All first year residents rotate twice through each service in order to have the opportunity for more senior responsibilities on the 2nd rotation. The basic learning experience on which all the rotations are based is laboratory diagnostics and clinical consultation. The former is the acquisition of critical skills in Clinical Pathology and understanding of laboratory principles; in the latter, the resident assists the medical staff with the interpretation of laboratory results and decision-making for optimal strategies for the use of the laboratory (including therapeutic apheresis and transfusion) in managing the patient.
Training also emphasizes exposure to the strengths and limitations of current and emerging laboratory technologies. In addition to clinical training and responsibilities, residents are encouraged to undertake clinically-directed research or developmental projects of limited scope during each rotation.
Drs. Donabedian, Hodsdon, Malkus and Jatlow
The Clinical Chemistry Laboratory performs over 150 different tests and provides a window on all aspects of clinical medicine. Rapid progress in areas such as automation, toxicology, endocrinology, therapeutic drug monitoring and "wellness testing" keeps the lab in a state of constant evolution with new or improved methods being introduced at a rate of one or more per month. Clinical Chemistry also provides oversight for all point-of-care testing in the hospital. The rotation is a busy one in which the resident takes first call for all consultations on the selection and interpretation of tests and for clinical problems arising in the laboratory.
Daily rounds are held in which current cases presented by the resident form the basis for discussions of all aspects of Clinical Chemistry. These rounds are supplemented by frequent informal discussions with the Chemistry faculty as needed. Monthly Toxicology Rounds are conducted by Dr. Hodsdon. The Clinical Chemistry section also participates in the weekly endocrine rounds of the Department of Internal Medicine. During this rotation the resident will learn the basic principles of laboratory management, laboratory automation, quality control, serum protein and isoenzyme electrophoresis, clinical enzymology, laboratory endocrinology, pharmacokinetics and the clinical interpretation of therapeutic and toxic drug levels, and the clinical interpretation of markers of cardiac injury, as well as personnel and data management in a large laboratory.
Research opportunities include assay development and pharmacokinetic studies of the latest drugs for HIV infection, the neurobiology of cocaine use, and clinical outcome studies of testing algorithms, including point-of-care testing and strategies for cardiac risk assessment.
The complexities of identifying the cause of a severe anemia, deciphering a coagulation or hemostasis problem, diagnosing a hematologic malignancy or monitoring the recovery of functions in a hematopoietic stem cell transplant recipient demand a particularly close collaboration between the laboratory and the clinical hematologist/oncologist. The use of flow cytometry and molecular diagnostics in hematologic diseases is bringing the latest developments in molecular biotechnology directly from the research laboratory to the clinical laboratory.
During the rotation in hematology the resident has the opportunity to learn general hematology as well as various specialty areas including coagulation, urinalysis, bone marrow interpretation and flow cytometry. The resident is responsible for the daily review of abnormal differential counts, blood or body fluid smears containing atypical cells, bone marrow aspirates, platelet function tests, hemoglobin electrophoreses and special hematology cytochemistries. The resident also reviews flow cytometry and special coagulation studies and prepares all reports on these studies in consultation with the attending staff. Drs. McPhedran, Smith and Rinder have joint appointments in Internal Medicine (and in the case of Dr. Smith, Pediatrics) and rounding with the clinical hematology team is available to interested residents.
Drs. Smith, Rinder, Ripps, and Howe
The first year resident rotation in Flow Cytometry is combined with the Hematology rotation while the Immunology rotation is combined with Chemistry. This provides an integrated case-oriented approach to education since it allows flow cytometry studies to be examined in the context of hematopathology morphology, cytogenetic and molecular diagnostic assessment and allows better integration of Immunologic work-ups with serum protein electrophoresis and other chemical analyses. Virology serologic assays are carried out in the virology laboratory; integration of bacterial serologic assays into the evaluation of the patient is undertaken by the resident rotating through Microbiology/Virology, working with the microbiology fellow and the Immunology resident. This approach, as for all of the resident rotations, allows emphasis to be placed on the acquisition of integrated consultative skills in these disciplines.
