Musings After the RISE

So how did you fare on your recent resident in-service exam, aka the RISE? For most of the residents I know, they did better on the AP portion over the CP portion. I would have to say that not surprisingly, I feel that I did the opposite. Last year, I definitely did much better on the CP portion than the AP portion but my overall percentile was still good.

Even though I usually narrowed down the answers on the AP section to the correct one and a distractor, when I looked up content after I got home, I discovered that I often picked the wrong answer. But even then, I feel that the AP section was fair and not overwhelmingly difficult for someone who is probably better at AP than me.

For me, I thought that the CP section was not that difficult but most other residents that I talked with thought the opposite. They felt that many of the questions were esoteric and possibly not relevant to the practice of pathology once we are out of residency.

What are your thoughts after taking the RISE? Did you feel that it was a fair test? Did you feel that the questions asked are relevant to what we need to learn in residency and for our practice as real-world pathologists?

In other specialties like surgery and anesthesiology, in-service exams have a greater importance and scores are often asked for on fellowship applications. For pathology, this is not the case but it still is important that we test ourselves yearly to pinpoint our strengths and weaknesses in some manner. Do you think that the RISE is the answer or does it need a revamp?

 

Chung

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

For Whom the Match Tolls

Last week, hundreds of M4 students across this country hoping to match at pathology residencies learned their fates. On the flip side, training programs also learned whom they would welcome as trainees come end of June/July 1st. We also learned that there were 51 unmatched positions, even at some of the so-called “highly prestigious” programs that one expects to always fill. That’s the most I’ve seen in recent memory and more than double the number that were unfilled when I matched 2 years ago.

Several questions went through my mind when I learned of the increased number of unfilled spots this year. Is this a harbinger of things to come for our profession? Did programs make their rank lists too short? Was there a significant decrease in the number and/or quality of the applicants this year? And if less people applied, what is the reason? Are the significant anticipated reimbursement cuts, for pathology services in the most recently released federal physician fee schedule part of the problem? Besides the decrease in compensation, did the uncertainty of the pathology job market also contribute?
I was talking with another resident who thought that it was a good thing that we had more unmatched spots. He felt that we have too many trainees and not enough jobs for when we graduate. Although I did point out that after the SOAP week, the majority, if not all of those 51 positions would most certainly fill. This year’s match results may indicate the start of a possible trend for our profession or it may just be a fluke…we’ll have to wait until next year to have a better idea.

Robboyet al in an article entitled the “Pathologist Workforce in the United States” in the Archives of Pathology and Laboratory Medicine predicted that a retirement cliff would begin in 2015, resulting in a steady decline in the number of working pathologists in this country. I served as the resident representative on ASCP’s Future of the Pathologist Workforce Round Table that discussed some of the preliminary data that was included in the aforementioned article. I’ve also participated on other ASCP and CAP committees/councils since then. Despite the predictions, what I’ve heard personally from the physicians that I’ve worked with on those committees/councils is that at their current locations of employment, the overwhelming majority are not looking to hire any new pathologists in the near future.

So for those of us hoping for employment as new physicians in the next few years, will we have even more difficulty finding jobs than those who are currently struggling now to get enough interviews to ensure employment? Do you have suggestions as to a solution to this issue? It’s hard to predict what our profession will look like in a couple of years, especially with all the changes occurring post-ACA. But instead of being passive bystanders to this process, we need to actively interact with other specialties and engrain our worth into the clinical process in a very visible and palpable manner that we are missed when we’re absent, or be left behind.

The results of the match highlighted to me that our profession is going through some growing pains right now. While the etiology is unclear, we can start attempting to treat our differential to shape the outcome we would like to see. So how did the match go for your program? Do you feel that the match results were a good measure of the pulse of our profession right now? And what do you see as our profession’s biggest issues and what are some possible solutions?

 

Chung

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

The Utility of the RISE…Or Not…

So, that time of year is now again upon us…the Resident In-Service Exam, aka the RISE. Even though this test is meant to assess our knowledge of what we’ve learned thus far, the competitive natures that have brought to this point in our careers push us to do well on it. We feel an impulse, regardless of whether we act on it or not, to cram some knowledge into our brains at the last minute for a test that we are told we are not supposed to study for. This is quite a paradoxical conundrum.

But just how much does it really test? We are graded on percentiles in comparison to others in our year taking the RISE. But there are those rumors we all have heard, of programs that have remembrance databases or have year-long RISE specific lectures or students taking the test at home unproctored…so how much of our scores are true measures versus our peers if we don’t have access to these things?

Additionally, there is the other question: just how relevant is the RISE? Rinder et al. published the article “Senior RISE Scores Correlate with Outcomes of the American Board of Pathology Certifying Exams” in 2011, but how much of their findings truly are tied to our RISE scores and how much to our inherent study habits and test taking skills? These questions may be even more apropos at this time when there is a stronger recognition that we need to develop curricula to teach true competency and not just the ability to pass standardized tests. So yet again we are confronted with this question of just what does true competency mean and how do obtain it?

For me, the competency that I want to gain means possessing the ability and confidence to practice with very little supervision the day after I finish my studies and get a job. For some, this may be directly after residency and for the majority of us, after fellowship(s). So do you believe that the RISE helps us to pinpoint our weaknesses or really doesn’t help us much on our journey to competency? Does it help predict whether we will pass the AP and/or CP boards or is just a meter of our test taking ability? As a second year resident at a program where we do not, to my knowledge, have any of those aforementioned aids, I’m not so sure that I can answer these questions. All I know is that I’m still not done taking day-long standardized tests.

