USCAP Fueled Thoughts about AP and CP

I recently returned from sunny San Diego where I attended the CAP Residents Forum and USCAP. While at USCAP, I met more than my fair share of pathologists from Canada. After all, the “C” in USCAP stands for Canadian. I was surprised to learn that pathology residency there is 5 years–they still have a clinical “intern-like” year–and their residencies are either AP only or CP (referred to as “general pathology”) only programs.

In the US, most pathology subspecialties belong to one group or the other. The one exception is hematopathology which bridges AP and CP;in some programs is considered as AP and in others as CP. So I asked how they consider hematopathology in Canada. Most of those whom I met were AP trained and told me that in terms of hemepath, they only look at bone marrows (“tissue”). The peripherals and aspirates (“liquids”) are read by hem/onc and not likely to be relinquished to pathology as it is a good source of revenue for them.

When I told them that I was trained to read peripheral blood smears, aspirates, clots, and bone marrows, they told me that was because I was “CP trained” in terms of hemepath. They also told me that when they study hemepath in Canada, (I’m not sure if I misunderstood this part) that they aren’t really trained to diagnose lymphomas well. So they prefer to go to the US to train in hemepath fellowships to get the exposure and tend to hire US-trained hematopathologists. But I was also told that Canadian residencies are transforming and now beginning to incorporate more training in lymphoma diagnosis.

So, this brings me to some thoughts on AP and CP training. I was re-reading my most recent posts and realized that some recent frustrations I’ve experienced on my surgpath rotations accentuated my natural proclivities and bias. So, first, I’d like to say that I do not dislike surgpath. But I do think that the culture and some personalities in surgpath don’t really mesh well with a research-trained physician-scientist me. I often get the comment that I am “too academic” or I’m “more like a scientist than a pathologist” (which I didn’t think was a bad thing for a CP-oriented resident).We all have our biases and there is nothing wrong with that. But I often notice that the needs of the AP portions of our programs sometimes dominate over CP.

At multiple programs I rotated through during medical school and in my current program, if there is no autopsy resident that month, residents on CP rotations are assigned autopsy duty during the week while the surgpath residents cover the weekends and holidays. AP inclined residents and attendings often try to convince me that I never know if I’ll end up practicing surgpath. Even though residents often take vacations during CP rotations or spend most of their time studying for boards and not 100% actively engaging in their CP rotations, most of the time, CP attendings just expect this sort of attitude towards CP.

And so this tension between the two pathologies sometimes befuddles me. A co-resident even asked me if I’d consider doing a little surgpath with hemepath like the general pathologists at our community hospitals do(my answer is “probably not”)or I’ve gotten the “what are you going to do with molecular training?” question as well. This is not because there is anything wrong with surgpath (I know I might rant when I’m frustrated but I think knowing surgpath can only help me with my future career choices). But I wonder why when a first year resident comes in saying they want to do dermpath, they get hooked up to do derm/dermpath research (it’s important to match for dermpath fellowships) and I have people trying to convince me that I should want to do surgpath. Why does it seem harder to accept when a resident says that they want to do a CP subspecialty (maybe with the exception of hemepath)? Have you had experiences where a tension between the AP and CP sides of pathology reared its ugly head?Why do you think this may be so?



Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

4 thoughts on “USCAP Fueled Thoughts about AP and CP”

  1. Hi,

    Just found this blog, great idea! I am a 5th year General Pathology (GP) resident in Canada, taking a break from studying for board exams in 2 weeks time! Actually, GP residents are very similar to AP/CP residents in the US – beyond the first clinical/internship-like year, we train in both CP (at least 18 months) and AP (at least 12 months surg path, plus extra requirements for autopsy, cytology and peds.) Most GP residents will end up doing most if not all their time beyond the mandatory 18 CP months in various AP subspecialties. AP-only residents (who again as you mentioned, do a clinical year first, then 4 years AP only) are much, much more common in Canada. Usually only a handful of GP residents will finish each year (I’d estimate <10% of the total graduating pathology residents per year). We GP residents generally receive much more hemepath training, naturally, and many of us will sign out heme with surg path +/- chem or micro duties in our careers, but most will end up practicing mostly or exclusively AP in their jobs.

    In addition, Canada actually has a few hemepath residency programs. These residents train exclusively in hemepath for 4 years, with one year usually being dedicated to clinical service (e.g. a year of hematology/oncology and related internal medicine specialties). Only a few of these programs exist, but they do produce very highly trained hematopathologists!

    Like you, I have a huge CP interest, and nearly did a fellowship in CP, but have ended up accepting a position that allows me to sign out surg path, heme and chemistry. I nearly switched to an AP only program, as there is tremendous pressure to do so with so few GP programs in Canada. Very, very happy I stuck to my guns, however. It's just too bad that many residents aren't aware of the opportunities for CP-related positions, or that hospitals prefer to hire specialists in a particular CP specialty only (whether a MD or a PhD), rather than generalists! I think there is a big general misconception about what CP specialists do, both amongst surgical pathologists as well as clinicians. We need to do a better job advocating for the importance of excellent training in these areas! After all, many more patients will interact with a clinical lab than a surgical pathology lab and its just as critical that bloodwork or urinalysis results be timely and accurate as the results of a biopsy.

    Either way, enjoy your training and study hard. It's bewildering how much we need to learn, but a great pleasure and honor to do so! Thanks for your blog postings!

  2. Hi Heidi: wow, I totally agree with you and am happy to meet another CP-oriented person who is also training in a more general (AP/CP) way! For me, I did do a year of PhD as I was a dual degree medical student initially so I tend to enjoy and gravitate more toward my CP rotations. But I also understand the interconnectedness and necessity of AP training for someone like me, especially since I will most likely do molecular and hematopathology fellowships. Its interesting to learn more about GP training in Canada for me since most of the Canadians I met at USCAP were of the AP variety =)

    I also agree that we need to do more advocacy to make the work of those in the clinical labs more visible, even to physicians – so that people understand the importance and clinical implications as more than just spitting out lab results.

  3. Love your blog post. I’m in the Chicago area as well as a PGY2 in an AP/CP program but have known for a while that I want to be in a CP -only field. My PhD mentor was a clinical lab director and I have an extensive research/laboratory background. I’ve been in training for a CP field for the last 12 years!. Everyone knows this and still try to convince me to do Surg path or cytology (which I believe is even worse…no structures!). There’s nothing wrong with being too academic, it’s just a different way of looking at the world. We also have grumblings from the CP faculty of the injustices they see concerning pulling residents from CP to cover AP responsibilities. I see it as a complete lack of respect of one side by the other. But like you said, they grumble but accept it as a fact of life.Especially when the program director and/or chair of the department are AP folks, no one to fight the CP fight. At some point I just stop telling people what I want to be when I grow old (like in med school, don’t tell people pathology…they give you weird looks).

  4. Dear C,

    I’m glad that you’ve found what you are passionate about! Its always best to stay true to yourself or at least, to what you decide to do with your life even it can’t be your first choice of things you want to do. And yes, I’ve gotten the funny looks and questioning about “why CP?” so you’re not alone…although I guess I’m more of an AP/CP hybrid now since I’ll hopefully be matching into hemepath and mol genetic path. Good luck on your journey!

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