Anatomic/Clinical Pathology Track
Years 1 and 2 introduce fundamentals in Anatomic and Clinical Pathology. Years 3 and 4 serve as a time to consolidate and integrate skills.
Specifically, PGY-1 is devoted entirely to Anatomic Pathology. In each month, residents train in both Surgical (~75% of the work time) and Autopsy Pathology (~25%). In Surgical Pathology, residents are exposed to different organ systems and the broad range of specimens, both small and large. Of note, in our program subspecialty signout rotations are of one or two week duration rather than one or two month blocks. We believe this provides a significant training advantage as residents are continually exposed to disease entities in each organ system throughout the year, thereby reinforcing learning. Importantly, to promote optimal acquisition of diagnostic skills, we give residents ample time to study and diagnose their slides prior to signing out their cases with attending staff pathologists.
Year 2 is devoted entirely to Clinical Pathology. The first eight months of the year are divided into four 2-month rotations in the core disciplines: Chemistry; Hematology/Coagulation/Hematopathology; Microbiology; and Transfusion Medicine. This sequence allows repeat, advanced, one month rotations in each of the core laboratories. This arrangement exposes residents to all of the laboratories as distinct educational experiences while allowing consolidation of the entire laboratory medicine experience by the end of the year. Laboratory management (including quality control, quality assurance and utilization review), informatics, and the use of new technologies (such as real time PCR, flow cytometry, and mass spectrometry) are introduced in our lecture series and integrated into the rotations. We emphasize clinical context and the laboratorian serving as a clinician and consultant. Furthermore, we integrate residents within greater hospital teaching conferences such as morning medical resident report.
Our clinical pathology experience is highly structured and may be broken down into a number of interrelated components. The clinical microbiology rotation will be used as an example. First, residents spend time becoming intimately acquainted with the different methods and technologies used in the clinical laboratories. This prepares them to troubleshoot assays and decide which technologies should be adopted in their future roles as laboratory directors. In the microbiology laboratory, residents spend their morning with technologists in the different sections of the laboratory learning about testing in the molecular diagnostics, mycobacteriology anti-microbial susceptibility testing laboratories, etc. Second, daily rounds in the different subspecialties provide clinical context. In clinical microbiology, residents and attendings visit the different areas of the laboratory and learn about important isolates. They discuss resistant patterns, underlying mechanisms of resistance, methods used to detect them, and their clinical impact. They address quality control issues, discuss results with clinicians and identify areas for additional workup. Third, residents carry a specialty specific pager. In this capacity, they serve as a focal point and liaison for interactions between the clinical staff and the laboratory. For example, they will respond to requests for help with test selection and interpretation. Fourth, residents keep track of educational issues, broadly defined, that arise during their day (e.g., clinical, operational, and quality assurance issues). They record these issues on their weekly lists and bring them to Tuesday Clinical Pathology Conference. Here they discuss them in an interactive format with the resident group and clinical pathology attendings. See Tuesday CP Conference description. Fifth, residents prepare for and attend weekly tutorial sessions. These sessions are designed to give our clinical pathology residents a broad and solid foundation in laboratory medicine. For example, in clinical microbiology, residents are assigned readings on two topics each week. These are drawn from the most relevant resources in our extensive clinical pathology resident library. To help focus their efforts, there are about 20 questions associated with each reading to which the residents will formulate answers. The attendings and residents will then meet to discuss the topics and questions. Sixth, residents present at subspecialty conferences. For example, microbiology residents prepare weekly plate rounds presentations and demonstrate isolates and methodology for the infectious disease team. Seventh, residents present clinical and anatomic pathology data on a rotating basis in hospital-wide conferences (Firm Conferences, Cardiology Conference, M&M, etc., see conference descriptions.)
On nights and weekends, one clinical pathology resident is on call for all of the CP specialties on a weekly rotating basis. During the first month of the 2nd CP year, call is covered by senior residents. Thereafter, both junior and senior CP residents rotate through the call schedule. How do residents handle questions about issues in laboratories through which they have not yet rotated? We have excellent faculty support built into our program. An attending is on call 24 hours a day/7 days a week. We expect that residents will contact staff about issues that they are not comfortable handling themselves. In the beginning, that will be most issues. Although residents will become familiar with an increasingly greater proportion of issues during the course of their training, there will still be issues outside their experience, even at advanced levels. We do expect for non-life threatening issues, whether arising on call or during the daytime, that residents will formulate their own plan and present this to their attending. This formulation will often require reference to the primary literature and/or subspecialty texts. We believe that residents become excellent problem solvers in clinical pathology by practicing this skill.
Integration of AP and CP starts at the beginning of training with residents attending both AP and CP conferences, regardless of their year in training. In this way, they develop a multi-disciplinary knowledge base and deeper appreciation for pathological issues that often optimally require insights from both arms of our discipline. In addition, they maintain skills obtained during their training in AP while in their CP years and vice versa.
Years 3 and 4 are divided between Anatomic and Clinical Pathology. The CP schedule also includes a formal one month rotation in Molecular Diagnostics and Cytogenetics. Six months of additional clinical pathology experience are available as Clinical Pathology electives, which may include time to pursue Clinical Pathology projects with our faculty. In addition to required surgical and autopsy pathology rotations, year 3 and 4 rotations in Anatomic Pathology include Cytopathology (3 months), Pediatric Pathology (4 weeks) and Forensic Pathology (2 weeks). Seven months of electives (that may be devoted to CP, AP, special projects or a combination thereof) are available for residents who have demonstrated proficiency in core requirements. Years 3 and 4 serve as a time for greater assumption of responsibility. Residents play a more important role in conference preparation and presentation. Furthermore, they act with greater autonomy during clinical consultations.
All of our rotations occur at BIDMC with two exceptions. Residents learn pediatric pathology during a rotation at Children's Hospital Boston, in a large, well-organized department with an excellent faculty and educational resources. The Forensic Pathology rotation occurs at the Massachusetts Medical Examiner's Office in Boston with a large volume of medical-legal autopsies.
Upon graduation from this pathway, a large proportion of our AP/CP residents pursue subspecialty fellowship training in one of the many fellowships offered by our department before going on to faculty positions, often at major academic medical centers.