Routine Pap Smear from a 33 Year Old Woman

You are reviewing a routine Papanicoloaou smear from a 33 year-old female. She has no complaints and appears healthy. A representative field from her Pap smear is shown here. What organism is the most likely cause of the morphologic changes seen here?

pap1

  1. Chlamydia trachomatis
  2. Human papillomavirus
  3. Trichomonas vaginalis
  4. Leptothrix
  5. Gardnerella vaginalis

 

 

The diagnosis in this case is Chlamydial infection. Genital infection by Chlamydia trachomatis is the most common sexually transmitted disease in the world. In women, chlamydial infection of the cervix is frequently asymptomatic, as it was in this patient. If untreated, however, the infection can lead to pelvic inflammatory disease, infertility and ectopic pregnancy.

Chlamydia trachomatis is a tiny, gram-negative bacterium that exists in two different forms: the elementary body, which is the infectious form, and the reticulate body, which is the replicative form. While Chlamydial organisms are too small to be visible with a gram stain, large, glassy inclusions containing both reticulate bodies and elementary bodies are occasionally clearly visible within cells, as seen in the squamous epithelial cells in this image (see arrows).

pap2

 

Krafts

-Kristine Krafts, MD, is an Assistant Professor of Pathology at the University of Minnesota School of Medicine and School of Dentistry and the founder of the educational website Pathology Student.

The Value of Electives (Both Internal and External) During Pathology Residency

It’s been a while since my last blog. I haven’t had as much time and energy as I would like this past year. For now, I’ll just say…appreciate all that your chief residents do because much more time and effort lies beneath the surface than everyone is able to see.

But the topic for this blog is the value of electives during pathology residency. Our programs vary with respect to electives in terms of number and ability to take them externally or not. My previous program had five electives that could be taken internally or externally. However, external electives did not receive salary support and I didn’t take any electives although I could’ve during my two years in Chicago. Since we had a decent number of electives, many residents scheduled them internally during fourth year to have lighter months to study for boards although a handful did utilize them during earlier years for external electives.

My current program has two and we do receive salary support with external electives. For my first, I had an extra month of hematopathology internally because I wanted to see another perspective on one of my chosen subspecialties. Internal electives are good to spend more focused time in an area of subspecialty interest that you may have for fellowship. It also allows for the opportunity to develop deeper relationships with the faculty who will most likely be writing your letters of recommendation for that fellowship. They may also provide you with the opportunity to become more involved in research and/or publications (eg – book chapters, case reports, research articles) with a mentor and these are all helpful in enhancing your fellowship and future job applications and build up your CV.

Currently, I’m on an external elective at the institution where I’ll do both my hematopathology and molecular genetic fellowships. I’m laying the groundwork for molecular hematopathology research now that hopefully results in data analysis over the ensuing months to culminate in an abstract submission for the American Society of Hematology (ASH) which has a deadline only a month after I start fellowship. I also want to use this time away to get to know people at my future program better, prepare for my eventual move here, and study for boards. Hopefully, I’ll also get a sense of the daily work flow as I am also attending signouts and intra- and interdepartmental conferences so that I can manage my time as efficiently as I can from day 1 of fellowship. I really like the culture and people here, but that’s subject matter for a future blog. I also am enjoying the benefits of attending inter-program activities as TMC is the largest medical center in the world with active interaction and collaboration between member hospitals. Not so much in my case since I obtained both my consecutive fellowships last year as a PGY-3, but for many, the value of an early external elective is that it can be seen it as an “audition” rotation to obtain a desired fellowship. You may even be able to ask for an interview before you finish (which saves you time and money). I also have some friends who were offered fellowship spots at the end of their elective rotation because they impressed the fellowship director. Obtaining fellowship positions is pretty competitive and there tends to be fewer spots than there are for residency. And in many cases, positions are not even available if an internal candidate is chosen early (even during their PGY-1) so anything to augment your fellowship application is a plus.

