Autopsy Pathology Rotation (AP-1)
- Dr. John Sinard and Faculty
Yale New Haven Hospital, as a tertiary care center, Bridgeport Hospital, representing a large community hospital, and the VA afford the opportunity to perform a diverse array of autopsies. This includes a number of perinatal/pediatric autopsies in addition to the adult autopsies. These cases are supplemented by a small number of consult cases from outside the hospital. Historically, this service represents a cornerstone in the Department and intense teaching and numerous conferences revolve around this service. Both junior and senior level residents are integral to the function of this service, beginning with review of the chart and discussions with the clinical team, through the performance of the autopsy, to presentation of the findings and generation of the final anatomic diagnosis.
Each case is presented in conference format to the autopsy attending, residents and students assigned to the service. Clinical staff are encouraged to attend. The initial emphasis is correlation of anatomic diagnoses with clinical diagnoses, problems, and management strategies. Microscopic evaluation and further correlation follow. Three weeks is the expected time for autopsies to be completed. In addition, the autopsy service is an important focus for teaching residents pathology. Autopsy case review conferences (gross), case microscopic reviews, construction of the clinical-pathological summary, resident conferences based on challenging cases, and related reading are the educational components of the autopsy. Intradepartmental consultation is encouraged. Case reporting and clinical investigation are academic exercises available to residents through autopsy services.
Typically, two AP-1 residents and one AP-2 or AP-3 resident staff the autopsy service. These residents cover all autopsies performed on patients from YNHH, Bridgeport Hospital, and the VA (West Haven campus). Patients from Bridgeport Hospital who are to be autopsied are transported to the Yale Autopsy facility for autopsy. VA autopsies are performed at the VA. Each weekend, two AP-1 residents are on call for weekend autopsies. They cover autopsies from all three facilities.
The goal of this rotation is to initially train the AP-1 resident in the techniques of performing an autopsy with evolution to becoming an adroit prosector with synthesis of all clinical and pathological data. The autopsy should be treated as a medical consult. The resident's goal is to perform a thorough examination and then interpret the findings in light of the clinical setting, drawing upon their professional knowledge and experience. The resident is always supervised by a faculty member throughout the course of an autopsy to its completion and this individual continuously evaluates the resident's progress. Each resident will be provided with a detailed manual describing the specifics of the service policies and procedures.
Residents on the autopsy service will be expected to select two of their cases for advanced diagnostic workups. The purpose of this activity is to provide residents a practical exposure to the growing breath of alternate diagnostic modalities such as molecular testing. Details of this are available in the Autopsy Service Manual.
Additional Resident Duties and Responsibilities for the Autopsy AP-1 Rotation
- Check in with the autopsy service immediately after conference and just after 9AM on weekends when on call
- Verify that the autopsy permit is valid before starting the autopsy
- Discuss the case with at least one member of the clinical team prior to performing the autopsy
- Be sure the technician has entered into the computer the names of all of the clinical team members so that they all receive copies of the report.
- Discuss the case with the AP-3 resident and then the pathology attending prior to performing the autopsy. If the brain is to be removed, discuss the case with the neuropathology attending as well.
- Assure that accurate photographic documentation of the case is completed.
- Enter the PAD into the computer following (or ideally, prior to) presentation of the case to the attending.
- Routinely select up to five cassettes for "rush processing" to allow incorporation of these findings into the PAD. If necessary, a limited number of special stains can also be requested rush.
- Contact the members of the clinical team (especially anyone with whom you discussed the case prior to performing it and also the individual who secured the autopsy permission) as soon as possible after the case to provide them with verbal feedback of your findings.
- Expect to be involved in any presentation of your cases at conferences within and/or outside of the department.
- With faculty assistance, identify at least two autopsy cases where an advanced diagnostic workup would be appropriate for the case, and perform that workup
- Do not forget about your autopsy cases or simply "let them sit" until the next time you are on a light rotation. The College of American Pathologists requires that final autopsy reports be mailed within 30 days of the autopsy.
- Although most cases which arrive for autopsy after 3PM are held over until the following day, there are rare occasions when you may be required to perform an autopsy after that point, even perhaps in the middle of the night. Therefore, when you are on the autopsy rotation, you should consider yourself "on-call" 24 hours a day, and be reachable by beeper at all times.
