Laboratory of Pathology - Staff

A. Program Philosophy and Overall Goals

The Laboratory of Pathology (LP) offers a multifaceted training program for residents in anatomic pathology at the National Institutes of Health (NIH) Warren G. Magnuson Clinical Center (CC). The NIH Clinical Center is the site of intramural clinical research for the NIH. Patients are enrolled in approximately 1,000 research protocols conducted by 15 institutes and centers. In addition, the staff of the Laboratory of Pathology receives more than 2000 cases in consultation each year, resulting in a rich and diversified exposure to the practice of anatomic pathology.

The philosophy of the training program is to provide broad and in-depth exposure to the subject matter of anatomic pathology, with an emphasis on clinical correlation, relationships to disease mechanisms, and exposure to investigational opportunities. Each case under study is viewed in the context of (1) the individual patient's clinical course, (2) strong personal interactions with the clinicians caring for the patient, and (3) the general relevance to disease pathophysiology and investigational questions. Residents become fully grounded in the laboratory techniques, observational and descriptive analysis procedures, and communication skills required to gain the maximum information prior to rendering a diagnosis. Each case under study is approached within the context of the individual patient's clinical course, strong collaborative interactions among the clinicians caring for the patient, and disease pathophysiology and investigational questions. Training occurs mostly within the Laboratory of Pathology and through our formal and informal affiliations with Childrens National Medical Center, George Washington University, and other area institutions.

Instruction in anatomic pathology starts with the examination of fresh tissue, microscopic slides prepared from representative sections, laboratory data, radiographs, and special studies including immunohistochemistry, electron microscopy, and molecular genetic analysis. The primary route for the resident to acquire knowledge and gain feedback on performance is direct one-on-one interactions with the staff. The formal aspects of the educational experience include systematic staff instruction in the categorical topics of anatomic pathology, supplementation of case material by study sets, lectures by consultants, and full pathology training courses provided within and outside the department. As the resident progresses through the program, increasing responsibility is provided for diagnostic decision making and teaching of other residents. Numerous conferences, seminars, rounds, and meetings provide exchange of information and points of view with patient care physicians. In addition to gaining knowledge and improving diagnostic skills, the resident should develop a maturity of judgment and the ability to work with peers, subordinates, supervisors, and clinicians in other disciplines to maximize the accuracy and quality of clinical care. Finally, the resident should learn to use and appreciate the new molecular diagnosis techniques (with a full understanding of their limitations), which will play an ever-increasing role in the future.

The structure of the residency training program provides for an intense experience in postmortem pathology, surgical pathology, and cytopathology diagnosis, with additional required subspecialty rotations during training. The residents usually start the first year on the autopsy service before moving to surgical pathology and cytopathology. Separate 1-month rotations in forensic pathology, pediatric pathology, hematopathology, and cytogenetics are required during the 3-year program. Integrated education in dermatopathology, neuropathology, pediatric pathology, hematopathology, immunopathology, electron microscopy, and cytogenetics is provided during all 3 years. Residents in the third year have more clinical decision making responsibilities in both surgical pathology and postmortem pathology. In the third year they also have more opportunities for clinical and research electives.

The residency program provides an in-depth didactic formal education program. At twice-weekly teaching conferences, the residents review unknown slides and formulate independent diagnoses prior to the conference. Rotating staff quiz the residents and discuss the cases, with an emphasis on clinical correlations. Teaching conferences are planned annually with a view to cover all didactic areas of anatomic pathology. A weekly autopsy conference and neuropathology gross and microscopic conferences provide supplemental instruction in these areas.

Residents are supported and encouraged to increase the breadth of their education through attendance at local and national conferences and courses. Residents attend scientific meetings to present their own research. Residents are also encouraged to participate in postgraduate courses offered by the Armed Forces Institute of Pathology (AFIP) and other universities and national organizations such as the United States and Canadian Academy of Pathology (USCAP) and the American Society for Clinical Pathology (ASCP). Travel and tuition is provided by the department.

The program provides frequent formal and informal evaluation of the residents' performance. All staff participate in the written review. The residents have frequent opportunities to formally and informally review all aspects of the training program. The Program Directors meet individually with the residents to discuss the evaluation, progress made over the last 6 months, and suggestions for future growth and improvement. Positive and negative aspects of each resident's performance are considered. Recommendations for individual use of elective time are provided to strengthen areas of diagnostic weakness.

The Anatomic Pathology Program is updated and improved based on new developments in the field of pathology, changing demands in the institutional environment, and suggestions made by residents, staff, or clinicians in other departments. The program is periodically reviewed independently by the NIH Office of Education. The NIH Graduate Medical Education Committee is composed of representatives from all of the clinical training programs in the NIH. They designate an Ad-Hoc review committee that reviews all aspects of the program, interviews residents, and provides a verbal and written report to the Program Directors.

The research activities of the staff are substantial and diversified, incorporating the most modern techniques available in biomedical research and based upon a firm foundation of an intricate knowledge of the biology of the disease state. The laboratory also offers sub-specialty fellowships in surgical pathology, cytopathology and hematopathology that integrate advanced diagnostic pathology with opportunities for laboratory research and instruction in sophisticated laboratory techniques.

