Year by Year Design of the Residency Program

The AP/CP curriculum at the Medical College of Wisconsin follows an integrated approach, with both AP and CP rotations in each of the four years of residency, although not evenly balanced in each year (the first year is weighted toward AP, while the second is weighted toward CP). The first two years of the curriculum are entirely structured, with rotations through each area of both AP and CP. This ensures that residents have a broad grounding across the spectrum of pathology sub-disciplines in order that 1) they achieve basic competencies necessary to function as autonomous clinical consultants in an on-call capacity, and 2) they can make an informed subspecialty choice if they choose to apply for post-residency fellowship training. The third and fourth years provide much more flexibility in rotation scheduling, as well as ample elective time.

PGY-1

At the beginning of the academic year, new residents receive a series of introductory lectures covering histopathology, basic grossing techniques, and orientation to the various clinical laboratory sections, focusing on issues likely to be encountered on call. After the introductory sessions, the core didactic curriculum begins.

The first year curriculum consists of 6 months of surgical pathology, organized as two 3-month blocks, three months of autopsy, one month of molecular diagnostics, one month of coagulation, and one month of transfusion medicine. The six months of surgical pathology include one month on each of the surgical pathology subspecialty rotations at FMLH (GI; GYN/Placenta; Lung/Breast; Bone/Soft Tissue/Head and Neck/Endocrine; Derm).

In surgical pathology and autopsy/neuropathology during the first year, residents learn basic gross and histopathology skills, along with skills for obtaining appropriate clinical histories from clinicians and the medical record, and communicating results verbally and through written reports. They also begin to learn to apply and interpret the results of ancillary tests (immunohistochemistry, cytogenetics, molecular diagnostics) in the work-up of patient specimens.

Initial rotations in Coagulation and Transfusion Medicine introduce the resident to the clinical laboratories and permit the resident to begin functioning as a clinical consultant. The introductory molecular rotation focuses on molecular techniques, but also includes didactic sessions devoted to molecular application in various areas of anatomic and clinical pathology.

The autopsy rotation also provides an opportunity to develop skills for integrating gross, microscopic, clinical, and laboratory information into cohesive pathophysiologic narratives. This rotation includes time at the Milwaukee Medical Examiner’s Office receiving in-depth training in autopsy techniques. Initial rotations in Coagulation and Transfusion Medicine introduce the resident to the clinical laboratories and permit the resident to begin functioning as a clinical consultant.

Through the preparation of intra- and inter-departmental presentations, the resident begins to polish his/her communication skills and proficiency in utilizing library and internet resources. Residents do not take call during the first year, but are asked to begin taking extended duty shifts in the fall of the first year, as permitted by ACGME duty hours and supervision requirement. On these shifts, they are first in line to address both AP and CP issues that come up in real time, which allows them to begin independent (but supervised) activity as a consultant in the medical center.

1
Medical Knowledge: Build foundational knowledge in basic histology, histopathology, and pathobiology; begin to be introduced to topics and illustrative cases in all subspecialty surgical pathology areas; begin to acquire depth of knowledge in coagulation and transfusion medicine; be introduced to molecular diagnostic as a critical ancillary technique in pathology and clinical medicine.
2
Patient Care: Acquire basic techniques for gross examination of surgical specimens and become proficient at autopsy prosection; begin to develop interpretive skills on slides, smears, and clinical laboratory test results; gain skills in obtaining relevant historical information for patient care from charts and other sources.
3
Interpersonal Skills and Communication: Begin to interact with clinicians and other health-care providers to obtain history and deliver results and interpretations; begin to learn modes of effective interaction within the laboratory and physician hierarchy; begin to compose effective autopsy, surgical, and clinical laboratory consultation reports; begin to give oral presentations.
4
Professionalism: Observe and begin to emulate professional behavior modeled by attending staff and colleagues; learn basic concepts of compliance, confidentiality, and ethics as applied to medicine; learn to recognize the importance of adhering to cultural and professional norms in the workplace; learn to be sensitive to diverse patient populations and co-workers.
5
Practice-based Learning and Improvement: Observe and participate in quality assurance activities such as peer review conference, autopsy conference, and CP conference; observe and participate in quality control and quality assurance activities in coagulation and transfusion medicine; review and refine basic skills in the practice of evidence-based medicine and review of relevant literature through journal club and independent use of library and Internet resources; become comfortable receiving constructive criticism; learn to self-identify gaps in knowledge and skills and begin developing a plan for ongoing learning through the residency and on a lifelong basis.
6
Systems-based Practice: Begin to learn appropriate utilization of testing through managing the work-up of autopsies and uncomplicated surgical specimens and through oversight of ordering of blood products in transfusion medicine; begin to appreciate how the laboratory interfaces with other service lines and hospital system in the delivery of cost-effective, timely, high-quality care.

