Anatomic and Clinical Pathology Rotations

The autopsy rotation will be staffed by 1-2 residents. First year residents will be paired with an upper level resident for their first rotation. Residents are responsible for verifying consent, communicating with the ordering physician about the decedent’s clinical history, performing the autopsy, reviewing the gross and microscopic findings with the attending, and writing the final report. Most autopsy cases are presented at the biweekly autopsy conferences on Thursday mornings and neuroanatomical examinations are performed  on Thursday mornings. Autopsy technicians perform eviscerations, although residents are required to learn how to eviscerate in preparation for their forensic pathology rotation. Any of our pathology assistants can assist with organ dissection as needed. Each year approximately 250 autopsies are performed at the University of Virginia. Residents average 30 – 40 hospital autopsies and another 10 – 20 autopsies during their medical examiner rotation by the end of their training. Autopsies are not performed on Saturdays except for emergencies, so call is covered by the resident on weekend surgical pathology coverage.

Typically two residents at a time are responsible for the daily oversight of the active blood bank and transfusion medicine service.  Residents follow multiple complicated patients on a daily basis, assessing transfusion needs and working closely with the clinical teams to optimize blood product utilization.  Responsibilities include serologic antibody identification, platelet triage, clinical team consultations, transfusion reaction work ups, hospital-wide product utilization reviews, and preparation for daily rounds with the Blood Bank attendings.  Residents are exposed to multiple facets of transfusion medicine.  New residents are introduced to the service with a practical training experience with our senior techs.

While on Chemistry, second year residents are charged with responding to inquiries regarding available laboratory tests, data interpretation, and testing results.  Residents play a major role in assisting clinical teams in appropriate test selection for their patients and are first responders to issues arising in or related to the clinical laboratory.  Residents get extensive training in quality measures and lab management approaches, including both statistical and financial considerations, and pursue opportunities for bench work and tech time.  Weekly obligations include QC review, laboratory rounds, endocrine conference with the clinical teams, and a call review conference with chemistry faculty and fellows.

This experience includes sign-outs with coagulation lab faculty.   UVA offers a broad spectrum of general and special coagulation assays, which require extensive and sophisticated interpretation and reporting.  UVA is a certified ECMO center, so residents have a unique opportunity to learn about the specialized protocols and coagulation monitoring required for these very ill patients.

Residents on the cytology service complete a variety of activities that fluctuate on a daily basis. Generally, residents preview cytology cases, participate in fine needle aspiration procedures, assist with on-site assessments and preliminary diagnoses, and attend daily sign-out. First year residents are encouraged to perform fine needle aspirations on palpable masses and learn how to prepare cytology slides. Highlights of this rotation include interacting with patients, performing procedures, and reasonable working hours. Residents also have the option to spend a few mornings in the histology lab learning how to embed tissue, prepare slides and process stains.

Third year residents complete their forensic rotation in one of the four medical examiner offices of Virginia: Central district (Richmond, VA – 70 miles from Charlottesville), Northern District (Manassas, VA – 80 miles from Charlottesville), Tidewater District (Norfolk,VA – 160 miles from Charlottesville), or Western District (Roanoke, 120 miles from Charlottesville). Residents can elect to either commute or relocate for the four-week rotation. Mileage reimbursement or a housing allowance is provided up to $1,200. During the rotation, residents perform autopsies (including eviscerations), visit crime scenes, and contribute to the legal aspects of cases. Work hours are usually from 8:00 AM until 4:00 PM. Most residents average 10-20 cases during this rotation, ten of which can be applied to ACGME board requirements.

Residents work closely with the UVA hematopathology fellows to run our busy hematopathology service.  Daily responsibilities include review of peripheral blood smears and select body fluids (wet-heme signout) with an attending, previewing in-house bone marrows and lymph node/tissues, interpreting flow cytometry results, and a main sign out to review in-house cases and flow cytometry with an attending. There are two multi-headed microscopes dedicated to hematopathology sign-out. There is a weekly hematopathology interesting case conference and journal club. Residents have the opportunity to attend a weekly meeting to discuss results of pertinent corresponding molecular and genetic studies and are invited to attend weekly tumor boards (adult heme-onc and pediatric heme-onc). Residents interested in hematopathology can elect to participate in our 2 week flow cytometry elective and/or can create an elective to rotate on the consult hematopathology service.

This rotation generally carries no more than one resident at a time and includes both ample tech time in the lab as well as daily rounds with both microbiology and infectious disease faculty.  The resident is expected to carry the pager, responding to all microbiology-related inquiries from the clinical teams.