Now that I’ve mentioned external electives, I’d like to give some advice on setting up an external elective. First, start as EARLY as possible! Even a year or more before isn’t too early to ask about getting the ball rolling. Start preparing and updating your CV from your PGY-1 as you’ll need this for both external elective and fellowship applications. Scan and keep a PDF of all your vaccinations and work-related health requirements (eg – PPD/Quantiferon results, flu vaccine, hepatitis B testing, MMR and hepatitis B antibody titers, and N-95 fit testing) as well because its likely you’ll also have to include this in your external elective application.

I initiated the elective rotation request about a half year prior to the actual rotation. And even then, that was not early enough and everything came down to the wire. It’s far more complicated than when we applied for elective rotations as a medical student and takes much more time. Since we are now physicians, you are more than likely required to have at least a medical permit in that state to rotate and this process can take a while. Also the back-and-forth between program coordinators and the respective GME departments can appear glacial at times, and in my case, was the main cause of delay. I hit several delays at obtaining paperwork (especially between Christmas and New Year’s when many staff were off at both programs, my medical school, and the Texas Medical Board where I needed paperwork from). It can be time-consuming to have to make multiple phone calls, and often, the process cannot be completed until its antecedent step has been approved. I know residents who have had to postpone external rotations because paperwork between GME departments (eg – PLAs or malpractice agreements) were not in place in time. Maintaining constant and open communication between all parties involved is a must and sometimes easier said than done the more people that are involved.

In addition to obtaining the state medical permit (which generally requires an application fee; in my case, $135), there may be other requirements that are also time-consuming and financially expensive. You may be required to do pre-employment-type health screening (in my case, a $36 urine drug screen) at your own cost as you are not a true employee. I also had to become ACLS certified (at $120, despite being BLS certified and a former American Red Cross CPR instructor). But since I’m going to be a fellow here, I can get it reimbursed through my GME funds and would have to do it later anyways so I might as well do it now. But if you are not doing an elective at your future fellowship institution, it’s good to find out what items may incur cost in your application for your elective since you are not likely to get reimbursed and so you can decide whether those expenses are acceptable. One way to defray costs is to apply for grants such as the ASCP subspecialty grant which is administered to six residents twice a year (Jan/Aug). In fact, the next deadline is this Friday, Jan 15th! You can find more information on how to apply at http://www.ascp.org/Residents/Resident-Grants.

 

Chung

-Betty Chung, DO, MPH, MA is a fourth year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Importance of Mentors

Hello again readers. It’s been a while as I took some time off from blogging. But I hope to update you every once in a while when I can. So, I’m currently in my final year of residency and have been serving as chief since April 1st. My chief term ends before the end of the year to provide time to focus on studying for the boards (we take our boards in mid-May).

When I reminisce about residency, I can’t believe that almost four years have flown by so quickly. I remember arriving in Chicago for a 2 week boot camp we had prior to our start date on July 1st just like it was yesterday. It was nice to be back in a familiar city (The University of Chicago is my alma mater), although many things had changed in the two decades since I had last been a college student in the Windy City.

Thinking about it now, I really appreciate all the thought and hard work that my director of surgical pathology, Dr. Elizabeth Wiley, had put into organizing this boot camp to ease us into the transition to residency (and surgical pathology). We learned Rokitansky method of autopsy dissection on 3 pig blocks that she personally picked up from the butcher’s for us and later had to complete a competency exam by ourselves on a 4th pig block. We learned to cut frozen sections on various tissues from our pig blocks (and of course, had a competency exam on that as well). We learned to gross uteri and prostates on ground turkey versions (complete with chickpea leiomyomas) that she and her fellows had made for us. We had weekly online exams on histology (we had a slide scanner which I now appreciate that not everyone has one) and special didactics on surgical pathology topics we don’t see much during general sign-out (dermatopathology, neuropathology, hepatopathology, and nephropathology) in addition to the usual goings-on during a surgical pathology rotation. We eventually had online modules on surgical pathology as well. And of course, we had three months straight (I hear its five months now) of learning to gross with our awesome fellows. I now appreciate more deeply just how innovative and dedicated Dr. Wiley was to our surgical pathology education. And even though I ultimately chose to pursue fellowships in hematopathology and molecular genetic pathology, the foundation in surgical pathology that was established during that boot camp still helps and influences me now.

