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                                            AUTOPSY PATHOLOGY ROTATION       

 

A.   Duration.
1st Year Resident: 4 weeks of the Introduction to Anatomic Pathology Rotation, and 12 weeks of the regular Autopsy Rotation.

B.    Teaching Faculty Responsible for Supervision and Instruction.

1.    Patricia A. Allenby, M.D.

2.    Sergey V. Brodsky, M.D., Ph.D.

3.    Charles L. Hitchcock, M.D., Ph.D., Director

4.    Abhik Ray-Chaudhury, M.D. (neuropathology only)

5.    Jonathan Rock, M.D.
 

C.  Objectives.

By the end of the rotation, the resident will be able to meet the following objectives.    

1. By the end of the 5^th case, independently provide a thorough written summary of a patient’s clinical records that take into account all of the following: progress notes, operation notes, radiologic findings, and laboratory results.
   
    
2. By the end of the 5^th case, based on the clinical review, plan an autopsy that includes special studies and expected findings.
   
    
3. By the end of the 5^th case, write a coherent preliminary note that includes a thorough review of the patient’s clinical record and gross and any histopathologic findings made at autopsy.
   
    
4. By the end of the 10^th case, write a final autopsy report that coherently explains the underlying and immediate anatomic causes of death, and includes a discussion of clinicopathologic correlations integrating the gross and microscopic findings with the clinical summary.
   
    
5. By the end of the rotation, master effective communication of pathologic findings and their clinical implications to colleagues during the weekly Autopsy Teaching Conference and the weekly Brain Cutting Conference. 

 

6. By the end of the rotation, perform all aspects of the autopsy to include removal of the brain, incision and evisceration, sampling of blood, tissue and ocular fluids for special studies, and sampling of the appropriate organs for the case.
   
    
7. By the end of the rotation, be able to recognize, sample, and diagnose the pathologic lesions encountered during the autopsy. 
   
    
8. By the end of the rotation, make accurate microscopic diagnoses of the common pulmonary, cardiac, renal, pancreatic, and hepatic findings. 
   
    

D.   Specific Goals

1.    General:  Competencies identified with an “*” must be demonstrated before the resident is allowed to perform an autopsy with indirect supervision with direct supervision available.       

 

2.    PATIENT CARE:  Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.  In the context of pathology, residents must demonstrate a satisfactory level of diagnostic competence and the ability to provide appropriate and effective consultation.  Residents should be able to:

 

*	Determine that an autopsy permit is valid, determine that the appropriate next of kin, as defined by statute, have signed the permit, and noted restrictions.
*	Adhere to and apply universal precautions in the autopsy room.
*	Perform an external examination of the body, appropriate for the circumstances, including positive patient identification.
*	Know how to take macroscopic photographs (and photomicrographs) that adequately document pertinent positive and negative findings.
	Perform a routine autopsy utilizing standard dissection techniques, e.g., Virchow and Letulle/Rokitansky types, in such a way that it will not compromise preparation and viewing of the body at a funeral.
*	Open the heart appropriately along the pathway of blood flow.
*	For cases of suspected acute myocardial infarction, cut ventricles parallel to base
*	As necessary, remove and dissect coronary arteries and bypass grafts and decalcify to demonstrate vascular pathology.
*	Remove and inflate lungs with formalin and other solutions as needed.
	Dissect pulmonary arterial tree to demonstrate thromboemboli and webs.
*	Dissect the entire gastrointestinal tract.
	Dissect the biliary tree maintaining appropriate relationships of gallbladder, bile ducts, pancreas and ampulla.
*	Dissect the kidneys, ureters, bladder and, in males, the prostate, maintaining continuity of organs for demonstration.
*	Dissect the female reproductive organs.
	Examine the testes in males.
*	Examine the breasts in females and males.
*	Dissect the thyroid and, as appropriate, the parathyroid glands.
	Remove the tongue and tonsils when appropriate.
	Obtain samples of bones, bone marrow, peripheral nerve, and striated muscle.
	Dissect the calf veins in cases of suspected pulmonary emboli.
	Remove the brain in adult, pediatric and perinatal cases, using electric saw and hand tools as appropriate.
	Be familiar with methods to remove the spinal cord partially by anterior approach, intact by posterior approach and via foramen magnum.
*	Weigh all organs and dictate a detailed gross description of major organs and organ systems.
	Be familiar with special dissection techniques such as removing eyes, middle and inner ears, paranasal sinuses, and bones and joints as permitted by regulations of the institution, laws of the state, and wording of the autopsy permit.
	Obtain vitreous humor (medical legal cases and/or forensic rotation).
	Select appropriate tissues for histologic examination.
	Know how to order and use appropriate special stains, immunohistochemistry, electron microscopy, and selection of materials for freezing or flow cytometry as appropriate.
	Formulate diagnoses based on gross and microscopic examination.
	Prepare well-organized, thorough preliminary autopsy report.
	Prepare final autopsy report combining and integrating gross and microscopic diagnoses after review of case with staff pathologist.
*	Perform a pediatric and/or perinatal autopsy using appropriate physical measurements such as crown-rump and head circumference, etc.
*	Examine placenta and incorporate findings into perinatal autopsy.
	Obtain appropriate tissue for cytogenetics.
	Independently perform all aspects of an autopsy at least five times by the end of the rotation.

