Surgical Path Rotation

[Microscope Eyes]

Recently my program reorganized how sign outs were done on our surgical pathology rotation to allow more time for resident review of cases. We moved from having a 24 hour turn-around time after receiving slides, to a 48 hour turn around time. Right now 4 residents cover this rotation each month.

Day 1 is Gross Room
Day 2 is Frozen section and Resident review of "Big" specimens
Day 3 is "Big" specimen sign out and Resident review of "Small/biopsy" specimens
Day 4 is "Small/biopsy" specimen signout
Day 5 back in the gross room

I was wondering how other programs have set up their surgical pathology rotations. Do you feel you have adequate time to review cases? What is the turn-around time for your specimens?

Thanks

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[beary]

I have posted a little bit about how other programs do this in the "interview experiences" thread. At Iowa, the program I am most familiar with, it is a 3 day schedule:
1) gross and frozens
2) preview and sign out (no real distinction between bigs and smalls, just whatever is out on day 2)
3) preview and sign out whatever is left from day 2
then day 1 again, back in the gross room

 

[yaah]

Here the cases follow a three day schedule

Day 1) Case arrives and is grossed in
Day 2) Slides come out and is previewed
Day 3) Signed out.

Sometimes another day or two is added in because day 1 is extended for a large specimen that has to fix or be decalcified or whatever. And sometimes cases will be rushed so day two is skipped, but this is not common.

As residents we do everything every day - signout from 9-12 or so, preview and gross the rest of the day. Large and small specimens are combined, although we don't gross most of the small stuff and a lot of the large stuff. It makes for a busy day but I like the variety and I learn a lot.

Can I just say I hate the term, "Bigs," when it refers to specimens? It drives me batty. I'm not trying to criticize you guys in particular for using the term because that is what most people call them. I just hate the word! It's similar to how there is one program out there (can't remember which) that calls things "bigs" and "quicks."

 

[AngryTesticle]

Went into detail regarding our surg path schedule (which can be quite daunting and complex upon the first read...and the first several weeks on surg path as an actual resident!) in my scutwork review on Brigham.

In brief, we roughly go in a cycle but we can do a little bit of everything in a given day.

For instance, two days ago, I was cutting in specimens until 5:30 pm and then I had to preview a couple of boxes of slides. Yesterday, all I did was sign out the cases I previewed and then start previewing the stuff that came out in the afternoon. Today I signed out in the morning and received specimens to tuck into formalin for me to cut in sometime during the weekend.

Can I just say I hate the term, "Bigs," when it refers to specimens? It drives me batty. I'm not trying to criticize you guys in particular for using the term because that is what most people call them. I just hate the word! It's similar to how there is one program out there (can't remember which) that calls things "bigs" and "quicks."

Yeah, that's my program. The terms are a bit misleading. Generally, quicks specimens don't have to be tucked into formalin overnight...instead they can be cut in that same day. Typically they tend to be smaller specimens but it's weird...if we get a breast excision specimen on our "Quicks" service, we usually fix them overnight anyway cuz floppy titty tissue is hard to cut in and they lead to crappy histology if not fixed for an appropriate amount of time.

Then there are "Bigs" which is a misleading term because some "Bigs" specimens are actually kinda small. I received some pretty small cases which I could've cut in today (if I had nothing else better to do on a Friday evening).

I propose the terms "Bigs" and "Quicks" to be changed to the following terms...

Bigs ==> Educational specimens or ES.
Quicks ==> Stupid specimens of little or no educational value or SSLNEV.

Man, if the terms "Bigs" and "Quicks" terms piss you off...you'd probably be even more flabbergasted that we split the "Bigs" specimens into Dry Bigs and Bigs. WTF? That makes no sense! WTF is a dry big? And why isn't the other Big called a Wet Big?

I propose the following changes to the terms:

Dry Bigs ==> not my problem bigs = NMP bigs (i.e., PA's cut these in for us).
(Wet? or Regular?) Bigs ==> oh **** I gotta get off my ass and work...bigs = simply denoted by the mnemonic called = F*CK.

---------------

And yaah, I know you got all engaged 'n all and you're probably the happiest acromegalic man on the planet but don't be a hater, OK?

