Month: September 2014

I was talking with my attending and fellow this week and was struck by the generation gap in terms of how we were/are trained. When my attending was in residency, he had to handle over 100+ CP calls in a week – he even keeps one of his call sheets to back up his stories. In some ways, we are spoiled because we can just say that there is an APP to do many of the calculations he had to do then and so we’re not even paged on these types of calls. These days, I may average 10+ CP calls/week at the same institution where he trained at. He also said that they didn’t have PAs back then and it wasn’t unusual to gross until close to midnight…and the grossing resident also covered all frozen sections at the same time, too. His is not the first attending story that I’ve heard like this. Obviously, this was before we had work hour reform. But I wonder what we’ve lost in training since his time?

I’ve often heard residents complain that we have too many service duties and that they feel that service duties supersede our education. Most of the time these complaints revolve around not having enough time to read and too much “scutwork” including grossing routine specimens. I’m no expert by any means but I feel that for me, I’ve learned more when I’ve had to do things as opposed to reading textbooks. And by doing things, I mean performing those duties that are required of my attending as close as possible to the real experience. And yes, that does include lots of reading, not just textbooks but also journal articles and other resources, but is not limited mainly to reading.

Gone are the days where I could skip (or attend) my medical school classes and watch a video of the lecture and read the textbook and do well on exams. The more important difference is that now the consequences of my actions can more directly harm patients so it’s vitally important to gain “attending skills” as well and as soon as I can. And even after graduation, I know that it will still take a few years before I am comfortable in my clinical competency. I know that I’ll be more stressed and OCD about details because it will be my name at the end of the report that is responsible for patient care decisions and also liable for medico-legal action. But I want to be as prepared as possible when that time comes.

Residency is the time when we should transition from passive learning (ie – learning mostly by reading textbooks) to active “on the job” learning. Sure, if no one at your program wants to teach you, then you may be stuck with textbooks and online resources. But I’ll take a bet that even at the most “malignant” programs, there is always at least one golden mentor (including non-attendings) who wants to teach. And remember, that during fellowship, your attendings will expect that you have most of these skills in your portfolio and that you have good time management skills. No one expects that we have knowledge of everything (even our attendings don’t have that), but they will expect that we know how to approach that situation if we find ourselves unsure.

Anyway, that’s not my most important point. I find that complaining just wastes my energy that can be directed to a more useful endeavor. Yes, if I feel something is truly unjust, I will be one of the first to say something. But I realize that the patient is the center of my training and not me, their needs supersede mine, and yes, there will always be scut but it depends on how I approach it what I get out of it. Plus, I realize that compared to other specialties, I didn’t have an intern year and don’t have to do overnights, so I’m thankful that my residency experience is not as bad as it could be.

A generation gap exists where our attendings can’t understand why we complain and where we don’t feel our attendings understand us. But I think that there is a middle ground. I don’t think that we should go back to unregulated work hours where we are dangerously fatigued and never get to see our family and friends. But I also don’t believe that residency training is there to spoon-feed me. It is the time for me to spread my wings (with supervision, of course) and learn how I’d navigate my clinical duties as a future independent attending.

For those going into surgical pathology, you may still end up working at a hospital where you may need to gross or at least, look at specimens or teach how to gross. The end of residency doesn’t necessarily mean the end of grossing (or insert you least favorite aspect of residency here). A friend was telling me that he overheard attendings at a networking reception complaining about a new hire they had who didn’t know how to gross. If that was at a private practice, I would expect that after a short time allowed for remediation, that if that new hire didn’t improve, s/he would be fired. There may be more leniency at an academic or VA institution, but I also believe that if a better replacement could be found, that person would still be fired.

So residency is the time to make sure we gain competency in skills like grossing, lab management, billing, CLIA regulations…even if these are usually the things that we find to be boring. Sign-out is not even half of what will be required of us when we are full-fledged attendings, especially if you want to work in private practice, which is where most of us end up since the compensation is greater.

Getting involved in leadership positions, whether at your hospital, state society, or within a national advocacy organization in my experience opens doors to many practical opportunities as well. For instance, I’ll be going with my hospital’s CAP lab accreditation inspection team this month to help inspect the hematology section of a lab in another state. Because my department chair knows I have an interest in hematopathology and because I performed well on my first CP rotation here, I was given this great opportunity. I’m now certified as a CAP inspector and will have a better idea of lab management issues after this experience. Due to my involvement as the junior member on CAP’s Council on Education, I’ve also been given the opportunity to serve as the ACCME/AMA compliance monitor at a joint CME activity of CAP and a state pathology society in the near future. I see this as active learning and a step toward gaining the competencies that I will need.

Right now, we are buffered from much more than we realize. Probably as a fellow, we will understand the end game better, just how much our attendings’ days are filled with more than just sign-out. I suggest reading the article, “Adequacy of Pathology Resident Training for Employment: A Survey Report from the Future of Pathology Task Group” that outlines specific competencies that employers wanted and that residents did not possess adequate competencies in. It goes on to state that 50% of employers felt that new graduates that they hired needed more support and guidance than was required 10 years ago. So what can we do now during training to ensure that we are not those new graduates who are perceived as needing “more” supervision at our first job?

 

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