Much of the strength of this residency training program comes from the internationally recognized reputation of the Anatomic Pathology staff. The staff is acclaimed in many areas of anatomic pathology and is committed to excellence in the teaching program. The staff conducts an integrated residency teaching program in which case material is incorporated with didactic sessions to explore all aspects of Anatomic Pathology. Because our clinical programs are integrated with the research activities of the NIH, our residents are exposed to information regarding the pathogenesis and pathophysiology of diseases that they are learning to diagnose on a regular basis. This insight into the basic disease mechanisms of pathology enhances their educational experience.

The training program has an abundance of formal courses, national meetings, and elective rotations at outstanding institutions across the country. The unique scientific environment of the NIH offers unmatched research opportunities, as well as a wealth of research conferences and lectures that supplement the clinical training. The superlative quality of our residents contributes significantly to the success of this program. LP consistently attracts top-rated candidates, many with both and M.D. and Ph.D. degrees or additional post-graduate training or experience. Most of our past residents pursue careers in academic Pathology. Our residents will become the future leaders in pathology and serve to elevate the entire discipline of Pathology, as they have in the past.

This manual was most recently revised for the academic year 2006. The material was placed on the Web for quick and easy access for Residents and employees and is available to the public for educational purposes. The information contained in this manual may be reproduced; however, reference to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government.

B. Specific Goals and Objectives

Patient Care

Technical Skills
The resident will master the technical skills relevant for the practice of pathology. Some examples of these technical skills are dissection, gross and/or microscopic morphologic evaluation, interpretation of special stains, examination, assessment, and interpretation of specimens, performance of aspiration procedures, interpretation of molecular diagnostic tests, perform and provide diagnostic interpretation of autopsies, extraction of relevant clinical information from a patient's medical record, evaluation of quality control data, etc.

Clinical Consultation
The resident will learn to provide appropriate and effective consultation to clinicians and other health care providers. Consultation may include providing a diagnosis, discussing the implications of a diagnosis in the management of a patient, providing advice regarding ordering of additional diagnostic tests, assisting in the interpretation of test results, etc.

Medical Knowledge

Fund of Medical Knowledge
The resident will develop a fund of general medical knowledge and focused pathology knowledge relevant to the practice of pathology. This will include an understanding of basic concepts of disease; the pathophysiology of common disorders; the epidemiologic, clinical, morphologic, biochemical, and/or molecular genetic features of common disorders; the prognostic and general therapeutic implications of common disease states; interpretation of laboratory data; and the societal impact and preventative aspects of common diseases.

Application of Medical Knowledge in the Practice of Pathology
The resident will learn to effectively apply his/her general and focused medical knowledge in the day-to-day practice of pathology. The resident must be able to apply her/his knowledge of the diagnostic, prognostic, and general therapeutic features of common disease states to analyze clinical situations, construct a reasonable differential diagnosis, establish a definite diagnosis, and discuss the prognostic and general therapeutic implications of a disease state with clinicians.

Practice-Based Learning and Improvement

Evidence-Based Practice
The resident will learn to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and help improve patient care through self-evaluation and life-long learning.  Residents will make effective use of conferences, lectures, and reading of the medical literature (texts, journals, and other medical databases) to inform his/her day-to-day practice of pathology, and in the development and resolution of a differential diagnosis. The resident must develop the ability to critically evaluate the quality of research studies and to be discriminating in the selection of information sources used to support medical decision making.

Resident Self-Evaluation
The resident will develop skills to identify strengths, deficiencies, and limits of their knowledge and expertise in the day-to-day practice of pathology.  Residents are expected to set learning and improvement goals in order to identify and perform appropriate learning and improvement goals in order to identify and perform appropriate learning activities, analyze and use quality improvement methods, and incorporate formative evaluation feedback in daily practice of pathology.

Use of Information Technology
The resident will learn to use a variety of information technologies to inform and improve his/her day-to-day practice of pathology. Examples of information technologies that must be mastered include electronic medical literature databases, Web-based information sources, and computer-based resources (CD's and other media).

Interpersonal and Communication Skills

Communication Skills
The resident will learn to communicate effectively and courteously with health care providers, laboratory staff members, administrators, patients, and other individuals in the course of her/his practice. These communications will include verbal (face-to-face and telephone conversations) and written (written reports, notes, e-mail messages, etc.) formats. The resident must strive to communicate in a clear, concise, accurate, and appropriately focused manner. Regarding the production of written reports, the ultimate goal is for the resident to produce essentially letter-perfect reports that require minimal or no modification by the attending pathologist, and that convey essential diagnostic information in a clear and concise manner.

Teamwork
The resident will learn to work as an effective member of the health care team in the course of his/her daily practice. The resident must strive to perform her/his tasks in a responsible and timely fashion, facilitate the tasks of other team members, and be cooperative in his/her interactions with team members. (Note: Other team members may include technologists, transcriptionists, other residents, fellows, attending pathologists, clinicians, administrators, and others.)

Professionalism

Courtesy and Collegiality
The resident must learn to treat health care providers (including clinicians, nurses, other pathologists, technologists, transcriptionists, etc.), administrators, patients, and others courteously and respectfully. The resident must learn to be collegial in all interactions with other members of the health care team.