Similarly, each rotation is characterized by tight integration and participation of the resident in joint Pathology-Medicine-Pediatric-Surgery conferences and rounds. In flow cytometry/hematology, the resident works closely with the resident rotating on surgical hematopathology and with the Hematopathology Fellow, presenting cases at weekly joint Hematopathology Conference with Medicine and Pediatric attendings and housestaff, at weekly joint Lymphoma/Stem Cell Transplant Conference and at weekly Flow Cytometry-Molecular Diagnostic Correlative Rounds.
In Immunology, a monthly Laboratory-Clinical Immunology Conference is well attended by adult and pediatric Immunology/Allergy and Rheumatology attendings and house staff and provides an excellent forum both for ongoing clinical diagnostic/therapeutic care and for education. These joint conferences also provide excellent quality assurance functions for all clinical services involved.
In Flow Cytometry, residents are responsible for formal interpretation of all immunophenotyping, DNA ploidy, and stem cell assessment reports and evaluating these in the context of all other relevant morphologic and molecular studies. All immunophenotyping (blood, marrow, lymph node, fluids) is handled in the same laboratory.
- Leukemia/lymphoma/transplant evaluations number approximately 1,600 per year
- Stem cell assessments approximately 600 per year
- Immunodeficiency evaluations approximately 800 per year (750 for HIV, 50 for extensive evaluation of congenital immunodeficiencies).
At the start of the day the resident and attending review the day's upcoming work by looking over the morphology and clinical data for each case and jointly choosing an appropriate 'panel' of tests. Residents later review each flow result independently and write down their preliminary interpretation; at afternoon sign-out rounds this is then reviewed with the attending and a final interpretive report generated. That result is frequently called to the ordering clinician by the resident, under supervision of the attending.
Graduated responsibility occurs both throughout the rotation and between the first-year and second-year rotation. First year residents initially may handle only a subset of the total daily workload in terms of detailed evaluation and gradually move to handling the entire repertoire; consultation with Medicine/Pediatric/Surgical attendings (by phone or in person) is initially carried out in the presence of the pathology attending but over time residents take sole responsibility for this.
Residents attend joint conferences initially and gradually take responsibility for primary presentation at those conferences. First year residents learn technical aspects of flow cytometry. The Hematopathology Fellow, when on a Flow Rotation, takes a senior educational role - substituting for the attending in the education of the resident as appropriate and responsible for education of medicine and pediatric housestaff rotating through the service. He/she assumes managerial responsibility, generally not assumed by first year residents.
Consultative interpretive studies in Immunology include:
- Immunofixation electrophoresis (800/year)
- Functional stem cell assays (15/yr)
- Lymphocyte proliferation assays (40/yr, coordinated with immunophenotyping)
- CSF oligoclonal banding (175/yr)
There are approximately 150 stem cell transplants and 300 solid organ transplants at YNHH per year. There are >2,000 ANA, 1,600 QIg, >10,000 syphilis serologies, 600 mycoplasma/toxo serologies per annum.
Graduated responsibility is similar to that outlined above: first year residents take all initial consultative calls to the laboratory but do not carry out managerial responsibility; second year residents (as an elective) assume a managerial role, and take primary responsibility for education of allergy/immunology housestaff rotating through. QC/QI duties are also gradually assumed based on what other rotations the resident may have had previously.
Drs. Edberg, Campbell and Bia
Viral diseases, cancer chemotherapy and organ transplantation programs are producing an increasing number of patients with acquired immunodeficiencies and a large number of opportunistic pathogens causing disease. The development of sensitive and specific diagnostic procedures for the responsible opportunistic pathogens presents an ongoing challenge. Novel, emerging infections and changes in the pathogenic mechanisms and antimicrobial resistance of familiar pathogens also provide new problems. In addition, the application of monoclonal antibodies and nucleic acid probes promises to revolutionize all of microbiology.