- If you are the one of the residents on-call over a weekend or holiday, be sure to check with the rest of the on-call team, including the attending, before the weekend begins. Make sure you are available by beeper or by phone at all times. If you think you may be out of range, call in every hour or so to make sure there is nothing requiring your attention.
Additional Goals and Objectives for the Autopsy AP-1 Rotation
- Determining that an autopsy permit is valid, that permission has been given by an appropriate individual, and noting any restrictions
- Recognizing when a particular case falls under the jurisdiction of the medical examiners office
- Adhering to and applying universal precautions in the day-to-day activities in the autopsy room
- Becoming proficient in the standard techniques for the evisceration and dissection of adults, children, and fetuses, preserving anatomic relationships and connections as appropriate, and understanding when it is appropriate and preferable to deviate from standard technique to better demonstrate the pathology in a particular case (first two months)
- Becoming proficient in specialized dissection techniques, performing them without prompting when the details of the case call for a specialized approach (second two months). These would include removal of the brain and spinal cord as a connected unit, preservation of the inferior vena cava and portal vascular systems, removal of the eyes, dissection of the mesenteric vessels, etc.
- Ability to generate appropriate differential diagnoses based upon gross examination of organs and tissues, and perform the appropriate histologic and special studies needed to resolve those differentials
- recognizing patterns of anatomic changes across organ systems as being related to a single underlying disease process
- Completing autopsy provisional and final reports in a timely fashion
- In a graduated fashion over the four months of the rotation, acquiring the ability to perform a complete autopsy examination independently
- Demonstrating an ability to glean from the medical record the pertinent clinical questions to be addressed during the autopsy examination
- Demonstrating an understanding of the clinical correlates and manifestations of pathology identified at autopsy
- Learning to photographically document an autopsy case, including all abnormal and pertinent normal findings
- Writing a well-organized, thorough, and educational summary which addresses the clinical questions and draws upon recent advances in our understanding of the particular disease processes manifested in the case
Practice-based Learning and Improvement:
- Actively seeking out additional clinical information by consulting patient information systems within the department and hospital
- Using on-line literature searching resources to identify recent advances in our understanding of the disease processes manifested in the autopsy cases
- Monitoring their own case distribution (adults vs fetal) to assure a broad-based exposure to the variations in technical and diagnostic skills based on patient age
- Obtain practical exposure to advanced diagnostic techniques
Interpersonal and Communication Skills:
- Contacting members of the clinical team and/or private primary care providers for the patients prior to beginning the autopsy and eliciting appropriate key information about the patient's medical history and specific questions to be addressed during the autopsy
- Learning to present a concise, organized clinical summary of the patient to the attending pathologist prior to the autopsy and organ review, including pertinent negative information
- Re-contacting members of the clinical team upon completion of the autopsy to discuss findings and, as needed, obtain additional clinical correlation for pathology identified at autopsy
- Learning to draw upon the assistance of technicians, students, and fellow residents during the performance of the case without losing control of the case and with the understanding that the responsibility for all aspects of the case remains with the primary resident
- Writing a well organized, understandable, grammatically correct report which reports findings and educates without being overly critical or inflammatory
- Demonstrating an ability to prepare and present cases at interdepartmental conferences, appropriately summarizing the clinical history and selecting appropriate gross and microscopic photographs for presentation
- Effective teaching of fellow residents (second month on service), pathology assistant students, and medical students in various aspects of autopsy practice and the pathologic evaluation of organs and tissues
- Responding promptly when on service and/or on call to a case and promoting the efficient, thorough, and expeditious performance of that case so as not to compromise family funeral arrangements
- Interacting with fellow residents, assisting as needed to promote efficient running of the autopsy service
- Demonstrating an ability to view the clinical case from the point of view of the clinicians with the information available to them at the time, and not simply with the full knowledge of the autopsy findings
- Interacting with clinical colleagues in a non-confrontational and professional manner when issues of appropriateness of clinical care are discussed
- Demonstrating an ability to speak to family members about the autopsy in general and about the findings from an autopsy the resident has performed. This includes assisting in obtaining informed consent from family members for performance of an autopsy.
- Accurately and appropriately identify and enter Clarifications/Discrepancies from each autopsy case into the clinical information system to allow inclusion in institutional quality assurance programs