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Rotation Summaries - Clinical Pathology

Coagulation at University of Minnesota Medical Center, Fairview

This educational experience is designed to provide a broad based experience in coagulation through exposure to a diverse range of testing modalities for both bleeding and clotting disorders. The resident is expected to become proficient in interpreting these test both individually and collectively.

Daily Duties and Responsibilities

The major vehicle for instruction of a resident by the course director will be during test result interpretations. During the first few days of the rotation, the resident will observe the course director evaluate the interpretive test results. By the end of the first week, the resident will be expected to do interpretations ( generally 7:30 - 9:30 am), before presenting them to the faculty. The resident will be expected to review all interpretive tests done during in the laboratory and prepare the initial interpretive report for review with the course director. The interpretative reports are done on one of two intra-laboratory computer database systems. The resident is expected to learn to efficiently use these systems. It is expected that the resident will do this in a timely manner, so that there will be no delay in completion of the laboratory work. This may involve the resident staying into the early evening, or coming in early in the morning in order to be prepared for review of interpretations at the same time the course director would do them if there were no resident on the service.

At the end of the second week, the resident will be given an oral and a written quiz by the course director on the covered material. Shortly before the end of the rotation, the resident will be given another oral quiz by the course director to ensure that the rotation goals have been reached. Because the course director has a special interest in lupus inhibitors, the resident will be expected to learn a good deal about lupus inhibitors and the various tests that have been used, are in use, and are under development for lupus inhibitors.

Apart from this, the resident is expected to be on site, except when specifically directed to go to some other activity. Examples of this might be Hemophilia Clinic or to review a patient chart on a ward.

Due to the limited time on this rotation, the resident is expected to make the most of the opportunity that this rotation affords and to put out the extra effort needed to accomplish its goals and objectives. It is expected that the resident will accommodate their schedule and desires to meet the needs of the laboratory. This is not ex pected to be an easy rotation, but if the resident works hard enough and approaches the task cheerfully, he should both learn a lot and enjoy the rotation.

Demonstrations / Laboratory Testing Participation

The resident is expected to arrange with the senior technologist when to do the various activities in the laboratory. The resident is expected to observe as much as possible, ask questions when they will not interfere with performance of work, and to make the most of the opportunity to learn in the laboratory.

  1. The resident will observe tests done on the AMAX instrument, and should run a lupus inhibitor test and a Factor 8 assay, including doing the calculations manually for the interpretation (usually done by computer). This will help the trainee understand how the calculations are set up and what the potential problems are with both assays.
  2. The resident will observe platelet aggregation tests done as part of a bleeding workup and aggregation tests for heparin induced thrombocytopenia.
  3. The resident will observe at least one ELISA method, one "rocket" immunoelectrophoresis, and one crossed immunoelectrophoresis. The resident should actually do, under supervision, at least one of the electrophoresis tests. If he/she has not previously done an ELISA test elsewhere, he/she should do at least one of these.
  4. The resident should observe chromogenic tests done on microtiter plates and on the AMAX instrument.
  5. The resident should observe at least one set of activated Protein C resistance clotting tests done on the Stago ST-4 instrument.

Goals and Objectives

  1. Be able to do test interpretations with some supervision by the end of the first week and with minimal direct supervision by the end of the second week.
  2. Develop an understanding of the basis of all clotting based tests, which are primarily done on instruments.
  3. Develop an understanding for the rare manual tests, including thrombin time.
  4. Know and be able to present in detail the general methods for factor assays, lupus inhibitors, and platelet aggregation tests by the end of the first week
  5. Know and be able to present in detail the method for at least 1 ELISA test, one rocket immuno assay, and one crossed immunoelectrophoresis test by the middle of the second week.
  6. By the end of the second week, the resident should have an understanding of the pathophysiologic processes that affect interpretation of test results for both bleeding and clotting tendencies. Specifically, he will need to know processes and conditions (physiologic and pathophysiologic) that affect the levels and function of Factor 8, von Willebrand factor, fibrinogen, Protein C, Protein S, Anti thrombin-3, and plasminogen.
  7. By the end of the second week, the resident will also be expected to know in considerable detail about anti-phospholipid antibodies, and lupus inhibitors specifically. The resident should have reviewed the more important literature on lupus inhibitors, and be able make a coherent presentation about the whole subject.
  8. For the last 2+ weeks of the rotation, the resident is expected to be a fully functioning member of the Special Coagulation Laboratory team. In addition to the topics already covered, the resident will be expected to learn about the development, measurement, and treatment of both hemophiliac and non-hemophiliac anti-Factor 8 antibodies.
  9. By the end of the rotation, the resident will be expected to know in some detail about the effects of a variety of auto-immune and some endocrine diseases on hemostasis.

Supervisory Guidelines for Patient Care and Specimen Handling

Specimen handling in the laboratories is the direct responsibility of the laboratory technologists. Resident decision making in the laboratory is under the direct supervision of the teaching faculty at their assigned site. The on service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager. No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

Opportunities for Residents to Act as Consultant to Other Physicians

Residents play an important part in the daily activities of the Coagulation Laboratory, not only in the knowledge they share with the technologists, but also in their ability to interact with clinicians referring specimens to the laboratory. The resident may speak with these physicians, who may be from University of Minnesota Medical Center, Fairview, as well as from other institutions. Residents may discuss relevant clinical information about the patient and may also convey information to them about the status of testing.

On-Call Duties

The resident is expected to be available to laboratory personnel, either in person or by pager, throughout the working day. No on-call duties outside of regular laboratory working hours are assigned to the resident.

Communication with On-Duty Faculty

Teaching faculty members on service are physically present during standard operating hours (8:00 AM - 5:00PM); specific faculty members when not physically present in the laboratory are available by phone or pager. At all times, a supervising faculty member is on call for evening and week-end questions. No diagnosis is communicated to clinicians before a faculty member has evaluated the case.

Structured Formal Education in the Management of the Cytogenetics Laboratory

The resident is invited to attend the monthly Coagulation Laboratory Staff Meeting. The resident also becomes involved in management issues, as they arise during the course of the workday. Some of these issues may be further discussed in the daily focused tutorial sessions with the Laboratory Director.

Required Conferences / Seminars

In addition, many of you will also be assigned to teach sophomore medical student pathology course laboratories on Tuesday or Thursday afternoons.

Scholarly Activities/Research Activities During and After Rotation

During the rotation, residents are expected to perform literature searches with regard to difficult/unusual cases. The findings of the literature search are discussed with the Rotation Director.

Basis, Method and Criteria for Resident Evaluation

Residents will be evaluated on performance of daily activities (described previously), participation in required meetings and conferences, and presentations to the staff on assigned cases. The residents are provided with continuous feedback on their performance during the rotation. In general, only deficiencies are noted in writing. Residents are evaluated on their demonstrated ability to provide informative consultation to the clinical service teams, their medical knowledge, their application of this knowledge to efficient/quality patient care, and their diagnostic, technical and observational skills. Residents are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretive reports is another component of the evaluation. Residents on probation receive a written mid-rotation evaluation.

Educational Resources Available

Computer Information Systems Available for Resident Education and Service Duties

Residents have continuous access to patient data via two systems: the KDS system and the Abaton system (accessed via the Internet) for Fairview-University Hospital Laboratories. The residents also have access to on-line literature searching via the internet and the University Bio-Medical Library.