Pathology Residency Program

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Pediatric and Perinatal Pathology Rotation

Pediatric and Perinatal Pathology Goals and Objectives

During pediatric and perinatal pathology training in the Anatomic and Clinical Pathology Residency Program, each resident will master the following skills:

Pediatric and Perinatal Pathology Patient Care Aspects

Appreciate the three major roles of the perinatal pathologist: immediate diagnosis for the care and treatment of the mother and infant, determination of the primary and secondary causes of perinatal morbidity and mortality and genetic counseling and prediction of recurrence risk
Learn appropriate forms of communication with parents and treating physicians
Learn to read and understand the pediatric intensive care unit and pediatric hospital charts
Read and understand obstetric and neonatal intensive care unit hospital charts
Understand appropriate manners of communication with parents and treating physicians
Understand the specific roles of pediatric pathology in the clinical practice of specific subspecialties

Pediatric and Perinatal Pathology Medical Knowledge

Have a working familiarity with the etiology, diagnosis and treatment of the following:

Chromosomal abnormalities: trisomies 13, 18, 21, monosomy X, triploidy
Conditions of neonatal period: neonatal/hypoxic-ischemic encephalopathy, intraventricular hemorrhage, newborn respiratory conditions, iatrogenic lesions, neonatal necrotizing enterocolitis, early onset neonatal sepsis and complications of prematurity
Diseases of pregnancy: gestational trophoblastic disease, spontaneous abortion, ectopic pregnancy, intrauterine fetal death, preterm birth, fetal growth restriction, preeclampsia, acute and chronic abruption, perinatal asphyxia, congenital infections (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis) and chorioamnionitis
Endocrine conditions: congenital adrenal hyperplasia, hyperinsulinemia, thyroid disease, calcium and bone disorders and intersex disorders
Gastrointestinal diseases: reflex esophagitis, Hirschsprung's disease, neonatal necrotizing enterocolitis, malabsorption syndromes, inflammatory bowel disease, infectious colitis and allergic disorders
Genitourinary diseases: reflux uropathy, undescended testes and herniorrhaphies
Hepatobiliary tract diseases: infantile cholestasis, autoimmune and drug-induced hepatitis and others
Immunologic disorders: AIDS, congenital immunodeficiency, autoimmune disease and asthma and allergy
Infections: pediatric AIDS, lymphadenitis, osteomyelitis, H. Pylori and infections of immunocompromised host
Major congenital malformations: hypoplastic left heart, ventricular septal defect, atrial septal defect, tetralogy of Fallot, truncus arteriosus, anomalous pulmonary venous return, endocardial cushion defects, patent ductus arteriosus, coarctation of aorta, Eisenmenger's syndrome, neural tube defects, hydrocephalus, Potter's syndrome and osteochondrodysplasias
Metabolic diseases: glycogen storage diseases, Wilson's disease, Niemann Pick, Gaucher, tyrosinemia, galactosemia, urea cycle enzyme deficiencies and fatty acid oxidation defects
Pediatric forensic pathology: sudden infant death syndrome, child abuse and child neglect
Pediatric tumors: "Small, round blue cell tumors" - neuroblastoma, primitive neuroectodermal tumor, intrabdominal desmoplastic round cell tumor; Renal tumors- Wilms' tumor, mesoblastic nephroma and others; Pediatric bone and soft tissue tumors- rhabdomyosarcoma, osteosarcoma, others; Germ cell tumors- yolk sac carcinoma, teratoma, Liver tumors- hepatoblastoma, hepatocellular carcinoma, others; Lymphomas including Hodgkin's disease; Childhood leukemias, pediatric brain tumors, histiocytic disorders-Langerhans cell histiocytosis, Rosai-Dorfman disease and others
Renal diseases: nephrotic syndrome, other glomerular diseases and cystic disease
Transplant pathology (liver, heart, bone marrow, kidney, lung): rejection, vascular problems and associated conditions

Practice-Based Learning and Improvement

Acquire and master the following skills:

Autopsy techniques for fetuses (fragmented or intact), stillbirths and neonatal deaths with or without congenital anomalies
Autopsy techniques for an older child with particular reference to congenital heart disease, malignancy, metabolic disease and infection
Gross and microscopic examination: spontaneous abortion and gestational trophoblastic disease, fetuses and newborns third-trimester placenta
Interpretation of pediatric clinical pathology tests including, metabolic disease screens, hemoglobin electrophoresis, flow cytometry of leukemia-lymphoma, cytogenetics of congenital anomalies and pediatric tumors, granulocyte function studies and pediatric blood transfusion
Interpretation of perinatal clinical pathology tests: amniotic fluid chemistry, Kleihauer-Betke test, maternal-fetal antibody testing, serology of infection and autoimmune disorders and blood gas interpretation
Normal histology: fetal, neonatal
Patient presentations: prepare and present interdepartmental conferences, prepare and present pathology grand rounds
Research: Identify areas of potential investigation, formulate methods appropriate to carry out a potential research project
Surgical gross room techniques for the evaluation of tumor resections, explant organs, organs removed for non-neoplastic disease, skin specimens, bone specimens, open lung biopsies, endomyocardial biopsies and rectal suction biopsies

Interpersonal and Communication Skills

Acquire a clinically relevant patient history from the treating physician
Compose a pertinent autopsy discussion clearly stating the primary and underlying causes of death
Discuss the diagnosis and interpretation of perinatal and pediatric surgical pathology, autopsy and frozen section cases with the treating physician
Present pediatric tumors and other cases at clinical management and M & M conferences

Professionalism

Admit, rectify and learn from mistakes
Appreciate the role of ancillary staff: pathology assistants, histology, transcription
Render and communicate diagnoses in a precise, unambiguous, and clinically responsive manner
Respond in a timely manner to all clinical questions
Triage and prioritize cases for which they are responsible

Pediatric and Perinatal Pathology Systems-Based Practice

Master all aspects of the anatomic and clinical pathology information systems
Use computers to access information from online databases
Use hospital information system to gather patient data

Pediatric and Perinatal Pathology Rotation Duration

Training in pediatric and perinatal pathology takes place throughout the AP curriculum, which is spread over years one, three and four. Residents receive specific pediatric and perinatal pathology instruction in each of the three components which make up the AP core. The total pediatric and perinatal pathology experience encompasses approximately 62 weeks of the 144-week AP curriculum.

Surgical Pathology and Frozen Sections: residents gross and sign-out pediatric and perinatal specimens one of every two days spent on this rotation. Pediatric and perinatal specimens consist of 15-20 percent of all surgical accessions at our hospital. Residents participate in the preparation and analysis of all pediatric intraoperative consultations (approximately five to 10 a week).

Residents are encouraged to become involved in the ongoing clinical and basic research projects of the pediatric and perinatal pathology staff and their collaborators from both the clinical and basic science departments of the hospital and medical school. Dedicated time may be devoted to projects during the third and fourth-year electives block.

Duties and Responsibilities of Residents by Year

Residents are initially trained by being paired with an experienced resident and then assume independence for their own cases. Residents assume graded responsibility, first as apprentices, then as practitioners and then as teachers and supervisors.

First-Year Residents

First-year residents are encouraged to concentrate on technical skills and to collaboratively sign their cases with the attending pathologists. Residents should be aware that pediatric and perinatal autopsy procedures differ in many ways from those used for adult autopsies. Special concerns, procedures and differential diagnoses differ with the age of the patient. The first-year resident should develop an appropriate approach to the fetal, newborn and child categories.

Senior (PGY3, PGY4) Residents

Senior residents are expected to bring autopsy cases for sign-out in essentially complete form, ready for approval by the attending pathologist. Autopsy techniques for patients of different ages should be mastered.

Perinatal and Pediatric Surgical Pathology and Intraoperative Consultations

The expectations for residents training in pediatric surgical pathology are divided into four levels of experience.

