Frozen section resident duties

[alaska82]

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Hi Friends,
I was wondering how are frozen sections done at varoius programs?
IN my program we have to accession the case, give the gross description of every single specimen sent for frozen section (even ENT margins), and finally enter the diagnosis in the system.
Thanks

 

[Entgegen]

We do all of the above except accession the case...the accessioners up at the drop-off area do that then bring the meat back to us. Then we do a gross description, hack off the bits to freeze (or totally submit it they'er tiny) and give it to the techs to freeze and cut. They give us the slide and we multi-scope with the attending, call back the OR, then dictate the gross and frozen diagnosis.

 

[LaBelleVN]

Our residents are supposed to have protected sign-out time in the morning with the attending. However, if the PA is bombarded with frozens then the resident will be overheaded to assist. Once sign-out is done the resident on frozen section takes over. He/she receives the previously accessioned specimen, takes the portion for frozen section, cuts the frozen, prepares the slide, previews the case quickly on the scope, takes it to the attending for review, & occasionally calls back the frozen to the O.R. Afterwards, the resident breaks down the chuck and dictates the gross description & the frozen diagnosis. It seems like a lot, but it's not that bad especially if the month has good residents who help each other out. Having said that, my old program was really busy with frozens (up to 80 parts on a very busy day) since we had a lot of ENT cases with tons of margins and lots of Whipple cases that require margins, too.

 

[maji]

Depending on what hospital we are covering, we do it all. We accession the case when it first arrives, gross, sample, freeze, cut and stain. When the resident becomes bombarded, we call the PA for backup, not the other way around. We deliver the slides to the attd, and if we have time we sit and look at them, but if its busy we just drop them off, and go start cutting the other chucks. Afterwards we have to breakdown all the chucks and put the tissue in cassettes. Depending on the attending/schedule, we sometimes also call back the OR to deliver the results.

 

[2121115]

Depending on what hospital we are covering, we do it all. We accession the case when it first arrives, gross, sample, freeze, cut and stain. When the resident becomes bombarded, we call the PA for backup, not the other way around. We deliver the slides to the attd, and if we have time we sit and look at them, but if its busy we just drop them off, and go start cutting the other chucks. Afterwards we have to breakdown all the chucks and put the tissue in cassettes. Depending on the attending/schedule, we sometimes also call back the OR to deliver the results.

Umm... so how do you learn to sign out frozens?

 

[mlw03]

Umm... so how do you learn to sign out frozens?

Was waiting for someone to say that. In my residency program PAs mainly handled frozens until 5pm, then the resident on call was responsible for grossing, cutting, staining, etc. Attending would write their diagnosis and call it into the OR. Diagnosis was dictated when the final specimen was grossed. If time allowed you'd look at it with the attending, rarely on your own beforehand. This was one of the main weaknesses of where I trained, and were I not going into FP it would have been something I'd have had to rectify with an elective during PGY4 (which is what many residents did as a way to get more experience with frozens and have some study time in between specimens).

 

[alaska82]

Thanks all.

We have technicians to cut the frozens till 6pm. After that the resident does evrything. We have one resident covering frozen sections for the entire month. The frozen section resident covers another subspeciality service. When the frozen section resident is in signout, the backup resident covers frozens (but never PA).
The frozen section resident also has to go for glomerular count for renal biopsies. Sometimes the resident will be called into the OR for orientation of complicated specimens.
Sometimes we to send a piece of fresh tumor for research or special studies. Eventhough the frozen is not done on these specimens, we still have to accession and give the gross description.

 

[mlw03]

Thanks all.

We have technicians to cut the frozens till 6pm. After that the resident does evrything. We have one resident covering frozen sections for the entire month. The frozen section resident covers another subspeciality service. When the frozen section resident is in signout, the backup resident covers frozens (but never PA).
The frozen section resident also has to go for glomerular count for renal biopsies. Sometimes the resident will be called into the OR for orientation of complicated specimens.
Sometimes we to send a piece of fresh tumor for research or special studies. Eventhough the frozen is not done on these specimens, we still have to accession and give the gross description.

Just curious - what's the reason for the question?

