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.

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.

Are We Cheating Ourselves Out of Our Competency?

Last October, I attended the CAP Residents Forum where I heard the President of the American Board of Pathology speak about the use of remembrances for boards studying and how it was considered cheating and a breach of the honor code. I was a bit surprised when we took a live vote via text that the majority of residents felt that the use of remembrances was not cheating. But this all goes back to the medical school culture (and maybe even before that) in which we were trained.

During my 1st year of medical school, I remember feeling that it was inequitable that some students got old exams from their assigned 2nd year “big siblings” and that others got nothing. So I did something to neutralize the playing field – before every test, I scanned the old exams I had and emailed them to the class listserv. For the few exams that I didn’t have an old exam, other classmates stepped up and scanned and emailed them out. And so we built a culture of sharing. I was very proud that my classmates did not put having a personal advantage over the concept of equity.

But unexpected and unintentional shenanigans ensued. Once a classmate emailed out what was thought to be an old exam but was later found to be a “stolen” exam as that professor purposely did not give back his exams. This required our waiting while he re-wrote parts of the exam as this was discovered only on the morning of our actual exam. And during my 1st year of PhD (I was initially DO/PhD), when my original classmates were in the midst of their 3rd year rotations, a classmate emailed some study materials they had obtained from a friend at another DO school that unbeknownst to them were remembrances from previous NBOME shelf exams.

Eventually as the year went on, my classmates began to realize that what they had were remembrances and one classmate actually stepped up and turned them into one of our deans. Since I was no longer in this class, I only heard after the fact, but our dean had called the NBOME to warn them to retire the questions in these remembrances and had also called the school from which they originated to let them know what their students had done. At that time, I was not very invested in what was unfolding as I was in the graduate school portion of my dual degree program. But I do understand the fear of others having advantages that you may not and having that thought cloud one’s thinking.

These memories flooded back into my mind as I listened to this talk at the Residents Forum and voted. I didn’t realize it then when I watched from the sidelines but do now, that the use of remembrances—whether it is considered cheating or not—is in fact cheating oneself. A Machiavellian “ends justify the means” mentality is often used to justify such actions. But in the end, what have we truly accomplished? Yes, maybe passing our boards. But what happens when we become practicing pathologists if we didn’t understand what it was that we so diligently memorized off of remembrances?

It may be slower and more difficult, but I’ve pledged to myself that I won’t take the easy road, no matter how tempting it may be (I admit I’m just as vulnerable to temptation as everyone else). I tell my M2 students when I TA their pathology small group discussion lab that if they don’t know even one word when they are reading to learn a concept…to stop immediately and look it up, even if it just means to Google. And I’ve tried to practice this as well. I still may not pick up on surgical pathology concepts (especially grossing) as quickly as I do clinical pathology concepts, but I have noticed a difference. Concepts seem to stick better in my aging brain because I have shifted how I focus my efforts. I try not to waste as much time on worrying (but I still sometimes do) that others may have an advantage over me because that is wasted effort.

Gaining competency means to take ownership and responsibility for one’s learning. Figure out how you learn best and make a plan to do it. And if you fail, keep trying until you make it. Really try to understand the mechanisms and not just memorize minutiae or facts. I find that I can figure out the answers this way if I had a solid foundation. And don’t take too many shortcuts, which invariably, remembrances may turn out to be. But I’d like to hear your take on the topic…is the use of remembrances cheating or not? And do you think that using remembrances cheats you out of obtaining competency as fast and as well as you might have gotten there without 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.

What Does Competency Mean and Does it Really Matter?

Instead of having to deal with the sub-zero cold weather in Chicago (where my car doors froze earlier in the week and I had to tug on them for over half an hour to get into the backseat of my car to turn on the heat), I was fortunate last weekend to be in the sunny and warm wine countryof Temecula (near San Diego). I was there for a CAP Council on Education meeting where I served as their junior (resident) member. Due to confidentiality agreements, I can’t divulge specific details, but it did get me to thinking about what “true competency” means and what we need to do to obtain and maintain it after we graduate.

Residency is a transition for many (especially if you didn’t take time off to work before continuing your higher education) between two different mentalities: that of school versus employment. Ideally, there shouldn’t be a large difference between how we approach school and our job but that’s not always how it goes. In medical school, if we didn’t continually study, it was just our grade that would suffer and we could study harder for the next test to average out to a decent grade. But with residency, which is now my job, when I don’t apply myself to learn everyday (and I can’t say that I’ve perfected this yet but I keep trying), it’s really my patients, and possibly future patients, who suffer the consequences.

