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.
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 areas of the laboratory. After the introductory sessions, the core didactic curriculum begins.
The first year curriculum consists of one period of “Clinical Pathology Boot Camp,” 6 periods of surgical pathology, organized as two 3-period blocks, three periods of autopsy, one period of molecular diagnostics, one period of coagulation, one period of transfusion medicine. The six periods of surgical pathology include at least one period on each of the 5 surgical pathology subspecialty rotations at FMLH (GI; GYN/General; GU/Breast; Bone/Soft Tissue/Head and Neck/Endocrine/Lung; Derm/Neuro).
The Clinical Pathology Boot Camp, which occupies the first period of the first year of residency training, consists of one week general orientation to the general clinical laboratory, including patient safety, laboratory management, quality management, compliance, and related issues. The remaining weeks consist of one week each of didactic and bench session in each of the three high-volume laboratory areas (hematology, chemistry, and microbiology). The residents will also begin carrying the day pager for these areas to begin learning how to deal with laboratory issues in real time. The boot camp will provide all competencies necessary to begin taking CP calls with indirect supervision on extended duty shifts in the fall. It will also cover many of the clinical laboratory and management subcompetencies included in the milestones.
In surgical pathology and autopsy 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.
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 technical areas for these laboratory sections 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.
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.
During the second year, each resident engages in two required periods of rotation at the Children’s Hospital of Wisconsin. This rotation provides comprehensive, structured, organ system-based exposure to pediatric surgical pathology. A two-period 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-period 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.
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-period 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 rotation in year 3 or 4 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 rotations on surgical pathology (3-4) allow continued, in-depth refinement of subspecialty area expertise, as residents rotate through subspecialty areas for a second or third 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 quality/pathology informatics rotations provides a didactic and hands-on exposure to principles and practice of quality management, quality improvement, and process improvement, as well as a basic introduction to the various aspects of pathology informatics.
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.
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 periods on each of the 5 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.