 

[Mrbojangles]

At my program (a smaller program) we have a simple schedule:

Day 1 pm: gross and frozens
Day 2 am: attend other persons signout and cover frozens during that time
Day 2 pm: preview
Day 3 am: signout
pm: gross and frozens

But now we're going to change it so that we cover frozens on the day we preview, which I prefer.

 

[yaah]

And yaah, I know you got all engaged 'n all and you're probably the happiest acromegalic man on the planet but don't be a hater, OK?

I think you should just call them biopsies and resections!

 

[AngryTesticle]

I think you should just call them biopsies and resections!

Nah, I like my nomenclature better. Plus, our Quicks specimens encompass more than biopsies. For example, we get lung wedge resections on the Quicks bench. We also get cardiac specimens on the quicks bench (i.e., segments of aortas and valves).

Eat that biooooooooooooooootch.

 

[cytoborg]

I propose the terms "Bigs" and "Quicks" to be changed to the following terms...

Bigs ==> Educational specimens or ES.
Quicks ==> Stupid specimens of little or no educational value or SSLNEV.

Man, if the terms "Bigs" and "Quicks" terms piss you off...you'd probably be even more flabbergasted that we split the "Bigs" specimens into Dry Bigs and Bigs. WTF? That makes no sense! WTF is a dry big? And why isn't the other Big called a Wet Big?

I propose the following changes to the terms:

Dry Bigs ==> not my problem bigs = NMP bigs (i.e., PA's cut these in for us).
(Wet? or Regular?) Bigs ==> oh **** I gotta get off my ass and work...bigs = simply denoted by the mnemonic called = F*CK.

You just made my day. Thank you. *wiping away a tear*

Our schedule depends on the site.

At the main hospital:
Day 1: Cut in/frozens
Day 2: Preview bigs
Day 3: Sign out bigs
Day 4: Cut in/frozens
Day 5: Preview and sign out biopsies/preview bigs (busy day)
Day 6: Bigs sign out

At the county and VA hospitals:
Day 1: Cut in/frozens
Day 2: Preview/sign out
Repeat.

 

[miko2005]

You just made my day. Thank you. *wiping away a tear*

Our schedule depends on the site.

At the main hospital:
Day 1: Cut in/frozens
Day 2: Preview bigs
Day 3: Sign out bigs
Day 4: Cut in/frozens
Day 5: Preview and sign out biopsies/preview bigs (busy day)
Day 6: Bigs sign out

At the county and VA hospitals:
Day 1: Cut in/frozens
Day 2: Preview/sign out
Repeat.

Did I miss something? I thought that you guys do frozens on one of the preview days (at the main hospital)?

 

[pathres2]

here's our rotation (one site, but two operating rooms: a smaller one for same-day ambulatory type surgeries and a larger one for more complicated cases):

day 1 -- gross "regulars" (=bigs) and large "rush" specimens (i.e. lumpectomies). techs gross biopsies and "non-critical" specimens (see below) for us.
day 2 -- am: preview rushes and biopsies. pm: sign-out rushes and biopsies, cover frozen sections in smaller OR. then preview "regulars" in the evening.
day 3 -- am: sign-out "regulars" and cover frozen sections in smaller OR. pm: preview departmental consults and "non-critical" specimens (i.e. cardiac valves, joints, TURPs, etc.).
day 4 -- sign-out consults and "non-critical" specimens, cover frozens in larger OR, tumor banking and "floating" (=tuck in formalin) of larger specimens.

then cycle repeats with grossing, etc.

advantages: the same resident follows the specimen from beginning to end (tumor banking, floating, grossing, previewing, signing out), no grossing of biopsies or "non-critical" (=non-educational) specimens, residents preview and sign-out all specimens (biopsies, consults, etc.) i.e. no "direct for attending" grossing, grossing once every fourth day (not every day), protected previewing time for the resident for every case (turnaround time suffers but our education doesn't!).

disadvantages: 4 residents in surg path, two consecutive nights of previewing (but two nights off), a lot of frozen section coverage (some may see this as an advantage since residents get to see all frozens)

 

[AngryTesticle]

day 1 -- gross "regulars" (=bigs) and large "rush" specimens (i.e. lumpectomies). techs gross biopsies and "non-critical" specimens (see below) for us.
day 2 -- am: preview rushes and biopsies. pm: sign-out rushes and biopsies, cover frozen sections in smaller OR. then preview "regulars" in the evening.
day 3 -- am: sign-out "regulars" and cover frozen sections in smaller OR. pm: preview departmental consults and "non-critical" specimens (i.e. cardiac valves, joints, TURPs, etc.).
day 4 -- sign-out consults and "non-critical" specimens, cover frozens in larger OR, tumor banking and "floating" (=tuck in formalin) of larger specimens.

