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CLINICAL PATHOLOGY

CHEMISTRY
CLINICAL IMMUNOLOGY
CLINICAL MICROBIOLOGY AND VIROLOGY
FLOW CYTOMETRY
HEMATOPATHOLOGY
LAB MANAGEMENT AND INFORMATIONS SERVICES
MOLECULAR / CYTOGENETICS PATHOLOGY
TRANSFUSION MEDICINE
URINALYSIS AND BODY FLUID ANALYSIS

The resident will rotate through the various sections according to an individual plan prepared by the Residency Committee and the resident. Residents will develop substantial expertise in all aspects of sample acquisition, analysis and reporting. Residents are expected to master the basic principles and methodology of laboratory medicine as well as methods required to operate manual and automated equipment as well as problem solving in the clinical laboratory. The resident is instructed in quality control and assurance and may be required to develop a new test and evaluate its applicability to institutional needs.

An important aspect of all clinical pathology training, particularly that involving numeric data, is mastering of quality control procedures which are part of the quality assurance activities of the laboratories. As all the hospital training sites in the Program are inspected and accredited by the College of American Pathologists (CAP) Inspection and Accreditation Program, participation of the residents in the biannual accreditation of their own laboratories is required and their participation with senior pathologists in the evaluation of other laboratories within the CAP program is strongly encouraged.

Clinical Chemistry

3 months, Lifespan, MHRI, and WIH, required CP

Goals and Competencies:

1. Patient Care

a. The resident should be familiar with gathering essential and accurate clinical information about the patients, including:

  • Where applicable discussion of history with clinical house staff and/or attendings,
  • Review of laboratory reports of previous pathologic specimens
  • Review of the online medical record when applicable such as those provided by Cerner and Lifelinks.

b. Residents should be able to handle clinical questions with increasing degrees of independence including:

  • Researching and reviewing medical information.
  • Preparation and interpretation of Chem/Immunochemistry testing including cardiac markers, cancer markers, endocrine assays, vitamin assays, therapeutic drug monitoring, toxicology assays, serum protein electrophoreses.
  • Timely and effective communication with clinicians.

c. Residents demonstrate competence in the methodologies and performance of procedures considered essential for the understanding of all Chem/Immunochemistry assays performed, including:

  • Automated chemistry testing.
  • Interpretation of Chem/Immunochemistry tests.
  • Toxicology assays and therapeutic drug testing.
  • Cardiac and cancer markers.
  • Review of daily Q.C. and work center activity reports

d. Residents should be able to suggest to clinicians diagnostic workup including:

  • Consideration of specialized testing, etc. based on patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgement.

e. Residents should be able to use available information technology (hospital and laboratory information systems, internet-based literature searches)

  • To support workup and use Chem/Immuno chemistry assays for diagnostic purposes.
  • To help educate clinicians by providing relevant literature references.

f. Residents should be able to work with health care providers, in the generation of accurate and clinically useful Chem/Immunochemistry reports and effective communication of results to clinicians.

  • Residents should be able to demonstrate competency in handling practical problems related to laboratory operations and management through involvement with basic issues of laboratory management, such as evaluation of analytical instrumentation, laboratory staffing, cost accounting of a new analytical method relative to an older one, and new method evaluation for technical performance.

2. Medical Knowledge

a. Residents should be able to demonstrate an investigatory and analytical thinking approach to clinical situations, including:

  • Development of reasonable and complete differential diagnoses for Chem/Immuno cases based on the available clinical information, laboratory tests, and current published information.
  • As part of their workup of cases, suggesting appropriate additional testing (isoenzymes, immunofixation studies, and further clinical testing such as serology, etc.) if applicable.
  • encouragement to participate in at least one research project, such as clinicopathologic studies, or case reports with literature review.

b. Residents should be able to discuss the basic and clinically supportive sciences which are appropriate to the specialty of Chem/Immunochemistry testing, including:

  • Discussion of pathophysiology of various diseases, drugs metabolites, and metabolic disorders in the light of discussion of Chem/Immuno assays performed.
  • Discussion of basic statistical principles in order to analyze quality control and quality assurance data, to calculate normal ranges for new assays, and correlate methodology and instrumentation.
  • Explaining the clinical presentations and manifestations of various diseases during discussion of Chem/Immunochemistry testing performed.
  • Explaining the basic chemistry assays and instrumentation methodology, principles and applications.

3. Practice-Based Learning and Improvement

a. Residents should have the ability to analyze, practice experience and perform practice-based improvement activities using a systematic methodology, including:

  • Participating in Clinical Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, mislabeled/unlabeled specimens, clotted specimens, etc.)

b. Residents should have the ability to locate, appraise, and assimilate evidence from scientific studies related to patients’ health care problems, including:

  • Performing literature search and review to find relevant scientific references to aid in the workup of Chem/Immuno cases (computer-based searches).
  • Obtaining information about their patient population (via COPATH and computer searches and medical records chart review) for clinicopathologic study of selected diseases.

4. Interpersonal and Communication Skills

a. Residents should be able to demonstrate effective communication with other health care providers, patients by:

  • Presenting cases at in-house and conferences under direct faculty supervision.
  • Interacting with clinicians when providing support to clinicians during on-call assignments.

5. Professionalism

a. Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to confidentiality of patient information. Residents should be able to:

  • Demonstrate highest respect, compassion, and integrity and responsiveness to the needs of patients and professional staff with prompt response to calls from the clinical Chemistry lab, faculty and clinicians during their Chemistry and on-call rotations.
  • Exhibit a commitment to excellence and on-going professional development by reading of text books and journals for their own professional advancement.
  • Demonstrate appropriate behavior with the faculty, clinicians, their peers, and the administrative, technical and clerical staff of the hospital.
  • Systems-Based Practice

a. Residents must demonstrate an awareness 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.

  • Residents should become familiar with LIS “Cerner” for the review of complete chart, to track specimen status and during trouble shooting of a specimen.
  • Residents should become familiar with the use of LifeLinks to review all laboratory results, Pathology and Radiology findings.
  • Practice cost-effective health care and resource allocation that does not compromise quality of care, understanding the need for and cost of special studies, extended testing, and other send-out testing.
  • Residents may also inspect the section of Chem/Immunochemistry during a CAP inspection.

Faculty: D. Morris PhD, S. Latif PhD; J. Canick PhD, G. Messerlian PhD, J Murthy, PhD

Description: The clinical chemistry laboratory offers comprehensive training to residents in pathology. Thus, there is an opportunity for each resident to establish her/his own goals in consultation with the laboratory supervisors. The rotation consists of segments at individual hospital laboratories in the Brown system that have special expertise in particular areas of chemical pathology. Clinical pathology call by pager is a key component of this rotation and provides residents with the opportunity to act as clinical consultants. Daily participation in QA/QC activities is also a key component of this rotation that follows the following approximate schedule:

Segment 1 (at least 1 week)

introduction and training for CP call
review of physical and chemical principles
introduction to instrumentation
review of QC and statistical procedures
definition of normal and abnormal values

Segment 2 (2 weeks)

maintenance of homeostasis (renal, hepatic, electrolyte, pH)

Segment 3 (2 weeks)

endocrine biochemistry

Segment 4 (2 weeks)

chemistry laboratory results as indicators of disease in specific organs/tissues including
cardiovascular disease and neoplasia

Segment 5 (2 weeks)

toxicology

Segment 6 (1 week)

special procedures in prenatal, perinatal and neonatal clinical chemistry

Segment 7 (2 weeks)

laboratory organization and management

Residents are expected to gain a thorough knowledge of the organization of the clinical biochemistry laboratory and how it interfaces in both clinical areas and other sections of the Department of Laboratory Medicine. Residents should be aware of the kinds of material the laboratory handles and the sources of those samples. They will understand what constitutes a STAT specimen, a 'routine' specimen and a 'send-out' and on what grounds these categories have been established. They will become familiar with the equipment in the laboratory and understand the principles of their operation. In addition, they should become familiar with the principles underlying the operation of other types of major equipment that they are liable to encounter in other clinical laboratories. They will discuss the reasons for the choice of particular instruments with the clinical chemists.

