Wednesday, June 22, 2011

Gross Room Survival Guide Part 5. Dictating gross description

Probably not worth a separate section, you might say. However, a well dictated gross description goes a long way. It keeps your attending happy. It keeps the transcriptionists happy. It saves you time by not having to go over it with a red pen, redictate it the next day, or explain to your attending what exactly you meant by “tan to pink, red-brown, slightly yellowish, gray tissue”. It saves you an embarrassment at multidisciplinary conferences. It may mean a great deal should there be litigation.

A good dictation should be concise, clear, accurate, but without unnecessary details. Any pathologist 20 years from now should be able to pick up your description, read it and picture the specimen in their head. Be systematic. Go from outside in and from top to bottom (or the other way around, but be consistent). Do not overdo negative findings, but rather concentrate on positive ones. Keep it professional and be grammatically correct.

Templates versus no templates. Our institution utilizes templates for gross description. The idea is to make gross descriptions consistent and to save time typing reports. Templates are good for standard specimens like placentas or non-neoplastic colectomies. However, I do find them difficult to use with any more or less complex or non-standard specimens. It is a personal choice whether to use them or not. If you decide to use templates try to memorize the more common ones so you don’t have to look for the greasy bloody paper template every time.

Dictating as you gross saves enormous amounts of time. For the first month or two, until you become dab hand with dictating gross, you may find it easier to write down all the measurements and then dictate the description after you are done grossing. However, you really should try to move to dictating “as you go”, the sooner the better. It is doable for most specimens, even Whipple resections and composite neck dissections, as long as you think about the specimen for a minute beforehand and plan the way you are going to dissect and dictate it.

Do not dictate unnecessary details of no diagnostic value. Bundle lymph nodes together. Is there really any advantage in saying “A1: two possible lymph nodes, both of them bisected, one inked in black and the other one in blue” versus “A1: two lymph nodes”? They do look like lymph nodes grossly, why do you call them “possible”? You are going to see four pieces of lymphoid tissue under the scope, two of them with a rim of black and two with a rim of blue. You do the math…

Tuesday, June 21, 2011

Gross Room Survival Guide Part 4. Frozen sections

Frozen sections are like buses, you wait for ages then 12 arrive at the same time. The key to handling the stress of the frozen station is to be organized and be prepared. During your rotation month familiarize yourself with every cryostat your lab has. You may prefer one machine over the rest but you should be able to cut a good frozen section on all of them. A good tissue to practice on is placenta. Once you are good at that, try cutting gastrointestinal organs and skin. Skin is best cut with the epidermis positioned perpendicular to the blade. Trim excess fat unless it is diagnostically relevant. Once again, have your supplies checked. Everything should be clean and available within easy reach.

How to handle multiple frozen sections? Remember - you have the control of the frozen section. Do not let anyone, your attending included, to manipulate, move, or otherwise interfere with the specimen without checking with you first. This is a HUGE safety issue. If you receive multiple specimens and need help – delegate it. Tell people what exactly you want them to do. There is nothing worse than people coming up to the frozen section bench and grabbing things without asking, albeit trying to help. This creates confusion and compromises patient care as parts and even whole specimens can be switched.

Our gross room has two cryostats. The way I handle multiple frozen sections is as follows. If I receive two or three parts on the same patient I prefer to handle them myself. If it’s more than that, or two different specimens, I’ll ask for help from another resident. The way to go about it is to hand over one of the specimens and then forget about it for the time being and let them have their way with it. They should be able to handle it by themselves, and you should concentrate on the specimen of yours. If you get multiple parts (e.g. multiple margins on a squamous cell carcinoma of the skin) it makes sense to involve a third person to do the staining. This way two people cut and one stains. It is not practical, and even counterproductive, to have more people involved in cutting than you have cryostat units. It only creates unnecessary confusion.

When you get multiple frozens, the reporting time will be above recommended. There is nothing you can do about it. Therefore, there is no point in getting worked up over it. Stay calm at all times and know what you’re doing.

After you are done with a frozen, vacuum or otherwise clean the cryostat. Do it after every specimen and not just at the end of the day. The tissue will occasionally chip off of the chuck and fall down to the bottom of the cryostat. Now imagine having to fish it out from shavings of OCT and tissue that accumulated there from the previous frozen sections, with everything melting and sticking to your fingers. Not pretty.

Gross Room Survival Guide Part 3. Practical issues of the gross room

I am not going to go into details of grossing each type of specimen. Those you will either read about or pick up on the job. These are just a few general tips to make your life as a first year resident somewhat more tolerable.

Be organized. Arrive early on your gross room days. Get the surgery schedule and go over it. Cross off the cases that you are unlikely to get a specimen on. Highlight those that are likely to require a frozen section or a gross consult. Look up the patients’ histories and any previous pathology reports. Print out relevant information and highlight the most important findings.

Check your station. Have your tools clean and available. Check the supplies (formalin, ink, frozen section embedding compound, frozen section fixative, the staining panel etc). Make sure you have slides, coverslips and mounting medium for the frozen section. Nothing worse than cutting a perfect frozen section, reaching out for a slide and not finding any. Change the blades on the cryostats every morning even if they look visibly new. All these things will save you time during the day.

