Description of the Rotations

Written by the residents

Each rotation is five and one-half weeks in length with nine rotations in each year.

SURGICAL PATHOLOGY -- University Hospital (six rotations, plus one senior rotation as an acting fellow)
The surgical pathology rotation is a combination of general surgical pathology service and GI/Liver subspecialty signout on a weekly rotation with 2 weeks of multispecialty general surgical pathology service for every week on GI/Liver.

Surgical pathology general service follows a two-day schedule. Day 1 is spent in the gross room, while Day 2 is spent performing the microscopic examination of the specimens that were received in the gross room on Day 1. The resident on Day 1 staffs the gross room along with two surgical pathology fellows, an extern, three pathology assistants, and support staff. The resident's responsibilities on Day 1 include assisting with frozen sections and gross evaluation as well as cutting in cases. Since the gross room is located next to the operating rooms, the resident is easily able to interact with surgical staff. Visits to operating rooms to view the operative field and review specimen orientation as it appears in situ are frequent. The advantages of this arrangement to the resident's understanding of a case are obvious. The extern, pathology assistants and other support staff provide assistance with the workload, but the resident is responsible for being familiar with the gross appearance of all large cases.

On Day 2, slides go first to the surgical pathology fellow covering the preliminary diagnosis service ("hot seat"). They preview the cases quickly and place a short preliminary diagnosis in the computer. The case then goes to the resident and extern team on Day 2. The resident or extern previews the case, dictates a microscopic description and diagnosis, and the case is transcribed. The surgical pathology fellow does not tell the resident their diagnosis but is available to provide assistance when needed. This allows the resident to look at cases independently and formulate a differential diagnosis. Clinicians that need quick turnaround time can contact the fellow covering the hot seat when they need an answer, which takes pressure off the resident. Although this was painful for all of us at first (sometimes just trying to recognize the tissue), in the end this is an active learning process that is superior to passively looking at slides with a staff member and watching them dictate. Sign-out sessions usually occur in late morning as well as early afternoon with the resident and extern sitting down to review cases with the staff around a multi-headed microscope. This is an opportunity for one-on-one or two-on-one education time with staff. It is also important to know that although we have a general surgical pathology sign-out, (i.e., staff look at all types of cases regardless of their special interest), that subspecialty experts are available for consultation on cases. An advantage to this system is that generally the cases you gross are the cases you sign out. In addition, there is time to quickly read about challenging cases to reinforce your knowledge base.

The GI/Liver subspecialty service shares some of the advantages of the surgical pathology service, but also includes opportunity for focused study in a particular subspecialty area. All GI/Liver cases are previewed by the hot seat and residents preview and dictate cases prior to sign-out. Sign-out sessions occur daily in the morning with the resident and extern sitting down to review cases with the staff around a multi-headed microscope. Once again, this is an opportunity for one-on-one or two-on-one education time with staff. Sign out generally takes most to the morning depending on the volume of cases. The afternoon includes limited grossing of 1 or 2 large GI cases, followed by preview of the cases for the following day’s signout. The majority of biopsy cases and some large cases are grossed by the PA’s allowing residents on the GI service more time to preview and read about cases.

Call responsibility during the University of Iowa Hospitals and Clinics surgical pathology rotation is set up so that the Day 1 resident takes overnight frozen section call with a fellow or faculty. First year residents do not take overnight frozen section call on Day 1. This responsibility is the gross room fellow's. As a resident, your call duties are primarily preparing frozen section slides, and NOT rendering a diagnosis; this is left to the fellow or staff on call. Weekend surgical pathology call is taken jointly with clinical pathology call.

The two VAMC Surgical Pathology rotations offer senior level (generally 3rd and 4th year) residents the opportunity to experience a range of surgical pathology cases. The breadth of specimens is more akin to what one would see in a private practice environment (i.e. skin biopsies, GI/GU biopsies, etc). On a daily basis, the resident is responsible for grossing, dictating the microscopic descriptions and diagnoses, and signing-out all (including neuropathology) surgical pathology specimens with faculty. Other responsibilities include performing and interpreting frozen sections, with faculty back-up as needed. The resident also interacts with physicians at tumor board conference where all new malignancies are discussed. The VA Surgical Pathology experience is a rewarding one because it allows senior residents to accept more responsibility and be "on their own" with faculty assistance as needed.

