Guidelines & Policies

Responsibilities of Chief Resident In Anatomic/Clinical Pathology

1. Ensure smooth operation of departmental conferences by scheduling, organization of case materials, etc. as needed.
2. Direct supervision during credentialing of new residents.
3. Draft schedules for AP/CP resident service and call rotations (for review with the Directors of the involved services).
4. Coordinate and approve residents' vacation and business leave (for review with Residency Coordinator and the directors of the involved services).
5. Facilitate the relationship between residents and faculty to maximize learning and service efficiency.
6. Determine from each resident during each rotation whether problems exist.
7. Organize the annual orientation of new residents to AP and CP, and direct the tour of the department (for review with the Residency Coordinator).
8. Attend departmental administrative meetings, as required.

Book and Travel Allowance for Pathology Housestaff

First year of Program $200.00 (book purchases only; Travel not permitted during first year)

Remaining years of program $1700.00/year (for book and travel purchases)

When you want to order books, fill out the book order forms available from the Residency Coordinator (room 2123 WH). See Sample Housestaff Book Requisition for the correct way to fill out the form. Use a separate form for each book requested. Please make sure your name is on the requisition under department contact person.

Travel funds are available to housestaff only after his/her first year in the program. Carry over of travel money to subsequent years is not permitted.

For housestaff presenting original research at an approved meeting:

Upon advance approval from the Program Director, housestaff can utilize their $1,700 annual travel allowance to attend a meeting in which he or she will be presenting original research. In addition, he/she may apply for travel funds over and above the $1,700 allowance up to a maximum total of $3,000 per year for this purpose. Written requests must be made to the Department Chairman, Dr. Gregory Threatte and the Program Director, Dr. Paul Shanley outlining the following:

• Purpose of travel/name of meeting
• Destination of meeting
• Dates of travel
• Outline of research presentation
• Estimated total expenses

Please make sure to check with the Program Coordinator before registering for any conference to ensure that the funds are available. The Program Coordinator and the Program Director must sign off all travel requests.

Leave for attending scientific meetings or subspecialty conferences or training (not generalized Board-review type courses), including travel time, will be treated as business leave, not to exceed five (5) working days per year (including presentations at meetings). As in the case for vacations, it is necessary for the resident to secure appropriate prior approvals.

Attendance at non-approved meetings such as Board-review type courses and time spent for job interviewing must be considered as vacation time. The actual sitting for Board or licensing examinations including reasonable travel time can be considered business leave (maximum of 5 days).

AP Resident On-Call Responsibilities

The Anatomic Pathology (AP) services at University Hospital that must be covered continuously (i.e., nights, weekends and holidays) are surgical pathology, frozen section and autopsy). The AP service at the Veteran's Administration Medical Center, which must be covered, is the autopsy service. Night coverage begins at 5:00 p.m. each night. Residents are expected to perform autopsies and frozen sections under the supervision of an attending pathologist.

The resident is often the first person contacted by clinicians requesting rush processing on a specimen. Any request for rush processing must be approved by an attending. Cases may be made "priority one" with attending approval. Be sure to get the name and beeper of clinician to be called with the results.

If you are called for a Neuropathology frozen section (i.e., a frozen section by a neurosurgeon or other surgeon requested Neuropathology) you should contact the Neuropathologist on call. To reach the neuropathologist on call, try the home number first, and then the beeper number if there is no answer (both numbers are on the AP call schedule). If the neuropathologist on call cannot be contacted, call the other neuropathologist.

In addition, residents may be asked to come in during off-hours to take care of specimens that require prompt routing or special handling. This may include lymph ode protocols, freezing tissue for Tumor Bank, and fixing tissue for immunofluorescence and determination of cellularity and adequacy of FNA specimens. It is expected that after a short time on service, residents will be able to perform these tasks independently after getting the approval of the attending on-call.

Lymph node protocol

Lymph node protocols should be performed according to the normal procedure outlined in the gross room manual (i.e., touch imprints, B-5 and formalin fixed sections, EM, snap frozen tissue, and flow cytometry. Touch imprints and B-5 fixed sections are the most important for diagnosis if there is not enough tissue). B-5 solution should be made fresh by mixing 9 parts of B-5 stock solution and 1 part of concentrated (37%) formaldehyde, available in the gross room. Glutaraldehyde for EM is available in the gross room refrigerator in the accessioning area. The change form normal protocol is that tissue for flow cytometry (lymphocyte typing) needs to be stored for processing by the technologists on the next regular workday. Solid tissue should be stored in culture media (RPMI 1640) which is available in the refrigerator in WHA 1315, and then stored in the refrigerator. Snap frozen tissue is to be stored in a sealed plastic envelope or other leakproof container, with a label with the patient's name inside the container. The container itself is to be stored at -70ºC. Remember, if cultures are indicated (by clinical history), handle the lymph node with sterile gloves and instruments and separate the piece for culture first. This is often best done by the surgeon in the OR while the specimen is still in a sterile field. The piece for culture with appropriate requisition forms should be taken to the specimen processing area in CP.

Fluids for Lymphocyte Typing (pericardial or pleural effusions, etc.) should be spun down to a pellet and then gently resuspended in culture media, after which they can be stored at room temperature.

REMEMBER TO LABEL ALL CONTAINERS AND TUBES WITH THE PATIENT'S NAME AND HOSPITAL NUMBER —If problems arise, you can contact Donna in Dr. Hutchison's laboratory

Tumor Bank

Under the direct supervision of an attending, tissue may be snap frozen for the Tumor Bank (see section on Tumor Bank, and talk to Dr. Gonchoroff before assuming on-call responsibilities). Tissue is snap frozen, stored in a leak-proof plastic envelope with patient identification inside the envelope, and placed in a -70°C freezer.

