The four years of combined Anatomical Pathology/Clinical Pathology (AP/CP) training includes 27 months of required rotation in anatomic pathology, 15 months in clinical pathology and 6 months of electives (must include 3 months of CP to satisfy 18 month anatomic board requirement).

First year residents have primary responsibility for autopsy pathology and make use of this opportunity to develop skills in gross and microscopic examination and clinicopathologic correlation. While on autopsy rotation, first-year residents also assist with intraoperative consultations (including frozen sections) on the surgical pathology service. Surgical pathology rotations, per se, begin in the latter part of the first year. Clinical pathology also commences in the first year, typically with a major three-month rotation. The remaining three years contain a mix of AP and CP rotations, both required and elective, tailored to the needs and interests of each resident within the constraints of the staffing requirements of the autopsy and surgical pathology services. The bulk of the elective time is typically reserved for the third and fourth years and may be used for research or clinical rotations.

Surgical Pathology

Overview

1 (first year of training) 

Description:

In surgical pathology training, the resident will accompany the staff pathologist in intraoperative consultations. If a frozen section is required, the resident will participate in the preparation, interpretation, and reporting of the diagnosis to the surgeon. Subsequently, the resident will review the permanent tissue sections and additional tissue and other specimens obtained from the patient with the staff pathologists. The dual viewing microscope is used to maximize the educational value of the exercise.

The resident will also describe and take appropriate tissue sections from surgical specimens submitted to the laboratory for examination during his/her rotation on this service. With progressively increasing responsibility, s/he will be responsible for the proper examination of the full range of tissues submitted for diagnosis. As the permanent slides become available, the resident and the staff pathologist will examine the tissue together and make the diagnosis at the microscope.

Pertinent articles in the literature are made available to or obtained by the resident to be read and discussed with a staff member; laboratory collections of slides and related educational material are assigned. Knowledge of specific surgical procedures is also required to permit the resident to understand the needs of his/her surgical colleagues in evaluating tissue specimens with a view of planning therapy. Because the immediate practical diagnostic skills in pathology and the development of correlation of laboratory data and clinical medicine are so closely intertwined with basic knowledge of biology, throughout the course of training, exercises involving individual reading assignments, attendance at colloquia and lectures available in the hospitals or on the Brown University campus, assigned reading, medical and surgical grand rounds, and other educational opportunities are utilized by the residents beyond the information required solely for diagnosis. Schedules of all such activities in all of the hospitals affiliated with Brown and pertinent campus educational opportunities are prepared and distributed at regular intervals during the Program.

The first year rotation is intended as a hands-on introduction to procedures in the surgical pathology laboratory. The function of the rotation is largely to prepare residents for subsequent apprenticeships in surgical pathology. The second year rotation is structured to emphasize exclusively gross pathology in the first month with minimal emphasis on microscopic exam. The second month divides a residents' time equally between gross and microscopic examination and the third month provides more emphasis on microscopic examination. This emphasis is maintained through third and fourth year rotations in which residents' progress in responsibility and in the complexity of cases and procedures assigned to them.

Residents are evaluated on their progress in describing surgical specimens and taking meaningful tissue specimens for microscopy. He/she is judged by growth in skills as a microscopist as well as knowledge of the many biological variations that pathologists must consider when examining tissue specimens.

At all times, the resident will invite consultation with his surgical colleagues, demonstrate specimens on request, and participate in teaching sessions of the departments of medicine, surgery, OB/GYN, and pediatrics as a contribution to their teaching programs. From the outset, after an initial period of accompanying a staff pathologist, the resident will go to the operating room alone and receive the specimen from the surgeon. At this time, residents are expected to gather information relative to the location and nature of the clinical problem and attend to the specific questions asked by the surgeon. If a frozen section is required for diagnosis, the resident will select the appropriate area of the specimen with the aid of the staff pathologist and prepare a frozen section for examination. This tissue is examined at the same time by resident and staff pathologist and, by example, the resident will learn how to communicate most effectively with surgeons awaiting diagnosis for essential decision making. The necessity for careful gross examination of the excised specimen, the selection of specific areas of the tissue, the technical details for obtaining appropriate sections, and the interpretation of less than optimal tissue are specifically emphasized in the working relationship that develops between the resident and the staff pathologist. Ancillary procedures to aid in diagnosis will also be taught.

It is anticipated that all residents will learn tissue preparation for, and operation of, the transmission electron microscope during their anatomic pathology training and concurrently will see demonstrations of and learn to perform histochemical and immunohistochemical procedures appropriate to surgical pathology. Each specimen is "signed out" jointly using a dual viewing microscope with direct teaching of the resident to explain the diagnostic features that lead to the diagnosis. Residents will also be taught the proper means of reporting inconclusive and inadequate specimens. Evaluating the need for collegial and expert consultation and the means of reporting consultations also are taught.

Each resident, while on the appropriate anatomic pathology rotation, will learn to prepare and interpret frozen sections of renal and muscle biopsies stained by immunofluorescence methods and will learn to prepare tissues for electron microscopy for interpretation of cutaneous, renal, muscle, and neoplastic diseases. During the training in surgical pathology, the laboratories' collections of surgical pathology slides representing uncommon lesions are studied by the residents and reviewed with pathology faculty.

Regular participation in slide conferences is required. Numerous pathology specialty conferences are held in the affiliated hospitals. Residents are encouraged to attend meetings of the Rhode Island and the New England Pathology and Pathology Resident societies, particularly the slide review sessions.

Attendance at local/national meetings is encouraged and supported in the form of appropriate funds (specific amount noted in benefit package distributed each training year).

Goals and Competencies

Year 1 

1. Patient Care:

  1. The resident should become familiar with the techniques and protocols of processing and grossing most major common specimens as detailed in the Surgical Pathology Manual.
  2. By the end of the rotation, the resident should be able to dictate and perform a concise, yet comprehensive gross examination for common specimens.
  3. The resident is expected to develop grossing and sectioning skills and be able to gross all routine cases on the day of accession and process all large specimens for overnight fixation to be grossed on the following day.
  4. The resident must participate in intraoperative consultations and preparation of frozen sections and touch preparations when assigned. The resident is also expected to review the clinical history and prior biopsy material for all patients requiring frozen section. Slides should be brought to the surgical suite for review during intraoperative consultations. At the end of the rotation, the resident should be able to address basic intraoperative issues that are common in surgical pathology, and be able to effectively communicate with the surgical staff.
  5. The resident will become competent in the gross and microscopic photography of specimens.
  6. The resident is expected to collect and interpret pertinent clinical information and laboratory data from Lifelinks or discussions with clinicians prior to sign-out
  7. The resident should gain an initial exposure to how surgical pathology reports are formulated and signed-out, including the use of proper diagnostic terms and the process of coding. Reports should reflect an accurate and specific diagnosis, when possible, and should be corrected for spelling, grammar, and punctuation before sign-out.

2. Medical Knowledge:

  1. By completion of the first year rotation, residents should master the gross anatomy of common pathology specimens and be able to grossly identify common benign and malignant lesions.
  2. The resident is expected to review and master normal histology and become competent at microscopic description.
  3. The resident should develop basic diagnostic skills in surgical pathology and biopsy specimens, including most inflammatory lesions.
  4. The resident should begin to master more complicated specimens, including breast, colon, lung, kidney, and prostate carcinomas.
  5. The resident should understand the indications and use of common special stains.
  6. The resident is expected to demonstrate evidence of reading at the textbook level and begin to review the current surgical pathology literature.

3. Interpersonal and Communication Skills:

  1. The resident should learn to communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
  2. The resident should learn to communicate effectively with the pathology staff concerning individual cases, keeping in mind that the staff pathologist will often depend on the resident for complete and accurate gross examination of specimens as well as any clinical information obtained from clinicians.
  3. Politeness, discretion, and honesty are paramount in preserving a positive working relationship among professionals. Patient care depends on all these factors.

4. Practice-Based Learning and Improvement:

  1. Attend gross conferences, tumor boards, clinicopathologic conferences, as well as grand rounds in various clinical departments.
  2. First year residents are required to attend Rhode Island Hospital Joint Oncology Conferences when on rotations at the hospital, and are expected to attend weekly Tumor Board and Morbidity and Mortality conferences when at the Miriam Hospital.
  3. Research difficult cases prior to sign-out.
  4. Gain confidence in formulating surgical pathology final diagnoses prior to sign-out with the attending and sign out all cases that are grossed by the resident.

5. Professionalism:

  1. The resident must follow the highest standards of professionalism and ethics:
  2. Show respect for patients and their families as well as all members of the health care team in the pathology department and other departments.
  3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases in private areas.
  4. When in doubt about a particular work assignment, consult the attending pathologist.
  5. Perform all work assignments with diligence, accuracy, and timeliness.

