Surgical pathology refers to the study of tissue samples obtained by various surgical means, including core needle biopsies, skin punch and shave biopsies, open biopsies, video-assisted and laparoscopic biopsies and surgical resection specimens. The proper handling, processing and evaluations of such samples constitutes the core of the activities rendered by the majority of pathologists in the USA. The program utilizes a sub-specialty based system for the training of the residents in the various sub-disciplines in surgical pathology. Duties in surgical pathology include learning to properly gross and describe specimens, microscopic interpretation and diagnosis, and reporting of findings and proper communication with the clinicians regarding the results. The residents acquire graduated responsibilities as they advance in seniority. A practical slide based exam is given at the end of each block of rotations to assess the progress and identify areas of weakness.
A year-long lecture series in surgical pathology is given by the faculty twice a week. These didactic conferences are principally organized along a glass slide-based format, whereby faculty members review a set of glass slides on well-defined topics that cover the entire gamut of organ systems in surgical pathology. Such sessions take place at a multi-headed microscope. The objective of this lecture series is to ensure that all residents in the program are exposed to classical examples of all the major entities and conditions in surgical pathology and have had the opportunity to review an actual glass slide of all such conditions by the time they complete their residency. The department also houses a large teaching slide collection in the resident’s room that is categorized by organ-systems and contains a generous sampling of classical examples of common entities as well as examples of rare entities and unusual cases for the use of the residents. A multi-headed microscope with capacity for 10 viewers and with a live video monitor is available in the resident’s room for group review of slides by the residents.
The histology lab in surgical pathology counts with 5 modern grossing stations equipped with automated voice-recognition dictation equipment, computer terminals and digital cameras for macrophotography. The department has implemented a grossing guide online that is available to residents at each grossing station computer terminal which provides detailed step-by-step instructions for the grossing of all specimens. Supervision and assistance in the grossing of the specimens is provided by the Pathology Assistants (PA’s) and faculty members assigned to frozen section and to the gross room. Grossing of specimens is based on a “selective grossing” philosophy, whereby residents are assigned specimens based on their level of experience and skill, and the amount and complexity of specimens is gradually increased as the residents advance in their rotations. Residents are expected to have grossed a certain minimum number of cases for all major organ systems by the time they have completed their surgical pathology rotations.
The rotations in Surgical Pathology expose the resident to various organ systems and emphasize a broad exposure to the technical and basic interpretative aspects of surgical specimens. Residents are responsible for each case assigned to them and, with supervision by a faculty member, initiate all studies necessary for the completion of a case, including utilization of all available ancillary studies, such as immunohistochemistry, electron microscopy and molecular techniques. 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.
Basic rotations in Surgical Pathology consist of two 3-month blocks in the first year, and advanced rotations consist of in-depth experiences in specific areas of surgical pathology during the second through fourth years. The residents are given graduated responsibilities as they progress through their training and, thus, the degree of direct staff supervision varies, and is directly tailored to the level of competence of each resident.
All surgical pathology specimens are signed out with faculty. Independence is initially achieved in the gross evaluation of specimens and choice of sections to be submitted for histologic analysis. Every fourth day residents are assigned to “grossing” (i.e., description, cutting, sampling) of specimens. During their grossing days, priority is given to specimens corresponding to the organ system in which they are rotating. On these grossing days, residents are also assigned to the frozen sections diagnosis service. The first year resident is initially guided in the gross evaluation of specimens by the surgical pathology staff, senior pathology residents, two dedicated pathology assistants, and the online surgical pathology Grossing Manual. As experience is gained, the resident is encouraged to complete the gross evaluation and tissue selection independently, with the surgical pathology staff providing a more general supervisory role. After a specimen has been accessioned and subsequently “grossed” by a resident or Pathologist Assistant, a secretary transcribes the gross dictations. The resident reviews the paperwork and slides and formulates a preliminary diagnosis, correlating the histologic features with the submitted clinical information, laboratory studies, radiology reports, and additional clinical information provided by the submitting physician and/or resident. This information is combined into a preliminary document that incorporates all relevant elements necessary for a comprehensive surgical pathology report. This preliminary report is then reviewed with the surgical pathology faculty. Gradually, the resident is also expected to independently initiate the triaging of specimens for special studies (e.g. molecular studies, cytogenetics, electron microscopy, hormone receptor studies, flow cytometry, special stains, etc.) that complete the pathologic evaluation. The final reports are electronically signed out by the Surgical Pathology attendings, and copies are sent to attending physicians and medical records.