Pre-July 1st Reflections

So, July 1st is fast approaching. It is that date each year when new residents officially start their employment. And for us senior residents, even though it may not be as momentous as our first, it still is the start of our next year of rotations and a great time for reflection. As I sit here amidst an apartment full of unpacked and half-packed boxes as I prepare to move cross-country to start my new residency, like many of the PGY-1’s, I’m reflecting on what I’ve learned, what I should’ve learned but haven’t yet, and the journey that is to come at my new residency.

First, I’d like to congratulate all the graduating seniors and fellows! You finally are on to the next phase, whether that means fellowship or employment. Most of you have put the dreaded beast of boards behind you and have reached a milestone that says you are assumed to be ready for practice with less supervision. Gone is the safety net of having your attending verify the cases but you are not completely on your own because you will still have more veteran physicians who can help you. I know that there is a lot of negativity, especially on the internet, about the current job market and decreasing reimbursement codes, but persevere. There are pathologists and advocacy organizations lobbying for our profession. It’s easy to become disillusioned but uncertainty about our future can also be looked at in a ‘glass half-full’ view – we can shape how that future evolves because nothing is set in stone as of yet. In my grassroots organizing experiences, I have seen the underdog aka ‘the little guy’ win but only when they believe that they can bring about change, mobilize and organize together with like-minded individuals, and fight for what they believe is right.

Next, I’d also like to congratulate the incoming PGY-1 again for surviving that beast we call med school. You should be very proud. I know you are probably moving cross-country now and excited about what is to come. There’s a lot to learn but it’s a great time for you. My guess is that most of you will start with an introductory surgical rotation, although I do have some friends who are starting with a CP rotation. Either way, you have probably started your orientation and/or ‘boot camp’ so you can get acquainted with your hospital’s medical record system, dictation system, and pathology basics. Although I know that some of you won’t get a boot camp and will start on rotation immediately after orientation. Don’t despair…every first year in your program with you is in the same boat. And even if some people start off ahead of others on the learning curve, what I’ve seen is that by the end of first year, most people are caught up and at the same place. The thing that may set others apart is more the effort that they put in once residency starts.

So, what is essential during residency, not just for newbies but for all of us? Here’s some surgpath advice that can also apply to other rotations:

  1. Comfortable footwear: I can’t stress this enough, especially on rotations where you may standing for all or most of the day. I personally like Merell’s but I know that Dansko clogs are also popular – these may be expensive and sometimes not the prettiest but oh so worth every penny when your feet are not killing you at the end of the day.
  2. Teamwork: Working long hours with high expectations where your work will impact a patient’s health can be daunting. This element really can make things easier or much harder for you. So, be observant of your peers when they are having a hard time, don’t just point out that they “are getting slammed,” offer to help (eg – gross, take pictures for a conference they need to give soon but are stuck grossing, etc) and hopefully, they will return the favor. Sharing resources with each other is also helpful. Think of the Golden Rule.
  3. Responsibility: Pathology is one of those specialties where our hours can be reasonable and we do not have overnight call or night float. It’s also one where residents can feel as if they can leave the hospital early (especially on CP rotations) and no one will notice. But your attending will notice, especially if you are on call (eg – autopsy) and you’re not there when a task does come up. Make sure that you really take ownership of your assigned tasks. People want to know that you are reliable and keep your word (implied and explicit). And be honest…people don’t like liars who say they completed a task when they haven’t.
  4. 100% commitment: There will always be a task/rotation that we are not thrilled about (eg – performing/writing up autopsies) but remember that for each task, there is a patient attached to it. Even with autopsy, there is the patient’s family. There is always someone waiting for your diagnosis so take that responsibility seriously even though we may not feel the same urgency as those in fields who take care of the patient in person. Don’t cut corners (we all know what this means and have seen residents who do this even while we were in med school). Do things right the first time and you won’t have to repeat and waste resources.
  5. Make a plan and set aside dedicated study time: It helps if you have a (mental) checklist (eg – read one chapter or half of one in Robbins/your book of choice, work on writing that publication, etc) of tasks and a consistent time that you devote to it each week (eg – every Sunday night), otherwise, it’s very easy to get distracted…and behind…and it will just get worse as more time passes until you re-commit to doing this. But if at first you don’t succeed, you can always try again until you perfect your discipline and time management. A few trusted sources that fit your learning style is better than having too many sources. The internet is great for this (but also make sure that the info you get is correct and from a trusted source).
  6. Never stop reading: In addition to studying, you need to keep up on what’s current, whether via hard copy or the internet. This will help you in your daily work and also help develop yourself as a lifelong learner.
  7. Find a good mentor and learn from them: Learn from their experience and knowledge but also develop rapport with them as these are the people who will ‘go to bat’ for you and give you recs when you apply for fellowship or a job. Be a role model and give them good things to say about you through the quality of your work and dedication. And also don’t be afraid to ask for advice or help but be humble.
  8. Get involved: Whether it’s research, the GME council, a pathology advocacy organization, or something else, participate. It will enrich your experience and also help prepare you for when you are in these types of leadership roles as an attending.
  9. Learn to tie in the clinical with the practice of pathology: Make sure you know the clinical history, radiology, and previous pathology on your patient and tie them together. Get the previous slides or lab results for your patient (eg – biopsies) and compare the diagnosis with what you are seeing now. It usually matches up but occasionally you may get a surprise. Understand what’s needed for staging and the implications (eg – surgery, radiation, amputation, etc) of our diagnoses for our patients.
  10. Double check your work and QA yourself: One of my attendings has this method and I find it useful for surgpath – “skim” your slides to get a “feel”, then look at them again more closely and fill out your diagnosis, and finally, QA yourself after you’ve written in the diagnosis to confirm and to check for anything you’ve missed.
  11. Fix well and cut good sections: I have attendings who for cancer specimens will have you prep the specimen but fix overnight (and others who say cut fresh). Believe me, the specimen cuts better if fixed well and if you cut with skill (and a fresh sharp scalpel blade) but not force, especially with friable lesions. If you cut good sections, then you get good slides.