6. Systems-Based Practice:

  1. Become familiar with the software used to accession cases and generate surgical pathology reports, and be able to access pertinent patient information.
  2. Become familiar with the processing of tissue in the histology laboratory.
  3. Understand the role of pathology in the practice of medicine and attend clinicopathologic conferences.

Year 2

1. Patient Care:

  1. The resident should be able to describe and perform the technique for processing and grossing most major specimens as detailed in the Surgical Pathology Manual as well as identify specimens that require assistance from senior residents or attending pathologists.
  2. By the end of the rotation, the resident should be able to dictate and perform a concise, yet comprehensive gross examination for most surgical specimens.
  3. The resident should be willing to begin to assist more junior residents.
  4. The resident is expected to gross all routine cases on the day of accession and process all large specimens for overnight fixation to be grossed on the following day.
  5. The resident must participate in intraoperative consultations and preparation of frozen sections and touch preparations when assigned. The resident is also expected to review the clinical history and prior biopsy material for all patients requiring frozen section. Slides should be brought to the surgical suite for review during intraoperative consultations. The resident should be able to address basic intraoperative issues, formulate diagnoses with the assistance of the pathologist, and be able to effectively communicate with the surgical staff.
  6. The resident will master the gross and microscopic photography of specimens.
  7. The resident will become comfortable with the process of surgical pathology reporting. Reports should reflect an accurate and specific diagnosis, when possible, and should be corrected for spelling, grammar, and punctuation before sign-out.
  8. The resident should take additional responsibility for the completeness of information brought to sign-out, including adequacy of histologic sampling, selection of basic special studies, and gathering of necessary clinical information from Lifelinks or discussions with clinicians.

2. Medical Knowledge:

  1. By completion of the second year rotation, residents should master the gross anatomy of most pathology specimens and be able to grossly identify lesions.
  2. The resident should be able to competently formulate the microscopic description of most lesions.
  3. The resident should develop diagnostic skills in the sign-out of biopsy cases.
  4. The resident should gain diagnostic skills for more complicated specimens, including differentiating pre-malignant from in situ malignant lesions.
  5. The resident is expected to formulate a working diagnosis and differential diagnosis for complicated cases.
  6. The resident should understand the indications and use of common special stains and immunohistochemical markers to assist diagnosis.
  7. The resident is expected to demonstrate evidence of reading at the textbook level and demonstrate use of the current surgical pathology literature to solve diagnostic problems.

3. Interpersonal and Communication Skills:

  1. The resident should be able to communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
  2. The resident should be able to communicate effectively with the pathology staff concerning individual cases, keeping in mind that the staff pathologist will often depend on the resident for complete and accurate gross examination of specimens as well as any clinical information obtained from clinicians.
  3. Politeness, discretion, and honesty are paramount in preserving a positive working relationship among professionals. Patient care depends on all these factors.

4. Practice-Based Learning and Improvement:

  1. Attend gross conferences, tumor boards, clinicopathologic conferences, as well as grand rounds in various clinical departments. Residents should also attend departmental subspecialty pathology conferences when possible (ENT, GI, Hematology, Renal, Dermatology, Bone, etc.)
  2. Second year residents are required to present surgical cases at the Rhode Island Hospital Joint Oncology Conferences, and are expected to attend weekly Tumor Board and Morbidity and Mortality conferences when at the Miriam Hospital.
  3. Residents are expected to research difficult cases using the current surgical pathology literature prior to sign-out.
  4. Formulate surgical pathology final diagnoses and a differential diagnosis for more difficult cases prior to sign-out with the attending and sign out all cases that are grossed by the resident.
  5. Residents should be able to identify areas in need of investigation and formulate methods that might be used to solve research questions.

5. Professionalism:

  1. The resident must follow the highest standards of professionalism and ethics:
  2. Show respect for patients and their families as well as all members of the health care team in the pathology department and other departments.
  3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases in private areas.
  4. When in doubt about a particular work assignment, consult the attending pathologist.
  5. Perform all work assignments with diligence, accuracy, and timeliness.

6. Systems-Based Practice:

  1. The resident will master the software used to accession cases and generate surgical pathology reports, and be able to access pertinent patient information.
  2. The resident will develop an advanced understanding of the processing of tissue in the histology laboratory.
  3. Understand the role of pathology in the practice of medicine and attend clinicopathologic conferences.

Year 3

1.    Patient Care:

  1. The resident should be able to gross and dictate all surgical specimens with little direct supervision and be able to process all surgical and biopsy specimens.
  2. The resident should help to supervise junior residents and students on the rotation.
  3. The senior resident is expected to serve as a liaison between residents and faculty for difficult cases and problems and to solve basic problems that arise in the surgical suite.
  4. The resident is expected to gross all routine cases on the day of accession and process all large specimens for overnight fixation to be grossed on the following day.
  5. The resident must participate in intraoperative consultations and preparation of frozen sections and touch preparations when assigned. The resident is also expected to review the clinical history and prior biopsy material for all patients requiring frozen section. Slides should be brought to the surgical suite for review during intraoperative consultations. The resident is expected to formulate diagnoses for review with the attending pathologist, and be able to effectively communicate with the surgical staff.
  6. The resident will gain confidence with the process of surgical pathology reporting. Reports should reflect an accurate and specific diagnosis, when possible, and should be corrected for spelling, grammar, and punctuation before sign-out.
  7. The resident should take responsibility for the completeness of information brought to sign-out, including adequacy of histologic sampling, selection of basic special studies, and gathering of necessary clinical information from Lifelinks or discussions with clinicians.

2. Medical Knowledge:

  1. The third year resident should improve the diagnostic acumen to a high level of competence.
  2. The resident should be able to formulate a diagnosis for most complicated specimens and provide a differential diagnosis when appropriate.
  3. The resident should become aware of his or her limitations and the complexity of surgical pathology.
  4. The resident should be able to select and order pertinent special stains and immunohistochemical markers to assist diagnosis.
  5. The resident is expected to demonstrate understanding of the current surgical pathology literature and identify controversies in diagnostic pathology.

3. Interpersonal and Communication Skills:

  1. The resident is expected to teach junior residents both gross and microscopic pathology.
  2. The resident should be able to communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
  3. The resident should be able to communicate effectively with the pathology staff concerning individual cases, keeping in mind that the staff pathologist will often depend on the resident for complete and accurate gross examination of specimens as well as any clinical information obtained from clinicians.
  4. Politeness, discretion, and honesty are paramount in preserving a positive working relationship among professionals. Patient care depends on all these factors.

4. Practice-Based Learning and Improvement:

  1. Attend gross conferences, tumor boards, clinicopathologic conferences, as well as grand rounds in various clinical departments. Residents should also attend departmental subspecialty pathology conferences when possible (ENT, GI, Hematology, Renal, Dermatology, Bone, etc.)
  2. Third year residents are required to present surgical cases at the Rhode Island Hospital Joint Oncology Conferences, and are expected to attend and present cases at the weekly Tumor Board conferences when at the Miriam Hospital.
  3. Residents are expected to research difficult cases using the current surgical pathology literature prior to sign-out and identify major controversies in the literature.
  4. Formulate surgical pathology final diagnoses and a differential diagnosis for more difficult cases prior to sign-out with the attending and sign out all cases that are grossed by the resident.e. Residents should be able to identify areas in need of investigation and become involved in research with a faculty mentor.

5. Professionalism:

  1. The resident must follow the highest standards of professionalism and ethics:
  2. Show respect for patients and their families as well as all members of the health care team in the pathology department and other departments.
  3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases in private areas.
  4. When in doubt about a particular work assignment, consult the attending pathologist.
  5. Perform all work assignments with diligence, accuracy, and timeliness.

6. Systems-Based Practice:

  1. The resident will master the software used to accession cases and generate surgical pathology reports, and be able to access pertinent patient information.
  2. The resident will develop an advanced understanding of the processing of tissue in the histology laboratory.
  3. Understand the role of pathology in the practice of medicine and attend clinicopathologic conferences.

