SURGICAL PATHOLOGY

Resident Rotation Summary

Rotation Philosophy and General Purpose Statement:

The surgical pathology rotation at West Virginia University is designed to instruct trainees in surgical pathology in a tertiary care-academic setting and a large academic-affiliated community hospital. As they evaluate patient specimens, the physicians-in-training are instructed in the gross evaluation, microscopic evaluation, and ancillary studies of surgical pathology specimens. By providing residents with increasing responsibilities and duties, as their level of training increases, the teaching faculty hopes to instill the skills and tools necessary to develop a life-long course of continued professional development.

Teaching Faculty Members

West Virginia University

James E. Coad, M.D. (General Surgical, and Hematopathology)

Linda L. Cook, M.D. (General Surgical and Pediatric pathology)

Barbara S. Ducatman, M.D. (General Surgical, GYN, ENT, and Pulmonary pathology)

Robert Howell, D.D.S. (Oral Pathology)

Scott Nestor, D.O. (General Surgical and Neuropathology)

Jeffrey A. Stead, M.D. (General Surgical, Renal, GU, and Bone Pathology)

H. James Williams, M.D. (GYN and General Surgical Pathology)

Charleston Area Medical Center

Mario T. Anselmo, M.D. (General Surgical, GYN, and GI pathology)

Terry M. Barreta, M.D. (General Surgical and Pediatric pathology)

Ho-Huang Chang, M.D. (General Surgical, Renal, and EM pathology)

Oscar C. Estalilla, M.D. (General Surgical and Hematopathology)

David A. Hansen, M.D. (General Surgical pathology)

Tzong-Wen Edgar Huang, M.D. (General Surgical and Neuropathology)

William E. Mangano, M.D. (General Surgical pathology)

Milton J. Plata, M.D. (General Surgical and Orthopedic pathology)

EDUCATIONAL GOALS AND OBJECTIVES:

The goals and objectives of the surgical pathology experience are to prepare and enable residents to:

• Demonstrate competency in the work-up and diagnosis of surgical pathology specimens in order to effectively practice surgical pathology independently.
• Demonstrate professional behavior in all situations.
• Demonstrate a commitment to reviewing and improving practice patterns and to life-long learning.
• Demonstrate the concepts associated with the scientific basis of pathology, the ability to utilize the medical literature and the ability to utilize modern techniques to provide optimum surgical pathology patient care and to contribute to the education of their clinical colleagues.
• Communicate effectively in verbal and written form with clinical colleagues, administrative personnel, technical personnel, and clerical personnel and demonstrate respectful and caring behaviors when interacting with patients and their families.
• Discuss the policies and regulations affecting health care (i.e., CAP laboratory accreditation, HIPAA, compliance with Medicare and billing regulations, etc.) 

REQUIRED COMPETENCIES, DUTIES AND RESPONSIBILITIES:

PATIENT CARE

Residents preview surgical pathology cases prior to faculty sign-out and formulate their own diagnoses. Residents are expected to perform more independently and accurately as they progress through their training program in terms of both gross and microscopic evaluation.

• Their diagnoses are compared with the faculty diagnoses (agree/partially agree/disagree) and their gross descriptions are also graded. The results of these reviews are collated monthly. 
• In order to properly formulate concise and accurate differential diagnoses, residents:

Gather essential and accurate clinical information about the patients on whom they receive surgical specimens, including discussing histories with clinical housestaff and/or attending faculty members.

• Preview O.R. schedules and reports/slides of previous pathologic specimens.
• Review the online medical records when applicable.

Residents are actively involved with intraoperative pathology consultations and are able handle frozen sections with increasing degrees of independence including:

•  Inking and gross dissection techniques.
• Preparation and interpretation of frozen sections and/or imprint cytology.
• Timely and effective communication with surgeons.

Residents demonstrate competence in the performance of procedures considered essential for surgical pathology practices, including:

• Intraoperative surgical pathology consultation (see above).
• Ability to use a wide variety of gross dissection techniques as needed.
• Concise and accurate gross descriptions of surgical pathology specimens.

Residents make informed decisions regarding the diagnostic workup of surgical specimens:

• Consider special stains, deeper sections, immunohistochemistry, etc. based on the patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment. 
• Expected to be able to handle more difficult cases and their approach to the diagnosis should more closely correlate to the final diagnosis as they progress through their residency.

Residents use available information technology (hospital and laboratory information systems, internet-based literature searches)

• To support workup and diagnosis of surgical pathology specimens,
• To help educate clinicians by providing relevant literature references.

Residents work with health care providers, in the generation of accurate and clinically useful surgical pathology reports and the effective communication of results to clinicians.

Evaluation:

• Rotation evaluation

  Statistical analysis of a resident’s portfolio of cases generated by COPATH including concordance of resident vs. attending pathology diagnoses and evaluation of gross descriptions.

