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Surgical Pathology - UNM Hospital Rotation

Faculty: Nancy Joste, M.D. (Division Chief), Marc Barry, M.D., Thèrése Bocklage, M.D., Lesley Lomo, M.D., Von Samedi, M.D., Ph.D., Karen SantaCruz, M.D.

Length: two 3-month rotations

Rotation Structure: OPTIMIZED FOR RESIDENT LEARNING. Three day cycle in which Day 1 = grossing in cases, Day 2= reviewing the cases’ microscopic features and dictating diagnoses, Day 3= signing out the cases with the attending faculty member

Annual Surgical Pathology Cases: approximately 22,000

Annual Number of Challenging and Interesting Cases: approximately 22,000 (especially for a novitiate)

The STARK FACTS are actually not that stark. When you begin to learn a new set of skills, you may feel cerebrally challenged. In fact, reputable studies show that the process of assimilating new skills frets the frontal lobe; all that incessant, erratic neuronal firing can be exhausting. Once learning has settled into the synapses, however, it magically (well, we can’t explain how) transfers to some site in the temporal lobe where it quietly, nearly automatically, clicks and shifts in activity like well-oiled Shimano gears. Our goal as faculty teaching you how to recognize pathologic entities is to ease you with that transference from frontal to temporal lobes. We do it by leading you through varied terrain in varied conditions, as an expert guides a novice. You are never on your own, but you are accorded increasing responsibility and independence as you verify increasing mastery.

Another surprisingly healthful feature about divisions of AP like surgical pathology, cytopathology, and forensic pathology is that you use your hands to nimbly dissect a Whipple resection, perform an unwobbly FNA of a patient’s enlarged neck lymph node, and check assiduously for an obstruction of the left anterior descending artery. Why, you ask, is this healthful? Yet another set of studies (those psychologists keep themselves busy) reports that professions or hobbies that require hand motor activity are associated with a lower overall rate of depression.

So, be prepared for some initial arduous learning but also expect to be pretty happy while so engaged. Enough of the generalities…..As a resident on the UNM Surgical Pathology service, here’s how your days go:

Day 1: About 60-70 cases come in per day for grossing that are accompanied by daily frozen sections numbering from 3 to 50. Two pathologist’s assistants and three accessioners work with you in the Gross Room as you steadily increase your efficiency in dissection. These senior PAs are instructors at the University and are eager to teach you (they also give PowerPoint presentations on grossing the more common specimens).

Day 2 comprises a girl and her microscope (ditto for a boy)….and about 50 cases (we limit the amount of cases to this number in order to maximize learning and minimize fatigue and ACGME infractions). On a typical day, you will examine a diversity of cases such as gynecologic and GI biopsies, a breast biopsy or two, two to three large resections, and miscellaneous items such as an incisional biopsy of a deep hand mass or a lung wedge biopsy evaluating for infection versus neoplasm. On this day, you may also cut in a big case from the day before (we have rules for when a case is carried over). This is your day to revel in microscopic details (or feel grateful that you are not the person deciding whether low grade or high grade dysplasia is present in a Barrett’s esophagus lesion). Since your office is surrounded by the glowing intellectual nimbuses of more senior pathology residents in their nearby cubicles, you can ask them for their thoughts. They can direct you to the diagnostic clues, or, if pestered persistently, they may actually choke out the diagnosis like a harassed parent bird with its chick. In any case, you will only order special stains with the permission of the faculty member (there are over 350 immunohistochemical and other stains from which to choose).

Day 3 is the day of reckoning, the day you reveal your inmost diagnostic musings to the attending faculty member. This is the day you should prepare for by 1) reading about differentials, 2) checking that your gross descriptions don’t meander like the old Mississippi, and 3) dressing nicely (the last only is optional). It’s also the day when you confirm that your learning curve rockets beyond the stratosphere. You will spend about 6-8 hours one on one with the attending faculty member. Our styles differ, but all of us are keen to make sure that you are fit to practice surgical pathology independently by the end of your training (it’s a blood oath we take, or, in other words, an ACGME mandate). In summary, surgical pathology training is engrossing, cerebral that transforms to temporal, and fun. A 2008 poll of graduates from our program revealed a high regard for the surgical pathology training received in their residency, and they are truly testing it now. First time Boards pass rates in AP are high 90s, too.