Year 4

1. Patient Care:

  1. The resident should be able to gross and dictate all surgical specimens with little direct supervision and be able to process all surgical and biopsy specimens, knowing when to ask for help.
  2. The resident should function essentially as a junior colleague of the faculty and supervise junior residents and students on the rotation.
  3. The senior resident is expected to serve as a liaison between residents and faculty for difficult cases and problems and to solve most problems that arise in the surgical suite, i.e., act as a "Chief Resident" in the surgical suite.
  4. The resident is expected to gross all routine cases on the day of accession and process all large specimens for overnight fixation to be grossed on the following day.
  5. The resident must participate in intraoperative consultations and preparation of frozen sections and touch preparations when assigned. The resident is also expected to review the clinical history and prior biopsy material for all patients requiring frozen section. Slides should be brought to the surgical suite for review during intraoperative consultations. The resident is expected to formulate diagnoses for review with the attending pathologist, and be able to effectively communicate with the surgical staff.
  6. The resident should master the process of surgical pathology reporting. Reports should reflect an accurate and specific diagnosis, when possible, and should be corrected for spelling, grammar, and punctuation before sign-out.
  7. The resident will take responsibility for the completeness of information brought to sign-out, including adequacy of histologic sampling, selection of basic special studies, and gathering of necessary clinical information.

2. Medical Knowledge:

  1. The fourth year resident should have high level of diagnostic competence.
  2. The resident should be able to formulate a diagnosis for almost all complicated specimens and provide a differential diagnosis when appropriate.
  3. The resident should be aware of his or her limitations and the complexity of surgical pathology.
  4. The resident should be able to select and order pertinent special stains and immunohistochemical markers to assist diagnosis.
  5. The resident is expected to demonstrate an extensive understanding of the current surgical pathology literature and to identify controversies in diagnostic pathology.

3. Interpersonal and Communication Skills:

  1. The resident is expected to teach and troubleshoot for junior residents for both gross and microscopic pathology.
  2. The resident should communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
  3. The resident should communicate effectively with the pathology staff concerning individual cases, keeping in mind that the staff pathologist will often depend on the resident for complete and accurate gross examination of specimens as well as any clinical information obtained from clinicians.
  4. Politeness, discretion, and honesty are paramount in preserving a positive working relationship among professionals. Patient care depends on all these factors.

4. Practice-Based Learning and Improvement:

  1. Attend gross conferences, tumor boards, clinicopathologic conferences, as well as grand rounds in various clinical departments. Residents should also attend departmental subspecialty pathology conferences when possible (ENT, GI, Hematology, Renal, Dermatology, Bone, etc.)
  2. Fourth year residents are required to present surgical cases at the Rhode Island Hospital Joint Oncology Conferences, and are expected to attend and present cases at the weekly Tumor Board conferences when at the Miriam Hospital.
  3. Residents are expected to research difficult cases using the current surgical pathology literature prior to sign-out and identify major controversies in the literature.
  4. Formulate surgical pathology final diagnoses and a differential diagnosis for more difficult cases prior to sign-out with the attending and sign out all cases that are grossed by the resident.
  5. Residents should be involved in research with a faculty mentor and presenting their findings at a national meeting.

5. Professionalism:

  1. The resident must follow the highest standards of professionalism and ethics:
  2. Show respect for patients and their families as well as all members of the health care team in the pathology department and other departments.
  3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases in private areas.
  4. When in doubt about a particular work assignment, consult the attending pathologist.
  5. Perform all work assignments with diligence, accuracy, and timeliness.

6. Systems-based Practice:

  1. The resident has mastered software used to accession cases and generate surgical pathology reports, and is able to identify limitations of current software.
  2. The resident has an advanced understanding of the processing of tissue in the histology laboratory.
  3. Understand the scope of pathology in the practice of medicine and attend and contribute in clinicopathologic conferences.

Specific Requirements

  • Consultation: Clinical consultation is central to the quality practice of surgical pathology. Residents interact with staff, fellow residents and referring physicians regarding the findings and interpretation of clinical specimens. Residents enter the operating room to pick up specimens and communicate Frozen Section results (Lifespan). Residents present cases at interdisciplinary tumor boards (Lifespan, MHRI, WIH), morning report (TMH), and morbidity and mortality conferences (TMH). They present cases to one another in slide conferences (Monday 9:30a-10:30a) and at Residents' Hour (Friday 4:00p-5:00p).
  • Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility. They are also expected to develop expertise in the gross description and examination of specimens and their submission to the histology laboratory. While residents are supervised in all aspects of these procedures the level of autonomy and responsibility is increased with their experience and documented level of competence.
  • Required Departmental Conferences: side review and presentation conferences: Lifespan Monday 9:30a-10:30a required; Residents' Hour Friday 4:00p-5:00p Lifespan required; rotation specific conferences (Lifespan, WIH, MHRI)
  • Required Interdepartmental Conferences: Tumor Board (rotation and institution specific); Clinical Pathologic Conference TMH; Morbidity and Mortality Conference TMH (when pathology is presented); Medicine Morning Report TMH (when pathology is presented)
  • Objective Evaluation: Practical examination at the completion of the rotation with preparation of SP reported based on clinical history, gross description, and microscopic slides. 
Renal Pathology / EM

Overview

1 month, Lifespan, elective AP

Description:

Renal 

This rotation focuses on the diagnosis of renal biopsies utilizing clinical data, histology, ultrastructure, and immunofluorescence. Clinical correlation is strongly emphasized and is solidified at the multidisciplinary Renal Biopsy Conferences. An introduction to EM techniques is included but is not strongly emphasized.

Electron Microscopy 

This rotation permits residents to learn electron microscopy in substantial detail with the opportunity to complete a small project in the laboratory. Technical aspects of sample preparation and examination are emphasized along with the utility of EM in various clinical situations. 

 

Goals and Competencies

1. Patient Care

  1. Residents preview cases prior to faculty sign-out and formulate their own diagnoses.
  2. Residents are expected to perform more independently and accurately as they progress through their training
  3. Residents gather essential and accurate clinical information about the patients on whom they receive surgical specimens, including discussing histories with clinical house staff and/or attending faculty members.
  4. Residents should know how to gross and dissect renal biopsy when needed
  5. Residents should know how to use available information technology (hospital and laboratory information systems, internet-based literature searches)
  6. To help educate clinicians by providing relevant literature references.
  7. The resident should have the ability to prepare and present cases for renal pathology conference.

2. Medical Knowledge

  1. Understands electron microscopic techniques and their application to anatomic pathology
  2. Can effectively integrate clinical, morphologic, and ultrastructural data to reach a pathologic diagnosis
  3. Residents demonstrate an investigatory and analytical thinking approach to clinical situations
  4. Development of reasonable and complete differential diagnoses for renal pathology cases based on the available clinical information, textbook and current published literature.
  5. Formulation of a comprehensive, cohesive, and coherent microscopic description
  6. Encouraged to participate in clinicopathologic research projector case report with literature review.
  7. Residents demonstrate the knowledge and application of the basic and clinically supportive sciences which are appropriate to the specialty of renal pathology
  8. Demonstration of familiarity with the clinical presentations and manifestations of various common renal diseases
  9. Demonstration of familiarity with basic histopathology, immunofluorescence and electron microscopy of common renal disease.

3. Practice-Based Learning and Improvement

  1. 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.
  2. Residents are expected to learn the use and interpretation of ancillary modalities for the diagnosis of medical renal disease in biopsy specimens, including immunofluorescent detection of immunoglobulin, complement and fibrinogen, immunohistochemistry, and special histological stains (PAS, silver and trichome).
  3. Residents should be able to analyze practice experience that includes participation in kidney biopsy conferences, evaluating final reports for accuracy and pertinent clinical correlations
  4. Residents should become familiar with computer based literature researches relevant to their specific cases.
  5. Residents should be able to perform data base searches for analysis and comparison with their case material.
  6. Residents should become familiar with methods and approaches to design their own research projects.

4. Interpersonal and Communication Skills

  1. The resident should learn to communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
  2. The resident should learn to communicate effectively with the pathology staff concerning individual cases, bearing in mind that the attending pathologist will often depend on the resident for any clinical information obtained from clinicians.
  3. Residents should be able to communicate final results to clinicians effectively.
  4. Residents should develop the habit of seeking consultations from pathology and clinical staff with respect to specific findings in order to better understand their clinical significance.
  5. Learn proper terminology for microscopic descriptions of renal biopsy

5. Professionalism

  1. The resident must follow the highest standards of professionalism and ethics.
  2. Show respect for patients and members of the healthcare team in the pathology department and other departments.
  3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases only in private areas.
  4. Perform all work assignments with diligence, accuracy and timeliness.
  5. Residents are mentored to respect and understand the feelings and dynamics of others, to adhere to departmental rules regarding confidentiality and communicate with discretion.
  6. In conferences, they learn the process of presenting cases in a professional manner which includes polite concise discussion, the importance of preparation and acknowledging the efforts of other members of the team.
  7. Demonstrate appropriate behavior with the faculty, clinicians, peers, and the administrative, technical and clerical staff of the hospital.