PGY-2

During the second year, each resident engages in the first of two required months of rotation at the Children’s Hospital of Wisconsin.  This rotation provides structured, organ system-based exposure to pediatric surgical pathology.  A two-month rotation in cytopathology introduces the resident to the preparation and interpretation of gynecologic and non-gynecologic cytologic specimens, as well as administrative and quality assurance aspects in cytopathology. In addition, the resident participates in and attains competency in the performance of FNAs. The remainder of the second year curriculum consists of three-month blocks on hematopathology, microbiology, and clinical chemistry.

Overall, the intensive longitudinal experience in the clinical lab in the second year provides not only a thorough exposure to those areas of the laboratory, but also includes integrated instruction in laboratory management, both through didactic instruction and participation in real-time activities such as management meetings, trouble-shooting, instrument evaluation, quality control, QA/QI activities, proficiency testing, and preparation for accreditation visits.

On the CP rotations, the resident also helps serve as a consultant to the send-out area of the laboratory, helping to ensure appropriate utilization of unusual tests, locations and requirements for testing, and interpretation of received results. During hematopathology, the resident learns basic and intermediate skills in interpretation of peripheral blood smears, and bone marrow samples.

Also during this rotation, residents hone their skills in gathering clinical data from diverse sources and integrating this information with the results of morphologic and other laboratory analyses. Residents refine and expand skills in the application of ancillary testing to diagnostics, including an introduction to flow cytometry.

Communication skills are further polished as the resident gives increasing numbers of presentations and literature reviews. The majority of residents begin to participate in clinical or translational research projects, although this is not a requirement.

The resident begins to take formal AP and CP call for the clinical laboratories.

1
Medical Knowledge: Gain additional knowledge of histopathology and pathobiology through further exposure to surgical cases in the context of the pediatric pathology rotation; learn basic and intermediate concepts in interpretation of cytopathologic preparations from various organ systems; acquire depth of knowledge in microbiology, clinical chemistry, and hematopathology; begin to understand the principles, application, and interpretation of flow cytometry in hematopathology; further develop an understanding of the use of ancillary techniques in diagnostic pathology; learn basic principles of lab management as applied to the clinical laboratory; learn the basics of preparing research protocols and conducting clinical and translational research projects (optional).
2
Patient Care: Continue to develop skills in gross examination of surgical specimens; continue to develop interpretive skills on surgical slides; continue to develop skills in the application of appropriate and efficient workups to diagnostic specimens; develop interpretive skills on cytologic preparations; develop intermediate-level skills in interpretation of laboratory test results in the areas of microbiology, clinical chemistry, and hematology; begin to learns interpretations of flow cytometry; refine skills in obtaining and integrating information from diverse sources in the develop of pathology interpretations.
3
Interpersonal Skills and Communication: Continue to interact with clinicians and other health-care providers to obtain histories and convey results and interpretations; continues to learn modes of effective interaction within the laboratory and physician hierarchy, both through routine service and call activities; further develop skills in composing effective surgical and clinical laboratory consultation reports; enhance presenting skills; begin to develop teaching and mentoring skills by helping orient and teach first year residents and medical students.
4
Professionalism: Continue to develop concepts of professional behavior and begin acting as a role model for beginning residents and students; practice basic concepts of compliance, confidentiality, and ethics as applied to medicine; reinforce the importance of adhering to cultural and professional norms in the workplace; continue to develop sensitivity to diverse patient populations and co-workers.
5
Practice-based Learning: Continue to participate in quality assurance activities such as case reviews; observe and participate in quality control and quality assurance activities in microbiology, clinical chemistry, hematology, and cytopathology; continue to develop skills in the practice of evidence-based medicine and review of relevant literature through journal clubs, independent use of library and Internet resources, in depth literature reviews for research projects and through serving as a consultant to clinical services; continue developing a plan for ongoing learning through the residency and on a lifelong basis.
6
Systems-based Practice: Further develop appropriate utilization of testing through management of patient specimens; continue to develop an appreciation of how the laboratory interfaces with other service lines and hospital system in the delivery of cost-effective, timely, high-quality care; develop an appreciation of the importance of development and adherence to rational systems and processes for quality assurance and effective use of limited resources.

