Surgical Pathology Rotation

There are 16 months of surgical pathology during the four years of the residency program. Approximately one-third of these rotations are taken in the first year of training, with the remainder spread out over the rest of the program. Surgical pathology at Cedars-Sinai is completely subspecialized, with each faculty member participating in one to three subspecialty areas. Correspondingly for teaching purposes, surgical pathology is divided into seven organ-based specialty areas (GI, GU/endocrine, breast, GYN, lung, skin/bone/soft tissue, placenta/head and neck) and frozen section rotations. The quantity (> 50,000) and quality of surgical pathology specimens and expertise of the faculty ensure all residents become skilled broadly in surgical pathology during the program.

While on surgical pathology, residents are educated in all aspects of clinical diagnostic pathology, including gross and microscopic pathology, skills involved in
effective communication and clinical consultation. The surgical pathology rotations allow the resident to become a competent surgical pathologist in the broadest sense. This includes having the skills to make accurate and timely diagnoses in all areas of surgical pathology, integrate these findings with each patients' circumstances, communicate diagnoses and pertinent information clearly both orally and in writing, and develop a lifelong habit of self-education such that the information and skills learned can be applied to diagnostic problem-solving throughout one's career.

Rotation Structure

During July and August of the PGY 1 pathology year, residents rotate for one week each through 6 of the subspecialty areas (gyn, lung, GU, GI, breast, skin/bone/soft tissue) working one-on-one with a chief resident to learn the techniques and concepts of gross pathology and proper tissue sectioning. There also is an orientation lecture series during July and August, introducing first year residents to the basics of, and approach to, histology in the different organ systems, and providing an opportunity to learn hospital and departmental information systems. Biopsy sign-out does not begin until September, after the first year residents have learned the fundamentals necessary for timely technical handling of cases.

For the remainder of the surgical pathology education, rotations are in half-month (two week) subspecialty blocks, allowing for in-depth learning of gross and microscopic pathology and development of close working relationships with the faculty in each area. Each morning, residents preview then sign-out biopsies with a faculty member in the subspecialty area in which they are rotating. In the afternoons, residents alternate daily in grossing the cases in their subspecialty area with previewing and signing out these same large cases with a subspecialty faculty member. Residents order needed special stains and dictate preliminary reports starting in the second year of training. The Cedars pathology department has four PAs who participate in grossing biopsies and large cases daily, allowing the resident to be only responsible for their subspecialty area large cases. Residents rotate through each subspecialty area including the frozen section service at least four times during their residency, allowing for graduated responsibility in all areas.

There are weekly subspecialty surgical pathology and gross conferences, and many study sets are available to keep residents current in all specialty areas. At the more senior level, residents present at weekly tumor board and other conferences. Cedars-Sinai's surgical pathologists are always available for consultation, and due to the depth and breadth of the faculty, almost all cases are diagnosed using in-house expertise without need for outside consultation. Many faculty members are actively engaged in research projects with ample opportunity for resident research participation.

Specific Surgical Pathology Goals and Objectives

Patient Care:

Describe basic lesions in surgical pathology as defined in the subspecialty goals and objectives.
Develop basic diagnostic skills in common surgical pathology entities during years 1 and 2.
Become diagnostically accurate with complex surgical pathology entities during years 3 and 4.
Describe the role, ordering and interpretation of immunohistochemical and special stains in surgical pathology.
Accurately gross simple and complex surgical pathology specimens, and identify which relevant sections to obtain.
Develop differential diagnoses and final diagnoses based on all clinical and other information and studies available.

Medical Knowledge:

Develop a basic understanding of the classification of common neoplasms and inflammatory conditions in each specialty area.
Define the rationale and systems of tumor grading and staging in each specialty area.
Describe how to approach the components of grossing a surgical pathology specimen, and why specific sections are relevant to patient care.
Describe the need for, and mechanisms to, obtain proper fixation of gross specimens.
Explain the composition of a synoptic surgical pathology report.
Express the diagnostic features of surgical entities as detailed in the specialty goals and expectations.

Interpersonal and Communication Skills:

Construct a clear, cogent, accurate and properly formatted pathology report, including all required elements.
Interact with physicians or clinical support staff to obtain pertinent information and clearly report preliminary or final diagnoses.
Work effectively with others as a member or leader of a health care team or other professional group.
Create and sustain a consultative and ethically sound relationship with clinicians regarding mutual patients

Professionalism:

Demonstrate that the resident is the case physician and that assigned cases are the resident's cases to work-up, diagnose, and write up the report.
Display reliability in following instructions for obtaining additional studies or information, and complete reports in a timely manner.
Take the initiative to advance cases through stages of evaluation.
Fully participate in all mandatory conferences and other required activities.
Show respect, compassion, and integrity in interactions with patients, patients' families, all physicians, laboratory personnel, and hospital administrative and clerical staff.
Commit to ethical principles pertaining to patient confidentiality, informal consent and business practices.

Practice-Based Learning and Improvement:

Locate, appraise and learn from scientific studies related to the practice of surgical pathology using all resources (lifelong learning).
Analyze practical experience and perform practice-based improvement using methodologies such as a defined quality assurance program.
Utilize performance evaluations by superiors, peers and others to improve practice.
Demonstrate case-based and programmed reading.
Extrapolate principles learned on subspecialty rotations to other subspecialties and to surgical pathology problems in general.
Perform a self-directed case-appropriate literature search.

System-Based Practice:

Demonstrate how to properly employ CPT, and ICD-9 codes.
Utilize hospital, governmental, and other technology-based resources to enhance the practice of surgical pathology.
Practice cost-effective laboratory utilization and resource management that maintains quality of care.
Participate in the teaching of health care professionals including residents, clinicians, faculty and others.