6. Systems-Based Practice

  1. The resident develops knowledge of the hospital and departmental information systems, applying these tools to renal assignments.
  2. Rather than sign out a case with incomplete clinical information, the resident is expected to go to "EPIC" to read the patient's history, physical, laboratory and radiological data.
  3. The resident may be included in discussions of acquiring new instrumentation

Specific Requirements

Renal 

  • Consultation: Accurate diagnosis of renal biopsies depends critically on clinical data and ancillary studies. Close interaction with nephrologists and pathologists is essential for the process to work.
  • Clinical Correlation: Clinical correlation is central in this rotation and is emphasized at the multidisciplinary Renal Biopsy Conferences.
  • Quality Assurance: Limited, this specialty rotation falls under the quality control and quality assurance plan of the surgical pathology laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Conferences: Slide Review Conference (Lifespan)
  • Required Interdepartmental Conferences: Renal Biopsy Conference
  • Objective Evaluation: direct evaluation by the preceptors

EM 

  • Consultation: Primarily limited to referring pathologists in terms of appropriateness of EM testing and interpretation of results.
  • Clinical Correlation: Correlation of ultrastructural findings with surgical pathology and laboratory data is emphasized.
  • Quality Assurance: Residents are expected to gain an understanding quality assurance procedures relevant to an electron microscopy laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They are also expected to develop some technical expertise in the preparation and examination of specimens and to undertake a small project in the laboratory
  • Required Departmental Conferences: none
  • Required Interdepartmental Conferences: none
  • Objective Evaluation: independent project and/or practical examination with photomicrographs
Perinatal Pathology

Overview

1 month, WIH, AP required, year 2

Description:

Rotations to the Department of Pathology and Laboratory Medicine at The Women and Infants' Hospital are provided for all residents to study obstetric, fetal, and neonatal anatomic and clinical pathology. Embryopathology, causes of wastage in pregnancy, later fetal loss, neonatal diseases, childhood tumors, infection both in utero and in early childhood, disorders of immunity, hereditary disorders (morphologic and functional) and non-hereditary malformations and functional defects are emphasized. The methods used in Developmental and Pediatric Pathology are essentially the same as for general pathology. A pediatrician's approach to examining the external features is emphasized. Special techniques such as injections with radiopaque or colored plastic or other liquid materials in vessels, hollow viscera, are used to advantage. Approximately 100 autopsies are performed annually. Of these, 60% are liveborn neonates and children with a variety of illnesses, congenital and acquired. The remaining 40% of the patients are stillborns, also with a variety of congenital and acquired lesions. With this number of autopsies, a trainee who spends two-three months will have the opportunity to examine about 10 autopsies of fetuses, newborns, and children. An approximately equal number of fetuses are examined in the surgical material.

All placentas from infants or fetuses with fetal distress, birth asphyxia, meconium staining, suspected infection, maternal disease, normal twins or triplets or other multiple births, and primary placental abnormalities are examined. This results in examination of about 3000 placentas per year. Residents are trained in the routine gross and microscopic placental examination. Electron microscopy of the selected placentas is also performed.

Embryos are also examined. Malformed embryos have been revived as material for hospital pathologic study, having been relegated in the past to the interest of academic embryologists. The current resurgence of interest is due to in vitro human conception and other such advances.

Goals and Competencies

1. Patient Care:

  1. Be able to extract relevant and accurate information from the hospital charts of mother and infant
  2. Be able to interpret prenatal laboratory tests within the clinical context
  3. Be familiar with the laws regarding permission for perinatal autopsies in the State of Rhode Island
  4. Be able to independently perform a basic perinatal autopsy; characterize the main macroscopic findings; compose a provisional anatomic diagnosis of autopsy findings within 24 hours; compose a final anatomic diagnosis including clinicopathological correlations and mechanistic interpretations within 30 days after completing the postmortem examination; assess the relevance of the findings for current and future pregnancies; evaluate the need for additional studies and/or counseling
  5. Demonstrate respect for human remains and foster this attitude among other personnel
  6. Be able to perform gross and microscopic examination of products of conception (POC); understand the clinical context of POC diagnoses; understand the importance of specific diagnoses (e.g. negative POC, gestational trophoblastic disease) for patient care
  7. Be able to perform gross and microscopic examination of the placenta; understand the clinical context of placental diagnoses; understand the importance of selected diagnoses (e.g. marked acute chorioamnionitis with vasculitis, diffuse villitis) for patient care
  8. Communicate effectively with the medical staff and, if indicated, the patients/parents
  9. Demonstrate respect for the confidentiality of patient information

2. Medical Knowledge

  1. Be familiar with the technical aspects of the perinatal autopsy (radiography, biometry, photography, bacterial and viral cultures, cytogenetics studies)
  2. Be able to identify the presence and degree of maceration; be able to interpret the degree of maceration in function of clinical context
  3. Understand the proper use and interpretation of ancillary studies that must be anticipated at the time of autopsy including microbiology, toxicology, cytogenetics, metabolic and molecular diagnostics
  4. Be familiar with the etiology, diagnosis and treatment of common congenital, chromosomal, metabolic and infectious perinatal diseases; be able to use this knowledge in the formulation of differential diagnoses
  5. Be able to recognize and interpret complications of prematurity
  6. Have detailed knowledge of normal human embryology and anatomy
  7. Be familiar with the medicolegal aspects of the perinatal autopsy
  8. Demonstrate suitable gross and microscopic skills for identification and diagnosis of products of conception; be familiar with the availability and interpretation of techniques for chromosome studies in spontaneous abortions (cytogenetics and FISH); be able to diagnose gestational trophoplastic disease (histopathology, flow cytometry)
  9. Be able to recognize gross and microscopic patterns of common placental lesions; understand their clinical relevance
  10. Be familiar with the medicolegal aspects of the placental examination

3. Practice-Based Learning and Improvement

  1. Research cases prior to sign-out; be familiar with computer-based literature searches relevant to the case; be familiar with existing Internet databases in fields relevant to Perinatal Pathology
  2. Develop confidence in formulating diagnoses (autopsy, POC and placenta) prior to sign-out
  3. Attend conferences and seminars on topics relevant to Perinatal Pathology
  4. Research: Identify areas of potential investigation; formulate methods appropriate to carry out a potential research project (optional)

4. Interpersonal and Communication Skills:

  1. Recognize the need to immediately communicate "critical values" to the treating clinicians
  2. Communicate effectively with the medical staff (obstetricians, perinatologists, neonatologists, pathologists from referring hospitals), both to collect and transmit information relevant to patient care
  3. Communicate effectively, empathetically and respectfully with the patients/parents (if indicated)
  4. Prepare complete, concise and accurate provisional and final autopsy reports in a timely manner
  5. Develop a habit to seek consultations from fellow pathologists and/or clinicians with respect to specific autopsy findings in order to better interpret their clinical significance
  6. Be able to present placental and autopsy cases at clinical management conferences; prepare and deliver effective presentations

5. Professionalism:

  1. Appreciate the role of ancillary staff: pathology assistants, histology technicians, transcriptionists
  2. Perform all assignments with diligence, accuracy and timeliness
  3. Maintain patient confidentiality at all times
  4. Admit, rectify, and learn from mistakes
  5. Attend and participate in rounds, conferences, meetings and rotation in a punctual, consistent manner
  6. Know the regulations governing the safe practice of autopsy pathology including those related to exposure to blood-borne and airborne pathogens and formaldehyde
  7. Know the proper use of protective equipment for the practice of autopsy pathology
  8. Know special circumstances related to autopsy of members of different ethnic and religious group

6. Systems-Based Practice:

  1. Understand the role of perinatal pathology (perinatal autopsy, examination of POC and placenta) in the practice of medicine, especially in the area of obstetrics/gynecology and neonatology/pediatrics
  2. Be able to practice a cost-effective approach to the perinatal autopsy with respect to the appropriate utilization of ancillary studies including molecular and cytogenetics
  3. Be familiar with the hospital information system used to generate pathology reports and be able to access patient information
  4. Practice autopsy and placental pathology for off-site affiliated hospitals providing the same levels of communication with clinicians as would be provided in-house

Specific Requirements

  • Consultation: Residents are expected to consult with referring physicians prior to the autopsy to clarify issues of history and interest and to plan the autopsy approach and anticipate the need for special procedures. Residents consult with referring physicians during the autopsy or at post autopsy conferences to convey and demonstrate the preliminary findings in the case.
  • Clinical Correlation: Autopsy is the ultimate clinical correlation and the evaluation and synthesis of patient history and laboratory data with the autopsy findings is the essence of the final autopsy report.
  • Quality Assurance: Autopsies and placental examinations provide an critical component of QA in an obstetric hospital and residents are intimately involved in this process.
  • Required Departmental Conferences: Pediatric Pathology Conference, Friday 7:00 AM (monthly)
  • Required Interdepartmental Conferences: Perinatal Autopsy Conference, Pediatric Tumor Board
  • Objective Evaluation: (Year 4) Practical examination at the completion of autopsy rotations consisting of a clinical history, gross findings and microscopic slides. Residents prepare an FAD with correlation and brief microscopic description. 
Pediatric Pathology

Overview

RIH, WIH elective one month

Description:

Residents are treated as fellows with direct responsibility for the interpretation of frozen sections and the intraoperative management of pediatric cases under the supervision of an attending pediatric pathologist. The goal of the rotation is not only to provide specialized training in pediatric pathology but to provide an opportunity for substantially increased responsibility for senior residents.

