First Year, Clinical Pathology Residency Training Program, Department of Laboratory Medicine at Yale

CORE PROGRAM: First Year
The first year of the core program in Laboratory Medicine begins with a one-week orientation, followed by one week of mini-rotations through each service to gain overall familiarity with the Clinical Laboratories. These are followed by in depth rotations over 4-5 weeks on each of the 6 major services including Transfusion Medicine, Clinical Chemistry/Immunology, Hematology/Flow Cytometry, Microbiology/Virology, and the VA-1 and VA-2 rotations at the VA Connecticut Healthcare System. All 1st year residents rotate twice through each service in order to have the opportunity for more senior responsibilities on the 2nd rotation. Although the rotations differ in their details (as described below), the basic learning experience on which all the rotations are based is laboratory diagnostics and clinical consultation. The former is the acquisition of critical skills in Clinical Pathology and understanding of laboratory principles; in the latter, the resident assists the medical staff with the interpretation of laboratory results and decision-making for optimal strategies for the use of the laboratory (including therapeutic apheresis and transfusion) in managing the patient. Training also emphasizes exposure to the strengths and limitations of current and emerging laboratory technologies. In addition to clinical training and responsibilities, residents are encouraged to undertake clinically-directed research or developmental projects of limited scope during each rotation.

Transfusion Medicine is comprised of the Blood Transfusion Service, the Apheresis Unit and the Hematopoietic Stem Cell Processing Laboratory. A full range of routine and special transfusion medicine services are provided. We perform apheresis for collection of peripheral blood stem cells for use in support of high-dose chemotherapy. Some collections are processed on an investigational basis either to enrich stem cells or to deplete tumor cells. There are especially close interactions with the hematology/oncology program, the bone marrow and solid organ transplantation programs and the cardiac surgery service. An approved Transfusion Medicine Fellowship is funded for those wishing to pursue Transfusion Medicine as a career.

During the rotation the resident will learn the principles and skills involved in the workup of transfusion reactions, the indications for and the performance of apheresis procedures, the indications for use of various blood products, and the interpretation of tests for transfusion transmitted diseases. The fundamentals of blood typing and screening, antibody identification, cross matching, etc., are learned through a comprehensive series of laboratory exercises designed to introduce the trainee to safe transfusion practice. Clinical rounds are held daily with the discussion of clinical and apheresis cases, serology problems and transfusion reactions. Afterwards, ward rounds are made on apheresis patients, stem cell patients, patients with massive transfusions or transfusion reactions, and other cases of special interest to the Blood Bank.

The Clinical Chemistry Laboratory performs over 150 different tests and provides a window on all aspects of clinical medicine. Rapid progress in areas such as automation, toxicology, endocrinology, therapeutic drug monitoring and "wellness testing" keeps the lab in a state of constant evolution with new or improved methods being introduced at a rate of one or more per month. Clinical Chemistry also provides oversight for all point-of-care testing in the hospital. The rotation is a busy one in which the resident takes first call for all consultations on the selection and interpretation of tests and for clinical problems arising in the laboratory. Daily rounds are held in which current cases presented by the resident form the basis for discussions of all aspects of Clinical Chemistry. These rounds are supplemented by frequent informal discussions with the Chemistry faculty as needed. Monthly Toxicology Rounds are conducted by Dr. Hodsdon. The Clinical Chemistry section also participates in the weekly endocrine rounds of the Department of Internal Medicine. During this rotation the resident will learn the basic principles of laboratory management, laboratory automation, quality control, serum protein and isoenzyme electrophoresis, clinical enzymology, laboratory endocrinology, pharmacokinetics and the clinical interpretation of therapeutic and toxic drug levels, and the clinical interpretation of markers of cardiac injury, as well as personnel and data management in a large laboratory. Research opportunities include assay development and pharmacokinetic studies of the latest drugs for HIV infection, the neurobiology of cocaine use, and clinical outcome studies of testing algorithms, including point-of-care testing and strategies for cardiac risk assessment.