Professional Responsibility
The resident must learn to take his/her professional responsibilities seriously and act accordingly. The resident's professional responsibilities should adhere to ethical principles and may include clinical service (including on-call responsibilities), teaching, administrative tasks, research, institutional tasks, and work with professional organizations. The resident should strive to approach each of these responsibilities with enthusiasm and complete all tasks and assignments effectively and in a timely fashion.

Systems-Based Practice

The Health Care System and the Role of Pathology
The resident must acquire knowledge of practice and health care delivery systems and an awareness of the role of pathology in the context of the greater health care system. The resident will develop a working knowledge of different inpatient and outpatient delivery systems and the general regulatory and financial aspects of health care delivery. The resident must learn the importance of providing effective and timely consultation to clinicians, advising health care providers in the provision of cost-effective care, while cognizant and in accord with patient privacy and confidentiality. The resident should learn to provide coding, statistical and other relevant data, as needed in support of quality care and the Institution.

General Laboratory Administration
The resident will develop an understanding of the general
administrative aspects of pathology practice. The resident will learn to understand and apply the principles of quality control, quality assurance, and continuous quality improvement. The resident will develop a working knowledge of laboratory staffing, laboratory instrumentation, workflow, turnaround time management, safety, customer
service, regulatory accreditation, budget, and billing practices.

C. Structure of the Clinical Training Program

Clinical training in the Anatomic Pathology Program includes three years of rotations and subspecialty training. The program provides for diversified experience in postmortem, surgical pathology, cytopathology, hematopathology, molecular pathology and cytogenetics diagnosis. Separate one-month subspecialty rotations in forensic pathology, surgical pathology/OB GYN pathology, and pediatric pathology offered at affiliated institutions broaden the training offered at the NIH. Integrated training in dermatopathology, neuropathology, pediatric pathology, flow cytometry, immunopathology, electron microscopy, informatics, management, and quality improvement are provided during all three years. Residents in the third year gain more authority in making diagnostic decisions and supervising other residents in both surgical and postmortem pathology. There are also further opportunities for clinical and research electives at this time.

The LP conducts a fully accredited AP3 program in Anatomic Pathology. An optional fourth year of training may be available during which time the residents may participate in electives or research. The sponsoring laboratory, LP or other, provides supplies and services for approved research rotations.  The Laboratory of Pathology has a commitment to permit residents to do "research electives" in laboratories affiliated with the National Institutes of Health during the first three years, and the resident's salary will be fully funded for approved research rotations during years 1-3. The sponsoring laboratory, LP or other, provides supplies and services for approved research rotations. If a fourth year for electives or research is approved, the resident's salary will be funded by LP, NCI for any combination of clinical and research rotations done within the Laboratory of Pathology, NCI. At the discretion of the Program Director, salary funding may be provided for research rotations in other NCI Laboratories & Branches. However, for laboratories outside of the NCI, the sponsoring laboratory/institute is expected to provide salary support for the fourth year resident.

Instructions in anatomic pathology starts with the examination of fresh tissue, microscopic slides prepared from representative sections, laboratory data, radiographs, and special studies including flow cytometry, immunohistochemistry, electron microscopy, and molecular genetic analysis. The primary route for the resident to acquire knowledge and gain feedback on performance is direct one-on-one interactions with the staff. The formal aspects of the educational experience include systematic staff instruction in the categorical topics of anatomic pathology, supplementation of case material by study sets, lectures by consultants, and full pathology training courses provided within and outside the department.  A summary of what residents should expect to accomplish at each PGY level is summarized below:

At the PGY 1 level, residents learn the fundamentals of accessioning, gross dissection, dictation of reports, sign-out procedures, and communication of results. Residents become familiar with the guidelines of the service, and needs and expections of cl inical staff. Residents learn to create an organizational framework in the handling of their cases and to acquire normative skills of reliab ility, timeliness, and thoroughness.  Residents review their fundamental knowledge of normal histology and develop a working knowledge of basic pathologic principles and diagnosis. At the end of the PGY1 year, residents should be able to categorize pathological findings into their basic features (i.e. inflammation, degeneration, neoplasia, etc.) At the PGY2 level the resident should be able to perform gross descriptions with minimal guidance or supervision. They enhance their sophistication of pathologic principles and diagnosis. Residents are more competent in their handling of cases and are now more successful in rendering a working differential diagnosis. The sign out educational time is spent in more sophisticated aspects of pathologic diagnostic decision-making. The PGY2 resident should be able to formulate a list of additional studies required, and successfully draft a microscopic diagnosis in routine cases. At the PGY3 level the resident reviews biopsy specimens, arrives at a preliminary diagnosis, which is reviewed with the attending staff. The resident is expected to fo rmulate independently additional stains required to reach a final diagnosis. At the PGY3 level the resident assists in the instruction of PGY1 residents in principles of gross dissection and description. The PGY3 resident independently reviews cases with clinicians, and is able to discuss clinical correlations and implications of a diagnosis.