Remember: Only an attending can approve giving tissue for non-diagnostic purposes (i.e. research or Tumor Bank).

Immunofluorescence

Tissue for which immunofluorescence has been requested must be received fresh, on saline-soaked gauze. During off-hours, the specimen should be bisected, with half-fixed in formalin and half in Michel's solution (available in the OR and Histology). Do not put Michel's fixative in the refrigerator. If a frozen section has been made, the surface of the frozen block can be covered in OCT to prevent drying, and the block and chuck stored at -70°C for later use in immunofluorescence.

Kidney Biopsies

You may be asked to submit a kidney biopsy for processing. Kidney biopsies are treated differently than other tissues. Get the patient's name, the physician's name and beeper number, and then call Dr. Shanley (492-0270, beeper 441-4012) and Kathy Pelton-Henrion (258-3976, beeper 467-7587) for specific instructions (i.e. taking tissue for EM).

All kidney biopsies are fixed in Zamboni's solution for LM & EM and in Michel's (Zeus) fluid for IF. These are available in Histology and in the OR. If you cannot reach Dr. Shanley or Kathy Pelton-Henrion, leave the biopsy in Zamboni's and Michel's and it can be rush processed the next business day.

Cytopathology

Cytopathology laboratory hours are 0800 to 1700, Monday through Friday. Health care providers may be referred to the Cytopathology Clinical Reference Manual for specimen collection procedures, which is present at each of the patient care units and clinics.

You need to schedule an appointment to come into the Cytopathology Laboratory to review the preparation procedures prior to assuming on-call responsibilities. Any stat request for Cytopathology testing after laboratory hours should be communicated to the AP attending on call to verify the necessity and to determine what accommodations are needed. Stat requests most frequently involve cerebrospinal fluid (CSF), bronchoalveolar lavage (BAL) and fine needle aspiration specimens.

CSF stat requests are prepared by the Anatomic Pathology resident on-call who will consult with either the Clinical Pathology Attending on call when there is a question of hematopoietic malignancy or the Anatomic Pathology Attending on call for all other diagnoses.

Procedure for Processing Cerebrospinal Fluid Specimens

Principle: Cytologic evaluation is done to evaluate evidence of primary CNS malignancies and metastatic disease, infection (requires one fixed and one air-dried slide) or hematopoietic malignancies (requires two air-dried slides).

Specimen: If the specimen is not a traumatic tap it is usually clear, colorless and sparsely cellular, with no visible sediment present, even after centrifugation. If specimen is a traumatic tap some amount of blood will be grossly visible. Lumbar taps should be differentiated from ventricular taps or specimens obtained from reservoirs.

Reagents or Media —Special Supplies and Equipment

Reagents/ stains

• 95% ETOH
• Papanicolaou stain or H&E may be used for fixed slides (for evaluation of primary CNS malignancies and metastatic disease, or infectious processes)
  
• Wright's-Giemsa stain is used on air-dried slides (for evaluation of hematopoietic malignancies)

Supplies or equipment

• Centrifuge tubes
• Superfrost plus slides
• Pasteur pipette
  
• Cytofunnel
• Cytocentrifuge clip
• Cytocentrifuge
• Lead pencil

PROCEDURE (READ THE ENTIRE PROCEDURE PRIOR TO PREPARING THE SPECIMEN)

1. Record volume and gross appearance of specimen on bottom left corner of requisition.
2. Specimens over 0.5 mL are spun in a labeled centrifuge tube at 1800 rpm for 10 minutes. Hand pipette off the centrifuged specimen to 0.5 mL and resuspend remaining specimen by gently squeezing the pipette bulb in and out, but keeping the specimen confined to the lower portion of the pipette tip. Do this even if there is no visible sediment. Proceed to #4.
3. Specimens less than 0.5 mL do not require centrifugation prior to making the cytocentrifuge slides. Proceed to #4.
4. Prepare two slides labeled in lead pencil with patient name and date. Place each slide on top of a metal cytocentrifuge clip. Place a cytofunnel on top of the labeled slide and close the wire bar to lock in place.
   Place the chambers with slide and cytofunnel in the cytocentrifuge across from each other for balancing, taking care to fit them in securely.
5. Using all of the remaining specimen, divide specimen evenly between the two cytocentrifuge chambers by gently squeezing the pipette bulb in and out, keeping the specimen confined to the lower portion of the pipette tip, and placing an equal number of drops in each of the two cytofunnel chambers. Cap the cytofunnels. Place the top on the cytocentrifuge head pushing down on the center plunger to secure in place. Put the head squarely into the cytocentrifuge. Close the lid to the cytocentrifuge tightly.
6. Program the cytocentrifuge for 1300 rpm, 1 minute at high acceleration (see operating instructions for cytocentrifuge on following page). Hit the start button. Wait there for the cytocentrifuge to stop. As soon as the cytocentrifuge stops, hit the open button. Immediately open the lid, remove the cytocentrifuge head, take off the top by pulling up on the center plunger and take out the slide chambers. Unhook the fasteners to the clips by sliding down and over. Lift the disposable cytofunnel off the slide and dispose.

   For evaluation of hematopoietic malignancy precede to #7.

   For evaluation of primary CNS malignancies and metastatic disease, or infection precede to #8.

