Author: Lablogatory

What Type of “Graduated Responsibility” Do We Need in Order to Gain Competency?

Building on the brief historical piece I wrote last week about the progression toward “competency-based” resident training and the ultimate outcome of evaluation by the Milestones, I’d like to ask, “How can residents achieve competency in training?”

A resident recently stated at the most recent CAP Residents Forum that true graduated responsibility means to be able to verify a case, whether surgical pathology or frozen section, and I would guess clinical pathology results were implied, without the oversight of an attending. As a PGY-2, I am not sure I can agree with that statement. But who knows, maybe closer to graduation, I might. How many of us would be a Milestones rating of “4” by the end of our funded 3 or 4 years, and therefore, competent enough to theoretically verify a case on our own?

I would like to repeat some statistics from the 2013 ASCP Fellowship and Job Market Surveys: only 16% of residents felt they were ready to sign out general pathology cases upon graduation and 95% intended to seek fellowship positions. 59% of PGY-3 and PGY-4 felt that they needed fellowship training to feel confident in general pathology and 17% to address a perceived educational deficiency. So, if this is a true, then the majority of us may not feel comfortable verifying general pathology cases, with the possibility of malpractice, even as a PGY-4.

Even though I cannot verify cases, I still feel that my program has given me the opportunity for graduated responsibility. For instance, I began to enter my diagnoses into our electronic surgical pathology reports before the end of my first month of training. Then during sign out, my attending would teach me as well as correct my diagnosis prior to verification. As I mentioned before, I learn by doing and even more so by being wrong, than by reading or being lectured to so this works for me. I have the safety net of being allowed to be a trainee while applying and improving my developing surgical pathology skills. And for me, being able to verify or not, would not change how I approach my cases or my diagnoses.

Our PGY-2 and above, are encouraged to work up a case (eg, order stains, etc) prior to sign out at our academic and VA hospitals (not sure about the community hospitals since I haven’t rotated at them yet), even if it is not our names that go on the final “dotted line.” We don’t all reach this point at the same time – it is about trust in our knowledge and skills by our attending and our initiative to broach the subject before we can do so. At the start of my PGY-2, I was ordering flow cytometry panels on cases because my attending trusted my hematopathology skills.

So, for me, at least for now, “graduated” responsibility is in the eye of the beholder and I have been nurtured to be where I need to be at this point in my training. I feel that I have the freedom to grow under our system. So, what does “graduated responsibility” mean at your institution? Let me know by leaving a comment.

-Betty Chung

Adventures in Travel–A Very Spooky Moment

Coming up to All Hallows Eve reminds me of a very “spooky” moment with my passport; one that illustrates the odd and scary things that can happen when you are overly “travel tired.”

It’s said the longest flight on the planet is flying from the east coast of the United States to Johannesburg, South Africa.  I’d have to agree; no matter how you book it the flight is over 19 hours in the air, non-stop. It’s a bit of a flying marathon, and makes you a little mentally and physically fatigued just getting there.

I was on my way to Namibia with very tight connections (always a little stressful) and on arrival in Jo’burg I had less than an hour to catch the last flight out to Windhoek.  Our schedule for two weeks of laboratory assessments had been carefully arranged and there was no room for error in the schedule—so I HAD to make that flight.  If I missed it, I would be responsible for throwing the entire schedule off and so the pressure was “on.”

As I got off the plane there was a bright young man in an airport vest asking if he could help anyone.  I told him I had a very close connection and didn’t know where I was going, but had to catch the flight to Windhoek.  His eyes got big as he looked at my boarding pass, and said, “Come this way madam, you must hurry, they will be leaving and we have a long run ahead”.  Of course!  He grabbed my suitcase and headed out, I followed with a fuzzy brain and very wobbly legs from sitting so long.  We reached the ticket gate (me gasping for air) and they said “Sorry, we have closed the desk for that flight.”  I was obviously ready to come un-glued, and he said quietly, “Do not worry madam, I have another way to get you there—give me your ticket and passport, and I will run ahead and be sure they don’t leave you—please follow me as quickly as you can!”  In a stupor of exhaustion, I handed him my boarding pass and passport.  He jogged ahead and out a side door marked “Do Not Enter—Tarmac Employees Only” and held it open for me to follow, then ran.