In addition to gaining knowledge and improving diagnostic skills, residents develop maturity of judgment and the ability to work with peers, subordinates, supervisors, and clinicians in other disciplines in order to maximize the accuracy and quality of clinical care. Finally, residents learn to use and appreciate the new molecular diagnostic techniques (with a full understanding of their limitations) that will play an ever-increasing role in the future. 

D. Rounds, Conferences, Seminars, Journal Clubs, Courses, and Library Resources

Numerous conferences, seminars, rounds, and meetings provide exchange of information and points of view with patient care physicians.Residents attend regular departmental conferences and participate in Clinical Center Ground Rounds lectures. A schedule of lectures, seminars, journal clubs, and meetings is published each week and includes speakers of national and international note in all fields of biomedical science.

The National Library of Medicine is located on the grounds of the NIH and all its services are available. The NIH Clinical Center has one of the most complete medical libraries in the country and the Laboratory of Pathology has a small departmental library. Scholarly activity includes active participation in regional or national professional and scientific societies. Many other educational opportunities are available at NIH, visit http://www.cc.nih.gov/training/resources.html (page not found).

Residents may receive some formal training through the NIH Foundation for Advanced Education in the Sciences (FAES). The Accreditation Council for Continuing Medical Education accredits the NIH-FAES for sponsored continuing medical education for physicians.

E. After Hours and On-Call Coverage

Residents are not required to be present at the institution during periods of on call, unless there is an occasional rush case or autopsy. Residents' on call responsibilities include coverage of surgical pathology, post-mortem pathology and cytology services. Responsibilities include interacting with the clinical staff of the hospital to assess the clinical situation and patient care needs, assisting in providing a diagnostic interpretation in conjunction with clinical faculty, and if an immediate diagnosis is not required, preparation of the tissue specimens for future processing. PGY-1 residents do not take call. PGY-2 residents and above are on call by telephone or with long-range pagers.

While residents are technically on call for 1-week blocks, residents take calls from home and are not required to stay in the hospital. During the first 2 years of experience, the resident serves a total of 17 and 1/3 weeks on call. Third-year residents are relieved of call responsibilities, but are available to advise and mentor junior residents. Please be aware of the particular duty hour restrictions (see http://www.acgme.org/acgmeweb/tabid/271/GraduateMedicalEducation/DutyHours.aspx) in making up the call schedule, such as:

• Duty hours are limited to 80 hours per week, averaged over a four-week period.

• Residents must have 1 day off in 7 averaged over a 4-week period (i.e., a minimum of 4 days off per month) - without a pager.

• At-home call does not count toward the 80-hour work week, unless the resident is called into the hospital.
• The workload is such that residents should have at least 10 hours off between shifts, so that they be rested and minimize resident fatigue.

F. Residents' Benefits

Residents receive 2 weeks of paid vacation each year and 10 sick days per year. Benefits include on-site childcare, moving allowance, professional expenses, maternity leave for birth or adoption, family leave, and medical leave. Resident shares costs of health insurance, life insurance, and disability insurance. Residents may participate in federally sponsored retirement programs. Residents receive free parking or participate in the NIH Transhare Program to receive public transportation subsidies of approximately $100 each month.

Student Loan Repayment is available from $5,000 to $35,000 to qualified individuals accepted into the program.

No living quarters are provided, but homes and apartments at all price levels are available in the immediate vicinity.

The NIH is located in Bethesda, MD, a thriving urban district located just 10 miles North from the center of Washington, D.C. All of the historic, social and cultural advantages of the nation's capital are close at hand. There are 5 University Medical Centers in the area as well as the Walter Reed National Military Medical Center (WRNMMC).

G. Curriculum

The education in anatomic pathology includes the following specific disciplines:

• Advanced Diagnostic Techniques
• Autopsy
• Cytopathology
• Dermatopathology
• Flow Cytometry
• Forensic Pathology
• Histochemistry
• Immunopathology
• Laboratory Management
• Molecular Biology
• Neuromuscular Pathology
• Pediatric Pathology
• Quality Assurance
• Surgical Pathology
• Ultrastructural Pathology

The educational experiences detailed above are provided through separate exclusive rotations and by rotations that combine more than one area. The formal curriculum includes lectures by staff and consultants aimed at practical differential diagnosis and problem solving in anatomic pathology. Lectures are supplemented with slide reviews and written material.

Additional written instructional material is provided in the Residency Manual, the Laboratory Policies Manual, and as part of the resident's first introductory month in LP.  An institutional library (http://nihlibrary.nih.gov/Pages/default.aspx), a departmental library, and an extensive series of case review collections are also available to the resident.

Required 1-month rotations outside the parent institution provide specialized exposure and instruction in one or more disciplines, including OB-GYN Pathology, Pediatric Pathology, Forensic Pathology, General Surgical Pathology, and Cytopathology. The residents attend formal lecture series in Bioethics and Molecular Pathology.

