Surgical Pathology Service

The Surgical Pathology Service renders tissue diagnosis on biopsy samples and studies surgical resection specimens in an accurate and timely fashion. The service is staffed by several attending Pathologists, residents, and fellows. This service entails all facets germane to the evaluation of surgical specimens, including prosection, interpretation, communication, and report generation. As members of a tertiary care center, residents are exposed to a vast spectrum of material. The resident is responsible for each case assigned to him/her and, with supervision by a faculty member, initiates all studies necessary for the completion of a case, including utilization of all available ancillary studies and molecular technologies. Areas of intense sub-specialization include the fields of genitourinary pathology, endocrine pathology, orthopedic tumors, lung pathology, and ENT pathology. As residents accrue experience from the first to second years, they are given increasing responsibilities in this setting. The residents interface with numerous faculty members and experience ongoing evaluation and input that culminates in a formal written evaluation. The ultimate goal for this area is to produce experienced, qualified Surgical Pathologists who will have a solid foundation on which to build their careers and who will appreciate the need for consultation.

Because of the specialized nature of the clinicians who avail themselves of the expertise of the staff, the service is organized in programs that focus on one organ or specialty. Depending on the case load for each individual program, the residents will be assigned to one rotation or a combination of rotations that optimizes the learning experience and the smooth functioning of the service.

Each incoming case is assigned to a resident (AP-1 or AP-2) and an attending who will be responsible for the final report. The average time for a final diagnosis rendered on a biopsy is 24 hours; for resection specimens, it is two to four days. When cases demand a work-up that will prolong the turn around times, a provisional report may be issued and/or the attending will be notified by telephone. The senior resident assigned to the "hot seat" reviews every case and acts as focal point for the communication and exchange of information with the clinical staff.

The medical staff in surgical pathology is supported by the technical group in the gross room, the Histology Laboratory, the Co-Path medical information system, and the transcription pool. Separate summaries are provided in this manual for the histology laboratory and computer services. The gross room group is responsible for the intake of cases and helping the medical staff with the grossing and work-up of the specimens. A manual devoted to gross room procedures is distributed separately. Harmonious cooperation between the Histology Laboratory and the Yale Pathology Tissue Services staff optimizes the collection of samples for scientific purposes without compromising patient care.

After a specimen has been accessioned and subsequently "grossed" by a resident or Pathologist Assistant, a secretary transcribes the gross dictations. The Hot-Seat reviews the paperwork and slides and formulates a preliminary diagnosis. A final diagnosis is generated after further review by the resident and attending. The final reports are electronically signed out by the attendings and copies are sent to attending physicians and medical records.

It is very important for patient care to maintain continuity of knowledge about a specimen. When a resident has grossed in a specimen, that specimen remains the responsibility of that resident until a) it has been signed out, or b) responsibility has been formally transferred to another resident. Transferring responsibility occurs most commonly when one resident is rotating off service and another is rotating on, but also occurs when a specimen is referred to a different specialty service for signout. It is not sufficient to simply "pass on" the slides to the new resident. The resident transferrer must organize the case and sit with the resident transferee and clearly communicate how the specimen was grossed in and what workup, if any, has been initiated for the case. 

Rotation Redesign to Maximize Teaching

The volume of surgical material being evaluated by most pathology departments has been steadily increasing over the past several years. However, in most programs, the number of residents has not been increasing. As a result, residents are interacting with more and more specimens each year. Although this increased exposure provides new and important learning opportunities, volume overload can ultimately compromise training.

In response to this growing workload, the Resident Education Committee in Anatomic Pathology recommended redesign of each of the surgical pathology rotations to create two paths for specimens through the department: one path involving the residents, and one by-passing the resident, so that resident workloads remain reasonable. This process is currently underway. The Education Committee also developed guidelines for rotation directors to use in the redesign process. They are:

  • Residents must be directly and actively involved in all aspects of the real-time evaluation of active cases within the department.
  • It is not necessary for a resident to be involved in every case that comes through the department; however, guidelines need to be in place to ensure adequate exposure to neoplastic as well as non-neoplastic lesions specific to each specialty service. Typically, residents should be involved with all malignant resections.
  • Residents should be fully responsible for all cases they gross in until they are signed out with the attending. Residents are expected to be able to converse intelligently about their cases with the attending pathologist as well as residents and clinicians in other departments. Therefore, residents must routinely be given time to preview slides on all cases they gross in BEFORE taking them to signout. Residents must accomplish this in a timely fashion to prevent delays in the care of the patients. Previewing should include writing up the case, correcting the paperwork, pulling relevant prior material, and reading about the cases as appropriate. Exceptions may occur at the time of change in rotation, in which case a resident leaving a surgical service may sign-over a case to the resident coming on to the service.
  • Decisions about which specimens take a resident path and which take a non-resident path should be determined on a per-service basis and based on the educational value/need for the specimen. These decisions may take into account level (year) of training but should NOT vary based on the interests, efficiency or skill of a particular resident (all residents of equivalent training level should be held to the same standard) or on non-educational factors, such as who the submitting physician is.
  • There must be a mechanism to identify unusual and highly educational specimens that take the non-resident pathway to ensure resident exposure.
  • Rotations should be designed to provide the resident with a balanced exposure to all stages of the diagnosis, evaluation, and treatment of disease. This should include thorough exposure to primary biopsies (in which a diagnosis has not yet been made), involvement in selection and interpretation of ancillary techniques, evaluation of definitive resections, and participation in multidisciplinary clinical conferences. Opportunities for direct communication with clinicians should be encouraged.