Above all, put the patient first and stay positive!

 

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.

Advice for the Incoming PGY-1 Residents

As I am repeating the motions of yesteryear when I was moving from NJ to Chicago to start my residency, except this time in reverse to return to NJ to complete the final two years of my residency, I’m reminded that it’s always good to ask for advice from those who have blazed the trail before me. And so I’d like to start with a hearty CONGRATULATIONS to the incoming pathology PGY-1 residents! This is truly a time of excitement and maybe a little apprehension of the new and unknown for you. So, I thought that I’d devote this week’s blog to pearls of wisdom I’ve picked up along the way. Fellow residents, please pipe in if you also have some advice for our incoming residents.

  1. Enjoy your time before residency (and in some of cases, June orientation a la boot camp style) starts. Take that vacation backpacking through Europe that you always dreamed of…or volunteer overseas if you’re so inclined. Whatever you do, take some “me time” now. I know it’s easy to think that you might need to read up on your pathology but there’s time for that later. Once you start working (residency, fellowship, job), even if you are promised 4 weeks, it might be difficult to schedule that time off due to grossing schedules, your colleagues’ vacation requests, and so on. So decompress from the past 4 years of medical school and enjoy what’s left of your summer.
  2. Hopefully, you already have done this but look for your housing way in advance, especially if you are out-of-state from where you will be a resident. Apartment websites and Craigslist are good but be careful of scams especially if they ask you send in a deposit ahead of time without seeing the place. If something sounds too good to be true, it probably is. I strongly suggest going in-person or having a trusted friend or family member check out places for you if you can’t. A great piece of advice that was given to me was to use a realtor (or more than one) who can line up places and show you around. They are usually a good source of information about where is best to live and what are reasonable prices…and you can ask them to only show you places where the landlord pays the commission. It saves time to have someone organize the appointments according to your specifications (pets, within X distance to the hospital, safety, covered utilities, parking, amenities, etc) so that you only need to show up and view the places you like and decrease the number of apartment hunting trips/calls you make. You can even search for places you like off the realtors’ website just like you’d do on Craigslist, Trulia, or Zillow especially if you want to rent or buy a condo unit. Sometimes you may need a letter of employment stating your salary and a credit report (by federal law, you can get this free q12mo from all 3 credit reporting companies through www.annualcreditreport.com but you will need to pay a small fee, about $10, to get the credit score – you can get the score free via Credit Karma but a lot of realtors will not accept it from this company so be forewarned)
  3. Think about selling any large items you may have (such as furniture) to save on moving costs. If you really must move a lot of large items, look into moving options early because June/July is a busy moving cycle and you don’t want to be left with the less reputable companies that may be cheap but do not do a good job or very high prices or even worse, no options. You can either hire a moving company or use portable containers such as PODS, U-Haul’s U-box, or ABF U-Pack where you pack the container yourself and they drive the container to your new home and often have options to store it until you are ready to access it. Check to see if your program has an Employee Assistance Program (EAP) that can help you with relocation services and/or discounts but either way budget yourself 1-2 grand.
  4. Get all your paperwork done ASAP. You will receive mountains of forms that need to be filled out to obtain your (temporary) medical license and allow you access to the various hospitals you will rotate at. Make it a habit now to not procrastinate because once residency starts, you will find yourself often too busy and too tired. You also do not want any delay in starting your job due to incomplete paperwork. Better to find out now if you are missing an item (eg – vaccination, physicals) and take care of it before you arrive to start.
  5. Get to know your colleagues. Introduce yourself to everyone over email and offer to help out if they need (such as unloading their moving stuff). It’s a great way to break the ice and meet your fellow residents and start off on a friendly foot. You can even suggest some chillaxing activities to do together at the start of residency to explore your new city to get to know each other and your new home. Bonding starts from day one and it is difficult to do once the hustle and bustle of work starts and if you are in a program where you are separated to different hospitals. Also, you’ll find that your senior residents will have a lot of good advice to give and you might even find a new friend or mentor.
  6. Join pathology advocacy organizations like the American Society of Clinical Pathology (ASCP), the College of American Pathologists (CAP), and your state/city pathology societies because they often have resident resources and this is the last time you can get free membership. Once you graduate, then you have to pay membership dues. CAP has a Residents Forum with 2 meetings per year that I found a great place to meet other residents. Both ASCP and CAP have a Resident Council and Residents Forum Executive Committee, respectively. Get involved and run for a position on either of these or on ASCP or CAP committees where you will serve with attendings. Other international organizations such as USCAP or subspecialty organizations may have dues but these are often greatly discounted for trainee members and you get discounted registration if you need to attend their conference (eg – to present a poster) so it still makes sense to join – find out if your program will pay for the dues.

