"Hot-Seat" General Surgical Pathology Rotation (AP-3)

The "Hot-Seat" rotation is one of the most challenging rotations in surgical pathology. The senior resident/fellow on this rotation previews the vast majority of the in-house cases that pass through surgical pathology before the slides go to the resident who grossed in the case. This affords the resident exposure to a vast array of surgical pathology, crossing all subspecialties.

In addition to rendering preliminary diagnoses, the Hot-Seat functions as a hub of communication between clinicians and residents/attendings. The Hot-Seat should be aware of the status of high priority cases, anticipate potential problems, and alert those involved to important issues. He/she must use his/her judgment to facilitate the movement of cases through signout and transcription.

Another important role of the Hot Seat resident is to facilitate the interactions between the Department and our clinical colleagues from other departments. The Hot-Seat resident is responsible for troubleshooting cases for clinicians, showing cases to clinical teams, and generally being a collegial liaison on behalf of the department. As such, the Hot-Seat resident is expected to be available at the Hot-Seat desk at all times. In the Hot-Seat, one is an ambassador for the Department; professionalism must be demonstrated at all times.

Additional Resident Duties and Responsibilities

  • Review the slides for all cases that come to the Hot-Seat, recording provisional diagnoses in the HS log. If appropriate, order necessary special stains to facilitate the handling of the case. Make notations for any stains you have ordered or any other information you become aware of through your contact with clinicians.
  • Communicate any relevant information to the appropriate junior resident and/or signout team.
  • If you come across a case which you feel needs immediate clinical action, act. DO NOT CALL PRELIMINARY DIAGNOSES TO CLINICIANS without first discussing the case with the attending, except in response to specific inquiries.
    • When rendering a preliminary diagnosis, it is IMPERATIVE that the clinician understands that you are a resident and that the diagnosis is preliminary. Feel free to communicate your level of confidence, but remember that your diagnosis is still preliminary.
    • Give the clinician some idea of when the signout attending pathologist will see the case and offer to call back with the final diagnosis. Use Post-Its or some other system of organization to make sure you can do this.
    • Communicate to the signout team that the clinician/clinical team has inquired about the case, so the signout team may prioritize its review if indicated.
  • Check for cases with mislabeled slides, missing slides, parts, or entire missing cases. It is your responsibility to assure that each case is optimally ready for signout or, if issues arise, that these issues are communicated to the signout team expeditiously.
  • Biopsies should be read and in the residents' boxes by 8 AM. To facilitate this, you can work cooperatively in the morning with the residents on the biopsy-heavy subspecialty services, or begin earlier in the morning. (Biopsies are out the evening before at 10-11 PM; some Hot-Seat residents prefer to review the slides at night to avoid the morning rush.) Remember that the AP-1 and AP-2 residents are expected to have their biopsies ready for 9 AM signout.
  • Late biopsies (those arriving after 8 AM) need to be reviewed and given to the appropriate resident ASAP.
  • Flag important cases (unsuspected malignancy, cases requiring immediate treatment) to the resident's attention, so that he/she can alert the attending and prioritize signout.
  • Try not to bypass the resident on service in your enthusiasm to discuss cases with the attending, unless it is urgent. However, if, in your professional judgment, immediate review by an attending is necessary, please respond accordingly.
  • After the AP-1 and AP-2 residents have signed out their cases with their attendings, they should report the diagnoses back to you. Record cases as "signed out" in the Hot-Seat log by noting the date to the left of the case number, amending your preliminary diagnosis as necessary. All residents should report every final diagnoses back to you after signout; they should also alert you to the status of pending cases so you can function effectively in your communications with clinicians. This communication is MANDATORY.
  • In those cases in which you find a significant disagreement between your preliminary interpretation and the case final diagnosis, you are encouraged to discuss your discrepancy with the signout attending. This should be done in a respectful, non-confrontational manner, keeping in mind that the purpose of such discussion is not only educational, but also a reflection of your involvement in patient care. Not infrequently, the Hot Seat resident picks up on something which the attending may have missed.
  • CALL FINAL DIAGNOSIS on cases where the final diagnosis shows an unexpected malignancy or a significant change in diagnosis from that made at the time of frozen section, unless the junior resident, fellow, or signout attending has already done so.
  • The Hot-Seat resident is expected to remain at their "post" until at least 5:00 PM on weekdays, even if all slides have been reviewed. Hot-Seat is responsible for the organization of the "unknown" resident microscopic conference.

Additional Goals and Objectives for the Hot-Seat Rotation

Patient Care:

  • Increase your confidence and your ability to diagnoses a wide variety of specimens.
  • Make critical decisions regarding the workup of cases, ordering appropriate stains and ancillary tests, which may he crucial for the final diagnosis.
  • Report critical results to clinicians on a timely fashion, when appropriate.

Medical Knowledge:

  • Understand the key therapeutic consequences of the pathologic diagnosis and facilitate communication of diagnoses which require rapid treatment action.
  • Become proficient in multiple areas of surgical pathology through the daily review of a large number of cases spanning many different subspecialties.

Interpersonal and Communication Skills:

  • Learn to communicate effectively with clinical teams, providing preliminary diagnoses and following up on clinical issues.
  • Learn to communicate effectively with staff members of the Department of Pathology, making sure that cases are complete and ready for signout.
  • Learn to communicate effectively with colleagues and faculty members in the Department of Pathology, providing accurate and appropriate clinical information to signout teams, and discussing case workups and final diagnoses.