Typical Day on AP
Morning conferences are at 8 AM every morning, except Fridays when you can sleep in a half hour longer or go to the Friday morning dermpath lecture at 7:30 before conference. There is usually an unknowns session with Haines and autopsy conference with Sinard once a week each. Fridays are usually resident-given conferences (you give two your first year and one and a half your second year). Sign-out starts after conference (generally around 9 AM) and typically lasts until lunch time (but is variable depending on what service you're on). This is the time for you to present your cases to the attending and discuss what you thought and figure out any ancillary tests that are needed. Grossing generally takes place in the afternoon. There are four wonderful PA's who help out and specimens can come in until 5 PM. There is sometimes sign-out for biopsies in the afternoon (rotation and attending specific). Previewing takes place in the evenings and you start it all over the next day.
For nights, there is a general hospital resident lounge down the hall from surg path with a fridge that has free sandwiches (not gourmet, but free and is dinner), sodas, and a Keurig coffee machine with K-cups (variably stocked).
Rotations in AP
Two first-year residents and one senior resident are on the autopsy service at any given time (with a few exceptions). This is the time for first-years to take vacation, so if that occurs then there is just one first-year resident. When a new case comes, it will be alternatively assigned to each of the new first years. Your autopsy senior is there to help you through what to do. Autopsies average about 250 per year.
(Note: You can get CoPath from home, so you can work on your reports from the comfort of your couch.)
Heavier service. Keri (PA) will be your savior in the gross room and teaches you how to gross breast and can find any lesion that actually exists. There is a lot of organization involved. Before starting sign-out, try to put slides in order (will have keratin stains with the sentinel lymph nodes, pull previous biopsies, and print out diagrams from grossing.)
You get lumpectomies and mastectomies. (You'll get to know some of the surgeons' characteristics. Grube gives large margins, Lanin gives tiny ones.)
With Tavassoli here, we use the DIN (ductal intraepithelial neoplasia) categorization, not DCIS, as in most other institutions. (Though the equivalent DCIS categorization is still put in the sign-out, so you learn both.)
Tavassoli wrote a book, that is now out of print, but is next to the breast scope. This book is good for looking up pictures (has lots of them) and has lots of detail/depth when you want to learn more. To start, you might want to browse Foundations, the AFIP fascicle, WHO, or another book. (But the pictures are useful to browse during previewing if you have an unknown lesion and are trying to match appearances.)
One of the heavier services b/c the gyn surgeons, especially Rutherford, are pretty productive, but grossing tends to be fairly straightforward. Specimen types you get:
- Curettage specimens: Mostly you'll need to differentiate between proliferative and secretory phase. (The Kurman book is great.)
- Cervical biopsies/cones: Learn dysplasia (CIN I-III)
- Benign Uteri: You'll get a bunch of uteri for leiomyomas and will be pro after just a little bit.
- Malignant Cases: Often come in multiple parts, so time-consuming. Pelvic exentorations are the most complicated specimens you'll get. You fix these overnight and will get plenty of help grossing them in.
Another one of the heavier services and you will become quite familiar with searching for lymph nodes. The GI fellow is very involved with the resident on this service as well. He/she will come help you with all your livers and Whipple's and is available for questions you might have.
You're day starts about an hour earlier on this rotation, an hour before conference, to look at biopsies that come out in the morning.
Familiarizing yourself with the various types of mucosa before you start is helpful. (ie. Antral versus oxyntic in the stomach, and small bowel versus large.)
- Biopsies: some main samples:
- Esophagus: reflux esophagitis, infections
- Stomach: reactive gastropathy, H. pylori
- Duodenum: tends to be normal. r/o giardia, duodenitis, and celiac disease
- Colon: lots of hyperplastic polyps and adenomas, inflammatory conditions. (May get pan-GI biopsies for GVHD.)
- Resections: Most GI specimens, you measure and cut, and then fix it overnight, so grossing it in is a two day process. (You get better sections that way, especially of the mucosa.)
EHN (Endocrine/Head & Neck)
Medium/lighter surg path rotation. Lots of thyroids! The head of surgery here is an endocrine guy, so we get lots of thyroids here for head and neck and you'll see a lot of them on cyto as well. (You'll meet Larry the larynx in the gross room.) Composite resections and laryngectomies are the most complicated specimen for grossing.
For thyroids: you'll get to know papillary thyroid caner pretty well; for follicular carcinoma, you have to look for capsular invasion, so if it's called a follicular neoplasm on cytology, you'll need to entirely submit the capsule.
TGUM (Thoracic / Genitourinary / Miscellaneous)
There is a cheat sheet for the common diagnoses. Make sure you get it before starting. This is the "what's left general service" and consists of thoracic, GU, and miscellaneous. The miscellaneous are the "smalls." These are heart valves, DJD joints, degenerative disks...etc.
Thoracic and GU will have the larger specimens. This is what will take up most of your time in the gross room and previewing. The "bigs" (if you get a lot of them, it is more important to preview these over the smalls, especially later on when you get familiar with the small cases.) Urology isn't the most prolific service at YNNH yet, but the volume is increasing.
Lighter rotation and no grossing. There are separate attendings for non-gyn and gyn specimens. Sign-out for non-gyn is throughout the day. They start sometime in the morning and break for lunch. There is then consensus conference at 1 or 1:30, where whichever cyto attendings are around gather and come up with a group diagnosis for the questionable cases of the morning. Sign-out continues in the afternoon. You can get a tray of gyn specimens (PAP smears) from the gyn attending and go through them in the afternoon.
You'll sometimes go to help FNAs.
There are study sets if you want to see a greater diversity of cases. You get lots of thyroids on service. So, if you're motivated, you can grab sets from the filing cabinet and take a look.
Lighter rotation. Dermpath is located upstairs in the department of dermatology and spend part of the time downstairs in surg path and part upstairs.
A.M.: surg path sign out. In surg path, you're in charge of both consults and the in house cases. The consults can be tricky in terms of logistics sometimes, so try to stay organized. In surg path, you get mostly cysts and the resections after biopsies of melanoma. The consults are fairly variable.
P.M.: dermpath sign out upstairs. In the afternoon, you go upstairs to dermpath, where they have their sign-out. If you can get up there early, you can preview some of the cases with the fellow. Upstairs you see mostly biopsies (shave and punch) and they can go somewhat quickly, but they all teach a lot. Some go in a circle, some just ask questions randomly, and some just talk through the specimens themselves. There are usually several people at sign-out (path resident, sometimes derm resident, visiting people, fellow...)
You usually gross the surg path cases in the afternoon. The PA's usually help out with the smaller stuff. Resections you fix overnight and can gross in resections during the day.
Lighter rotation. You have renal in the mornings down in the basement near autopsy. They have a whole system down there and they'll show it to you. Dr. Moeckel does daily teaching sessions when he's on service.
You go to the VA in the afternoons. There is a shuttle that runs every 15 minutes from in front of the med library you can take. The last shuttle from the VA leaves at 6:15, so unless the attending you're with is going to give you a ride, remind them you have to leave by 6 (though sign-out does not usually last that long). You preview as many of the cases as you can when you get there and sign-out afterwards with the respective attending. The sign-out is general, but you do tend to see a lot of skin and GI, while gyn is on the lower side.
We get forensics lectures with dinner the first Wed night of the month. For the rotation, it's at the Bronx ME (Jacobi Medical Center, 1600 Pelham Parkway, South Bronx, New York 10461, 718-829-2030). You get a refund for the travel costs, but you have to ask Dr. Gill for a form that states the dates you were in attendance, so just ask him before you leave.