Residency Program

Cleveland Clinic's AP/CP 4 curriculum consists of the following:

• 21 months core Anatomic Pathology.
• 21 months core Clinical Pathology.
• Six months of electives in Anatomic or Clinical Pathology.

The first year consists of 12 months core Anatomic Pathology, evenly divided among Surgical Pathology and Autopsy Pathology with one month of Forensics Pathology.

During the second year, residents complete 12 months of core Clinical Pathology.

In the third year, residents finish the last nine months of core Anatomic Pathology, one month elective in Cytopathology and complete two months elective time in either Anatomic or Clinical Pathology.

Nine months of the fourth year are devoted to core Clinical Pathology, with the remaining three months available for elective time in either Anatomic or Clinical Pathology.

These programs consist of 24 month core rotations in Anatomic or Clinical Pathology, and 12 months elective time or subspecialization/mentored research within the discipline.

Residents are encouraged to participate in Divisional research projects. Residents from Cleveland Clinic regularly present research papers at the College of American Pathologists/American Society of Clinical Pathologists national meetings and The United States and Canadian Academy of Pathology annual meeting, as well as at the Cleveland Society of Pathologists and Ohio Society of Pathologists Annual Resident Competition.

Research efforts of the Divisional faculty and residents have resulted in over 360 publications (articles, books/book chapters and abstracts) during the last academic year.

Following the guidelines of the ACGME, residents in pathology have at least one of seven days free of routine responsibilities. Furthermore, residents cannot be on-call in the hospital more than one out of three nights. Actual call rotations average three "on-call days" per month.

Training in anatomic pathology occurs predominantly during the first and third years of the AP/CP 4 program. First year residents evenly divide 11 months experience between the autopsy service and surgical pathology. An additional two weeks are spent studying the basics of electron microscopy and immunohistochemistry.

Approximately 250 autopsies are performed annually at Cleveland Clinic. Fully trained pathologist assistants help the resident in dissection. All aspects of the dissection are closely supervised by the faculty. The resident learns methods of evisceration and dissection skills. All gross anatomic findings are reviewed with faculty. Following a discussion of the case, the resident formulates a provisional anatomic diagnosis. Selected microbiologic cultures and postmortem chemistry supplement the anatomic studies. The microscopic analysis is also reviewed on a one-on-one basis with a faculty member, and the final anatomic diagnosis rendered.

The surgical pathology service processes approximately 80,000 specimens annually. The material reflects the highly specialized medical and surgical practice of Cleveland Clinic. Residents augmented by pathologist assistants are responsible for the description and dissection of the gross surgical specimens. Residents review and sign out all microscopic sections with a faculty member the following day.

The surgical pathology faculty is organized by subspecialty areas and sign-outs are scheduled among approximately 13 subspecialty committees, each of which contain 3-8 subspecialty surgical pathologists. Six residents share the daily responsibilities. Residents also prepare, render, and report frozen section diagnoses and actively consult with the surgeons in the operating room.

During the third year of the program, emphasis is placed on surgical pathology with approximately nine months devoted to it. One month is spent in core cytopathology with two months in the third year and four months in the last year used for elective study in anatomic and/or clinical pathology. Elective options in anatomic pathology include cytopathology, forensic pathology, pediatric pathology, dermatopathology, surgical pathology (including all specialty areas), immunohistology, electron microscopy, molecular biology, and flow cytometry.

In addition to routine tissue processing techniques, residents are exposed to a wide assortment of neuropathologic staining techniques, enzyme histochemistry, immunohistochemistry, flow cytometry, computer assisted morphometric techniques, and gene probe analysis.

During the rotation in Electron Microscopy, residents learn all aspects of tissue processing and gain experience in both transmission and scanning electron microscopy.

In Cytopathology, the resident learns methods of collection, preparation, and staining of cytologic material. Approximately 81,000 specimens are examined each year. During the resident's first year, he/she is introduced to basic cytopathological principals during formal sessions conducted during the residents off-service time on the Autopsy Service. During the third year of ANP, each resident does one month of elective study in experienced cytopathology.

Under the direction of Dr. Jennifer Brainard, we are currently performing approximately 5-10 fine needle aspirations (FNAs) per week with resident participation. These FNAs are done in the Departments of Hematology/Oncology, Infectious Disease, and General Surgery. In addition to routine cervical, sputum, and body fluid examination, experience with techniques such as Cytyc ThinPrep® Pap smears and immunocytology is available. The correlation of cytology with tissue diagnoses is stressed and the residents review slides daily with the faculty.

An extensive formal conference schedule moderated by the faculty complements the hands-on experience. These conferences are summarized below:

Mondays - S.O.D. (Slides of the Day) Conference

Interesting and/or difficult diagnostic problem slides are selected from recent surgical and autopsy cases. These are presented to the residents in advance as unknowns. Residents are expected to prepare. Clinicopathologic correlation is discussed. The conference stresses methods, the approach to problem solving, and differential diagnosis.

Tuesdays - Neuropathology Conference

Residents in Pathology and Neurology attend a brain cutting conference. Gross pathology of the central nervous system is stressed as are differential diagnoses and clinical pathologic correlation. Alternate weeks are devoted to didactic presentations of central nervous system pathology.

Wednesdays - Weekly Dermatopathology Conference

The total scope of dermatopathology is systematically reviewed. The format utilizes unknown slides and accompanying reading assignments.