Residents are expected to develop a working knowledge of the technical operations of the laboratory. The resident will learn the underlying principles of spectrophotometry so as to appreciate both why this is the most common analytical system and the limitations on its use. The resident will learn how both gamma and liquid scintillation counters operate and the statistical nature of counting process. They will become familiar with the basic principles underlying the numerous electrophoretic methods. The resident will become familiar with the theory of potential measurements and their application in combination with selective electrodes for measurement of blood gases, pH, and ions. They will learn the basis of ion measurements by means of flame emission and absorption instruments, specification electrodes and the reasons for the choice of instrument in particular cases.

Residents are expected to acquire an understanding of the chemistry and biochemistry underlying commonly performed clinical biochemistry measurements. The resident will become familiar with the most commonly used reagent systems. These are used on 'type cases' from which the reason underlying the application of a particular reaction may be studied and understood. The principles underlying the use of enzymatic methods and how coupled reactions are chosen and used are taught. The differences between end-point and kinetic methodologies should be studied. The resident will understand the principles of competitive binding studies and their application to RIA. The resident will use the literature and the daily laboratory work experience to become familiar with the mechanisms underlying common separation techniques including GLC, HPLC, and simple column chromatography.

Quality control and quality assurance in Chemical Pathology are emphasized in all aspects of the rotation. The resident will learn to calculate statistical parameters from data sets and how parameters are applied to quality control. From this s/he should be able to appreciate the meaning of the terms 'positive and negative predictive values', 'precision,' 'accuracy,' 'reproducibility,' and 'coefficient of variation.' In turn the application of these concepts to the choice and development of methods will be studied. Having understood the objectives in (a) the resident should then be able to appreciate the application of statistics to the ongoing control of the quality of laboratory output. By working with supervisors s/he should gain insight into the factors that enter the professional judgment regarding the quality and validity of the daily clinical service work.

Residents must also expand their knowledge of the clinical significance of chemical laboratory tests. The resident will become familiar with the derivation of the 'normal range' and the meaning of this expression in the laboratory as well as its application of clinical medicine. Because of the frequency with which 'profiles' appear in the clinical record, the residents will become familiar with the most commonly occurring test groupings which form profiles; the patterns which these show in specific diseases or organ dysfunction; and (relating back to (a) the relative significance of changes in single components in these profiles. The resident will begin to collect an individual database of those single tests that are most useful in the specific diagnosis of particular pathological processes. Comparisons between findings in the clinical chemistry laboratory and those in other sections of the laboratory, including anatomic pathology are made. Finally, the resident should become familiar with the clinical chemistry literature, particularly sources dealing with the interpretation of tests and those texts that deal adequately with the ever present problems of interferences and sources of error. Useful integration of the Chemistry Laboratory with the LIS and HIS will be emphasized.

In clinical biochemistry, specific procedures related to OB/GYN patients such as estriol determinations, amniotic fluid bilirubin scans, lecithin/sphingomyelin ratios, and phosphatidyl glycerol determinations are taught to evaluate fetal well-being. The microsample techniques are emphasized and differences in neonatal reference values are evaluated by the trainee. Rapid determination for bilirubin is stressed along with other tests for neonatal jaundice.

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations at the discretion of the medical director.The level of participation and responsibility is determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. Residents will also attend selected medicine morning reports to provide consultative services for medical residents.

Clinical Correlation: Clinical correlation is provided through consultation with clinicians and by comprehensive review of patient laboratory data and clinical history.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to take on a defined role in the collection and analysis of data including chart review.

Graduated Responsibility: Residents are expected to gain substantial technical expertise in the performance of routine and special chemistry testing. They will participate in clinical consultations at the discretion the medical director depending on their level of ability and documented responsibility.

Required Departmental Conferences: Daily Staff QA/QC conference; Departmental QA meeting

Required Interdepartmental Conferences: Medicine morning report as appropriate

Objective Evaluation: Written examination at the completion of the rotation in an essay format in response to specific topics in clinical chemistry.

Clinical Immunology

1 month, Lifespan, elective CP

Rotation Philosophy and General Purpose Statement:

The goal of Clinical Immunology is to enhance the resident’s knowledge of the performance, interpretation and use of immunology tests in evaluating patients with immunodeficiency, autoimmune and infectious diseases. The rotation will provide the resident with a set of tools to develop and maintain a level of expertise in clinical immunology appropriate to the professional responsibilities assumed as a practicing pathologist. Opportunities will be provided to become proficient through employing these tools in the immunology laboratory setting by:

  • Performing the laboratory procedures involved in the work-up and diagnosis of laboratory cases in order to practice clinical immunology with competence.
  • Demonstrating professional behavior regarding patients, other physicians and all clinical laboratory personnel.
  • Demonstrating a commitment to reviewing and improving clinical immunology practice patterns.
  • Discussing the scientific basis of clinical immunology and the ability to utilize the medical literature and modern techniques to provide accurate diagnoses.
  • Communicating effectively in verbal and written form with their clinical colleagues, administrative, technical, and clerical personnel.
  • Explaining the policies and regulations affecting health care (i.e., CAP accreditation, HIPAA,
  • compliance to Medicare and billing regulations, etc.)

Objectives:

A number of specific objectives support the overall goal. These objectives are presented below, organized by the general competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) and the Pathology Residency Review Committee (RRC) as expected of all residents.

Goals and Competencies:

1. Patient Care

The resident will demonstrate ability to:

a. Collect appropriate and accurate clinical information (Medical charts, Online medical records) (Cerner & LifeLinks )

b. Interpret immunology test results within the clinical context

c. Use clinical decision-making concepts and techniques in interpreting immunology results

d. Advise clinicians on the choice of clinically appropriate, cost-effective immunology tests

e. Advise clinicians on appropriate follow-up for unexpected test results

2. Medical Knowledge

The resident will demonstrate:

a. Knowledge in basic immunology so as to develop a scientific working skill in this complex area.

b. Knowledge of common clinical immunology tests and their medical application and correlation

c. Knowledge of the effects of disease, drugs, matrix and pre-analytical variables on immunology test results

d. Ability to collect and evaluate medical evidence regarding the utility of laboratory tests

e. Ability to use a variety of resources to investigate clinical questions

f. Development of a personal strategy to regularly maintain and update medical knowledge

3. Practice-Based Learning and Improvement

The resident will demonstrate:

a. Ongoing identification and remediation of gaps in personal medical knowledge

b. Understanding of and ability to apply the principles of quality control and quality assurance

c. Ability to evaluate current and proposed testing methods for analytical performance, clinical utility and cost-effectiveness

d. Use of proficiency-testing results to improve laboratory practice

e. Ability to use laboratory problems and clinical inquiries to identify process improvements that may minimize opportunities for medical errors

