Graduate Medical Education (GME): Anatomic Pathology
National Institutes of Health - Maryland

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Anatomic Pathology

Graduate Medical Education (GME): Anatomic Pathology

John C. Oberholtzer, MD, PhD
Entry Id: TP-4

Eligibility Criteria

Qualified candidates must have completed an M.D. degree from an approved U.S. or Canadian medical school or must hold an E.C.F.M.G. certificate. The majority of successful applicants have prior research experience, or have a Ph.D. degree.

Overview

The Laboratory of Pathology (LP) offers a multifaceted training program for residents in anatomic pathology at the NIH Clinical Center (CC). The CC is the site of intramural clinical research for the NIH (see http://www.nih.gov ), and home to more than 1500 clinical research protocols. Excelling in both clinical diagnosis and translational research, the department provides a stimulating intellectual environment for the resident or fellow interested in an academic career. The department emphasizes excellence in diagnosis and the use of modern technological tools to enhance accuracy and decipher disease mechanisms. In addition, the staff of the LP receive more than 2000 cases in consultation each year, resulting in a rich and diversified exposure to the practice of anatomic pathology.

The philosophy of the training program is to provide broad and in-depth exposure to the subject matter of anatomic pathology, with an emphasis on clinical correlation, relationships to disease mechanisms, and exposure to investigational opportunities. Each case under study is viewed in the context of (1) the individual patient's clinical course, (2) strong personal interactions with the clinicians caring for the patient, and (3) the general relevance to disease pathophysiology and investigational questions. Residents become fully grounded in the laboratory techniques, observational and descriptive analysis procedures, and communication skills required to gain the maximum information prior to rendering a diagnosis. Training occurs mostly within the Laboratory of Pathology and through our affiliations with the George Washington University Medical Center, and Children’s National Medical Center.

The research activities of the staff are diverse, incorporating the most modern techniques available in biomedical research and based upon a firm foundation of an intricate knowledge of the biology of the disease state. The laboratory also offers ACGME-accredited subspecialty fellowships in cytopathology and hematopathology that integrate advanced diagnostic pathology with opportunities for laboratory research and instruction in sophisticated laboratory techniques.

Much of the strength of this residency-training program comes from the internationally recognized reputation of the Anatomic Pathology Staff. The staff is acclaimed in many areas of Anatomic Pathology and is committed to excellence in the teaching program. Because our clinical programs are integrated with the research activities of the NIH, our residents are exposed to information regarding the pathogenesis and pathophysiology of diseases that they are learning to diagnose on a regular basis. This insight into the basic disease mechanisms of pathology enhances their educational experience.

The training program has an abundance of formal courses, national meetings, and elective rotations at outstanding institutions across the country. The unique scientific environment of the NIH offers unmatched research opportunities, as well as a wealth of research conferences and lectures that supplement the clinical training. The superlative quality of our residents contributes significantly to the success of this program. LP consistently attracts top-rated candidates, many with both and MD and Ph.D. degree or additional post-graduate training or experience. Most of our past residents pursue careers in academic Pathology or biomedical research.

For those residents with a particular interest in and commitment to a career in experimental pathology research, a competitive option will be available in which three additional years of research time and support are provided by the Department. Interested residents can apply for this option at any time during their second year of residency. It is anticipated that many of our residents will successfully choose this option.

Structure of the Clinical Training Program

Clinical training in the Anatomic Pathology Program includes three years of rotations and subspecialty training. The program provides for diversified experience in postmortem, surgical pathology, cytopathology, hematopathology, molecular pathology and cytogenetics diagnosis. Separate one-month subspecialty rotations in forensic pathology, surgical pathology, and pediatric pathology offered at affiliated institutions broaden the training offered at the NIH. Integrated training in dermatopathology, neuropathology, pediatric pathology, flow cytometry, immunopathology, electron microscopy, informatics, management, and quality improvement are provided during all three years. Residents in the third year gain more authority in making diagnostic decisions and supervising other residents in both surgical and postmortem pathology.

An optional fourth year of training is fully funded at which time the residents may participate in electives or research. The sponsoring laboratory, LP or other, provides supplies and services for approved research rotations.

Rounds, conferences, seminars, journal clubs, courses, and library resources

Residents attend regular departmental conferences and participate in Grand Round lectures (see http://calendar.nih.gov/app/MCalWelcome.aspx ).

A schedule of lectures, seminars, journal clubs, and meetings is published each week and includes speakers of national and international note in all fields of biomedical science.