 

3.    MEDICAL KNOWLEDGE:  Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and application of this knowledge to patient care in pathology.  Residents should be able to:

 

*	Abstract pertinent information from the medical record necessary to perform a thorough autopsy and determine cause of death.
	Determine which cases fall under the jurisdiction of the coroner.
	Demonstrate an understanding of clinical signs, symptoms, and diagnostic studies and how they manifest themselves in pathology identified at autopsy.
	Demonstrate knowledge of the gross and microscopic manifestation of disease by converting observations and findings at autopsy into diagnoses.
	Prepare a thorough autopsy summary in which there is documentation of the cause of death and a clinicopathological analysis, integrating an understanding of the pathological basis for disease.
	Perform an appropriate literature search to support pathologic diagnoses.

 

4.    PRACTICE-BASED LEARNING AND IMPROVEMENT:  Residents must be able to demonstrate the ability to investigate and evaluate their diagnostic and consultative practices, appraise and assimilate scientific evidence, and improve their patient care practices.  They should be able to:

 

	Actively search for previous pathology diagnoses within the anatomic pathology database.
	Make use of on-line resources to identify recent advances in understanding disease processes manifested in a particular autopsy case.
	Monitor their own case mix, such as numbers of adult, neonatal/pediatric, and neuropathological cases, and types of diseases to assure a broad-based exposure to both diagnostic and technical aspects of autopsy pathology.
	Attend departmental Autopsy Teaching and Brain Cutting conferences in order to maximize exposure to findings of different diseases.
	Accept and learn from constructive feedback and guidance from staff physicians, clinicians, laboratory supervisors, pathologists’ assistants (PA), anatomic pathology technicians (APT), and house staff colleagues, and modify behavior as appropriate.

 

5.    INTERPERSONAL AND COMMUNICATION SKILLS:  Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange in teaming with other health care providers, patients, and patient’s families.  Residents should be able to:

 

*	Present a concise organized clinical summary of the patient’s history to the attending pathologist prior to beginning the autopsy.
	Contact members of the clinical team and/or primary care provider prior to beginning the autopsy and elicit appropriate key information about the patient’s medical history and determine specific questions to be addressed during the autopsy.
	Consult and interact with pathologist assistants (PA), anatomic pathology technicians (APT), medical students, and fellow residents during the performance of a case to obtain assistance without losing primary responsibility for the case.
	Prepare and present cases at the Autopsy Teaching Conference with synoptic clinical history and appropriate selection of organs for illustration of gross pathology.
	Prepare and present cases at Brain Cutting Conference with synoptic clinical history.
	Teach fellow residents, medical students and pathology assistants (PA) in various aspects of autopsy practice and the pathologic evaluation of organs and tissue.
	Write a well-organized and grammatically correct final report with accurate listing of findings, mechanism of death, immediate and underlying causes of death, and clear presentation clinicopathologic correlation as warranted, but which does not overly criticize or inflame a potential reader with regard to the quality of clinical care.
*	Communicate autopsy findings to clinicians and staff pathologists.
	Meet or speak with families of the deceased to discuss findings in an open and supportive atmosphere (with appropriate supervision).