7. Allow both slides to air dry. Precede to #9.
8. Allow one of the two slides to air dry. Immediately fix the other slide in 95% EtoH (have coplin jar with alcohol ready before the cytocentrifuge stops spinning. Allow the slide to fix for a minimum of 10 minutes prior to staining. Precede to #9.
9. Perform a Wright-Giemsa stain on air-dried slides (this can be done in Clinical Pathology or in Cytopathology). For fixed slides perform the Papanicolaou stain and allow to clear in Hemo-De for a minimum of 10 minutes prior to coverslipping. Refer to the Cytopathology Operating Manual for staining and coverslipping procedures.

Reporting Results

Confer with the appropriate attending on call for evaluation of the specimen. The diagnosis that is communicated to the physician requesting the stat diagnosis should also be written in the blank area on the bottom of the Cytopathology requisition. The person to whom the results were given, the name of the physicians(s) who rendered the diagnosis, and the date and time also need to be recorded. The slides and corresponding requisition are to be left in the Cytopathology preparatory room (2141A) by the computer.

Reference: Manual of Cytotechnology, 7th ed., American Society of Clinical Pathologists, 1993: 423-424, 440.

OPERATING INSTRUCTIONS FOR CYTOSPIN 3
(To be used when processing Cerebrospinal Fluids or bronchoalveolar lavage for Pneumocystis)

• Turn power on.
• Program speed for 1300 rpm.
  Press SET TIME.
• Press 1, 3, 0, 0
• Press ENTER.
• Check digital display (if wrong, press CANCEL and repeat).
• Program time for 1 minute.
• Press SET TIME.
• Press 1.
• Press ENTER.
• Check digital display.
• Set acceleration for HIGH.
  Press cover release (from left) and remove head from instrument.
• Secure chamber and slide in clip, check to make sure the chamber and filter holes are correctly aligned.
• Fit clip assembly into hinges in the head. It will tilt towards the center.
• Place the appropriate number of drops of resuspended material into the chambers, cap (refer to specific procedure, section 101 of manual).
• Place the head squarely in the instrument. Be careful not to disturb chambers. Check to see that all clip assemblies are fitted evenly into hinges.
• Spin at 1300 rpm for 1 minute.
  When the instrument stops spinning, the audible signal will sound.
• Press cover release and remove head with the chambers.
• Remove cytofunnels by releasing the clip taking care not to disturb the cellular area.
  
• Allow slides to air dry.
• Disinfect clips immediately by soaking in Cidex solution for 10 minutes, then and rinse with water.
• BAL specimens for Pneumocystis (PCP) should be referred to the Clinical Pathology resident and attending on call for immunofluorescent stains for PCP. This stain is more sensitive than the silver stain.

Procedures for processing all cytologic specimens for morphologic evaluation are located in the Cytopathology Standard Operating Manual located in the Cytopathology preparatory room.

If it is necessary to provide a preliminary diagnosis on a fine needle aspiration specimen while on-call consult with the AP attending pathologist.

Equipment and supplies are available in the FNA basket located in the Cytopathology preparatory room (2141A Weiskotten Hall). This includes:

• 20 cc syringe
• fine gauge needles (25, 23 or 22 g)
• sterile gauze
• bandaids
• coated glass slides
• 10 mL 0.9%NaCL, normal saline or RPMI for needle rinse (in refrigerator)
• formalin tubes (in refrigerator)
• lead pencil
• permanent marker
• box to hold glass slides
• Cytopathology requisition (general, breast or thyroid)
• coplin jars of methanol for fixing Diff-Quik slides
• coplin jars of Diff-Quik stains (two jars I & II)
• 95% ETOH (cytology fixative)

Before/ during the aspiration procedure

Lay out 2 to 10 glass slides and label frosted end with patient's name and site of aspiration with lead pencil (ink can smudge during cytopreparatory processing). Label saline, RPMI, or formalin container with patient's full name, site of aspiration and date. Uncap the specimen coplin jar and saline/ RPMI tube to be ready for immediate fixation of slides and needle rinse, respectively.

Handling the aspiration material

Pull back plunger slightly and then advance the plunger of syringe expressing one to two drops of the specimen onto one to three slides.

Invert another clean glass slide horizontally over the drop of specimen and pull slides apart, applying gentle and constant pressure in a single motion. Repeat this process for each slide that you applied a specimen drop(s) to.

Allow one or both of the pull apart slides to air dry. (You may choose to allow both slides to air-dry in order to stain them immediately with Diff-Quik stain for preliminary evaluation). If you choose to fix one of the pull apart slides place the slide immediately in a coplin jar 95% ETOH. The fixed slides will be stained with the Papanicolaou stain in Cytopathology on the next business day, and therefore will not be available to you for immediate evaluation.

Immediately after the slides are prepared rinse the needle several times by aspirating saline or RPMI back and forth prior to evacuating contents into the test tube.

If a core of tissue is obtained, a role prep or touch imprint of the core can be made by gentle distribution of the core on a labeled glass slide. Allow the slide to air dry for Diff-Quik stain and place the core tissue into a labeled tube of formalin.

The Diff-Quik stain is used in performing adequacy assessment, or preliminary diagnoses. To perform the Diff-Quik stain:

• Allow the slides to completely air dry.
• Dip the slide in methanol slowly 2 to 3 times.
• Dip the slide slowly in stain solution I (orange) 4 times or until the slide is uniformly coated by the stain.
• Rinse the slide in a slow stream of running water.
• Blot slide by tapping vertically on paper towel.
• Dip slide slowly in stain solution II (dark blue)about 8 times.
• Examine slide under microscope.
• Consult with the attending pathologist on call. Be sure to record the information that you give to the health care provider regarding the diagnosis on the FNA requisition under the adequacy/ preliminary diagnosis area. Record your name and the name of the physician you gave the results to, date and time.