Goals and Competencies

1. Patient Care

  1. The resident should appreciate the role of the Pediatric Pathologist in the clinical practice of specific subspecialties: Most commonly: Gastroenterology, Pediatric Surgery, Less Common: Cardiology and Cardiac Surgery, Pediatric Critical Care, Pulmonology, Rheumatology, General Practice, Transplant Medicine
  2. Appreciate the urgency of treating physicians in arriving at a diagnosis so that anxious parents can be counseled appropriately and enrollment in treatment protocols may be facilitated e.g. solid malignancies
  3. Become familiar with pediatric intensive care unit and pediatric hospital charts where necessary

 2. Medical Knowledge

Have a working familiarity with the etiology, diagnosis, and treatment of:

  1. Common non-CNS pediatric solid malignancies from each system e.g. neuroblastic tumors, Wilms tumor, hepatoblastoma, Ewing's sarcoma/PNET, rhabdomyosarcoma, hepatoblastoma, osteogenic sarcoma, germ cell tumors
  2. Gastrointestinal diseases: including reflux esophagitis, Hirschsprung's disease, neonatal necrotizing enterocolitis, malabsorption syndromes, inflammatory bowel disease, infectious colitis, allergic disorders.
  3. Genitourinary diseases: reflux uropathy, undescended and atrophic testis/testicular nubbin, herniorrhaphies
  4. Liver diseases: infantile cholestasis (biliary atresia and differential diagnosis e.g. TPN), auto-immune and drug induced hepatitis, others
  5. Metabolic and storage diseases: glycogen storage diseases, Wilson's disease, Niemann Pick, Gaucher, tyrosinemia, galactosemia, urea cycle enzyme deficiencies, fatty acid oxidation defects
  6. Infections e.g. pediatric AIDS, lymphadenitis, osteomyelitis
  7. Immunologic disorders: AIDS, congenital immunodeficiency, autoimmune disease

3. Practice-Based Learning and Improvement

  1. Frozen section performance in cases of Hirschsprung's Disease (need for multiple levels), frozen section of tumor cases with appropriate triaging of specimen for histology, cytogenetics and molecular studies particularly when dealing with limited biopsies (possible role of touch preparation even for molecular genetics )
  2. Surgical gross room techniques for the evaluation of tumor resections, organs removed for non- neoplastic disease, skin specimens, bone specimens, open lung biopsies, rectal suction biopsies
  3. Handling of special biopsies (e.g. metabolic disorders) and advising clinicians or radiologists on what would constitute an appropriate specimen
  4. Coordinating with clinicians specimens that are to be sent to specialized labs; the ordering physician may not be the one doing the biopsy so all appropriate paperwork and arrangements need to be made ahead of time.
  5. Appropriate use of ancillary studies (immunohistochemistry, EM, conventional cytogenetics and molecular genetics in arriving at the diagnosis and excluding other differential diagnoses
  6. Use of conventional cytogenetics and molecular studies as prognostic indicators that may affect treatment strategies
  7. Patient Presentations: Prepare and present interdepartmental conferences (e.g. Pediatric GI conferences and Pediatric Tumor Board) and recognize the role of the conferences in reporting on difficult cases(clinical correlation), Prepare and present Pathology Grand Rounds.
  8. Research: Identify areas of potential investigation, formulate methods appropriate to carry out a potential research project (optional)

4. Interpersonal and Communication Skills:

  1. Acquire a clinically relevant patient history from the treating physician
  2. Present pediatric tumors and other cases at clinical management and M&M conferences (see above)
  3. Learn to discuss the diagnosis and interpretation of pediatric surgical pathology, and frozen section cases with the treating physician (develop the temperament of giving information sufficient for management at the time of frozen section)

5. Professionalism:

  1. Appreciate the role of ancillary staff: pathology assistants, histology, transcription
  2. Respond in a timely manner to all clinical questions
  3. Triage and prioritize cases that you are responsible for
  4. Render and communicate diagnoses in a precise, unambiguous, and clinically responsive manner
  5. Admit, rectify, and learn from mistakes

6. Systems-Based Practice:

  1. Use hospital information system to gather patient data
  2. Master all aspects of the Anatomic information systems
  3. Use computers to access information from online databases

Specific Requirements

  • Consultation: Residents are expected to consult with surgeons and referring physicians as needed for the intraoperative management of pediatric patients and the appropriate grossing and signout of permanent sections.
  • Clinical Correlation: Interaction with clinicians in the gross and microscopic evaluation of pathology specimens and the assessment of clinical laboratory and radiologic data provide complete clinical correlation.
  • Quality Assurance: Autopsies and placental examinations provide an critical component of QA in an obstetric hospital and residents are intimately involved in this process.
  • Graduated Responsibility: The goal of the rotation is not only to provide specialized training in pediatric pathology but to provide an opportunity for substantially increased responsibility for senior residents.
  • Required Departmental Conferences: Pediatric Pathology Conference, Friday 7:00 AM (monthly)
  • Required Interdepartmental Conferences: Perinatal Autopsy Conference, Pediatric Tumor Board
  • Objective Evaluation: Practical examination at the completion of the rotation consisting of a clinical history, gross findings and microscopic slides
Neuropathology

Overview

1 month, required AP

Description:

Rhode Island Hospital has a high-volume neurosurgery service and a workload more than adequate to occupy a resident full time. Residents are responsible for reviewing neuropathology cases including muscle and nerve biopsies with attendings. This rotation provides intensive exposure to neurosurgical pathology, with weekly brain cutting conferences for autopsy pathology including selected forensic cases from the Rhode Island Medical Examiner's Office. Residents are expected to prepare complete neuropathology reports on 10 brains during their rotation. Residents work with attendings and Neuropathology Fellows (2). Residents also participate in neuropathology conferences with the clinical neurology staff. Emphasis is placed upon correlation of pathologic with clinical manifestations and with CT and MRI findings. The residents are encouraged to attend this conference throughout their training period.

Goals and Competencies

1. Patient Care

The resident is expected to develop an appreciation of the importance of providing information to clinicians that will help them to better care for their patients. This includes pre-intervention strategic planning, intra-interventional monitoring and feedback, and post-intervention interpretation of pathologic findings. The aim of these skills is to provide the maximum amount of useful information to the clinician with the minimum amount of inconvenience to the patient. This includes developing awareness that while more tissue may provide more information, the cost of this information must be weighed in terms of possible damaging effects on the patient. It also includes the recognition that an anxious patient and family await each and every lab result, which must therefore be accurate, comprehensive, unambiguous, and timely. Particular sensitivity is required in the evaluation and communication of diseases known, or suspected to be, genetically based.

2. Medical Knowledge

During the course of training, the resident is expected to develop an understanding regarding the etiology, pathogenesis, differential diagnosis, and treatment for neoplastic and non-neoplastic diseases of the central nervous system, as well as inborn and acquired disorders of the peripheral nervous system. It is expected that the resident master "textbook" knowledge in each of these broad areas, and then keep up on primary literature particularly with regard to factors influencing optimal treatment and care of patients suffering from disorders of the central and peripheral nervous system. Board-style review questions will be used to assess knowledge.

3. Practice-Based Learning and Improvement

A. Surgical Neuropathology:

  1. The handling, processing, and diagnosis of neoplastic and non-neoplastic brain and spinal cord. Biopsies. Particular emphasis will be placed on acquiring facility with neuropathologic intraoperative consultation, including clinico-radiologic correlation, gross examination and selection of tissue for processing, and the use and interpretation of both cytological (smear) and histologic (frozen section) preparations. Familiarity with important ancillary studies will be acquired, both during intraoperative consultations and at final sign out of these complex and challenging cases. Follow-up of these intraoperative consultations with examination of the completed case completes a recurring feedback loop leading to increased competence in this critical area of neuro-pathologic practice.
  2. The handling, processing, and interpretation of peripheral nerve and muscle biopsies. This experience will enable the Resident to appropriately triage and process fresh peripheral nerve and muscle biopsies, including preparing tissue for histochemical, immunohistochemical, and ultrastructural, and nerve teasing studies. Selection and interpretation of these special studies, in addition to routine sections of peripheral nerve and muscle, will be learned by the Resident as he/she guides each case through appropriate diagnostic algorithms under the supervision of the Attending Neuropathologist.
  3. The handling, processing, and interpretation of specimens derived from the eye and ocular adnexa. These range from skin, conjunctival, and orbital biopsies, to enucleation and orbital exenteration specimens. The Resident will process and interpret these cases in order to acquire competence in diagnostic ophthalmic pathology.

