Goals and Objectives:

1. To teach residents to recognize disease, make clinicopathologic correlations and convey information to clinicians.
2. To teach residents how to dissect and describe organs and lesions, submit tissue blocks for sections and analyze the histology.

The Autopsy Pathology service does over 300 postmortem examina-tions each year, including over 225 adult and over 75 perinatal cases. Compared to many autopsy services, our caseload remains high, with approximately 25% of adult deaths coming to post mortem examination. A Guide to Autopsy Division Procedures and Policies provides detailed assistance in method-ology, documentation and administrative procedure; it is updated yearly and a copy given to each resident. The Chief of Autopsy Pathology is Dr. Gayle Winters.

Typically, 3 residents cover the Autopsy Service (with shared responsibilities on frozen section coverage; see below) during which they perform autopsies, present them at the Gross Conference, and sign them out with the autopsy senior staff. The pace is quite variable with an average of 2-3 cases per resident per week. The Chief Resident oversees and is an integral part of the autopsy service.

Residents begin a postmortem examination with review of the chart and phone discussion with physicians caring for the patient concerning clinical questions. The resident then reviews with the senior pathologist (1) validity of the autopsy permit, (2) need for subspecialty consultation, (3) need for infectious precautions, (4) general approach to the case, and (5) key clinical questions to be answered by the autopsy. After the training period comprising several cases at which the Chief Resident and/or senior pathologist are present throughout, residents contact the Chief Resident or senior pathologist at any time during subsequent autopsies when questions arise. In all cases, following a dissection which takes 2 to 5 or more hours depending on complexity and prosector experience, the resident and senior pathologist review the organs in detail. --They also decide how the case will be presented at the Gross Conference and which grossly selected lesions may benefit from frozen sections or paraffin-embedded sections processed overnight in order to render a definitive diagnosis rapidly, often in time for the Gross Conference and to be included in the preliminary report to the clinicians. -A resident on the Autopsy Service attends and present his/her cases at the following Gross Conference (3 per week), including a short clinical summary, presentation of the gross specimens, and review of any available microscopic sections, followed by discussion. The conference is typically attended by at least 4 senior staff pathologists, including ----Drs. Schoen, von Lichten-berg, Winters, and the senior pathologist assigned for that week, as well as residents, rotating medical students, subspecialty fellows and staff, and neuropathology residents and fellows. In addition, a radiology resident assigned to the Autopsy Pathology service presents pertinent radiographs. Clinicians and their house staff are encouraged to and often do attend Gross Conferences where patients they have cared for are discussed. The resident prosector cuts in the specimens, writes up the Preliminary Anatomic Diagnoses (PAD) document which is reviewed with and signed out by the senior pathologist and distributed to the clinicians. He/She later writes the Final Anatomic Diagnoses (FAD), following both detailed examination and review of the microscopic sections with the senior pathologist. PADs are signed out within 2 days, while the FADs take on average approximately 1 month; both are immediately and automatically available to clinicians on the hospital-wide computer system. The resident prosector also cuts the brain on his/her autopsies and generates a gross description and final neuropathology report based on clinical history, gross findings, and histologic sections under the direction of the neuropathology fellow and/or staff. Subspecialty pathologists provide formal consultation on selected cases as appropriate. Most autopsy cases are presented to the clinical services at Medical, Surgical, and Cardiology Morbidity and Mortality/Clinicopathologic Conferences, Dana-Farber Oncology Conference, Neurology/ Neuropathology Conferences, as well as others. Many cases are presented at various pathology departmental conferences.

Autopsies on non-BWH patients are frequently received in consultation and may consist of a complete autopsy or single organs (e.g. heart or brain). Residents are routinely assigned to these cases and work them up under the supervision of the autopsy senior staff.

The three residents assigned to the autopsy service have shared responsibilities on frozen section coverage. On any given day, one resident is assigned to frozen section coverage, and the others are on-call for an autopsy, according to a rotation schedule.

As residents become more proficient, they assume more responsibility for the total workup and presentation of their cases, including selecting and notifying appropriate subspecialty consultants, deciding on a method of dissection (when options are available) which best displays the pathologic findings, communicating independently with clinicians, and completing the full write-up of the case including microscopic descriptions and finalizing the FAD prior to sign-out with the senior staff. Some Chief Residents serve as sub-attendings on the autopsy service with final signout supervised by the senior pathologist.