Pathology Residency

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Curriculum | Educational Conferences

Curriculum

The Hartford Hospital four-year combined AP/CP training program is scheduled as 52 four-week blocks with 30 blocks of Anatomic Pathology and 21 blocks of Clinical Pathology.

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Orientation to Anatomic Pathology (Boot Camp)

Our intensive Anatomic Pathology Orientation is scheduled in the first 8 weeks of training for all three PGY-1 residents; it instructs residents on the basics of autopsy, intraoperative consultations and gross surgical pathology. Residents are provided with a comprehensive Boot Camp Manual, which details goals and expectations, procedures and responsibilities for the autopsy, pediatric and surgical pathology services, safety, and proper grossing and dictating techniques. The first few pages of the Boot Camp Manual is the list of critical values in surgical pathology, as the importance of patient safety cannot be overemphasized in the minds of the trainees as they start getting actively involved in patient care. Residents learn the basic approach to surgical specimens from the time they are accessioned until slides are delivered to the surgical team for the formulation of a final diagnosis. This includes instructions on the basics of histology, laboratory processing, the departmental and hospital computer systems, gross specimen evaluation, and frozen section assessment of active surgical cases. Under the guidance of the department’s four pathology assistants, residents will be instructed on the proper dictation and sectioning of surgical pathology cases and will be given a broad cross section of specimen types to process, with an emphasis on tumor pathology. Orientation to frozen section/intraoperative consultation technique entails a week-long rotation in the frozen section room, located on the same floor as the over 40 operating rooms of the main hospital. There will also be a specialized orientation to Connecticut Children’s frozen section room where the trainee is also instructed on triaging pediatric tumor specimens. At the end of Boot Camp, the resident is well prepared to participate as the junior member on one of the surgical pathology teams. PGY-1 resident training in autopsy occurs with near total initial immersion in the process during Boot Camp. All new PGY-1 residents and the autopsy attending prosect the first, second and third autopsies together. Subsequent autopsies will be done on a rotation-basis allowing all PGY-1 residents to develop autopsy skills quickly. Residents are instructed on all elements of autopsy, which includes: chart abstraction, prosection, gross pathology, microscopic pathology, development of written reports, and communication of results to staff and peers. Although direct supervision is not required on subsequent autopsies, the autopsy faculty is always immediately available for consultation. An experienced diener will assist the resident in organ removal and provide technical assistance.

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Autopsy Service

After the initial Boot Camp training, PGY-1 residents will independently cover the Autopsy service at Hartford Hospital and the John Dempsey Hospital (University of Connecticut Health Center, Farmington, CT). When rotating on the autopsy service, the PGY-1 resident is considered the “first-up” for all autopsies; accommodations are made if multiple autopsies occur on a given day. Additional autopsy training includes a twice monthly brain cutting conference attended by neuropathologist and neurology house staff, and a twice monthly autopsy gross conference during which PGY-1 residents present the gross findings of recent autopsies to the autopsy faculty and fellow AP/CP residents. The residents present autopsy findings at the monthly Medical-Pathology Grand Rounds for the medical attendings and house staff. Clinical-Pathologic Conferences are also conducted at the University of Connecticut Health Center and each of the three PGY-1 would be assigned to present the autopsy findings in at least one of these conferences during the year. PGY-1 residents are expected to obtain competency with hospital-based medical autopsies during their first year of training, performing at least 30 hospital autopsies. During their PGY-3 year, residents are scheduled to a four-week rotation at the Office of the Chief Medical Examiner (OCME) in Farmington, CT; during this rotation, the resident learns proper procedures for dealing with forensic cases, participating in all conferences, performing autopsies, interpreting postmortem toxicology tests and when scheduled, attending scene investigations and viewing medical examiner’s expert witness testimony. A scheduled lecture series will also be provided by the OCME faculty.