So, do you feel that the RISE is useful? Why or why not?

 

Chung

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

 

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?

 

Chung

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

Balance Between Service Obligations and Education

These past couple of days I attended the CAP Residents Forum and USCAP in San Diego. It was both an inspiring and daunting experience. Inspiring because of the breadth and depth of research and amount of scholarly expertise in the room every time I attended a lecture; daunting because of this same fact and also because of the reminder that someday soon I will need to be as expert and competent as these speakers.

With these thoughts in mind, I attended the first half of the morning of the CAP Residents Forum for their “Dating Game” panel where new-in-practice and veteran pathologists spoke about to getting and keeping your first job. It was actually an engaging panel and I learned practical information that was new to me and that will help me not only to obtain my first job but also when I apply for fellowship in a couple of months.

I attended mostly molecular pathology talks and the cytology short course that for someone who hasn’t had cytology yet, was informative. I got to hang out with friends from other programs that I met through the CAP Residents Forum and to hear how they are taught the practice of pathology. These conversations got me to thinking about whether service obligations can compromise our education.

For someone who is CP-oriented, I am at a program that is heavy on the surgical pathology (we do 17 months; previous classes did many more). And most of us are trained at academic institutions but my program also has rotations at a VAhospital and two community private practice hospitals. Life is different at the community hospitals but I hear that most residents will go on to practice in this type of setting. The volume can be high, there may be many tumor boards/conferences to present at or attend, and the turnover time is so strictly adhered to that you might not always be able to get protected preview time – even if eventually you do get to sign-out with the attendings after they’ve verified a case.

But does it matter about protected preview time if you don’t look at the verified diagnosis before you sign out with your attending? Does your program have CP residents covering autopsy call? Do your residents gross on Saturdays? Just what constitutes service obligations interfering with resident education in your perspective? Working in a clinical setting, patient safety and service obligations can take on a predominant role, but the quality of our work cannot suffer. So what makes for the right balance between service obligations and resident education and what can we do to ensure that resident education is made a priority?

 

Chung

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

Resident Didactic Training – How Do You Learn Best?

Lately, I’ve been thinking about what I need from my residency training to become a competent pathologist when I graduate and how I learn best. I’ve never been a good audio learner so I don’t learn as much from a purely lecture-based education. And truth be told, I often skipped classes during medical school but wasn’t reprimanded probably because I did fine in my classes. It’s taken me years to realize but I learn best by making connections. Maybe it’s the scientist in me but I remember more, and can figure out the concept again if I forget it, if I understand mechanisms than by rote memorization. So for me, what I need most is time that often is not afforded in a live lecture. I often prefer to watch video recordings on pathology topics because I can stop the recording and think (or jot down a note or two). The “flipped classroom” concept works better for someone like me.

And so, this brings me to resident education. Unlike other specialties, we spend a lot of time on didactics. But there are many different permutations to how programs accomplish this objective. At my program, we have a lot of live lectures or multi-scope sessions. I faithfully try to attend (especially since we have a 90% attendance policy), but most of my attendings know that this is not how I learn best. Anything I have to learn by hearing on the spot has never been my strength.

But, I’ve found two methods at my program that do fit my learning style. First, we have a whole slide scanner. It’s great because we are allowed to scan slides to build our own virtual slide sets for repetitive study later if we so choose. Also, our surgical pathology director has given much of her time to annotating slides for us to use for “unknowns.” She can even compile data such as tracking how long it takes us to find an important required feature on the slide as well as our movements on the slide. She can also compare our scores from year to year if we use the same slide set (which we found didn’t significantly increase our knowledge if tested on the same subject the following year so we’re no longer required to do so).

With digital slides, I like having the option to go back and look over the slides as many times as I need. I didn’t realize how fortunate we were to have a slide scanner at our disposal until I presented some of this data at USCAP during my first year – many residents and attendings that stopped by my poster told me that they didn’t have access to digital slides or a slide scanner at their institutions. But looking at whole slide imaging (WSI) is a skill we all need to master since up to 2/3 of our AP boards can be digital (not glass) slides so I’m glad that I’m exposed to it early and throughout my training.

The second method that I found that really helps me to learn surgical pathology is the unknowns conference conducted at one of our four hospitals. We’re given four slides (which is the perfect number to cover in up to an hour) a couple of days in advance and the residents work together to come up with a differential and diagnosis. Since our attending always gives us papers on the diagnoses, we often read articles while we are working up the differential – which for someone who is used to reading journal articles and reviews, is right down my alley! We take turns during the conference driving at the scope and describe what we see at low then high power and then we give our differential and begin to narrow it down.

After each slide, our attending will reveal the correct diagnosis, point out salient morphologic features (especially with mimickers that can confuse us), and ask us about appropriate ancillary tests and expected results before giving us articles to read on the diagnosis. I’ve found that the interactive approach really helps but more so than that is the visual learning (ie – reading books and articles, googling on the internet) that I did to prepare for this conference. More important than getting the right diagnosis by “wallpapering” (ie – matching up a picture with the slide to reach a diagnosis) is the thought process to narrow down the differential.

And lastly, this is not specific to my program, but I am a strong supporter of open sourcing and sharing of free online didactics. I’ve often found great videos from other programs online or on YouTube to supplement my learning. So how do you learn best? Does your program provide all the tools that you need?

 

Chung

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