A completed cytopathology requisition must accompany all specimens. This should include:

1. Patient name, hospital #, and account #
2. Patient location
3. Attending and ordering physician
4. Site of lesion aspirated, be specific as to side and lobe, etc.
5. Clinical diagnosis and all pertinent clinical information including radiologic findings when available
6. Date, time and location of procedure
7. ICD-9 diagnostic code
8. Ordering physician's signature
9. Ordering physician's MMIS number
10. Collect all of the slides placing the air-dried slides (Diff-Quik stained and any unstained air dried slides) in the slide box. Count and record on the requisition the number of air-dried slides and the number of fixed (95% ETOH) slides.
11. Bring the entire specimen with corresponding requisition to Cytopathology, Room 2141, Weiskotten Hall, placing the needle rinse on the top shelf of the refrigerator. Leave the slide box (dried slides), coplin jar (fixed slides) and core biopsy on the counter top with the completed requisition.

CP RESIDENT ON-CALL RESPONSIBILITIES

General

• Prepare Service Review Report.
• Check technical staffing in each section.
• Assess major equipment in each section and computer for malfunction.
• Consult with on-call attending clinical pathologist as needed.
• Be familiar with resident responsibilities as per disaster plan, which is located in the Pathology Safety Manual.

Chemistry

• Review clinical history of all extraordinary toxicology requests and communicate with the clinician as needed.
• Review requests for tests for appropriateness of medical necessity.
• Review requests for special STAT chemistry tests.
  

Cytogenetics

Routine Cytogenetics services are not offered after normal laboratory hours (0800 to 1700, Monday through Friday). The Cytogenetics Laboratory is staffed Saturday 0800 to 1630. On-call service is available after hours or weekends - see the on-call list posted at the Clinical Pathology Front Desk or in the AP/CP residents' rooms.

• For all specimens received after hours or on weekends, see the on-call list and contact the appropriate Cytogenetics Laboratory personnel.
• Requests for stat testing should be reviewed with on-call cytogenetics personnel or the Cytogenetics Laboratory director before agreeing to perform the service.

If there are any questions regarding appropriate specimen handling or disposition, contact the appropriate staff member as indicated on the on-call list.

Cytopathology - Cytopathology Specimen Collection Procedures

Routine Cytopathology service is not offered after normal laboratory hours (0800 to 1700, Monday through Friday):

A Cytopathology Clinical Reference Manual for specimen collection is present at each of the nursing stations and clinics as well as in the Cytopathology Laboratory. If a physician should call inquiring about a cytologic procedure, please refer them to the manual.

• Be sure to contact the Cytopathology Laboratory personnel prior to assum-ing on-call responsibil-ities.
• You should schedule an appoint-ment to come into the Cytopathology Laboratory to review the procedure ahead of time.

The Cytopathology Laboratory manual is located in the Cytopreparation room 2141A. Refer to the procedures and operating instructions prior to performing any procedure.

All cerebrospinal fluid specimens for Cytopathology, whether inpatient or outpatient, MUST BE BROUGHT DIRECTLY TO THE CYTOPATHOLOGY LABORATORY AND REFRIGERATED. If it is absolutely necessary to obtain a cerebrospi-nal fluid for an immediate evaluation during off hours, the speci-men is to be prepared by the Clinical Pathology resident on-call who will consult with the Hematopathology attending, when appro-priate (leukemia, lymphoma). The diagnosis that is communicated to the physi-cian requesting the rush diagnosis should also be written in the blank area of the Cytopathology requisition. The person to whom the results were given, the name of the physician(s) who rendered the diagnosis, as well as the date and time also need to be recorded on the Cytopathology requisition. The slides are to be left in the Cytopathology Laboratory (2141 WH) with the completed requisition on the multi-headed microscope table.

STAT requests for GMS stains of bronchoalveolar lavage (BAL) fluids for detection of Pneumocystic carinii are the responsibility of the AP resident and attending on call. Be sure to familiarize yourself with the proper procedure before going on call. STAT requests for immunofluorescent stains are handled through Clinical Pathology see Microbiology/Virology)

If there is a request to perform a fine needle aspiration or provide a diagnosis on a fine needle aspirate after laboratory hours, the Anatomic resident will consult with the Anatomic attending pathologist.

All fluids for cytopathology should be stored in the refrigerator for routine processing on the next regular work day. STAT requests for Cytopathology are not accepted unless approved by the attending on-call.

Hematology

Check with technologist in charge of Hematology, review abnormal blood films by 1000 on weekends or holidays, as requested, and sign CBC slips. Consult with hematology fellow (or attending) on call, as necessary, and notify clinicians of any important new findings.

Follow through on abnormal coagulation studies brought to your attention, insuring that appropriate definitive studies are performed and reported.

Perform blood and bone marrow Wright-Giemsa and peroxidase stains when necessary.

Transport fixed bone marrow biopsy and clot section specimens to the Histology Laboratory in Anatomic Pathology. Bone marrow biopsy and aspirate clot sections are fixed in freshly prepared B-5 fixative (9 parts B-5 stock solution and 1 part 37% formaldehyde, available in the bone marrow processing area) for 2 hours and then transferred to 70% ethanol (available in the bone marrow processing area). DO NOT allow specimens to fix for more than 2 hours in B-5. The technologists in the core lab or the processing area can assist by transferring the specimens from B-5 to 70% ethanol after 2 hours. The fixed specimens in 70% ethanol are then decalcified and processed by the Histology Laboratory.

The processing of lymph node biopsies is the responsibility of the AP resident on-call (see page 46).

