Clinical pathology training emphasizes developing residents for the role of effective consultant to clinicians regarding appropriate test ordering and interpretation, with the goal of being integrated members of the healthcare delivery team. Also emphasized is the role of the medical director in ensuring the delivery of high quality laboratory testing to produce the best patient outcomes within a framework of fiscal responsibility.
Clinical chemistry is the application of biochemical scientific knowledge and techniques for medical testing and using those results to diagnosis, prognosis, and improve healthcare. Today, clinical chemistry/toxicology plays an essential role in disciplines such as cardiac care, cancer testing, organ transplant, poisoning, forensic workplace drug testing collection, prenatal testing, diabetes management, infectious disease testing, therapeutic drug monitoring, genetic testing, and personalized medicine. As a discipline, it is a fundamental branch of Pathology and Laboratory Medicine.
The Clinical Chemistry/Toxicology division performs over five million tests each year in a state-of-the-art laboratory (Wisconsin Diagnostic Laboratories) that provide 24-hour service to Froedtert Hospital, several community outpatient facilities, physician offices, long-term care facilities, and other institutions throughout Southeastern Wisconsin. Chemistry and biochemical genetics testing services are also provided at the Children’s Hospital of Wisconsin clinical laboratory.
Residents and fellows rotate through routine automated chemistry (high-volume testing), critical care (blood gases, stat testing), special chemistry (immunoassay for endocrine function and tumor markers), heavy metal testing, and drug analysis (therapeutic and abused drug testing) laboratories. The program is designed to provide training in the operation of a clinical laboratory, quality control and assurance, laboratory management, analytical methodologies and test interferences. The clinical interpretation and diagnostic relevance of tests are emphasized through clinical consults. Residents and fellows are actively involved in method development, test validation, and clinical and scientific investigation in any of the areas within clinical chemistry/toxicology.
The Coagulation rotation combines laboratory aspects of coagulation with clinical experience managing both adult and pediatric patients with coagulopathies. Residents will begin the rotation discussing pre-analytical variables and specimen collection issues specific to the coagulation laboratory and then throughout the month, become familiar with the instrumentation and methodologies available in our coagulation laboratories, including the BCS® and Stago coagulation analyzers and PFA-100®.
The resident will learn detailed information about available in-house tests, including the PT, PTT, fibrinogen, factor 8, antithrombin 3, factor Xa, D-dimer, and platelet function assays, mixing studies, platelet counts, and lupus anticoagulants through daily interaction with faculty and technologists. Experience with more specialty coagulation testing, including platelet aggregation studies, von Willebrand tests, factor and inhibitor assays, PF4 and ADAMTS13 assays will be provided by weekly participation in the combined Versiti Blood Center of Wisconsin/Children’s Hospital of Wisconsin coagulation conference. Residents will have exposure to available molecular testing as it relates to hypercoagulable work-ups. The resident will apply their acquired knowledge of coagulation testing in concentrated studies on specific disease states, including platelet hypofunction states, von Willebrand disease, disseminated intravascular coagulation, hemophilia/coagulation factor deficiencies, and thrombocytopenic and hypercoagulable states.
At the end of the rotation, aspects of laboratory management and regulation specific to a coagulation laboratory will be emphasized, using the College of American Pathologists coagulation inspection checklist as a guide. Additionally, opportunities exist for resident involvement in several clinical settings during this rotation, including the Children’s Hospital of Wisconsin outpatient coagulation clinic, adult outpatient hematology clinic, inpatient benign hematology consultation service, and the transfusion medicine service.
The Clinical Cytogenetics Laboratory provides a full range of cytogenetic and fluorescent in situ hybridization (FISH) diagnostic testing for congenital disorders, mental retardation, pre-natal and pre-implantation testing, leukemia, lymphoma and solid tumors. Uniquely, in addition, definitive DNA testing for Fragile X mental retardation or carrier status and Prader-Willi/Angelman syndrome are both performed on-site by methylation analysis. Testing is performed on a variety of tissues as appropriate: peripheral blood, product of conception, skin, amniotic fluid, chorionic villus, bone marrow, lymph node, solid tumor, paraffin-embedded tissue, urine and blastomere nuclei.