Thursdays

1. Gross Pathology Conference Weekly (Summer) and monthly (Fall, Winter, Spring)
   This conference emphasizes the review of interesting gross specimens derived from the surgical pathology and autopsy services. The cases are reviewed by the residents as unknowns, and the differential diagnosis and approach to diagnosis are discussed by faculty and residents. This conference emphasizes the review of interesting gross specimens derived from the surgical pathology and autopsy services. The cases are reviewed by the residents as unknowns, and the differential diagnosis and approach to diagnosis are discussed by faculty and residents.
2. Biweekly Pathology Grand Rounds (Winter and Spring)
   This is a formal presentation prepared by residents and delivered to the entire Division. Topics are selected by the residents and explored in depth. Topics that bridge clinical and anatomic pathology, offer educational reviews, and present recent clinical research projects are encouraged.
3. Biweekly Electron Microscopy (Fall)
   Didactic presentations cover the basic principles of electron microscopy and analytical electron microscopy.
4. Biweekly Pediatric and Obstetrical Pathology Didactic Lecture Series (Spring)

Weekly Consult Case Conference

This is an informal conference presented by staff where 1-2 interesting cases, received in consultation, are discussed.

This conference emphasizes the review of interesting gross specimens derived from the surgical pathology and autopsy services. The cases are reviewed by the residents as unknowns, and the differential diagnosis and approach to diagnosis are discussed by faculty and residents.

Fridays - Review of System (ROS) Conference

This conference reviews in detail systemic gross pathology and histopathology and is presented by the faculty. The format varies, but is usually didactic with glass slides available for resident review.

In addition to these intradepartmental conferences, residents and faculty regularly attend and participate in over 25 extra-departmental conferences. The conferences are focused on subspecialty areas of pathology. Senior residents routinely present at these hospital-wide conferences.

Residents have the opportunity to teach medical students, in addition to opportunities provided through the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. In addition, medical students from around the country regularly do clerkships in pathology. One or two medical students are assigned to the services per month. Resident are assigned to the medical students and are responsible for daily instruction and conference preparation.

During the Anatomic Pathology rotations, residents are on call approximately one weekend per month and approximately three weekday nights per month. Residents on weekday night call are responsible for after-hours "emergency" autopsies (regular autopsy hours are 8 a.m. to 4:30 p.m. Monday-Friday), transplantation triage and frozen sections. Weekend call is divided between two residents. The resident assigned to "A1" on one weekend day is responsible for the first two postmortem examinations of that day and all of the frozen sections. The other weekend day that resident will be assigned to "A2", being responsible for the third and fourth postmortem examinations of the day. Call is taken from home and long-range beepers are provided.

Each resident has a personal computer in his/her cubicle. These computers are part of Cleveland Clinic health system intranet and have access to the internet as well as online medical literature search services (PubMed, Medline, etc.). Computer printers are available in the residents' area of the division. In addition, the photomicroscopy facilities has a video disc player to be used with the Intellipath Interactive Video Disc Teaching system. Additional computer access is provided through Cleveland Clinic's Educational Foundation Library.

Anatomic Pathology maintains a library with over 300 textbooks and 15 journal titles covering all of the areas of anatomic pathology, experimental pathology, surgical pathology, cytology, and electron microscopy.

In addition, Cleveland Clinic's Alumni Library contains over 50,000 volumes and 850 subscriptions to periodicals. The medical library has MED-line and other search capabilities (Medical Library CD-plus system) with connection to the National Library of Medicine Bibliographic Indexing Services. Additional library facilities are available through the Cleveland Medical Library Association.

At the completion of the program in Anatomic Pathology the resident is expected to be proficient in the following areas:

• Be able to perform a complete autopsy including evisceration, removal of the central nervous system, eyes, and examination of the internal ear and peripheral nervous system.
• Be proficient in dissection and can tailor this to the necessities of any type of disease process.
• Have a firm knowledge of gross autopsy diagnosis and should be able to select tissue for microscopic analysis and be able to use special staining techniques on a rational basis.
• Be able to describe concisely the histopathologic changes seen in the microscopic sections and construct a concise summary of the case with clinicopathologic correlation.
• Have mastered methods of examination, dissection, and description of all surgical pathologic materials.
• Be an expert in tissue selection and interpretation of routine, as well as special histochemical, electron microscopic, immunohistochemical, and molecular biologic procedures.
• Have broad knowledge of pathologic changes of all areas of systemic disease, including a knowledge of classifications of disease, in-depth knowledge of the pathologic changes in the more common disease processes, and a working knowledge of other disease processes.
• Have the ability to find additional information in the medical literature concerning any disease.
• Be proficient in the preparation and interpretation of frozen sections.
• Have knowledge of the theory of exfoliative cytology and the methods of preparation and staining.
• Have diagnostic ability using Papanicolaou stained cervicovaginal preparations, as well as preparations of tumor aspirates, gastrointestinal sediments and body fluids, including Thin Prep®.
• Be familiar with the use of special and immunocytochemical stains in the diagnosis of bacterial and fungal diseases, as well as the cytologic appearance of viral diseases.
• Be familiar with and recognize processes that could lead to false positive as well as false negative diagnoses.

Residents are formally reviewed by the faculty every six months. At the individual's review conference, strengths and weaknesses are discussed and suggestions for improvement are made. The residents actively review the faculty every six months through an anonymous evaluation procedure processed through the Division of Education.

1. Pathology Residency: one-four month rotation electives within the AP/CP 4 program.
2. Dermatology Residency: Three month rotation in dermatopathology in a three year training program.
3. Dermatopathology Special Fellowship: The one year special dermatopathology fellowship is an integrated training program to combine the resources of pathology and dermatology.

