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Elaine S. Jaffe, MD
Entry Id: TP-4

Eligibility Criteria
Qualified candidates must have completed an MD degree from an approved United States (US) or Canadian medical school or must hold an Educational Commission for Foreign Medical Graduates (ECFMG) certificate. Many candidates also have a PhD degree, and some have completed a general or subspecialty residency.

Overview
The Laboratory of Pathology (LP) offers a multifaceted training program for Residents in anatomic pathology at the National Institutes of Health (NIH) Clinical Center (CC). The Clinical Center is the site of intramural clinical research for the NIH (see http://www.nih.gov). Patients are enrolled in approximately 1,000 research protocols conducted by 15 institutes and centers. In addition, the staff of the LP receives more than 2,000 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 Accreditation Council for Graduate Medical Education (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.

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. There are also further opportunities for clinical and research electives at this time.

The LP conducts a fully accredited AP3 program in Anatomic 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. During the fourth year, the resident's salary will be funded by LP, NCI for any combination of clinical and research rotations done within the Laboratory of Pathology, NCI. At the discretion of the Program Director, salary funding may be provided for research rotations in other NCI Laboratories and Branches. However, for laboratories outside of the NCI, the sponsoring laboratory/institute is expected to provide salary support for the fourth year resident.

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.

Residents may receive some formal training through the NIH Foundation for Advanced Education in the Sciences (FAES). The ACGME accredits the NIH/FAES for sponsored continuing medical education for physicians.

After Hours and On-call Coverage
Residents are not required to be present at the institution during periods of on call. During the first two years of experience, the resident serves a total of seventeen weeks on call. Third-year Residents are relieved of call responsibilities but are available to advise and mentor junior residents. On-call schedules are fully in compliance with ACGME standards.

Resident Salaries and Benefits

• Residents receive appointments as Clinical Fellows (Civil Service). Clinical associates receive a starting salary of $51,782 per year for residents entering the program in July 2007. Additional compensation is provided for a post-baccalaureate degree (PhD) or for residents beyond the PGY1 year. A supplement of approximately $3400 is provided for on-call activities.
• Residents receive 2 weeks of paid vacation each year and 10 sick days per year. Other benefits include on-site childcare, moving allowance, and funding for scientific meetings and courses outside of the NIH. Resident shares costs of health insurance, and life insurance. Disability insurance is available at the resident’s expense. Residents may participate in federally sponsored retirement programs. Residents receive free parking or participate in the NIH Transhare Program to receive public transportation subsidies of up to $100 each month.
• 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, DC. 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.

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 cytopathologic 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 problems 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 diagnostics 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 neuropathologic 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 neurologic history and pertinent systemic clinical history at the brain cutting session with relevant areas of neuropathology 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 histologic 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 histologic 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 pathologic 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.

Clinical Proteomics
The Laboratory of Pathology Proteomics Core Lab provides 1) technical expertise in proteomic analyses for basic, translational and clinical research programs of collaborators primarily using current reverse phase protein microarray technology, in addition to other standard protein-based methods such as ELISA and western blotting; 2) training and technical assistance to interested users of the core lab for current protein microarray technology and automated microdissection; and 3) research and development advancing the science of high throughput protein microarray technology to support clinical proteomics, molecular diagnostics, and enhanced basic research programs.

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.

The residency-training program offers research-training opportunities virtually unmatched internationally. Each resident develops a research program with any of the world-renowned scientists in our Laboratory at the National Cancer Institute. Each resident plans a research project with a designated mentor and reviews the experimental plan with the Program Director. The residents are encouraged to choose exploratory projects, which lead to new discoveries and open new fields.

Residents are expected to serve as consultants and collaborators for clinical studies and case studies, which stem from findings made during routine diagnosis. During research rotations, each resident is provided with laboratory space, equipment, reagents and technical support. They show their research findings in weekly data clubs, and brainstorm ideas in weekly conferences and journal clubs. Research ele