The Lab remains one of the first group of about 30 national and international laboratories approved by the Pediatric (now Children’s) Oncology Group (COG) to determine the cytogenetic status of pediatric leukemic patients as one of the crucial components of diagnostic and prognostic testing. It is one of a handful of laboratories nationwide to perform aneuploidy testing on pre-implantation embryos following in vitro fertilization in infertile couples. In 2002, it was chosen by the College of American Pathologists to be a referee lab for Proficiency Testing in Cytogenetics.
The Cytogenetics Laboratory Director regularly meets and consults with hematopathologists and hematologists, Surgical pathologists, pathology residents and fellows, clinical geneticists and genetic counselors and reproductive medicine staff at MCW. Residents rotating for a month process their own tissue and perform chromosome analysis to become familiar with the range of procedures and techniques. This culminates in karyotyping with a digital imaging system. Weekly rounds are attended in hematopathology and in reproductive medicine, monthly in clinical genetics wherein abnormal cytogenetics results are presented and discussed with the clinical genetics/counseling group at Children’s Hospital. In a week-long stint in the first year and again in the fourth year Molecular rotation, the resident performs a batched assay for Fragile X or Prader-Willi/Angelman by DNA analysis.
Flow cytometry training is an integral part of the Hematopathology rotation, which stresses a combined diagnostic approach that synthesizes morphologic, immunophenotypic, and molecular/cytogenetic information. Residents will be exposed to the principles of flow cytometric analysis of hematologic malignancies during their 3-month junior and 1-month senior Hematopathology rotations, respectively. In addition, a 1-month Flow Cytometry elective rotation is available to those interested in expanding their knowledge base and practical skills in this area.
The flow cytometry laboratory is a state-of the art facility, which supports the MCW Cancer Center and a busy bone marrow transplant service of the Division of Hematology/Oncology. The instrumentation consists of two Becton-Dickinson FACSCanto II flow cytometers, equipped with three lasers, which allows routine 8-color analysis of 2,300 leukemia/lymphoma cases per year. All three Hematopathology faculty have extensive expertise in the immunophenotypic analysis of hematologic neoplasms, and run a busy flow cytometry research program, in addition to their clinical responsibilities.
The Hematopathology rotation at MCW consists of a 3-month block during the second year, followed by a 1-month senior rotation during the 3rd or 4th years. Because MCW/Froedtert is a tertiary referral center with a large adult bone marrow transplant program, and by virtue of the fact that we are the only academic medical center in Southeast Wisconsin, residents are exposed to a wide range and large volume of neoplastic and non-neoplastic hematologic disorders.
Teaching occurs in the context of daily signout sessions at a 10-headed microscope, including all trainees and students rotating on service at a given time, as well as through a comprehensive series of didactic lectures, monthly unknown conferences, and journal clubs. A weekly working conference around an 18-headed microscope with faculty and fellows from the division of Hematology/Oncology provides an opportunity to build professional, consultative relationships with our clinical colleagues, and also provides valuable insight into the way our work impacts the care of patients.
The overall goal of the hematopathology resident rotation is to provide broad-based training in the laboratory approach to diagnosis of hematologic disorders, both benign and malignant, as well education in the structure and function of the routine hematology laboratory. A multimodality approach is stressed, with incorporation of information from multiple sources, including clinical, hematologic, cytogenetic, flow cytometric, and molecular data. Eight-color flow cytometry analysis and interpretation is integrated into the microscope signout sessions, as well as into the final interpretations and reports. Although all resident work proceeds under the supervision of an attending pathologist, development of increasing degrees of independence and responsibility commensurate with the resident’s ability and level of training is fostered.
The ultimate goal is to allow the resident to function as effective laboratory consultants to their clinical colleagues, both in the interpretation of pathologic material, as well as by providing input into the proper utilization and interpretation of laboratory tests for the patient work-up.
Resident training in microbiology is divided into two blocks taken during the second and fourth year of training. Training during the second year consists of a 3-month rotation focused on mastering diagnostic microbiology. The knowledge provides the resident with a core understanding of microbiology which is reviewed on a brief one-month rotation in the fourth year for board review.
