I wanted to devote this blog to my experience at the recent Training Residents in Genomics (TRIG) one-day workshop at the ASCP Annual Meeting in Chicago. I admit that I am biased since I had ten years molecular and cell biology and transgenics research experience prior to medical school and enjoy all things molecular. But I really I do think that TRIG is an idea whose time has come.
TRIG is a group of molecular pathologists, medical educators, and geneticists who came together in 2010 with the goal to create a standardized, high quality genomics curriculum and to promote adoption at >90% of pathology residency programs by the end of their 5-year grant period. A 2010 survey of 42 pathology residency program directors found that only 93% confirmed molecular pathology as a part of their training and only 31% had established curricula on relevant topics. So, TRIG plans to provide online resources, lectures and workshops, and to assess the efficacy of genomic medicine curricula at residency programs through RISE performance. From speaking to other residents I’ve met over the past year, I know that the teaching of molecular pathology at each program can vary significantly.
The TRIG workshop had four sessions that followed the case of a woman with newly diagnosed breast cancer while applying specific hands-on skills related to the genomic related elements of her case. I missed the first session so I can’t say too much except that they discussed single gene testing and assessment of BRCA mutations of unknown clinical significance. Session two covered the assessment of prognostic gene panels (Oncotype DX) and compared them versus the standard breast IHC panel. We also learned to plot Kaplan-Meier survival curves based on a patient’s genomic profile on a publicly available website.
After lunch, session three dealt with the selection of genes to design a breast cancer multi-gene assay for this patient. Questions considered were the availability of targeted drug therapy for specific somatic mutations, the strength of association of selected genes with breast cancer, frequency of these variants, reimbursement, and choice of PCR based genotyping versus next-gen sequencing. The final session focused on the creation of a genomic pathology report for this patient after analyzing the clinical significance of each result from multi-gene mutational analysis using free web-based tools.
This workshop was a great introduction for the genomics neophyte (especially if one’s residency is weak in this subject or doesn’t have a molecular pathology rotation) and even someone with some experience like myself, learned how to use some new tools and applications even though the concepts were not new to me. As I mentioned in previous blogs, I learn more from having to tackle issues hands-on and being able to participate in a bidirectional discussion about a topic versus reading textbooks or attending lectures. The workshop was a good intro albeit too short to learn to apply these skills comfortably and effectively…but it is definitely a step in the right direction and I expect to see more great things coming out of the TRIG Working Group. More info about TRIG is at www.ascp.org/trig.
Last week, I attended subspecialty talks as well as informative sessions on policies that will affect the future and practice of pathology at the 2013 ASCP Annual Meeting in Chicago. I also attended special events such as the Keynote given by Hillary Clinton, the Raible Lecture for Residents about the “Pathology of Bliss: Searching for the Happiest Place to Work,” the Training for Residents in Genomics (TRIG) workshop, multiple receptions, and the president’s black tie dinner. To top it off, I also presented during the poster session and saw old friends as well as made new ones.
But what I am struck by most about the myriad of experiences and conversations that I had last week is that as 21st Century physicians, we need to be forward thinking to contribute at a systems or global level. Sometimes, as Americans, we can be insulated and shortsighted, and as physicians we are not exempt. In the midst of talk of multiple technologies, often expensive and not available routinely at many institutions, focus on resident boards review sessions, and subspecialty relevant talks, it is easy to forget that we can transform the delivery of healthcare in this country and throughout the world not just by what we learn but also by what we do, especially in resource limited settings.
Currently, over 70% of diagnostic and treatment decisions are made based on the results of laboratory tests in this country. Much needed health reform will increase coverage for all but will also place an emphasis on outcomes based compensation. Therefore, we need to build interdisciplinary interactions between lab staff, pathologists, and other healthcare providers to work on common goals, and work together to perform the “right test, for the right person, at the right time”. We just have to work smarter, not harder. Our challenge as residents is to not bury our heads in our books or go through the motions, but to see the “bigger picture.”
During PGY-1, my effort was mostly focused on navigating and finding where I fit into the system that is known as residency. Having not been the most clinically oriented medical student and unfamiliar with gathering patient info from electronic medical records (we had paper charts during medical school), I initially found the task of working up a patient difficult. I was often so focused on not missing an important detail that I missed the forest and only saw the trees. But in clinical medicine, it’s most important to discern what the most relevant facts are and integrate them quickly to uncover the big picture.
Being a resident is not like being a student and we eventually have to outgrow these growing pains or get left behind. It’s no longer a situation where the consequence of not doing well only impacts oneself. The stakes are higher because patient safety is involved. I know friends who were let go from their programs, not because they were not hard working, but because they could not adapt, multi-task, and keep up the required pace.
As pathology residents, we do not often see patients and it is easy to become disconnected from them.