Now you might be saying, “Are you kidding me? You handed a young man built like a Kenyan marathon runner your PASSPORT and BOARDING PASS? And went running across the restricted tarmac??  Which South African jail will we find you in?!”  Well, yes, I did…and when that realization found its way to my conscious brain I kicked it up a notch and ran harder, determined to keep him in sight even if I couldn’t catch him!  We jogged under the belly of two huge planes, around luggage carts, through a garage and a tunnel, and headed straight for a large bus just closing the doors to take a load of passengers to the Windhoek plane.  He waved and shouted and ran in front of the bus…forcing them to stop, waving my passport and boarding pass wildly over his head.  He and the security guard on the bus had a robust and heated discussion while he blocked the closing door and threw my suitcase on the bus. Just as I breathlessly caught up he said, “Madam, they are taking this group to your plane, please hurry to get on…are you OK?”  Completely breathless, I could not answer but shook my head “yes” and could have hugged him.  In some moment of clarity, I reached into my vest pocket and handed him the two twenty dollar bills that I keep there—he refused, saying “No, no madam, this is my job to get you safely to your destination!”  I pressed them into his hand and said, “You have helped me more than you know, thank you for your kindness, do something nice for you and your family, please!”  The bus door closed, the security guard frowned and called me some Swahili name I have yet to translate, and we chugged to the plane.

Suddenly realizing what just happened, I scared myself enough to be very wide awake all the way to Windhoek…

So travel fans, if you are ever on the long journey to Jo’burg, I recommend a very strong cup of coffee on the last leg of the flight.  I personally like coffees grown and harvested in Africa…but any cup will do to help you avoid a fatigue-inspired “spooky passport adventure.”  If you want a few recommendations on wonderful coffees, contact me at bsumwalt@pacbell.net, and let’s have a round of applause please for a young man who works in the Johannesburg airport for his integrity, his smile and his unparalleled customer service!

Cheers,
Beverly Sumwalt

Multiplicity

How many of you remember the movie “Multiplicity?” If you don’t, Michael Keaton is offered the opportunity to clone himself so he can be many places at once. If you are a supervisor who also finds yourself on the bench you may be wishing for that same offer. With many healthcare organizations trimming the budget and looking to decrease the work force, (Cleveland Clinic wants to trim $330 million from the 2014 budget), finding time for those administrative duties is going to become extremely difficult. Without two or three of you, organization and prioritization will be your biggest allies in the fight against time.

A few things that have helped me in this endless fight are simple yet save me enough time that I do not have to take a lot of work home with me. The first is I have a love/hate relationship with paper. If I can scan it into a PDF file I will. It doesn’t matter if it is one page or 200 I will scan to prevent my desk from looking like a shred box. These PDF files are unalterable, time stamped, and pass as an original document during inspection. Virtual files on your computer take up a lot less space than filing cabinets and in most labs space is at a premium. Second, if you can delegate to staff some of the general duties, paperwork, or reports, do it. The benefit is threefold. You ease up your task list, you empower your employees, and you start to find who among your staff has the ability to fill your spot once you have the opportunity to move up. Yes, mistakes will happen at first but the benefit far outweighs the possible speed bumps.

Organization and prioritization will be your biggest allies in the fight against time.

A third helpful tip is to make templates and use them. If you are not strong in Microsoft Office have someone help you. Setting up the same report each month can take hours in itself. I have an electronic copy ready and available for every paper form I use. Furthermore, for my temperature logs I have 12 months in a file so at the end of the month my technologists can just pull the next month’s forms out and place them in the binder. Nothing needs to be printed or created.

This brings me to my next tip: think ahead. If you know you’re going to need a form each month print them out for the year and place them in an easily accessible folder or drawer.

My final tip, be consistent. If you need to pull a report on a certain day of the month, print it, perform the task associated with it and get rid of it. You don’t want to put it off for an off-bench day you have coming up. You could then get put on the bench because of a call-off, and now you have a mound of paper on your desk collecting dust. There may only be one of you, but you can work like there are more.

