The blood bank transfusion rotation consists of five months. Residents rotate through the blood bank laboratory and the American Red Cross for blood collection. Residents are required to acquire competency in general immunohematology/ transfusion medicine, including pre-transfusion and post-transfusion testing, ABO/Rh testing, antibody screening and identification, transfusion reactions, infections, disease complications of transfusion medicine and therapeutic apheresis. Residents are expected to become knowledgeable in the indications for appropriate use and indications for blood components, methods of blood conservation, the pathophysiology and treatment of alloimmune disease of the red blood cell and platelets, maintenance of the blood bank inventory, requirements for blood collection including allogenic vs. autologous and donor blood testing, transfusion reactions, the indications, principles and application of therapeutic apheresis and regulatory compliance issues (FDA, AABB, JCAHO and CAP).
The residents are exposed to donor center activity through a special arrangement for a rotation at the Mid Atlantic Regional American Red Cross (3 days). During the daily transfusion medicine rounds, the residents present the daily cases where all uncrossmatched blood released by the blood bank, antibody work ups, therapeutic apheresis, and transfusion reactions are reviewed with the attending transfusion medicine faculty. After rounds, the residents are required to write a complete report.
Residents participate and review consultations for special product requests such a leukocyte reduction filters, CMV, serologically negative and irradiated blood products. The blood bank releases approximately 23,000 units of packed red blood cells and performes approximately 950 antibody work ups per year. The initial consultation for apheresis patients is the responsibility of the resident and the resident writes a consultation request note in the clinical chart with a brief summary and plan following discussions with the attending. The resident is also responsible everyday for gathering information about the apheresis patients. The resident writes a brief note in the clinical chart which is followed by an attending note. The residents participate in approximately 760 written consultation reports per year.
Residents are required to attend didactic lectures offered by the Department of Pathology and Medicine and participate in the hospital transfusion committee. The residents are encouraged to attend many intradepartmental and interdepartmental conferences and journal clubs. Residents are also expected to improve teaching and communication skills by reviewing cases with house staff and medical students and reviewing peer-reviewed journal articles in transfusion medicine.
This period of training is designed to teach pathology residents clinical microbiology and immunology, and to prepare them for a career in clinical pathology. The development of knowledge and new methods in microbiology and immunology, including automated and rapid techniques, has been extensive in recent years. Pathology residents training to become directors should be adequately informed about these developments. The Clinical Microbiology and Immunology Laboratories at Temple University Hospital are composed of the specialty areas of bacteriology, mycobacteriology, mycology, parasitology, virology and immunology. In one calendar year approximately 160,000 specimens are processed for microbiology and approximately 55,000 specimens for immunology. The residents who complete this program are expected to acquire sufficient understanding of theoretical and technical aspects to aid them in the successful attainment of their Clinical Pathology Board (ABP) certification as well as help them to make proper policy and operational decisions in their future careers.
Approximately 16 weeks are spent rotating through the various areas and working at the laboratory bench. During the 4 month rotation, selected unknowns are given to the resident for identification. Any remaining time, or elective time spent in the Clinical Microbiology and Immunology Laboratories consists of returning to selected areas for additional in-depth training, or identification of unknown microbiologic isolates. Included in these rotations are infectious disease/clinical microbiology laboratory rounds held three time weekly (Monday, Thursday, and Friday) during which microbial isolates from cases are discussed from a clinical and microbiologic perspective. In attendance at these rounds are infectious disease attending physicians, infectious disease fellows, internal medicine residents who are rotating on the ID service (usually 2-3), medical students currently taking the Infectious Disease Senior Elective (usually 3-4), pathology residents, medical technologists and the clinical microbiology director. If any clinical laboratory, surgical pathology, or autopsy information is available, it is discussed at this meeting. Also, any infection control investigation or possible outbreak is discussed and reviewed during these sessions, in addition to autopsy/surgical cases, transplantation cases and other interesting patients, isolates and cases. Following the rounds on Thursdays, an informal didactic teaching session is held for medical students, pathology residents and infectious disease fellows on laboratory methods in clinical microbiology/immunology.