4. Interpersonal and Communication Skills

The resident will demonstrate:

a. Ability to communicate clearly and effectively with clinicians, medical technologists and other medical personnel

b. Ability to use appropriate modes of communication (direct, telephone, e-mail, written)

c. Ability to communicate clearly and effectively in written documents (including legible handwriting)

d. Ability to prepare and deliver effective presentations

5. Professionalism

The resident will demonstrate:

a. Knowledge and understanding of ethical and privacy issues affecting the clinical laboratory

b. Maintenance of confidentiality of patient information

c. Respectful behavior towards all patients, laboratory medical and staff personnel

d. Prompt and courteous response to all pager and telephone calls

e. Regular, punctual attendance and participation in rounds, conferences, meetings and rotation responsibilities

6. Systems-Based Practice

The resident will demonstrate:

a. Understanding of the role of the laboratory in the health care system, and the importance of reliable, cost-effective and timely laboratory results in clinical decision-making

b. Ability to work with clinicians, administrators and others to determine the role of the laboratory in specific situations to optimize patient outcomes

c. Understanding of CLIA, CAP, HIPAA and JCAHO requirements for clinical laboratories

d. Understanding of basic laboratory reimbursement mechanisms and regulatory requirements and compliance with Medicare/Medicaid rules

e. Ability to do cost analysis of laboratory tests

Faculty: A. Rifai

Description: The resident will have hands on experience with a variety of serologic tests and techniques. These may include serologic titration, immunodiffusion, latex agglutination, hemagglutination, enzyme linked colorimetric and luminescence immunoassays, direct and indirect immunofluorescence assays, serum and urine protein electrophoresis, immunofixation, and nephelometry. In addition, the resident will review 20 case studies in clinical immunology.

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations at the discretion of the medical director. The level of participation and responsibility is determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. SPEP and UPEP consultation are emphasized

Clinical Correlation: Clinical correlation is provided through direct consultation with physicians and the laboratory director.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to perform patient chart reviews in specific cases.

Graduated Responsibility: Residents are expected to gain some technical expertise in the performance of serologic testing. They will participate in clinical consultations with the medical director with increased resident input expected as the rotation progresses.

Required Departmental Conferences: Brown University Immunology and Pathobiology weekly seminar; Dept. Pathology Teaching and Research Rounds

Required Interdepartmental Conferences: none

Objective Evaluation: oral presentation and interpretation of immunology results

Clinical Microbiology and Virology

3 months total, Lifespan, MHRI, required CP

Goals and Competencies (first month in MHRI)

1. Medical Knowledge

a. Be familiar with different types of media and how they are used in planting cultures from various sources.

b. Have an understanding of methods and interpretation of antimicrobial susceptibility tests (AST).

c. Be able to categorize different types of bacteria based on their morphological appearance in the Gram stain.

d. Know how to recognize and work up potential pathogens isolated from different body sites.

e. Be familiar with blood culture methods, and the significance of positive blood cultures

f. Be familiar with biochemical methods used to identify potential pathogens

g. Know how to plant cultures to rule out tuberculosis, and to interpret Kinyoun-stained smears.

h. Have some knowledge of the morphology and clinical conditions associated with intestinal parasites.

2. Patient Care

a. Know how to correlate antimicrobial susceptibility test results with antibiotic treatment of patients

b. Be familiar with standards provided by the national committee on clinical laboratory standards

(NCCLS) and their use in setting guidelines for various aspects of laboratory procedures.

c. Be familiar with the pathology users’ manual, which is provided to all units to be used to order laboratory tests

d Become familiar with the format of reports provided to clinicians by the laboratory

3. Practice-Based Learning and Improvement

a. Attend conferences and seminars on relevant topics in microbiology.

b. Review patient charts to provide added patient history to aid in the interpretation of results and the diagnosis of infectious diseases.

c. Research unusual diagnoses by referring to current journal articles.

4. Interpersonal and Communication Skills

a. Recognize the need to immediately communicate “critical values” to physicians.

b. Show respect for patients and their families, as well as to other members of the health care team.

c. Communicate effectively with the medical staff, especially infectious disease physicians, and other personnel to transmit information relevant to patient care.

5. Professionalism

a. Maintain patient confidentiality at all times.

b. Follow the highest standards of professionalism and ethics.

c. Perform all assignments with diligence, accuracy and timeliness.

6. Systems-Based Practice

a. Use the password provided to search the laboratory information system (LIS) to access needed clinical data.

b. Understand the role of microbiology in the practice of medicine, especially in the area of infectious diseases.

c. Understand the use of the hospital based information system (CASI) in transmitting laboratory results from the laboratory information system (LIS) to units, for access by physicians on these units.

Faculty: K.Chapin, J.Heelan

Description: The rotation is divided into two portions with one month of virology at Lifespan and one month of microbiology at MHRI (general) and Lifespan (special). A detailed syllabus is in place for the rotation to direct resident learning. Competency based curriculum has been fully implemented in this rotation with defined objectives for the residents to complete and be certified in.

A major goal of training in Clinical Microbiology is to provide the resident with in depth familiarity with the techniques of culturing clinical pathogens. The resident is taught methodologies of planting cultures and will learn to compare and contrast the different kinds of culture media commonly used. Residents will learn to streak plates in an appropriate manner and will become familiar with the criteria for rejecting samples. S/he will be asked to describe the techniques for collecting various specimens and will be apprised of the advantage and limitations of each method. The correct performance and interpretation of gram stains is taught.

Residents are introduced to the techniques for the proper collection of blood cultures including clinical indications for ordering blood cultures and the proper time for drawing them. S/he will become familiar with the constituents found in the blood culture of bottles and the media used for primary isolation and growth of organisms. Familiarity with the common isolates, both anaerobic and aerobic, and their clinical significance is an important part of the program. Residents will learn to perform primary isolation from blood culture specimens.

An important part of the Program is to acquire skills in plate reading. The trainee is expected to become familiar with the major gram positive cocci, learning the reactions which differentiate them, and will also learn methods used for typing streptococci. The different tests used for speciating the gram negative cocci are taught. The trainee will also compare and contrast media used for the primary growth and identification of gram positive rods and will become familiar with the major staining characteristics of each of these microorganisms. Considerable emphasis is put on contrasting the different species of clinical pathogenic enterobacteria. Comparison of the various selective media used for identifying these organisms is considered in detail. The biochemical reactions that are used to discriminate the bacteria are covered including the API system for speciation and the Vitek identification/susceptibility system.

The resident will set up and learn to interpret correctly the Kirby-Bauer antimicrobial susceptibility method and will also become familiar with the determination of minimal inhibitory concentrations by manual and automated broth dilution. Special techniques used for speciating the non-fermenting gram negative rods are taught as well. The techniques of cultivating, recognizing morphology on gram stain, and colonial characteristics of an anaerobe isolate are taught. Current methods of performing susceptibilities on anaerobes are explored.

Understanding mycobacteriology techniques is an important part of the training program. Staining methods for acid-fast organisms are emphasized. The safety precautions necessary in running a mycobacteriology laboratory will also be emphasized. The resident will acquire familiarity with the different kinds of media used for isolating mycobacteria and with the digestion procedures used in processing specimens. The automated broth system for M. tuberculosis culture will also be included.

The basic principles of mycology are taught. Tests for the identification of the yeasts are stressed, including the principles underlying assimilation and fermentation tests. The resident will acquire familiarity with the various specialized media used for isolating fungi. The staining patterns and morphology of these microorganisms are stressed.

