PATU-4008 - Acting Internship: Autopsy Service

PATU-4008 - Acting Internship: Autopsy Service

Elective Title: Acting Internship: Autopsy Service
Course Number: PATU-4008
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 1
Prerequisites: Successful completion of Year 3
Additional Requirements: Successful completion of all year 3 clerkships. C-form required to register, send to Tracy Wilkins,
Responsible Faculty Director: Judith Aronson, M.D. Periods Offered: 1,3,5,7,9-11 excluding holiday period 8 
Coordinator: Tracy Wilkins Other Faculty: Dr. Walker, Dr. Campbell, Dr. Olano, Dr. Felicella
Location to Report on First Day:
Dr. Judy Aronson, 5.144 CSW; 7:45am, 409-772-6547

1. Gain an understanding of the autopsy procedure.
2. Perform an autopsy from start to finish.
3. Begin to learn interpretation of gross autopsy specimens, with integration of microscopic sections and ancillary procedures employed during the autopsy.
4. Gain experience in correlating anatomic pathology changes with clinical history, physical findings, and laboratory results.

1. Perform basic autopsy prospection of adult or pediatric patient and record systematic macroscopic observations
2. Summarize a decedent's clinical record and communicate the information in an organized oral and written fashion
3. Diagnose common pathologic lesions based on gross examination
4. Select and prepare appropriate tissue blocks for histopathologic processing
5. Recognize histology of major tissues and organs, interpret general pathologic processes, and correlate with gross pathologic findings
6. Correlate autopsy findings with patient's clinical course
7. Organize pathologic diagnoses according to pathogenetic sequence
8. Correctly complete a (mock) death certificate
9. Describe procedures for obtaining authorization for autopsy (please see relevant EPA "Obtaining informed consent for tests and procedures").
10. Outline value of and limitations of autopsy examinations

Description of course activities
The student should first learn the autopsy procedure by reading the procedure manual, observing one or two cases, then assisting the Resident Pathologist. When the student and faculty feel that the student is ready, the student may then prosect cases under the direct supervision of the faculty member. Students will be required to perform at least two autopsies under the direct supervision of the faculty and present these cases at autopsy conference. Students will attend and participate in the following conferences: Gross Autopsy Conference (twice weekly), Autopsy Gross-Microscopic Conference (once weekly), Brain Cutting (once weekly), Pathology Grand Round (once weekly), Medicine Clinicopathologic Correlation Conference, Surgery Morbidity and Mortality Conference (once weekly). Students will review textbooks as well as relevant current literature to gain understanding of the clinical, pathologic, and pathophysiologic features of their cases.

Type of students who would benefit from the course
This elective would be useful for students planning careers in any field of medicine, particularly those interested in Pathology residency.

    Weekly Schedule
          Estimated Course Activities (Start-Time/Finish-Time):
Day of Week   AM   PM
Monday 8-12 1-5
Tuesday 8-12 1-5
Wednesday 8-12 1-5
Thursday 8-12 1-5
Friday 8-12 1-5

 Average number of patients seen per week: 3-5
 Call Schedule: NA

Research / Other Course Activities
(estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    Daily - Students will be directly observed by the attending pathologist, resident pathologist, and a Pathologist assistant.
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Students will present their autopsy cases to autopsy faculty and residents at divisional conferences.
  B. Frequency / Duration of Presentation(s)?
    At least twice during the month long elective. Each presentation is approximately 15 minutes long.
  C. Format - What guidelines are set for the student's presentation?
    Presentations consist of clinical summary, followed by presentation of the pathologic findings, with discussion by participating faculty and residents.
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Twice during the A/I. Students will be responsible for completing a full autopsy report.
  B. Format - What guidelines are set for the student's written work?
    Standard autopsy report format, with final anatomic diagnoses, clinical summary, gross description, microscopic description, and clinicopathologic correlation.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
    For most cases, an academic style CPC with references will be required. Students should identify relevant references using PubMed or equivalent database.
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    The write-ups are based on cases that the students have prosected and worked up. Faculty will assist in identifying relevant issues to discuss.
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Students are expected to attend all divisional conferences, as described above. Students should attend at least three autopsies per week, along with gross and microscopic "sign-out" sessions for cases they are not assigned. Students will also be expected to participate in neuropathology ("Brain-cutting") conferences and examine brains on their assigned cases. Students will be expected to participate in the discussion of cases at gross conferences, particularly toward the end of the rotation.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Evaluation will be based on daily observation by pathology residents and faculty. The quality of autopsy performance, write-ups and conference presentations will be considered.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    Students will receive oral and written feedback on their oral presentations at autopsy gross conference and will receive written feedback per rubric (aligned with ACGME Milestones for Path residents) on their 2 autopsy reports.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    The students will be learning how to perform and autopsy and integrate clinical information from the record with pathologic findings. Revier and summary of the clinical record is an important skill that will be practiced. This will require that they review the clinical record in detail, interpret clinical tests done pre-mortem and generate a differential diagnosis of expected pathologic findings. The acting intern will also communicate with clinicians taking care of the patient prior to, during, and after the autopsy.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    The skills related to macroscopic and microscopic pathology interpretation will help students prepare for pathology or radiology post-graduate training. All students will develop a deepened sense of clinical anatomy and a picture of the diseases that they will be treating in their patients as interns and beyond.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    All students will have the opportunity to practice oral presentations, including clinical summary at the beginning of the autopsy case presentations. As we see many interesting cases, there are opportunities for any interested students to develop case report or work on case series with residents/faculty.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    Similarities: Students will function as PGY1 residents on the service. They will be responsible for all aspects of 2 autopsy cases, including reviewing the medical record, communicating with clinicians, prospecting the case with faculty guidance, writing provisional and final reports, presenting case at conferences, submitting sections, reviewing slides with faculty, etc. Differences: The only difference is that their case assignment will be limited to 2 cases per month. In some cases, they may be supervised by an upper- level resident in addition to faculty pathologist.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    As this is an autopsy activity, students will not be developing a management plan. Instead, they are likely to assess the diagnostic process and management plan that was done pre-mortem against autopsy findings. Part of their duty as A/I will be to document in EPIC Beaker any diagnostic discrepancies identified at autopsy.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Residents will encounter 2-4 different faculty. Faculty rotations are generally one week at a time. They will work closely with 1 or 2 faculty on their autopsies. In most cases, students will work directly with faculty pathologist who co-signs the report. In some instances, a senior resident may participate in the supervision of the AI. Students will get explicit verbal and written feedback on their first oral case presentation; this will serve as mid-module feedback and help them with their second case presentation.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    During this course, students will interact closely with 1 or 2 faculty members who will oversee their overall work-up of the two assigned autopsy cases. All additional autopsy faculty members will observe their oral presentations and interactions at conferences. Residents and Pathologists Assistants will be involved in training the acting intern in prospection techniques and general expectations, but review of gross findings, microscopic findings and provisional and final reports will be done directly with faculty pathologist. Therefore, staffing pathologists will have ample opportunity to gather data about the student to write a letter of recommendation for those interested in Pathology residency.