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.

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.

What Are Better Ways to Learn and Retain New Pathology Concepts?

So, I’m curious…how are pathology concepts taught in your program and are these methods effective? We use multiple modalities in my program. We have mandatory core curriculum didactics three mornings each week, 2 days of AP and 1 day of CP. Additionally, we also have either cytology (lecture or multi-headed session) or hematopathology interdisciplinary conference on alternating Fridays. On some Tuesdays, we have invited guest lecturers for grand rounds. During PGY-1 while on our “intro to SP” rotations, we had additional histology, gross organ, and subspecialty didactics.

And even though, we have 4 sites, those who cannot be at the main site for lecture, teleconference in to the core lectures. So, our mornings are pretty full and it almost feels like we’re still in medical school during our clinical years with needing to balance service work with didactics. This year, they’ve tried to make the curriculum more interactive with more pre-assigned virtual slides or reading, occasional pre- and post-didactic quizzes, and a case-based rather than lecture-based structure.

And this is before all the tumor boards, morbidity and mortality, interdisciplinary specialty conferences, journal club, conferences, and CP call conferences that we make presentations that require prior research. So, sometimes, I’m amazed that in the midst of all this, that we can fit in all our service duties. We also make consistent use of our slide scanner – to create virtual re-cut sets for study, prepare presentations, and put together educational modules (at least our attendings do for this last one). And I didn’t realize until I met other residents at conferences, that heavy use of virtual slides isn’t the norm everywhere so I feel fortunate. And of course, there is sign-out (and sometimes, grossing) with the attending and learning from our fellows.

So in terms of the aforementioned, I expect that many programs teach utilizing a similar mix of modalities. But how do you learn on your own personal time? I’ve never been a student who would win an award for lecture attendance but since our “core” is mandatory, I attend most despite the fact that I don’t learn best in this way. I’m not a big textbook reader either – I have a decent number of books but can’t say I’ve finished any entirely. Having been graduate school trained initially, I’m much more of a journal article reader, which for me, as a CP-inclined resident, works well when I’m on CP rotations where I tend to excel more than I do on AP.

But what is the best way to learn on AP rotations? As an artist, I like pictures and there are some good websites (and even textbooks out there). But most days, I come home too tired to retain anything even if I could read more than for the pre-assignment for our “core”. I have to admit…I have not figured out that secret yet and would love to hear your thoughts. How best do we learn and retain pathology concepts?

-Betty Chung