• Dermatology Department
• Plastic Surgery Department
• General Surgery Department
• Medical and Surgical Departments
• Outside Consultations

Associated Facilities:

• Immunopathology Laboratory
• Fluorescence microscope
• Transmission and scanning electron microscopes with EDAX capabilities
• Research Division
• Microbiology Laboratory
• Molecular techniques

Daily responsibility for interpretation of the Dermatopathology materials. These include the outside consultations and in-house Cleveland Clinic materials.

The trainee will participate in teaching conferences, research projects, and scientific presentations.

Conferences

1. Weekly unknown slide session - Wednesday, 7-8 a.m. for Dermatology and Pathology residents and visiting physicians.
2. Immunopathology (direct immunofluorescent interpretation) Wednesday, 2:00 p.m.
3. Dermatology Grand Rounds, Thursday, 8:30-9:30 a.m., Education Building.
4. Trainees are encouraged to attend the Dermatology Journal Club, Medical Grand Rounds, General Pathology Conferences and appropriate visiting Professor lectures.

The trainee will be evaluated by his or her ability to interpret dermatopathology materials. In addition, a yearly quiz will be given using unknown histological specimens.

To meet the standards established by the American Board of Dermatopathology and Pathology, which will enable the candidate to qualify for the American Board of Dermatology and Pathology co-joint examination.

1. To establish confidence in light microscopy and other investigative parameters (immunofluorescence, immunohistochemistry, electron microscopy, microbiology, and immunology) and laboratory management.
2. To understand the biological behavior of cutaneous diseases related to the pathological findings.
3. To stimulate an active interest in Dermatopathology.
4. To perform clinicopathologic research suitable for publication.

Library Facilities

• Intradepartmental Pathology and Dermatology Libraries
• Cleveland Clinic Alumni Library
• Case Western Reserve University Library
• Allen Memorial Library and Dermatopathology Library

Clinical Pathology training consists of core rotations in these six sections: Clinical Biochemistry (includes Immunopathology), Transfusion Medicine, Hematopathology, Hemostasis and Thrombosis, Clinical Microbiology, and Molecular Genetic Pathology.

During the first year of training in Clinical Pathology (the second year of the AP/CP 4 program), the residents spend three months in Hematopathology, two months in Clinical Microbiology, two months in Transfusion Medicine, two months in Lymphoma/Immunopathology, one month in Clinical Biochemistry, one month in Molecular Pathology and Cytogenetics, and one month in Thrombosis and Hemostasis.

The second year of core Clinical Pathology training (done during the fourth year of the AP/CP 4 program) focuses on increased resident responsibility and provides flexibility for the residents to pursue areas of special interest.

Each resident spends three months in Hematopathology, two months in Clinical Biochemistry, and one month each in Lymphoma/Immunopathology, Clinical Microbiology, Transfusion Medicine, and Thrombosis and Hemostasis. Three months are available for Anatomic or Clinical Pathology electives in the fourth year of the AP/CP 4 program.

Accredited fellowships are offered in Hematopathology, Clinical Microbiology, and, in conjunction with the American Red Cross, in Transfusion Medicine.

The Clinical Pathology portion of the training program includes the following formal teaching conferences:

1. Core Curriculum in Clinical Pathology
   This conference is held weekly on Wednesday mornings from 8-9 a.m. and covers, in lecture format a variety of core topics in clinical pathology. The lectures run in a two-year cycle, and are given as blocks. The faculty presents the lectures, and handout material and references are provided at the conference, at the discretion of the faculty. Because this conference runs in a two-year cycle, all residents are expected to attend.

2. Clinical Pathology Unknown Conference
   This conference, held monthly on a Tuesday morning from 8-9 a.m. involves discussion and diagnosis of Clinical Pathology cases which have been presented to the residents as unknowns. The Unknown cases address topics that have been recently presented in the Core Curriculum in Clinical Pathology, and provide an opportunity to work through case material. Case material is available at least one week prior to the conference.

3. Clinical Pathology Case Conference
   This conference, held monthly on a Tuesday morning from 8-9 a.m. is an opportunity for residents on the various CP services to share interesting cases with each other and the CP faculty. Cases are presented from each CP service (10 minutes) and are selected as examples of particularly instructive learning.

4. Laboratory Management Seminar
   This seminar, held at noon on the first Monday of each month (September-June), provides an opportunity for fourth year residents to discuss topics in laboratory management with faculty in a small group setting.

   In addition, residents are expected to design and complete a small management project under the supervision of a staff pathologist (preferably in an area of the laboratory that they are interested in as a career).

5. Informatics Conference
   Dr. Henricks, Director of Center for Pathology Informatics, meets regularly with the residents to discuss topics in laboratory informatics.

6. Leukemia Case Conference
   This conference is held once/month (first Wednesday from 7-8 a.m.) and is jointly sponsored by Hematopathology and the Department of Hematology & Medical Oncology. Rotating pathology residents and hematopathology fellows, in conjunction with faculty, photograph and present three-four cases, and diagnostic and therapeutic options are discussed.

7. Microbiology/Infectious Diseases Conference
   This weekly conference is jointly sponsored by the Section of Microbiology and the Department of Infectious Diseases. An interesting case is presented to lead off the discussion of the topic for the day. Faculty, fellows, residents, and invited speakers give the conference.