Processing and examination of stool specimens for parasites are emphasized and methods such as formalin-ethyl acetate sedimentation concentration techniques are taught. Methods used in preparing permanent mounts for microscopic examination, including iron hematoxylin trichrome techniques, are described. The resident will acquire familiarity with the "wet prep" technique as well.

Introduction in the principles of administration of a Microbiology Laboratory will involve familiarity with workload indexing and their relationship to laboratory productivity and budgeting. Methods of quality control, budgeting for the laboratory and the evaluation of the personnel are emphasized as well. The use of electronic data processing in microbiology lab will be taught.

The curriculum for Virology includes a review of the biological and structural characteristics of viruses including virus differentiation on the basis of nucleic acid type, size and shape as well as information related to virus replication. Also emphasized are clinical features of medically important virus infections and aspects of their epidemiology. Safety precautions related to the handling of infectious agents are emphasized including proper use of disinfectants and sterilization procedures.

The resident will learn how viral diagnoses are made using virus isolation procedures, serologic tests, and the cytopathic changes in infected cells. The successful isolation of viruses from clinical specimens depends largely on the proper collection, handling, processing, and storage of specimens. A clinical history and/or reference to suspected viruses assists in the selection of an appropriate testing system that enhances the success of pathogenic virus isolation.

Methods for virus isolation utilize mice, embryonated eggs, plaque assays, physicochemical characteristics of viruses, and various living cells. Various primary cell cultures and passaged cell lines are used because there is no single cell type that can be used for all virus isolation procedures. The resident will learn the tissue culture systems commonly used for each virus group as well as the cellular pathology induced by individual viruses. The resident will learn the basic requirements for growing cells and tissues in culture and should be able to follow a flow chart for the isolation and identification of viruses using accepted procedures and methods and be able to perform relevant tests.

The use of light microscopy and immunofluorescent methods as well as electron microscopy to identify viral cytopathic changes is emphasized. The resident will be taught the potential value of these techniques as part of the routine work-up of each specimen. The resident will be able to interpret test results and report results in a timely manner to his/her clinical colleagues in consultation.

Clinical Microbiology Schedule

Week

Topic

1

gram stain interpretation/specimen processing & plating

2

urine/genital culture

3

stool culture/susceptibility testing

4

bacteremia and sepsis

5

wound and body fluid culture

6

respiratory culture

7

mycobacteriology and parasitology

8

mycology

9

virology culture

10-11

virology practical exam

12

Infectious Disease

Specific Requirements:

Consultation: Once residents are familiar with basic laboratory procedures, they are expected to respond to inquiries for the laboratory. These typically include procedural questions as well as more complex issues related to the interpretation of test data and its impact on patient care. Residents will have direct, real time technical and professional backup from laboratory personnel on pager. Issues regarding call are reviewed with the laboratory director weekly. Residents attend infectious disease rounds in the afternoon.

Clinical Correlation: Clinical correlation is provided through direct consultation with physicians and the laboratory director. More structured clinical correlation occurs when the resident attends infectious disease rounds in the afternoon.

Quality Assurance: Residents are expected to participate in quality assurance and control procedures as they occur in the laboratory at the level of technicians and with the laboratory director.

Graduated Responsibility: As first year residents gain experience in the laboratory they are called upon to interpret increasingly complex tests and to respond to a greater volume of clinical inquiries.

Required Departmental Conferences: Laboratory Section Conferences

Required Interdepartmental Conferences: Infectious Disease Rounds, Lifespan; morning report (selected), MHRI

Objective Evaluation: Practical examinations in microbiology and virology; certification of competency based curriculum

Flow Cytometry

1 month, Lifespan, elective CP

Goals and Competencies:

1. Patient Care

a. The resident should review the order for flow cytometry on each case and assemble the patient history using information from the LIS and COPATH or speaking with the physician ordering the testing.

b. The resident should review present and past slides pertinent to the case and prepare a review of the past and present information.

c. The resident should prepare an outline of the flow cytometry testing to be performed.

d. By the end of the rotation the resident should be able to prepare a flow cytometry report detailing the support of a specific diagnosis or the need for further specific testing.

e. An exam is given at the end of the rotation consisting of three cases for which the resident completes all of the results and proposed signouts.

2. Medical Knowledge

a. The resident should have had a previous hematology rotation and be capable of reviewing the blood smear, bone marrow, lymph node, or body fluid morphology of the case.

b. By the end of the rotation the resident should be able to integrate the morphology, and cytochemical results if performed, with the flow cytometry results.

c. By the end of the rotation the resident should understand the role of flow cytometry, the use of the many specific antibodies, and the limitations of flow cytometry as they apply to a specific case

3. Practice-Based Learning and Improvement

a. By use of the manual provided for the rotation and participation with the technologists the resident should understand the principles of flow cytometry, the design and operation of the flow cytometer and the quality controls necessary to assure correct performance.

b. The resident should become progressively familiar with the use of specific antibodies and the gating strategies used for specific flow cytometry cases.

c. The resident will learn to interpret the flow cytometry histograms and how to prepare a flow cytometry report.

d. During the rotation the resident should become familiar with the flow cytometry of T cell panels, flow panels designed for lymph node analysis, peripheral blood and bone marrow lymphocytosis analysis, acute leukemia analysis at presentation and the analysis for minimal residual disease, as well the workup of cases for PNH and granulocyte associated antibody.

4. Interpersonal and Communication Skills

a. The resident should learn to communicate effectively with the clinical staff to gather and transmit information concerning current flow cytometry cases.

b. The resident should communicate with the pathology staff and participate in sign outs of blood, bone marrow, and lymph node cases which have flow cytometry.

c. The resident should have a good working relationship with the staff on the flow cytometry laboratory.

5. Professionalism

a. The resident must maintain patient confidentiality at all times.

b. The resident should maintain a high standard of professionalism and ethics.

c. The resident must perform all assignments in a timely manner and feel free to consult others if there are doubts about testing result

6. Systems-Based Practice

a. The resident must be capable to using all the available informations systems to obtain clinical data pertaining to the patient.

b. It is expected that the resident will make use of the library information system to research reports pertinent to the patient cases.

Faculty: B. Barker

Description: Residents are expected to gain a detailed understanding of flow cytometry for phenotypic analysis of hematopathology cases and DNA ploidy and S phase fraction by flow cytometry. manuals are provided containing pertinent articles in all aspects of hemic flow cytometry. Residents will become familiar with the working principles and quality control in flow cytometry. They must understand the theoretical and practical aspects of these procedures in detail and be able to competently analyze the results of routine analyses to produce a coherent and useful clinical report. The rotation is a mixture of hands on experience and correlation with hematopathology and surgical pathology data. Residents will participate in the evaluation, work up, and interpretation of cases.

Flow Cytometry Syllabus

Day

Assignment

1

read

Instrumentation I; introduction, lasers, fluorochromes, filters

2

read

Instrumentation II; basic elements of flow cytometry operation principles

3

read

Instrumentation III; clinical flow cytometry instrumentation

4

read

Immunology I; flow cytometry

5

read

Immunology II; CD classification

6

read

Immunology III; cell surface immunofluorescence

7

read

Quality Control; introduction, gating

8

read

Gating I; strategy

9

read

Gating II; CD45 and light scatter

10

read

Leukocyte analysis

11

read

HIV flow cytometry

12

read

Clinical Flow cytometry; distinguishing benign and malignant populations

13

read

Bone Marrow Analysis

14

read

Leukemia

15

read

Lymphoma

16-20

read

DNA Analysis

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations with hematopathology and surgical pathology faculty regarding cases analyzed in the laboratory.