PGY-3

Residents often complete an additional required month of cytopathology in year 3, although this may be deferred to year 4, if desired. This allows the resident to further refine and deepen the skills and knowledge obtained during two-month cytopathology rotation in the second year.

A second, intermediate-level rotation through transfusion medicine is also often performed in year 3, although again this may be deferred to year 4.  This allows residents to assume greater responsibility in the management of component therapy, transfusion work-ups, and therapeutic apheresis.

A required cytogenetics month allows hands on exposure to the techniques of karyotyping and FISH analysis, as well as practical and didactic exposure to the application of cytogenetics to constitutional and acquired disorders.

Additional months on surgical pathology (3-4) allow continued, in-depth refinement of subspecialty area expertise, as residents rotate through subspecialty areas for a second time.

Residents may complete their Medical Examiner rotation in either the third or fourth year, providing additional training in autopsy prosection and introducing them to the specialized aspects of the forensic autopsy, crime-scene investigations, and courtroom experiences for criminal cases.

Advanced rotations in microbiology and/or chemistry may be taken in the third year. These allow reinforcement of previously acquired knowledge in these areas, opportunity for developing additional depth of knowledge, further refinement of skills as a clinical consultant, and honing of knowledge and skills related to laboratory management.

A two-month advanced rotation in molecular diagnostics allows reinforcement of basic knowledge and techniques, but also an opportunity to keep pace with the cutting edge applications for clinical diagnosis and translational research.  Additionally, it allows the opportunity to engage in and complete a translational research or method development project in the Clinical and Translational Research Core Lab.

A second required pediatric pathology month at the Children’s Hospital of Wisconsin provides the opportunity to deepen and broaden
skill and knowledge related to the unique aspects of pediatric organ system pathology, as well refine general surgical pathology skills.

Finally, the third year provides elective time, which can be used to obtain additional expertise in areas of interest or work on clinical or translational research projects.

Residents continue to take AP and CP night and weekend call.

1
Medical Knowledge: Learn advanced concepts in interpretation of cytopathologic preparations from various organ systems; gain knowledge in techniques for obtaining and preparing cytopathology slides; deepen knowledge of histopathology and pathobiology through further exposure to topics and illustrative cases in subspecialty pathology areas; reinforce and deepen knowledge to a level of basic proficiency in microbiology and chemistry (if advanced rotations are taken during third year); become familiar with the techniques employed in generating and interpreting cytogenetic tests, and understand how these are applied to diagnostic pathology and clinical medicine; enhance autopsy prosection skills and gain basic knowledge regarding forensic sciences; learn the basics of preparing research protocols and conducting clinical and translational research projects; achieve advanced knowledge in principles and applications of molecular diagnostics as a critical ancillary technique in pathology and clinical medicine..
2
Patient Care: Refine skills in basic and more specialized techniques in autopsy prosection and gross examination and microscopic interpretation of surgical specimens; develop interpretive skills on cytologic preparations; continue to build knowledge regarding the use of ancillary studies in diagnostic pathology and achieve greater autonomy in the work-up of cases; refine skills in interpreting and providing clinical consultation regarding laboratory test results, especially in chemistry, microbiology, and cytogenetics; continue taking service call for surgical pathology and the clinical laboratories, further developing comfort and skills in the role of independent consultant.
3
Interpersonal Skills and Communication: Refine skill in interacting with clinicians and other health-care providers to function as an integral part of the healthcare delivery team and provide optimized patient care; refine effective interaction within the laboratory and physician hierarchy, both through routine service and call activities; refine skills in composing effective autopsy, surgical, and clinical laboratory consultation reports; refine skill in giving oral presentations through additional practice; continue to develop teaching skills through orientation and teaching of new residents and medical students.
4
Professionalism: Further refine concepts of professional behavior and continue to act as a role model for peers, beginning residents and students; practice basic concepts of compliance, confidentiality, and ethics as applied to medicine; reinforce the importance of adhering to cultural and professional norms in the workplace; continue to develop sensitivity to diverse patient populations and co-workers.
5
Practice-based Learning: Continue to participate in quality assurance activities such as case reviews; observe
and participate in quality control and quality assurance activities in clinical pathology rotations; continue to develop skills in the practice of evidence-based medicine and review of relevant literature through journal clubs, independent use of library and Internet resources, in depth literature reviews for research projects and through serving as a consultant to clinical services; continue developing a plan for ongoing learning through the residency and on a lifelong basis.
6
Systems-based Practice:  Further develop appropriate utilization of testing through managing of patient specimens; continue to develop an appreciation of how the laboratory interfaces with other service lines and the
hospital systems in the delivery of cost-effective, timely, high-quality care; further develop an appreciation of the importance of development and adherence to rational systems and processes for quality assurance and effective use of
limited resources.