8. Infectious Disease/Microbiology Case Rounds
   This weekly conference involves case presentations as unknown by Infectious Disease residents and faculty with differential diagnosis and discussion by Infectious Disease and Microbiology faculty.

9. Lymphoma Pathology Conference
   This conference is held once/month (second Wednesday from 7-8 a.m.) and is jointly sponsored by Hematopathology and the Department of Hematology & Medical Oncology. Rotating pathology residents and hematopathology fellows, in conjunction with faculty, photograph and present three-four cases, current topics in biology, pathology, and treatment of lymphoma are discussed.

10. Benign Hematology Conference
    This conference is held once/month (fourth Wednesday from 7-8 a.m.) and is jointly sponsored by Hematopathology and the Department of Hematology & Medical Oncology. Rotating pathology residents and hematopathology fellows, in conjunction with faculty, photograph and present three-four cases. Clinical features, pathophysiology, and treatment options are discussed.

11. Hematopathology Journal Club
    This conference held on the last Friday of each month is sponsored by the Section of Hematopathology. Rotating pathology residents on Hematopathology and Lymphoma, select articles to critically review for study design, methods, and data interpretation, in conjunction with faculty.

12. Clinical Coagulation Conference
    This conference, held on the third Wednesday of each month, is sponsored by the Sections of Vascular Medicine and Hemostasis and Thrombosis. Clinical features, differential diagnosis, and management options are discussed.

Residents are on call in Clinical Pathology during the second and fourth years of the residency an average of every twelfth weeknight and four-five weekends per year.

When on call during weeknights, residents are in-house until 7 p.m. and take call from home via pager until the following morning. When on call during weekends, residents are in-house from 9 a.m. to 3 p.m., and take call from home via pager during the other times.

Duties may include review of peripheral blood smears and bone marrow aspirates, evaluating appropriateness of flow cytometry requests and interpreting results, triaging requests for after-hours coagulation testing, reviewing stat Gram stains, and evaluating transfusion reactions or unusual requests for blood products.

Residents are always on call with attending staff from each CP area who are available by phone or pager to provide supervision and back-up. Residents do not have responsibilities for call in Anatomic Pathology when on Clinical Pathology call.

Library facilities are available on the third floor of the L building 24 hours a day, seven days a week. In addition to reference texts, the library includes subscriptions to many specialty CP journals that may not be available in Cleveland Clinic's library.

Residents on CP rotations have access to the laboratory information systems (CoPath and Mysis) as well as the clinical information systems (LastWord). Computer workstations are provided for each resident on Hematopathology, Hemostasis and Thrombosis, and Lymphoma rotations, in addition to those provided in each resident cubicle.

Facilities for image acquisition (digital camera, microscope camera, document scanner, slide scanner) and editing (Photoshop) are available for resident use.

Residents are evaluated at the end of each rotation. The evaluations are reviewed with the resident. Strengths and weaknesses are discussed and suggestions for improvement made. Residents actively review the Clinical Pathology faculty yearly through an anonymous evaluation process through the Division of Education and via yearly group summation conference.

The first year core rotation occurs during the second year of the AP/CP 4 program. The resident spends eight weeks, distributed over two month long rotations, learning the administrative, laboratory, and clinical aspects of Blood Bank activities. This includes learning the essentials of a blood donor service, organization of a transfusion service, the details of blood procurement, and the preparation of blood components.

The typing and crossmatching of blood, the detection and identification of atypical antibodies, the pre-transfusion testing necessary to provide safe blood, and the evaluation of a patient with a positive direct antiglobulin test make up the laboratory aspects of this service. The resident learns basic principles behind the utilization of blood products and component therapy, as well as the adverse effects of transfusion. Time is devoted to learning appropriate therapy for blood donor and transfusion reactions.

The resident receives exposure to the principles of apheresis, including platelet transfusion and support of medical and surgical patients. The resident rotates through the Hepatitis Serology Laboratory becoming familiar with current methods for detection of hepatitis serologic markers. The resident interprets the results of these tests with respect to their chronologic significance in the clinical course of the various types of hepatitis.

In conjunction with the Department of Hematology and Medical Oncology, the resident observes and learns the process of human progenitor cell collection by apheresis. The processing of these cells including concentration, freezing and thawing is performed in the Progenitor Cell Processing Laboratory.

The resident assumes the role of the Blood Bank physician as clinical consultant. Interpretive reporting of serologic results, investigation of transfusion reactions with recommendations for treatment and future therapy, and evaluation of patients with unique clinical and transfusion problems, including dialogue with the clinical service, serves to provide experience in this area.

The resident is expected to handle other problems arising in the laboratory related to evaluation of prospective allogeneic and autologous donors, and therapeutic phlebotomy patients.

The resident learns quality assurance procedures, component preparation procedures, and testing reagents used in the Blood Bank. The resident is expected to be familiar with the standards required by the American Association of Blood Banks (AABB), College of American Pathologists (CAP), Joint Commission on Accreditation Healthcare Organization (JCAHO), and Food and Drug Administration (FDA).

The following topics list is presented as a guide to the residents for organization of reading schedules.