B. Autopsy Neuropathology:

  1. Residents will become competent in the field of post-mortem neuropathologic diagnosis. This builds upon the skills enumerated above:
  2. Residents will become competent in selecting areas of the central and peripheral nervous system for histologic examination based on careful study of the patient's medical/neurologic histology and gross findings.
  3. Residents will learn to harvest both CNS and PNS tissue, with the latter including performance of nerve and muscle biopsies at autopsy. Dissection and sampling of sural and motor nerves, muscles, and ganglia will be performed at the time of the autopsy, as will the procurement of cerebro-spinal fluid by lumbar or cisternal puncture. Similarly, procurement and processing of ocular tissues will be performed, as indicated.

4. Interpersonal and Communication

The resident should become competent and confident in guiding clinical colleagues when pathologic assessment becomes necessary in the optimal treatment of a patient. The resident should understand how to communicate information necessary for optimal operative intervention during the course of a procedure, providing relevant information in a concise and unambiguous fashion. At final pathologic sign-out, the judicious use of notes to convey important additional details and relevant negative information will be learned. An appreciation of which special cases require either telephone-related or even face-to-face communication will also be assimilated, as will knowledge of what constitutes inappropriate requests by clinicians.

5. Professionalism

The resident will develop an appreciation that his or her chosen discipline is one of service to those individuals unfortunate enough to require the services of a pathologist. The principles listed above regarding accuracy, clarity, timeliness, and sensitivity are underscored, as is the importance of taking responsibility both for one's decisions in approaching each patient's case and for the well-being of the patient at every step of the evaluation and communication of the pathologic diagnosis.

6. Systems-Based Practice

The principles of providing maximally accurate information regarding each pathologic consultation without excessive removal of tissue extends to parsimonious use of ancillary studies in the rendering of a final diagnosis. Through developing awareness regarding the salient diagnostic and therapeutic decisions regarding the care of a patient, unnecessary and potentially confusing additional information will be avoided, as will undue financial strain both to the patient and to the system.

Specific Requirements

  • Consultation: Interactions with neurosurgeons and neurologists is integral to this specialty and is emphasized at Frozen Section, case sign out, and at multiple interdisciplinary conferences. Residents also provide neuropathologic consultation on brains from autopsies examined grossly and microscopically.
  • Clinical Correlation: Correlation is critical in neuropathology and is solidified at multiple interdisciplinary conferences and through the preparation of detailed neuropathology reports on 10 autopsy brains.
  • Quality Assurance: Limited, this specialty rotation falls under the quality control and quality assurance plan of the surgical pathology laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Conferences: Brain Cutting (micro), Friday, 2:30 PM;
  • Required Interdepartmental Conferences: Brain Cutting (gross), Friday 2:30 PM; Neurosurgery Conference, Monday 1:00 PM; Muscle Biopsy Conference, Tuesday, 12:30 PM; Brain Tumor Board, Monday, 11:00 AM; Neurosurgical Grand Rounds, Monday, 8:30 AM
  • Objective Evaluation: direct evaluation by neuropathology attending and completion of 10 brain gross and microscopic examination
Immunohistochemistry

Overview

1 month, Lifespan, elective AP

Description:

The rotation provides hands-on experience in the preparation of IHC slides and immunofluorescence stains of frozen sections. Residents are responsible for reviewing all stains produced by the laboratory and developing interpretations based on histology and immunostaining. They act as consultants for other pathologists in terms of antibody selection and interpretation. They take on an important role in the QC of stains produced by the laboratory in conjunction with staff and the medical director.
 

Goals and Competencies

  • Can select an appropriate panel of antibodies based on microscopic and clinical features of tissue biopsy
  • Understands basics of immunohistochemistry techniques and their application to anatomic pathology
  • Can integrate morphologic and immunohistochemistry data to make a pathologic diagnosis
  • The resident should become familiar with the immunohistochemical characteristics and staining patterns of selected pathologic specimens
  • The resident should become familiar with the daily quality assurance/quality control mechanisms of the immunohistochemical laboratory.

Specific Requirements

  • Consultation: Primarily with referring pathologists in terms of test selection and interpretation.
  • Clinical Correlation: Direct correlation with histologic findings and patient clinical data.
  • Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Conferences: Slide Review Conference (Lifespan)
  • Required Interdepartmental Conferences: Tumor Board (Lifespan)
  • Objective Evaluation: direct evaluation by preceptor based on interpretation of immunoperoxidase slides
Gynecologic Pathology and Cytopathology

Overview

3 months, WIH, required AP, year 2

Description:

The rotation is divided into two week blocks with focus on either gynecologic pathology or cytology. Direct correlation of surgical and cytologic material is included in the rotation and residents may participate in both surgical biopsy and cytology sign out on a given day. Because of the extent and variety of gynecologic specimens in the routine practice of the average pathologist, this rotation is designed to provide basic competence in the handling of gynecologic tissues, and an understanding of the differences between gynecologic and other specimens. WIH has the largest GYN Oncology program in the Northeast providing state of the art training. Accurate and complete staging of gynecologic tumors is emphasized. Diagnostic breast biopsies (excisional and stereotactic) as well as sentinel lymph node biopsies in breast cancer patients provide cutting edge training in all aspects of women's health care. Thin prep technology is included in the cytology curriculum as well as conventional smears.

Goals and Competencies

  1. Patient Care
    1. The resident must participate in intraoperative consultations and preparation of frozen sections, as needed. At the end of the rotation, the resident should be able to address intraoperative issues that are common to gynecologic surgery cases, and be able to effectively communicate with the gynecologic surgeon.
    2. By the end of the rotation, the resident should be familiar with grossing protocols for basic and complicated gynecologic surgical specimens and be able to dictate a concise, yet comprehensive gross examination.
    3. The resident should have basic diagnostic skills in gynecologic pathology and understand the clinical context of gynecologic biopsy diagnoses.
    4. The resident should have basic diagnostic skills in gynecology cytology.
  2. Medical Knowledge
    1. By the end of this rotation, residents should be able to recognize the gross and microscopic features of common benign and malignant lesions of the female genital tract.
    2. The resident should be familiar with the classification and staging of tumors of the female genital tract.
    3. The resident should be familiar with the Bethesda nomenclature for gynecology cytology, understand the importance of cervical cytology-biopsy correlation and CLIA requirements in cytology.
    4. Practice-Based Learning and Improvement
      1. Attend Gyn Tumor Boards and Gyn Oncology-Pathology conference weekly.
      2. Research difficult cases prior to sign-out.
      3. Gain confidence in formulating gynecologic surgical pathology diagnoses prior to sign-out and sign-out all cases that he/she grosses.
    5. Interpersonal and Communication Skills
      1. The resident should learn to communicate effectively with the clinical medical staff and other personnel, both to collect and to transmit information relevant to patient care.
      2. The resident should learn to communicate effectively with the pathology staff concerning individual cases, bearing in mind that the attending pathologist will often depend on the resident for a complete and accurate gross examination of the specimen and any clinical information obtained from clinicians
      3. Politeness, discretion and honesty are paramount in preserving a positive working relationship among all laboratory professionals, including clerks, technicians, technologists and transcriptionists.
    6. Professionalism
      1. The resident must follow the highest standards of professionalism and ethics.
      2. Show respect for patients and their families as well as all members of the healthcare team in the pathology department and other departments.
      3. Strictest adherence to patient confidentiality and HIPAA requirements with attention to names on slides and paperwork transported within the hospital as well as discussion of cases only in private areas.
      4. When in doubt about a particular work assignment, consult the attending for the week, or the rotation director, Dr. Steinhoff.
      5. Perform all work assignments with diligence, accuracy and timeliness.
    7. Systems-Based Practice
      1. Become familiar with the software system used to generate surgical pathology reports and be able to access pertinent patient information.
      2. Understand the role of pathology in the practice of gynecology, especially gynecologic oncology.