The early phase of training emphasizes diagnostic microbiology, during which time trainees are expected to master a core of tests in diagnostic bacteriology, mycology, mycobacteriology, virology and immunology. This is most concentrated in year 2 of the program and with continued, increasing, responsibility for the resident throughout the rotation. The microbiology rotation is conducted at Wisconsin Diagnostic Laboratories, Froedtert Hospital and Children’s Hospital of Wisconsin to provide the resident with experience in both pediatric and adult microbiology. Combined, the laboratories process more than 900,000 tests annually. Teaching on this rotation is accomplished through a combination of didactic teaching sessions, formal lectures, bench rotations, participation in multi-disciplinary conferences, and through daily rounds. Bench rotations during the second year include:
- Molecular Virology
- Infectious Diseases
While residency training is designed to provide broad coverage of all aspects of diagnostic microbiology, research projects available to the resident can be custom-tailored to accommodate individual trainee’s interest in virology, bacteriology, or immunology.
This experience includes close interaction and communication with the faculty microbiologists, technologists and clinical colleagues. Trainees are expected to become competent in a wide variety of microbiological techniques, interpretation of results, and formulating recommendations for follow-up investigations of cases of special interest. Teaching sessions consist of case discussions and residents present specific topics to faculty in an informal manner.
In addition to scheduled rotations, residents attend hospital infection control meetings, clinical pathology conference, infectious diseases case conference, infectious diseases interest rounds and the microbiology-infectious diseases research conference.
During the fourth year rotation, residents will review the core competencies of microbiology and will be expected manage the clinical microbiology service in consultation with faculty attending. This will include sole responsibility for direction and management of the clinical microbiology laboratory, interacting with the clinician staff, leading daily laboratory rounds and solving day-to-day operational problems.
Molecular diagnostics is an emerging discipline within pathology which is focused on the study and diagnosis of disease through interrogation of nucleic acids and proteins within solid tissue and body fluids. In our view, molecular diagnostics is an interdisciplinary science shared between anatomic and clinical pathology.
Resident training in molecular diagnostics is divided into two blocks taken during the first and third or fourth year of training. Training during the first year consists of a 1-month rotation focused on core principles of molecular pathology and application of molecular techniques through all disciplines of pathology. The knowledge provides the resident with a core understanding of molecular techniques for use in rotations throughout training and is followed by an advanced rotation in the fourth year.
The early phase of training emphasizes diagnostic techniques, during which time trainees are expected to master a core of tests in diagnostic microbiology, hematopathology, cytogenetics, coagulation, and genetics. Specific tests to be discussed will include: viral load testing, hypercoagulation screening, Cystic Fibrosis mutation carrier screening, Fragile X testing, genotyping, respiratory virus testing, quantitative BCR ABL, and sexually transmitted disease screening.
The Molecular Diagnostics rotation is conducted at Wisconsin Diagnostic Laboratories, Froedtert Hospital and Children’s Hospital of Wisconsin to provide the resident with experience in both pediatric and adult molecular diagnostics. Teaching on this rotation is accomplished through a combination of didactic teaching sessions, formal lectures, bench rotations, and participation in multi-disciplinary conferences.
Pathology residents spend three months on the Transfusion Medicine rotation. Two and a half months are spent in the hospital transfusion service at Froedtert Hospital and Children’s Hospital of Wisconsin, while two weeks are spent at a regional blood center, Versiti Blood Center of Wisconsin.
The first month of the rotation is dedicated to learning the basic concepts of transfusion medicine. During this time, they learn laboratory practices, make daily rounds and see patient problems and are involved in therapeutic plasmapheresis.
Two weeks of the second month of rotation are spent at Versiti Blood Center of Wisconsin, our regional blood supplier. During this time they are exposed to blood collections, processing, and component preparation. They are also exposed to special aspects of transfusion medicine, such as autologous and directed blood donation, the acquisition of HLA-matched platelets and granulocytes for transfusion therapy. Residents spend time in a number of reference laboratories: Platelet and Neutrophil Immunology Laboratory; Hemostasis Laboratory, HLA Laboratory, Immunohematology Reference Laboratory and a Molecular Diagnostic Laboratory.
During the third month of rotation the residents solidify their basic knowledge and begin to learn newer aspects of transfusion medicine, i.e, role of acellular oxygen carriers effect of blood transfusion on immune modulation, blood transfusion for neonates, etc.
These three months of clinical rotation are divided into one month in each of three separate years. In addition to their time spent on transfusion medicine, residents also take day call during their transfusion medicine rotations, particularly during the second and third months. Residents on Clinical Pathology night call handle all blood bank calls with a blood banks staff physician providing back up.