Anatomic pathology is the science devoted to the study of diseased tissues. Tissues are usually obtained for study by a variety of methods, including skinny needle biopsies, incisional biopsies, excisional biopsies, and surgical resection of organs or tumors.
Pathology residents rotate for three months on the autopsy service during their first year of residency. The autopsy resident is responsible for all weekday autopsies performed at Froedtert Hospital (FH), Children’s Wisconsin (Children's), and the Veterans Administration (VA) Hospital during their rotation.
Average number of autopsies per year (over the last few years):
- FH – 60
- Children's – 65
- VA Hospital – 15
Autopsies performed at each hospital are usually on patients who have complicated clinical courses, with multi-organ involvement, and significant unanswered questions about their disease processes such that the autopsy serves as a valuable educational experience for both the pathology resident as well as the hospital services.
Complementary to the experience of performing autopsies on patients from a tertiary care medical center, the autopsy resident also goes to the Milwaukee County Medical Examiner’s Office to perform autopsies on days when there are none at FH, Children's, or the VA. The Department of Pathology maintains a close relationship with the Milwaukee ME Office as the pathology residents rotate with the medical examiners during their first year and then return in their senior year to complete a forensic rotation.
The Milwaukee ME office is under the direction of Dr. Brian Peterson, and Dr. Agnieszka Rogalska directs the residents during their rotations. Valuable aspects of the rotation of the first year residents in the ME office are the opportunity to learn varied evisceration techniques and to experience a different “patient” population. With the opportunity to perform autopsies at FH, Children's, the VA, and the Milwaukee ME Office, the pathology residents obtain a well-rounded experience and more than sufficient numbers of autopsies to qualify for board examination.
At FH, the autopsy room is outfitted with state-of-the-art equipment. There is room for general autopsy performance and a separate room with negative pressure ventilation for all suspected infectious cases. Autopsy performance is also always assisted by an experienced autopsy technician.
General autopsy work flow
The autopsy resident reviews the autopsy consent and the clinical information on the patient (now obtained on the electronic medical record, EPIC) and presents this information to the autopsy attending prior to beginning the autopsy. The attending and resident discuss any special procedures that might be needed on that autopsy. On the first several autopsies performed by the first year resident at FH, the attending is present for all aspects of the procedure. As the resident becomes more experienced, he/she is gradually given more independence in the performance of the autopsy.
A template for the gross description of the autopsy findings is used to aid in completion of the report; the autopsy service is in the process of transferring from a traditional dictation system to the use of a voice-activated dictation system. All reports are created and maintained on Cerner Millennium Laboratory Information System.
The attending and resident always review all organs at the conclusion of the dissection. A dedicated digital camera is used to document important gross pathological abnormalities. A provisional anatomic diagnosis list is created based upon the gross findings at autopsy and examination of slides from five “stat” blocks processed, cut, and stained within a day of the autopsy performance. Slides from all submitted blocks are typically available for review within a week after the autopsy completion. The resident previews all slides and then reviews them with the attending physician. The resident writes the microscopic description and summarizes the autopsy findings and writes the clinical-pathological correlation of the final autopsy report.
As part of the resident’s autopsy experience, selected cases are the subject of formal quarterly clinical-pathological conferences given in conjunction with the Division of Internal Medicine and the Department of Neurology, at which the resident prosector of the autopsy presents all the autopsy findings and gives a short didactic presentation on a pertinent topic.
Surgical pathology refers to the study of tissue samples obtained by various surgical means and utilizes a subspecialty-based system for training.
The Cytopathology rotation of the pathology residency program is designed to provide a foundation for a resident physician to excel and develop competence in the diagnosis and evaluation of clinical cytology specimens, and an interest in research applications within the discipline of cytopathology.
The overall goal of the rotation is to provide broad-based training in the approach to diagnosis of both benign and malignant diseases, as well education in the structure and function of the routine cytology laboratory.
A multimodality approach is stressed, with incorporation of information from multiple sources, including clinical, radiological, and sometimes flow cytometry data. Through participation in conferences and teaching activities, an academic approach to cytopathology is encouraged.
Ultimately, in concert with the rest of the training program, the aim is to develop pathologists who understand the management of a laboratory enterprise by instilling an understanding of the medical decision-making role that pathologists bring to the laboratory, and to the broader system of healthcare.
Pediatric pathology is concerned with the study and diagnosis of human disease manifested in the embryo, fetus, infant, child and adolescent.
The curriculum of the core pediatric pathology rotation is centered on general and systemic aspects of pediatric surgical pathology of all organ systems (including cardiac, vascular, pulmonary, neuro-, head and neck, endocrine, hepato-gastrointestinal, renal, urogenital, dermato-, bone and soft tissue pathology), with incorporation of pediatric hematopathology.
Residents participate in routine gross exam of complex cases, frozen sections, obtaining clinical history, microscopic exam and work-up with faculty sign-out, incorporation of ancillary studies, presentation at a set of conferences with clinico-pathologic correlation, further communication with other specialties, journal club presentation, retrospective case reviews, and short studies with pathology and other pediatric clinical faculty, as applicable, and complement resident’s professional goals.
Core pediatric autopsy and developmental pathology (fetal, perinatal and pediatric autopsy pathology, placental pathology) are incorporated into the autopsy rotations. Elective rotations at upper levels are further tailored to meet and enhance residents’ professional goals in any of the above areas at greater depth, with further options in neuro-muscular pathology. Pediatric aspects of clinical pathology and laboratory medicine (clinical chemistry and biochemical genetics, microbiology/virology and molecular diagnostics of infectious and heritable disease, and an introduction to pharmacogenomic diagnostics) are incorporated into respective clinical rotations with participation of our faculty.
Pathology residents experience a one-month rotation in forensic pathology during the second year of their residency. Additional experience can be made available as needed to obtain American Board of Pathology-required numbers of autopsies and if the resident chooses to do an elective month at the ME’s office.
During the course of their rotation, residents will be expected to perform assigned autopsy examinations, review records pertaining to deceased individuals, formulate accurate causes and manners of death, review and interpret necessary ancillary tests (microscopy, toxicology, radiology, neuropathology, and microbiology), communicate with interested parties regarding the decedent (family members, law enforcement personnel, and medical personnel), and produce accurate and understandable autopsy reports in a timely manner.
Other requirements include making a single half-hour PowerPoint presentation on the topic of the resident’s choice, attending morning rounds, attending educational conferences, and viewing physician courtroom testimony (when possible).