Rotations

Written by the residents

Each rotation is 4 weeks for a total of 13 rotations per year.

“GENERAL” SURGICAL PATHOLOGY -- UI Hospitals & Clinics (six rotations)

Surgical pathology currently follows a three-day schedule.

Day 1: The resident staffs the gross room alongside a surgical pathology fellow, an extern, five pathology assistants, and support staff. The resident's responsibilities on Day 1 include assisting with frozen sections and gross evaluation as well as cutting in cases. Since the gross room is located next to the operating rooms, the resident is easily able to interact with surgical staff. Visits to operating rooms to view the operative field and review specimen orientation as it appears in situ are not uncommon. The extern (medical student), pathology assistants and other support staff provide assistance with the workload, but the resident is responsible for being familiar with the gross appearance of all large cases.

Days 2 and 3: Slides first go to the surgical pathology fellow covering the preliminary diagnosis service ("hot seat"). The fellow previews the cases quickly and places a short preliminary diagnosis in the computer, which is hidden from the resident. The case then goes to the resident and extern team on the service. The resident or extern previews the case, dictates a microscopic description and diagnosis, and the case is transcribed. Clinicians that need a preliminary diagnosis can contact the fellow covering the hot seat, which allows residents to focus on previewing cases and dictating reports. We believe an active learning process is superior to passively looking at slides with a staff member and watching them dictate. Sign-out sessions usually occur in late morning as well as early afternoon with the resident and extern sitting down to review cases with the staff around a multi-headed microscope. Residents always sign out across the scope from staff (never a fellow).

Special opportunities at Iowa:

- Residents start dictating and taking ownership of cases from day one.

- Five pathology assistants in the gross room ensure that residents spend time grossing educational specimens and guarantee adequate supervision for junior residents.

- Residents microscopically see what they gross.

- There is adequate preview time. In recent surveys, every Iowa resident said they get adequate or more than adequate preview time for dictating cases.

- Residents are not required to present at tumor boards; however, many attend and present based on their interests.

- Residents will experience the importance of molecular pathology as it relates surgical pathology through correlation with molecular rotations.

- Residents are exposed to a wide array of diagnostic techniques including immunohistochemistry; many residents are able to be involved in the process of bringing up and validating new IHC in the department.

- Acting fellowships and VA rotations (see below) allow for graduated responsibility and autonomy.

GASTROINTESTIAL SURGICAL PATHOLOGY (three rotations)

One resident is on the Gastrointestinal Pathology service. They are responsible for previewing and writing up GI/Liver biopsies and resection specimens as well as grossing one large GI case per day (the most educational case). The resident/extern team sign-out is variable, but generally occurs in the morning, which leaves the afternoon available for previewing and grossing.

Special opportunities at Iowa:

- Weekly GI conferences are held Friday at 8 AM to discuss interesting cases with GI clinical faculty. Residents are never required to present but are encouraged to attend.

- Residents will experience the importance of molecular pathology as it relates to GI surgical pathology through correlation with molecular rotations.

VETERANS AFFAIRS MEDICAL CENTER (VAMC) SURGICAL PATHOLOGY (three rotations)

The three VAMC Surgical Pathology rotations offer senior level (generally 3rd and 4th year) residents the opportunity to experience an even broader range of surgical pathology cases with increasing autonomy. The breadth of specimens is more akin to what one would see in a private practice environment (i.e. skin biopsies, GI/GU biopsies, etc). On a daily basis, the resident is responsible for grossing, dictating the microscopic descriptions and diagnoses, and signing-out all surgical pathology specimens with faculty. Other responsibilities include performing and interpreting frozen sections with faculty back-up as needed. The VA Surgical Pathology experience is a rewarding one because it allows senior residents to accept more responsibility and be "on their own" with faculty assistance as needed.