 

[2121115]

The above descriptions are classic cases of pathology programs training fellowship applicants rather than independent surgical pathologists. They just assume you will learn to sign them out during fellowship. In the mean time they use you to run around and accession cases. Wow. Grade A examples of what is wrong with pathology training.

 

[mlw03]

The above descriptions are classic cases of pathology programs training fellowship applicants rather than independent surgical pathologists. They just assume you will learn to sign them out during fellowship. In the mean time they use you to run around and accession cases. Wow. Grade A examples of what is wrong with pathology training.

Agreed, but what can applicants do? Frozens are low-enough priority that no one is going to not choose a program over it. Complaining is obviously useless. And heck, if you do a hemepath or cyto fellowship, you may never get that training before you have to go out and do it.

 

[Pathwrath]

Depending on what hospital we are covering, we do it all. We accession the case when it first arrives, gross, sample, freeze, cut and stain. When the resident becomes bombarded, we call the PA for backup, not the other way around. We deliver the slides to the attd, and if we have time we sit and look at them, but if its busy we just drop them off, and go start cutting the other chucks. Afterwards we have to breakdown all the chucks and put the tissue in cassettes. Depending on the attending/schedule, we sometimes also call back the OR to deliver the results.

This sounds like excellent training for a P.A., or even a super competent histotech. Maybe your attendings are thoughtfully helping to maximize your employment opportunities in a tough job market.

 

[Euchromatin]

Geez, the frozen training in a lot of the programs mentioned sounds kinda iffy.

At our program residents on a frozen day are expected to: scan the OR schedule to look up clinical history on cases likely to need a frozen, go to the OR to get the specimen and info from the surgeon when the pager goes off, do a quickie gross (i.e. ink/measure whatever is necessary before the first cut - we usually check in with staff at this point if they haven't already come up to ask exactly how many sections of x, y or z they want frozen or whatnot), section the specimen, freeze it, cut it, stain the slides, double scope with the attending (so we get to see the slides as the case is being evaluated), then contact the surgeon with the results. Once the frozen diagnosis is rendered, we'll take the tissue down to our gross room where the surg path assistants accession it, then we'll finish grossing it later.

The amount of independence of course increases as we gain experience and is a little bit staff dependent, but the majority like us to practice communicating with the surgeons ourselves and we ALWAYS look at the slides with the staff as we make them. Having to cut and stain our own frozens can be a little tedious at times (especially when things get really busy), but I think it is a good skill to have for later.

 

[TMZ2007]

The experience in my program is very similar to what Euchromatin describes. Our frozen room is separate from the main gross room and near the ORs. We fetch the specimens from the OR, speak with the surgeon regarding clinical findings, measure/ink/section specimen, cut slides and then interpret with staff. We have a histotech who does the staining and can do additional cuts if necessary (although residents or attendings cut most everything). The attending is always present and will ensure that the proper sections are taken, that orientation is correctly preserved, etc. With more resident confidence and experience, the attending will back off and let you do all the work, including driving and making the first call on the Dx. We communicate dxs face-to-face, not over the phone, so the resident who is typically wearing scrubs gets to tell the surgeon (since the attendings generally don't want to put on a bunny suit). Not quite sure how this would work in an institution that has a busy frozen service; we have one attending and one resident per service day and typically get 5-7 calls

 

[KCShaw]

At one program, the attending was usually called directly and the specimen brought to the small but noisy gross room (which doubled as the frozen room) by a surgical runner. The grossing resident would sometimes not realize a specimen had come in, as the attendings &/or PA tended to grab, freeze, cut, stain, review literally behind your back (note 'noisy' above). Unfortunately the program at that time was not particularly used to having residents around nor was there a uniform culture for training; after a year of hassling it improved such that residents were notified of frozens regularly, a tech would accession, we would freeze/cut/stain, and reviewed the case with attending (and often with the surgeon).

At the other program, the frozen room was on the other side of the hospital from the path department but close to the OR's. There was one resident assigned to cover the frozen room as well as sign out biopsies. Usually there was plenty of time to do both without major interruption of sign-out, which took place in the frozen room, which was fairly well equipped. Frozen requests went to a single frozen pager, that resident would go to the frozen room if not already there, and a surgical runner would bring the specimen(s) over. I don't recall how we labeled/accessioned them as they came in. Residents would freeze, cut, stain, and preview if the attending wasn't already there; would notify the attending once we knew what kind of specimen we had so they could start the long walk from the department. Diagnoses were handwritten and dictated later, if memory serves. Residents would progress to calling diagnoses to the OR, though it wasn't uncommon for the surgeon to wander over. It was by far a better format than the first program.