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Surgical Pathology Service

After initial Boot Camp training, PGY-1 residents will start their formal Surgical Pathology training. The Surgical Pathology (SP) service is organized as a 3-day cycle covered by three teams, each composed of a junior resident, a senior resident or SP fellow, two SP attendings and multiple pathology physician assistants (PAs). On Day #1, the “team” covers the frozen section room and is ultimately responsible for grossing and signing out all of the cases, both inpatient and outpatient, that enter the Department on that day. While PAs gross the high-volume of outpatient biopsy material, residents and SP fellow, supported by faculty and PAs, perform the day’s intraoperative consultations and gross the larger, more complex case specimens from the OR. On Day #2, biopsy slide material is distributed among the residents and faculty in a manner that balances our high volume with our expectation that residents preview the slides and generates a provisional diagnosis prior to sign out. The biopsy sign-out is generally completed by early afternoon. By this time, slide trays from the major resections grossed on Day #1 are available to be divided among residents and SP fellow for preview and preparation of provisional diagnoses for sign-out on Day #3. Residents are expected to review their slides, form independent morphologic diagnosis, and put their cases in final form with all necessary information for accurate staging. If a final diagnosis cannot be made, the resident should develop a differential diagnosis and a plan for workup of the case. On Day #3, the resident signs-out with the attending at a multi-headed microscope; during this process, faculty trains the residents in histomorphology, differential diagnoses and patient care management decisions. In the afternoon of Day #3, residents will preview “holdover” cases that were held for fixation, or those requiring cut downs or special stains for sign-out later that day.

The organization of the Surgical Pathology service remains constant throughout the resident’s four years of training. However, our expectations for the resident, detailed in the Year Specific Goals, vary significantly from year to year, with increasing graduated responsibility and diagnostic independence as the resident gains in experience and competence. A variety of departmental and interdisciplinary conferences supplement the residents’ experience on the surgical pathology teams. Three senior level Subspecialty Surgical Pathology rotations include combined Pulmonary Pathology and Neuropathology and Medical Renal Pathology with electron microscopy at the University of Connecticut

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Pediatric Pathology Service

The Pediatric pathology service is a four-week rotation for the PGY-1 residents. A full-time pediatric pathologist instructs the PGY-1 resident in the special requirements of the pediatric and perinatal autopsy, placental pathology and surgical pathology specimens from the CT Children’s Medical Center, with emphasis on intra-operative consultations and diagnostic work-up of small round blue cell tumors. During this rotation, the resident is also expected to perform all pediatric autopsy cases, as well as, prosect placentas three times a week. At the end of this rotation, a set of slide test is given to the resident and the score is documented in the biannual report. Pediatric pathology is also available as an AP elective in the senior years.

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Dermatopathology Service

As skin is one of the most common surgical pathology specimens, the dermatopathology rotation is introduced early in the training of our residents. During the first four-week rotation, the resident is expected to gross skin specimens at least one afternoon a week and is instructed on the importance of orientation, inking of resection margins and proper embedding of these specimens. A dedicated sign-out of skin lesions, both neoplastic and non-neoplastic, is conducted by a full-time board-certified dermatopathologist, during which time, the faculty trains the resident on histomorphology, differential diagnoses and patient care management decisions. The faculty additionally gives the trainee unknown slide test in the afternoons and at the end of the first rotation, a post-rotation slide test is given to the trainee in which the score is documented in the biannual report. A second four-week rotation is taken during the junior or senior year. A third four-week rotation in dermatopathology may be used as an AP elective. The dermatopathology faculty also gives the AP/CP residents and the fellows monthly unknown slide conferences.

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Cytopathology Rotation

Residents rotate early in the Cytopathology Division, a state-of-the-art laboratory offering comprehensive gynecologic and non-gynecologic diagnostic services in a high volume setting. Cytopathology resident training includes a balanced emphasis between gynecologic, non-gynecologic and aspiration specimens with emphasis on diagnostic criteria, accurate reporting and communication of diagnostic interpretations, and ancillary techniques applicable to cytopathology (automated screening devices, immunocytochemistry, flow cytometry, and molecular studies). The resident participates in FNAs and FNA adequacy assessments. Residents work very closely with the cytopathology fellow and attending, receiving extensive one-on-one education during sign outs. They are integrated into all services of the laboratory, providing a well-rounded educational experience. Other educational activities include quality assurance, laboratory management, cytopreparatory techniques, and cytology/surgical pathology correlation; organized teaching sets and an extensive library of current textbooks and DVD video conferences are available for resident education.