Our residents as a group are involved in a wide variety of pathology-related professional activities, ranging from those at the local level to those at the national level. Within the Laboratory of Pathology (LP), residents participate as members of the Quality Improvement Committee, the Tissue Resource Committee, the Safety Committee and College of American Pathologists (CAP) Readiness and Inspection Committees.  Residents participate in the departmental Quality Improvement Committee as part of LP's Quality Management and Quality Assurance program, which meets monthly. Residents participate in departmental Quality Assurance by preparing monthly frozen section reports. Residents receive Quality Assurance training while performing a yearly Quality Assurance assessment under the supervision of an assigned staff member. Each resident prepares a report of their findings for presentation to the Quality Assurance committee. Satisfactory participation in Quality Assurance Assessments is required for certification of completion of residency training. As members of the Tissue Resource Committee (TRC), residents rotate on a monthly basis and assume responsibility for reviewing requests from investigators for tissues to be used in research. Through this activity, they become familiar with the regulations governing research involving human subjects, and with the operation and activities of the Office of Human Subjects Research (OHSR). They also gain critical knowledge about the function and operation of the Institutional Review Board (IRB) process. They review TRC requests, and respond, under the supervision of a staff pathologist. All residents serve on the TRC at least one month each year. Several of our senior residents have conducted CAP Interim Internal Inspections, most recently in 2010, in conjunction with senior technical or professional staff. Topic areas covered include the Lab General and Surgical Pathology checklists. An inspection team from the NIH will review an institution in New Jersey in May 2012, and this team included one of our Chief Residents.

Residents in the LP have been active participants in the NIH-wide Fellows Committee (FELCOM). As members of FELCOM, they have been involved in the evaluation of programs at the NIH regarding issues of importance to their peers; e.g., duty hours, mentoring, recruitment. Several residents in recent classes were elected by their peers to serve as one of the two fellow representatives to the NIH Graduate Medical Education Committee (GMEC). Such activities provide these residents with a perspective and experiences that can be expected to facilitate leadership roles in their academic careers.

In depth training is provided in the very latest molecular technology and advanced diagnostic techniques. This includes cell cycle and DNA ploidy analysis by multichannel flow cytometry, automated immunohistology, in situ hybridization, polymerase chain reaction amplification, Northern blotting, Southern blotting, probe isolation and labeling, DNA sequencing, karyotypic analysis and immunoelectronmicroscopy. The residents learn to independently perform the techniques in the laboratory and are instructed in data interpretation and troubleshooting for errors and artifacts. The typical educational experience of residents is summarized in the table below:

Notes:
(1) Cover Frozen Section Service during Surgical Pathology and Autopsy rotation
(2) Including autopsy
(3) Includes perinatal and pediatric autopsies
(4) PGY4, if approved, may be fully funded at which time the residents may participate in other electives or research

H. Resident Responsibility

Residents are integral members of the staff of the Laboratory of Pathology. They have opportunities to participate in discussion of matters related to management of the department. Residents' input is provided at the Monthly Residents' Meetings, and residents participate directly in submitting cases to the Quality Improvement (QI) Committee. Representative residents serve on the QI Committee during the month they rotate on the autopsy service and participate directly in residency candidacy selection.

The third-year "Hot Seat" rotation is a time when decision making in surgical pathology is the direct responsibility of the resident, under appropriate supervision.

The schedule for duty hours, night and weekend call is made by the second-year residents in conference with the other residents and staff. The on-call schedule is monitored and approved by the Staff Residency Education Committee. An organized hierarchy of backup support is provided for difficult cases.

I. Supervision of Residents

Guidelines and Implementation of NIH Policy

The chain of supervision applies to both clinical and administrative issues. Residents are physicians in training and the privilege of progressive authority and responsibility, conditional independence, and supervisory role must be assigned by the program director and faculty members. As residents learn to operate with increasing levels of responsibility and autonomy as he/she progresses through the program, specified levels of supervision must be in place and exercised through a variety of methods to include direct supervision, indirect supervision, and oversight.

The levels of supervision are defined as follows:

Direct supervision requires a supervising physician to be physically present with the resident. Indirect supervision requires that direct supervision is immediately available either by the supervising physician being physically available or (at a minimum) is available by telephonic and/or electronic means and can provide direct supervision. Lastly, oversight requires that the supervising physician is available to provide review of procedures/encounters with feedback provided.

Please note, that residents must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence. In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident and delegate to him/her the appropriate level of patient care authority and responsibility. In general, while residents may consult with upper level residents, residents should always discuss with their attending or direct supervisor prior to any final decisions are made regarding clinical and administrative decisions. Chief residents are expected to provide leadership throughout the residency; however the attending on service or direct supervisor should be consulted prior to any final decision is made.

Additional supervisory guidance is provided as follows:

Autopsy Service
A first year resident is closely supervised, and the staff pathologist is generally on-site with the resident during all activities. For example, the staff pathologist would assist a first year resident during the autopsy examination. Most second year residents are considered qualified to complete an autopsy examination under conditional independence; however they must consult with senior staff prior to beginning the case regarding the diagnostic questions and any special procedures to be performed. At the conclusion of the case, the second-year resident will again consult with the senior staff regarding the Provisional Anatomic Diagnosis based on gross examination. A third-year resident assumes still greater responsibility, assisting in the supervision of junior residents, and instructing them in procedures of gross and microscopic examination.