A Clinical Microbiology and Immunology conference is held weekly which is led by a pathology resident and includes topics such as case reports, selected infectious diseases and microorganisms, and laboratory testing. Also discussed at this weekly conference are research topics, administration and management issues, and other aspects of the Clinical Microbiology and Immunology laboratory. The clinical microbiology director also presents lectures and reviews in the clinical pathology lecture series held throughout the year.
The resident training program in clinical chemistry is designed to familiarize the pathology residents with all aspects of chemical pathology. This includes a basic knowledge of the principles of the assay and instrumentation employed in performing the tests. The program also gives the residents a clear understanding of pathophysiological correlations that allow them to properly interpret test results and provide effective clinical consultation.
The resident training in chemical pathology is organized to stress increasing responsibility during the three month rotation augmented by didactic lectures, seminars, case presentations, conferences and on call activities. The first month is a period of general orientation during which the residents become familiar with the practical aspects of the clinical chemistry laboratory. Residents rotate through each section learning the principles of the tests as well as their clinical correlation. During the next two months, the residents are involved in a supervisory role and assist the clinical chemistry director in managing the clinical chemistry laboratory. The responsibilities include interpretation and clinical consultation of test results, review of quality control reports, preparation or revision of procedures and other laboratory policy documents, assistance in the evaluation and implementation of test methods or instruments, and a discussion of laboratory management problems. The residents, under the supervision of the clinical pathologists, are also responsible for the interpretation and reporting of serum and urine protein electrophoresis, and evaluation of hemoglobinopathy assays. In one calendar year, there are approximately 1,500 serum and urine electrophoresis cases and 350 hemoglobinopathy cases. When on call in clinical chemistry (about 3 times/week), the residents actively participate with the cases and serve as a clinical consultant for the interpretation of test results under the direction of the director of clinical chemistry. The degree of resident participation in these activities is based on the resident’s skill, ability and experience. Residents are expected to obtain the knowledge of instrumentation and analytical techniques in the performance of routine and special chemistry testing. They are also expected to carry out effective consultations on clinical chemistry issues.
The residents will obtain experience in all the major aspects of clinical chemistry including renal and hepatic function testing, blood gas analysis, serum proteins tests, lipid profile tests, endocrinology testing, reproductive and obstetrics clinical chemistry, pediatric clinical chemistry, toxicology testing in urine drugs screening, therapeutic drug monitoring, and point of care testing (POCT). They will also have experience in laboratory management and become familiar with the laboratory information system. Residents will establish the ability in interpreting test results and consulting on clinical chemistry issues. Residents are expected to evaluate and implement test methods by clearly understanding the parameters including accuracy, precision, analytical sensitivity and specificity, linearity, and reference interval. Finally, residents should understand the general principles of quality control, and are expected to assess method performance and improve laboratory practice by reviewing the quality control data and proficiency testing results.
Routine urinalysis (RUA) and urine microscopy are performed in the clinical chemistry section. The medical microscopy procedures for other body fluids are performed in the hematology section. They are supervised by the directors of clinical chemistry and hematology. In one calendar, year approximately 2,500 body fluids are tested.
The rotation of urinalysis and urine microscopy is one week. Residents are instructed in the performance of routine urinalysis and interpret routine urinalysis tests with particular emphasis on the microscopic examination. Residents become familiar with each test performed by learning the methodology and operate the instruments used in the urinalysis section, such as automated reagent strip reader and osmometer. The residents gain proficiency in identifying urine sediment (cells, casts, crystals, etc.) with the experienced medical technologist, supervisors, and director of clinical chemistry.
During the hematology laboratory rotation, the residents review the microscopic examination of body fluids, which include spinal, synovial, pleural, peritoneal, and other fluids. The residents are expected to review the cases independently prior to sign-out, formulate a differential diagnosis, and draft a preliminary report for review by the directors. When necessary, correlations are made with the surgical pathology, microbiological, hematological, and chemical findings. The attending pathologists in hematology also review interesting/difficult cases with the residents during their rotation in hematology.