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Transfusion Medicine Rotation

Training is scheduled as three separate rotations: a 8-week rotation either late PGY-1/early PGY-2, a 4-week rotation during PGY-3 and a 4-week rotation during PGY-4. During their rotation in transfusion medicine, the resident develops a thorough understanding of methods of preparation, composition, action, indications, contraindications, and possible side effects of blood and its components. Hands-on evaluation and appropriate management of the patient who is difficult to crossmatch is part of the resident’s training. The transfusion service also distributes clotting factors and similar derivatives, and the resident gains a level of comfort in their proper administration. Hartford Hospital is a level 1 trauma center and the resident becomes facile in the resuscitation of the massively transfused patient. Heart, liver and kidney transplantation are performed at Hartford Hospital; the resident and blood bank attending are contributing members of the clinical teams. Cardiothoracic, medical, surgical and neurotrauma intensive care units regularly engage the transfusion service in active patient consultation, and the resident benefits from exposure to the benign hematology of the critically ill patient. Connecticut Children’s offers pediatric and neonatal ICUs, ECMO, and one of the Northeast’s largest sickle programs, and the resident learns all about the special transfusion needs of children. All aspects of apheresis therapy are covered during the rotation, and the resident is expected to be familiar with the most recent evidence-based guidelines of the American Society for Apheresis (ASFA). Residents gain exposure to therapeutic apheresis, which is performed by dialysis nurses and nephrologists who collaborate and consult with the transfusion medicine physicians. The transfusion medicine division oversees Hartford Hospital’s I.V. Donor Center, which manages venous access, performs therapeutic phlebotomy and draws autologous blood donors. A dedicated transplantation laboratory directed by the division of surgery shares a very close relationship with the blood bank. The pathology resident rotates in this specialized laboratory to learn aspects of HLA testing, PRA screening and the methods used to characterize donors and recipients. Many patients followed at our adult and children’s hospitals are status-post bone marrow transplant, and direct experience in appropriate transfusion therapy of these patients is gained to facilitate the resident’s understanding of peripheral stem cell biology and immunology. An additional 4 week rotation in Blood Bank may be used as CP elective.

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Laboratory Hematology and Hematopathology Rotation

Training is scheduled as three separate rotations: a 12-week rotation either late PGY-1/early PGY-2, a 4-week rotation during PGY-3 and a 4-week rotation during PGY-4. The resident will develop in-depth knowledge of the basic science and applied clinical science of Hematology and Coagulation and gain an understanding of the Main Hematology/Coagulation and Special Hematology laboratories. The residency training also focuses on diagnostic aspects of Hematopathology. All aspects of Laboratory Hematology/Hematopathology are integrated under one division at Hartford Hospital and include:

• Routine Hematology - complete blood counts with differential cell counts, abnormal peripheral blood smear review, reticulocyte counting, erythrocyte sedimentation rate, and related tests, hemoglobin electrophoresis testing.
• Coagulation - prothrombin time and partial thromboplastin time, thrombin time, fibrinogen, and fibrin split products, clotting factor assays, and tests for hypercoagulable states including factor V Leiden, prothrombin G20210A, lupus anticoagulants.
• Body fluids - morphological assessment of cerebrospinal, pleural, peritoneal and joint fluids.
• Special Hematology – wide variety of flow cytometry applications including immunophenotypic analysis of leukemia/lymphoma, immunodeficiency evaluations and DNA ploidy/cell cycle analysis.
• Hematopathology - daily sign-out with the attending staff of all abnormal peripheral blood /body fluid slides, hemoglobin electrophoresis testing, bone marrow aspirates and biopsies, surgical hematopathology, and flow cytometry and molecular genetic applications.

The educational activities are structured with a detailed Checklist and include: daily sign-out with attending staff, Hematology laboratory administrative meetings, twice monthly Intercity lymphoma conference and monthly Pediatric Heme Oncology tumor board, Coagulation lecture series. Residents are engaged in consultative activities and participate in developmental projects occurring in the Division.

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Microbiology Rotation

This 12-week PGY-2 level rotation is scheduled between Hartford Hospital and the Newington campus of Clinical Laboratory Partners. Residents will develop clinical expertise and fundamental technical and interpretive expertise in the science of Microbiology through interactions with the Division director, technical staff and clinical colleagues, particularly infectious disease clinicians. Residents must develop knowledge and skills of Microbiology.

• Knowledge: specific bacteria, fungi and parasites, viral classification and identification, practical knowledge of infectious disease pathogenesis, common infectious diseases as they relate to body sites, normal microbiologic flora and pathogens common at various infection sites and a working knowledge of newer molecular diagnostic methodologies (including molecular fingerprinting, resistance determination, and the detection of pathogens).
• Skills: common bench level methods, including manual, semi-manual, and automated systems, ability to prepare and interpret Gram, acid fast and other special stains for fungi and parasites, ability to perform and interpret fluorescent microscopy, ability to recognize common bacterial species using conventional biochemical tests and commonly used kits, ability to recognize common bacteria and parasites in human tissue, ability to utilize serologic and culture investigations for the diagnosis of common infections and the ability to perform and interpret susceptibility testing and to interpret the results.