Consultation autopsies in which the prosection is done elsewhere are divided into two broad categories. The first category, which accounts for most of the cases, involves autopsies performed on NIH patients at other hospitals. In these cases, formalin fixed tissues (usually a whole brain), and/or blocks and slides are received, usually before a final report is issued by the originating institution. The junior autopsy resident rotating in the month during which the materials are received is responsible for preparing a final autopsy report under the supervision of an attending pathologist. The resident participates in all aspects of case management and write-up. In the second category are cases sent for a second opinion. In these cases a final report from another institution has been completed and specific questions are addressed to the pathologist. As with the other type of consultation cases, these cases are assigned to a junior resident who manages the case through sign-out and report preparation under the supervision of a staff pathologist. Preliminary Anatomic Diagnosis reports are not issued for consultation cases.

Surgical Pathology Service
At the PGY 1 level, residents learn the fundamentals of accessioning, gross dissection, dictation of reports, sign-out procedures, and communication of results. Residents become familiar with the guidelines of the service, and needs and expectations of clinical staff. Residents learn to create an organizational framework in the handling of their cases and to acquire normative skills of reliability, timeliness, and thoroughness. Residents review their fundamental knowledge of normal histology and develop a working knowledge of basic pathologic principles and diagnosis. At the end of the PGY1 year, residents should be able to categorize pathological findings into their basic features (i.e. inflammation, degeneration, neoplasia, etc.) At the PGY2 level the resident should be able to perform gross descriptions under conditional independence with minimal guidance or supervision. They enhance their sophistication of pathologic principles and diagnosis. PGY2 residents are expected to be more competent in their handling of cases and are more successful in rendering a working differential diagnosis. The sign out educational time is spent in more sophisticated aspects of pathologic diagnostic decision-making. The PGY2 resident should be able to formulate a list of additional studies required, and successfully draft a microscopic diagnosis in routine cases. The PGY3 resident reviews biopsy specimens, arrives at a preliminary diagnosis, which is reviewed with the attending staff. The resident is expected to formulate independently plans for additional stains required to reach a final diagnosis. PGY3 residents assist in the instruction of PGY1 residents in the principles of gross dissection and description. The PGY3 resident under conditional independence, reviews cases with clinicians, and is able to discuss clinical correlations and implications of a diagnosis.

Cytopathology Service
As time goes on during the year the fellow assumes graduated responsibility for the primary sign out of cases. Although residents are expected to review all of the cytology cases while on the cytopathology service, rendering diagnoses and reviewing all of the cases with the attending or fellow on service, the resident does not assume independent sign out responsibility. The resident does, however, become trained in the performance of fine needle aspirations, and does perform fine needle aspirations under the supervision of an attending or fellow.

Adjustment of Resident Supervision
A resident's level of conditional independence is adjusted by the faculty and program director, based on his or her level of achievement and advancement in the program. Some residents require greater supervision than others, and residents do not graduate from the program until they have achieved competence in all required areas. Residents performing at a higher skill level may be given greater responsibility for education and mentoring of their peers, or more independence and autonomy in discussing cases with clinicians. These higher levels of conditional independence are generally awarded to senior (third-year) residents. In rare circumstances a resident may be required to do remedial work in order to advance further in the program. This decision is reached by performance on standardized tests, evaluations performed by faculty, review of the resident's progress by the Program Director, and discussion and deliberation with the resident in question.

On-Call Supervision
It is the responsibility of the resident on call to operate within his/her abilities and request help from attending on call. It is the responsibility of both the resident and on call attending to assure that the highest level of patient care is maintained. As reviewed above, the level of staff supervision for autopsy performed outside of normal working hours varies according to the experience level of the resident. Before starting an autopsy the resident must verify that the autopsy permit is adequately executed, review the patient's chart to familiarize him/herself with the clinical case, discuss the case with the clinical attending/fellow, establish the specific questions to be addressed by the postmortem examination, and discuss the case with the attending staff pathologist. At the PGY 1 level, the attending pathologist is likely to be present during the prosection. At the PGY 2 level, most residents can complete the prosection under indirect supervision without the attending physically present. However, the attending should be readily available, should any questions arise during the course of the autopsy that may require immediate direct supervision.

For surgical pathology and cytopathology diagnoses which impact patient care, prior review by an attending staff pathologist is required before a diagnosis is provided to clinical staff.

J. Research Mentors

With the goal of enhancing each resident's educational experience while at NIH, the Residents Education Committee has instituted a mentoring program. Each resident chooses a Research Mentor. The role of the Research Mentor complements the role of the Program Director in providing career guidance.

Research Mentor
The research mentor has first line responsibility for the immediate supervision of the resident during a research elective. The nature of the guidance received will vary, depending on the nature of the research, basic or clinical. See section four for information on resident research. Examples of research guidance are outlined in the table below.

Examples of Research Guidance

As the resident becomes more scientifically independent, the research mentor should have less day to day oversight, and provide advice in the form of general guidelines rather than explicit recommendations.

Based on direct observation and interaction, the research mentor can evaluate the scientist's progress in creative thinking and analytical ability, time management, technical mastery, scientific writing, and communication skills. The resident meets with the research mentor on a prn basis.

Anatomic Pathology Program Director

The Anatomic Pathology Program Director provides counseling and guidance for broad issues related to the resident's career development.

