Neuropathology Goals and Objectives
During neuropathology training in the Anatomic and Clinical Pathology Residency Program, each resident will master the following skills:
Neuropathology Patient Care Aspects
The resident is expected to develop an appreciation of the importance of providing information to clinicians that will help them to better care for their patients. This includes pre-intervention strategic planning, intra-interventional monitoring and feedback and post-intervention interpretation of pathologic findings.
The aim of these skills is to provide the maximum amount of useful information to the clinician with the minimum amount of inconvenience to the patient. This includes developing awareness that while more tissue may provide more information, the cost of this information must be weighed in terms of possible damaging effects on the patient. It also includes the recognition that an anxious patient and family awaits each and every lab result, which must therefore be accurate, comprehensive, unambiguous and timely. Particular sensitivity is required in the evaluation and communication of diseases known, or suspected to be, genetically based.
Neuropathology Medical Knowledge
During the course of training, the resident is expected to develop an understanding regarding the etiology, pathogenesis, differential diagnosis and treatment for neoplastic and non-neoplastic diseases of the central nervous system, as well as inborn and acquired disorders of the peripheral nervous system. It is expected that the resident master "textbook" knowledge in each of these broad areas and then keep up on primary literature particularly with regard to factors influencing optimal treatment and care of patients suffering from disorders of the central and peripheral nervous system.
Practice-Based Learning and Improvement
- The handling, processing and diagnosis of neoplastic and non-neoplastic brain and spinal cord biopsies: particular emphasis will be placed on acquiring facility with neuropathologic intraoperative consultation, including clinico-radiologic correlation, gross examination and selection of tissue for processing and the use and interpretation of both cytological (smear) and histologic (frozen section) preparations. Familiarity with important ancillary studies will be acquired, both during intraoperative consultations and at final sign out of these complex and challenging cases. Follow-up of these intraoperative consultations with examination of the completed case completes a recurring feedback loop leading to increased competence in this critical area of neuropathologic practice.
- The handling, processing and interpretation of peripheral nerve and muscle biopsies: this experience will enable the resident to appropriately triage and process fresh peripheral nerve and muscle biopsies, including preparing tissue for histochemical, immunohistochemical and ultrastructural and nerve teasing studies. Selection and interpretation of these special studies, in addition to routine sections of peripheral nerve and muscle, will be learned by the resident as he/she guides each case through appropriate diagnostic algorithms under the supervision of the attending neuropathologist.
- The handling, processing and interpretation of specimens derived from the eye and ocular adnexa: these range from skin, conjunctival and orbital biopsies to enucleation and orbital exenteration specimens. The resident will process and interpret these cases in order to acquire competence in diagnostic ophthalmic pathology.
- Residents will become competent in selecting areas of the central and peripheral nervous system for histologic examination based on careful study of the patient's medical/neurologic histology and gross findings.
- Residents will become competent in the field of post-mortem neuropathologic diagnosis. This builds upon the skills enumerated above.
- Residents will learn to harvest both CNS and PNS tissue, with the latter including performance of nerve and muscle biopsies at autopsy. Dissection and sampling of sural and motor nerves, muscles and ganglia will be performed at the time of the autopsy, as will the procurement of cerebrospinal fluid by lumbar or cisternal puncture. Similarly, procurement and processing of ocular tissues will be performed, as indicated.
Interpersonal and Communication
The resident should become competent and confident in guiding clinical colleagues when pathologic assessment becomes necessary in the optimal treatment of a patient. The resident should understand how to communicate information necessary for optimal operative intervention during the course of a procedure, providing relevant information in a concise and unambiguous fashion. At final pathologic sign-out, the judicious use of notes to convey important additional details and relevant negative information will be learned. An appreciation of which special cases require either telephone-related or even face-to-face communication will also be assimilated, as will knowledge of what constitutes inappropriate requests by clinicians.
The resident will develop an appreciation that his or her chosen discipline is one of service to those individuals unfortunate enough to require the services of a pathologist. The principles listed above regarding accuracy, clarity, timeliness and sensitivity are underscored, as is the importance of taking responsibility both for one's decisions in approaching each patient's case and for the well-being of the patient at every step of the evaluation and communication of the pathologic diagnosis.
Neuropathology Systems-Based Practice
The principles of providing maximally accurate information regarding each pathologic consultation without excessive removal of tissue extend to parsimonious use of ancillary studies in the rendering of a final diagnosis. Through developing awareness regarding the salient diagnostic and therapeutic decisions regarding the care of a patient, unnecessary and potentially confusing additional information will be avoided, as will undue financial strain both to the patient and to the system.
Neuropathology Rotation Duration
Autopsy training is integrated with the anatomic pathology rotation schedule and is conducted throughout the three years of training usually reserved for anatomic pathology. Approximately 30 percent of the anatomic pathology rotation is dedicated to autopsy pathology.
Duties and Responsibilities of Residents by Year
Training in surgical and autopsy neuropathology is integrated into the main anatomic pathology rotation. Residents are therefore actively trained in neuropathology throughout the duration of the first and third years of training.
Residents in their first year of neuropathology training are expected to concentrate on mastering the technical skills involved in processing surgical and autopsy tissues.
In the second year of training and beyond, residents are expected to take a more active role in the diagnosis of central nervous system pathology by bringing to sign-out a working diagnosis based on independent examination of anatomic materials. Before completing training, Residents should learn the proper methods to retrieve central nervous system tissue, including the brain, the spinal cord, and the spinal ganglia. Residents should also learn proper techniques for sampling muscle tissue for biopsy studies using the biopsy forceps.
Neuropathology Rotation Supervision and Evaluation
Patient care, medical knowledge, practice-based learning and improvement, communication skills, professionalism and system-based practices are verbally reinforced each time a clinical encounter is experienced by the resident. This takes place most often in the context of intra-operative consultations and at final sign-out of surgical neuropathologic cases.
Medical knowledge, communication skills and system-based practices are also evaluated within the context of Socratic case-based conferences. Written evaluations are completed every three months for residents actively involved with autopsy and surgical neuropathology, and an in-service exam is administered once per year.