Autopsy Rotation at Your Program

[big al]

I didn't want to hijack the other post concerning autopsies that is currently ongoing so I started this new thread. Just wondering how the autopsy rotation is dealt with in your program. At my institution the first year resident does two months of autopsy and the first month is spent with an upper level resident learning the ropes. Otherwise there is only one resident on autopsy per month. If we have above a certain number of autopsies per day a resident on a "lighter rotation" is recruited to help eviserate, etc. We don't have a written policy specifically concerning the details of when this should happen and it has lead to some confusion. Do any of you have a written policy concerning the number of autopsies/per day and how this is handled? Most of the time it is not really a problem, we are not inundated (~110/year) with autopsies but some residents have abused others in the past and I would like for this to end. Any advice would be appreciated.

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[Cloaca]

I didn't want to hijack the other post concerning autopsies that is currently ongoing so I started this new thread. Just wondering how the autopsy rotation is dealt with in your program. At my institution the first year resident does two months of autopsy and the first month is spent with an upper level resident learning the ropes. Otherwise there is only one resident on autopsy per month. If we have above a certain number of autopsies per day a resident on a "lighter rotation" is recruited to help eviserate, etc. We don't have a written policy specifically concerning the details of when this should happen and it has lead to some confusion. Do any of you have a written policy concerning the number of autopsies/per day and how this is handled? Most of the time it is not really a problem, we are not inundated (~110/year) with autopsies but some residents have abused others in the past and I would like for this to end. Any advice would be appreciated.

We don't have a limit on the number per day. At our program there are always two residents on the service and you alternate cases. The most I have seen any one person do is two in one day, although one adult and two babies wouldn't be outrageous. Any cases that can't be started by, say 4:30 or 5pm will be pushed off to the next day.

 

[yaah]

Ours is changing. When I started you did 3-4 months of autopsy, all in first year. 2 residents on at a time, alternated cases (or shared if it was interesting or at the end of the year and someone's numbers weren't high enough). First years also take all the autopsy call on weekends.

Now it is changing so that we will do most of our autopsy first year, but have a "senior" year, I don't know what year, in which we help educate the new person as well as doing more cases ourselves.

There are no policies on # of cases per day. During my year, the most we had in a day was 5 (we had that happen twice). Both times, I did 3 of them. Wasn't that bad. First case done by 10-11, second one by 1-2pm, third one by 4pm. If you have a diener that works fast and helps a lot, it goes faster. The paperwork takes awhile though.

I can see that being a problem though if certain residents abuse the policy you are talking about, or if only a couple of people are ever willing to help out. We have residents like that - the first ones to ask for help, the last ones to offer it. Then there are the people who will never volunteer for anything, and finally the group of people who will help out. Unfortunately the only way around it is to have a strict policy (such as, any autopsy after the 2nd one of the day will be done by the resident on rotation X).

 

[CameronFrye]

We have five months of autopsy as a first year, followed by one month as a third year (your main responsibility that month is to teach the first years). There are two first years on service at a time, although autopsy months are a popular time to take vacation, so you may be on service by yourself at times. There is a primary resident on each case who will handle the paperwork, talk to the clinicians, take sections, etc. The secondary resident helps dissect the organ blocks and clean up. The primary resident alternates on each case. Typically, if there are two autopsies in a day, we will do them sequentially. If there are more than two cases then they will be performed simultaneously (we have two rooms and two autopsy techs), but those days suck b/c you lose your secondary resident. Each resident alternates weekend call, which means that you do any cases that come in before noon. I only had to come in a couple times all year, but other people came in almost every call weekend.

Autopsies here are really feast or famine. One month, I picked up four primary cases all month. Another month, I picked up nine primary cases in a week. The most autopsies I ever remember having in a day was four. The other resident took two and I took two. There has never been an issue with residents equally dividing up cases. We even try to equally divide up the brain-only and fetal autopsies.

 

[YoungFP]

We do 5 months. Sometimes 1 resident is on, sometimes 2 per month. All autopsy is completed in the first 2 years. Though it is not written, no resident here has done more than 2 autopsies in a day in the past 4 years (at least to my knowledge). Our senior forensic attending has always been strict on 1 per day per resident. A more junior faculty let me do 2 in day sometimes, just because it's my field of interest. Case load ~ 100 hospitals, 500 forensic (complete and external only). Hope this helps.

 

[green mantis]

The format at my residency was different than what the rest of you are describing. We had 24 months of surgical pathology, in which autopsy was every 3rd day. You typically did the autopsy by yourself, unless there was an available senior resident that was willing to help. I don't think I've heard of any residents doing more than 3 autopsies on 1 day, though 1 of them was a stillborn fetus. I'm sure that if it was an adult, it would be pushed off to the following day.

On a side note, we rotated at 3 hospitals, all of which did about 50-70 autopsies a year. On forensics, residents were expected to do 1 autopsy per day.