Triage the specimens as they arrive. This will depend on your institution policy on grossing fresh or fixed tissue. In my program most specimens are grossed fresh. Things that get fixed overnight are bladders, stomachs, and any late specimens. Certain kinds of specimens only need to be in formalin for a few of hours and can be grossed the same day (prostates, Whipple resections, partial mastectomies). Sections of any breast specimen, whether you gross it fresh or fix it first, need to go in formalin as soon as possible, preferably within an hour of surgery, in order to preserve estrogen and progesterone receptor immunoreactivity. If you cannot gross a breast when it arrives – ink it, measure it, cut into the tumor and put it in formalin. It only takes 10 minutes, you can gross it at any time at your convenience, and you haven’t compromised patient care. Same applies to prostate. Ink the capsule and throw it in formalin. You don’t even have to measure it – all that can be done later. If you cannot get to the specimen now, put it in the refrigerator. If you are swamped with specimens – ask for help from your fellow residents and/or PA’s. See what has to be grossed today and what can be held until tomorrow without compromising patient care and turnaround time, when possible.

When taking representative sections of an organ, be consistent in the order you do it. I usually go proximal to distal, right to left and top to bottom. You can do it any way you like, but make it the same way for each specimen, unless you encounter something unusual that would warrant a different approach. This way you eliminate the time you would spend on keeping a track of your sections.

Saturday, June 18, 2011

Gross Room Survival Guide Part 2. Reading

Grossing skills are essential for any practicing pathologist. Even if you are going to practice in a large academic institution with a squad of residents ready to jump out of their skins at your wish, you ought to know how to gross for several reasons. Firstly, you need to make it through your own residency in order to be able to practice. The ratio of grossing to study time varies by program, but even in the most lenient institutions you will be required to cut up specimens. When you do enter independent practice, you may end up in a place with no residents where you will be required to gross your own stuff. In any case, you should be able to guide your resident or PA in cases of unusual or complex specimens. You may be an excellent diagnostician at the scope but you cannot be a good pathologist without being good at the grossing bench. How do you learn grossing? The way that worked for me was supplementing hands on experience with some relevant reading.

Regarding reading, both before the start of your residency and during the first few months, I would leave alone the major pathology texts (and I am not talking Robbins, either). Those will come into picture later. And in order to find time to read them later you will need to be efficient at grossing to get it out of the way pronto. So what do you read? Manual of Surgical Pathology by Susan Lester is an excellent guide to surgical pathology grossing. It is concise, to the point and full of useful tips. This is probably the only book I would recommend to go through before starting your residency. I would not recommend buying it though. This is the kind of text you will probably read once during the first couple of months of training, and then very occasionally use for reference while grossing some obscure type of specimen. If you can get it on loan from a library or a friend – do it.

Another read that I find extremely useful and that is, unfortunately, rarely mentioned to new residents, are College of American Pathologists Cancer Protocols. They are not an easy read, and I wouldn’t read them at my leisure. The good way to go through them is before you are about to gross any particular type of specimen. If you have a gastrectomy on the schedule, read the CAP protocol for stomach that morning. Did you know that a stomach has four surgical resection margins? Those protocols bulletpoint all the information about the specimens that will have to be included on the diagnostic report. By reading those beforehand you will know what sections you have to take in order to answer those questions. Explanatory notes that follow each protocol are also a mandatory read. Last but not least – the protocols are available on the CAP website for free.

The above two sources are probably the only ones I would use, at least for the first couple of months. You may want to start flipping through Sternberg or Rosai once you settle in and start your signouts with an attending (more about that later). To get a basic grasp of immunohistochemistry I would recommend Immunohistochemistry Vade Mecum, an excellent online resource by Dr Paul Bishop.

Friday, June 17, 2011

Gross Room Survival Guide Part 1. General issues/settling in

Your pathology training will likely begin with an introduction period. In my program it was one month long. Approximately half of your time during this month, sadly, will be spent attending introductory lectures and trainings highly irrelevant to your future career. You may be forced to attend an ACLS training or an IT training for a patient management system that you are never going to use. You would probably have to undergo employee health screening and sign up for benefits. These things are annoying but need to be done. The best way to go about them is to keep track of everything you need to do or attend, and try to get it done as fast as possible. You really ought to be spending time in the gross room, which takes us to the next paragraph.

If your program is anything like the one I train in, you will be spending the majority of your first year grossing surgical pathology specimens. It is in everyone’s interest that you become good at it as fast as possible. Do not spend your orientation month looking over a senior resident’s shoulder. They probably would prefer to do the grossing themselves to get it out of the way faster but this way you’ll end up in the deep end the month after, when you’re in it on your own. (Yes, yes, I know… The new ACGME regulations mean you are not supposed to work unsupervised for the entire length of your first year. However, in reality, even with supervision, you will be the one doing most of the grossing.) The approach that worked for me was that of “watch it – read about it – do it” (and you can switch the first two around as needed). After you’ve seen a certain type of specimen being grossed, go and read about the technique if you haven’t done so already. Then ask to gross the next one with someone watching you or guiding you through. Then check it off the list. (Yes, you should probably make a list of the major bread-and-butter types of specimens you have to be able to handle.)

Ask questions. That is what your orientation month is for. Show initiative. Volunteer to do things that need to be done. Help each other (especially your fellow first year residents). This year is not going to be easy but it will go by fast.

Gross room survival guide for first year pathology residents (drawn from personal experiences and by no means exhaustive)

So you have matched into pathology. I would guess you are an inquisitive and analytical person with a low threshold for nonsense. You have a rewarding career ahead. However, the first year of residency training, and especially the first few months, can be extremely stressful and demanding. This is an attempt to share bits of knowledge that were either passed on to me by my more senior peers or learned the hard way. The kind of information that you can’t find in the books and that will hopefully make the process of settling in a little easier. The below narration is based on my personal experience in my training program. It for the most part reflects my personal views. By no means do I claim it to be universally true. Your own experience will invariably differ depending on the specifics of your program, your own personality traits and those of people you are going to be working with. Take everything with a pinch of salt.

I will continue adding posts to this series in future. This is a list of what is there so far.