All I Really Need to Know I Learned in Residency

If you are old as I am (I was a non-traditional medical student), then you might remember a book called All I Really Need to Know I Learned in Kindergarten that remained on the NYT Bestseller List for an impressive two years back in the 80s. It was full of aphorisms of how a simpler perspective might prove to be a better and/or happier way to live. So, I’ve been wondering all week while frantically trying to get my USCAP poster done before the rush fee deadline goes into effect (I guess I never learn)…do we really learn everything we need to know to be good pathologists during residency?

Training programs are variable – some make you work for it while others, not so much. But in the end, the day after graduation, we are all expected to be full-fledged competent pathologists…as if, in those magical 24 hours, we have all become smarter, have mastered our inefficiencies and time management issues, and are suddenly better than we were a short time before.  But honestly, since you probably spent that last day not in pathology mode, the only thing that we can be sure of is that you are 24 hours older. Despite the differences in our training, the majority of us will go on to pass our boards, and scary thought, practice the day after we graduate (although that might mean postponement until after fellowship).

Residents are also variable in terms of how and what they learn. I admit that I never expect to be the best at surgpath, especially grossing. But I do keep trying and hope that I don’t hurt patients in the process. I hope to at least survive until I’m done with surgpath for good. And I know regardless, it will still help me whether I decide to go into molecular pathology or hematopathology or a combination of both. I do know that I excel on my most of my CP rotations. But what do we need to do to learn and improve on our deficiencies and move past our comfort zones? For me, I’m comfortable in the lab since I went to graduate school, originally was a dual degree medical student, and had a decade of research experience prior to medical school but I’d love to hear advice and stories of how residents improved their grossing skills and surgpath differentials or finally triumphed over that weakness or deficiency that kept showing up on your evaluations.

Despite where we train (even at the best programs), I’ll bet that most of us in our initial years will need to know the following, but not in any particular order:

  1. When in doubt or you don’t know, ask for help from someone you trust and respect
  2. The printed word…whether journals, textbooks, or Google…is your friend, so use it, and use it often
  3. Sticky notes or checklists really do help keep us organized
  4. There is never enough time in the day so plan and use it wisely
  5. Getting angry (at ourselves or others) really won’t help so re-direct that energy towards something positive
  6. You are never too old to learn something new
  7. If at first you don’t succeed, keep trying until you do (hopefully)
  8. Learning doesn’t stop with graduation
  9. Make time for yourself to recharge your batteries
  10. Despite everything we do, we will make mistakes, but try to learn from them so we don’t repeat them.

 

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.

MALDI-TOF podcasts

Recently Dr. Nate Ledeboer from the University of Wisconsin talked with Lab Medicine about the clinical applications of MALDI-TOF in the clinical microbiology laboratory. The first podcast discusses anaerobic identification and the second discusses the identification of mycobacteria and fungi.

If you’re interested in listening to more Lab Medicine podcasts, you can find them here and here. 

 

 

Want Some Wine With That?

The other day I read an interesting tidbit about acne bacteria found in grapevines. Propionibacterium acnes–an anaerobic gram-positive bacilli that lives on human skin and occasionally causes acne–was found in the bark and pith of grapevines in Italy. The researchers could have assumed the bacteria was a contaminant, but they didn’t. Inspired by Frank Zappa’s propensity for thinking outside the box, they delved a little deeper and realized this strain has been living on grapevines for thousands of years.

The best part? They named it Propionibacterium acnes type Zappae.

 

Swails

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

 

 

Fecal Transplants and the Laboratory Professional

Fecal transplants are used to cure patients with stubborn C. difficile infections by repopulating their colons with normal flora. (If you want a refresher, check out Lab Medicine’s podcast on fecal transplants.) Ideally, family members of such patients donate the necessary stool, but that’s not always possible. Perhaps the family member has bowel issues themselves, or maybe they have an infectious disease that can be transmitted through stool. So what’s a patient to do? Thanks to companies like OpenBiome, they can use banked stool for their procedure.

The New York Times published an article about OpenBiome. The article touches on the FDA stance on this procedure and mentions that if this procedure is restricted, there is a risk of a black market. Fecal transplants are effective, after all, and the source material is free and easy to obtain. However, like anything done in the metaphorical back alley, there could be serious consequences (disease transmission comes to mind).

Fecal transplants aren’t going away, so if you work in micro they need to be on your radar. Perhaps making a fecal bank of sorts for your patients is an avenue worth exploring.

 

Swails

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

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.

Dispensaries

I know a lot of you have heard already, but for those of you who haven’t, last week CMS ruled to amend CLIA regulations that will now allow laboratories to release test results directly to patients.  Once you pick your jaw back up off the floor your mind will start processing a mile a minute what this means for individual laboratories.  If you are a supervisor/manager such as me your mind is going exponentially faster thinking of all the ways that this now makes your life more difficult.

Right off the bat as a supervisor/manager you should be thinking about producing an SOP (standard operating procedure) that details how you will handle requests and what you are and are not responsible for when it comes to providing information to patients.  You are going to need detailed information on how you will properly identify the patient, patient’s personal representative; or my personal favorite, a person designated by the patient.  I can hear the phone ringing now.

“Laboratory this is Matt, How can I help you?”

“Yes, Hello, My name is Lenny Lipase and my neighbor Pete Potassium wanted me to call in to your laboratory and get some of his lab results.”

There is most definitely going to be some individual interpretation of this new amendment and each laboratory is going to have to determine how it wants to address requests.  No matter which direction you go a solid policy/procedure for handling these new requests will be your best friend.  When you receive complaints, and you know they will come, you will have something to fall back on that states a definite policy/procedure and that meets the new standard that has been set forth by CMS.

So let us address the 800lb. gorilla in the room.  You have started taking requests for results and a patient comes to your lab, picks up the results, opens them, and then says, “Why is my glucose so high? Does eating a candy bar for breakfast affect this?”  Your worst nightmare, right?  A patient wanting counsel on results will be the biggest challenge for any laboratory and may have been a possible oversight by CMS on this ruling.  One way to nip this right off the bat is to send hard copies of results in the mail.  This assures that patients will not be wandering around your lab asking for counsel on their results.  If you decide to be brave and let patients physically pick their results, I would either have a disclaimer page with every result handed/mailed out or written very clearly in your policy/procedure stating that patients only discuss their results with their physician.  You must protect yourself from liability when it comes to discussing results with patients.  I felt as though the previous ruling was a laboratory professional’s layer of protection against this.  We could not directly give patients results so it forced them to speak with their physicians.

I have read that some laboratory professionals are happy with this saying that patients should take more of the responsibility of their own healthcare.  I agree with this but I also have spoken to physicians who are not happy with this ruling because they want to go over results with their patients to properly explain what they mean.  More than likely a physician will still have to release the results first before a patient can view them but if not you may have a panicked patient calling physician offices or even worse 911.  This may seem extreme but you don’t know how patients will react seeing results they do not know anything about.  We will now be another controller of patient information that has been deregulated a bit.  It is for medical use only of course but how comfortable will you feel being a result dispensary?

 

Herasuta

Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.