1. Volunteer and Autologous Blood Donation
2. Therapeutic phlebotomy and Apheresis
3. Direct Antiglobulin Test
4. Pretransfusion Testing
5. Hemolytic Disease of the Newborn and Pediatric Transfusion
6. Choice of Blood Components for Transfusion
7. Adverse Effects of Transfusion, Including Therapy and Prevention
8. Evaluation and Management of Autoimmune Hemolytic Anemia
9. Paternity Testing and other Forensic Applications
10. The HLA System
11. Transfusion Therapy of Patients with Selected Clinical Problems Including Coagulation Abnormalities
12. Quality Assurance and Good Manufacturing Practices
13. Certification and Licensure (AABB, CAP, JCAHO, FDA)

The second year core Transfusion Medicine rotation (scheduled for the fourth year of the AP/CP 4 program) emphasizes laboratory aspects of the Blood Bank, but places more emphasis on the role of the pathologist as an administrator, director of a clinical laboratory, and a clinical consultant. Blood Banking principles and laboratory techniques will be covered during the rotation in a "case-discussion" format.

Administrative aspects emphasized in this year include organization, inventory management, blood banking charges, and the role of the computer in the Blood Bank. The resident participates in all Blood Bank administrative meetings.

Clinical alternatives to blood transfusion are emphasized. The importance of perioperative transfusion is stressed. Intraoperative blood salvage strategies are discussed.

The resident is familiarized with blood procurement services provided by the Red Cross in the community and the role of the hospital-based Blood Bank director. Residents may participate in an elective two-day introductory program conducted by the Red Cross.

Residents regularly participate in the various consultative activities of the Section staff. This includes interpretative erythrocytes antibody reporting, hepatitis profile reporting, and evaluation of patients with selected clinical problems requiring transfusion support, including coagulation abnormalities.

The latter, conducted in conjunction with the Section Head of Thrombosis and Hemostasis, includes diagnostic evaluation of the patient with recommendations for specific transfusion.

The resident functions as a consultant to the donor Apheresis service. Additional responsibilities include recommending guidelines for the treatment of patients requiring specialized platelet transfusion support.

Residents will also become familiar with the Standards of the AABB and CAP. The residents are expected to participate in a Blood Bank Inspection for either organization should one be conducted at a hospital in the area during the rotation.

The objective of the training program is to give the resident in Clinical Pathology a firm grasp of the methodologies, principles, and interpretation of clinical chemistry testing. This training ensures that the resident is capable of directing a clinical chemistry laboratory. Data interpretation and interpretive reporting are strongly emphasized.

The resident rotations are tailored around the following laboratory areas: Automated/Acute Care, Chromatography/Spectroscopy, Electrophoresis, and Immunoassay. Integrated into these laboratories are benches devoted to trace metals analysis, metabolic diseases, and drug testing.

The four week, first-year rotation (done during the second year of the AP/CP 4 program) is designed to ensure exposure to select aspects of clinical biochemistry in a structured, didactic setting. One week is devoted to each of the following areas: Automated and Acute Care Chemistry, Enzymology, Lipids/Lipoproteins, and Therapeutic Drug Monitoring.

Each day of the week is devoted to a specific topic so that the significant laboratory and diagnostic issues are covered in an organized fashion. Endocrine immunology, tumor markers and Immunoassay methods are covered during the second rotation in the fourth year.

All weeks include interaction with faculty and appropriate reading. Daily informal sessions are held with the assigned faculty member to cover each area in an interactive manner. Clinicopathologic correlation is also stressed using chart rounds on selected patients. Selected laboratory experiences are included in this rotation where the benchwork adds to the understanding of the topic being covered.

The second year rotation (done during the fourth year of the AP/CP 4 program) covers all the technical areas of Automated and Manual Hematology, Automated/Acute Care, Chromatography/Spectroscopy, Electrophoresis, and Immunoassay. It also includes a practical exposure to quality control and quality assurance of results, troubleshooting at the bench, and review of common laboratory results.

Communication skills at the bench and with the clinical services will be stressed, together with an appreciation of the day-to-day activities in a high volume laboratory setting. The resident interacts with faculty on an informal basis, discussing topics of interest, with an emphasis on management issues and problem solving.

The resident has the opportunity to be intimately involved in the day-to-day running of the laboratory, serving as a resource person and acting faculty for the technologists in an area of the laboratory.

Both the one month first-year rotation (done during the second year of the AP/CP 4 program) and the two month second-year rotation (done during the fourth year of the AP/CP 4 program) incorporate sign-out and result review responsibilities, quality control review and decision-making, and exposure to laboratory instrumentation and techniques.

Resident activities during these months will be in three general areas:

• Sign-out:
  • Electrophoresis (isoenzyme, lipid, and protein)
  • Interpretive Coagulation
  • Hepatitis Profiles
  • Laboratory Staff Review
  • Point-of-care Testing

All sign-out/staff review material will go through the resident(s) on service. The technologist will be expected to page or otherwise contact the resident, who then has the responsibility to complete the sign-out/staff review with the responsible faculty member.

Point-of-care Testing will function in a different manner from the other sign-out activities, involving considerable interaction with the responsible technologists on an ongoing basis and a formal presentation of the findings of the review at the end of the rotation.

• Results Review:
  • Anti-nuclear antibodies and autoantibodies
  • Kleihauer-Bettke
  • Monthly QC

The resident is expected to be actively involved in reviewing this material and, in appropriate cases, will have oversight responsibilities for these activities.

• Benches-scheduled:
• Blood gases and acute care testing (1 day)
• Automated chemistry analyzers (1-2 days)
• Automated hematology analyzer (1 day)
• Automated coagulation (1 day)
• Manual coagulation (1 day)
• Automated Immunoassay analyzers (2 days)
• Manual Immunoassay (1 day)
• Electrophoresis (2 days)
• Allogen (HLA) laboratory (1-3 days)
• Urinalysis (1-2 days)

These scheduled bench experiences represent a minimum rotation. This will be scheduled by the appropriate supervisory personnel, and the technologist on the bench is expected to give an overview of the methodology, range of testing, maintenance, specimen flow and quality control issues for the testing being performed.