During my first year, I was also fortunate to have hematopathology at Jesse Brown VA Medical Center with Dr. John Kennedy. He is a hematopathologist who was trained as a morphologist before the heavy reliance on flow cytometry and IHC. And he taught me to love the morphology of blood cells especially with respect to lymphomas. I had enjoyed my hematology sub-I at the NIH when I was a medical student but had originally entered residency thinking that I’d pursue molecular genetic pathology and clinical microbiology. But a great mentor can really open your mind to a different path and that is what Dr. Kennedy did for me. The second time I rotated with him, he was away for much of the rotation. But I loved the opportunity that I was given to take care of the hematopathology service in his absence. I looked at all the daily cases and performed path reviews and counts on peripheral blood smears and body fluids and the surgical pathology attending at the end of the day would review and sign-out my work. This experience of graduated responsibility helped me to decide to pursue hematopathology and it was nice to have someone believe in me and my abilities. I was also fortunate that I was in a city where the Lymphoma Foundation also held quarterly inter-program Lymphoma Rounds which I was able to attend.

So my advice is to identify mentors early on in your residency. You may not be able to see the ripple effect they have on your life until later on but I promise that they will touch your lives in an indelible manner that will help shape the pathologist you will become later on in life.

This week I’m at the ASCP Annual Meeting and will write about those experiences in a future blog, but for now, I’d like to take this opportunity to personally thank my mentors. I hope that I take your lessons and make you proud as a future physician-scientist with a public health (molecular epidemiology aka biomarker discovery which was one of my areas of specialization during my MPH) focus. You have touched my life in ways that I may not always be able to articulate but do acknowledge and appreciate.

 

Chung

-Betty Chung, DO, MPH, MA is a fourth year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Importance of Time Management and Benefits Outside of Residency Training

So I was recently in beautiful Miami for the ASCP Leadership Forum as the resident representative on their Commission on Science, Technology, and Policy (CSTP). While I can’t talk about the specific details of our work, I’d like to take this time to elaborate on some benefits of working within organized medicine for residents and on the realizations that it has brought me concerning the importance of time management.

As residents, it’s difficult to see the “big picture” sometimes because residency training feels like a journey with multiple landmarks we must pass in order to reach a destination far into the future. But I’ve found that my work in organized medicine has always expanded my peripheral vision. In these roles, I have increased my exposure by meeting residents and attendings from other programs – I’ve been able to hear how training differs between their experiences and mine. And this provides me with a context in which to view both the strengths and weaknesses of my previous and current training. And as a chief resident, these experiences have provided me with invaluable insight that allows me to come up with creative solutions to improve both myself and my program. Of course, organized medicine also has provided me with a myriad of benefits from networking.

But participating in extracurricular activities, and in particular, organized medicine efforts as well as union efforts (as one of my hospital’s five CIR/SEIU delegates), takes a lot of time and as expected, time management. In terms of long term time management, I would say that the many leadership positions I have held have helped me to plan out tasks and to meet deadlines. And so as a first year resident, after my first three months or surgical pathology, I was surprised to see “needs to improve time management skills” on my evaluation. And even though I improved on subsequent rotations, I think it has taken me until now as a third year and as a chief to truly understand what that comment meant.

My time management is fine when planning long term goals and overseeing the tasks of those I supervise – skills I honed while participating in organized medicine for many years. But what my first evaluation as a resident was pointing out was that I had trouble initially managing my time in terms of my DAILY service duties (ie – very short term goals). Despite rotating in pathology as a medical student, as a neophyte first year, I didn’t truly understood the scope of what pathologists really did day in and day out, and more importantly, the workflow to achieve these goals. And each year, my skills have improved and shaped my outlook about what is required to be a good, patient and public health centered pathologist. But as a chief now, my view has again been further refined in this regard.