 

6.    PROFESSIONALISM:  Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.  Resident should:

 

	Where appropriate, be able to assist clinicians and family members in obtaining proper informed consent for performance of an autopsy.
*	Demonstrate unconditional respect for the body of the deceased patient.
*	Demonstrate respect for clinical colleagues, ancillary laboratory staff, and the medical profession.
*	Promote the efficient, thorough, and expeditious performance of an autopsy so as not to compromise family funeral arrangements or departmental work schedules.
*	Demonstrate an understanding of the importance of preserving patient privacy and confidentiality in the performance of the autopsy.
*	Gain a working knowledge of universal safety precautions and protect the safety of all employees taking part in the performance of a given autopsy.
	Interact with and help fellow residents needing assistance in the performing of autopsies in order to assure efficient running of the service.
	Respect the clinician’s interpretations of patient care and consider the case from their point of view when dealing with apparent discrepancies.
	Interact with clinical colleagues in a non-confrontational and professional manner in discussing issues of appropriateness of clinical care with reference to the case at hand.
	Demonstrate an ability to communicate with family members regarding autopsies in general, and in particular, the findings of the case.

 

7.    SYSTEMS-BASED PRACTICE:  Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value.  Pathologists occupy a unique position with health care delivery.  Free from the day-to-day details of direct patient care delivery, pathologists have the opportunity and obligation to analyze and explore human disease.  Residents should acquire the ability to assume this role by learning to:

 

	Actively seek out additional clinical/laboratory information by consulting patient care information systems within the hospital and consulting with clinicians.
	Demonstrate an awareness of regulations such as CLIA (Clinical Laboratories Improvement Act), HIPAA (Health Insurance Portability and Accountability Act) Privacy and Security rules, and CAP laboratory accreditation standards.
	Advocate for the role of the autopsy in performance improvement, promoting the practice of obtaining autopsy permissions to other departments within the institution.
	Complete the preliminary autopsy report within 2 working days and, for the majority of cases, the final autopsy report within 30 working days such that the findings can be released to family and clinicians per CAP laboratory accreditation standards.
	Collaborate with other members of the health care team to improve patient care by learning from the autopsy results and developing evidence-based health care delivery strategies.
	Demonstrate judicious use of special procedures such as freezing and retaining tissues and performing cultures to assure accurate diagnoses without over utilizing laboratory resources.
	Understand how diagnoses are coded for retrieval by a lab information system and how to retrieve diagnoses for use in studying human disease while maintaining patient confidentiality.
	Understand the role of the autopsy in quality assurance and risk management.

 

E.    Curriculum.

1.    Introduction to Anatomic Pathology Rotation.

a.    This is the first 4 week rotation for a resident entering the program in July of their PGY 1 year.  

b.    Each resident will conduct at least three autopsies under direct supervision of the attending pathologist and the anatomic pathology technician.  

c.    The resident is responsible for assigned material including a recent autopsy performance manual, CAP-approved autopsy practice guidelines and the CAP Autopsy Performance and Reporting manual.  

d.    A series of lectures and demonstrations will be provided on universal precautions, safety, autopsy permission, performing an adult and fetal/perinatal autopsy, autopsy microbiology and toxicology, access to electronic medical records and images, and photography.