Clinical Correlation: Clinical correlation is provided through examination of bone marrow and lymph node morphology.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to take on a defined role in the collection and analysis of data including chart review.

Graduated Responsibility: Residents are expected to gain significant technical expertise in the performance of flow cytometry and to be able to communicate and apply these results effectively in clinical situations.

Required Departmental Conferences: Section Conferences for Medical Technologists; Heme/Onc Pathology Conference

Required Interdepartmental Conferences: none

Objective Evaluation: Practical exam based on the interpretation of flow cytometry results with clinical correlation.


Hematopathology

3 months, Lifespan, required CP

Goals and Competencies

1. Medical Knowledge

a. Residents acquire medical knowledge in a graduated manner in the following areas: blood smear, bone marrow, abnormal hemoglobins, lymph node pathology, coagulation, special studies, preliminary knowledge of interpretation of immunophenotypes and automated hematology.

b. Multiple teaching tools are used that include the following: structured learning with study sets, unstructured learning during case sign outs with the attending, video tapes, computer assisted learning, and interpretive reports.

c. Exams are given to assure competence. Practical exams are given in interpretation of blood smears, bone marrows, lymph nodes, hemoglobin electrophoresis and coagulation studies. A didactic exam covers erythropoiesis and erythrocyte abnormalities.

2. Patient Care

a. Under supervision, residents sign out blood smears, special studies (PNH, granulocyte associated immunoglobulin, EMA, osmotic fragility), hemoglobin electrophoreses, coagulation profiles, bone marrow aspirates, bone marrow biopsies, cytochemical and immunohistochemical studies.

b. They also have direct patient contact and perform 10 bone marrow aspirates and 10 bone marrow biopsies under the supervision of a Hematologist or Oncologist.

c. Residents prepare and present cases for the Cancer Tumor Board, weekly. In addition, they participate in a monthly conference for Hematology/Oncology Fellows.

3. Practice-Based Learning and Improvement

a. Residents sign out cases within the context and time constraints of medical necessity.

b. They also respond to medical technologists to resolve technical and interpretative laboratory problems.

c. Residents research the literature involving consultations.

4. Interpersonal and Communication Skills

a. Residents discuss each of their cases with the ordering clinicians. During this exchange the resident’s pathologic findings are transmitted to the clinician and unanswered questions are discussed and resolved. If necessary, additional studies are ordered.

b. At times Hematology/Oncology Fellows rotate with the Pathology resident. The Hematology/Oncology Fellow is able to impart his medical specialty expertise to the Pathology resident, who imparts his specialty skills in a reciprocal manner.

c. If a junior resident is also rotating, the senior resident takes an active role in teaching and guidance.

d. Communication also takes place daily with the technical and secretarial staff. During this association, residents learn the importance of the teamwork and begin to understand the perspectives of paramedical personnel.

5. Professionalism

a. Residents develop an appreciation of the medical process through their contact with patients (e.g. when performing BM aspirates/biopsies), clinicians, medical technologists, nurses, attending physicians, medical students and administrators. Attending physicians may become role models.

b. Residents are mentored to respect and understand the feelings and dynamics of others, to adhere to departmental rules regarding confidentiality and communicate with discretion.

c. In conferences, they learn the process of presenting cases in a professional manner which includes polite concise discussion, the importance of preparation and acknowledging the efforts of other members of the team.

6. Systems-Based Practice

a. The resident develops knowledge of the hospital and departmental information systems, applying these tools to Hematology assignments. Rather than sign out a case with incomplete clinical information, the resident is expected to go to “Life-Links” to read the patient’s history, physical, laboratory and radiologic data.

b. When consulting with clinicians, the resident is expected to be cognizant of the economic impact of his recommendations as it pertains to the patient and hospital system.

c. The resident may be included in discussions of acquiring new instrumentation. The analysis of costs, methodologic advances or deficiencies, through put time, and compatibility with other systems.

d. The resident may also participate in government mandated inspections, gaining an appreciation of today’s regulatory environment.

Faculty: R. Griffith, D.Treaba

Description: Residents will interpret peripheral blood smears and correlate them with the clinical findings. Interpret bone marrow specimens: biopsy, clot and smear and correlate the findings with the clinical diagnosis, peripheral blood smear and other laboratory data (serum iron, TIBC, B12, folate, immunoelectrophoresis, etc.). Residents will learn to interpret coagulation profiles, considering the clinical diagnosis, previous therapy and any additional relevant laboratory data. They will be able to perform other tests done in the Section and be familiar with the theory behind the meaning of the obtained data. They will become familiar with cytochemical, immunochemical, and flow cytometry procedures on peripheral blood and bone marrow cells especially for the diagnosis and classification of leukemia, lymphoma and other proliferative diseases of the hematopoietic system. Residents should be familiar with the principles of operation of instruments used in the Section, including blood cell counters, coagulation equipment, etc., and understand the theory of their operation and the commonly encountered causes of error. Learn the principles of quality control and the more specific special methodology used in Hematology and Coagulation. Residents should become familiar with cytogenetics and chromosomal changes as they relate to neoplastic and preneoplastic blood diseases. Hemoglobin electrophoresis and its interpretation are emphasized.

Residents are expected to become familiar with the differences in normal values of hematologic data of newborns, children, and adults and the incidence and presentation of hematologic diseases in different age groups. They should become familiar with the contents of the sections procedure manual, become familiar with the description of each test, their common pitfalls and the interpretation of the results obtained. Correlation of tissue or cytologic examinations of patients with hematologic disorders with a blood examination will be carried out whenever possible with the surgical pathology, cytopathology, and autopsy services. The resident will also participate in clinical rounds of the Section of Clinical Hematology and will correlate the patients' clinical findings with the hematologic laboratory tests.

Residents are exposed to lymph node biopsies and other surgical pathology specimens in which hematopoietic pathology is present or suspected. Coordinated use of light microscopy and ancillary studies (flow cytometry, molecular diagnostics, cytogenetics, immunohistochemistry) will be emphasized. Basic understanding of the diagnosis, staging and treatment of lymphoma will be expected of all residents. Residents are typically asked to prepare a differential diagnosis and indicate needed ancillary studies after review of clinical history and light microscopy. Residents must develop a thoughtful and logical approach to the work up of complex biopsies. The curriculum and degree of expertise achieved are adjusted for the resident's level of training in anatomic pathology. Residents will also be exposed to and expected to acquire specimens by performing iliac crest biopsies and aspirations under clinical supervision.

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations at the discretion of the medical directors. The level of participation and responsibility are determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. Residents will also attend Hematology/Oncology rounds to provide consultative services relevant to hematopathology.

Clinical Correlation: Clinical correlation is provided through interaction with physicians and the laboratory director. Structured clinical correlation occurs when the resident attends hematology/oncology rounds.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to take on a defined role in the collection and analysis of data including chart review.

Graduated Responsibility: Residents are expected to gain substantial technical expertise in the evaluation of peripheral blood and bone marrow samples. After their competence has been demonstrated, they will do differential counts of blood and aspirate smears for inclusion in patient reports. They will participate in clinical consultations at the discretion the medical director depending on their level of ability and documented responsibility.