The complexities of identifying the cause of a severe anemia, deciphering a coagulation or hemostasis problem, diagnosing a hematologic malignancy or monitoring the recovery of functions in a hematopoietic stem cell transplant recipient demand a particularly close collaboration between the laboratory and the clinical hematologist/oncologist. The use of flow cytometry and molecular diagnostics in hematologic diseases is bringing the latest developments in molecular biotechnology directly from the research laboratory to the clinical laboratory.

During the rotation in hematology the resident has the opportunity to learn general hematology as well as various specialty areas including coagulation, urinalysis, bone marrow interpretation and flow cytometry. The resident is responsible for the daily review of abnormal differential counts, blood or body fluid smears containing atypical cells, bone marrow aspirates, platelet function tests, hemoglobin electrophoreses and special hematology cytochemistries. The resident also reviews flow cytometry and special coagulation studies and prepares all reports on these studies in consultation with the attending staff. Drs. McPhedran, Smith and Rinder have joint appointments in Internal Medicine (and in the case of Dr. Smith, Pediatrics) and rounding with the clinical hematology team is available to interested residents.

The first year resident rotation in Flow Cytometry is combined with the Hematology rotation while the Immunology rotation is combined with Chemistry. This provides an integrated case-oriented approach to education since it allows flow cytometry studies to be examined in the context of hematopathology morphology, cytogenetic and molecular diagnostic assessment and allows better integration of Immunologic work-ups with serum protein elecrophoresis and other chemical analyses. Virology serologic assays are carried out in the virology laboratory; integration of bacterial serologic assays into the evaluation of the patient is undertaken by the resident rotating through Microbiology/Virology, working with the microbiology fellow and the Immunology resident. This approach, as for all of the resident rotations, allows emphasis to be placed on the acquisition of integrated consultative skills in these disciplines. Similarly, each rotation is characterized by tight integration and participation of the resident in joint Pathology-Medicine-Pediatric-Surgery conferences and rounds. In flow cytometry/hematology, the resident works closely with the resident rotating on surgical hematopathology and with the Hematopathology Fellow, presenting cases at weekly joint Hematopathology Conference with Medicine and Pediatric attendings and housestaff, at weekly joint Lymphoma/Stem Cell Transplant Conference and at weekly Flow Cytometry-Molecular Diagnostic Correlative Rounds. In Immunology, a monthly Laboratory-Clinical Immunology Conference is well attended by adult and pediatric Immunology/Allergy and Rheumatology attendings and house staff and provides an excellent forum both for ongoing clinical diagnostic/therapeutic care and for education. These joint conferences also provide excellent quality assurance functions for all clinical services involved.

In Flow Cytometry, residents are responsible for formal interpretation of all immunophenotyping, DNA ploidy, and stem cell assessment reports and evaluating these in the context of all other relevant morphologic and molecular studies. All immunophenotyping (blood, marrow, lymph node, fluids) is handled in the same laboratory. Leukemia/lymphoma/transplant evaluations number approximately 1,600 per year, stem cell assessments approximately 600 per year and Immunodeficiency evaluations approximately 800 per year (750 for HIV, 50 for extensive evaluation of congenital immunodeficiencies). At the start of the day the resident and attending review the day's upcoming work by looking over the morphology and clinical data for each case and jointly choosing an appropriate 'panel' of tests. Residents later review each flow result independently and write down their preliminary interpretation; at afternoon sign-out rounds this is then reviewed with the attending and a final interpretive report generated. That result is frequently called to the ordering clinician by the resident, under supervision of the attending. Graduated responsibility occurs both throughout the rotation and between the first-year and second-year rotation. First year residents initially may handle only a subset of the total daily workload in terms of detailed evaluation and gradually move to handling the entire repertoire; consultation with Medicine/Pediatric/Surgical attendings (by phone or in person) is initially carried out in the presence of the pathology attending but over time residents take sole responsibility for this. Residents attend joint conferences initially and gradually take responsibility for primary presentation at those conferences. 1st Year residents learn technical aspects of flow cytometry. The Hematopathology Fellow, when on a Flow Rotation, takes a senior educational role - substituting for the attending in the education of the resident as appropriate and responsible for education of medicine and pediatric housestaff rotating through the service. He/she assumes managerial responsibility, generally not assumed by 1st yr residents.