During the rotation, the resident will learn general microbiology techniques as well as the interpretation of cultures from blood, CSF, the respiratory tract, genital areas, wounds and stools. Skill will also be obtained in mycobacteriology, mycology, parasitology, molecular diagnostic methods and the interpretation of antibiotic sensitivity profiles. These skills are learned by rotations through the various stations of the laboratory as well as daily rounds in which instructive cases are discussed from both the microbiological and clinical points of view. In order to provide greater clinical correlation, Infectious Disease fellows attend these rounds each day. The resident also attends the weekly clinical conferences of the Infectious Disease Service. [LINKS] An approved Clinical Microbiology Fellowship is funded for those wishing to pursue Microbiology as a career.
Drs. Snyder, Shlomchik, Stack, Krause, and Wu
Transfusion Medicine comprises the Blood Transfusion Service, the Apheresis Unit and the Hematopoietic Stem Cell Processing Laboratory. A full range of routine and special transfusion medicine services are provided. We perform apheresis for collection of peripheral blood stem cells for use in support of high-dose chemotherapy. Some collections are processed on an investigational basis either to enrich stem cells or to deplete tumor cells. There are especially close interactions with the hematology/oncology program, the bone marrow and solid organ transplantation programs and the cardiac surgery service. An approved [LINK] Transfusion Medicine Fellowship is funded for those wishing to pursue Transfusion Medicine as a career.
During the rotation the resident will learn the principles and skills involved in the workup of transfusion reactions, the indications for and the performance of apheresis procedures, the indications for use of various blood products, and the interpretation of tests for transfusion transmitted diseases. The fundamentals of blood typing and screening, antibody identification, cross matching, etc., are learned through a comprehensive series of laboratory exercises designed to introduce the trainee to safe transfusion practice. Clinical rounds are held daily with the discussion of clinical and apheresis cases, serology problems and transfusion reactions. Afterwards, ward rounds are made on apheresis patients, stem cell patients, patients with massive transfusions or transfusion reactions, and other cases of special interest to the Blood Bank.
Drs. Stack, Campbell, and Shafi
The VA-1 rotation provides the resident with the opportunity to practice Clinical Pathology in the setting of an integrated Pathology and Laboratory Medicine Service. Residents cover all sections of the clinical laboratories and have the option to interact more closely with the Anatomic Pathology laboratories. This allows the resident to gain a broader view of patient diagnostic services than is possible in the more specialized rotations.
Of particular interest are two national reference laboratories for virology and mycobacteriology. These laboratories serve the entire Veterans Administration health care system, as well as many non-government medical facilities. The VA has a recently established molecular diagnostics laboratory with state-of-the-art equipment, which provides opportunities for residents to participate in new test development.
During this rotation, the resident also has the opportunity to observe and perform bone marrow aspirations and biopsies, and to interpret those tissues for final diagnosis, providing a 360 degree experience in aspirate procedures.
The VA-2 rotation provides residents with a formal graduated responsibility with senior level duties. The resident may elect to act as the assistant director of a subspecialty laboratory, handling all procedural and personnel issues, CAP surveys, budget and capital issues, and of course, all interpretative aspects of that laboratory. In addition, the VA-2 rotation offers specialized experience at the central virology laboratory, the state epidemiologic center, and other VA sites of excellence.
The Clinical Virology Laboratory performs conventional virus isolation and identification as well as the following rapid tests: direct immunofluorescent staining, centrifugation cultures, and enzyme-linked immunosorbent assays for viral antigens in clinical specimens, HIV and HCV viral load by RT-PCR, HSV and VZV PCR and enterovirus NASBA on CSF. HCV genotyping is performed by line probe assay. In addition, the laboratory performs a variety of assays to detect viral antibodies, including antibodies to hepatitis viruses, HIV and EBV. The cytotoxicity assay for Clostridium difficile toxin requires cell culture and is performed in the Virology Laboratory.
A teaching schedule has been organized so that residents will become familiar with all testing done within Virology. The resident is expected to investigate problems, determine clinical correlations when needed, consult with physicians, interpret HIV western blots and correlate virology results with pathologic findings. Biweekly virology case presentations with demonstrations are prepared for Infectious Disease rounds. The resident has the responsibility of contacting the Infectious Disease team and preparing the case history. A close working relationship between the virology laboratory and the transplant and AIDS care programs is essential and the resident helps to communicate and maintain this relationship.