Required Departmental Conferences: Section Conferences for Medical Technologists; Heme/Onc Pathology Conference

Required Interdepartmental Conferences: Lifespan Hematology/Oncology rounds as appropriate, Lifespan Tumor Board when hematopathology cases are presented

Objective Evaluation: Practical examinations in peripheral blood smears, bone marrow aspirates, bone marrow biopsies, lymph node biopsies with written responses including differential counts as appropriate. Written and practical coagulation examinations.

Lab Management and Laboratory Information System (LIS)

1 month, Lifespan, WIH, MHRI, required CP

Goals and Competencies

1. Medical Knowledge

By the end of this one-month rotation, the resident should:

  • Understand the basic elements of management.
  • Understand the basic elements of budgeting.
  • Understand the basic elements of coding, billing and reimbursement.
  • Be familiar with the Model Compliance Plan for Clinical Laboratories
  • Be familiar with Medical Necessity and Advance Beneficiary Notice.
  • Understand the basic elements of Laboratory Information System:

Hardware, operating system, application software, interface networks (intra and internet) HL7 and LOINC.

  • Understand the basic elements of Laboratory Automation and Autoverification.
  • Be familiar with laboratory safety (OSHA-CAP).
  • Have in depth knowledge of federal regulations (CLIA-88).
  • Understand the basic elements of 6 Sigma metrics and Lean methodology.

2. Patient Care

  • Evaluation of Patient Safety, Sentinel Event and Root Cause Analysis.
  • Evaluation of Critical Values.
  • Evaluation of Specimen Rejection Policy.

3. Practice-Based Learning

  • Attend meetings relevant to management.
  • Participate in a Laboratory Accreditation inspection (if possible).
  • Review Quality Control records.
  • Evaluate Proficiency Testing results.
  • Evaluate Quality Assurance reports.

4. Communication and Interpretation Skills

  • Communicate effectively with the medical staff and other personnel to transmit information relevant to patient care

5. Professionalism

  • Maintain patient confidentiality at all times.
  • Follow the highest standards of professionalism and ethics.
  • Perform all assignments with diligence, accuracy and timeliness.

6. System-Based Practice

1. Understand the role of management in the practice of Pathology and Laboratory Medicine, especially in the area of patient safety.

2. Understand the use of 6 Sigma to improve the quality of care.

3. Understand the use of root-cause analysis in improving patient care.

Faculty: N. Kessimian (MHRI), G. Wexler (TMH), S. Smeal (TMH), J. Michaels (WIH)

Residents work in an independent manner through much of the rotation with required reading assignments and various projects. This course manual provides the resident with required readings and project instructions. Throughout the rotation, the resident will be required to set up appointments with specific contact people who possess particular expertise in the various facets of laboratory information systems and laboratory management. These same people will act as mentors and overseers of the various small projects that are assigned. Residents are asked to read the required reading assignments prior to setting up appointments and meeting with the mentors.

Project 1- Laboratory/Hospital Information Systems

This project needs to be started as early as possible within the first few days of the rotation. Residents will set up an appointment to meet with Gloria Wexler (ext. 3-4260) at The Miriam Hospital to discuss a basic overview of the laboratory/hospital information systems that are in place in today’s hospitals. During this meeting the resident will choose one to two current implementation projects that are taking place within The Miriam Hospital or Rhode Island Hospital. In order to familiarize themselves with the chosen project(s), the resident will obtain the meeting schedule and any recent meeting minutes for this project from Gloria Wexler. The resident will attend the meetings for this project throughout the month and will prepare a short summary of the implementation project and the various issues that were brought up at the meetings. This assignment will be presented to Gloria Wexler at the end of the month.

Project 2- Laboratory Information Flow Sheet

The resident will arrange to meet with Steve Smeal (ext. 3-4202) at The Miriam Hospital. This short project is designed to provide residents with a basic understanding of the flow of information that occurs from the patient samples to the hospital computer systems that then becomes accessible to appropriate health care workers. The resident will construct a flow chart illustrating the manner in which information flows from a simple CBC order to the hospital computer system.

Project 3- Laboratory Regulations

After a review of the required readings (including internet sites) under the topic of “laboratory management (LM)- regulations”, the resident will schedule an appointment to meet with Dr. Kessimian (phone # 729-2393) at Memorial Hospital to discuss various facets of laboratory regulations.

Project 4- Laboratory Management- Business and Finances

The resident will set up a meeting with Joe Michaels (phone # 274-1171) at Woman & Infants’ Hospital. Various topics of laboratory business management will be discussed. Under the guidance of Joe Michaels, a cost analysis project, focusing on a particular piece of laboratory equipment will be completed.

Project 5- Laboratory Organization and Operations

The resident will again meet with Steve Smeal (or incorporate this into your meeting for “project 2”). The resident will construct a chart that illustrates the basic setup of The Miriam Hospital Chemistry lab (the different stations and their functions).

Required Readings:

  1. LIS: Chapter 4 in: Laboratory Information Systems in McClatchey, KD. Clinical Laboratory Medicine. p.97-113 (photocopy provided in course binder)
  2. Laboratory Management:
  3. Organization & Operations
  4. Chapter 1 in: Henry, JB. Clinical Diagnosis and Management by Laboratory Methods. p. 3-12 (photocopy provided in course binder)
  5. Business & Finance
  6. Chapter 1 in: Henry, JB. Clinical Diagnosis and Management by Laboratory Methods. p. 36-49 (photocopy provided in course binder)
  7. Laboratory Regulations
  8. Chapter 2 in: Henry, JB. Clinical Diagnosis and Management by Laboratory Methods. p.50-59 (photocopy provided in course binder)
  9. Internet Sites:
  10. http://www.fda.gov/cdrh/clia/
  11. http://www.vh.org/Providers/CME/CLIA/Introduction.html (History of CLIA section)
  12. http://www.cms.hhs.gov/clia/

http://www.clianet.org/

Specific Requirements:

Consultation: not applicable

Clinical Correlation: not applicable

Quality Assurance: Residents are expected to gain a detailed understanding of LIS quality assurance and of how the LIS can be used to manage, prepare, and analyze QA and QC data in different laboratories.

Graduated Responsibility: Residents are expected to gain substantial understanding of the LIS.

Required Departmental Conferences: LIS implementation conferences

Required Interdepartmental Conferences: none

Objective Evaluation: Projects assigned within in each subsection.

Molecular/Cytogenetics Pathology

1 month, Lifespan (3 weeks) and WIH (1week), required CP

Molecular Pathology and Cytogenetics are growing divisions within the Department of Pathology. In the 1 month required rotation, each resident trainee receives exposure to all aspects of molecular genetic pathology including infectious diseases, hematopathology, oncology, and medical genetics. Some molecular pathogen detection and quantitation such as HIV viral loads are performed in the Microbiology laboratory and instruction in that area of molecular pathology occurs within the Microbiology rotation. Residents receive exposure to all tests performed in the cytogenetic and molecular pathology laboratories with emphasis on the clinical relevance, molecular biologic principles, interpretation and quality control. The depth of exposure will depend on the prior experience of individual residents and the expectations are adjusted accordingly. In addition, residents have the option to spend elective time in molecular pathology and carry out research or other projects. The rotation stresses the teaching of fundamental concepts in the design and execution of molecular diagnostic testing as well as the medical relevance.

Goals and Competencies

1. Patient Care

a. Resident must be knowledgeable and be able to discuss the collection and proper preparation of specimens for cytogenetic and molecular tests including the appropriate specimen type for each type of test.

b. Resident must be able to explain the information obtained by cytogenetic and molecular tests

including supplying relevant references to clinicians for educational purposes.

c. Resident must be able to make decisions regarding the workup of genetic specimens including any additional testing that might be required.

d. Resident must be able to interpret molecular genetic laboratory results and correlate results with patient information including the review of the online medical record when appropriate.