Pathology is the “end game.” We are the regulator of most diagnostics (both on the CP and AP sides) that other physicians use to make treatment and prognostic decisions.And so, we need to train now and develop a trainee culture that nurtures life-long learning (and truly mean more than just lip-service). We need to allow residents to participate in true “practice-based” learning (not just passive learning) and to feel the punitive consequences if we ignore our responsibilities or are incompetent. I believe in second, and even third, chances. I believe that our residency programs should remediate residents who are not where they should be in a non-threatening manner. But I do also believe that there is a minimum bar that we all need to meet within a specified time frame.

I believe that we need to be good representatives of our respective programs as graduates, and more importantly, “competent” pathologists who do not hurt our patients due to lack of important knowledge that we should possess – and of course, it’d be nice not to have to worry about malpractice issues as well. Developing this mentality starts during residency – where we should study a little everyday in order to perform as much as we can– and where we can take feedback from our attendings and work to improve our areas of deficiency while we have them around to guide us.

Some pathologists on forums that I’ve visited decry maintenance of certification (MOC) and the continuing medical education (CME) and/or self-assessment modules (SAM) as money-making measures for the organizations who put together CME/SAM material. This weekend, I learned what these and many other acronyms mean. I can see their point since it often costs money to obtain CME/SAM; also, physicians do not want to think of having to take tests once they graduate med school. However, I do think that in a rapidly changing field such as pathology, not being up-to-date may have detrimental effects on patient care, so CME/SAM are necessary. We can’t always expect that everyone in our profession will be motivated to be up-to-date without some sort of “carrot stick.” It’s sad but true. So my main point, fellow residents, is that we should develop good habits now that encourage life-long learning and an attitude that shows that we put our patients first…and we’ll probably find that without even realizing it, we have worked toward gaining competency in our profession. So what do you think about the need for CME/SAM and MOC every 10 years? There’s no “grandfathering in” for any of us, so we will have to deal with this. But do you think that this is the way to go to help our maintain competency once we’ve achieved it?

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.

Engage Yourself to Transform Our Profession

It’s never too early to be an engaged pathologist-in-training. This means that we must understand our past and have a strong vision of the future we hope to shape. We must evaluate the forces that have influenced the role and perception of our profession within society, what we did or didn’t do in the past that has led us to our current status, and not only what things we would like to change but also to what do we want to change them.

Since I have an advocacy and organizing background, I may look at our profession a little differently than other residents. First, we are a small profession. The majority of medical students do not choose to become pathologists. But I believe that may be due to at least in part, to a lack of commitment to nurture our pipeline. There is no national medical student organization for those who are interested in learning more about pathology as a profession, and often the little exposure that medical students do get is not an accurate representation of what they would do during residency and ultimately, in the working world.

It’s never too early to be an engaged pathologist-in-training. This means that we must understand our past and have a strong vision of the future we hope to shape.

Secondly, we are still more discohesive (and I’m not talking about a lymphoma here) than we should be as a profession. This may partly be due to the diverse nature of our profession where AP and CP are all considered pathology. In many Asian or European countries, pathology residents must choose one track or the other; they, more times than not, do not have the option for combined AP/CP. So does this confuse or hurt us to educate our future pathologists in this manner where allegiances are often diluted? I say no, not directly. But since we do have so many subspecialties, and consequently, subspecialty organizations, many residents and pathologists who are limited in terms of time and energy have to choose and prioritize which organization to devote their efforts. Even though we have ASCP and CAP as more all-encompassing organizations, we could still have stronger solidarity and more frequent interactions between these groups.

Thirdly, from my n=1 (level 3 evidence which isn’t always worth much), most residents and attendings I see have very little interest or experience in political advocacy even though this may be the greatest avenue we have for palpable change. I have seen some committed to curricular reform. I have also seen some who promote the profession by serving on hospital and program committees as well as leadership in state and national societies. But what I don’t see much of are those who keep track of what is going on in DC and within society that affects our profession and who attempt to do something to change what they perceive as negative. We need to change our culture and encourage and train our residents to get involved early in such activities.

And last, but not least, we need to own our value as physicians. We must not allow anyone to treat as us less than a physician from another specialty. And practice makes perfect–we as residents should start early by serving on organizational committees, etc. I will be doing my part this weekend serving on the CAP Council on Education (COE). I’ll let you know how that goes.

As an aside, creating an organization to educate medical students about pathology is a pet project of mine. If you’re interested in helping to start such an organization where we can also serve as mentors to pathology residents-to-be, please feel free to email me at bchung73@uic.edu.

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.