Once you start residency, I won’t lie, it will be stressful. There will be times you wonder what you’ve gotten yourself into and when you may doubt if you can do all that is expected of you. But persevere and this, too, shall pass. Find yourself some good mentors – other residents, attendings, and/or ancillary staff. You may feel that you are behind and that there is so much to learn but I promise if you make sure you have a solid foundation at each step, one day you will be that senior resident who seems to know so much more than you did on day one. But for now, enjoy yourself! The studying can wait–at least until July 1st!

 

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.

Halfway Through…and What’s Left to Do

I had originally started writing about a recent article I read on residents organizing as a collective bargaining unit for salary negotiations. But I’ll leave that for another day and give you a more informal blog post today.

So, for those of you who don’t know, I will be transferring to a program in my home state of NJ for personal reasons for my last two years. When I initially applied to residencies, I didn’t apply to any of the three programs in NJ because I wanted to be in a large (>4 residents/year), urban program that served a significant number of underserved minority and immigrant patients. Chicago was a familiar choice as I had attended college at The University of Chicago alongside my brother here many moons ago. It was also where I first began working with minority and immigrant community advocacy and grassroots organizing groups and my oppas (“older brothers”) and unnis (“older sisters”) then, are the leaders of these groups now.

But two years later, circumstances in my life change, priorities change, and the reasons to go home were more compelling than those to stay. It wasn’t an easy decision. My chairman and attendings here have been very supportive, especially of my extracurricular activities and research. I know that when I go to fellowship interviews, people will ask why I transferred. The reasons are innocent and legitimate enough but I do wonder if they may affect how programs will view me as a potential candidate when they hear my reasons. After all, fellowships are more competitive to obtain than residencies and any small possibly of negative perception, whether true or erroneous, can make or break whether you get those fewer positions available.

I took this week off to deal with moving tasks and my apartment is a mess of half-packed boxes. I need to get as much done before I’m back at our busiest surgpath site again next week until I leave for NJ. But the déjà vu act of packing, calling up moving companies for quotes, and selling items in order to lighten my load has put me in a contemplative mood. I realize that now I am almost halfway through this part of my journey to become a practicing pathologist.

Sometimes, I feel as if I have been weighed and measured and found wanting in terms of where I should be in AP. With my research and heavy science background, CP has always been a comfortable fit. I haven’t had any cytology rotations yet but I get to do four months in NJ. In terms of surgpath, I’m knowledgeable enough with the “bread and butter” that I see during sign-outs but not knowledgeable enough when it comes to unknowns. I know I should read more and often wonder why I don’t do as much as I could.