Time should be limited to one-two hr/bench. Actual hands-on activities will also be designated.

1. Ensure that the resident understands the principles, methods, and interpretation of all laboratory testing utilized to diagnose hematologic disorders.
2. Develop the morphologic skills necessary to become competent in the interpretation of bone marrow aspirates/biopsies, peripheral blood smears, and body fluid cytospin preparations.
3. Understand the basic principles of management and the operations of a hematology laboratory.
4. Train the resident to oversee the activities of a general hematology laboratory.

The resident rotation in Hematopathology has three components:

1. Bone marrow, peripheral blood smear and body fluid interpretation.
2. Automated hematology (Automated Laboratories).
3. Special hematologic studies (Manual Laboratories).

During the rotations through these areas the resident will receive training in: the principles of instrument operation, test methodology, interpretive test reporting, CBC interpretation, flow cytometric analysis, bone marrow immunohistochemistry, special red cell studies including abnormal hemoglobin identification, the basic principles of laboratory management, including cost-containment, test utilization management, quality control, quality assurance, specimen handling and result reporting.

The resident spends three months in Hematopathology. A portion of each week is spent in the different laboratory areas with hands on exposure to peripheral blood and bone marrow morphology.

A large part of the three-month rotation focuses on the development of bone marrow, peripheral blood, and body fluid morphologic skills. This is accomplished through direct interaction with the hematopathologist, hematopathology fellows, senior residents, and medical technologists. The resident is directly involved in the work-up of hematologic disorders. The resident closely interacts with the hematopathologist and clinical hematologist in the review and interpretive reporting of cases.

The resident spends an additional three months in Hematopathology. These months are geared toward increased resident responsibility in signing out peripheral blood smears, bone marrows, and flow cytometric evaluations, as well as assuming responsibility for anemia work-ups.

Elective rotations in the other areas of the laboratory and participation in research projects are encouraged. Residents are required to become proficient in the performance of bone marrow aspirates and biopsies during this rotation by arrangement with the Department of Hematology and Medical Oncology.

As part of the Clinical Pathology core lecture series, the residents receive a series of didactic presentations covering all the major topics in Hematopathology. These are given by the faculty in the Section of Hematopathology. In addition, there are several hematopathology case review conferences given throughout the year. There is also a monthly hematopathology journal club.

The Hemostasis and Thrombosis Rotation during the Clinical Pathology training is intended to expose the residents to clinical disorders leading to bleeding and thrombosis. The rotation will introduce the resident to the performance and interpretation of laboratory testing for bleeding and thrombotic disorders.

Through participation in daily clinical diagnostic signout, the resident will learn the importance of clinical-pathologic correlation in evaluating the hemostatic system. The effect of antithrombotic drugs and their laboratory monitoring will also be a focus of the rotation. It is hoped that, at the completion of the rotation, the resident will be able to understand which laboratory tests are appropriate to evaluate patients with hemostatic disorders and be able to interpret the results from those tests.

During the Hemostasis and Thrombosis Rotation, the Resident will:

• Review the molecular biochemistry of the hemostatic system.
• Learn about congenital and acquired hemostatic and thrombotic disorders.
• Understand algorithmic diagnostic test strategies.
• Observe the technical performance of general coagulation tests (PT, APTT, Fibrinogen).
• Observe and understand the technical performance of coagulation tests (factor assays, chromogenic assays, von Willebrand assays, lupus anticoagulant assays, Bethesda assay, fibrinolytic assays, platelet aggregation, platelet flow cytometry).
• Review data on development and implementation of new hemostasis assays.
• Give a lecture to the technologists on some aspect of hemostasis testing.
• Participate in answering questions from clinicians and reference laboratory clients regarding hemostasis testing.
• Help in troubleshooting laboratory testing, as necessary.
• Be involved in evaluation of quality assurance projects in the laboratory.
• Review recent CAP hemostasis surveys to understand proficiency testing programs.
• Be Involved in Diagnostic Interpretive Hemostasis Testing.
• Review the coagulation laboratory pending list for diagnostic interpretive coagulation testing panels every morning.
  • Previous laboratory testing results for each of these patients will be printed out. Clinical data will be obtained from LastWord.
  • The clinical ordering service will be contacted to determine the reason for the test order and the information the clinicians are seeking.
  • Based on this information, and the preliminary laboratory testing results, the resident, together with the staff pathologist and the established coagulation testing algorithms, will determine the next set of hemostasis tests to be performed.
  • Alternatively, if the order for the tests seems inappropriate, the resident, with the consultation of the staff pathologists, will recommend that the tests be credited.
  • The patient's chart may be consulted, if necessary.
  • When the laboratory studies are completed, the resident will render a diagnostic interpretation, using either the established coded comments or free text. These comments will be reviewed by the staff pathologist and validated by the technologists.
  • The clinical service will be re-contacted and the results discussed with the ordering physician.

The major objectives of training in lymphoma pathology and related immunologic assays are: to become proficient at the histopathologic interpretation of lymph node biopsies and related extranodal lymphoid tissue biopsies; to understand the tissue requirements and interpretation of immunohistochemistry, FISH testing, flow cytometry and PCR, RT-PCR, and Southern blotting, and to independently interpret flow cytometric data in the context of lymph node morphology.