The educational activities are structured with a detailed Checklist and include: daily bench rounds, in-service for the medical technologists, Technologist Staff Meeting, weekly intercity Infectious Disease Conference (UConn Health Center), attending the infection control committee meetings, attending monthly administrative meeting, and rounding with the Infectious Disease service . Residents are engaged in consultative activities and participate in developmental projects occurring in the Division.

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Immunohistochemistry and Special Hematology Rotation

This 4-week combined rotation provides the resident to exposure to three important special technologies: immunohistochemistry, flow cytometry in special hematology and electron microscopy. During this rotation the resident will learn the technique and diagnostic potential/limitations of immunohistochemistry, become familiar with the immunohistochemical characteristics of selected pathologic specimens and review the daily immunohistochemical studies with the director of the laboratory for QA/QC purposes.

The resident will evaluate needle core biopsies of medical kidneys and will process them for immunofluorescence and electron microscopy. The resident will also learn the principles of the flow cytometry instrumentation participate in the triage of fresh specimens in Special Hematology and review characteristic electron microscopic images for infectious diseases, neoplasms and medical renal diseases.

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Molecular Pathology and Cytogenetics Rotation

This 8-week PGY-3 level Hartford Hospital rotation is designed to provide the resident with the basic knowledge and principles in Molecular Biology and Genetics and to understand the principles of molecular genetics as applied to diagnostic testing. The resident will learn major techniques used in clinical molecular genetics, including PCR, Southern analysis, DNA sequencing, electrophoresis, and other technologies. In addition to the technical aspects, the resident will learn the clinical indications for molecular testing and the clinical implications of test results including calculating genetic risks. The resident will assist the Division director in these activities and become familiar with reimbursement details and quality management measures necessary to manage a diagnostic laboratory, including the process of planning and implementing new diagnostic techniques. Opportunities to participate in an ongoing research activity in molecular genetics are available.

The Cytogenetics portion of the rotation includes both observation and active participation in the preparation of chromosome specimens from various tissues including blood, bone marrow and amniotic fluid. Currently offered tests include: Identity testing on the ABI 310 system, Microsatellite Instability assay (MSI), Cystic fibrosis mutation screening and diagnosis, Ashkenazi Jewish disease, Thrombophilias, Fragile X testing, Huntington disease, Friedrich’s ataxia, Kennedy’s disease and myotonic dystrophy, Non-Syndromic hearing disorders, Infertility panel in collaboration with the Cytogenetics lab, DNA methylation and Imprinting testing of Prader willi and Angelman syndrome, Mitochondrial diseases, Fluorescent In situ Hybridization assays (FISH) on interphase nuclei for the diagnosis of urothelial cancers, AML, CML, CLL, MDS and others. The rotation also includes exposure to a long list of DNA diagnostics utilized in clinical genetics and in oncology. Often molecular testing and cytogenetic testing overlap for a given case. Resident participates in deciding which molecular tests, FISH probes and tissue culture set-ups are required to answer a diagnostic problem, as well as develop hands on experience. At regular sign outs, residents learn to correlate findings from different tests and to generate an interpretative final report.

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Clinical Chemistry Rotation

This 12-week late PGY-3/early PGY-4 level rotation takes place at the Newington campus of Clinical Laboratory Partners. Residents will develop technical and interpretive expertise in the following areas: blood gases, electrolytes, proteins, enzymes, endocrinology, laboratory management/administration, laboratory statistics, instrumentation, immunoassays, quality control and quality assurance, therapeutic drug monitoring and toxicology. The educational activities are structured with a detailed Checklist and include: discussions with Division director based on pre-assigned reading (held approximately 3 times per week), scheduled laboratory rotation to observe specific laboratory procedures and clinical chemistry instrumentation, daily sign-out of serum and urine protein electrophoresis and immunofixation electrophoresis, and toxicology rounds. Residents are engaged in consultative activities and participate in developmental projects occurring in the Division.

During the Clinical Chemistry rotation, LABORATORY MANAGEMENT AND INFORMATICS training is solidified using multiple venues. In additional to didactic lectures, training expectations include hands-on direct management responsibility for first 6 months of PGY-4 in self-selected laboratory division, attendance to management meetings within that self-selected division, participation in a required quality process improvement project, and completion of a organized 15-day independent reading/structured learning activity program with checklist.

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Educational Conferences

Case-Based Learning

Didactic Lecture

Interdisciplinary Conferences

Other

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