• Critique of overall educational progress and individual clinical/scientific growth
• Formulation of a 6-month or annual curriculum plan to include electives and required rotations
• Creative problem-solving relating to interpersonal skills, time management, and rotational conflicts
• Recommendations for places and people to go to for additional advice on specialized topics
• Job placement
• Advice about NIH quality of life, career coping, and personal decisions influencing scientific/career issues

The Program Director should refer the resident to the appropriate person to cover topics related to ethics, discrimination, or harassment.

K. Chief Resident

One or more senior residents is appointed to serve as Chief Resident for the academic year, July 1-June 30. The appointment is made by the Resident Education Committee after consultation with the senior staff, and is based on professional and administrative abilities, maturity, and responsibility. The duties of the Chief Resident are diverse.

The Chief Resident duties include:

• Chair the monthly Resident Meetings.

• Prepare Agenda for meeting, and minutes.

• Coordinate the Resident Call Schedule, including adjustments for unexpected absences due to illness or other emergencies.

• Coordinate outside required rotations, in conjunction with the Program Directors, to ensure that all residents complete the program requirements.

• Coordinate the Resident's lecture series, in conjunction with faculty advisors, to meet curriculum goals.

• Invite outside faculty to participate in the Resident's Lecture series, and coordinate their visits to the department.

• Take attendance at Resident's conferences.

• Assist in the organization of the Resident-led Journal Club.

• Oversee the distribution and availability of the Check Sample slides and other teaching materials.

• Coordinate the office assignments for incoming and current residents, and coordinate with administrative staff the relocation of current residents, and installation of new residents in their offices.

• Oversee the orientation of incoming residents, both during their initial orientation month, as well as during their initial service rotations.

• Ensure adequate supervision by the designated hot seat resident rotating with the junior residents.

• Coordinate resident needs for supplies used for clinical activities (film, digital media, etc.)

• Coordinate Resident requests for additions to departmental library.

• Coordinate additional service coverage on an as-needed basis, in the event unusual workload requirements or competing demands for residents on service.

• Provide back-up to the Hot Seat Resident, when needed.

L. Evaluation of the Residents

At 6-month intervals, residents receive formal, written evaluation of their performance by the teaching staff. The Residents' Education Committee meets and determines a numerical score (1-9) under a series of 21 categories:

1. Clinical judgment
2. Medical knowledge
3. Procedural skills
4. Practice-Based Learning and Improvement
5. Humanistic qualities
6. Professional behavior
7. Interpersonal Skills and Communication
8. Medical care
9. Team leadership
10. Commitment to scholarship
11. System-based learning
12. Attention to administrative needs
13. Participation in departmental programs
14. Progress in pathology diagnostic skills (Patient Care)
15. Quality of pathology diagnostic write-ups
16. Efficiency of case completion
17. Quality of conference presentations
18. Communications with staff and clinicians
19. Personality and attitude toward fellow residents
20. Research accomplishments
21. Professionalism

These categories reflect the standard competencies identified by the ACGME guidelines. An overall rating score is recorded. The passing grade is 4. Immediately following the written evaluation, the Program Director meets individually with the resident and review their progress. At that time, the residents provide confidential reviews of the pathology staff. In addition, residents are expected to bring up suggestions and concerns on any aspect of the residency program during the periodic Residents' Meetings.

Monthly residents' meetings (Fridays, 4:00 p.m.) are held for the express purpose of allowing residents to voice concerns and make suggestions for improvements in the educational and diagnostic aspects of the program. The Chief Resident coordinates the agenda. Residents suggest discussion topics for the meeting. Agendas for the meeting are sent out ahead of time. At the time of the meeting, action items are formulated and progress is reported at subsequent meetings.

Evaluations are received after each outside required or elective rotation from the training director at the outside institution.

Each year the residents take the National Pathology Residents In-Service Examination, administered by the American Society of Clinical Pathology. The exam has a practical and a written portion. Each resident receives a copy of the test score, which contains a comparison of his/her score with anatomic pathology residents in the same year nationwide. The resident's performance is reviewed individually and confidentially with the Program Director. The overall performance of the residents as a group is used in judging the effectiveness of the teaching program by the Residents' Education Committee.

The clinical performances of the individual residents are evaluated using written evaluation surveys that are distributed to all members of the Anatomic Pathology teaching staff. The residents are rated, using the attached form, in the following performance categories: diagnostic skills, diagnostic write-ups, efficiency of case completion, conference presentations communications with staff and clinicians, personality and attitude, and finally research accomplishments (1). The performance evaluations are performed at six-month intervals. The evaluations of each resident are pooled and a composite report is prepared by the program director. The composite evaluation is reviewed with the resident in an individual, one-on-one meeting with the program director. Progress over the last rating period, as well as suggestions for future growth, development and improvement are discussed. Positive and negative aspects of each resident's performance are considered. Areas of weakness in diagnostic skills are identified and recommendation for use of elective time to correct these deficiencies is made, if appropriate. The resident's signature is required on the form that states that their performance during the most recent rating period has been reviewed with them, and that they acknowledge having received this review.

Following completion of the review process the composite and individual reviewers' comments are retained and held confidentially. Copies are provided to the NIH Office of Education, upon request.