Immunology/Flow Cytometry/Electron Microscopy

Perform cryptococcal antigen test when necessary. The processing of tissue for immunofluorescence is the responsibility of the AP resident on-call.

LIS:

• Computer staff will notify on-call resident of any downtime and an estimate of when the system will be up.
• If downtime is of an extended period, implement computer disaster plan.
• Notify units of downtime if reporting systems are affected.
  

Microbiology/Virology:

• Approve and read "STAT" acid fast stains.
• Notify physicians of positive blood and spinal fluid cultures if the laboratory staff cannot locate the physician, and notify physicians of positive acid fast results.
• Insure optimal collection and plating of unusual cul-tures, i.e. lung aspirates, brain abscess, lung abscesses, etc.
• STAT requests that must be approved by either Pediatric or Adult Infectious Disease attendings (depending on the age of the patient):
  • Influenza A antigen
  • RSV antigen
  • Legionella DFA
  • Pneumocystis DFA
• Residents are expected to perform STAT RSV and Influenza antigen tests after hours, i.e. after 4:00 p.m. on weekdays, after 2:30 p.m. on weekends.
• All other STAT requests must be approved in conjunction with Drs. Forbes or Kiska. If they are not available, involve the Infectious Disease attending on-call.
• If the STAT tests are approved, notify Virology personnel by use of the re-call list posted in Microbiology.

Note: Under certain circumstances, you may be expected to process specimens and perform cell culture inoculation for viruses with the aid of Virology personnel via phone.

Note: If STAT requests are made by Pediatric or Adult Infectious Disease attendings, no further approval is required.

Molecular Pathology

Routine Molecular Pathology Laboratory services are not offered after normal laboratory hours (0800 to 1700, Monday through Friday).

Specimen requirements:

Adults and children

• 10 mL EDTA
• infants, 1-2 mL EDTA (pediatric tube)
• Store at room temperature
• receipt Monday through Friday, within 24 hours of collection

Refer to the Molecular Pathology procedure manual located in the main lab (Rm. 3814) for more specific details (i.e., for gene rearrangement assay, see section 200.4). Part Two of the Molecular Pathology procedure manual contains procedures for each test that is currently offered clinically. Each procedure has a subsection titled "specimen (sample) collection and transport" which details sample requirements and handling.

Any requests for STAT testing should be reviewed with the director (Dr. Antony E. Shrimpton) or the technical supervisor (Celeste Lamberson).

Transfusion Medicine

Review requests for:

Fresh frozen plasma: more than 4 units per patient or any volume in a patient with normal coagula-tion studies.

Platelets: single donor units, HAL Pharisees products. All platelet requests, especially those exceeding 6 units should be reviewed to determine if appropriate.

Leukocyte reduced packed red cells, washed red cells, frozen red cells, requests for irradiated blood.

Contact ordering physician if blood component order form does not have an appropriate indication noted. Consult with attending if necessary on unusual circumstances. Record changes in orders and rationale for unusual orders on blood component order form. If an order is not changed and seems inappropriate, bring information to supervisor's attention for review by Blood Utilization Review Committee. Follow-up cases for who orders were canceled. Note any adverse outcomes that may have resulted from use of the guidelines.

Follow-up transfusion reactions by ascertaining present status of patient, necessary emergency therapy, if any, desired follow-up laboratory assessment and future blood requirements by clinicians with a verbal preliminary report to clinicians. Any hemolytic transfusion reaction requires your presence at the bedside immedi-ately and to promptly telephone the attending clinical pathologist. Present written report to Transfusion Medicine attending within 24 hours (including weekends).

• Check the Transfusion Medicine inventory and be aware of any blood shortages (especially O negative).
  Be aware of antibody work-ups in progress and communicate antibody or crossmatch problems to the appropriate physicians.
  Review blood orders for Monday surgery. Complete OR schedule and compare with "Guidelines for Ordering Blood for Elective Surgery".
  
  If a request is made for an emergency therapeutic apheresis on the weekend, the resident is required to evaluate the request and make recom-mendations to attending apheresis physician in regard to treatment. The resident must be on site during the apheresis procedure.
  

Change of Address

The Department of Pathology and the Office of Graduate Medical Education must know your address and telephone number at all times. Give the Residency Coordinator your New York address and phone number as soon as you know it. If you move, notify the Residency Coordinator as soon as possible. When you complete your training, leave a forwarding address with the Residency Coordinator.

Code 405 Regulations

Code 405 - "The scheduled work week shall not exceed an average of eighty (80) hours per week over a four week period."

Summary of Requirements

A limit of 80 hours for the scheduled workweek of residents averaged over a four-week period. On-call duty in the hospital for surgical residents is not included in the 80 hour limit when evidence of adequate rest time is available and the number of interruptions are infrequent.

• Assigned work periods should not exceed 24 consecutive hours. The on-call duty of surgical residents in hospital is not included in the 24-hour limit with evidence that rest time is adequate and interruptions infrequent.
• For hospital emergency departments with more than 15,000 unscheduled visits per year, the on-duty assignment of residents should not exceed 12 consecutive hours.
• Dual employment or "moonlighting" by residents must be monitored by hospitals and any such hours worked must be considered as part of the working hour limitations.
• Non-working period following scheduled on-duty or on-call periods, and one 24 hours period of scheduled non-working time per week must be provided.
• Onsite, 24 hours per day, seven days per week, supervision of residents by physicians in their respective specialties is required.
• Direct in-person supervision by an attending surgeon is required for all surgical procedures involving general anesthesia.
• In addition to adhering to the schedules that have been made up to accommodate these rules, you are to contact your supervisor and/or your attending whenever you feel tired. It is the responsibility of your direct supervisor and/or you attending to allow you to go home with no penalty or negative rating or other consequence on your residency record. If you find that you are not provided with relief at these times nor have reprisals taken against you, you should bring these issues to the direct attention of either the Department Chair or the Residency Program Director. (See example of Resident Work Hour Monitoring Sheet)

Conferences

• Attendance at weekly conferences is mandatory. Each resident/fellow is required to attend at least 80% of the conferences. A low attendance will be cause for concern. Conference attendance will become part of your review with the program director.
• It is your responsibility to inform the Residency Coordinator if there is an instance where you miss a conference due to a conflict.