Specific Requirements

  • Consultation: Residents present cases at Friday 1 PM Pathology Oncology Conference to fellows and GYN residents rotating through GYN oncology.
  • Clinical Correlation: Direct correlation of surgical and cytologic material is emphasized. Tumor Boards provide high quality correlation with radiographic and clinical findings.
  • Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory. CLIA issues in gynecologic pathology are emphasized and residents are expected to assist in the collection of data and the preparation of cytology QC/QI reports.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Consensus Conferences: Slide Review Conference (M-F 1:30-2:30)
  • Required Interdepartmental Conferences: GYN Tumor Board (Tuesday 7:30-9:00); Breast Tumor Board (Friday 7:30-9:00); Pathology Oncology Conference (Friday 1 PM)
  • Objective Evaluation: Practical examination in surgical and cytopathology at the completion of the rotation with preparation of SP or cytology reports based on clinical history, gross description, and microscopic slides. 
Forensic Pathology

Overview

1 month, required AP, year 1 or 2

Description:

This rotation serves as an introduction to Forensic Pathology and covers issues in sufficient depth to give residents a general understanding of the methods and procedures employed in Forensic Pathology. The following specific areas are addressed:

Scene Investigation. The trainee will study the investigation of violent and natural deaths. The resident may participate in telephone investigations regarding potential cases where jurisdiction is not accepted ("no cases"). The resident is informed of work with members of a team investigating particular problems which require the expertise of interrelated disciplines, such as engineering in automobile and aircraft accidents, psychiatry in suicide investigations, anesthesiology in operating room deaths in hospitals, and radiation biology in deaths from therapeutic or accidental exposure to radioactive substances.

Forensic Autopsy. The resident will study medico-legal autopsies under supervision during his/her training period. These cases would be carefully selected for variety and subsequently reviewed by senior members of the staff. The resident will also learn the fundamentals of external examination of a body and the proper certification of such a death without autopsy. Categories of difficult and unusual cases such as decomposed bodies and criminal abortion deaths are explained to the trainee.

Jurisprudence. The resident may observe selected legal material covering aspects of evidence, torts, and the science of proof. The trainee may become familiar with relevant laws in his/her own jurisdiction, review the model Medical Examiner's Law, and familiarize him/herself with the recent pertinent statutes, such as the Uniform Anatomic Gift Act and traffic safety laws dealing with the use and abuse of alcohol ingestion and intoxication. The resident may attend Grand Jury and other preliminary court hearings. The resident will accompany senior members during their medical testimony in selected homicide trials.

Personal instruction concerning the finer points of expert witness testimony is afforded the trainee coinciding with the above proceedings.

Death Certification. The resident will become familiar with the intricacies of the proper certification of the cause of death and the classification of the manner of death.

Forensic Toxicology and Serology. The resident is afforded observation in the toxicology laboratory, learning analytical methodology through actual processing of current cases in the department. The trainee will be familiar with the common drugs, such as barbiturates, alcohol, and carbon monoxide. S/he will become familiar with lethal levels of most toxic agents, learn the proper removal and preservation of tissues and fluids derived from the autopsy, and which to submit for maximum results in recovery and interpretation. The resident may spend some time with a qualified serologist, with emphasis placed on the examination of dried stains, seminal fluid identification, elementary paternity testing, and methodology regarding liability for human blood group interpretation.

Forensic Anthropology. The resident will become acquainted with the principles of osteology with emphasis on the identification of skeletal and dental remains relating to body parts, age, race, sex, and disease. The resident may incorporate this portion of study with the special procedures recommended in the medico-legal investigation of mass disasters.

Forensic Science. The resident observes selected techniques in ballistics, scene investigation from the point of preservation of evidence, with emphasis placed on the "custodial chain" of evidence, fingerprints, hair and fiber examination, questioned documents, and other relevant and related topics.

Goals and Competencies

  1. Patient Care
    1. The resident should be familiar with the laws of the State of Rhode Island regarding jurisdiction of autopsy cases by the Medical Examiners Office.
    2. The resident should be able to gather essential and accurate information about the forensic case from police, hospital, and witness reports.
    3. The resident should be able to make informed decisions about necessary investigate interventions based on case information, up-to-date scientific evidence, and clinical judgment.
    4. The resident should understand all aspects of a detailed forensic autopsy, including taking photo-graphs and gathering of all trace evidence and body fluids.
    5. The resident should develop the ability to determine the "manner" and "cause" of death in a Forensic case.
    6. The resident should be able to characterize and describe common diseases, traumatic/inflicted wounds, and injury patterns routinely seen in Forensic cases.
    7. The resident should be able to characterize, describe, and understand the significance of common radiographic findings in Forensic cases.
    8. The resident should be able to compose a complete Medical Examiner's Report utilizing informa-tion gathered from the post-mortem exam, toxicology, firearms examination (ballistics), trace evidence, forensic serology, and DNA technology.
    9. The resident should be familiar with standard precautions for handling all cases and should be thoroughly familiar with precautions for handling cases of HIV and Hepatitis B.
    10. The resident should develop the ability to perform special dissection procedures including removal of the brain and spinal cord, tracing of wound tracts, and identifying soft tissue hematoma in suspected child abuse.
    11. The resident should have the ability to prepare and present cases at Medical Examiner conferences.
    12. The resident should develop an understanding of the procedures and techniques involved in investigating the crime scene.
    13. The resident should observe medical examiner court testimony and develop an understanding of the presentation of Forensic cases to the jury and the basic rules of the court.
  2. Medical Knowledge.
    1. The resident should demonstrate an investigatory and analytic approach to Forensic cases and their pathological associations.
    2. Residents should develop the ability to formulate differential diagnosis for Forensic autopsy cases on the basis of investigative, clinical, and pathologic findings.
    3. Residents should demonstrate knowledge of the epidemiology of Forensic cases with regard to the five "manners" of death (homicide, suicide, accident, natural, undetermined) in relation to various population groups.
    4. Residents should demonstrate basic knowledge of, and apply the supportive sciences utilized in Forensics (toxicology, firearms examination (ballistics), trace evidence, forensic serology, and DNA technology) and understand their role in the investigative process.
    5. Residents should demonstrate basic knowledge of the ancillary areas of Forensics (psychiatry, odontology, anthropology, entomology) and understand their role in the investigative process.
  3. Practice-Based Learning
    1. Residents should be able to analyze practice experience, which includes participation in Medical Examiner conferences, evaluating Medical Examiner reports for accuracy and pertinent medicolegal correlations, and evaluating crime scene investigatory techniques.
    2. Residents should become familiar with computer based literature searches, and be able to locate, appraise, and assimilate evidence from scientific studies and case law related to their Forensic cases.
    3. Residents should be able to apply knowledge of study designs and statistical methods to the appraisal of scientific studies and other information on diagnostic and investigatory effectiveness.
  4. Interpersonal and Communication Skills
    1. Residents should develop the ability to communicate effectively with Medical Examiners, Police, Crime Scene Investigators, and Forensic Scientists before the autopsy to determine specific issues and problems that need to be resolved.
    2. Residents should work effectively with other members of the Forensic team in determining "cause" and "manner" of death, and in completing the Medical Examiners report.
    3. Residents should be able to effectively communicate the findings of the Medical Examiners report to both clinicians and a jury in a manner consistent with an understanding of court testimony.
    4. Residents should seek consultations from ancillary Forensic areas with respect to specific questions that arise from the autopsy and investigation.
  5. Professionalism
    1. Residents should demonstrate respect, compassion, and integrity in dealing with families of the deceased, and should accommodate requests for specific autopsy limitations when it does not impede the medicolegal investigation.
    2. Residents should demonstrate the highest respect for the deceased during performance of the autopsy procedure.
    3. Residents should demonstrate a commitment to the ethical principles relating to confidentiality of the deceased and their families, and in preserving the integrity of the medicolegal case.
    4. Residents should demonstrate a commitment to ongoing professional development, including reading of textbooks and journal articles relevant to their Forensic cases.
  6. Systems-Based Practice
    1. Residents should understand how performance of the Forensic autopsy and investigation, and communication of the results affects the deceased's families, other medical professionals, the individual(s) indicted in the crime, and society as a whole.
    2. Residents should understand the value of the Forensic autopsy as a tool to explain sudden unexpected deaths, effectively prosecute criminals, prevent false incarceration of the innocent, and protect society.
    3. Residents should practice a cost effective approach to the Forensic autopsy with respect to the extent of investigatory procedures and laboratory analysis as needed on a case-by-case basis.
    4. Residents should know how to partner with law enforcement and legal professionals to assess, coordinate, and improve the medico-legal system and know how these proceedings can affect system performance.