2.    Autopsy Rotations

a.    The 12 week rotation on Autopsy Services provides autopsy experience at OSU with adult, fetal, and neonatal cases from both within and outside the OSU system.

b.    Four week rotation at Nationwide Children's Hospital provides pediatric autopsy experience.  

c.    Four week rotation at the Franklin County Coroner's office provides experience with forensic autopsies during the 3^rd year.

3.    Quality Assurance

a.    The organization of the Autopsy Pathology Rotation quality assurance program is discussed during the Introduction to Anatomic Pathology early in the rotation, and the resident will attend all faculty and staff meetings held during their rotation where these issues are discussed.  

b.    By the end of the rotation the resident will have reviewed with an attending pathologist

1)    monthly report of discrepant findings

2)    updated TAT spreadsheet

3)    pathologist indicators

4.    Laboratory Management

a.    Issues in management are discussed throughout the course of the rotation.  

b.    Attend monthly Autopsy Service faculty and staff meetings.

5.    Teaching by Residents

a.    First year residents are involved in teaching 3^rd and 4^th-year medical students who elect to rotate on Autopsy Services.  

6.    Opportunity for Scholarly Activity

a.    In preparation for presentations at the Autopsy Teaching Conference, residents review the literature pertinent to a specific aspect of the autopsy.  A literature review is also done in the course of preparing the final report for many autopsies and references are included in the report.

b.    Residents are encouraged to actively participate in preparation of manuscripts of both interesting cases and in-depth analysis judged to be worthy by the teaching faculty.  

7.    Autopsy Related Conferences

a.     Wednesday 4 PM Autopsy Teaching Conference is a mandatory conference where the resident will review the pertinent history and gross autopsy findings with those attendings, house staff, and medical students in attendance.  

b.     The Brain Cutting Conference, held at noon on Thursdays, is a mandatory conference conducted by a Neuropathologist who reviews the morphologic features and significance of all pathologic findings.  The residents also receive instruction on and perform brain dissections and selection of tissue for histological preparation.  

c.     Perinatal conferences are held weekly.  Pathology residents and faculty occasionally present pertinent autopsy findings and clinical-pathologic correlation.  This is a joint conference including Obstetrics & Gynecology and Neonatology. 

F.   Resident Supervision       

1. Each day a member of the teaching faculty is assigned as the Attending Autopsy Pathologist.

a.    The attending pathologist is responsible for the performance of the autopsy, as well as subsequent preparation of the preliminary and final autopsy reports for every autopsy performed on his or her assigned days.  

b.    Each resident will require direct supervision for at least three autopsies, or until they meet the competencies noted in the Specific Goals.  

c.    After a resident has met the necessary competencies, the attending pathologist will provide indirect supervision with direct supervision available.      

2.    Before the autopsy is performed the attending pathologist will work with the resident to:

a.    Review the autopsy permit to determine the legality.  

b.    Review the patient's clinical history/course to assist in developing a list of clinical problems to be addressed during the autopsy, and the resident’s plan for special studies.  

3.    After the resident has demonstrated the necessary competencies in at least three autopsies, the attending pathologist will be available during the entire procedure and in attendance for critical parts of the autopsy procedure.

a.    As the resident gains experience, he or she is provided the opportunity to work more independently during prosection.  

b.    The autopsy pathologist and/or APT/PA will be available to assist in photographic documentation.

4.    The attending pathologist will work with the resident to issue a Preliminary Autopsy Report within 48 hours of the autopsy.

5.    The attending pathologist will be available for selection of tissue samples for histology.

6.    After an initial review by the resident, the attending pathologist will review all of histopathology findings and help to select the appropriate special stains needed to define the pathologic processes of a case.

7.    The attending pathologist will work with the resident to issue a Final Autopsy Report within 30 working days of the autopsy.

G.   Resident Responsibilities and Procedures to be Accomplished

1.    Check the legality of the autopsy permit and have the permit reviewed by the responsible autopsy pathologist.

2.    Review the clinical history and available imaging studies to develop a list of the clinical problems to be addressed at autopsy; contact the clinical house-staff before beginning the autopsy.