Faculty Evaluations

Keys

• Keys to the Anatomic Pathology and Clinical Pathology floors and to the OR can be obtained in the department coordinator's office (2123 WSK).
• Keys must be returned to the coordinator's office upon the completion of your residency. No certificate will be issued until they are returned.

Leave

Family Leave

The Family and Medical Leave Act (FMLA) gives eligible employees the right to take unpaid leave, or paid leave charged to appropriate leave credits under certain circumstances, for a period of up to 12 workweeks in a 12-month period (calendar year for State employees). Eligible employees are those who:

• have completed one year of service and
  
• have worked, or otherwise were in paid status, for a minimum of 1,250 hours during the 12-month period immediately preceding departure on leave.
  
  
• Under certain conditions, FMLA leave may be taken on an intermittent basis. Employees are also entitled to continuation of health and certain other insurances, provided the employee pays his or her share of the premium during this period of leave.
• If an employee desires to take FMLA leave, but the Health Science Center Office of Human Resources is not made aware of the reason, the employee must notify his/her supervisor of the reason for the leave no later than two business days of returning to work. Absence of such timely notification, she cannot assert FMLA protection for absence.
• Leave is available for the following circumstances:
  • Placement of a child in the resident's home for adoption or foster care.
  • Birth of a child to the resident or the resident's spouse.
  • The need to care for a family member with a serious health condition.
  • The resident's own serious health problem.
• Residents with scheduled family leave should contact the Office of Graduate Medical Education and hospital personnel offices concerning maintaining their health care coverage while on leave without pay.
• Questions regarding the application and interpretation of the leave policy should be directed to the Benefits Office in Jacobsen Hall.

Maternity

Maternity leave results in the least dislocation when planned promptly. Early consultation with the director of the Resident Training Program is very important.

• Some rotations present fetal risk. Pregnant residents should contact their program director promptly regarding such risk.
• Pregnancy is considered a short-term disability.
• Maternity leave can consist of vacation, sick leave, or leave without pay in any combination. Additional information can be obtained from the Personnel Benefits Office.

Sick Leave

• All full and part-time faculty and professional staff employees earn sick leave credits on the same basis as vacation credits, and may accumulate up to a maximum of 200 sick leave days.
• A Sick Leave Exchange Program will be available to full-time UUP-represented employees during the term of the 1999-2003 negotiated agreement between the State and the UUP.
• Eligible employees may elect once a year to reduce their sick leave accrual rate in exchange for a credit to be applied against the cost of the New York State Health Insurance Program (NYSHIP) premiums.
  
  In order to participate, you must:
  
  
  • Be a member of the SUNY Professional Services Negotiating Unit;
    
  • Be employed on a full-time basis;
    
  • Be eligible to earn sick leave credits;
    
  • Be on the payroll for some portion of the election period;
    
  • Be covered under NYSHIP; and
    
  • Have a sick leave balance of 15 days or more at the time of the election
    
• Participation in the Program automatically ceases at the end of each calendar year covered by the agreement and employees return to earning their sick leave at their normal rate and resume payment of the normal employee share of the NYSHIP health insurance premium unless they file a new election to participate for the next calendar year.
  
• If you are sick, notify one of the chief residents and the residency coordinator. The chief resident with whom you speak will let you know if anyone else needs to be notified.

Vacation

The present contract provides for 15 working days of vacation for the first year of service at SUNY Upstate, (16 for the second year; 18 for the third, fourth and fifth years; 20 for the sixth year), and increasing to a total of 21 days per year for the seventh year and beyond.

Vacation may be scheduled in advance of actual accrual as necessary to provide for a smooth flow of scheduling of resident assignments throughout the year.

All requests for vacation and or travel arrangements are to be submitted by completion of the proper request form (See accompanying example) at least one month in advance of the requested date of departure. In order to assure adequate service coverage, these requests should first be cleared through the Program Director's Office.

Leave for vacation and/or business is not ordinarily permitted for a period of time exceeding two full calendar weeks. Requests also require the approval of the chief resident, attending(s) responsible for the rotation(s) concerned, and the appropriate division director. Approval is not automatic, and depends on staffing, schedules, service responsibilities, etc.

• When two residents have been assigned to a rotation, only one may be on vacation at any time.
  
• The institution asks that vacation time be used during the year in which it is earned and not carried over for accrual in the following year.
  
• New residents and residents continuing in the program are not to schedule vacation during the last three weeks of June or first weeks of July.
  
• Residents who are leaving the program may reserve and schedule a maximum of one week of vacation time at the end of their residency training program.
  
• All request forms must be submitted to the appropriate timekeeper for recording of accruals and time taken off for vacation and sick leave. (Ms. Ginger Gigantelli for residents assigned to Clinical Pathology, and Ms. Chris McGivney for residents assigned to Anatomic Pathology).
  
• Vacation can be taken on any rotation except when serving in Surgical Pathology at UH. Exceptions are at the discretion of the Rotation Director.
  