----- Antony

 

[Gene_]

We have no autopsy rotation at all. Autopsies are handled on a rotating basis as they come up. There's just not enough autopsies to justify an entire rotation - you'd be sitting around a lot. The downside is that you get pulled off of your other duties to perform the autopsy and have to whittle out time in your day or stay after hours to do the report. To the OP, the best way to not be abused is to stand up for yourself. This is applies to other residents and staff. If residents are truly being abused, then the program director needs to cover your 6, or else you're generally screwed.

 

[KCShaw]

At one place I trained we only had up to ~70 autopsies per year, and handled it similarly to Gene_, with the responsibility rotating among residents on certain rotations (and some flexibility for those lacking numbers, etc.). Where I am now, we have 1 resident on the autopsy service at all times, and we cover approximately 200 (almost all "complete") hospital autopsies per year. It's surprisingly rare to have more than 2/day, and the occasions we've had 3+ we've either been able to do them all or push one to the following day using just the 1 resident. Because it's one resident covering all of it (with very rare "emergency" exceptions), we don't have the problem of one resident screwing another by not doing their work. We do have a cutoff of having a body, paperwork, and resident ready to start by 3PM (barring religious or significant diagnostic reasons for doing it immediately), as neither deiner nor attendings like to stay late.

For training, right now we have 1 senior assist/train during the first month of a new resident's 2 month autopsy rotation (everyone gets at least 4 months of autopsy, at least 2 in first year). This works well until you try to change something, as our residents have a tendency to do it the way they always have, and mistakes or just "old ways" get passed along. It seems to work best with at least 1 heavily involved & interested attending (at some places, easier said than done). Unfortunately, our senior is also on cytopathology, so they pull some double duty and miss out on cytopath more than we'd like. But we haven't found a happier alternative tradeoff yet.

Our biggest problem is getting an acceptable consent filled out. We depend on the clinicians taking care of this, though we also accept faxgram consents (through a hospital approved service that deals with identifying appropriate family member, taking verbal consent, and transcribing everything). Unfortunately we also have only one person/tech managing all incoming & outgoing: bodies, death certificates, consents, medical charts, and deiner duties, which pulls the noose tighter on the paperwork bottleneck -- but that's another story.

We have a completely separate 1 month forensic pathology rotation, also required (after -at least- 2 months of hospital autopsy), and which is technically "off site" but actually closer to the resident parking lot than the hospital is. We do this for the forensic experience; we don't need the numbers, though residents handle 1/day there. Also another story.

 

[schweet]

slightly off topic:

1) Does anyone use a manual/book for autopsies? For technique we mostly rely on our dieners and attendings. For gross/micro/CPC I used a lot of Robbins (ASCVD) or other relevant texts (WHO for lymphomas, Daner for pedi path etc.)


2) At the MEO we can only "do" the natural cases. However, I did watch a lot of the homicide, accidents as well (Some of the FP's are OCD about resident involvement in non-natural deaths). Do you think if you watch and understand the mechanism/cause of death you can count that toward your numbers?

 

[green mantis]

At the MEO we can only "do" the natural cases. However, I did watch a lot of the homicide, accidents as well (Some of the FP's are OCD about resident involvement in non-natural deaths). Do you think if you watch and understand the mechanism/cause of death you can count that toward your numbers?

The issue w/ non-natural deaths is that there's a potential that you may be called in to testify. I was told this was a possibility even if you were just an observer. Having to go to court would be pretty disruptive to residency & maybe even afterwards. If you wanted courtroom exposure, you could always go to court w/ one of the the FP's.

Where I did my rotation, there was a separate suite for homicides. The only observers were typically police officers.

You can't count an autopsy unless you actually did the case. One exception would be a brain only case. Using your thinking, you should be able to count an autopsy you watch in the hospital. There's no need to travel.


----- Antony

 

[KCShaw]

1) Manual/book: We don't (didn't) use a specific "this is our institutional book everyone must follow" book, but we're now getting everyone using a modified technique based on CAP (1) and a protocol used by one attending at their previous institution. Prior to this, where I've been we used the "my diener/attending/senior-resident showed me to do it this way" technique. For reference numbers (weights, etc.) we largely use Finkbeiner's (2), though Ludwig's (3) is also pretty useful. I think for CPC/discussion Robbins can be useful, but doing searches based on specific findings is ideal to polish it off -- meaning I think one should go to an organ/system specific text or article, eventually.

1. Kim A. Collins, MD, and Grover M. Hutchins, MD. An Introduction to Autopsy Technique. 2nd ed. College of American Pathologists, 2005.
2. Finkbeiner, Walter, Richard Davis, and Philip Ursell. Autopsy Pathology -- A Manual and Atlas. 1st ed. Churchill Livingstone, 2003.
3. Ludwig, Jurgen. Handbook of Autopsy Practice. 3rd ed. Humana Press, 2002.