AUTOPSY SERVICE (four rotations)
The four autopsy rotations cover both UI Hospitals and Clinics and VAMC. The autopsy service consists of two residents, one or two externs, decedent care specialists (hospital morticians), occasionally a 4th year medical student on elective, and a faculty member. Residents are assigned alternating autopsy cases and are responsible for each case from start to finish. In general, each case involves chart review, consulting with clinicians, external and internal examination, organ dissection, microscopic examination, and review of the case with the staff member and any consultants as necessary. Determination of ancillary testing including toxicology, microbiology, cytogenetics, etc., is also performed. A complete report is written by the resident. The entire process takes anywhere from several days to one month.

The autopsy rotation utilizes a six-day workweek. The residents on autopsy cover autopsies performed on Saturdays. On both the weekend and during the week, any case that comes in after 2:00 p.m. is generally performed the next working day.

The breadth of cases on our autopsy service is outstanding. We see a variety of medical, forensic, and pediatric/neonatal autopsies. Approximately 50% of the autopsies we perform are medical examiner cases. As residents, we have no problem getting the requisite number of cases needed to sit for boards (50) within four autopsy rotations.

During cytopathology, residents perform fine needle aspirations (FNAs) in the FNA clinic, which is run by the Department of Pathology. The resident, fellow and staff make an initial on-site adequacy evaluation of FNAs in the clinic, radiology suites, endoscopy lab, and bronchoscopy lab. When the additional slides are processed, the resident and the fellow review the slides and enter a diagnosis in the computer. The slides are then reviewed with the fellow and the staff. Abnormal pap smears, fluids (such as cerebral spinal fluid and urine) are also examined this way. Case sign-out occurs throughout the day in-between procedures. Most residents will perform at least 50 FNA procedures over the two rotations.

A day on the "derm/neuro" rotation typically involves dividing one's time between dermatopathology and neuropathology. Part of the morning is spent looking at both neuro cases (1-5 cases per day) and derm cases (50-60 cases per day). Again, the resident interprets and dictates their impression of the case before sign-out with the staff. The resident is also called to assist with neuro frozen sections. Derm staff sign-out begins in the early afternoon. The resident grosses in neuro specimens at the end of the day. A dermatology resident also rotates on the dermatopathology service and shares microscopic dictation responsibility with the pathology resident. Derm specimens are grossed in by either histology technologists or pathology assistants.

CHEMISTRY (two rotations)
Resident duties on the clinical chemistry service include signing out gel electrophoresis, working with medical technologists to solve laboratory problems and reviewing study cases provided by the faculty. Serum protein electrophoresis and immunofixation electrophoresis gels are evaluated by the resident who enters an interpretation in the computer, followed by staff sign-out. In addition, residents contact clinicians about test reports and may suggest alternative testing which would better answer the clinical question. Throughout the week, clinical cases with interesting laboratory findings are directed to the resident who then independently studies the underlying pathophysiology. One of these cases is typically presented by the resident in the clinical pathology conference on Fridays. Finally, during the second rotation, the resident is involved in a laboratory management project. This could range from determining whether the lab should perform a test that is currently a send-out test or determining the effectiveness of the current methodology for a given test.

HEMATOPATHOLOGY (three rotations)
There are generally two people on hematopathology service, either two residents or one resident and the hemepath fellow. The hematopathology rotation is divided into two blocks. During one block the resident works on the bone marrow service, writing descriptions of the marrow aspirates and biopsy and entering a diagnosis in the computer. A major part of the write-up consists of performing a manual differential on the bone marrow aspirate. Bone marrow technologists perform counts on some of the marrows as well. Similar to surgical pathology, sign-out occurs in the early afternoon and is generally finished by 5:00 p.m. The second block is spent on the "wet" bench where the resident reviews and writes-up peripheral blood smears, CSFs, body fluid, abnormal urine sediments, and other laboratory procedures including hemoglobin HPLC. Hemepath unknowns are given once a week by staff and reviewed at a multi-headed microscope. This is very similar to the surgical pathology microscopic unknown conference held on Tuesdays (see below for list of educational conferences). Lymph node pathology is covered during the final hematopathology rotation.