ACTING FELLOWSHIP (one rotation)

The acting fellowship allows for more graduated responsibility by residents during their final year of residency. Residents spend time in the gross room teaching junior residents and interpreting frozen sections (with faculty backup as needed), rotating through preliminary diagnoses (“hot seat”), and previewing outside cases sent for consultation or needing second review.

AUTOPSY SERVICE (five rotations)

The five autopsy rotations cover both hospital and forensic cases, all of which occur in our state of the art facility within the hospital. The autopsy service consists of two to three residents, one or two externs, decedent care specialists (hospital morticians who assist in dissection), and faculty members. Residents are assigned alternating autopsy cases and are responsible for each case from start to finish. In general, each case involves chart review, consulting with clinicians, external and internal examination, organ dissection, microscopic examination, and review of the case with the staff member and any consultants as necessary. Determination of ancillary testing including toxicology, microbiology, cytogenetics, immunohistochemistry, etc. is also performed. A complete report is written by the resident prior to sign-out.

The autopsy rotation utilizes a six-day work week. The residents on autopsy cover autopsies performed on Saturdays. On both the weekend and during the week, any case that comes in after 2:00 p.m. is generally performed the next working day.

The breadth of cases on our autopsy service is outstanding. We see a variety of medical, forensic, and pediatric/neonatal autopsies. Approximately 50% of the autopsies we perform are medical examiner cases. Residents have no problem getting the requisite number of cases needed to sit for boards (50), without sharing.

Special opportunities at Iowa:

- Meet with law enforcement and medical investigators during a daily morning report.

- Attend court hearings and depositions with forensic staff.

- Periodic Friday forensic didactics (lunch provided) covering a variety of special topics (mass casualty, environmental deaths, cause of death. etc).

- Learn how to comfortably and efficiently perform an autopsy from start to finish.

- Forensic cases performed on site.

CYTOPATHOLOGY (three rotations)

During cytopathology, residents preview cytology cases, go to adequacy assessments, and perform fine needle aspirations (FNAs). FNAs are either done on the hospital inpatient floors or in the FNA clinic, which is run by the Department of Pathology. The resident, fellow and staff also make an initial on-site adequacy evaluation of FNAs performed by the radiology, endoscopy, and bronchoscopy suites. When additional slides are processed, the resident and the fellow review the slides and enter a diagnosis in the computer. The slides are then reviewed with the fellow and the staff. Abnormal pap smears and fluids (such as cerebral spinal fluid and urine) are also examined this way. Case sign-out occurs throughout the day in between procedures.

Special opportunities at Iowa:

- Residents will experience the importance of molecular pathology as it relates cytology. Iowa is leading the way with molecular cytology (correlate with molecular rotation).

- FNAs are performed by the department of pathology. Residents will perform numerous FNA procedures over the three rotations.

DERMATOPATHOLOGY (two rotations)

Pathology residents work with a dermatology resident to preview and write up in house and consult dermatology cases. Residents usually preview cases in the morning and sign out with staff in the afternoon. Residents are also responsible for previewing and writing up direct immunofluorescence (DIF) reports on skin. Dermatology specimens are grossed by either histology technologists or pathology assistants (no resident grossing required on this rotation).

Special opportunities at Iowa:

- Work alongside dermatology residents to correlate clinical histories with histology.

- Correlate DIF with H and E slides.

NEUROPATHOLOGY (two rotations)

Residents are required to gross neurosurgical specimens, then preview and write up neuropathology cases. Residents preview in the morning and sign out one-on-one with on staff neuropathologists. Specimens may be grossed throughout the day as time allows. Residents may attend autopsy brain cutting. More senior residents may present at tumor board and spend more time in ocular pathology and neuro/muscular pathology during their second rotation.

Special opportunities at Iowa:

- Iowa is a referral center for neuromuscular pathology and autopsy brains.

- See a wide variety of specimens from brain tumors to muscular dystrophies.