Molecular genetics is a busy service with a rapidly expanding menu of genetic tests and panels. Typically a second and/or fourth year resident runs the service and is responsible for specimen evaluation and data interpretation on multiple platforms, including next generation sequencing, pyrosequencing, real-time PCR, and capillary electrophoresis. The residents investigate and coordinate send-out requests for molecular studies not available at UVA. The rotation encompasses constitutional and cancer genetics as well as cutting-edge genomics approaches to diagnosis. Residents have robust involvement in chromosomal microarrays, fluorescence in situ hybridization (FISH), and conventional karyotype analysis. Residents attend daily rounds for molecular and cytogenetics sign-outs, participate in a biweekly pediatric genetics conference and in a weekly hematology/oncology tumor board, and act as liaison between the labs and the clinical teams.

Residents participate in all activities of the diagnostic service of the Division of Neuropathology, which includes the examination of brain smears, frozen sections, and permanent sections of neurosurgical specimens, as well as the gross and microscopic examination of brains obtained from the autopsy material. Consultation case materials submitted from outside centers are also part of the routine evaluation. Residents essentially function as fellows in studying first-hand the neuropathological material under the guidance and supervision of a Neuropathology Fellow and faculty member.

Residents also participate in all clinical and teaching conferences of the division including Neuro-Oncology Tumor Board, Combined Neuropathology Conference, Neuroradiology Rounds, Neuromuscular Conference, Pituitary Conference, Neuropathology Journal Club, etc. Projects in clinicopathologic correlation and/or experimental Neuropathology may also be possible during this rotation.

Surgical pathology consists of a four-day rotational cycle, with one resident covering the responsibilities for each day of the cycle (4 residents on service each rotation). Residents sign-out the majority of the specimens they gross, with the exception of small specimens (i.e. biopsies). Surgical pathology follows a general sign-out model, with the exception of Dermatopathology and Neuropathology which are independent services. To learn more about general sign-out, please refer to Questions and Answers.

Our surgical pathology service is split into three surg path teams: A (resident + faculty), B (resident + faculty), and C (faculty only or trainee + faculty). The majority of the cases are signed out by the A and B teams. Residents on the A and B services have daily case caps stratified by their PGY year to preserve education time at the scope and to ensure their workload is manageable. Cases are overflowed to the C service which is typically a faculty-only service with the opportunity for trainees (residents and surg path fellow) to rotate if they desire. When residents choose to rotate on the C service, their cases are tailored to the sign-out faculty’s area of expertise which offers an additional avenue for focused training in a sub-specialty area of interest.

Day 1 – Frozens: Residents are responsible for sectioning specimens for intraoperative evaluation and communicating with surgeons. Histotechnologists assist with processing the slides. First year residents are on shift from 7:30 AM (operating room start time) until 9:30 PM for their first few rotations on this service. Upper level residents cover call after 9:30 PM on the weekdays and after 5:30 PM on Saturday. Later in the year, all residents cover the frozens call from 7:30 AM the day of until 7:30 AM the next day. All residents are responsible for communicating the results to the surgeon in the operating room and documenting the diagnosis.

Day 2 – Grossing: Grossing is the most rigorous part of surgical pathology. On average, residents gross from 9:00 AM to 6:00 PM as well as one Saturday per block. Residents are responsible for grossing or triaging specimens that are accessioned before 3:00 PM. Specimens that arrive between 3:00 PM and 6:00 PM are triaged for the following day. Residents often gross the more complex specimens while support staff cover the small specimens (i.e. biopsies). There are three dedicated pathology assistants who help with a variety of activities in the gross room.

Day 3 – Smalls Sign-out and Preview: Slides for biopsies are usually available at 7:30 AM for the resident to preview in the morning, and sign-out often begins around 9:00-9:30 AM. After sign-out, the resident is responsible for dictating the final report, ordering stains, and contacting physicians with urgent results. In late afternoon, the main cases will be available for the resident to preview. First year residents are not expected to comprehensively preview all of the slides nor all of the cases; the purpose of previewing for first year residents is to review interesting or complex cases in depth, gather paperwork that may be needed for specific cases, and become familiar with the patient’s clinical history. Residents are free to preview anytime from the afternoon of Day 3 until morning conference on Day 4. Some residents prefer to preview in the evenings/nights while others prefer to come back early the next day to preview. Residents should always get 8 hours off between Day 3 and Day 4.

Day 4 – Mains Sign-out: Residents begin mains sign-out around 9-9:30 AM. Each week there are different attendings on service, so residents experience a variety of diagnostic approaches. Following sign-out, the resident is responsible for dictating, reviewing billing codes, ordering stains, obtaining additional sections, and dictating the final report. The resident is also expected to review the operating room schedule for the next day in order to prepare for potential frozen section specimens. On average, most residents are finished by 6:00 PM.