I believe transplant frozens were usually handled differently, going down to the department instead of the frozen room. They tended to arrive after hours, though, which the surgical resident on call dealt with separately.

 

[sirenomelia]

The experience in my program is very similar to what Euchromatin describes. Our frozen room is separate from the main gross room and near the ORs. We fetch the specimens from the OR, speak with the surgeon regarding clinical findings, measure/ink/section specimen, cut slides and then interpret with staff. We have a histotech who does the staining and can do additional cuts if necessary (although residents or attendings cut most everything). The attending is always present and will ensure that the proper sections are taken, that orientation is correctly preserved, etc. With more resident confidence and experience, the attending will back off and let you do all the work, including driving and making the first call on the Dx. We communicate dxs face-to-face, not over the phone, so the resident who is typically wearing scrubs gets to tell the surgeon (since the attendings generally don't want to put on a bunny suit). Not quite sure how this would work in an institution that has a busy frozen service; we have one attending and one resident per service day and typically get 5-7 calls

Very similar to my program and is IMO the correct model. I dont understand those that had PA's doign frozens during the day. What the hell was the resident doing during that time? Thats the most highest yield on-the-spot learning situation and the only time you'll apprentice to triage frozens before you will have to do them at your eventual employment.

 

[pathstudent]

Depending on what hospital we are covering, we do it all. We accession the case when it first arrives, gross, sample, freeze, cut and stain. When the resident becomes bombarded, we call the PA for backup, not the other way around. We deliver the slides to the attd, and if we have time we sit and look at them, but if its busy we just drop them off, and go start cutting the other chucks. Afterwards we have to breakdown all the chucks and put the tissue in cassettes. Depending on the attending/schedule, we sometimes also call back the OR to deliver the results.

This sounds like it is filled with a lot of non-educational busy work and is likely a violation of ACGME rules. You should bring it up at the next retreat or some other appropriate time.

 

[mlw03]

My program didn't do a "rotation" the way many do. Frozens had its own attending, and residents were off on various surg path areas. In theory, we were supposed to get out frozen learning time when on-call, and while that sometimes worked, I left residency feeling that frozen section experience was one of the main weaknesses.

Very similar to my program and is IMO the correct model. I dont understand those that had PA's doign frozens during the day. What the hell was the resident doing during that time? Thats the most highest yield on-the-spot learning situation and the only time you'll apprentice to triage frozens before you will have to do them at your eventual employment.

 

[LADoc00]

Does anyone really find it essential to actually go into the operating room, get the specimen and come physically back to get a frozen section done??

Seriously. Thats seriously humiliating IMO.

Surgeon: Go powder monkey, get me my FS result on the double!
Pathologist: Yessum!!

I basically havent done that since training but went to a colleague's shop where they did that, I had to laugh.

Someone PLEASE tell me why you physically picking up the specimen and delivering an answer in person is somehow better than a phone??

 

[LaBelleVN]

Does anyone really find it essential to actually go into the operating room, get the specimen and come physically back to get a frozen section done??

Seriously. Thats seriously humiliating IMO.

Surgeon: Go powder monkey, get me my FS result on the double!
Pathologist: Yessum!!

I basically havent done that since training but went to a colleague's shop where they did that, I had to laugh.

Someone PLEASE tell me why you physically picking up the specimen and delivering an answer in person is somehow better than a phone??

I agree. When I was a fellow, the only surgeon who asked us to come to the O.R. was the ENT doc. He did so to verify that we knew how the specimen was oriented since there were various margins, which is totally understandable. But for me to go to the O.R. each time there was a frozen, get changed or put on those silly bunny suits, would be a pain in the butt. When the chair of surgery first started at my residency hospital, he purposely would call the pathology residents down for all of his Whipple specimens just because he could. No one had the balls to object. He would then crack jokes about how it must suck for us to be disrupted from our long coffee break to go to the O.R.