Interesting. Does this mean that you gross a lot of your bigs specimens more or less fresh? I always wondered about this. Here, grossing bigs becomes a two-day operation since on the first day, you take the basic measurements, describe lesions/tumors/masses, and then the next day we cut in the relevant sections.

I wonder if there are other institutions that diverge from our practice by cutting in more of their bigs specimens fresh. Again, I'm always curious as to how other institutions do things...it's nice to compare notes.

 

[DarksideAllstar]

Did I miss something? I thought that you guys do frozens on one of the preview days (at the main hospital)?

A cutting day (day 1 or 4) resident may or may not be carrying the frozen pager that day (since there are usually 3 residents cutting). Sometimes if the frozens get crazy the other residents and gross room supervisor will chip in and help out.

So, to summarize...

Day 1: Cutting (with or without frozen pager)
Day 2: Frozens/preview
Day 3: Signout
Day 4: Cutting (with or without frozens)
Day 5: Biopsies/preview
Day 6: Signout

 

[cytoborg]

Thanks for clarifying UCSFBound.

 

[pathres2]

Interesting. Does this mean that you gross a lot of your bigs specimens more or less fresh? I always wondered about this. Here, grossing bigs becomes a two-day operation since on the first day, you take the basic measurements, describe lesions/tumors/masses, and then the next day we cut in the relevant sections.

no, we gross most big cases fixed (even small cases, like lumpectomies, we try to let fix for an hour or two). the resident on day 4 is receiving some of the bigs for tumor banking and frozens and tucks them in formalin for the night. these specimens are for her/him to gross the next day... the other half of the big cases are received by the resident on call that night who is responsible for measuring, weighing, taking margins, taking pictures, inking, etc. before floating the specimen in formalin for the night.

i prefer to gross specimens that have been fixed: it is much easier to take sections without destroying the architecture of the tissue (e.g. layers in the colon) or messing up the inked margin (e.g. in the breast!!!). however, i think there is also a push for grossing things fresh (for turnaround time) and some say it is easier to find lymph nodes fresh...

 

[Mindy]

At MGH:

Everyday (on grossing services, by organ system that changes weekly):

8-12pm: sign-out
12:30-1:30: unknown conference
Afternoon: Gross
Late afternoon / evening: Preview

Organ systems are:
Gyn large
Gyn small / ob (gross placentas)
GI large
GI small (non-gross)
Derm (rare gross)
ENT
CV/Lung
GU
Bone & Soft Tissue
Breast

Mindy

 

[AngryTesticle]

i prefer to gross specimens that have been fixed: it is much easier to take sections without destroying the architecture of the tissue (e.g. layers in the colon) or messing up the inked margin (e.g. in the breast!!!). however, i think there is also a push for grossing things fresh (for turnaround time) and some say it is easier to find lymph nodes fresh...

i agree...i haven't mastered the art of cutting in many specimens fresh...i tend to play it safe and cut sections when they're nice and firm post-fixation.

of course, there are some cases i could cut in fresh, but i don't feel like changing blades everytime i cut each section.

 

[cytoborg]

Mashing the fat on those (damned) colons is a lot easier fresh. But keeping the layers together while cutting the mucosa is trickier.

 

[AngryTesticle]

Mashing the fat on those (damned) colons is a lot easier fresh. But keeping the layers together while cutting the mucosa is trickier.

Yeah, I have noticed this as well. In fact, I will strip off the fat off the colon fresh (except in the area involved by the tumor). That way I've found some nodes already. The next day, I search around the peri-tumoral fat (after taking a few "deepest extent" sections) and I can find a few more.

Oh yeah, the Bouin's trick is so overrated. Yeah, the lymph nodes are visible but it's a bitch to mash firm Bouin-ized fat.

 

[GreatPumpkin]

We do a rotation like Mindy. We divide into 4 rotations.