What really refined my outlook was when I began to interact more with the lab technicians during my hematopathology rotation. They identified patients with concerning peripheral blood smears and often asked follow-up questions to find out what happened to that particular patient. Even though they could not access medical records, they still wanted to know how that particular patient fared, even though they scanned many other patients’ smears that day. I find the same with the technicians on my current molecular pathology rotation and I look forward to these interactions each day.
As pathology residents, we do not often see patients and it is easy to become disconnected from them. The many hours grossing, putting together tumor boards and morbidity and mortality presentations, and following up on critical values and inappropriately ordered tests can leave us jaded. I find that I follow up on patients more now even after the case is signed out. I credit working more closely with our technicians for my rejuvenated interest in patients as more than a case number. So, my advice to residents out there is to interact with and learn as much as you can from your technical staff because they really do have much to offer if asked.
I’ll be at the ASCP Annual Meeting this week to present a poster and receive a resident leadership award, so next blog post, I’ll let you know how it turned out!
People assume that I chose pathology because I didn’t like patients but this couldn’t be further from the truth. During medical school, I was a Schweitzer Fellow and volunteered at two free health clinics in the Philadelphia Asian community where I helped start hepatitis B screening and vaccination programs in populations with a high prevalence of this disease. I also served as the student director of my school’s migrant farm worker health clinic where we provided screenings and care to farm workers every summer. In fact, I often was asked to speak with patients because I could convince reluctant patients to comply with care.
But this doesn’t mean that I was the best medical student on the wards or in the clinics; in fact, far from it. Now that I look back, I was often too stressed to quickly triage what was most important to do clinically. But being a trained critical thinker, I could often reason out the answers. A couple of my residents thought that I wasn’t made for clinical medicine because I thought things out in a different way than most.
For an artistic and introspective person like me, I found my home in pathology. I need work that visually stimulates me and provides variety, challenges, and most importantly, enough time to take a breath, gather my facts, and think things through. Sometimes, even my physician friends joke that we are introverts who don’t like patients. They think that we sit at microscopes all day, can’t write prescriptions, make diagnoses in isolation, and prefer to release reports with the words “recommend clinical correlation” so that other doctors can provide the actual care. All of these things are so untrue.
On my molecular pathology rotation, I was reminded how the pathologist and the clinical lab are integral to the complete clinical care of the patient. A transplant patient on anti-CMV prophylaxis was admitted for diarrhea. His labs were positive for both C.difficile and a very high CMV viral load. He was given antibiotics and an increased anti-CMV medication dosage before being subsequently discharged. He was again admitted a few days later with worsening diarrhea despite medication compliance. He was again C.difficile positive and his CMV load was now three times higher than his previous result. He was put on IV gancyclovir and a repeat CMV load ordered to assess therapeutic response before discharge with a prescription for the same dosage of valgancyclovir he was given on his previous recent admission.
Our techs always compare abnormal results with previous values, so my attending and I were notified of the elevated CMV viral loads. The techs in my facility cannot access patient medical records so I was responsible to work up this case. I’m often amazed at how often they pick up a serious issue even without access to clinical records– more than just looking at the number, they know that something is not quite right.
I noted that the patient had been on valgancyclovir with dosage increases for CMV prophylaxis since discharge from his transplant. His CMV load was previously undetectable prior to the recent admissions. I called the transplant surgeon and suggested CMV resistance genotyping based on the clinical history and blood was sent that day. As the experts in diagnostic medicine, we can impact clinical care even when we don’t physically examine the patient. We must serve as the bridge between the clinical lab and primary physician – both informing them of available diagnostics as well as suggesting appropriate tests – because care is more than just the numbers.
As a pathology resident that is just barely into the start of my second year, I’m often amazed at how my perspectives about the profession, the training, and my role within this system have changed. My program has four hospitals through which we rotate: an urban academic center, a VA hospital, and two community hospitals. During PGY-1, the six of us residents remained entirely at the academic center with one month of hematopathology at the VA. For the first three months, we were on an “intro to surgical pathology” rotation together before we were separated to various clinical or anatomic pathology rotations.
No program is perfect, but one of the assets of the surgical pathology department at our main academic center was the active hands-on effort our pathology assistants and fellows made to help us learn to gross and manage our time. Our attending physicians, if asked, also would come to the gross room to explain how and why we should gross their specimens in a specific manner. They were also very open to feedback and incorporated our comments into refining the two week orientation “boot camp” that is given every year to new PGY-1’s. Without being overbearing, they allowed us to progress at our own pace and constantly nudged us to improve in areas where we were weak, because as a PGY-2’s at the VA and community hospitals, we would be on our own. I would hear them say this over and over but didn’t really internalize the true impact of their words until the end of my first year.
During PGY-1, I was able to attend multiple conferences where I met other residents who told me about how surgical pathology was taught at their institutions. Of course, I had appreciated and recognized the extra time our PAs, fellows, and attendings had put into our learning then but now a year later, I truly understand how lucky I was to have them because not all residents were as fortunate. The interactions that staff has with residents can have a lasting impression on what type of pathologists we become, so I’d like to start my inaugural blog with a simple “thank you.”