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.

ASCP Call for Abstracts

Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.

Preventing (Pathology) Resident Physician Burnout

Fellow residents, do you sometimes feel burned out, especially with the dismal winter weather than many of us have been experiencing lately? There have been many, predominantly small sample size, cross-sectional studies over the years on this topic. Methodological deficiencies in many of these studies may bring into question some of the generalized conclusions that they assert but does not discredit the truth that resident burnout exists and should be taken seriously by training programs.

In 2004, an article in JAMA on this topic defined “burnout” as a “pathological syndrome in which emotional depletion and maladaptive detachment develop in response to prolonged occupational stress.”1 Multiple studies have identified factors such as time demands, variability in faculty expectations, work overload that inhibits learning, systemic program issues, inadequate elective time, and lack of communication and support from faculty and peers as potent contributors to resident burnout.1,3 Furthermore,a subsequent study identified that burnout was associated with absenteeism, low job satisfaction, and medical errors.2

So, first, how can we identify if we are experiencing burnout? As with everything in life, know thyself. Conduct an honest self-assessment of your strengths and weaknesses as well as your absolute needs, both at work and outside of it. If you are not good at honestly evaluating yourself, then ask a trusted person who has your best interests at heart their opinion and truly listen. Then set aside designated time to recharge your batteries. For some this means exercise, for others, it may mean spiritual or community volunteer experiences, or even, just doing “nothing.” The key is to not do any residency work during this time. This is often easier said than done but the first step is to make a commitment to try to do so.

Next, be proactive to bring out the change you want to see. Often when we feel that a situation is out of our control or that we have no choice but to submit to a situation that makes us unhappy, fatigued, or emotionally drained, these negative feelings we internalize may manifest as burnout. So, find a way to take back some control. Frequently, part of this does mean cutting out those aspects of your life that have become toxic, whether it be negative situations or negative people. Of course, this is also easier said than done. If I had the cure for this, I’d bottle it and sell it.

Finally, find support. This statement can mean interacting with a mentor who will both personally and professionally “be in your corner” and help guide you through acquiring the necessary skills you need to be a good doctor. It also means to turn to those positive people in your life, whether it is a family member or a good friend, who will listen to you without judgment, let you vent, encourage you in healthy pursuits, but most importantly, remain honest with you and not just be your cheerleader.

Interestingly, a small survey study in 2013 by Medscape of pathologists showed that only 32% of respondents stated that they were burned out.4 Even though the methodology for this study is not stated to be able to determine the legitimacy of this study, it at least gives me hope that if I survive residency, there is hope at the end of the tunnel for a reprieve from those often seemingly, hydra-like tentacles of burnout that threaten to bring us down.

  1. NK Thomas. Resident Burnout. JAMA, 2004;292(23):2880-2889.
  2. LW McCray, PF Cronholm, RA Neill. Resident Physician Burnout: Is There Hope? Fam Med, Oct 2008; 40(9): 626-632.
  3. L Joseph, PF Shaw, BR Smoller. Perceptions of Stress Among Pathology Residents. Am J ClinPathol 2007; 128:911-919.
  4. Pathologist Lifestyles – Linking to Burnout: Medscape Survey. Last updated on 3/28/13. Accessed on 2/11/14 at http://www.medscape.com/features/slideshow/lifestyle/2013/pathology#1

 

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 Poisoner’s Handbook by Deborah Blum–Book Review

I recently read The Poisoner’s Handbook by Deborah Blum, a book about poison and forensic investigation in Jazz-age New York City. Dr. Norris and Dr. Gettler transformed death investigation from a good-old-boy coroner system to one based on science and data analysis. Blum weaves several cases into a narrative that covers several poisons used during the 1920s and ‘30s. Over time, poisoning deaths decreased due to public awareness as well as the realization that murderers were increasingly likely to get caught. Blum discusses Prohibition at length and its contribution to poisoning deaths in New York City. I found this particularly fascinating; not only were people willing to risk their lives to drink alcohol, the government tried to dissuade people from drinking by actively poisoning the supply.

Several of the reviews of this book note Blum’s lack of chemistry knowledge, and I can’t disagree. While my own knowledge base isn’t wide, even I notice a few inaccuracies (HCN isn’t a “potent” acid, for example). One must remember that Blum is a journalist, not a chemist; I tend place blame on the publisher’s fact-checker as well as the author. Because this book is about the evolution of the public perception of forensic toxicology and not just the science behind it, I could overlook the scientific stumbles.

As a laboratory professional, I loved reading about the early days of forensic science and forensic toxicology. While these professions existed in Europe well before 1920, Norris and Gettler forever changed how we treat death, murder, and justice in this country.

