Flexibility within Structure: Towards Competency-Based Clinical Pathology Training

Since I previously blogged about introductory surgical pathology training, I thought that I’d switch gears and focus this week’s post on introductory CP training. Based on my limited experiences during medical school rotations and at two different residency programs, I can say that developing a targeted CP curriculum (both introductory and more advanced) to train pathology residents can be difficult. Often many of the CP services can function without a resident so clinical laboratory scientists (CLSs) may be in a quandary as to what to do with residents when we are present.

I found that I’ve had the best and most educational experiences when I spent time at a CP lab bench with a CLS who likes to teach and does it well. Lab directors should either identify techs who excel at or train their CLSs how to teach. It’s not as easy as it sounds. The technologist has to not only complete their usual daily workload but at the same time break down the important and most clinically relevant parts of what they do to residents as well as to deliver all this information in an engaging manner.

Having a written syllabus with a logical flow of requirements that builds on previously learned concepts helps to provide structure for those who need it. The syllabus should include rotation objectives, important contact information, and topics and tests necessary to cover by rotation-end. But within CP, I see more of an opportunity for us to train in a competency-based manner at our own pace and toward our individual interests. For someone like me with extensive, hands-on lab and research experience, I need less (sometimes none) of my time spent learning how tests are set up (I basically told my attendings that it wouldn’t be useful for me to watch the CLSs pipetting; by reading up quickly on an unfamiliar permutation of a test based on a concept I already know, I usually can understand it as well). Also, since I learn more by doing, letting me act as a first consult for referring physician calls about test issues really accelerated my learning because if I didn’t know about the test/issue, you can bet I did by the time I called the physician back with a response. And I also learned that a good clinical work-up is key to good care but that applies in any area of pathology that we work in.

But I understand that not everyone has experience or comfort in the lab setting. At my current program, they do two months of an introductory ‘wet lab’ rotation during their first and second years. They have competency/credentialing checklists of tasks they must perform during these rotations. The first month is spent in chemistry, special chemistry, microbiology, hematology, and blood bank becoming acquainted with the staff as well as understanding the theory and performing hands-on applications and analysis of the repertoire of tests available in each section. This is not because we will be expected to do things like a Gram stain in the future but so we have some context to understand what we will be explaining often to referring physicians when they call about a particular test. I think it also helps us to understand the time frame of task completion to help explain when we do serve as the intermediary with referring physicians. And most importantly, you get friendly with technologists who honestly really will help you a lot. Being competency-based, I was allowed the flexibility to decide my competency level (ie – I skipped the ‘perform a Gram stain’ portion of my checklist because I already had done many of these in the past). The second month is spent in more specialized areas such as molecular diagnostics, cytogenetics, advanced microbiology, and special coagulation.

Telling residents to just ‘go sit at a bench with a tech’ is not all that useful, especially if the tech is busy or not interested in or good at teaching. That’s why it is so pivotal that medical directors identify technologists who can serve in this role or do in-service trainings so they understand how to participate in resident teaching. Also, telling residents to just ‘go read up on X’ is also not the most helpful because we learn more by actively doing than just passively reading. For residents in specialties with more patient contact, they have no choice but to participate in direct patient care. At times, it seems more difficult to remember to train pathology residents to feel that same urgency they would if they had the patient in front of them and also to train them in a manner that more actively engages them, but it’s possible. It just requires more effort and thought during the curriculum design phase.

Another thing that I like here at my current program is how during July they have separate orientations to each service regardless of the fact that the first years are on intro to SP and I’m on a hybrid intro to wet lab/comprehensive CP (chemistry and microbiology) rotation with some grossing time to learn the nuances of how grossing is done at this institution. We all have to attend these AP and CP orientation sessions that are geared toward preparing us for situations we will see on call – grossing late Friday prostates for the Saturday call person, how to accession and handle a frozen, transfusion reaction calls, and so on. First years also participate in supervised CP day call with an attending to learn how to handle specific situations so that they are pros by the time they have night/weekend/holiday call as a senior resident. Here, we cover both AP/CP call at the same time as senior residents.

So, how do they teach intro to CP at your institution? How do you think is the best way to train residents during introductory CP rotations? I would love to hear your opinions.



-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

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