IMMUNOPATHOLOGY (two rotations)
The experience on this rotation includes interpretation of flow cytometry analysis performed on a variety of specimens, interpretation of direct immunofluorescent studies of skin, interpretation of indirect immunofluorescence tests (ANA, ANCA, and other autoantibodies), and ancillary assistance for immunoperoxidase studies. When problems and questions occur in the immunology lab, the resident has the opportunity to troubleshoot them first. All flow cytometry reports are written by the resident and signed-out with staff throughout the day. In addition, an interesting case is presented by the resident at the clinical pathology conference each Friday morning.

MICROBIOLOGY (two rotations)
The two rotations in microbiology include a wide variety of activities. Time is allowed to sit on the bench with the technologists as they process specimens and identify organisms. (Benches include blood cultures, urine, wound/sterile body fluids, respiratory, surveillance, tuberculosis (TB)/mycology, antimicrobial susceptibility, and virology). The resident also participates in daily lab rounds with the lab directors. During these rounds, the technologists in each area of the lab present interesting cases and ask questions regarding extent of identification required for a particular isolate, clinical significance of an organism, need for susceptibility testing, etc. Gram and Giemsa stains on a variety of organisms are reviewed weekly with staff. The resident carries a service pager as well. The resident also works-up a series of "unknowns" including mycology and bacteriology specimens. In addition, an interesting case is presented by the resident at the clinical pathology conference each Friday morning. The research activities of the microbiology division are extensive and there are numerous opportunities to become involved in projects.

Residents are responsible for interpretation of a variety of molecular tests within three broad categories of molecular pathology (genetic diseases, molecular infectious disease testing, and molecular oncology). Among many others, T- and B-lymphocyte clonality studies, Hepatitis C viral genotyping, factor V Leiden and Prothrombin gene mutation studies, and muscular dystrophy studies are offered. Residents learn the clinical applications and limitations of gel electrophoresis, polymerase chain reaction, and Southern Blot technique. The in-house test menu of molecular tests expands each year, and ample material will be available for resident education in molecular pathology.

The transfusion medicine resident oversees the acquisition and distribution of blood products for the hospital. Residents frequently become involved in the care of patients who require massive transfusion (i.e. patients with trauma, coagulopathy, or surgical difficulties). This may require the resident to visit the operating or emergency room to assess a situation before providing advice or authorizing the release of blood products. The transfusion medicine resident evaluates requests for special products such as granulocyte transfusion or crossmatched platelets. The transfusion service performs apheresis procedures for conditions such as thrombotic thrombocytopenic purpura (TTP), Guillain Barre, and hyperviscosity syndromes, as well as collects peripheral stem cells for bone marrow transplants. Finally, the transfusion medicine resident assists the blood donor nurses in screening potential blood donors.

The two VAMC Clinical Pathology rotations offer residents the chance to experience an integrated clinical pathology laboratory (blood bank, hematopathology, chemistry, microbiology, immunopathology). On a daily basis the resident is responsible for interpreting, writing up and signing-out bone marrow examinations with faculty consultation. The resident interprets blood smears, body fluid analyses, bronchioalveolar lavage specimens (BALs), flow cytometry, microbiology slides, and electrophoreses with faculty back-up as needed. Other duties include blood bank audits and approving send-out tests. Each week the resident leads a laboratory meeting discussing the send-out tests that they were asked to review as well as any pages received during the week.

Furthermore, on this rotation the resident will gain experience performing bone marrow biopsies, under the supervision of Hematology-Oncology fellows. Finally, the resident is responsible for "troubleshooting" problems that arise in the laboratory, being a clinical laboratory consultant for physicians, and other projects. The VAMC clinical pathology rotation offers residents the chance to have an experience akin to the private practice environment. The residents perform laboratory management, make interpretations and diagnoses with faculty backup as needed, and act as a laboratory consultant. However, there is adequate time available for reading or research projects.

ELECTIVE (five rotations)
Each resident is allowed five electives over the four years of AP/CP residency. Residents spend this time in a variety of ways including further experience in some of the service rotations (particularly Hemepath or Cytology), clinically related research in almost any area of the department, and special electives like Ocular Pathology.