The National Library of Medicine is located on the grounds of the NIH and all its services are available. The Clinical Center has one of the most complete medical libraries in the country and the Laboratory of Pathology has a small departmental library. Scholarly activity includes active participation in regional or national professional and scientific societies. Many other educational opportunities are available at NIH (see http://www.cc.nih.gov/researchers/training.shtml ), including diverse educational experiences offered through the NIH Foundation for Advanced Edcuation in the Sciences (FAES) . [ disclaimer ]

After Hours and On-call Coverage

Residents are not required to be present at the institution during periods of on call. No call is required of PGY-1 residents and PGY-2 residents may have up to a total of nine weeks on call. All on-call schedules are in full compliance with ACGME standards.

Resident Salaries and Benefits are detailed on the GME program page (127 KB)

First-year residents with a biomedical Ph.D. may be appointed at the PGY-2 level of pay resulting in a somewhat higher salary. An additional supplement of approximately $3400 may be provided for residents at the PGY-3 level or higher.

Student Loan Repayment is available from $5,000 to $35,000 to qualified individuals accepted into the program.

No living quarters are provided, but homes and apartments at all price levels are available in the immediate vicinity.

The NIH is located in Bethesda, MD, a pleasant residential community just ten miles from the center of Washington, D.C. All of the historic, social, and cultural advantages of the nation's capital are close at hand. There are five University Medical Centers in the area as well as the Armed Forces Institute of Pathology.

Goals and Objectives of Residency Rotations

Clinical Cytogenetics

Learn the indications for clinical cytogenetics testing.

Become familiar with specimen requirements, and the various techniques used to process different tissues for cytogenetic analysis.

Review the more common constitutional chromosomal abnormalities, and the mechanisms by which these abnormalities arise.

Learn the more common, recurring chromosomal abnormalities found in hematologic malignancies and nonhematologic solid tumors, and the diagnostic and prognostic implications of these abnormalities.

Participate in the interpretation and sign-out of current Clinical Cytogenetics Laboratory reports.

Cytopathology

Learn to recognize cytomorphologic features of different cell types and range of normal morphology.

Learn criteria of malignancy in various body sites and types of specimens.

Gain experience in screening of cytology specimens to detect possibly rare abnormal cells amid a predominance of normal cells.

Learn cytodiagnostic terminology for cervical/vaginal specimens.

Learn limitations of cytopathological diagnosis as compared to histopathologic diagnosis.

Learn the appropriate use of ancillary diagnostic techniques such as immunocytochemistry and electron microscopy in the work-up of diagnostic ms encountered in cytopathology.

Learn rapid triage of specimens in order to utilize patient material to best advantage in diagnostic work-up and avoid contamination of stains by highly cellular malignant fluids.

Learn to recognize cell patterns that indicate a possible infectious process in order to consider options such as sending material to microbiology and/or obtaining special stains for organisms.

Learn fundamentals of various specimen preparation techniques, including advantages and drawbacks of cytocentrifugation, membrane filtration, smears, and the new technology of monolayer ThinPreps.

Appreciate the advantages and drawbacks of different staining methods such as wet fixed Papanicolaou versus air-dried modified Wright-Giemsa stains.

Learn proper specimen collection techniques for various specimen types including cervical/vaginal smears and fine needle aspiration specimens.

Learn fundamentals of quality assurance methods in pathology, particularly as applied to cytopathology.

Flow Cytometry

Attain competency in interpreting flow cytometric histograms, dot plots, and contour plots.

Understand the utility as well as the limits of the method and how the data generated integrates into the diagnostic interpretation.

Acquire familiarity with criteria for diagnosis of malignant lymphoma using flow cytometry.

Acquire familiarity with criteria for diagnosis of aneuploidy using DNA content analysis.

Understand concept of determination of S phase fractions and variables important in this determination.

Understand the need for quality control and know what currently is acceptable in this area.

Forensic Pathology

Gain experience in the principles and practice of forensic pathology.

Develop a systematic approach to the forensic autopsy, including evaluation of gross, microscopic, biochemical, and genetic evidence.

Perform an autopsy safely, in an efficient, organized fashion.

Interpret and correlate the postmortem pathologic findings with other clinical, laboratory, and evidentiary data.

Learn to present autopsy findings to official personnel from the medical, legal, and investigative communities.

Hematopathology

Prepare trainees to deliver state of the art diagnostic and consultative services in the field of hematopathology.

Introduce trainees to research in hematopathology, and to inspire them to pursue a lifelong career of academic inquiry.

Challenge trainees to think critically and in innovative ways about problems in hematopathology and to prepare them for a career of continued learning in pathology.

Advance medical knowledge by striving for the highest standards of clinical care, scientific inquiry, and productivity.