When I interviewed for fellowships, the #1 attribute that programs mentioned as important in a fellow was great time management skills. #2 was being a good team player. My yearly residency training and leadership roles in organized medicine have both hopefully nurtured those two desirable characteristics. But I guess we’ll see when I start my first fellowship in July 2016. Don’t forget to include in your planning time to relax, eat and exercise, sleep well, and set aside one day each weekend to do some casual training-related work such as reading on your current rotation topic.

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Importance of Truly Internalizing Feedback and Learning From It

Recently, I’ve felt a shift in the timeline. Part of this I can attribute to having less time to myself as I ease into chief resident duties. Time I would’ve spent doing (or postponing) other activities is now relegated to this new role. But this increased demand on my time is not the only factor. Time feels like it is more rapidly passing with each year of residency, and more accelerated as of late.

Taking the annual RISE this time of year also contributes to this. I’m reminded that I should have reached some invisible bar on the meter stick in terms of my knowledge base and hope that I am commensurate with where I should be at this point in my residency. Because sooner than I may feel comfortable with, I will be expected to be “competent” enough to serve as a junior attending during my fellowships. And even though I’ve put it off until a later date, I know that I should also start composing a study plan soon for my boards because time is short between now and graduation.

Lately, probably because it was my most recent rotation, I’m reminded of my surgpath fellows during my PGY-1 telling me that I would learn the most from my cases, both AP and CP. Even though I was listening, I don’t think that I quite understood the depth of those words until my third year. During residency, we often don’t have much time to think because our service duties occupy much of that time. And the desire and need for sleep occupies much of the remainder of the time. But the light bulb moment has gone off so to speak in terms of what they meant by “learning from my cases” – be deliberate and start early.

For much of my first two years, as I’ve previously written, I’ve had a love/hate relationship with surgpath. Maybe those words are too strong, because I neither loved nor hated it, more like was ambivalent toward it. I naturally gravitated toward those subspecialties (obviously not surgpath) that I felt more comfortable with because of my previous training and interests – we all do.

But now I find that grossing is more meaningful and less of a chore to get through for me because I truly understand now how important it is that I do it well – be able to identify the important lesions and sections (90-95% of the diagnosis is off the gross, after all), cut thin and deliberate sections that look like “sushi” as one resident described my grossing, and understand how the sections I provide contribute to staging in the case of cancers. I understand these aspects better now because my grossing skill was called into question during my 2nd year. Since then, I’ve put a good amount of effort into correcting any deficiencies. Even the rotation director who originally brought up this issue, joked about the disasters of my first day on surgpath at his hospital at every end-of-the-rotation evaluation I had since then. His method of feedback may have been dramatic at the time but he really did provide me with a defining moment that changed my outlook and approach and for that I am grateful.

But it’s necessary to be deliberate and start early whatever rotation you’re on. Even though I read about the diagnoses for most of my big resection cases or at least did a quick pathology outlines search each time, I really wish that I would’ve spent even more time really reading up on those cases besides the cursory skim to come up with a diagnosis earlier in my residency. These days, I try to read a little every day, whether it be from a textbook or a journal article. And I’ve found that my knowledge, understanding, and skills improve at a faster rate. But I do wish that I had started this process from my PGY-1 so that I wouldn’t feel like I’m behind where I should be in terms of being ready for boards…so that I didn’t feel like I’m going to have to cram like I used to during college and med school for boards or wonder how to retain info that I learned two years ago on a rotation I haven’t had since PGY-1.