Residents serve two months on the lymphoma services during the first clinical pathology year (second year of AP/CP 4 program) and one month during the second clinical pathology year (fourth year of AP/CP 4 program).

During the first month on service, the junior resident is paired with a senior resident to facilitate teaching. Residents are active in all areas of the service: reviewing frozen sections for tissue adequacy and diagnosis; triaging fresh lymph node and spleen specimens for flow cytometry, molecular testing and cytogenetics; evaluating lymph node biopsies; recommending further testing, including flow cytometry and immunostains; evaluating and interpreting results of ancillary studies, including FISH, flow cytometry, and molecular testing; and organizing and previewing cases for daily sign-out.

During the second rotation, residents are expected to take a more independent role in managing the service, including dictating cases under staff supervision.

A teaching slide set is available for review.

The major objectives of training in Clinical Microbiology are to provide residents with experience in the isolation and identification of medically important microorganisms and in the interpretation and application of laboratory results.

During the first rotation during the second year of AP/CP 4 program, residents have assigned responsibilities in each area in Microbiology with emphasis on acquisition of technical experience and clinical application of the data provided to the attending physician. This rotation is given in a two-month block.

The second rotation (fourth year of AP/CP 4 program) is for one month. During this month the resident is responsible for handling procedural and interpretive questions from technical staff, acquiring additional training in one or two specific areas of the laboratory, and carrying out assigned reading and problem-solving.

The resident receives technical training in Clinical Microbiology by qualified technologists and, under direction, is expected to participate in the work routinely performed in each area. Emphasis is placed on specimen quality and processing, microbial identification and susceptibility testing. Where appropriate, the residents will participate in direct specimen testing for specific significant organisms.

The use of "unknowns" for the resident to work-up will complement the daily work to increase the resident's technical abilities. Opportunities for residents to become involved in or participate in administrative functions are available, but generally require the full-time presence of the resident in the section. The second rotation emphasizes this type of participation. Quality assurance and cost-effectiveness activities are useful for the resident to enhance the clinical correlation aspects of microbiologic data.

Specific responsibilities assigned to the resident include reading and interpretation of a variety of Gram stains. The resident also serves as a consultant by recommending appropriate cultures and culture processing for autopsies. The resident reports significant positive cultures - CSF, blood, mycobacterial, enteric, deep fungal, viral and parasitic. Daily lab rounds, weekly plate rounds, and a continuing education presentation are given by the resident during both rotations.

Daily laboratory rounds review the significant positive microbiologic data and the correlation with the clinical picture. These offer an opportunity for interpretation of microbiologic data, discussions on treatment and appropriate selection of antimicrobial agents. Case discussions by the faculty occur during laboratory rounds.

Weekly, the resident will give plate rounds following laboratory rounds. Plate rounds consist of an informal concise description of a microorganism.

Infectious Diseases rounds are held in the Clinical Microbiology Conference Room weekly on Friday afternoons. The pathology residents are expected to attend in order to become familiar with the value and use of microbiology information for diagnosis and care of patients.

Two continuing education programs are usually presented each month. The resident is asked to present a topic of his/her choice at one of these during their rotation. In addition, the faculty meets with the residents for a formal presentation of a specific topic at least twice during the course of the rotation.

Twice per year, a City Wide Infectious Disease Conference is held at Cleveland Clinic. The pathology residents are encouraged to attend this meeting, and they often are called upon to present the histopathologic materials for some of the cases, when applicable and of interest to the participants.

In addition to the ongoing activities, kodachrome slide collections are available for review in the section. Collections are also available in the Clinic's Audiovisual Department. The section library contains textbooks, manuals, journals, report (Clinical Microbiology and Antimicrobic Newsletters, Morbidity and Mortality Weekly Report).

• Orientation (One Week)
  This rotation is an intensive review of stat procedures, basic microbiology techniques, media, stains, organism identification, susceptibility testing, laboratory safety and autopsy protocols for microbiology.

• Central Processing and Media Preparation (One Week)
  In the Central Processing area, the resident learns guidelines for proper specimen collection, transport and processing for all areas of microbiology. Hands-on experience in processing of selected specimens is expected. Media preparation includes observation of media preparation, inventory control, and related administrative functions.

• Bacteriology, Mycobacteriology, Mycology and Parasitology (Five Weeks)
  Scheduled rotations throughout these laboratories include opportunities to work-up individual patient cultures with guidance from technologists, observation of work-up of cultures, and interpretation of significant findings.

  During the rotation, "unknown" cultures will be given to the resident to supplement the technical knowledge skills required in each area. During the rotation, demonstrations may also be used for uncommonly used procedures and tests. Residents are given experience with the use of genetic probes for microbial detection and/or identification.

• Virology/Serology (One Week)
  The resident will become familiar with techniques used for the detection and culture of commonly encountered viruses by conventional and rapid techniques. Available direct specimen testing by enzyme immunoassay and fluorescent techniques will be reviewed.

  Various serological procedures, including agglutination, fluorescent and enzyme immunoassays, complement fixation, immunodiffusion, and PCR are reviewed and discussed regarding their use for either nucleic acid, antigen or antibody detection.

The second rotation is individualized according to length of assignment (minimum of one month). Elective time may be used to increase length of exposure; however, residents are introduced to molecular diagnostic techniques, including methodologies for DNA/RNA amplification.