Immunohistochemistry Laboratory

Learn basic techniques of immunohistochemistry including methods of antigen retrieval.

Learn how an immunohistochemistry lab is organized from specimen receipt to report generation.

Learn to perform and interpret the common immunohistochemistry tests.

Attend and present results of immunohistochemistry tests at a diagnostic conferences. These conferences emphasize the integration of the immunohistochemistry tests in the context of the whole case.

Learn how to properly select and interpret appropriate controls.

Develop the ability to be judicious in ordering practices.

In situ Hybridization

Learn basic techniques of in situ hybridization.

Learn how an in situ hybridization lab is organized from specimen receipt to report generation.

Learn to perform and interpret the common in situ hybridization tests.

Attend and present results of in situ hybridization tests at a diagnostic conferences. These conferences emphasize the integration of the in situ hybridization tests in the context of the whole case.

Learn how to properly select and interpret appropriate controls.

Develop the ability to be judicious in ordering practices.

Laboratory Management & Information Systems

Develop an awareness of and responsiveness to the health care system, both at the National Institutes of Health, and in the broader national community.

Develop the ability to effectively call on system resources to provide care that is of optimal value.

Molecular Pathology

Learn basic techniques of nucleic acid handling, including proper storage of tissue samples and the extraction of intact materials from tissue samples.

Learn electrophoresis methods for analysis of DNA and RNA, including agarose gel electrophoresis and acrylamide gel electrophoresis.

Learn basic polymerase chain reaction (PCR) techniques to amplify targeted DNA from tissue samples. Learn how to select primers and proper controls.

Learn basic Southern blot hybridization techniques.

Learn how to label probes with nonisotopic methods.

Learn basic methods of in situ hybridization of cytospins and tissue samples.

Learn how a molecular diagnostics lab is organized from specimen receipt to report generation.

Learn the proper set up to perform PCR laboratory so as to minimize the chances for contamination. Learn how to identify and handle contamination problems in the laboratory.

Learn to perform and interpret the common molecular tests.

Attend and present results of molecular diagnosics tests at a weekly molecular diagnostics conference. This conference emphasizes the integration of the molecular diagnostic test in the context of the whole case.

Neuropathology

The overall objective is to learn those aspects of neuropathology particularly relevant to the practice of general anatomic pathology.

Ensure proper neuropathological examination; each case discussed with neuropathologist prior to autopsy vis-à-vis: a) special sampling, i.e., base of skull, sella turcica en bloc, orbital soft tissues, dorsal root ganglia, peripheral nerves, postmortem CSF by cisternal tap b) tissue handling: frozen tissue, fixation for EM.

Be able to present the neurological history and pertinent systemic clinical history at the brain cutting session with relevant areas of neuropathogy discussion to follow.

Be able to examine a brain for external evidence of disease or trauma.

Be able to cut the brain with a purpose in mind.

Be able to block in relevant sections.

Be able to generate an order for relevant special stains needed for diagnosis.

Learn basic neurohistology and generate a coherent, relevant, and concise neuropathologic autopsy report that integrates the history, gross, and microscopic findings.

Learn how to handle neuropathologic surgical cases, including those submitted for frozen section.

Evaluate the microscopic findings and order and interpret relevant special stains in neuropathologic biopsies.

Learn how to generate a clearly written surgical pathology report containing that information specifically relevant to neurology and neurosurgery.

Pediatric Pathology

Learn the principles and practice of pediatric pathology, and to acquire the skills necessary to function independently in the diagnosis of surgical and autopsy specimens in the pediatric age group.

Recognize normal gross anatomical and histological structures (including normal variants) as they pertain to surgical specimens.

Process gross specimens appropriately as regards dissection, sampling, fixation, and special studies.

Cut, stain, and interpret frozen section biopsies.

Make diagnoses on surgical pathology specimens using gross, microscopic (H&E stains) and special studies.

Write and dictate clear and concise surgical pathology reports.

Organize the workload so that cases are processed, signed out and dictated in a timely manner.

Communicate with clinicians in order to facilitate appropriate clinicopathologic correlations.

Develop a systematic approach the evaluation of postmortem pathologic findings.

Perform an autopsy safely, in an efficient, organized fashion.

Interpret and correlate the postmortem pathologic findings with the clinical findings.

Present autopsy findings to clinicians, both in written form (autopsy protocol in provisional and final states) as well as oral forms.

Postmortem Pathology

Develop a systematic approach the evaluation of postmortem pathologic findings.

Perform an autopsy safely, in an efficient, organized fashion.

Interpret and correlate the postmortem pathologic findings with the clinical findings.

