October 2014 – Page 2

Dilutions: How Are You Doing Yours?

If you ask someone to dilute a sample in half, pretty much everyone will do it the same way – add an equal volume of sample to an equal volume of diluent, whether that’s 1 mL to 1 mL or 100 µL to 100 µL. But if you ask people to do a 1 to 2 dilution, you may be surprised to get different results. That’s because I’ve found that the convention for writing dilutions is taught differently at different Medical Laboratory Science (MLS) schools.

A 1 to 2 dilution should be written as ½. It means to dilute something in half. But many times it will be written as 1:2. These two forms are actually not equal, despite the fact that they are used interchangeably in the laboratory. One is a dilution and the other is a ratio. In the scientific literature, if you see “1:2”, it means to add 1part to 2 parts. That will be 1 mL added to 2 mL, for a total of 3 mL, or a 1/3 dilution.

Unfortunately, this problem is prevalent in the laboratory. I’ve seen 1 to 10 dilutions written both as 1/10 and 1:10. It’s very important to know how the technologists in the lab are performing that 1 to 10 dilution. Are they doing a true 1/10 (1 mL sample plus 9 mL diluent) or are they actually doing a 1 to 11 dilution (1 mL sample plus 10 mL diluent)? Your patient results may be different depending on who does the dilution!

Coming into this field from a scientific background rather than an MLS background, I prefer the convention of writing a dilution as 1 over something, ½, 1/10, rather than as a ratio, 1:2, 1:10. However, perhaps the majority of medical laboratory scientists are taught the ratio. Either convention works fine as long as it is clear to everyone in the lab what dilution they are actually performing and being asked to perform. You might want to just check your own MLS and see how they do their dilutions.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Management and Administration Housekeeping Items

A few items relevant to your interests have crossed the editor’s desk over the past few days.

1. As we mentioned several months ago, laboratories need to provide lab results to patients (or their representative) when requested to do so. The Privacy Rule amendments went into effect on October 6, 2014. Is your lab compliant? Read the regulations to be sure.

2. The Draft Guidance for the FDA regulation of LDTs has been published. You can read them here and here. The FDA will accept comments about the draft for the next 110 days.

The Beginning of the Fellowship Trail

Well, last week my fellowship applications became quasi-complete. All my letters were sent for molecular genetic pathology (MGP) programs although I did find out that several never received them. Most of the hematopathology programs I am applying to had received three out of four letters of recommendation. And some did offer interview invites before the third letter came in (but most programs want at least three letters to consider my application complete for review). Basically, I’ve been receiving one to two interview invitations by email each day.

I thought to myself that I should’ve started this whole process earlier. I thought that I had started early enough. I had asked for letters of recommendation (LoR) informally before I transferred from my previous program in June and then formally asked at the beginning of August. I had intended to submit my applications on September 1^st and hoped that the letters would be in by then or shortly thereafter. Throughout this process, I did find out that some programs began accepting applications as early as July 1^st and some had deadlines of September 1^st. I hadn’t been able to research as much as I would’ve liked before I left Chicago because I was on our busiest surgpath rotation (with over an hour drive twice a day and I only got the last day off) and I was also in the middle of moving cross-country.

I encourage you all to be early birds – to put everything together and ask early enough so that your application is complete (ie – letters are written and ready to be sent) by sometime in July, August by the latest. Remember that your letter writers are probably writing letters for other residents are well, especially if they are your program director since every program requires a PD letter.

After I sent my applications in early September, some programs responded with a thank you email but most did not respond at all and so I wasn’t sure if they had received my application materials. I would receive weekly emails from a couple of programs telling me that my letters were missing but that was the exception and not the norm. So I would suggest following up with programs to make sure about the status of your application. I had no idea that programs were missing some letters I believed had been sent until I received an email from one. So then I called or emailed all the others to find that other programs were just waiting for letters as well to send my application for review.

Some of this confusion could have been avoided. I think that some of this happened because I added on additional programs – I was overcompensating thinking that I might not have applied to enough programs – and my letter writers weren’t sure which programs they had already sent letters to. Avoid this scenario by researching your programs early. Then make ONE master list of places you are applying to for your letter writers to have to (e)mail their recs all at once (at their convenience).

In terms of personal statements, programs seem to like them short and sweet. Most had limits of 500 words or one page and a couple even had a limit of 250 words. I found it very helpful to have multiple attendings in my subspecialty of interest and fourth year resident friends (who had gone through this process last year) read my personal statement and give feedback. You can write the personal statement any which way you like but the advice I received that helped me most was to write it in 3-paragraph (not too many sentences) form: 1) why/how I decided to pursue the subspecialty, 2) what I bring to the table in terms of the programs I am applying to, and 3) what I am looking for in a program and my future as a practicing pathologist.