 

[Euchromatin]

While I'm not crazy about having to go to the OR myself to pick up specimens, it seems that there are enough occasions that I end up asking the surgeon a question or clarifying the orientation or what exactly they want done that it doesn't seem unreasonable. Also, our frozen section room is located extremely close to the ORs (literally just a few steps down the hall - and it is closest to the OR that is typically used for Whipples and other complicated abdominal resections), but is on a completely separate floor and a good distance from the main gross room. So having a SPA or PA totally drop everything they were doing to go pick up a frozen specimens (when the attending +/- resident actually doing the frozen will be steps away from the ORs anyway), seems like it would cause more problems in the gross room workflow than it would be worth. Typically most of our staff will just have us call the frozen results to the ORs if it is something simple like margin/lymph node/whatever negative for carcinoma, parathyroid tissue present, etc., but we'll go in person back to the OR if there is anything more complicated than that to explain that the scrub nurse/tech taking the phone call might screw up. Staff and residents wear scrubs on the days they are assigned to frozens (which I think most people like because they are comfy - I know I do), so there aren't any clothing-related, bunny suit inconvenience issues.

 

[KCShaw]

IMO there is some utility in it on special occasions, but probably not as a matter of routine. At least not as far as good/best practice of pathology goes. However, as marketing goes, making some personal contact with your clients (surgeons) also has its place -- although I think there's a difference between being a sought after consultant paying a polite visit, and being a pandering tool.

 

[yaah]

There's a fine line between learning too much about the technical side of frozens and the diagnostic (slide viewing) part of frozens. Where I trained the only time we physically cut the frozens was when we were on call in the evenings. I had tons of exposure in my PSF where we cut them all and looked at the with the attending, but some of my resident colleagues had pretty weak frozen-cutting skills (like taking 20 minutes to get tissue onto a slide). However, we had lots of exposure to selecting the right piece of tissue for frozen and then seeing the slide. In practice now we occasionally have to go to an offsite and cut a frozen and there is no backup for technical problems.

THings have changed I think in my former training program so there is more cutting experience.

BUt yeah, if you are not seeing the slides and learning how to make rapid diagnoses on frozen material, you are not geting adequately trained. It won't help you pass the boards most likely, but it certainly won't help you get a job either.

 

[LADoc00]

I agree. When I was a fellow, the only surgeon who asked us to come to the O.R. was the ENT doc. He did so to verify that we knew how the specimen was oriented since there were various margins, which is totally understandable. But for me to go to the O.R. each time there was a frozen, get changed or put on those silly bunny suits, would be a pain in the butt. When the chair of surgery first started at my residency hospital, he purposely would call the pathology residents down for all of his Whipple specimens just because he could. No one had the balls to object. He would then crack jokes about how it must suck for us to be disrupted from our long coffee break to go to the O.R.

Good. Im not crazy it seems.

I felt bad at the time for dressing down a friend's practice because they still go into the OR. I guess you need to assess your customer service time. I have plenty of face to face with my surgeons where I dont feel the need to be a glorified courier for them.

 

[maji]

This sounds like it is filled with a lot of non-educational busy work and is likely a violation of ACGME rules. You should bring it up at the next retreat or some other appropriate time.

Perhaps I should have written more clearly.
Depends on the hospital. At one hospital, we dont accession before 5, but the other we only accession frozens and have no PA.
Usually it is not so hectic, and usually we see the frozens with the attendings. So, it is usually not a problem.
With that said, does anyone else have a program where they are first up to cut a frozen? Usually, if I am not currently grossing, and the PA is not currently grossing, I cut the frozen since it will be my case.

 

[BrainPathology]

At my program after the first 2 months of surg path if you were at the grossing station responsible for frozens (the 4 day rotation was frozens/grossing, sign-out, grossing, signout), you got the specimen after it was logged in. You were expected to triage the specimen (including asking for help if it was a specimen you were not familiar with), select the area to freeze, freeze it on the cryostat, cut the specimen, prepare the slide including staining the specimen, look at it at the scope in the gross room.. write down your interpretation and then bring it to the attending. Exceptions were using techs if there were a lot of frozens, calling the attending in for specimens you felt uncomfortable with, and various others. We were expected to get all of the above done for single specimens in under 15 minutes so that the attending had enough time to call in the results in under 20.