Present autopsy findings to clinicians, both in written form (autopsy protocol in provisional and final states) as well as oral forms.

Complete the autopsy report in a timely fashion; i.e., PA in 72 hours and FAD in 60 days.

Surgical Pathology

The overall objective is to acquire the skills necessary to function independently in the diagnosis and interpretation of surgical pathology specimens.

Recognize normal gross anatomical and histological structures (including normal variants) as they pertain to surgical specimens.

Process gross specimens appropriately as regards dissection, sampling, fixation, and special studies.

Cut, stain, and interpret frozen section biopsies.

Make diagnoses on surgical pathology specimens using gross, microscopic (H&E stains) and special studies.

Write and dictate clear and concise surgical pathology reports.

Organize the workload so that cases are processed, signed out and dictated in a timely manner.

Communicate with clinicians in order to facilitate appropriate clinicopathologic correlations.

Ultrastructural Pathology

Provide all residents with knowledge of the ultrastructure of pathologic conditions and with the understanding that the final diagnosis is the result of a combination of available methods.

Familiarize residents with the ultrastructural features of pathological conditions and to teach them how to use these features in combination with other available diagnostic tests and clinical information to reach a final diagnosis.

Laser Capture Microdissection Core
Laser Capture Microdissection (LCM) was invented at the NIH. The LCM Core is directed by Dr. Michael Emmert-Buck, one of the inventors. The Core has several PixCell, Veritas, and AutoPix units. Residents may use the LCM core to aid in their research projects. Formal training and technical support is provided for users of the Core facility. Expression-based microdissection is currently under development, and an alpha test unit is in place at the NIH.

Program Faculty & Publications
Further information about the program faculty and departmental publications can be found on the Laboratory of Pathology, Center for Cancer Research web site:
http://ccr.cancer.gov/labs/lab.asp?labid=106

Program Graduates
The following is a list of recent graduates of the Laboratory of Pathology:

David S. Cassarino, M.D., Ph.D, UCLA Medical Center

Paul C. Herrmann, M.D., Ph.D., Loma Linda University

Kevin Rosenblatt, M.D., Ph.D., Univ of Texas Medical Branch-Galveston

Katherine Rizzo, D.O., Ph.D., University of Indiana School of Medicine

Laszlo Karai, M.D., Ph.D., University of Texas Southwestern Medical Center

Carlos Torres-Cabala, M.D., M.D. Anderson Cancer Center

Dara Aisner, M.D., Ph.D, University of Pennsylvania

Michael W. Beaty, MD: Wake Forest University School of Medicine

Demetrious Braddock, MD, PhD: Yale University, School of Medicine

Peter Bryant-Greenwood, MD: University of Hawaii

Timothy Cote, MD, PhD: Centers for Disease Control

Andrew Feldman, Mayo Clinic, Rochester, MN

Michael Fritsch, MD, PhD: University of Wisconsin

Thomas Giordano, M.D., Ph.D. University of Michigan

Stephen Hewitt, MD, PhD: National Cancer Institute

Alex E. Lash, MD: Memorial Sloan Kettering Cancer Center

David Mauro, MD, PhD: Merck & Company

Lavinia Middleton, MD: University of Texas M.D. Anderson Cancer Center

Robert T. Pu, MD, PhD: University of Michigan School of Medicine

Martha Quezado, MD: National Cancer Institute

Julie Teruya-Feldstein, M.D., Memorial Sloan Kettering Cancer Institut

Alexander O. Vortmeyer, MD, PhD, Yale University

Application Information
The Anatomic Pathology Program at NIH is fully accredited by the Accreditation Council for Graduate Medical Education. There are three to four positions available per year.

For further information, the applicant should contact:
John Carl Oberholtzer, MD, PhD
Chief, Laboratory of Pathology
CCR / National Cancer Institute / NIH
10 Center Drive, Rm 2N208, MSC 1500
Bethesda, MD 20892
Office: 301-594-1884
FAX: 301-402-0043

Electronic Application
We do not participate in the National Resident Matching Program, but advise that applications be submitted through ERAS.

For further information you may contact Ms. Susan Hostler,

Admissions Coordinator:
Ms. Susan Hostler
Laboratory of Pathology, CCR, NCI
10 Center Drive, Room 2A33 MSC 1500
National Institutes of Health
Bethesda, MD 20892

Only three positions are open to new applicants each year. Applications should be submitted by December 1 for appointments beginning the following July. After review of completed applications, qualified candidates will be invited to meet our staff and residents.
The NIH is dedicated to building a diverse community in its training and employment programs.

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