processing, identification of slides/cassettes and re-labeling. Sign-Out 1. Preparing cases for attending review (reviewing/pulling prior cases and reports or patient information when necessary). 2. Reviewing biopsies and large cases, formulating a correct diagnosis 25% of the time. 3. Follow up on re-cuts, additional sections and special stains for assigned cases. PGY 2/SECOND YEAR RESIDENTS Should be able to perform the above and in addition: Medical Knowledge 1. Utilize texts and appropriate library resources to review and read about their cases. 2. Surgical pathology diagnoses should be accurate in 75% of cases. Patient Care 1. Perform specialty work-ups on lymph nodes, and specialized tumor cases 2. Prepare cases for sign-out based on priority Professionalism 1. Collect interesting cases for expansion of virtual pathology case studies Communication and Interpersonal Skills 1. Instruct junior residents on grossing skills and frozen section technique 2. Guide and instruct the medical students as they rotate through the department (when applicable). Practice-Based Learning 1. Learn to interpret slides to arrive at the correct pathologic diagnosis as well as generate comments that are clinically relevant and serve as a guide to the clinician (patient care) Systems-Based Learning 1. The resident should be aware of proper billing and coding for all specimens. 5
RESPONSIBILITIES The resident is responsible for: Intraoperative Consultation/Frozen Sections: 1. All of the above listed under PGY 1 and in addition: 2. To cut and submit appropriate sections for review under indirect supervision with direct supervision immediately available. 3. Going into the operating room alone and communicating with the surgeon as necessary. 4. Reviewing frozen sections/smears formulating a diagnosis in at least 50% of cases. 5. Knowing when to ask for help (may handle >3 specimens). Grossing 1. All of the above listed under PGY 1. 2. Grossing with indirect supervision with direct supervision available. 3. Make corrections to the grossing section of the surgical pathology report without the direct help of the attending. Sign-Out 1. All of the above listed under PGY 1. 2. Reviewing small and large cases, formulating a correct diagnosis 50% of the time. 3. Writing a comment along with the diagnosis in at least 50% of cases. 4. Reviewing the immunohistochemical stains for all assigned cases. PGY 3 and 4: THIRD AND FOURTH YEAR/SENIOR RESIDENTS 1. Should be able to perform the above with ease and in addition: Patient Care 1. Learn to interpret slides to arrive at the correct pathologic diagnosis as well as generate comments that are clinically relevant and serve as a guide to the clinician. Should be accurate in 90% of cases. (Medical Knowledge) Professionalism 1. Participate in interdepartmental conferences. Communication and Interpersonal Skills 1. Spend increasing amount of time teaching and instructing junior residents. Practice-Based Learning 1. Recognize one s limitations and learn the proper channels of consultation 2. Realize the need for teamwork in maintaining a well-run and effective laboratory and participate in laboratory management in the surgical pathology suite. 6
RESPONSIBILITIES The resident is responsible for: Intraoperative Consultation/Frozen Sections: 1. All of the above listed under PGY 1 and 2. 2. Reviewing biopsies and large knife cases, formulating a correct diagnosis 85% of the time. 3. Going into the operating room with junior residents as needed. 4. Knowing when to ask for help regarding the processing of frozen tissue. 5. Being available to teach and help junior residents with frozen sections. Grossing: 1. Grossing assigned cases. 2. Being available to teach/help junior residents and students. Sign Out: 1. Formulate a correct diagnosis on assigned cases 85% of the time. 2. Deciding and ordering the appropriate additional sections, special and immunohistochemical stains for assigned cases. 3. Dictating the diagnosis and comment for assigned cases as recommended by the attending on service. TEAMWORK **ALL residents are expected to work as a team in surgical pathology, including assisting a colleague with intraoperative consultations when needed. Each resident is responsible for keeping his/her area clean and adhering to laboratory regulations. Coverage: The resident in surgical pathology is expected to be available in surgical pathology from 7:30AM until 5PM at a minimum with the exception of the 8-9AM protected time. The hours may be longer on any given day depending on the case load not to exceed an 80 hour work week or a 16 hour work day for PGY 1 residents. The resident is expected to stay and finish their grossing as well as preview their slides with written diagnoses and comments prior to sign-out with the attending. The resident should make arrangements to have longer days in surgical pathology. Scheduling: Each resident is assigned to a specific duty each day of the week as follows, duties and scheduling varies depends on site (see site specific schedules), but generally: Grossing: On a grossing day, the assigned resident will gross and process all tissue that is accessioned to him/her until the cut off time. Sign-out cases: Biopsies: the resident will have the morning to review biopsies, diagnose and make comments, and then signed out with the attending on service or start signing out directly with the attending on service. Large cases: residents are expected to review large cases the evening prior to sign-out the following day. The resident is expected to order any pertinent studies, read appropriate topics or search the literature regarding a particular case and help out should the need arise in surgical pathology. Frozen sections: the resident should be prepared to enter the operating room if necessary with appropriate scrubs. The resident should be present or available by 7:30AM. Reviewing the operating room schedule, obtaining the history of the patient, pertinent 7
radiologic studies and prior surgical specimens is required. This aids the resident in identifying and preparing the specimen and the attending during the intra-operative consultation. The resident is responsible for processing all frozen and smear preparations. Should the need arise, the frozen section resident should ask for help. During any down time, the resident should review cases and read topics of the days cases is also a useful activity between frozen sections. Special Cases: Work-up Lymphoma: The case should be referred and discussed with attending and resident on hematopathology rotation, but in brief: The resident should be familiar with the protocol for the work-up of suspected lymphomas. All lymph nodes other than those that are removed as part of staging for solid tumor metastases should follow this protocol. These include: previous lymphoma diagnosis by history; current suspicion of lymphoma; unknown history or diagnosis; reactive process and if in doubt, contact attending, clinician. The tissue should be divided and prioritized as follows: 1. First priority: Formalin fixation of thin (2-3mm) representative section. 2. Second priority: 0.1cm (minimum) in RPMI or more if larger lymph node. Kidney and muscle biopsy: sent out to Columbia Presbyterian as per our protocol. SUPERVISION Each resident in surgical pathology is under the supervision of the Director of Anatomic Pathology and the assigned attending on service. PGY 1 PGY 2 PGY 3 PGY 4 Direct supervision and indirect supervision with direct supervision immediately available (attending or senior resident). (Pathologist assistant is usually available and in the same room as the resident). Indirect supervision with direct supervision available Indirect supervision with direct supervision available Indirect supervision with direct supervision available and oversight EVALUATION The attending that works directly with the residents is responsible for daily verbal feedback. Each resident is evaluated monthly by the staff on service in a written evaluation. In addition, resident performance is discussed two times per year at departmental faculty meetings. IV. Recommended readings: 1. Manual of Surgical Pathology, Susan C. Lester 2. Robbins & Cotran Pathologic Basis of Disease, Vinay Kumar 3. Rosai and Ackerman's Surgical Pathology 2 Volume Set (Rosai & Ackerman's Surgical Pathology), Juan Rosai 4. World Health organization series 8
5. Armed forces institute of pathology series. 6. Enzinger and Weiss's Soft Tissue Tumors AP RESIDENT COURSE OUTLINE.DOC 9