So really listen to the feedback from those more experienced then you. It probably took them longer than they would’ve liked to get to that light bulb moment. That is probably why they are making it a point to bring up that pearl of wisdom to you that they should’ve and wished they could’ve known then.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Passing of the Gauntlet

Time passes in cycles. And the time has come for the passing of the gauntlet. Two weeks ago, anxious and eager fourth year medical students found out what their fates would be in terms of internship or residency (in the case of pathology, where we don’t do an intern year) for the coming year. Those of us who are newly appointed chief residents either have already transitioned or are starting our terms soon. And as chief resident, I’ve made that last connection to loop in the new and been in contact with our incoming first years and new CP only senior.

Two weeks ago in Boston at our ASCP Resident Council meeting, I listened to a presentation by the CEO of USCAP and a resident working with him and ASCP on the development of our resident engagement strategy. It was a thoughtful presentation and I wondered to myself as the resident presented his experiences with engagement entitled “From the View of a Chief Resident” whether there would have been any difference in how he felt whether he had been chief resident or not. And I can’t say that I know the answer yet to that question.

I’ve always been pretty proactive and I can be mad vocal sometimes, especially when it comes to ethical, policy, and health equity issues that I feel affect marginalized populations that often don’t have a voice. I’ve spent decades organizing and advocating for health equity for the minority and immigrant communities so I’m quite passionate about improving health for these populations. Part of my MPH study was dedicated to this. And I went to medical school after spending significant time in biomedical research so I am much older than the average resident. So I’m not always sure if I see things differently because of those things about me or that I would’ve anyway despite them.

But the gauntlet has been passed. My two co-chiefs this past year were great. They were organized and dealt with much more than was perceptible to the eye. Since our program is small, they so did much more than make our schedules and sign off on our leave of absence forms – they were masters of conflict resolution. They had many additional meetings in addition to their rotation duties. They were responsible for teaching and guiding the first years in grossing and through their first year of residency and for solving the frequent quality improvement issues that would come up between technical staff and house staff and between our residents and our distant off-site hospital that we also rotate at.

So, I guess as a chief resident, I might see things differently, or have no choice but to. I’ve never been the best about being early but I know that I need to be a role model now. So even though it’ll be tough for me, I’m going to have to do things that I normally wouldn’t do. My schedule will need to be more conducive to this new role – like I will have surgpath in July so that I can train the PGY1 in grossing. And since I signed contracts for two consecutive fellowships last year, I won’t need to dedicate any of my PGY4 to interviewing and should have more time to mentor the PGY1. Chiefs set the tone for resident culture which can be especially important for incoming PGY1.

I’m not sure if my thinking will magically change. And because I have no co-chief, I can see that my life will change drastically in terms of what I take into consideration when I make decisions since I will have more responsibilities that will demand my time.

Regardless, it does seem like we’ve passed a moment. The PGY4 are now focused on studying for their boards since they’ve passed on their chief duties. The PGY2 are starting to think about fellowship interviews and setting up audition rotations. And the PGY1 are now starting to feel less like the newbies and more comfortable in their residency duties and rotations. One thing is certain, time does keep on moving.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

 

Advantages of Resident Engagement: BE PROACTIVE AND GET INVOLVED!

So, I was recently in Boston at the start of the USCAP Annual Meeting in the midst of our American Society for Clinical Pathology (ASCP) Resident Council meeting and we were talking about a topic close to my heart, that of resident engagement. As I’ve mentioned before, one of the greatest benefits of becoming a resident member (often for free as a resident) of organized pathology organizations are the opportunities for engagement. So, what do I mean by engagement?

Pathology is a small world. And in the past, we’ve been stereotyped as likely to be the more introverted out of our physician counterparts. And there may be some truth to that stereotype. But I’ve always been pretty involved and vocal since my high school days when I worked with grassroots organizing groups in the minority and immigrant communities in Chicago. Even now as a resident I’m involved as one of the five elected (and only non-primary care specialty) delegates for my hospital’s resident union, the Committee of Interns and Residents (CIR) which is affiliated with the Service Employees International Union (SEIU).