But now that I’ve come to this fork in my journey, moving back to NJ and thinking about applying for my first fellowship, I wonder what do I need to become the best pathologist I can with the time I have left? I don’t want to be cramming everything I should’ve learned in three years into my last year when boards studying fever hits. If anyone has some advice or anecdotes about their training to illustrate something that is working for them, please feel free to share.

And yet, even though our studies and service duties are, of course very important, how should we engage in molding our profession into the pathology of the next age? What are the most salient skills we need to acquire and how do we show the clinical care teams that are evolving within healthcare reform just where our place is within it? What are the most pressing issues for residents? Salaries, autonomy to influence our education, didactics, service duties, or clinical care? Where should we most focus our efforts?

 

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.

 

Training Towards Boards and/or Practice? Or a Little of Both?

So when I was in medical school, we all had our medical licensing boards (aka “the Steps”), at least two of them, to worry about passing in order to matriculate into residencies and to start the process for obtaining our medical licenses. It was a rite of passage. And even though many of us stressed and spent many a sleepless night in worry and study to pass them, they were not seen as insurmountable by most. The Steps were perceived as an important exam we had to take while going about the actual practice of medicine. During my second year, we only got two weeks off at the end for Step 1 study time. During my clinical years, we didn’t get any specifically designated time off to study for Step 2 unless we used our two week vacation.

And yet, when it comes to our specialty boards, the stakes feel immeasurably higher and most training programs do not set aside an uninterrupted study time period for these exams. After all, we are employees, where our absence means someone else is doing our work. While I was rotating as a medical student on elective pathology rotations and from what I’ve seen and heard since becoming a resident, many PGY-4 everywhere spend their senior year using their saved up vacation time and/or lighter CP rotations to study mainly for boards. Some are even barely seen on the rotation service and are more often seen glued to their cubicles studying or listening to boards review lectures. But what does this say for how we train our pathology residents?

Full disclosure…I am a concentrated crammer, always have been – a habit that I am still working to break but since I generally so well on standardized tests, I haven’t had the selective pressure to change as quickly as I probably should. So, I can’t imagine consistently studying for a year or two for these exams. Although I can imagine stressing over them for that long, I don’t have the attention span, memory abilities, or discipline to learn in this way. There is nothing wrong with the slow and steady study personality. But for me, I learn more by doing than by just reading or listening to lectures. And hopefully, this translates to needing to study less and not needing to feel as if I have to learn everything I should have in 3 years of residency crammed into 1 when my time comes.

But the specialty boards really seem to push our buttons, even to the point where there have been headlines of residents and fellows punished for their use of remembrances with some cases resulting in cancellation of scores. For many of those providing such remembrances to others, suspension of medical licenses have even occurred. Are we conditioned to feel that we need protected study time in order to feel confident that we will pass? Because as residents, who are no longer medical students, no such time is allotted because we need to carry out patient care.

So why do we seem to freak out so much more about our boards exams as a resident/fellow, then we did as a medical student? As a medical student, we learned most of the material for Step 1 during our basic science years. If we studied for our clinical rotations and attended clinical lectures, then we also were exposed to much of the material we would see on Steps 2 and 3. But do we learn enough while on pathology rotations to recognize most of the material we will see on our AP and CP boards? Or is it just the perception that we aren’t exposed to everything we need to be during our rotations that makes many residents spend a year or more studying for these exams?

From my experience, residency training programs are more variable than medical schools are in terms of their curriculum and exposures. So, how can we transform our training within the confines of our specific program’s idiosyncrasies to provide what we 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.

General Versus Subspecialty Surgical Pathology Sign-Out

I’m currently on a month of neuropathology/autopsy at our main academic center. After 2 months at a busy surgpath site with a 1-1.5 hour drive each way, it’s finally nice to be able to take a breather. Here, I’m responsible for any neuro frozen and grossing that doesn’t go to the SP resident, helping with the cutting of autopsy brains, and sign-out of neuropath cases. Since we don’t have a heavy neurosurgery service, this allows me more time to learn at my own pace and I feel that I’m able to retain more.

Not including CP rotations, I’ve always learned more, retained knowledge, and performed better on the subspecialty rotations that I’ve had – hematopathology, pediatric pathology, and now neuropathology. While I acknowledge that part of this is my own fault because when I’m on surgical pathology (we do general SP sign-outs), I read up pretty much only on my cases. I know that I need to preview them for sign-out so I read up on the SP diagnoses and differentials. But I often am not motivated to read up on general systems, so I can be real hot mess (and as one senior resident called me recently, “stupid”) during unknown conferences. In CP topics and those subspecialty areas I’ve had rotations in, I’m quite the opposite and tend to excel.