• Residents are expected to be judicious in the timing of vacation, with primary concern for patient care, as well as consideration towards their colleagues, both resident and faculty.

Long Distance Telephone Policy

Upstate employees are assigned a 6 digit authorization code for long distance access. Please do not allow other personnel to use your authorization code. To place a long distance call, enter:

6 digit authorization code —# - 9 - Area Code - Number

• Only business long distance calls should be placed from telephones in Upstate Medical University. You will be asked to confirm that calls identified by your authorization code are business related.
  
• See Upstate Telephone Directory Resource Guide for personal long distance dialing instructions.
  
• Problems with telephones should be reported to the hospital operator —ß "O".

Mailboxes

Every pathology resident and fellow has a mailbox: in Room 2106 WSK. All correspondence with department members will be through your mailbox in the department. Most housestaff members choose to use the departmental mailbox for delivery of journals, etc. You should check your mailbox frequently

Meals while on-call

• Sleeping quarters (on-call rooms) will be provided for nights on in-house duty assignment.
• Residents on first call at University Hospital or the Veterans Administration Medical Center will receive meal tickets to defray the costs of either dinner or breakfast or both depending on the length of duty

Moonlighting

Upstate Medical University philosophically opposes involvement in extra-curricular professional activities (moonlighting) during graduate medical education training.

• Such activities are permitted only with the express written permission of the department chair.
• A resident's annual agreement may not be renewed if, in the opinion of the department, such activities are interfering with my duties and educational progress.

Pagers

You will be assigned a pager within a few days of your arrival. You will keep that pager throughout your training.

• As with keys, your pager must be returned before you leave, or your certificate will not be issued.
• If you lose your pager, report it to Lisa Glowacki, Residency Coordinator (2123 WSK) immediately
• There is a supply of batteries for the pagers in Chris McGivney's office (2108 WSK) or the AP front desk (2106 WSK).
  

Promotions, Probation and Dismissals

Policies and procedures regarding academic promotion, probation, and dismissal are printed in the Housestaff Handbook published by the Office of Graduate Medical Education (Room 3235 WSK) as well as in the front of the Residency Manual.

Residency Coordinator

The residency coordinator, Lisa Glowacki, is located in Weiskotten Hall, Room 2123. Her office phone number is 44670. She will try to help you with any question or problem you may have.

Resident Evaluations

From the onset, the residents should identify strongly with the patient problems assigned, contribute to the extent that they are able and make appropriate corrections in their deficiencies. All of the programs will provide ample learning opportunities but consolidation and extension of the experience is the responsibility of the resident through intensive perusal of texts and, where appropriate, the literature. Evidence of continuing growth and maturation will be met with increasing independence and responsibility.

• Summary evaluation of each resident will be issued for record twice a year
• Evaluation will be the result of periodic meetings of the program director with the pathology faculty to obtain a consensus view of the resident's performance in recent rotations
• Consensus evaluation will then be discussed with the resident by the program director
• Opportunity for clarification of issues, which have arisen, and planning for the residents future will occur during discussion
• Result of this meeting will be a summary letter from the program director to the resident outlining the consensus evaluation by the faculty and the result of the discussion with the resident
• Resident will be given the option of writing a response and will be asked to sign the letter as acknowledgment of its appropriateness

Rotation Evaluations

After each rotation, the resident is asked to complete a brief evaluation form for review by the Program Director. Training credit for the rotation is contingent upon completion of this form.

Supervision Policy

All cases to be signed out in all laboratories will have an attending physician who is responsible for the diagnosis.

Individual residents may expect increasing levels of responsibility in the work-up and management of cases as they progress through their training. However, since residents progress at different rates, specific responsibilities at specific PGY levels are impossible to define. The level of responsibility given to a resident is therefore at the discretion of the designated attending. At no time, however, will a resident function without clear and readily available supervision.

General Goals in Anatomic Pathology

The following are goals for Anatomic Pathology training for all residents. They are flexible and certainly should not be considered final. Nonetheless, the context of these goals is defined by the time and resource constraints of pathology practice and by the fundamental principle that our efforts must always serve the patient.

1. Learn to use gross inspection, routine histology, cytopathology and special investigations to formulate differential diagnoses, arrive at diagnoses, and solve clinical problems.
2. Learn to communicate your findings and conclusions clearly, in a manner useful to all appropriate audiences, especially clinicians. Skill in both oral and written communication is critical.
3. Learn to constantly update and expand your knowledge of facts, terminology, and classifications of disease. Clinical correlations are often key to meaningful diagnosis, problem solving, prognostication and thus effective pathology consultation. Furthermore, understanding limits of knowledge is essential to obtaining assistance in difficult situations.
4. Maintain enthusiasm for continued learning. Nurture your familiarity with bibliographic resources. Learn how to critically evaluate literature. Recognize and apply self-motivation in your work. Prepare yourself for assumption of major responsibility.
   

Learning Resources

References for Anatomic Pathology Rotations:

• The basic student texts (Robbins and Anderson) are good for general pathobiology and autopsy pathology but should serve only as a starting point. You should be reading regularly in monographs and the journals.
• Organize your time to systematically read and review topics and organ systems. Fundamental texts (Rosai, Silverberg, Sternberg) should be read, re-read, scrutinized, etc cover to cover.
• Please make heavy use of the Surgical Pathology Library areas. (Remember to keep the volumes and shelves tidy and organized. Do not remove materials from the immediate library area as this removes reference material from common access.)

