So, What Does MLPW Mean to Me?

So, I’m going to continue the thread from my previous blog post next week since this is Medical Laboratory Professionals Week (or what we affectionately refer to as Lab Week). Coincidentally, for a public health-oriented person like me, Earth Day (April 22) is also during this week; globally, some celebrate the entire week as Earth Week. So, I encourage you to celebrate both.

Pathology can be a hidden or invisible profession to many, even more so on the lab side. Even though we are dependent on lab results to guide clinical care (at least 70% of clinical decisions are guided by lab results), it’s easy to forget that there are lab professionals and pathologists working assiduously, sometimes late into the night, behind the scenes to make sure we receive timely and accurate, lab results for our patients.

So, what exactly is Lab Week? It’s the time each year when we celebrate and recognize these lab professionals and pathologists, a time where we recognize them as more than nameless faces but as team members who vitally and equally contribute to patient care. Many hospitals and health care centers will highlight the work of those in their clinical labs with poster sessions and talks on relevant topics this week. Some will also cater Lab Week celebrations for their staff as a thank you for all their diligent work that often goes unrecognized or taken for granted during the rest of the year.

So, as we residents, what can we do? Well, first, we can get to know our lab professionals and this week in particular, personally thank them for all their hard work. I’m pretty sure it’ll bring a smile to their faces if you make a deliberate effort to recognize and say “thank you” this week. We can learn their names and get to know them on a personal level and not just when we need a test result or to troubleshoot a lab related issue.

I’m on pretty friendly terms with most of the lab techs from my clinical rotations. They have invited me to department holiday celebrations (even when I’m not on their rotation), gave great feedback about me to my rotation director/attending (trust me, they often do get to comment on how you perform during a CP rotation), and gave me a heads up to help me out of potentially difficult situations. I’ve learned a lot from them and they’re always happy when we show interest in their work. Plus, I never treat anyone in a formal hierarchical manner (no one calls me “Dr. Chung” but rather “Dr. Betty” or just by my first name). I acknowledge that there is always something that they teach me and that I believe that we are colleagues working together on a team…not that I am the doctor and they are not. And often, lab professionals will be the first to detect a potential patient clinical issue, even if they have limited patient history access, so I totally give them props when they help me out in this way. And having a good attitude with your lab staff, as I mentioned, can go a long way for both your learning and advancement on the rotation.

As residents, CP rotations are often when we have the opportunity (as opposed to surgpath) to take vacation time and many look at these rotations as unofficial boards study time. But spending physical time in the lab is still learning. And for me, I learn better by doing as opposed to sitting in a lecture or sitting at my desk reading a textbook. The lab regulatory policies and management issues (and even the basic science concepts) we need to know to pass boards, we can learn more efficiently if we spend actual time IN the lab working alongside our lab professionals on these very issues. In the lab, we can also serve as consultants for our referring physicians on the intricacies and appropriateness of specific lab tests and help with regulatory (CAP/CLIA) inspections – even if your rotation doesn’t specifically require this, you can still ask to be more involved – trust me, you’ll learn more this way (and it is boards studying).

So, how are you planning to celebrate Lab Week and acknowledge those in the clinical labs this week? While you’re at all, you can help contribute to Earth Day/Earth Week as well by committing yourself to being more environmentally conscious (don’t forget to recycle!) from this week forth.

 

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.

Adventures in Grossing, Part I

So its no secret that I don’t feel that I’m the world’s best or fastest grosser. I didn’t read Lester or Westra (aka the grossing Bibles) as much as I should’ve first year and still have never finished either cover to cover. And the fact that we had surgpath fellows stand by our side and teach us how to gross initially was probably more of a crutch for me than I should’ve allowed it to be. I need to understand why I should gross a specimen a specific way because memorizing the steps does not work for me – because I forget the next time and because not every specimen is “perfect” and I may need to modify the general protocol.

But for the past two months, I’ve been at our program’s busiest surgpath site, a private practice in a community hospital setting that sees a whole lot of cancers. My first day definitely was not a good one. I had spent 10 hours traveling from USCAP back to my apartment and had gotten a mild migraine in between…so much so that I got off at my layover asking if I could take a later flight back. Unfortunately, the next flight would get me home close to 7 AM and it’s a 1-1.5 hour drive to this hospital for me during rush hour traffic. This site is close to the airport so I would’ve been better off going straight from there.

It was the perfect storm, both figuratively and literally. I was tired from travel and nursing the residual headache that always follows one of my migraines… it was snowing yet again…and this caused a few accidents…and for me to be late my first day at this site after I had missed the first two days of the rotation (which is generally a no-no). So my first impression was most definitely not a good one. Couple that with being assigned grossing duty for a moderately heavy day, not knowing where anything was or how things were supposed to be done at this site, not being able to access the EMR, and not knowing what my responsibilities were versus those of the tech assigned to stand by and assist me (at other sites, I had to do everything by myself), and its not surprising that I failed to impress my attending.