As for CV’s, there is no one accepted way (like there is in the business world) to write a pathology-oriented CV (or at least that I know of; enlighten me if you know better). I’ve been updating my CV since college so I already had the basic structure. I’ve had a lot of leadership positions so much of it had to be abridged or left out when I composed my CV for residency applications so I didn’t need to do much this time around either. Speaking with one MGP fellowship director, it was suggested that I include my lab based skills on my CV since I have significant research/wet lab experience and she would like to see where I would start from in terms of my knowledge base. I already had this information from one of my previous job resumes so I just added it on to the end of my CV. So, if you are applying for MGP and have some skills in the lab, then highlight them!

The tricky part I’m finding is scheduling interviews. It’s not as easy to get time off during residency especially with call/tumor board/conference schedules and other service duties as when we had residency interviews as a medical student. So plan ahead and ask for lighter months during the interview season when your chiefs/PD compose the schedules for the coming year. I’ve found that it helps to call programs that are near each other to ask about the review process timeline once I receive an invite in a city where I applied to multiple programs. Let them know the situation and ask politely when a decision will be made so that you can schedule interviews in the same city/area together (especially if they are on the opposite coast from where you live).

There hasn’t been any method to the madness when it comes to each program’s interview schedule. One program emailed last week and asked if I could interview during their first round this week but I’ll be leaving for ASCP Annual Meeting for the whole week in a couple of hours. Other programs gave me dates to choose from in either October or November. For those programs which adhere to the CAP suggested deadline of December 1^st (which I’m finding to be rare), those interviews occur in Jan/Feb but since I’m on rotations like surgpath where it’s difficult to get time off, I most likely won’t be able to make these. And with limited vacation days and finances to interview for 2 consecutive fellowships, I’ll most likely not be able to attend all the places I’ve received invites from for interviews.

I’ll let you know how it goes from time to time and hopefully someone will find my experiences on the interview trail useful.

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

Thoughts from Pathology Job Market Conversations

So, as you know, I recently attended the 2014 CAP Annual Meeting in Chicago. In addition to meeting with residents, I also had many interesting conversations and meals with non-trainees. I met new-in-practice pathologists who had completed two or three fellowships who were unemployed and were at the meeting networking with potential job prospects. I met veteran pathologists who were working in part-time or locums tenens positions while searching for a more permanent position. And finally, I met pathologists who were currently working but who told me that over the years, the amount of work that they have had to do for the same or less pay had significantly increased.

These conversations left me wondering how we can address this issue. How do the reports that this country would see an impending shortage of pathologists in the near future fit in with these first-hand stories? Most, if not all, of the reports about a pathology workforce shortage were based, at least partially, on survey data. This can be influenced by selection bias, volunteer bias, or both depending on how the survey was conducted. Also the modeling applied, at best, can only make estimates about future occurrences based on the data available now. It cannot take into account unforeseeable game changers (eg – Affordable Care Act) that may significantly alter the practice of medicine compared to the practice today. I’m not saying that we should discount these reports, just that we should be aware of how to critically analyze the conclusions from them.

I do believe that there is a pathologist shortage in terms of misdistribution geographically and subspecialty-wise, but this is a trend that holds true for most medical specialties. We may not have enough pathologists per person (aka a shortage) in this country but we definitely have a surplus in many urban settings where it may be more popular to practice. Certain popular and well-paying subspecialties, like dermatopathology, could have a surplus but don’t because the number of fellowship positions are limited. But other popular subspecialties like hematopathology seem to be saturated in terms of positions near cities that are popular to live in from my anecdotal experience.

And even though an impending shortage is always the battle cry to increase the number of residency spots, our community is polarized on this issue. Some residents and pathologists I’ve spoken with feel that we should, like other specialties have done in the past, limit the number of residency positions we have. Without more data, I can’t really say which side of the argument I agree with but I do acknowledge that we are at a crossroads. The decisions we make now about how we train our residents and what roles pathologists should fill (eg – molecular diagnostics) will affect our future, patients’ futures, and our profession’s future.

But regardless, the problem does remain that the job market currently seems tight and that pathologists have had to perform more work than they have had to in the past. So, what is your take on the situation and your suggestions for a possible solution? And how can we incentivize to address misdistribution of pathologists to address a shortage in more underserved areas?

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