- Attend weekly interdepartmental conferences, including neuromuscular conference Friday morning with neurologists in attendance

- Updated intraoperative study sets.

CHEMISTRY/INFORMATICS (three rotations)

Resident duties on the clinical chemistry service include signing out protein electrophoresis, working with medical technologists to solve laboratory problems and reviewing study cases provided by the faculty. Serum protein electrophoresis and immunofixation electrophoresis are evaluated by the resident who enters an interpretation in the computer, followed by staff sign-out. Residents may be asked to contact clinicians about test requests reports and may suggest alternative testing which would better answer the clinical question. Throughout the week, clinical cases with interesting laboratory findings are directed to the resident who then independently studies the underlying pathophysiology. One of these cases is typically presented by the resident in the clinical pathology conference on Fridays. During the second or third rotation, the resident is involved in a laboratory management project which often results in publication or presentation at national meetings. Though informatics is incorporated throughout each rotation, it is formally introduced in the curriculum during the third rotation.

Special opportunities at Iowa:

- Be involved with staff during mock CAP surveys; upper level residents are often asked to join CAP survey teams for inspecting outside laboratories.

- Exposure to in-vitro fertilization (one of the best in the country)

- Thorough exposure to informatics

- Attend diagnostic services committees and other high level meetings.

HEMATOPATHOLOGY (four rotations)

Special opportunities at Iowa:

- Weekly blood club: Clinicians from the hematology and pathology (heme and transfusion) meet to discuss interesting cases. Fellows usually present; residents are encouraged to attend.

- Lymphoma conference: Pathologists and clinicians discuss interesting patients with lymphoma. Heme fellow or resident usually presents.

- Correlation with molecular testing (PCR, FISH, etc.) during molecular and cytogenetics rotations.

- Bone marrow biopsies are not required for residents; however, scheduled training can be done through the hematology/oncology department at the University and the VA.

IMMUNOPATHOLOGY (three rotations)

Residents are required to preview and write up all flow cytometry cases on lymph nodes, peripheral blood, CSF etc. Cases are usually looking for tumor; however, immunodeficiency cases are also reviewed. Residents may be asked which particular panel to perform on cases. All flow cytometry reports are written by the resident and signed-out with staff throughout the day. In addition, an interesting case is presented by the resident at the clinical pathology conference each Friday morning.

Special opportunities at Iowa:

- 10 color flow cytometry is performed (6 color flow cytometry is still used at the VA).

- Residents perform cluster analysis using specialized computer software.

- Monthly Chairman’s Rounds review special topics and interesting cases in flow cytometry.

MICROBIOLOGY (two rotations)

The two rotations in microbiology include a wide variety of activities. Time is allowed to sit on the bench with the technologists as they process specimens and identify organisms. The resident also participates in daily lab rounds with the lab directors. During these rounds, the technologists in each area of the lab present interesting cases and ask questions regarding extent of identification required for a particular isolate, clinical significance of an organism, need for susceptibility testing, etc. Gram and Giemsa stains on a variety of organisms are previewed then reviewed with staff. The resident carries a service pager as well. The resident also works-up a series of "unknowns" including mycology and bacteriology specimens. In addition, an interesting case is presented by the resident at the clinical pathology conference each Friday morning.

Special opportunities at Iowa:

- Exposure to MALDI-TOF technology as well as traditional chemical diagnostics.

- The research activities of the microbiology and immunology division are extensive and there are numerous opportunities to become involved in projects.

- Exposure to the Iowa State Hygienic Laboratory (ran by the University of Iowa)

- Weekly meetings with infectious disease fellows to discuss interesting cases.

MOLECULAR PATHOLOGY (two rotations) and CYTOGENETICS

Residents are responsible for interpretation of a variety of molecular tests within three broad categories of molecular pathology (genetic diseases, molecular infectious disease testing, and molecular oncology). Residents are exposed to different molecular techniques including next generation sequencing, Sanger sequencing, PCR, etc. Residents are required to preview and interpret and write up molecular reports. Residents field molecular questions from clinicians and are also involved in microdissection of surgical and cytology specimens.