Yesterday, was the first time I’ve been at consensus conference since my first year. At the community and VA hospitals where I’ve spent most of my SP rotations during my second year, we didn’t have group consensus conferences. I remember last year thinking during consensus, “please don’t pick on me to answer a question” during the inevitable pimp sessions that evolved. But yesterday, besides the fellow, I was the only senior resident present. But I was less apprehensive and intimidated than I had been when I sat in the same place the year before. So even though I don’t consider myself a person who is good at SP, I was adequate enough and I must have learned something over the past year without realizing it.

Obviously, how we teach surgical pathology is restricted by the type of sign-out practiced at the institution we are at and this often is dictated by specimen volumes, faculty expertise, and the cultural philosophy dominant there. Even though I thought that I had taken this question into consideration when interviewing and ranking programs, I realize now that I didn’t have a complete grasp on how training styles and cultures really would affect me. Probably since I’m graduate school trained first and naturally think more like a scientist that focuses on one area and learning everything about that area, subspecialty sign-out works best for me.

Before starting residency, I had an intuition that this was true but thought that I would eventually adapt to a general sign-out format since that is how my institution practices. And I’ve adjusted, albeit maybe not progressed as quickly as my peers. It’s difficult to maintain all surgical pathology as subspecialty unless the volume is high enough and this usually means a large, well-known academic center if that’s what you need during your training. The majority of residents will end up in private practice and many often train at places where the sign-out is a more generalized one. So how do we match our learning needs with practice requirements at our training institutions with our eventual responsibilities as a pathologist in terms of sign-out? I can’t say that I have a solution for this conundrum but would welcome opinions on the topic. What works best to train our residents in surgical pathology?

 

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 End of the Rotation

Since my program is on a monthly rotation schedule, last Thursday was the last day of my 2-month surgpath rotation at our busiest site, which is private practice at a community hospital that serves a more middle class and affluent patient population than our main academic hospital. So, it seems appropriate to finish my “Adventures in Grossing, Part I” post from 2 weeks ago now. As I think I mentioned in that previous post, my first day at this site (right after I just had gotten back from almost 10 hours of traveling due to layovers coming back from USCAP and getting a migraine during my flight to boot), was a disaster to say the very least.

I had made the mistake of jokingly saying to my rotation director that I was the most CP oriented of those in my year (I’m the last 2nd year to rotate at this site this year)…and he had mistakenly heard my statement as “I dislike surgpath and because of that probably wouldn’t work hard at this rotation.” We were reminiscing about it today as we had our face-to-face end of the rotation evaluation about how much has changed since that first day.

Communication is very important and sometimes that also entails knowing what not to say in a situation, especially if it can be misinterpreted. Luckily for me, after I had another talk with my rotation director, he was willing to ‘start fresh’ and see whether his initial impression of me held true. We did not work together again until the end of the month as I was assigned to other attendings during the interim. But by the time, we were assigned together again, he was “happy” with what he had heard about me from the other attendings.

As a first year, I had heard rumors about how hard this site and some of the attendings were…the stuff of legend so to speak. First years do not rotate at this site as we need to build up our grossing and time management skills to be able to adequately manage the higher volume of grossing at this site. We have a three-day schedule that includes two days allotted to finish grossing and a third intra-operative consultation day which includes frozen sections, sentinel node touch preps, and intra-op gross examination of specimens.

I still need to work on my grossing speed and time management skills but after two months of instruction and experience at this site, I do recognize that I have improved. It’s almost the end of my second year and I generally do fine with diagnoses at sign-out because they are either things I’ve seen before or things that I have some time to read about prior to sign-out. But when it comes to unknown conferences or my RISE surgical pathology scores for the past two years, I know that I am horribly deficient and need some work.

In two months, I will be transferring to a much smaller program in my home state for personal family reasons. My medical school friend will be one of the chiefs next year and one of their incoming first years is also from my medical school. Plus, they rotate mainly at one site and do 1-2 rotations/year at another site that is near where my parents live and where I went to medical school. So it will be different than my current program which has 27 residents that rotate at four sites. The culture also seems very different and I worry that I may be behind the curve in terms of my surgical pathology (SP) knowledge. I’m not worried about CP as my strengths and background are in CP.

So, I’ve been wondering…what are some good resources to learn SP and some good approaches to learn while busy on rotations? I still haven’t found a good solution to these questions yet.

 

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.

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.