Pathologist and Pathologist-in-Training Engagement as Patient Advocates

I’m used to being surrounded by people who are passionate about transforming systems. I’ve spent many years involved in organizing grassroots movements, health advocacy, and health equity campaigns in the minority and immigrant communities. And the year before I started residency, I studied for a masters degree in public health where I focused on these same issues,  along with more scientific training in molecular and infectious disease epidemiology. But as a resident, I have had to make some tough choices.

Even though I am back in Chicago where I attended college and first got involved working with minority and immigrant health issues, my community organizing, for now, will take a back seat to my education and service duties. And even though I sometimes reminisce about and miss the electrifying momentum involved in pushing toward such social change, I know that once I’m finished my training that I can return to contributing to these movements again on a more personal level. So I’m fine with the decisions I’ve had to make. We all have to make choices about what is most important at that specific time in our lives.

And so as a resident, I’ve focused my thoughts and efforts on how to create a movement within pathology to question our role on the clinical patient care team and to engage those in our profession to respond to this question – reasons why I got more involved with ASCP and CAP. With the gradual implementation of portions of the ACA since 2008 that is now moving into a more palpable phase, pathologists, tech staff, and residents have an opportunity to show our worth to the health care team. We have the opportunity to show that we are the experts in data interpretation and that in terms of more complicated testing such as flow cytometry, cytogenetics, or molecular tests, that the pathologist would be the best person to order the most appropriate tests.

No one knows better that we do what are the costs, indications, and limits of specific tests and despite what non-pathologists may think, we were trained just as they were in how to work up a patient and differential diagnosis. So who better to choose the right test for the right patient at the right time? I know that pathologists have the reputation of being not the most vocal or interactive doctors so how do we engage not just our leaders but also pathologists in general to take more ownership of patient care decisions and to speak up? How do we train our next generation to also see this as the big picture?

In grassroots organizing, strategy requires an understanding of the power dynamics and forces involved in decision making within the system one wants to change. So what drives pathologists and pathologists-in-training and how do we light a fire within our profession not to waste this opportunity that has been provided by health care reform to redefine our role within the patient care team? How do we nurture true patient advocates? I’ve been a little frustrated with these thoughts lately so please leave a comment with suggestions on how you think that we can accomplish these goals.

 

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.

Acknowledging and Transforming Pathology Stereotypes

I find that in interactions with other specialties, even attending physicians who far surpass me in age, that many have very little idea of what pathologists do. Those who do not work closely with pathologists are the first to mention CSI, forensics, autopsies, and an office in a windowless basement morgue. In fact, I recently heard the story that when a group of attendings and residents from another specialty along with their medical students were told to meet a pathologist for a teaching session in the anatomic pathology department…that they waited outside the locked morgue door before realizing that no one was there and that the morgue was not probably not the intended meeting location.

And for those who work more closely with pathologists, there exists a spectrum of attitudes and perceptions about our profession. We have surgeons who were trained “old school” style with six months of surgical pathology during residency who will sit at the multi-headed scope during intra-operative consultations and who know more than beginning junior residents. Hematology/oncology physicians often stop by hematopathology to look over slides together or to discuss a case. And then there are those who think that pathologists exist to provide them only with diagnoses and who do not look at us as equal members of the patient care team. I’ve heard some even question a diagnosis without ever seeing the slide and others grumble or joke that pathologists take too long to render diagnoses.

I’ve more than a few times had to call attendings, residents, or fellows to recommend canceling an inappropriately ordered test or less commonly, to suggest ordering an indicated one. I found that this more often occurs when there is not a strong differential of diagnoses. Even so, I still have the person on the other end of the line bellowing at me that they just MUST have this expensive molecular test ASAP.

Recently, a medical student who is interested in pathology told me that some residents from a non-pathology rotation harassed and made fun of this student for choosing pathology as their future career. I could continue with more examples but instead I ask this question, “Why is pathology as a field not valued?” especially with respect to specialties like surgery where there is a heavy reliance on pathologists to provide them with diagnoses?

I believe part of the reason lies in lack of exposure to the practical and daily aspects of pathology as a legitimate medical field during medical school. Furthermore, those who chose pathology as a career are often not personality types who proactively engage in promoting or advocating on behalf of the profession, especially at the state and federal levels. We also subconsciously contribute to this issue. For example, we often refer to all non-pathologists as “clinicians” as if there is a difference between these types of doctors and pathologists even though we all completed four years of medical school.

So, what are other reasons do you think contribute to the undervaluing of pathology as a profession, and more importantly, what can we do to change these stereotypes and misconceptions? Let me know by leaving a comment.

-Betty Chung

It can be hard to find “fun” pathology sites–you know, the ones that talk about pathology in a way that makes it fun to learn. Pathology Student is one. It’s written by Dr. Kristine Krafts, Assistant Professor with the Department of Pathology at the University of Minnesota School of Medicine. She features short case studies and answers to the questions that some pathology students might find confusing. Clinical laboratory scientists will find the content interesting even though this blog isn’t tailored strictly for them.

If you check it out and like it, let her know Lablogatory sent you!

-Kelly Swails

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

 

“Light Bulb” Moments During Residency

After four months on CP rotations, I am now on a 2-month surgical pathology rotation at the VA hospital where we have a 2-day grossing schedule. While it is not as busy as the two community hospitals I will rotate in surgical pathology at in 2014, the time away from anatomic pathology brings some trepidation as I feel I’ve lost some expertise in this area. Use it or lose it. But again, it helps to have a great support staff that makes life easier by helping me out and providing me with daily laughs to make the day go by faster and almost feel like I’m not at work

While I remember being stressed when I started my 3-month “intro to surgical pathology” rotation last year as a PGY-1, a lot has changed in a short year. Last year, I felt as if there was so much that I did not know but eventually a time came, without my even realizing it, when I got most of my diagnoses correct. Clinical pathology rotations were inherently easier for me due to my research and grad school background and my comfort level in the lab setting. But since I am in an AP/CP track, its important to maintain perspective as well as skills in both disciplines.

To accomplish these goals, I approach service duties on each rotation with the same diligence. I don’t play favorites even with those rotations that I find easier, more comfortable, or more likely to be my future choice of subspecialty. There is always something I can learn and I give each rotation and every patient that same respect. Next, I learn by performing my duties with as close to the same responsibility level as my attending as I can. I find that I learn more by “doing” than by just studying. This is especially true if I interact with all members through the clinical care process – from technicians to attendings to primary care physicians and other subspecialists, not just to deliver diagnoses but to help influence healthcare decisions. This was especially true on my lab medicine rotations. But I understand that this learning style may not be the same for others.

For whatever reason, PGY-2 feels as if it has flown by more quickly, probably because I have more responsibilities and also cover night/weekend calls. But whatever what advice I or another senior gives their junior, people will only listen when they are ready to hear and have their “light bulb” moment. I know it took me a while to understand the significance of much of what I was told last year…Are you ready for your “light bulb” moment?

I will leave tomorrow to attend CAP HOD and to present a poster at the CAP conference (where I probably won’t get to visit Disneyworld). I’ll let you know how it goes in my blog post next week!

-Betty Chung

 

How My Interactions with Lab Staff Refined My Perspective

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!

-Betty Chung

How We Can Make a Clinical Difference Despite Not Seeing Patients

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.

-Betty Chung