-Matthew Herasuta

ASCP’s 2013 Wage Survey

It’s that topic about which no one talks but everyone wonders: how much money do your colleagues make? ASCP answers that question with The American Society for Clinical Pathology’s 2013 Wage Survey of Clinical Laboratories in the United States. In it, you’ll learn the average age of clinical laboratory scientists, which states have the most union representation, and how much the average histotechnologist makes in a year. Take a peek behind the curtain. Who knows? You might strengthen your bargaining position for next year’s performance appraisal in the process.

-Kelly Swails

ACGME Competencies and Milestones: What Does It Take to Be a Good Pathologist?

In 1998, the Accreditation Council for Graduate Medical Education (ACGME) advocated the Outcome Project, a competency-based paradigm for resident training. Previously, completion of a residency was based on a fixed number of years of training specific for each specialty. “Competency” to practice was based on the passage of a certifying board exam. Notable changes due to this initiative were the increased use of objective structured clinical exams (OSCE), increased resident engagement in quality improvement and evidence-based medicine projects, and the incorporation of additional didactics and approaches in GME curricula. Given all this, did the requirements for residency completion truly change?

In 2012, the ACGME introduced their standards for the evolution of the Outcome Project to the Next Accreditation System (NAS). Each specialty developed their own outcomes-based milestones within the 6 clinical competency domains. Residents are graded on a scale from 1-5 in each domain; level 4 represents the “graduation target.” Level 5 is the equivalent to the performance of a pathologist who has been in practice for several years.

The Milestones should be applied without regard to the trainee’s specific year. But would exceptional trainees then graduate earlier, and those who fall behind, later? Currently, the federal government funds residents based on a specific number of years for a given specialty. Can we apply the Milestones in a standardized manner for each AP/CP subspecialty? And what about a resident who excels in some rotations but doesn’t meet the Milestones in another? Anecdotally, based on a few pilot beta sites, each interpreted the Milestones and conducted their evaluation process, differently…so is there a best way to implement them? Or are there multiple, equally acceptable, ways?

In terms of the resident perspective, the 2013 ASCP Fellowship and Job Market Surveys, indicated that only 16% of residents felt that they were ready to sign out general pathology cases upon graduation and that 95% would seek fellowship positions. 59% of PGY-3 and PGY-4 felt that they needed fellowship training to feel confident in general pathology and 17% to address a perceived educational deficiency.

When I started residency, I was evaluated on a scale of 1-5 with 3 being “usually meets expectations,” (a permutation of the A-F scale we’ve all known since elementary school)in the 6 ACGME core competencies: 1) patient care, 2) medical knowledge, 3) practice-based learning and improvement, 4) interpersonal and communication skills, 5) professionalism, and 6) systems based practice. And for my next to final rotation of PGY-1,the same as my first, I was evaluated by my rotation director and performed a self-evaluation with the Milestones. We then met and discussed our respective evaluations. We pretty much agreed in scoring and with respect to those that we disagreed, I usually graded myself harsher.I’m not sure if one method of evaluation was better than the other – what I found most helpful in both processes were always the comments, not the numerical score.

So are the Milestones an improvement in terms of how we evaluate competency of residents for practice? Only time will tell.

You can find the Pathology Milestone Project, published in September 2012 at http://www.acgme-nas.org/assets/pdf/Milestones/PathologyMilestones.pdf.

Let me know how you feel about the Milestones and resident competency in our comments section.

-Betty Chung

New Product Friday–Alifax SPA

Using light scattering technology to identify bacteria has been around for a few years (as evidenced by this paper from 2009 and this article from 2006. The methodology described in these articles use actual bacterial colony growth on conventional media for identification. This only shaves a day off turnaround time. This is handy, but can we do any better?

Enter Alifax SPA. They claim to have an automated analyzer capable detecting the presence of pathogenic bacteria, quantifying (in CFU/ml) that bacteria, and measuring the drug resistance of that organism in a few hours by using light scattering technology. Those techs that have worked in hematology or urinalysis are no stranger to this type of analyzer, but how well does it translate to the world of microbiology?