Specific Requirements

  • Consultation: Interaction with law enforcement personnel and other professionals concerning the aspects of individual cases.
  • Clinical Correlation: Integration of scene findings, forensic science data, toxicology data and autopsy results to prepare a final report.
  • Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens. For residents with a special interest in forensic pathology, a second elective rotation is offered with substantially greater participation in autopsy performance and report preparation.
  • Required Departmental Conferences: daily business meeting, RI Medical Examiner's Office
  • Required Interdepartmental Conferences: joint brain cutting conference with Lifespan
  • Objective Evaluation: Written and practical (kodachrome) examination at the completion of the rotation.
Dermatopathology

Overview

1 month, Lifespan, required AP

Description:

Description: The rotation consists of an apprenticeship in dermatopathology with review of the daily dermatopathology sign out with the attending and dermatopathology residents on the service. Approximately 11,000 dermatopathology specimens are examined yearly at Lifespan. Emphasis is placed on inflammatory dermatoses. Immunofluorescence and other special procedures are included as well as patient examination at dermatopathology rounds. An elective experience is available in addition at RWMC which process 16,000 dermatopathology specimens yearly.

Goals and Competencies

  1. Medical Knowledge:
    1. Investigatory and analytic thinking as well as the application of basic sciences are taught on an on-going manner during clinical activities.
    2. Residents will refine their diagnostic skills and further their knowledge base by formulating appropriate differential diagnoses.
    3. Residents are encouraged to utilize literature searches in their daily clinical activities.
    4. Weekly lectures and interesting case conferences facilitate the learning experience.
    5. The dermatopathology faculty play a major role in helping the resident broaden their medical knowledge.
  2. Patient Care Skills:
    1. Learning the unique issues that one encounters when grossing dermatology specimens.
    2. Developing a systematic approach to the microscopic assessment of various skin lesions.
    3. Developing a solid differential diagnosis for various skin lesions.
    4. Understanding the therapeutic and management implications with a given diagnosis.
    5. Faculty role modeling and feedback along with clinical teaching and case discussion help residents refine these skills.
  3. Interpersonal and Communication Skills:
    1. Continual interaction between the resident and the dermatopathologists.
    2. Communication with various clinicians prior to and after the formulation of a diagnosis.
    3. Communication with the laboratory personnel.
    4. These skills are strengthened by faculty role modeling and feedback.
  4. Professionalism Skills:
    1. Respectful and altruistic behavior.
    2. Ethically sound practice and sensitivity to cultural, age, gender and disability issues.
    3. Teaching is by example on the part of the faculty.
  5. Practice-Based Learning and Improvement Skills:
    1. Analyzing one's own practice for needed improvement.
    2. Use of evidence from scientific studies and application of research and statistical methods.
    3. Use of the institution's information technology system.
    4. Utilization of literature searches in the formulation of their diagnoses, in order to further develop their differential diagnoses.
    5. Faculty feedback is instrumental in the development of these skills.
  6. System-Based Practice Skills:
    1. Understanding the interaction of their practices with the larger system.
    2. Knowledge of this particular practice and delivery systems.
    3. Practice of cost-effective care with continued emphasis on billing issues.
    4. Faculty feedback is vital in the development of these skills.

Specific Requirements

  • Consultation: Direct interaction with dermatologists on rounds and participation in discussions of the clinical implications of biopsy findings.
  • Clinical Correlation: Participation in dermatology rounds with direct observation of skin lesions to be biopsied.
  • Quality Assurance: minimal
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Conferences: Dermatology rounds; Dermatopathology lecture series
  • Required Interdepartmental Conferences: Dermatology rounds; Dermatopathology lecture series
  • Objective Evaluation: direct evaluation by the preceptor.
Cytopathology

Overview

2 months, Lifespan (beginning with class of 2004), required AP

Description:

Anatomic pathology residents spend a minimum of two months in general cytology in the third or fourth year. Residents are instructed in the preparation and fixation of smears and fluid specimens. This is accomplished by following specimens at the time of receipt in the laboratory to the final preparation of the slides.

Collections of cytologic smears of normal and abnormal conditions are available for study. The majority of these have corresponding histologic sections for correlation and quality control. After several introductory sessions with the cytotechnologists and the pathologist using a dual viewing microscope, the resident is expected to review these slides in detail utilizing reference texts and manuals available in the laboratory. Subsequently, the residents are expected to review and in selected cases scan current cytologic smears of all types. During cytology rotation the resident will examine all cytological material and correlate this data with available clinical and surgical pathology information.

Questions pertaining to these are then reviewed with the pathologist using a dual microscope. Residents are expected to follow-up these cases whenever possible with a study of histologic sections when and if they become available. Discussion of various aspects of administrative functions pertaining to the cytology laboratory are held informally with the cytotechnologist and Director of Anatomic Pathology.

Emphasis is placed on non-GYN cytology specimens with specific coverage of respiratory, urinary, gastrointestinal, body fluid, breast, and fine needle aspiration cytology, and laboratory administration and quality control. Residents are encouraged to attend CT and ultrasound guided FNA procedures to permit direct correlation of cytopathology with clinical and radiographic findings. Evaluation of the residents' proficiency in cytology is accomplished by the pathologist and cytotechnologist during the frequent teaching sessions and by quizzes with unknown slides. Learning is complemented by a series of lectures and workshops included in the Monday morning conference schedule.

Goals and Competencies

  1. Patient Care
    1. The resident must be able to evaluate any gynecologic cytopathology specimen and properly classify it using The Bethesda System 2001.
    2. The resident should demonstrate the ability to examine and properly classify FNA biopsies and exfoliative non-gynecologic cytopathology specimens from various body sites.
    3. The resident must be able to communicate the proper technique and complications of the FNA procedure to clinicians in a concise manner.
    4. The resident should have knowledge of administrative and quality control activities in the cytopathology lab.
    5. The resident will evaluate body fluids from the hematology laboratory stained with Romanowsky dyes. Correlate the findings with chemical analyses and clinical diagnosis. They are expected to resolve clinical questions from the medical staff and queries from the medical technologists.
    6. Fluids will represent both non-neoplastic and neoplastic conditions. In addition to the Cytology Rotation, they will deal with difficult problems when on call.
  2. Medical Knowledge
    1. The resident should develop an analytical approach to clinical conditions and their cytologic manifestations.
    2. The resident should have knowledge about ancillary techniques and their application in cytology.
    3. The resident will learn how to distinguish exudates from transudates, traumatic CSF taps from pathologic bleeds, differences between gout, pseudogout and other inflammatory joint diseases and diagnostic problems of iatrogenic fluids (i.e., dialysate, lavage fluids).
  3. Practice-based Learning and Improvement
    1. The resident should preview and sign out all cases with the attending pathologist daily.
    2. The resident should participate in tutorial sessions provided by the cytology staff.
    3. The resident must understand the basic technique of cytology specimen preparation.
    4. The resident should attend all FNAs that require on-site assessment.
    5. Resident will review body fluids from the weekend with the pathologist
  4. Interpersonal and Communication Skills
    1. The resident should be able to communicate effectively with clinicians and other health care personnel.
    2. The resident should be comfortable discussing cases with the pathology faculty and to initiate surgical pathology-cytology correlation as needed.
    3. The resident will interact with clinicians, medical technologists, nurses and mentors regarding all problems related to benign reactive and neoplastic body fluids.
  5. Professionalism
    1. The resident must follow the highest standards of professionalism and ethics.
    2. The resident must show respect for patients and members of the health care team.
    3. The resident must adhere to patient confidentiality regulations.
    4. The resident must perform all assignments with accuracy, diligence and timeliness.
  6. Systems-Based Practice
    1. The resident must become familiar with the LIS and learn how to use the system to access reports and clinical history.
    2. The resident must understand the role of cytopathology in the practice of medicine.
    3. The resident must understand the role of the hematology laboratory in the evaluation of body fluids to complement his role of evaluating body fluids for neoplastic diseases in the Cytology Laboratory.
    4. The resident will understand the meaning of critical values and communication with ancillary personnel, physicians and regulatory agencies.

Specific Requirements

  • Consultation: Limited because most communication is by reports, residents are encouraged to respond to inquires about proper mechanisms for specimen collection and to participate in discussions with referring clinicians on difficult or interesting cases.
  • Clinical Correlation: Correlation with SP and prior cytopathology results is critical and mandated under CAP regulations. Residents actively participate in this process.
  • Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to understand the impact of CLIA on the cytology laboratory.
  • Graduated Responsibility: Residents are expected to progress in their ability to recognize and diagnose specimens and to write reports. They do not have ultimate sign out responsibility.
  • Required Departmental Conferences: Review conference of PIP slide sets with lab personnel.
  • Required Interdepartmental Conferences: Tumor board for cases which include significant cytopathology input
  • Objective Evaluation: unknown glass slide examination.