The hematology rotation consists of two three-month rotations. The residents rotate for the first three months at Temple University Hospital and the second three months at the Jeanes Hospital (BMT). Residents are required to acquire competency in general hematology, hemostasis/coagulation, including normal hematopoiesis and hemostasis/coagulation involving the various disorders of the red blood cells, white blood cells and coagulation, and the performance of bone marrow aspiration/biopsy. Residents are expected to become knowledgeable in the principles of laboratory instrumentation and the clinical findings, pathophysiology, laboratory findings and clinical features of the various disorders of the red blood cells, white blood cells, coagulation system and platelets. Residents rotate through the general hematology laboratory and special ancillary laboratories including flow cytometry, immunohistochemistry and coagulation laboratories. Residents review peripheral blood smears, bone marrow aspirates/biopsies, lymph node biopsies, platelet aggregation studies, hypercoagulation cases, flow cytometry, immunohistochemistry, cytogenetics and molecular diagnostic data. The hematology/coagulation section performs approximately 405,000 test/year. In a calendar year the residents are exposed to approximately 250 peripheral blood smears, 700 bone marrow aspirates/biopsies, 300 flow cytometry cases, 350 lymph node biopsies, 20 platelet function studies and 400 hematopathology consultations. The residents are expected to review cases independently, consider additional studies for further work-up, formulate a differential diagnosis and draft a preliminary report prior to review with the hematopathologist. The goal of this process is to integrate the critical thinking skills/process with the ancillary techniques while instilling confidence and developing clinical competency. At both institutions, the reports include peripheral blood smears, bone marrow aspirate/biopsies, lymph node biopsies, platelet function studies, hemoglobinopathies, flow cytometry, immunohistochemistry cytogenetic and molecular diagnostic data.
The residents acquire graduated responsibility as they advance their critical thinking skills/process, interpretation and analysis of data, considering additional studies for work up, expanding their differential diagnosis and developing competency in advanced hematopathologic cases. The initial residents training process begins with the review of hemoglobin synthesis, iron/B12/folate metabolism, differentiation of hematopoietic cells (red blood cell, white blood cell, platelet), the principles of laboratory instrumentation (red blood cell analyzer, white blood cell immunphenotyping by flow cytometry or immunohistochemistry, and platelet aggregometry) the gross evaluation of hematopoietic specimens (bone marrows, lymph nodes and spleens) and recognization of normal hematopoietic cells (red blood cells, white blood cells and platelets). As the residents progress through their training, they learn to integrate the clinical history/presentation, recognize abnormal cell populations by morphology (light microscopy), general analytical techniques (red blood cell analyzer) and special ancillary tests (immunohistochemical and cytochemical stains, etc.) and analytical techniques (white blood cell flow cytometry, etc). By the middle of the training, most residents should be capable of diagnosing the most common hematopoietic disorders through the integration of clinical history, morphology, cytochemistry, immunophenotyping, molecular diagnostic and cytogenetics. During this continuing process, the residents expand their differential diagnosis. By the end of the training, most residents should be capable of working up and listing a complete differential diagnosis for most advanced hematopoietic disorders.
Residents are expected to attend didactic lectures offered by the Department of Pathology and Medicine. The residents are encouraged to attend many intradepartmental and interdepartmental conferences and journal clubs. Residents are also expected to improve teaching and communication skills by reviewing cases with house staff and medical students. Residents rotating at Jeanes Hospital are responsible for the work up of all hematopathology cases. In addition, the residents prepare a weekly conference where all hematopathology cases are presented and discussed with the bone marrow transplantation staff. Bone marrow procedures are performed by residents under the supervision of two clinical hematologists at Temple University Hospital. Residents are required to perform at least 5-10 aspirates/biopsies before graduating from the program.
Residents participate in an outside rotation with Quest Diagnostic Laboratories. The cytogenetics laboratory is a full-service facility that processes over 30,000 tests per year for cancer or cancer suspicion, pre- and postnatal diagnostics, and recessive disease assays (Bloom syndrome, Fanconi anemia).