 

Swails

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

 

 

Use of Remembrances, Part Deux

So, I’d like to continue with the thread of thinking on my previous blog post about the use of remembrances–and thank you to those who have either commented on the blog or emailed me. I personally believe that using old questions that I know are questions that will more than likely be recycled on a standardized exam (which is how I define remembrances), is not for me. However, I don’t believe that using other study materials that may give you an idea of topics or styles of questions that may be asked is the same–after all, there is a whole industry devoted to the topic of study materials for specific tests. For me, it’s about the intention more so than the action because I don’t see life in terms of “black and white”. But I understand that it is often difficult to distinguish between these two and that lines may get blurred unintentionally. But writing down the questions after taking a test and using them or passing them down to one’s juniors to use to study for an upcoming version of the test is using a remembrance in my book.

To me, to cheat or not to cheat, that’s a personal choice and I don’t really judge (or honestly, feel it’s worth my effort to do so) and I think we can say we all have different definitions. But for me, the more important question is whether I choose to cheat myself. Multiple times during my medical training, I’ve felt like I’ve had to play catch-up. I think that this is because I didn’t truly take the time and effort when I should’ve to learn the material in a way that I could internalize it enough to stick–and often that may be because I was too stressed to see the “forest through the trees.” But, now I’ve begun to see the outlines of the forest.

Being more of a scientist-trained person and less of a clinical one, I still find myself having to go back and relearn a concept I should’ve learned well during medical school to carry out my resident responsibilities. And while I may internally curse myself for this, I understand that I need to do this–that I may hurt a patient if I just brush under the rug that I’m missing some knowledge, no matter how small a crumb it may be. I might be able to get by without fully understanding it, but I need to participate in their care. First, we need to be self-aware enough to even question ourselves. I believe that starts with at least making the decision to make an effort to ask these questions, which we can all do. And much of that comes from experience. But it also comes from listening to the consistent patterns that percolate throughout the feedback we have been given over time from our mentors and from identifying what characteristics we want to live up to in our role models.

I also believe that this effort should not be one-sided in that all the responsibility is on the trainee. Factors in this equation equally include our residency programs, and specifically, those who serve as our role models and mentors. Even if our attendings may not realize it, they do serve these two roles just as much as they fill the role of being our didactic teachers in their topic area. Also important is the critical thinking or analytical process that we need to learn and make our own. I’ve found that the best teachers, or at least the ones I relate to most, are the ones who lead me through the thinking process–to look first at low power at the architecture and then to move on to high power where I consider the nuclear and cytoplasmic features, chromatin texture, the company that the primary lesional cells keep, and so on, to put together the pieces of the puzzle to come to a reasonable diagnosis and differential. Same process, albeit with different pieces, when it comes to my CP rotations. And I’m slowly but surely attempting to get there.

I also believe that the American Board of Pathology (ABP) who writes our board exams, and even the American Society for Clinical Pathology (ASCP) who writes our resident in-service exam (RISE), have an equal responsibility to help us transform our culture. Pathology and diagnostics are changing at a rapid pace and both organizations need to be up-to-date and reflect this in how they construct our exams. We are (or are training to be) the diagnostics experts and we need to know not only certain facts but also understand the relevant concepts—and truly understand the importance of training ourselves to be life-long learners. If both organizations want to absolve themselves from culpability in maintaining a culture that silently endorses the use of remembrances, must not recycle old questions. Of course, this does not mean writing exams from scratch each and every year. And of course, I am not trying to belittle the efforts that these organizations do make every year on our behalf when they write these exams. I am only entreating them to make honest, focused, and deliberate efforts each year to re-examine the content of these exams and to retire those that may fall under the definition of a remembrance. We need to have these exams truly reflect the knowledge and critical thinking we need as a practicing pathologist—more case based multiple-step questions rather multiple-choice (which I’ve always called “multiple-guess”) might help.

So, fellow residents, figure out how you learn best–and in a nice and respectful way, convey your expectations to your teachers–ask questions, read more books and journal articles, step up and take more responsibility in your rotations for patient care and safety issues and don’t just do the minimum amount of work required.If you are so inclined, get more involved. Next week, I’ll talk about resident engagement in pathology organizations and my recent experience serving as the resident representative on ASCP’s Annual Meeting Steering Committee Education Working Group. I encourage all residents to at least take advantage of the FREE resident memberships from both ASCP and CAP (you get discounts on books, apply to serve on committees, etc).

And also, turn in abstracts to present at their annual meetings, both have their submission period open NOW!

CAP in Chicago, IL Sept 7-10, 2014

ASCP in Tampa. FL during Oct 8-11, 2014

 

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.