Special opportunities at Iowa:

- Exposure to next generation and Sanger sequencing interpretation

- Molecular oncology tumor board is a great learning opportunity

- Correlation of surgical and cytology specimens

- During the cytogenetics rotation, residents will get hands on training with karyotypes and FISH. Residents will perform their own karyotype from start to finish (optional).

TRANSFUSION MEDICINE (three rotations)

The transfusion medicine resident oversees the acquisition and distribution of blood products for the hospital. Residents frequently become involved in the care of patients who require massive transfusion (i.e. patients with trauma, coagulopathy, or surgical difficulties). The transfusion medicine resident evaluates requests for special products such as granulocyte transfusion or crossmatched platelets. The transfusion service performs apheresis procedures for conditions such as thrombotic thrombocytopenic purpura (TTP), Guillain Barre, and hyperviscosity syndromes, as well as collects peripheral stem cells for bone marrow transplants (residents write the orders and the notes for all procedures). The transfusion medicine resident assists the blood donor nurses in screening potential blood donors. Residents write orders and notes for all procedures. Residents are also required to write reports for suspected transfusion reactions and positive antibody panels, to be signed out later with the staff.

Special opportunities at Iowa:

- Exposure to a variety of procedures performed in the apheresis clinic: plasmapheresis, leukapheresis, photopheresis, LDL pheresis, red cell exchange, therapeutic phlebotomy, stem cell collections, and T cell collections (for oncologic immunotherapy).

- Residents oversee a blood collection center, apheresis clinic, and blood bank, which are all located within the hospital.

- Weekly blood club: involves clinicians from the hematology department and pathology (heme and transfusion) to discuss interesting cases. Fellows usually present; residents are encouraged to attend.

- Weekly hands on lab exercises: residents will perform several lab assays including type and screens (can be done on their own blood), elutions, and antibody panels.

VAMC CLINICAL PATHOLOGY (three rotations)

The three VAMC Clinical Pathology rotations offer residents the chance to experience an integrated clinical pathology laboratory (blood bank, hematopathology, chemistry, microbiology, immunopathology). On a daily basis the resident is responsible for interpreting, writing up and signing-out bone marrow examinations with faculty consultation. The resident interprets blood smears, body fluid analyses, bronchioalveolar lavage specimens (BALs), flow cytometry, microbiology slides, and electrophoreses with faculty back-up as needed. Other duties include blood bank audits and approving send-out tests. Each week the resident leads a laboratory meeting discussing the send-out tests that they were asked to review as well as any pages received during the week.

On this rotation the resident may gain more experience performing bone marrow biopsies, under the supervision of Hematology-Oncology fellows. Finally, the resident is responsible for "troubleshooting" problems that arise in the laboratory, being a clinical laboratory consultant for physicians, and other projects. The VAMC clinical pathology rotation offers residents the chance to have an experience akin to the private practice environment. The residents perform laboratory management, make interpretations and diagnoses with faculty backup as needed, and act as a laboratory consultant. There is adequate time available for reading or research projects.

Special opportunities at Iowa:

- The VAMC in Iowa City is a national leader in test and protocol development and is a referral center for other VA hospitals.

MEDICAL RENAL (one rotation)

Residents will preview and write up medical renal cases following interpretation of H & E slides, special stains, electron microscopy, and DIF. Residents are also required to gross medical renal biopsies using light microscopy for glomerulus evaluation and divide the specimen up for DIF and EM studies.

Special opportunities at Iowa:

- Residents will spend time in the EM lab to understand its role in diagnostics.

ELECTIVE (seven rotations)

Each resident is allowed seven electives over the four years of AP/CP residency. Residents spend this time in a variety of ways including further experience in areas of interest, as well as clinically related research.