Residents are given basic skills examinations after completion of core rotations. These tests allow the staff to evaluate an individual residents progress in diagnostic skills. The resident also obtains insight into his or her level of diagnostic ability. Residents are able to evaluate their areas of strength and weakness, and to supplement their training as needed. Based on these tests, and other objective measures of resident achievement, residents are allocated varying degrees of responsibility. Some third year residents can review cases and provide diagnostic information to clinicians without immediate staff review, if they are confident in their interpretation. Other residents are not granted this level of autonomy until they have advanced further in their diagnostic skills.

Each resident keeps a personal work recording log of the cases, autopsies, surgical specimens, specialized diagnostic procedures they have experienced. This information is reviewed and utilized for Board Eligibility determination at the conclusion of training. A completed final evaluation, written letter of evaluation/recommendation and certificate of completion of the program is provided to each graduate. The final evaluation is part of the resident's permanent record maintained by the institution.

A detailed logbook is maintained tracking all outside rotations and elective rotations. The logbook contains the resident's evaluation of each rotation and the evaluation of the residents by the outside institution. Dr. Jaffe, residency co-director, is the personal contact with all rotation directors to review the progress of each resident who rotates at that institution. After completion of an outside rotation, the supervisor of that rotation immediately prepares an evaluation form, which is submitted to the one of the Program Directors.

The resident receives the completed form, signs it and dates it, and it is filed with other program evaluations. Any deficiencies in performance are discussed with the Program Director, who may consult with outside staff if needed. High-level achievement also is immediately recognized and acknowledged by the Program Director.

We are expanding our areas of educational outcome assessment, defining specific knowledge skills, and instituting educational experiences, as needed, in order for our residents to demonstrate the ACGME competencies. We plan to review the impact of our measuring tools on the success of our residents during the program, and eventually, in their future careers. Our overall goals will be a) to ensure that competencies are measured and that our response to the assessment influences the training and counseling of the individual resident, b) to verify that full competency translates into a career performance that is compassionate, appropriate and effective, and promotes a healthy society in general, and survey residents after they are in practice to determine areas of emphasis and improvement.

We plan to work with other academic program directors, pathology societies involved with competency testing (e.g. CAP) and our local Institution Graduate Medical Education Committee, as appropriate, to develop general didactic methods and objective measurements to ensure competency testing is fully instituted and meets the goals stated above.

M. Evaluation of the Program

Input about ongoing concerns and service issues are gathered on a monthly basis at the residents' meetings. The educational effectiveness of this Anatomic Pathology Residency Training Program is assessed on a semi-annual basis. This is accomplished through written evaluations of both the program and individual teaching staff by the current residents. The evaluation is performed using two standardized forms that ask the residents to rate 1) the program and facilities overall, and 2) the faculty. The faculty evaluations address availability, teaching quality, subject matter, attitude and communication. The program evaluation forms assess program administration, overall staff supervision, facilities, research support, safety issues as well as adequacy of technical assistance. These forms also include "Comments" sections for the residents to complete if they feel necessary. The residents may complete these reviews on an anonymous basis, or may identify themselves, if they desire immediate feedback on their recommendations.

The written evaluations are compiled and presented to the Education Committee for review on an annual basis. Specific comments regarding the program are included. Positive and negative feedback are considered. If problem areas are identified these are presented to the entire clinical staff for discussion and resolution. The Clinical Chiefs meet on a monthly basis to review any problems or concerns related to the clinical services, and the performance of the residents or teaching staff.

In addition to written evaluations, each resident meets with the Program Directors every six months, and group meetings are held with all of the residents and the Program Directors at least one time per year. The residents are encouraged to make suggestions about ways in which the program can be improved, and these are acted upon, after conferring with the Resident Education Committee. The residents may compile their suggestions in written form and present them to the Program Directors and Resident Education Committee for review. Based on resident recommendations for improvement, changes were implemented to improve the rotation schedule and sign-out schedule. Changes were also made to the teaching conferences. A formal curriculum was established to ensure that all areas of diagnostic anatomic pathology and laboratory management are covered. These changes were judged to be successful as discussed in follow-up resident meetings.

The education committee meets at least once a year (and more often if needed). It reviews the organization of the program and its resources. Comments provided by the residents in written and narrative form are considered. Matters discussed and acted upon in the last year include 1) funding of outside "long distance" elective rotations by the department, approved and limited to one rotation per year per second or third year resident; 2) establishing new rotations to increase exposure to peri-natal autopsies, now being implemented at Holy Cross Hospital; 3) altering frozen section coverage to allow the resident on the autopsy service to cover frozen sections in the afternoon, thus freeing up the "in-house surgical pathology resident" to have uninterrupted time to block in surgical specimens; 4) changes in the residents lecture series to provide for a more structured curriculum to ensure coverage of all areas of anatomic pathology and laboratory management; 5) Formalized list of duties for the Chief Resident.

Statistics on resident workload and turn around times are generated and printed from the SoftPath™ Laboratory Information on a quarterly basis. These are reviewed and maintained by the program director and clinical chiefs, and allow the evaluation of the efficiency of case completion for each resident on an objective basis. The results of these statistical reports are integrated into the six month formal evaluations.