Does anyone have any experience with the HB&L or the Alfred 60? How do you feel about these analyzer? Do you like this much automation in the microbiology laboratory? Let us know in the comments.

-Kelly Swails

 

 

 

CAP 2013 and My First Residents Forum

This past weekend, I attended my first College of American Pathologists (CAP) Residents Forum (RF) and Annual Meeting in Orlando, FL.

I had previously served as a delegate to the Student Osteopathic Medical Association (SOMA) House of Delegates (HOD) during medical school when I was my school’s chapter president. I was also the alternate delegate for the state of NJ at the American Osteopathic Association (AOA) House of Delegates when I was on the Council of Osteopathic Student Government Presidents (COSGP). And lastly, for the three years I served on the DO Advisory Board for the American Medical Students Association (AMSA), I wrote DO relevant resolutions for AMSA’s HOD.

In all three of my previous experiences with an organization’s HOD, I actively participated in some shape or form in voicing the opinion of those I represented – whether through writing resolutions or debating and voting on resolutions. In this manner, I, and other delegates like me helped to shape the final form of our organization’s constitution and by-laws. And this is the mindset with which I attended the Residents Forum and even ran for the position of alternate delegate to the CAP HOD on the Residents Forum Executive Council.

However, I must have misunderstood the purpose of the RF and I think it worked out that I did not win the position I ran for. What I had expected and wanted was to participate in a resident caucus to identify the consensus opinion on resident-relevant HOD resolutions similar to my previous experiences as an HOD delegate – to see my fellow residents empowered and engaged in the parliamentary process. Don’t get me wrong…I did enjoy meeting other residents at the RF – that was one of the highlights of my experience and I made some new friends who are also passionate about transforming the future of our profession.

The talks were also informative for many of the first-timers although most of the topics were not new to me and about content that I had heard before during my work with AMSA and my MPH studies. But that doesn’t take away from the fact that it was resident-relevant information that each delegate could take back to their programs for their co-residents. So, my experience was mixed in terms of what I had expected and what I saw as benefits for delegates who attended.

Then, I presented a poster during the CAP conference, listened to the keynote by Dr. Eric Topol (although I did not agree with everything he said, it was thought provoking and informative), attended didactics, and participated in a mock fellowship interview with one of the CAP Board of Governors. But the encounters that I enjoyed most were those when I discussed the future of our healthcare system with physicians that I met. I did end the conference on a good note as I found out that I was chosen as the resident/junior member on CAP’s Council on Education for the next 2 years.

-Betty Chung

The Importance of Global Outreach

In the wake of the September 21st shootings and hostage takings at the Nairobi Westgate Mall I have found it difficult to write about the minutiae of laboratory medicine and the details of running a laboratory in the developing world. Instead, my mind wanders to my own personal experiences in Kenya and Nairobi and the people I have encountered in my travels.

In all my times on the African continent I have only been to Nairobi twice (not counting transiting through the airport, which would take the number up to at least ten). My first time in Nairobi was for one day as I made my way to a six month volunteer position in Tanzania. I landed at the Nairobi airport, an intimidated 25-year-old, all alone. I was scared and nervous but incredibly excited. My memory of the city that time is hazy but I can still smell the distinct scent of the air upon exiting the airplane, and I can still feel the knot of nervous excitement in my stomach.

By my second trip to Nairobi, years later, I was much more accustomed to East Africa. This time I was there with an ASCP colleague and volunteer to conduct laboratory assessments at level I and II labs throughout the city. We spent a week driving all over Nairobi and the surrounding suburbs visiting multiple labs. We saw a lab being run out of a container, and another that was inaccessible by car, it was so tucked away in one of the poorer areas of the city that the road was too narrow for anything but foot traffic. We saw labs in desperate need of basic supplies and electricity. We met lab techs who were working hard to do their best with the few available resources.

As we drove around the city we not only had the opportunity to visit these labs and conduct our assessments but, while mired in the worst traffic jams I have ever experienced, we had time to observe the city. We watched women and men working, shopping, socializing; children playing, and running to and from school. We saw an energetic city with millions of people going about their daily lives. People who I imagine are touched by this tragedy. People I have been thinking about these past couple of weeks.