3.    Develop a plan or approach for examining the clinical problems including special dissections and special studies.  

4.    Identify the body by checking the attached name tag, usually attached to a toe.

5.    Following the guidelines provided in the Autopsy Service Manual, perform the autopsy dissections to include external examination, and, when possible, the Y incision, tying off of vessels, evisceration, removal of the brain and, when needed, the spinal cord.

a.    Collect and properly label tissue and fluid samples for appropriate special studies (e.g. cytogenetics, electron microscopy, frozen section, cytology, toxicology, immunofluorescence, and/or culture).  

b.    Review appropriate radiographic and laboratory findings.  

c.    Carefully examine each organ for a disease process.  

d.    Obtain appropriate digital images of gross pathologic findings. 

e.    Select appropriate tissue samples to save for tissue archives and the Autopsy Teaching Conference.

6.    Present the gross pathologic findings with the Attending Autopsy Pathologist immediately after the dissections are completed.

7.    Contact the clinical attending physician and/or residents as soon as possible after the autopsy and report the preliminary findings. 
 

8.    Prepare and review with the Attending Autopsy Pathologist the Preliminary Autopsy Report that includes a concise, but thorough, summary of clinical history and gross anatomic findings in a logical sequence.  This report must be signed out within 2 working days of completing the autopsy. Templates are available to help with this

9.    Sample appropriate lesions and normal tissue for histology.

10.    Prepare/dictate a complete and accurate gross description of the organs and cavities using the template.  Note, this template should be expanded or contracted based on the nature of the autopsy.

11.    Present the clinical histories and preliminary gross autopsy findings at the Autopsy Teaching Conference.

12.    Attend brain cutting conference, cut brains, and select tissue for histology.

13.    Prepare a list of tissue diagnoses for each of the histopathology slides submitted, and review these findings with the attending pathologist for that case.

14.    Within 25 working days after performance of the autopsy, prepare the final diagnoses, final autopsy note with pertinent references when indicated, and review the report with the attending pathologist for that case. 

15.     Proofread the final autopsy report after final typing.

16.    By the end of the rotation, assist in preparation of manuscripts for publication developed from personal autopsy experience.

17.    By the end of the rotation, assist in the education of medical students on the service.

18.    By the end of the service, perform all aspects of the autopsy with minimal faculty and diener involvement.
 

  Responsibilities of the Attending Pathologist

1.    The attending pathologist has overall responsibility for performance and reporting of the autopsy.

2.    Approve the autopsy permit – appropriate signatures and any limitations.  This will be repeated during the Time Out procedure.  

3.    Insure proper body identification.  

4.    Review the patient's clinical history, clinical problems and autopsy plan with the resident.

a.    Check to be sure that clinical physicians have been contacted prior to beginning the autopsy.  

b.    Plan for ancillary studies
 

5.    Be readily available during the autopsy procedure and be in attendance during critical parts of the autopsy.

a.    In attendance throughout HIV (+), TB (+), and hepatitis virus (+) cases, (Neuropathologist and APT/PA only).

b.    Review external examination and exposure of the internal organs prior to evisceration.

c.    Be available for immediate consultation.

6.    At completion of the autopsy

a.    Review the gross findings with the resident.

b.    Determine the tissue specimens to be retained.  

c.    Determine if any photographs are needed.

 

7.    Discuss the diagnoses and their listing, as well as the immediate and underlying causes of death.

8.    Make attempts to contact the clinical attending physician as soon as possible after the autopsy (unless done by the resident) to report the preliminary autopsy findings.

9.    Review the preliminary report and insure that it is completed within two working days.  

10.    Review the histology and final autopsy report with the resident for language, accuracy, and completeness.  

11.    Insure that the following Pathology Department mandated deadlines are met

a.    50%  + 1 of cases are signed out within 30 working days

b.    100% of cases are signed out within 60 working days, or document extending circumstances  

12.    Provide instruction during the autopsy, histology review, and final autopsy report review.

13.    Whenever possible, attend the Autopsy Teaching Conference.  It is particularly important for the responsible faculty to be present when his or her cases are being discussed.