• 360o Global evaluation

MEDICAL KNOWLEDGE

·Residents demonstrate an investigatory and analytical thinking approach to clinical situations, including:

• Development of reasonable and complete differential diagnoses for surgical pathology cases based on the available clinical information, gross and microscopic features, and current published literature.
•  Suggest appropriate additional testing (special stains, immunohistochemical studies, and further clinical testing such as serology) as applicable.
• Formulation of a comprehensive, cohesive, and coherent discussion of the differential diagnoses and final interpretation and discussion of clinical significance in the final pathology report.
• Encouraged to participate in at least one clinicopathologic research projector case report with literature review.

Residents demonstrate the knowledge and application of the basic and clinically supportive sciences which are appropriate to the specialty of anatomic pathology, including:

• Demonstration of knowledge of epidemiology of various infections and neoplastic diseases during the discussion of surgical pathology cases and use of such knowledge to formulate pathologic diagnoses.
• Demonstration of familiarity with the clinical presentations and manifestations of various diseases during discussions and workups of surgical pathology cases and use of such knowledge to formulate pathologic diagnoses.
• Demonstration of familiarity with basic histochemical and immunohistochemical stains, including biochemical and immunologic principles, methods, and applications.
• Demonstration of a detailed knowledge of human anatomy during dissection and description of surgical pathology cases.

Evaluation:

• Rotation evaluation

Surgical pathology score for the in-service examination compared to national means

PRACTICE-BASED LEARNING

Residents show the ability to analyze their practice experience and perform practice-based improvement activities using a systematic methodology, including:

• Evaluating their gross reports for diagnostic and typographical errors.
• Assessing slides for technical and staining quality.
• Residents are given results of their concordance with staff diagnoses and are expected to use this information to direct their learning toward improving their diagnostic acumen.
• As senior residents on Anatomic Pathology Services, residents actively participate in monthly Anatomic Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, frozen section discrepancies/deferrals, histology quality monitors, amended/addended cases, cyto-histologic correlation, etc.).

Residents show ability to locate, appraise, and assimilate evidence from scientific studies related to patients’ health care problems, including:

• Perform literature search and review to find relevant scientific references to aid in the workup of surgical pathology cases (computer-based searches).
• Obtain and incorporate information about their patient population (via COPATH computer searches and medical records chart review) for clinicopathologic study of selected diseases.
• Residents are able to apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
• Residents demonstrate competency in the use of information technology to manage information, access on-line medical information, and support their own education, including:
• Accessing of patient clinical information and previous pathology accessions via Medsite and Copath.
• Performance of computer searches of the medical literature.
•  Utilize digital imaging technology.
• Access web sites pertaining to specific pathologic diagnoses (grading systems for tumors, etc.).

Residents actively participate in the teaching of medical students and other health care professionals rotating through the anatomic pathology section, including:

• Teaching medical students as lecturers (senior residents only), leaders in small groups and laboratory sections.
• Teaching medical students and residents from other disciplines during surgical specimen gross description and dissection.

Evaluation:

• Rotation evaluation

Review of resident portfolio yearly to assess improvement and discuss self-education

INTERPERSONAL AND COMMUNICATION SKILLS

Residents demonstrate effective communication with other health care providers, patients, and patients’ families by:

• Presenting cases at in-house tumor boards and conferences under direct faculty supervision.
• Interacting with clinicians during performance of frozen sections and the preparation of final surgical pathology reports and by providing support to clinicians and patients during on-call assignments.

Evaluation:

• Rotation evaluation
• 360o Global evaluation

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

• Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest with prompt response and accountability to calls for frozen sections, from faculty and clinicians, and while on-call.
• Exhibit a commitment to excellence and on-going professional development by utilizing study materials within the department including the slide file, the image database, books and journals for their own professional advancement.
• Demonstrate a commitment to ethical principles pertaining to the practice of pathology, confidentiality of patient information, informed consent, and business practices.
• Demonstrate appropriate behavior with the faculty, clinicians, peers, and the administrative, technical and clerical staff of the hospital.

Evaluation:

• Rotation evaluation
• 360o Global evaluation

SYSTEMS BASED PRACTICE

•  Residents must demonstrate an awareness and responsiveness to the larger context of the system of health care and the ability to call on system resources to provide pathology services that are of optimal value.
• Residents are expected to comprehend how their own surgical pathology diagnoses affect health care decisions for patients and the health care system.
• Discuss how the various types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
• Practice cost-effective health care and resource allocation that does not compromise quality of care, while understanding the need for and cost of special stains, immunohistochemistry and other adjunct techniques.
• As senior residents attend QA committee meetings to discuss how to partner with the administrative and technical staff to assess, coordinate, and improve health care and know how these activities affect system performance.
• Residents may also inspect the section of anatomic pathology during a CAP inspection.

Evaluation:

• 360o Global evaluation

Supervisory Guidelines for Patient Care and Specimen Handling

The resident discusses each specimen with the supervising faculty member prior to its dissection, including documentation of relevant prognostic information, the approach to the specimen, and procurement of tissues in special fixatives or frozen, if necessary. The faculty members and pathologist assistant supervise gross room operation. It is the resident’s responsibility to handle all cases in the gross room with the assistance of the supervising faculty. The faculty pathologist is responsible for the final diagnoses of all surgical pathology cases.