2. Medical Knowledge

a. Resident must understand the basic concepts underlying the scientific basis of genetics. The principles of molecular biology and the gene or organism involved in each test must be understood.

b. Resident must understand the nomenclature used in molecular genetics including the nomenclature used in describing cytogenetic abnormalities.

c. Resident must be able to identify chromosomes using banding techniques and fluorescent in situ hybridization (FISH).

d. Resident must be able to use available information technology including hospital-based resources such as the laboratory information system and Internet resources such as NCBI, OMIM, Gene Tests and AMP test directory.

3. Practice-Based Learning and Improvement

a. Resident must be competent in the procedures involved in karyotyping including the culture and harvesting of chromosomes, the banding and analysis of a karyotype.

b. Resident must be able to perform and interpret a digital karyotype.

c. Resident must be familiar with the procedures for FISH and the interpretation of the results.

d. Resident must be competent in the basic procedures performed in the molecular pathology laboratory including DNA isolation from blood, paraffin blocks and other specimens, setup and running of PCR and invader reactions, Southern hybridization, agarose and acrylamide gels, interpretation and documentation of results. Residents will review laboratory procedure manuals and carry out representative assays using patient material.

e. For surgical specimens residents are encouraged to participate in the sign out of the case with the pathologist. For residents with experience in hematopathology, integration of molecular findings with histology, flow cytometry, and IHC is expected.

f. Resident must be familiar with the procedure involved in test development (a mandatory project will be assigned to each resident at the outset of the rotation; a brief written report is required); possible projects include:

  • Research and identify new tests to bring on-line.
  • Technical development of new test ("home-brew" or commercial kit).
  • Validation of new test.
  • Participate in on-going translational research project.
  • Develop control nuclei acids (e.g., clone mutant alleles).

g. Resident must be understand the limitations of cytogenetic and molecular testing and be familiar with all of the quality control procedures.

4. Interpersonal and Communication Skills

a. Residents must be able to communicate effectively with clinicians and staff at physicians offices concerning questions related to molecular genetic testing.

b. Residents must be able to communicate effectively with laboratory personnel including technologists, managers and students.

c. Residents must be able to interact effectively with pathologists in the department regarding clinical cases.

d. Residents should develop the ability to present molecular genetic cases at clinical conferences as required.

5. Professionalism

a. Resident must demonstrate a commitment to carrying out his/her professional responsibilities with the highest ethical standards.

b. Residents must demonstrate an understanding of HIPAA regulations pertaining to patient privacy.

c. Resident must demonstrate a commitment to excellence and professional development by consulting additional resources relevant to the clinical cases.

6. Systems-Based Practice

a. Resident must understand how genetic diagnoses affect the health care for individual patients and the healthcare system in general.

b. Resident should be cognizant of the impact of a molecular genetic result as it relates to the individual patient as well as the hospital system.

c. Resident may be involved in the discussions regarding new technologies or instrumentation. This may involve a cost analysis, comparison of methodologies, time and effort analysis and throughput time.

d. Resident may participate in a CAP inspection of a cytogenetics or molecular laboratory.

Faculty: C. Jackson, U. Tantravahi

Molecular Pathology

Description: Residents are introduced to Diagnostic Molecular Pathology. Applications in oncology (Lifespan) and genetic disease (WIH) are emphasized with exposure to topics in microbiology. The rotation content is spelled out in a daily syllabus including readings, problems, tasks, and evaluations. The depth of exposure will depend on the prior experience of individual residents and the expectations are adjusted accordingly. Approximately half of residents taking the rotation have minimal knowledge in molecular biology and half have quite detailed knowledge and experience, many at the PhD level. Curriculum is adjusted based on these factors but quality assurance and clinical correlation and consequences are emphasized to all. Residents are expected to complete a PCR assay and develop some technical competence in the performance of tests but the emphasis is on test interpretation and clinical correlation. For residents with experience in hematopathology, integration of molecular findings with histology, flow cytometry, and IHC are expected and emphasized.

The core curriculum is defined by the daily syllabus and includes:

basic molecular biology
DNA isolation including paraffin tissue blocks, tissue, blood, etc.
Southern hybridization theory and practice
polymerase chain reaction theory and practice
PCR applications in hematopathology
PCR applications in infectious disease
PCR applications in genetic disease
quality assurance/control in molecular pathology

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations at the discretion of the medical director. The level of participation and responsibility are determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. Residents will also attend selected medicine morning reports to provide consultative services for medical residents.

Clinical Correlation: Clinical correlation is provided through direct consultation with the laboratory director and by examination of other relevant patient laboratory data and surgical and cytopathology specimens.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to evaluate patient data in specific cases.

Graduated Responsibility: Residents are expected to gain some technical expertise in the performance of molecular testing. They will participate in clinical consultations with the medical director with more resident input expected as the rotation progresses.

Required Departmental Conferences: none

Required Interdepartmental Conferences: none

Objective Evaluation: Practical exam based on the interpretation of PCR gels and Southern blots with clinical correlation.

Cytogenetics

Description: The one month rotation is intended as an introduction to cytogenetics. Residents are expected to gain a detailed understanding of the role and utility of cytogenetics in the diagnosis of genetic diseases and in the characterization of human tumors. ). Residents should understand the sample requirements for successful cytogenetic analysis and the appropriate clinical indications for each type of testing. They should understand the relationship of classical cytogenetic testing with fish and related molecular testing (e.g. Philadelphia chromosome by classical cytogenetics, fish, and bcr-abl rt-pcr) and the relative advantages and disadvantages of each technology. Residents will become familiar with routine quality control and quality assurance issues in the laboratory including those related to cell culture. The resident will perform cytogenetic analysis with the assembly of a karyotype during their rotation but they are not expected to become expert in the preparation and analysis of karyotypes which is beyond the scope of a one month rotation. At WIH, emphasis will be placed on understanding the importance of chromosome abnormalities in the prenatal setting, turnaround time, aneuploidy screening of uncultured amniotic fluid cells and follow-up by full cytogenetic analysis. Residents are expected to provide detailed and understandable interpretation of cytogenetic reports for clinicians.

Specific Requirements:

Consultation: Residents are expected to be present during clinical consultations when possible but are not expected to function autonomously due to the introductory nature of the rotation.

Clinical Correlation: Clinical correlation is provided through direct interactions with the laboratory director and from review of other pertinent laboratory data from affected patients.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory.

Graduated Responsibility: Residents are expected to gain some technical expertise in the one month rotation but are not expected to function independently due to the introductory nature of the rotation.

Required Departmental Conferences: Educational Conference (WIH, bimonthly)

Required Interdepartmental Conferences: none

Objective Evaluation: Written examination, unknown karyotype or completion of a short project.

Transfusion Medicine

3 months, Lifespan, RI Blood Center, required CP

Goal and Competencies

1. Patient Care

a. The resident must participate and observe the collection and labeling of blood bank specimens; observe and perform routine and special immunohematology procedures: observe clerical procedures, blood and component storage requirements, selection of ABO compatible blood, plasma and platelets, observe and perform tests for incompatibility; observe inventory management of blood and blood component, observe issue of blood, plasma and platelets for transfusion; quality control (QC) procedures for equipment and reagents and handling of reagents; observe preparation of washed red cells, pooled platelets and cryoprecipitates and the administration of blood products.

b. By the end of the rotation, the resident should be familiar with the clinical indications, doses and appropriate laboratory monitoring for all therapeutic blood products.

c. By the end of the rotation, the resident should be familiar with the clinical indications for, and operation of plasma and cellular apheresis procedures.