J.    Methods for Resident Evaluation

1.    Each resident on the service will be evaluated according to the previously noted Specific Goals.

2.    Objective evaluation of Patient Care Competencies is related to the performance of the actual autopsy.  To be considered to be competent by the end of the 12 week rotation, the resident will be able to perform each major component of the autopsy – incision of the head and body, brain removal, block removal, block dissection, and suturing of the body – at least five times.

3.    The written Preliminary and Final Autopsy Reports serve as objective evaluation tools for assessing resident competencies related to Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice. The following Autopsy Report Timeline has been implemented to help the resident meet these competencies.

 

Working Day	Person Responsible	Expectation
0	Resident	Performance of the autopsy
0 (day of the autopsy)	Resident	Dictated gross description
2	Resident	Final Draft of the Preliminary Report to Office Staff by 7:30 AM
2	Resident	Review/edit Preliminary Report for content.  Give to Office Staff.
2	Office Associate	Review/edit for typos, grammar and punctuation.   Format and put in Attending's queue.
2	Attending	Sign out Preliminary Report
3 to 5	Office Associate	Preliminary Report, Gross Description, and Cassette Summary transferred to Final Report
6  to 10	Resident	Review slides alone and with Attending Enter Microscopic Description
11 to 15	Resident	Obtain special stains, extra tissue sections, consults etc. and review with attending
16 to 21	Resident	Complete 1st Final Report Draft
21	Resident	1st Final Report Draft to the Attending
21 to 25	Attending & Resident	Review and edit Final Autopsy Report for Content
25	Resident	Final Draft of the Final Autopsy Report to Office Staff
25 to 29	Office Staff	Review and editing for typos and  grammar
30	Attending	Sign Out Final Autopsy Report

 

4.    Subjective Evaluations

a.    Resident presentations at the Autopsy Education Conference will be evaluated based on:

1)    The ability of the resident to clearly describe the clinical case as he/she knows it

2)    To clearly demonstrate the relevant autopsy findings

3)    To demonstrate an understanding of the underlying mechanism, including immediate and underlying causes of death, of the patient’s disease process when questioned.

 

b.    Evaluation of the final autopsy report will be based on:

1)    Clear and accurate listing of the Final Diagnosis in the order of underlying cause of death, immediate cause of death, and other findings.

2)    Clear and accurate description of the Gross Autopsy Findings.

3)    Clear and accurate description of the Microscopic Findings.

4)    Clear and accurate description of the Special Studies Findings.

5)    Clear and accurate Clinicopathologic Correlation that includes

integration of the gross and microscopic findings, and the findings from special studies, with the patient’s clinical course.

6)    Clinical Summary that includes a clear and accurate description of the patient’s clinical history and clinical course.

 

5.    Objective Evaluation

a.    Each autopsy report will be graded according to the following criteria.  Formal grading will begin after the 10^th report.

b.    Point Scoring

1)            Correct Autopsy Permit  (1)

2)            Contact the clinical team and ask for their questions of the autopsy. (1)

3)            Correct identification of the body. (1)

4)            Thorough clinical history, including labs, imaging, and surgical pathology. (1-10)

5)            Detailed external exam and recording of findings and transfer to the preliminary report (1-10)

6)            Perform the autopsy to include removal  of the block, dissection of the block, weighing organs, sampling of appropriate lesions, and accurate notation of gross findings. (1-25)

7)            Preliminary report to include clinical history and gross findings, (1-10)

8)            Gross description with external and internal exam findings to include weights and reference ranges. (1-10)

9)            Microscopic description (1-15)

10)         Final report with clinicopathologic correlation (1-10)

11)         Meets deadlines (1-7)

c.    Grades

1)    A  =90

2)    B =80

3)    C = =70

4)    failure <70

 

6.    By the end of the 12 week rotation, the resident must show progression in meeting these competencies.