The second year in the straight Clinical Pathology track includes a required four-week rotation divided between Cytogenetics and Molecular Diagnostics; most residents additionally take an elective rotation in Informatics. The remainder of the year is designed according to the individual interests of the resident and clinical service needs; residents rotate through multiple services during the year, but unlike the core rotations in the first year, residents now act in a senior supervisory role and choose directed clinical responsibilities within each laboratory rotation.
Residents in the AP/CP program similarly acquire subspecialty experience during the last six months of their 18-month CP core. During the subspecialty rotations, the resident affiliates with one of the laboratories and serves as a junior attending, responsible for QC assessment, CAP surveys, troubleshooting methods, and backup to the first year residents assigned to the lab. The resident's major goals during the subspecialty rotation are to acquire subspecialty expertise and perhaps to carry out a project of applied or basic research related to the clinical subspecialty. These projects are often begun during the second year and then are intensively carried out in the third year of the CP program.
Dr. Peining Li
In the cytogenetic training program, the trainee will receive training by the director and the laboratory staff in aspects of clinical cytogenetics including background on biology and genetics of chromosomes, analytical cytogenetic techniques (specimen requirements, processing etc), cytogenetic nomenclature, and management and counseling of cytogenetic diseases.
Skills and areas of instruction offered during rotation:
- Human chromosome identification and nomenclature.
- Peripheral blood culture and harvest.
- Chromosome banding techniques.
- Chromosome abnormalities (slide viewing, image analysis, case logbooks, reporting).
- Brief overview on Cancer cytogenetics techniques
- Interpretation and reporting of numerical and structural chromosome abnormalities
- In situ hybridization (this is becoming an integral tool in clinical cytogenetics).
- Possibility of doing a Research projects or at least a case report.
Drs. Rathbone and Wardlaw
In today's highly automated laboratories, results can be generated at rates which can only be handled by computer. The Yale Clinical Laboratories were pioneers in laboratory information systems and today boast an extensive computer system which has been completely developed and maintained with in-house expertise. The same staff of computer scientists, programmers and engineers also carries out maintenance and repair of existing instrumentation as well as design and development of new instruments, instrument interfaces and software. Although there is no formal rotation in this area, the service is an integral part of all the laboratories, so learning occurs on a continual basis. Those wishing more in-depth exposure may pursue research and development projects as part of a second year subspecialty focus.
Drs. Howe, Smith, Rinder, Edberg, Landry, and Campbell
Molecular techniques are changing the face of medicine. Few areas are being more intensely affected than Laboratory Medicine, which has the duty of translating assays developed in the research laboratory into routine, rapid and cost-efficient clinical laboratory assays. Believing that techniques based on recognition of nucleic acid sequences will become widely applicable, we have established a Molecular Diagnostics Laboratory that has the job of developing molecular assays, transferring them to routine clinical use and overseeing their continued use. We are currently developing a wide range of molecular diagnostic assays that will affect all aspects of Laboratory Medicine and are at the forefront of the molecular diagnostics field.
A large number of tests, including those for genetic disorders such as hemochromatosis, prothrombin G20210A mutation, Factor V Leiden, HPA-1 and cystic fibrosis screening, as well as those for tumor diagnosis and minimal residual disease detection, are carried out. Techniques include several amplification strategies, sequencing, quantitative PCR, RFLP analysis and in situ hybridization. Bacterial and mycobacterial identification by 16S ribosomal amplification and sequencing are also performed.
Residents are regularly exposed to molecular techniques in the majority of their rotations. For example, the Virology and Microbiology laboratories test for a number of organisms by molecular diagnostics methods, such as, HIV, HSV, enterovirus, chlamydia and mycobacterium.
In addition, the pathology department at the affiliated VA, performs molecular diagnostics testing for HCV and Factor V Leiden. Residents also have the opportunity to work on new assays in the Molecular Diagnostics Laboratory, either as a rotation project or as a development project in their rotation. Finally, a lecture series in molecular diagnostics is taught jointly by Anatomic and Clinical Pathology.