The resident receives exposure to all technical areas (culture, chromosome preparation, karyotype preparation and analysis) working with NACLS-certified laboratory technologists and associates as well as didactic/discussion with the laboratory technical director inclusive of interpretation, procedural rationales, risk calculation, and theoretical considerations. Extensive discussion of routine and specialty areas ('chromosome breakage disorders', interphase and metaphase FISH, analyses for cancer / acquired cytogenetic change, etc,) is provided. A basic background in genetics pertinent to cytogenetics is provided through didactic/discussion and recommended readings. Reading material in the form of texts and significant journal publications is provided. Opportunity for clinical-cytogenetic case work-up and/or methods development is provided for the interested resident. The resident will have the opportunity to culture, “harvest” and prepare/study metaphase preparations (from peripheral blood). For the interested resident, there is opportunity for performing specialized technical procedures such as FISH analyses. Cytogenetic analyses for constitutional and acquired (cancer associated) abnormalities are reviewed and interpreted by the pathology resident. Findings, interpretations, and suggestions for further testing are discussed with a laboratory director who issues the final report. The numbers of reports reviewed in this manner is variable. The laboratory generates approximately 750 to 900 total test reports per week. During this rotation, the review of archival material (reports, slides) by the resident provides a varied and useful clinical exposure. Consultation by the pathology resident includes suggested work-up for hematological specimens (cancer related) based on available pathology reports. The resident has the opportunity to generate an integrated comprehensive report based on Quest Diagnostics laboratory findings in cytogenetics, flow cytology and pathology. The resident receives exposure to all technical areas (culture, chromosome preparation, computer-assisted karyotype preparation and analysis) working with NACLS-certified laboratory technologists and associates. The resident gains hand-on experience in handling peripheral blood lymphocyte cultures for chromosome preparations.
Flow Cytometry (FCM) is included as part of the 6-month hematopathology rotation and histocompatibility (HLA) as part of the 5-month rotation in transfusion medicine. Resident education in serology, including microbial immunology and autoimmune diseases, is encompassed in the clinical microbiology and immunology rotation, the resident taking 3 weeks for serologic tests for syphilis (RPR, VDRL), tests for Hepatitis A, B, and C, screening and confirmatory tests for HIV (EIA and Western Blot), antibody tests for bacteria and viruses, and tests for autoimmune diseases. Weekly clinical pathology conferences and a clinical microbiology and immunology conference are attended by pathology residents and are also described in the clinical microbiology and immunology section of the program outline. The residents work closely with the technical staff and director in one-on-one sessions during these rotations. He/she first learns the basic technology at the bench, and then learns how to evaluate and interpret data. In addition, while rotating through FCM and HLA, the resident is also required to present at the monthly journal club, and to attend the weekly solid organ transplant conferences.
The number of transplants performed in one calendar year at Temple University Hospital (TUH) include: 20 kidneys, 13 hearts, 10 lungs and 1 heart-lungs. Histocompatibility services in support of transplantation included 266 HLA typing, 1,647 lymphocytotoxic alloantibody screenings and 422 direct lymphocyte crossmatches. Immunodeficiency evaluations at TUH include 509; 431 follow-ups are with CD4/CD8 counts (FCM). Other histocompatibility tests include 43 HLA-typing for B27.
Residents are provided a theoretical foundation in leadership and administration through a series of didactic lectures that reinforces their cognitive learning of this topic. Specific attention is placed upon current practices and emerging trends in performance improvement and regulatory compliance management affecting laboratory licensure and accreditation. Additional lectures focus on financial and management accounting fundamentals, capital equipment proposals, statistical trend analysis and operating budget preparation. While on rotation, residents are invited to participate in fact finding sessions with faculty mentors and section managers who are engaged in cost analysis and ROI evaluation when choosing replacement equipment or new methodologies. During the meetings, they do have the opportunity to see the actual hospital budget and management accounting documents discussed in their lectures. Clinical rotations also provide the residents affective and behavioral learning experiences in professional management that arise in day-to-day operations. These challenges may include clinical problem investigation, assessment of medico-legal risk of testing, and service recovery to improve customer satisfaction with laboratory services.
Resident experience with laboratory information systems and database management techniques is obtained as a component of most of their rotations, during which they utilize these tools to locate information for their interpretive (sign-out) duties (e.g. surgical pathology, autopsy pathology, cytopathology, chemistry, hematopathology, and microbiology). The residents receive basic training in medical information so that they may competently perform their service responsibilities; this is accomplished through a combination of interactions with faculty mentors, secretarial personnel and members of the pathology management team.
Department of Pathology and Laboratory Medicine Residency Program
Residency Program Director:
Varsha Manucha, MD
Residency Program Assistant Director:
Carrie Schneider, MD
Room 346 Outpatient Bldg.
Philadelphia, PA 19140