PGY-4

In the final year of training, residents take final required rotations in the surgical pathology subspecialty areas (2-3 months).  Having spent at least two months on each of the 6 surgical pathology subspecialty rotations, residents should achieve competence in all major subspecialty areas of surgical pathology.

A senior rotation in hematopathology allows reinforcement of material learned on the second year rotation, but also allows increase in depth and breadth of these knowledge and skills, including more intensive exposure to flow cytometry.

If not performed during the third year, advanced rotations in microbiology and chemistry allow reinforcement of previously acquired knowledge in these areas, opportunity for developing additional depth of knowledge, further refinement of skills as a clinical consultant, and honing of knowledge and skills related to laboratory management.

A senior transfusion medicine elective (if not performed during the third year) allows further development of independent competency in the management of component therapy, transfusion work-ups, and therapeutic apheresis, as well as exposure to more esoteric testing during two-weeks spent at the Blood Center of Wisconsin’s downtown facility.

Finally, additional elective months are used to obtain expertise in areas of interest or work on clinical or translational research projects. Residents continue to take AP and CP night and weekend call.

1
Medical Knowledge: Achieves competency in the knowledge of anatomic pathology and hematopathology through further exposure to topics and illustrative case; achieves competence in clinical pathology through additional study, call, and advanced and elective rotations; achieves competency in knowledge related to laboratory management through study and hands on involvement in advance CP rotations.
2
Patient Care: Achieve competency in techniques in autopsy prosection and gross examination and microscopic interpretation of surgical and cytologic specimens; achieve competency in interpretation of laboratory test results, through service and call activities; achieves competency in laboratory administration through study and hands on participation in management activities in advanced CP rotations.
3
Interpersonal Skills and Communication: Achieve competency in interacting with clinicians and other health-care providers to function as an integral part of the healthcare delivery team and provide optimized patient care; achieve competency in effective interaction within the laboratory and physician hierarchy, both through routine service and call activities; achieve competency in composing effective autopsy, surgical, and clinical laboratory consultation reports; achieve competency in giving oral presentations; achieve competency in teaching skills through orientation and teaching of new residents and medical students.
4
Professionalism: Have fully internalized concepts of professional behavior and act as a role model for peers, junior residents and students; practice basic concepts of compliance, confidentiality, and ethics as applied to medicine; adhere to cultural and professional norms in the workplace; be sensitive to diverse patient populations and co-workers.
5
Practice-based Learning: Fully internalize the importance of quality assurance activities in both anatomic and clinical pathology; achieve competency in the practice of evidence-based medicine and critical review of relevant literature; solidify habits that will allow an individual program of continuous lifelong learning.
6
Systems-based Practice: Achieve competence in the appropriate utilization of testing through managing of patient specimens; appreciate how the laboratory interfaces with other service lines and the hospital systems in the delivery of cost-effective, timely, high-quality care, and the pathologist’s role in enabling this process; appreciate the importance of development and adherence to rational systems and processes for quality assurance and effective use of limited resources.