Residents are instructed in principles of molecular diagnosis for applications in anatomic and clinical pathology. The rotation occurs relatively early during their training, so that they may take advantage of the skills learned during this rotation for subsequent rotations in anatomic and clinical pathology.

The emphasis throughout the residency training program is the integration of Molecular Pathology into multiple disciplines. For cytogenetics, principles of sample selection and handling, mechanisms of chromosomal rearrangement, and interpretation of the common constitutional and acquired abnormalities are discussed.

Teaching of Molecular Pathology is done in a one-month core rotation occurring in the first year of Clinical Pathology (second year of AP/CP 4 training). Molecular pathology teaching also occurs in the context of clinical case sign out in Anatomic and Clinical Pathology. Training in molecular microbiology is an integral part of the rotations in Clinical Microbiology.

Interpretation of T&B cell gene rearrangements by both amplification and Southern Blotting techniques is an integral part of the lymphoma rotation. In situ hybridization for EBV and immunoglobulin light chain mRNA is similarly incorporated in this rotation.

Teaching of cytogenetics is done concurrently during this one-month rotation.

Electives in Molecular Pathology and Cytogenetics may be taken.

Residents spend one month concurrently in the Molecular Pathology and Cytogenetics Laboratories. They rotate through the bench areas in Molecular Pathology and meet daily with the staff to discuss topics and sign out cases. In Cytogenetics, residents are given the option to examine their own karyotype, and rotate through the benches to learn specimen set-up, culture, harvest, slide making, and chromosome analysis.

Residents also spend time in the FISH laboratory, learning the principles of translocation probes (dual fusion, break apart) for t(14;18), t(11;14), t(9;22), t(15;17), inv(16), t(8;21), t(12;21), t(11;18), and others.

At the conclusion of the rotation, the resident is expected to present a continuing education conference on a topic of their choice to the technologists in either molecular pathology or cytogenetics.

The overall goal of the resident rotation will be to expose senior level residents to a busy general community-based practice. The exposure will encompass professional activities in anatomic and clinical pathology and administrative activities in the Clinic and Hospital laboratories.

The resident will be immersed daily in activities that include multiple laboratory areas. At the end of the rotation, the resident will be able to define more clearly the practice features (demands, responsibilities, skills) which he/she may experience in a community-based general practice of pathology.

1. Gain increased proficiency in formulating and dictating final reports in surgical pathology, cytopathology, and hematology.
2. Participate in at least one microscope case conference with either Dermatology or GI/Colorectal Surgery Department.
3. Respond to clinician inquiries regarding abnormal or unexpected test results and troubleshoot problems with test orders.
4. Attend and participate in meetings and conferences with the Division Chairman and Laboratory Manager.
5. Give a one-hour continuing medical education seminar to laboratory personnel and to Internal Medicine residents.

Allocation of Time

This rotation is designed as a one-month rotation. The time will be divided equally between clinic and hospital with some of the tasks ongoing throughout the entire rotation. For example, there will be daily activity related to sign-out of anatomic pathology, hematology, and interpretative clinical pathology specimens. There will also be ongoing exposure to inquiries from clinicians as they arise. It is not intended that the resident assumes call responsibility after 5:00 p.m. or on weekends.

Teaching Techniques

During this rotation the resident will assume responsibility for completing the tasks set out by the specific aims. It is this kind of responsibility that is experienced in a practice setting and which effectively underlines the practical aspects of discharging one's responsibilities as a practicing pathologist.

The teaching environment will also, by necessity, emphasize in the course of a single day the multiplicity of tasks encountered in the diverse areas of laboratory medicine. The quality of this experience will be ensured by the close presence of a staff pathologist experiencing the same diversity of tasks in the course of his/her daily work. Tutorial/didactic sessions will be employed for appropriate topics.

The combined volume of anatomic pathology approaches 10,000 surgical pathology accessions and 6,000 cytopathology accessions annually.

The evaluation process will be two-fold. First, the resident will be evaluated on the basis of how well he/she successfully completes the items mentioned in the specific aims section. The larger question being asked in the evaluation will be how well did the resident progress toward a fuller appreciation of general pathology practice and how well would the resident make the transition from residency to a position in a group practice.

In the second phase of the evaluation, the resident will document the quality of the experience, the amount of new knowledge/skills attained, and whether or not the experience has contributed to his/her ability to function in a small group practice.

Recruitment efforts and appointments are limited to candidates who meet the general institutional eligibility requirements and those requirements outlined in the essentials of accredited residencies in Graduate Medical Education. All applications are reviewed by the Program Director who selects the best applicants based on academic credentials to be invited for a formal interview.

The formal interview includes an explanation of the program by the Program Director, interviews with representatives of the Tomsich Pathology Laboratories Education Committee, an interview with the Chief Resident or designate, a tour of the division, and lunch with the residents.

Resident selection and the ranking of candidates are done by the Tomsich Pathology Laboratories Education Committee. These selections/rankings are based on the candidates' aptitude, academic credentials and ability to communicate.

Senior medical students must go through the National Resident Matching Program. The program will also consider individuals outside of the National Resident Matching Program (e.g., transfers from another specialty, and individuals who have done one year of clinical training with intention to go into pathology).

Cleveland Clinic residents continue to be prolific with 70 published abstracts and manuscripts this academic year, along with 52 presentations at national meetings. Cleveland Clinic's Residency Program has ranked in the top 4 programs nationally for the past 5 years in the number of resident abstracts accepted for presentation at the national meeting of the United States and Canadian Academy of Pathology.