While my heart breaks for those who suffered and lost loved ones, a tragedy like this reminds me why the work of global outreach is so important. With injuries (both catastrophic and not) the lab is an important part of overall health care. A situation like this reminds us of the importance of having well-run, safe, accurate blood banks to treat the wounded and sick.

-Marie Levy

The Rogue Suitcase, Part II

I’m sure you’re anxious to hear what happened to my little suitcase packed for two continents and extremes in weather—part of my “Adventures In Travel” as an ASCP Consultant. We left the little rogue somewhere in Amsterdam with several airline baggage officers giving chase in multiple languages. My hotel concierge in Kazakhstan was very sympathetic to my plight, and they sent me in a car to the city’s one shopping mall. Remember it’s about -30 degrees, and so they dropped me off to find what I needed and would pick me up in two hours. I have a very good friend I’ve worked with internationally who would call that “power shopping.”  I needed professional clothing and shoes to work in, a few essentials, and definitely a coat, hat and gloves. It should be noted that, with rare exceptions, body sizes differ across the globe….and the language of sizes is a challenge. One kind store clerk kept bringing me black pants to try on that would have fit Twiggy (and if you know who that is, well, you know the root cause of my problem!).  Finally in sign language, she convinced me that “these were the biggest sizes she had” and with no other choices available I set my goal for lighter breakfast in the weeks ahead. The coat was another matter. After looking in every store I found the ONLY one in the entire mall that actually fit me, and was warm enough, and was not a men’s musher’s parka. Of course, it was not on the bargain rack, but it was worth every KZT tenge!

My suitcase caught up with me the last two days in northern Kazakhstan just in time to board the plane for our next few days in southern Kazakhstan. One of my travel companions shared a furry lambs’ wool hat with me and I had the rest of my travel wear for the next few days. At the end of our time in Kazakhstan I was headed for Namibia for another week of work in the summer sun with our colleagues there, and en route I had a 2 day layover in Frankfurt, Germany, where I celebrated my birthday! Armed with my coat and hat and gloves and boots on my body, I boarded the plane for Frankfurt. Due to the size of the plane they would not allow me to carry on my little rogue suitcase, but I figured what could possibly happen? We’re not stopping anywhere. I reluctantly gave it to the baggage handler. It made it to Frankfurt according to the computer, but was somewhere inside the Frankfurt air terminal and they “couldn’t exactly locate it just now.” Well … it caught up with me again just as I was leaving the hotel to board the plane to Namibia. By this time I’m having fun with this little game, and happily checked it at the airport wondering where in the world it would travel without me this time! Lo and behold, it didn’t make it to Namibia either … no surprise. It probably missed the last plane from Johannesburg to Windhoek (which I’ve almost done several times myself!) You can imagine that my new coat and hat and boots are a bit overdressed for the Namibia summer climate, so I was glad I had “layered” my working outfit in the bottom of my backpack—and I was good to go, but I had quite a story to share with my ASCP colleagues and Namibia classmates about lost luggage.

My little rogue suitcase finally caught up with me in Ondangwa the next day, so I was now well dressed for the remainder of my trip; I actually had too many clothes, and had to purchase a small duffle to get things home. Oddly enough, that little suitcase made it all the way back to San Diego without incident through intricate travel on the home stretch—I fully expected it to end up in Brazil, but it must have been tired of the game by then!

Lessons learned? 1) Never trust your luggage to make it to your destination—even if it’s your carry-on; 2) Always have one change of clothing with you at all times, even if you have to wear it; and 3) You can actually live and work for three weeks out of a backpack, on two continents and extremes in weather with both professional and casual attire—but you’ll have to trust me on that one!

Next time I’ll share a little about “Adventures in Travel” that involve passports … stay tuned. And, if you are ever in Frankfurt celebrating your birthday, I highly recommend the Marriott Hotel restaurant. They treated me like royalty and were very attentive since I was celebrating all by my self—and served me a very fine birthday dinner with a complimentary glass of champagne!  I had a lovely day actually, and if you would like to know how to spend your birthday in Frankfurt, contact me at bsumwalt@pacbell.net. I’ve got some ideas for you!

Cheers, Beverly Sumwalt