First Year Residents, First Six Months

General Skills

Demonstrate habits of punctuality and efficiency in the cutting and frozen section rooms
Develop competence in reporting information to and receiving information from clinicians whether in person or by telephone
Learn how to perform a good frozen section and touch preparation
Learn the location and contents of common sources of the major pediatric pathology textbooks and journals
Read and understand the Pediatric Pathology Resident's Manual and relevant sections of the Surgical Pathology and Autopsy Manuals

Gross Room Skills

Become competent at gross description of common specimens
Learn to section tissues thinly to allow adequate fixation
Learn to select, prepare and if necessary, fix tissues for various specialized laboratories, including cytogenetics, immunohistochemistry, flow cytometry and molecular diagnostics
Learn to use the gross photography equipment

Microscopic Skills

Become competent at microscopic description
Diagnose with relative confidence common placental and gastrointestinal lesions
Learn how to perform microscopic photography
Review and master normal histology
Understand the use of common special stains

Pediatric and Perinatal Pathology Teaching Skills

Participate actively in teaching medical students during pathology electives and in medical school pathology course (all four levels)
Recognize cases that may add to the existing base of knowledge in pediatric and perinatal pathology
Research skills

Pediatric and Perinatal Pathology Learning Skills

Show evidence of reading at the textbook and review article level

First-Year Residents, Second Six Months

General Skills

Begin to recognize and seek to correct specific deficits in one's fund of knowledge
Know when to seek advice

Gross Room Skills

Be able concisely to describe and perform the technique for cutting in most major specimens as described in the various resident manuals specified above
Take responsibility for the completeness of the information brought to sign-out including adequacy of histologic sampling, selection of special studies and formulation of a working diagnosis

Microscopic Skills

Competently formulate a differential diagnosis for most lesions
Demonstrate ability to use journal literature to solve diagnostic problems
Develop diagnostic skill with more difficult specimens, including pediatric tumors, pulmonary pathology, inflammatory bowel disease, common bone lesions, liver lesions unique to infants and children and lymphoproliferative diseases

Teaching Skills

Participate actively in conferences

Research Skills

Formulate methods that might be used to solve a research question
Identify areas in need of investigation

Learning Skills

Discuss most topics at the textbook level and review journal article level

Third-Year Residents

General Skills

To be a liaison between residents and faculty in case of problems/conflicts
To improve diagnostic acumen
To oversee the performance of other residents and students on service
To troubleshoot difficult logistical problems

Gross Room Skills

Able to gross in large specimens without direct supervision
Able to help supervise junior residents

Microscopic Skills

Able to diagnose most cases and be aware of limitations
Able to select appropriate areas for frozen sections
Correctly interpret many frozen sections

Teaching Skills

Become involved in the preparation of interdepartmental conferences
Prepare and present a case discussion for pathology grand rounds
Teach junior residents both gross and microscopic pathology

Research Skills

To become involved in studies with senior faculty members

Learning Skills

Aware of controversies in diagnostic pathology
Read and integrate the latest literature into day to day practice

Fourth-Year Residents

General Skills

Able to effectively supervise other residents effectively acting as "Chief Resident" if needed
Function essentially as a junior colleague of the faculty

Gross Room Skills

Able to gross virtually any specimen with little supervision

Microscopic Skills

Able to formulate a final diagnosis for most cases with limited supervision
Able to interpret most frozen sections
Able to supervise frozen sections

Teaching Skills

Functions as a general resource for all junior residents and rotating medical students

Research Skills

Present original work at local and national meetings

Learning Skills

Have acquired through reading a complete base of knowledge in pediatric and perinatal pathology

Administrative Skills

Able to help junior residents organize work and avoid mistakes and delays in sign-out

Resident Supervision and Evaluation

Each pediatric pathologist evaluates residents in the following manner:

Daily

Evaluation of medical knowledge and practice-based learning and improvement occurs at the time of microscopic sign-out in surgical pathology, formulation of the preliminary and final anatomic diagnoses in autopsy pathology, and performance and interpretation of frozen sections at the time of intraoperative consultation.

Evidence of progress in utilizing a systems-based approach to pathology practice is assessed by review of the resident's handling of specimens, interaction with the clinical staff and preparation of surgical and autopsy reports.

Monthly

Formal online evaluations of each resident (MyEvaluations system) addressing the following criteria:

Interpersonal and communication skills
Medical knowledge
Patient care
Practice-based learning and improvement
Professionalism
Research and scholarly activities
System-based practice

Yearly

Each resident's performance on the annual in-service examination is reviewed in detail.

Ad Hoc

Each resident will critique and modify case presentations and research projects.