VoiceBrook (Medical Dragon dictation software), the bane of my existence right now, was not working and their staff kept calling since there was miscommunication about my appointment to re-train with VoiceBrook. On top of all of this, I didn’t get to do the compensatory rituals I usually do to feel less stressed about grossing – work up my patients/specimens ahead of time, read Lester and Westra, and triage my grossing day based on the OR schedule. I pretty much felt like a “robot” (a sick one at that) that went straight through the manual motions of continuous grossing until the time came to close the gross room.

The attendings at this site have very specific ideas of the “right way” to gross and their expectations varies from the other in terms of their views on these topics. It is very busy in terms of grossing, intraoperative consultations, and weekly tumor boards that the residents prepare and present. But this post is actually not to complain but to elaborate on a light bulb moment that I had today that I had subconsciously somewhat improved my speed and many of the gaps in my understanding of what to gross and how to do it. Sometimes, repetition can be a great teacher. Good communication with those you work with is key. And lastly, nothing beats a good mentor who is willing to work with you to address your weaknesses… so what were your light bulb moments during your most difficult rotation and how did you come to recognize them? I’ll continue next week with a little more on this topic but for now, its bedtime since I anticipate a busy grossing day tomorrow.

 

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.

 

Trainee Worries, Level III Anecdotal Evidence, and Thoughts to Keep in Mind During Training

As you know, I serve as a junior member on one of CAP’s councils. Besides enjoying the opportunity to participate and represent the resident voice on issues that will shape the future of our profession, I always value the thought provoking conversations I am fortunate to have during our meeting dinner. And this past weekend’s meeting did not disappoint.

So, we’ve all heard the opposing arguments. There’s the one side that anticipates an impending “retirement cliff” and not enough pathologists to serve the needs of future patients. Then there’s the “doom and gloom” side that states that we have too many pathologists and no jobs for those of us who will graduate in the near future. So which side is correct?

As someone who was trained in critical analysis and statistics during my public health training, I can see a scenario where both of these situations can co-exist. Like the Indian story of six blind men who feel different parts of an elephant, our perception of reality is based on our experience (or if you think of grossing-speak, sampling informs our eventual conclusion). For trainees, of course, we fear  not being able to obtain this “competency.” Everyone seems to be stressing as of late and more so of not being able to find a job when we graduate. Couple that with the frequent nay-saying we hear about the paucity of job opportunities available (which amounts to level III anecdotal evidence), the landscape is set for us to believe that our profession is in a crisis.

We discussed these issues and more during our dinner last week and practicing pathologists pointed out to me that they had heard the same when they were training and yet, they were indeed employed, and in jobs that they love…so there is hope. I was told that if we focus on becoming “good” pathologists and working to obtain “true competency,” the rest should follow. A “good” pathologist is always employable and sought after.

But what about those of us who don’t make that cut of being the “cream of the crop” and who are your average trainee? After all, average means the majority. What I seem to hear repeatedly (even from the nay-sayers) is that there are jobs out there…just maybe not in the location or at the salary/benefits we initially want. But maybe we need to look at this as a “glass half full” opportunity. Most of our future “dream” positions may still be within our grasp but we need to be humble and realistic and may need to work our way up to it.

The most desirable characteristics in a successful job applicant, from what I heard over and over during this conversation and multiple others, are competency (especially since no one wants lawsuits), ability to fit in (of course, people have to like you and not think you will cause drama), and experience. This often translates to a fellowship or junior attending experience during residency training where we can build up our confidence and ability to sign out on our own (or almost with little supervision). So, the suggestion was to obtain employment (and it may not be your “dream” job) to nurture that capacity and then if you possess the other two characteristics, you should be able to find employment at a situation closer to what your “dream” job looks like in time. But patience is the main virtue here.

I found this outlook a little more practical than either of the two aforementioned, more extreme arguments. And either way, it is not worth wasting time and energy worrying about what may never come to pass (and attendings really get tired of the whining)…but rather to set the goal to become the best pathologist we can be in the present. Obviously, this is easier said than done or we’d all be acing our boards and RISE.

Making the transition from student to almost practicing pathologist is difficult. We may not be as used to the demands of a job (versus studying mentality) that we are expected to already possess during training and the volume of knowledge we need may seem prodigious at times. But set yourself some small sequential goals and push yourself to have the humility and dedication to meet them…and put entitled behaviors aside. If your residency isn’t giving you what you need, proactively (and nicely) ask for it…or find other outlets to obtain it – there are a lot of online free resources and your fellow residents, at your program and others, are a valuable, understated resource. Don’t expect others to do for you what you must now learn to do for, and demand, for yourself.

I feel inspired after the meeting last weekend and the conversations we had and I am re-dedicating myself to continue to address my weaknesses. Leave us a comment if you have an opinion on how we should approach residency training or how we should view the future of pathology in this ever changing health care environment.

 

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.

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.