References for Clinical Pathology Rotations:

Journals (partial listing only)

• Acta Cytologica Cytometry
  
• American Journal of Clinical Pathology Transfusion Diagnostic Cytopathology
  
• American Journal of Human Genetics Diagnostic Molecular Genetics
  
• American Journal of Medical Genetics Diagnostic Molecular Pathology
  
• Archives of Pathology and Laboratory Medicine Hematology/Oncology Clinics of North America
  
• Blood Human Genetics
  
• Clinical Chemistry Human Molecular Genetics
  
• Clinical Laboratory Hematology Human Pathology
  
• Clinical Laboratory Management Review Genetic Testing
  
• Clinical Microbiology Newsletter Journal of Clinical Investigation
  
• Clinics in Laboratory Medicine Journal of Clinical Microbiology
  
• Cytogenetics and Cell Genetics Journal of Infectious Diseases
  
• Laboratory Medicine
  
• Molecular Diagnosis
  
• New England Journal of Medicine Review of Infectious Diseases
  
• The American Journal of Pathology
  
• Seminars in Hematology

Policy for House Staff to Take an Elective Rotation at an Outside Hospital/Institution without an Affiliation Agreement with SUNY Upstate

It is necessary that we complete the "Residency Affiliation Agreement Information Sheet" and return this to Kip VanBuren in the Office of Finance & Management, along with the other information below needed for outside hospital/institution elective rotation (MARKED AS "EXHIBIT B"):

1. Name of institution and program director (with address & phone number)
   
2. Name and length of approved elective rotation and name of direct supervisor
   
3. Specific responsibilities/duties and range of clinical activities of the resident during the rotation
   
4. Statement regarding ACGME program accreditation
5. *Statement regarding malpractice liability & disability insurance coverage for resident while on elective rotation at outside facility

*Clinical Coordinator or other administrative official at outside hospital will need to verify this information. We should ask them to send us a copy of their residency affiliation agreement for our Finance & Management office to review and approve (or, if they do not have an agreement established for accepting residents for an elective rotation from another hospital, we can send them a copy of our agreement for their review and approval).

Note: IF APPROVED —

• Resident will stay on SUNY payroll (with vacation/sick leave and health insurance benefits).
  
• Malpractice insurance through SUNY ordinarily will NOT cover the resident while on rotation at the outside hospital. Outside institution needs to be encouraged to provide malpractice liability & disability coverage. However, if they cannot provide this coverage, the affiliation agreement can be written so that SUNY Upstate will cover our resident.
• We will need assurance from the outside hospital that they will provide an evaluation on the resident's performance for this elective rotation.
• The resident may require health clearance and proof of appropriate credentialing prior to being accepted for elective rotation. This is the resident's responsibility.
• There is no institutional provision for payment of housing/meal expenses for the resident while on elective rotation.
• Graduate Medical Education Office needs a copy of the correspondence for their records.

Malpractice - Liability/Worker's Comp/Disability Coverage

• Residents on rotation at Upstate or one of the Upstate satellite facilities are covered by SUNY statutory coverage (no commercial insurance policy)
• Residents on rotation at St. Joseph, CIM, or CGH (or any other outside hospital with or without affiliation agreement - i.e. MD Anderson Cancer Center) are covered by the outside hospital - commercial or self-retained insurance
• Residents on rotation at VAMC or other Federal institution (AFIP) are covered by Federal govt. coverage. Residents on rotation at a "non-for-profit, charitable" facility (i.e. Onon. Indian Nation Clinic) are covered by SUNY statutory coverage (no commercial insurance policy)
• Upon receipt of a signed affiliation agreement at any other ACGME-accredited facility, coverage will be provided by SUNY Upstate for our resident to take an elective rotation at that facility.
• Residents on rotation at a "non-for-profit, charitable" facility (i.e. Onon. Indian Nation Clinic) are covered by SUNY statutory coverage (no commercial insurance policy)
• Upon receipt of a signed affiliation agreement at any other ACGME-accredited facility, coverage will be provided by SUNY Upstate for our resident to take an elective rotation at that facility.

Research and Teaching Opportunities

Research

The residents are exposed to an environment, which values a scholarly approach to the problems of pathology and disease and are encouraged to participate in this through opportunities for teaching and clinical or basic research. Research projects may develop as a result of pursuing in-depth studies on subjects in which the resident has a special interest, or may emerge during rotations in the various services. Each resident is strongly encouraged to pursue pathology practice and training intellectually, with curiosity and imagination, and, as appropriate, to submit manuscripts for publication during his/her residency training. This is considered a valuable learning experience and an important part of the residency program, regardless of the eventual practice setting for the individual resident. The work may be related to methods development, clinical or basic research, or reviews.

A separate "research track", which does not include rotations outside of University Hospital (Binghamton and VAMC) as mandatory rotations is available with the approval of the program director. Residents interested in this track must apply in advance to the department for one year of dedicated research time based on a formal proposal and with an identified mentor (who may be inside or outside the department) and an identified source of funding support. Active projects with extramural funding within the department are found in Hematopathology, Cancer genetics, Eye pathology and Urologic pathology.

Teaching Responsibilities

Residents are required to participate in the teaching programs of the department. Residents will serve as teaching assistants in laboratory sessions for medical students in the pathology course for second year medical students (PATH 200) as well as teaching the Cytotechnology students.

Exhibits and Presentations

Residents are encouraged to present papers or poster sessions at any of the local or national meetings or proceedings of various research or professional societies. Residents will find the annual and semi-annual meetings of the US - Canadian Academy of Pathology, The American Society of Clinical Pathologists, the College of American Pathologists, and other Pathology and Laboratory medical organizations appropriate for most oral and poster presentations.

Residents will summarize and present articles for Journal Club and will prepare presentations for the Resident Conference on a rotating basis.

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