Gyn/GU
GI
Breast/Heart/Lung
Ent/General


During a work day/night you will be grossing, doing frozens, signing out and previewing for the next morining. It is pretty hectic. You learn to multitask real fast or you suffer.

We have a PA and a PA in training that handles the smalls.

 

[DarksideAllstar]

I think the breast tops my list of most undesirable specimens (particularly the mastectomies). Its fatty. **** gets all greasy and slides around in my hands. The ink runs everywhere. No matter how you cut it somehow the pectoral fascia wont overly the breast tissue in a proper way, so you can get nice sections demonstrating a deep margin. Half the time the surgeon has it oriented all f*ed up. The funniest thing happened to me last week. I get this wide local excision with wire localization and its completely unoriented. So I page the surgeon. The page gets returned by the circulating nurse in the OR and I ask if someone wants to come and orient the specimen. I hear the nurse ask, then I hear the surgeon in the background say, "its got a wire in it" as if that solves the problem. No ****. You think I didnt see that 6 inch wire sticking out the end? Do you even know what medial/lateral or superior/inferior are? I bet your patient would be thrilled. I hate the fing breast.

 

[yaah]

One surgeon here does the following with breast lumpectomies:

1) Main specimen has three sutures for orienting, which are often in impossible configurations (like superior and inferior on the same half of the specimen, and "deep" right next to the skin).

2) 6 separate specimen containers submitted with each margin, even if the tumor is a foot away from that margin. And the separate margins are sometimes smaller than one square cm. And each of these specimens is also oriented.

 

[beary]

2) 6 separate specimen containers submitted with each margin, even if the tumor is a foot away from that margin.

Boy, that's a pretty big lumpectomy!

 

[Mrbojangles]

One surgeon here does the following with breast lumpectomies:

1) Main specimen has three sutures for orienting, which are often in impossible configurations (like superior and inferior on the same half of the specimen, and "deep" right next to the skin).

2) 6 separate specimen containers submitted with each margin, even if the tumor is a foot away from that margin. And the separate margins are sometimes smaller than one square cm. And each of these specimens is also oriented.

Too bad patients don't know that that surgeon has no idea what they're doing.

 

[pathres2]

One surgeon here does the following with breast lumpectomies:

1) Main specimen has three sutures for orienting, which are often in impossible configurations (like superior and inferior on the same half of the specimen, and "deep" right next to the skin).

2) 6 separate specimen containers submitted with each margin, even if the tumor is a foot away from that margin. And the separate margins are sometimes smaller than one square cm. And each of these specimens is also oriented.

actually, this is fairly standard at a lot of places now (the extra margins, not the three sutures!). sampling the "cavity margins" can save a lot of patients another trip to the operating room. and they are oriented because these are now the "final" margins of this "modified" lumpectomy. there is a recent article by a hopkins group on the subject in the american journal of surg path:

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=16327435&query_hl=1

interestingly enough, the distance of the carcinoma to the lumpectomy margins does not predict (in a statistically significant way) whether there will be residual carcinoma in the "cavity margins." and, in some cases, there was residual carcinoma in these extra specimens even if the initial lumpectomy margins were negative.

anyway, i only remember this article because it was recently discussed in our breast tumor board and the surgeons here wanted to evaluate their results in a similar manner. somebody here calculated the volume of tissue removed with these extra margins as opposed to standard lumpectomies and it was only about 20% more...

 

[yaah]

actually, this is fairly standard at a lot of places now (the extra margins, not the three sutures!). sampling the "cavity margins" can save a lot of patients another trip to the operating room. and they are oriented because these are now the "final" margins of this "modified" lumpectomy.

Oh, I'm not saying it isn't standard of care, it's just kind of frustrating to deal with. Part of the problem is that the fat is loose and fragments easily and the "true margin" is not always equivalent to the external fat on the specimen because things fold over or retract or whatever. Next step will probably be Mohs surgery for the breast.

 

[pathres2]

Oh, I'm not saying it isn't standard of care, it's just kind of frustrating to deal with. Part of the problem is that the fat is loose and fragments easily and the "true margin" is not always equivalent to the external fat on the specimen because things fold over or retract or whatever. Next step will probably be Mohs surgery for the breast.

pitty the patient whose pathology is "read" by a breast surgeon...

 

[pathres2]

pitty the patient whose pathology is "read" by a breast surgeon...

oops, i meant 'pity'...