By the 4th year you were expected to be able to be performing at the level of a junior attending with the second of the attending basically a formality. You were then expected to communicate the interpretation to the OR.. including diplomatically explaining that "no you're not right in the middle of the lesion" etc. when needed.

 

[Path or bust]

At my program, it isn't unheard of for our pathologists to help the residents out when the frozen room is swamped (and even when it's not). While the residents are technically 'in charge' of the frozen room, you'd be surprised to know that even top, well-known pathologists at my program who have written chapters in Sternberg and WHO will help us cut and even stain/cover slip.

In one case I was cutting frozens and so was the attending, the surgeon comes in and my attending tells me to go show the surgeon what we have so far while he takes care of cutting and staining the rest.

We have good people here and reading through this page makes me realize how good we really have it.

 

[dermpathdoc]

you work as an attending in a small community hospital with no PA and no histotechs to do the scut work for you....you need to learn to go to the OR and communicate with the attending surgeon...
I worked with a new pathologist who had been at a huge university medical center for training...he got in a fight with an attending surgeon because the surgeon demanded he come down to the OR to pick up the specimen because he had something he wanted to show the pathologist. The pathologist quit on the spot because he felt he had been insulted. Turned out the surgeon needed to show the pathologist the tumor was wrapped around the aorta and would be unresectable.
It was not unreasonable for the surgeon to want the pathologist down for a look see...small community med centers also do not have staff to do the scutwork for you, you need to be able to do it all

 

[KCShaw]

Or he could have said on the phone "This sucker is wrapped around the aorta and will be unresectable (so I'm just debulking, I have no need to do a frozen, and I'm not worried about the margins which are going to be positive, but gosh it's cool and I thought you might like to see)."

Not saying there ain't such a thing as being too stubborn for your own good, and it sounds like a very odd thing to have a quitting conniption over -- as if there may be more to it, as there usually is.

But I certainly agree one needs to be able to walk into their "real job" on the first day and survive without a PA or tech if need be. Which should generally also include not melting down at the first unecessary/unusual/unexpected/unwanted request from a surgeon, which sorta comes with the territory.

 

[Tissue issue]

you work as an attending in a small community hospital with no PA and no histotechs to do the scut work for you....you need to learn to go to the OR and communicate with the attending surgeon...
I worked with a new pathologist who had been at a huge university medical center for training...he got in a fight with an attending surgeon because the surgeon demanded he come down to the OR to pick up the specimen because he had something he wanted to show the pathologist. The pathologist quit on the spot because he felt he had been insulted. Turned out the surgeon needed to show the pathologist the tumor was wrapped around the aorta and would be unresectable.
It was not unreasonable for the surgeon to want the pathologist down for a look see...small community med centers also do not have staff to do the scutwork for you, you need to be able to do it all

Dermpathdoc- Sounds like you do all the grossing. Without histotechs, what happens after you put the tissue in the cassettes??

 

[horrendoma]

At our program, its a one-week long roster, with attending and resident both going up to the OR complex all six days of the week, plus on call if needed, which is rare. The modern OR complex is about 500 meters from the very old, 1970's pathology building, so the frozen section room has to be built inside the OR complex.
Resident does cutting, staining and coverslipping under the guidance of the histotech. The hardest part is cutting, as the staining is just a brain-dead exercise in being able to follow the ass-big written recipe instructions stuck on the wall. (how many dips for how many seconds etc)
After double scoping, the diagnoses are handwritten on a triplicate carbon copy, and countersigned by the attending.
The tissue on the chuck is then allowed to thaw in formalin and grossed downstairs by the other residents/ histotechs.
No accessioning machines in the little frozen room, so all assescioning is done downstairs.

 

[oldfatman]

Good. Im not crazy it seems.

I felt bad at the time for dressing down a friend's practice because they still go into the OR. I guess you need to assess your customer service time. I have plenty of face to face with my surgeons where I dont feel the need to be a glorified courier for them.

I go to the OR if asked, which is rare. Usually it is pertinent to the case. Most of the time the surgeons will come to the frozen room. I like my surgeons. Otherwise the nurse brings me the specimen. Having a histotech cuts the frozens is a useless luxury. It's not that difficult if you have adequate equipment.