In the summer between my second and third year, I did an American Society of Clinical Pathology(ASCP) fellowship in Surgical/Anatomical, Transfusion Medicine and Forensic Pathology. This fellowship is open to any medical student who has finished second-year Pathology and is willing to take USMLE Step I early in the summer. You have to send in an application and be recommended by your Chairman of the Department of Pathology. This fellowship enables you to explore the work and lifestyle of a Pathologist in order to make a more informed decision about applying for residency in Pathology. After you have been accepted, you have to arrange to do your rotation at a community hospital (read non-university). This requirement it to make sure that you get a well-rounded experience as opposed to staying in one area of Pathology.
I chose INOVA Fairfax Hospital for my fellowship because it is a huge department with lots of experience. I spent some time in the DC Medical Examiner’s office and in the Northern Virginia Medical Examiner’s office for my Forensic experiences.
I started out doing Surgical Anatomical. This involved shadowing one of the pathologist’s when they went into the OR to do frozen sections. I spent the rest of the time, learning to cut surgical specimens that came in from the OR. After taking appropriate sections, baskets are made and numbered and logged. These were sent to the local reference lab so that slides could be cut. When a specimen was logged, it was described grossly, measured and then sampled for the best tissue. I was also required to attend daily conference at 2pm.
If there was a post-mortem exam, I was required to observe the performance of this procedure. The body of the deceased is weighed and all scars and tatoos are carefully logged. A Y-incision is made and the chest is opened. The diener (autopsy assistant) generally make the incisions, weigh and remove organs for the pathologist. After the initial incision is made, the pathologist will make a detailed description of the insitu appearance of each body cavity before any organs are pulled. The pathologist will section each organ looking for gross pathology and finally take tissue sections for baskets to be made into slides. Every organ is examined.
The diener will peel back the skin on the face and scalp so that the skull is exposed. Using a powersaw, the skull is opened and the brain is removed for preservation. The brain has to be immersed in formalin for two weeks before it may be cut. We will generally take cross sections of the medulla. The face and scalp are then carefully sutured back into place so that the body may be displayed in the funeral home if necessary. Our diener’s at INOVA Fairfax were trained in mortuary science so they knew how to remove the brain without disturbing the facial contour of the deceased.
All organs not kept for preservation are put back in the body cavities and sent to the funeral home with the body. We were required to release the body within 48 hours of death so we generally performed post-mortem exams very quickly after the body is brought to the morgue.
We were also required to examine any legs, toes, fingers or other amputated body parts before they were sent to the funeral homes for cremation. Any fetal tissues weighing less than 500 grams were treated like surgical specimens. If the fetus weighed more than 500 grams, we had to fill out a death certificate and do an automatic post-mortem exam. My first post mortem exam was a one-day old infant who had suffered SIDS. Members of the local police homicide unit were on hand to observe. It was very interesting.
During my transfusion medicine rotation, I assisted with harvesting stem cells, photopheresis for solid organ rejection, plasmapheresis and bone marrow transplants. I also investigated transfusion reactions and worked with quality control in the blood bank. My preceptor was a wonderful professor who allowed me to work on a paper with him describing our experiences with granulocyte transfusions.
In the Medical Examiner’s office, the autopsies are done differently from the hospital autopsy. We do each procedure the same way. We have to examine bullet trajectories, impact information and we visit the death scene to assist with determining the time of death. For most homicides, the liver temperature is used unless the body has begun to decompose. If there is significant decomposition, we use insect infestation to help determine the time of death. We are also called upon to determine if remains are human. This can be pretty difficult if there has been significant fire damage to the body or in the case of an explosion. Identification of remains is also under the review of the local medical examiner.
I really enjoyed my summer in Clinical and Forensic Pathology. I really considered pathology but opted for living patients instead. I had excellent preceptors and observed many things that helped me become a better physician. While performing a post mortem exams on a child is difficult, the parents really appreciated knowing that we had the highest level of respect for the child and were dedicated to finding out why the child died.
After you have finished your second-year pathology class, consider doing a fellowship in Pathology for experience.
Thanks for the info Nat-very interesting and helpful information as usual!!!