Consultative interpretive studies in Immunology include: immunofixation electrophoresis (800/year), functional stem cell assays (15/yr), lymphocyte proliferation assays (40/yr, coordinated with immunophenotyping), CSF oligoclonal banding (175/yr). There are approximately 150 stem cell transplants and 300 solid organ transplants at YNHH per year. There are >2,000 ANA, 1,600 QIg, >10,000 syphillis serologies, 600 mycoplasma/toxo serologies per annum. Graduated responsibility is similar to that outlined above: 1st year residents take all initial consultative calls to the laboratory but do not carry out managerial responsibility; 2nd yr residents (as an elective) assume a managerial role, and take primary responsibility for education of allergy/immunology housestaff rotating through. QC/QI duties are also gradually assumed based on what other rottaions the resident may have had previously.

Viral diseases, cancer chemotherapy and organ transplantation programs are producing an increasing number of patients with acquired immunodeficiencies and a large number of opportunistic pathogens causing disease. The development of sensitive and specific diagnostic procedures for the responsible opportunistic pathogens presents an ongoing challenge. Novel, emerging infections and changes in the pathogenic mechanisms and antimicrobial resistance of familiar pathogens also provide new problems. In addition, the application of monoclonal antibodies and nucleic acid probes promises to revolutionize all of microbiology.

During the rotation, the resident will learn general microbiology techniques as well as the interpretation of cultures from blood, CSF, the respiratory tract, genital areas, wounds and stools. Skill will also be obtained in mycobacteriology, mycology, parasitology, molecular diagnostic methods and the interpretation of antibiotic sensitivity profiles. These skills are learned by rotations through the various stations of the laboratory as well as daily rounds in which instructive cases are discussed from both the microbiological and clinical points of view. In order to provide greater clinical correlation, Infectious Disease fellows attend these rounds each day. The resident also attends the weekly clinical conferences of the Infectious Disease Service. An approved Clinical Microbiology Fellowship is funded for those wishing to pursue Microbiology as a career.

A teaching schedule has been organized so that residents will become familiar with all testing done within Virology. The resident is expected to investigate problems, determine clinical correlations when needed, consult with physicians, interpret HIV western blots and correlate virology results with pathologic findings. Biweekly virology case presentations with demonstrations are prepared for Infectious Disease rounds. The resident has the responsibility of contacting the Infectious Disease team and preparing the case history. A close working relationship between the virology laboratory and the transplant and AIDS care programs is essential and the resident helps to communicate and maintain this relationship.

The VA-1 rotation provides the resident with the opportunity to practice Clinical Pathology in the setting of an integrated Pathology and Laboratory Medicine Service. Residents cover all sections of the clinical laboratories and have the option to interact more closely with the Anatomic Pathology laboratories. This allows the resident to gain a broader view of patient diagnostic services than is possible in the more specialized rotations. Of particular interest are two national reference laboratories for virology and mycobacteriology. These laboratories serve the entire Veterans Administration health care system, as well as many non-government medical facilities. The VA has a recently established molecular diagnostics laboratory with state-of-the-art equipment, which provides opportunities for residents to participate in new test development. During this rotation, the resident also has the opportunity to observe and perform bone marrow aspirations and biopsies, and to interpret those tissues for final diagnosis, providing a 360 degree experience in aspirate procedures. The VA-2 rotation provides residents with a formal graduated responsibility with senior level duties. The resident may elect to act as the assistant director of a subspecialty laboratory, handling all procedural and personnel issues, CAP surveys, budget and capital issues, and of course, all interpretative aspects of that laboratory. In addition, the VA-2 rotation offers specialized experience at the central virology laboratory, the state epidemiologic center, and other VA sites of excellence.