I had originally contacted our CIR/SEIU contract organizer because I was one of the many residents who paid my parking fee early and before they realized that the parking office was overcharging at the non-resident rate. Within this conversation, I had mentioned that I knew three key members of CIR/SEIU who are still active in the organization now from when I was the American Medical Student Association’s (AMSA) Race, Ethnicity, and Culture in Health (REACH) national chair in charge of AMSA’s immigrant and minority health equity campaigns and education during medical school. We even held one of our Health Equity Leadership Institute where participants came from as far as France to attend, at the CIR/SEIU office in NYC when we organized it during medical school.

Fast forward a few conversations later and I had agreed to have my name on the delegate election ballot since they were a delegate and two alternates short. We didn’t have speeches or bios, only our house staff pictures. I was stuck grossing during elections and didn’t even get to vote nor did I tell my co-residents to go vote. But despite four write-in candidates, I was surprised to learn that I had been elected. And when I asked the contract organizer how this happened she said that residents from other departments said they knew me because I had been helpful to them – either when they came to the pathology department because they needed help with an issue or when I took extra time to answer their questions after a tumor board or presentation. My point is, even when we’re not trying, the impressions we can leave on others can have an unexpected, indelible impact.

What’s even more powerful is the next step – that of joining your voice together with others to make a stronger collective voice for our profession. I cannot quantitate what I’ve received in return when I chose to become engaged, and not with a Machiavellian “ends justify the means” mentality where I do something or manipulate people to receive a gain. I don’t believe in that. But the wonderful surprises of seeing work (especially in health policy) that I’ve either participated in or supported becoming a reality, the totally unexpected relationships I’ve developed where pathology leaders saw something in me that they thought to invest in by thinking of and providing me with opportunities (eg – fellowships, work on publications, etc), and relationships with other residents that I met either through ASCP, CAP, or this very blog. I’ve kept in touch with those of you through email, social media, and texts and I appreciate that you privilege me by asking my opinions on CVs, fellowship applications, etc. Thank you and I hope that I was helpful.

These are the types of non-quantifiable benefits I’ve experienced by being more engaged. Of course, there is the satisfaction of contributing not to just a collective voice but also to a larger work to impact our profession (most of my focus has been in the realm of graduate medical education). Life seems fuller when I am involved. Our ASCP Resident Council, for instance, will have a number of members graduated and spots to fill in the next coming months so make sure that your program’s ASCP Resident Representative keeps you updated as to the application deadline. We also have a resident representative on many of ASCP’s commissions and committee where you can represent the resident voice (and your travel costs are all paid for if you can get the time off to attend meetings). So please feel free to email me at chungbm@rwjms.rutgers.edu if you want to get more involved and I’ll get your info to the correct people.

We’ve already planned the sessions for 2015 ASCP Annual Meeting in Long Beach – don’t forget to register early at http://ascp.org/2015-Annual-Meeting/index.html – and it’ll be around Halloween so I promise it will be fun! And it will be in conjunction with the Society of Hematopathology and European Association for Hematopathology (http://www.sh-eahp.org/meetings/details/19-SH-EAHP%202015%20Workshop) at the Long Beach Convention Center for those hemepath people like me =) …but if you want to help go through abstracts and chose session speakers for the 2016 Annual Meeting in Las Vegas (Sin City baby!), then email me and indicate if you have an area of interest and I’ll pass along your info. If you’d like to blog for the Lablogatory, also let me know. We are working to get more residents engaged in ASCP and I promise that we are in the planning stages now to provide more resident focused time (on top of the subspecialty sessions and mini-boards course sessions) during our Annual Meeting in Long Beach. We want to provide a physical space for those of you who are resident reps to come together to not only be recognized but also to talk together about issues important to us…so stay tuned! And let me know if you have any ideas for a resident rep session at the Annual Meeting or would like to become more involved with ASCP in any way!

Positive change takes time and persistence. Don’t just complain but get involved in a collective to bring about the change you want to see.

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.