2) ME cases & autopsy numbers: Although the board of pathology isn't specific about this, the ACGME is. To count an autopsy towards your required numbers, you should be directly involved in 7 things -- review of history/circumstances of death, external exam, gross dissection, review of micro & any relevant lab findings, preparing the description of gross & micro/lab findings, developing opinion of cause of death, and review with an attending. There is some loose wording surrounding these requirements, like residents must participate in all aspects "as appropriate to the case," etc., which leaves the door cracked a bit to count things that really aren't appropriate but may be necessary because of a variety of problems culminating in too many programs being unable to provide adequate autopsy training. However -- I wouldn't start counting forensic autopsies that you only look over someone's shoulder for during just the first 3 of those 7 things. It's pretty hard to justify, IMO, despite it having some educational value.

 

[mlw03]

on the topic of counting cases: i'm about to start PGY-1, and given my interest in forensic i'm hoping to go in on some weekends to participate in forensic cases with the FPs so that i can improve my skills/knowledge and also continue to see if FP is a fellowship i'd want to pursue. that said, would i be allowed to count those cases towards my required 50 (assuming i really am involved with the case)? i'll obviously talk to people at my program about this, but i thought i'd seek the opinion of people here also.

 

[green mantis]

on the topic of counting cases: i'm about to start PGY-1, and given my interest in forensic i'm hoping to go in on some weekends to participate in forensic cases with the FPs so that i can improve my skills/knowledge and also continue to see if FP is a fellowship i'd want to pursue. that said, would i be allowed to count those cases towards my required 50 (assuming i really am involved with the case)? i'll obviously talk to people at my program about this, but i thought i'd seek the opinion of people here also.

Definitely talk to your PD 1st. At my residency, the coroner's officer required that we had NP before we could do FP. You needed some knowledge of braincutting. We were responsible for an autopsy from head to toe w/ minimal help from the diener at times, meaning we had to pull out organs from the bodies by ourselves.

There were constantly medical students rotating through, but they didn't get to do much. They did get to cruise from body to body, so they got to see all of the interesting cases. At my program, that's probably what you would've gotten to do before you did an actual FP rotation. After that, I'm sure they wouldn't mind if you wanted to spend time there on weekends. I doubt you could count cases where you only watched.


----- Antony

 

[KCShaw]

Your mileage may vary. I agree that each program will have quirks regarding when & how "they" will let you count cases -- some will be reasonable, and some might not make sense to you. But, my opinion is that yes, if you're directly involved in the case from start to finish, at least as much as you would be when allowed to count those cases while actually rotating there, then you should be able to count them when helping on the weekends too. Either way, I would log them in an excel file or some similar manner for future reference, or in case someone changes the rules on you mid-stride.

 

[mlw03]

good suggestions. thanks, guys and gals.

kc: as i make the spreadsheet, what type of data should i be keeping track of? i can think of obvious stuff like data, case #, PAD, and final cause/manner, but what else would you recommend?

 

[DarksideAllstar]

good suggestions. thanks, guys and gals.

kc: as i make the spreadsheet, what type of data should i be keeping track of? i can think of obvious stuff like data, case #, PAD, and final cause/manner, but what else would you recommend?

For your board app, I was told you need age/sex/diagnosis (not sure if there is anything else). I have spread sheet with case #, date, age, sex, diagnosis, attending, primary or secondary (prosector). Also have all my discussions for each case.

 

[KCShaw]

Unfortunately my "new" work computer is locked down so tight I can't pull my board app off my usb drive, and the ABPath website has pulled down the old application because they're putting up an online one in a few months. At any rate, right now I can't verify what all the board required. Basically I agree with DarksideAllstar. I'd say that keeping the discussion/CPC is a bonus, not so much a necessity -- by that point you might as well keep a copy of the entire report (properly de-identified or secured, of course).

The ACGME case-log system asks for only generic age (adult vs pediatric), but I distinctly remember a senior resident a few years ago having to go back to ALL her old autopsies to look up the specific age when she applied for the boards, which is more of a pain than it sounds...so I logged that for all of mine. ACGME also asks whether you're primary or secondary (this is the "shared autopsies" thing with another resident), and whether it's limited but not always what it's limited to; I recall them only wanting to know if it included brain or not (I added what it's limited to for mine -- head only, chest only, no head, etc.). They also try to break it down into neonatal, death in utero, and so forth -- generally you'll be able to figure that out by looking at age/PAD/COD-MOD anyway.

I don't recommend using the ACGME case-log system as your only method of tracking these, which some residents do, and which can get you in a pickle if the board wants different/more info...like that senior resident of mine. And if you want it for your records down the line you have to manually copy it. I think they only let you export it as a PDF.

 

[mlw03]

good suggestions, KC and darkside. thank you.

 

[yaah]

They asked for age, sex, and underlying cause of death, I believe.

They asked you how many cases were forensic, I believe, and how many cases were shared, but they didn't ask you to clarify which ones. Basically, I think they depend somewhat on your program director to certify that your list is real and valid.

I don't think autopsies you participate in prior to residency starting would ever be allowed to count. It is 50 during residency.