2. Medical Knowledge

a. By the end of the rotation, the resident should be familiar with the etiology and mechanisms of anemia, compatibility testing and treatment with red cell products and the composition of these products.

b. By the end of the rotation, the resident should be familiar with the etiology and mechanisms of thrombocytopenia, the role of platelet transfusion and composition of platelet products and understand the laboratory and therapeutic approach to a platelet transfusion refractory patient.

c. By the end of the rotation, the resident should be familiar with the etiology and mechanisms of common coagulopathies, understand their laboratory evaluation and treatment with plasma or cryoprecipitate and the composition of plasma products and cryoprecipitate.

d. By the end of the rotation, the resident will understand the major blood groups systems in red cells and platelet s and the processes of compatibility testing.

3. Practice-Based Learning and Improvement

Attend daily coagulation sign-out, weekly hematology grand rounds and Medicine morning report when appropriate.

Research difficult cases prior to daily sign-out.

Gain confidence in independently formulating immuno-hematologic and coagulation diagnoses.

4. Interpersonal and Communication Skills

a. The resident should learn to communicate effectively with the clinical medical staff and other personnel both to gather and to transmit information relevant to patient care.

b. The resident should learn to communicate effectively with the pathology staff concerning the science and art of pathology and medicine, and concerning individual cases, keeping in mind that the staff pathologist will often depend on the resident for complete and accurate clinical information.

c. Politeness, discretion, and honesty are paramount in preserving a positive working relationship among professionals.

5. Professionalism

a. The resident must follow the highest standards of professionalism and ethics.

b. Show respect for patients and their families as well as members of the health care team in his own department as well as in other medical departments.

c. Strictest adherence to patient confidentiality with attention to names on samples and paperwork as well as discussion of cases in private areas.

d. When in doubt about a particular work assignment, consult the attending.

e. Perform all work assignments with diligence, accuracy and timeliness.

6. Systems-Based Practice

a. Become familiar with Blood bank software with particular attention to its built-in safety features for error trapping.

b. Become familiar with the basics of bar-code technology and its application to patient, product and sample identification.

c. Understand the role of Transfusion Medicine in the practice of medicine and attend clinico-pathologic conferences.

Faculty: J. Sweeney, J. Kurtis, C. Young, and the MD Lifespan and RI Blood Center Staff

Description: The rotation includes experience at Lifespan and the Rhode Island Blood Center. The core aspects of the rotation are coordinated at The Miriam Hospital Blood Bank. Residents complete a detailed syllabus and sign off on the completion of specific procedures and areas of competence in Transfusion Medicine. The major topics included are:

Lifespan
basic transfusion service issues
specialized blood products
therapeutic apheresis
autologous blood
stem cell
guidelines for transfusion including utilization review and regulatory issues
transfusion service informatics
quality assurance and quality control
Rhode Island Blood Center
donor recruitment, screening, care and record keeping
blood component preparation
apheresis donation
inventory and shipping of blood products
HLA testing reference testing

Residents will observe the collection and labeling of blood bank specimens; observe and perform routine and special procedures: observe inventory management of blood and blood component, observe clerical procedures, blood and component storage requirements, selection of ABO compatible blood, plasma and platelets, observe and perform tests for incompatibility; observe issue of blood, plasma and platelets for transfusion; quality control (QC) procedures for equipment and reagents and handling of reagents; observe preparation of washed red cells, pooled platelets and cryoprecipitates.

Residents will perform and grade serological reactions, using reagents according to manufacturers' directions; ABO and Rh testing; compatibility testing and clerical procedures associated with tests performed. Residents will perform tests to detect and identify unexpected antibodies in serum and/or on the red cells, perform additional tests to confirm antibody specificity and select donor units that are expected to be compatible with the recipient.

Residents will observe the technique of starting a transfusion, review clinical laboratory data on transfused patients and four platelet recipients and all patients with reported transfusion reactions, all panels, and make clinical rounds on patients on whom blood is being held; perform serological evaluation of several problem patients from receipt of specimen to completion of testing. Residents will observe and participate in clinical consultations depending on their level of knowledge and skill at the discretion of the laboratory director.

At the completion of this rotation, residents are expected to demonstrate knowledge in the following key areas: nomenclature of blood groups; immunology of blood groups; immunoglobulin specificity and reactivity; factors affecting Ag/Ab union and agglutination; common antibodies and their effect; and resolution of problems encountered in testing, (e.g. weak reactions, false positive/negative reactions, controls, serum/cells discrepancies); autoantibodies vs. alloantibodies, drug related antibodies, transfusion reactions: kinds and laboratory investigation

Specific Requirements:

Consultation: Residents will actively participate in clinical consultations at the discretion of the medical director.The level of participation and responsibility are determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. At a minimum, residents are expected to be capable of managing a transfusion reaction, a complex crossmatch, and an emergency request for blood products in the case of trauma.

Clinical Correlation: Clinical correlation is provided through interaction with physicians and the laboratory director and by review and audit of patient charts.

Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory.

Graduated Responsibility: Residents are expected to gain technical expertise in the performance of routine cross matching and coagulation studies. They will participate in clinical consultations at the discretion the medical director depending on their level of ability and documented responsibility.

Required Departmental Conferences: Transfusion Committee Meetings

Required Interdepartmental Conferences: Hematology Rounds as appropriate, Medicine morning report as appropriate

Objective Evaluation: Completion of observations and abilities requirements (Appendix 7)

Urinalysis and Body Fluid Analysis

3 days in Clinical Chemistry rotation (urinalysis) and 2 month during Cytopathology rotation at Lifespan

Goals and competencies:

See Cytopathology (body fluid) and Clinical chemistry (urinalysis) rotations:

Faculty: J. Murthy

Description:

Residents are expected to perform and interpret routine urinalysis tests. Special emphasis will be placed on examination of urine sediment (cells, casts, crystals, and other formed elements). Residents will spend mornings reviewing audiovisual materials on urinalysis in the school of Medical Technology at Lifespan (Caramate). Afternoons are spent in the urinalysis laboratory at Lifespan with hands on training. Residents are expected to understand the principles utilized and operate all instruments used in the Section including osmometers, refractometers, etc. Residents will learn to perform preventive maintenance and routine trouble-shooting for these instruments. Residents will understand the principles of and perform quality control of the tests done in this Section. Residents will review the procedure manual and become familiar with each test performed. They are exposed to automated urinalysis procedures. The resident will be evaluated by observing his or her performance in the laboratory by the Section Supervisor and Clinical Pathologist. Training is supplemented by interactive conferences in urinalysis as part of the general conference schedule.

For body fluid analysis, areas of study include serous, synovial, cerebrospinal, peritoneal dialysate, peritoneal lavage, and bronchoalveolar fluids. The resident will review all body fluids from the clinical laboratory with the attending pathologist for one hour per day. Chemical and morphologic data are synthesized and correlated with the clinical history. Residents will review patient charts for selected cases. Correlations are made with the Cytopathology, Microbiology, Hematology, and Immunology laboratories if indicated.
_______________________________________________

i Microbiology Syllabus
ii Microbiology Competency Based Curriculum
iii Molecular Pathology Syllabus
iv Transfusion Medicine Syllabus

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