The on service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager. At all times, a supervising faculty member is on-call for evening and weekend questions. No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

Daily Duties and Responsibilities - Surgical Pathology

Based on their level of training, residents are provided increasing autonomy with close faculty supervision. The residents have the responsibility of grossing the specimens, which come into the laboratory on their designated days. This includes the dictation of the clinical history, gross features of the specimen, and the appropriate sampling of any lesions. The residents also participate in any special procedures performed at this time, such as gross photography, sampling of tissue for electron microscopy, cell surface markers, cytogenetics, and tissue banking.

On the subsequent day, the residents are required to review the microscopic findings of each specimen grossed. Residents are expected to preview as many of their cases as possible prior to signing them out with faculty in concordance with their level of training. With faculty guidance, residents are responsible for deciding what additional ancillary studies may be necessary in order to complete each case.

Each resident will be graded as to “agree, partially agree, or disagree” for each microscopic diagnosis and gross description/dissection. The resident will receive a written evaluation with summary statistics for him/herself compared to the overall resident mean. In addition to feedback provided at the time their cases are signed out, the resident can review selected cases in which he/she had a discrepancy with the faculty pathologist by requesting a print-out of such cases from Mr. Ed Gray, the informational technology specialist for Co-Path. The number of cases previewed independently and the accuracy of both gross descriptions and microscopic diagnoses as measured by percentage agreement and the rotation evaluation are expected to increase with increasing resident seniority.

Fellows follow basically the same schedule as residents; however, they are also expected to assist in teaching more junior residents in the Gross Room. In addition, fellows may preview their cases and hand these to the supervising faculty when completely worked up. While they do not need to review each case directly with the attending faculty, they are expected to review all cases for which they have questions. Fellows will be expected to function with minimal discrepancies with the faculty.

Opportunities to Function as Consultant to Other Physicians

Residents have the responsibility, under faculty supervision, of discussing the interpretive consultative reports and frozen sections with appropriate members of the clinical/surgical teams. Through their discussions with the clinical team members, the residents have the opportunity to directly impact patient care. Other departments on the WVUH campus, with ACGME approved post graduate training programs include, but are not limited to the following: Anesthesiology, Internal Medicine, Family Practice, Neurosurgery, Obstetrics & Gynecology, Ophthalmology, Otolaryngology, Orthopedic Surgery, Pediatrics, Radiology, Surgery, and Urology.

• During the rotation the residents are exposed to laboratory correlation studies. These will include, but are not limited to, the following:
• Correlation of fine needle aspiration studies with subsequent surgical pathology specimens.
• Correlation of cervical Pap test findings with cervical biopsies.
• Correlation of ancillary studies with histology in the work-up of lymphomas and hematologic disorders.
• Correlation of liver function tests with liver biopsies.
• Correlation of X-rays with bone tumor biopsies.

On Call Duties:

West Virginia University Hospital

• The residents communicate with surgeons and others who require frozen sections or rush processing for specimens on evenings and weekends.
• The residents accession, perform gross evaluation, dissection and description, and selection of blocks for freezing or rush processing.
• Residents freeze tissue, cut frozen sections and stain frozen section slides.
• Residents assist the faculty in reaching an accurate frozen section or rush diagnoses, formulating their own opinion prior to faculty review whenever possible.
• Residents communicate results of frozen sections and rush cases to the clinical staff and answer questions about the diagnostic and prognostic implications.

During this rotation the residents will on average have at least one out of every seven days free of hospital duties. Due to the at-home nature of call and the limited number of emergencies, the call duties are constructed in the following fashion. The residents are on at-home/pager call every other to every third week. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday. While on-call, residents are supervised by a West Virginia University Teaching Faculty Member, who is available at all times, either via their office phone, pager, or home phone. On-call activities are reviewed with the residents on an on-going basis as evening and weekend calls are received. A faculty member is always present when a final diagnosis is established and at any time before, as necessary.

During the on-call period, the resident is responsible for handling clinical requests that arise during off hours, emergent operating room consultations, weekend rush biopsies, emergency off-hour autopsies with the approval of the on-call staff pathologist, and routine weekend autopsies that present before 2:00 P.M.

Charleston Area Medical Center

Same as WVUH except that there is no weekend on-call rotation.

Communication with On-duty Faculty

During general working hours, the on-service teaching faculty is available in person; other faculty members are available by scheduled appointment, by phone, by pager. During the on call hours, the on-call teaching faculty is continuously available either at home by phone or by pager.

Structured Education and Management of the Surgical Pathology Laboratory

The residents attend scheduled quality assurance, laboratory safety, and other appropriate staff meetings, as they relate surgical pathology. As opportunity provides, residents will be allowed to participate in CAP laboratory accreditation activities, including self-inspections and inspections of other institutions. Residents are urged to attend an Inspection Training Course provided by the CAP.