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!
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!
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.
As a pathology resident that is just barely into the start of my second year, I’m often amazed at how my perspectives about the profession, the training, and my role within this system have changed. My program has four hospitals through which we rotate: an urban academic center, a VA hospital, and two community hospitals. During PGY-1, the six of us residents remained entirely at the academic center with one month of hematopathology at the VA. For the first three months, we were on an “intro to surgical pathology” rotation together before we were separated to various clinical or anatomic pathology rotations.
No program is perfect, but one of the assets of the surgical pathology department at our main academic center was the active hands-on effort our pathology assistants and fellows made to help us learn to gross and manage our time. Our attending physicians, if asked, also would come to the gross room to explain how and why we should gross their specimens in a specific manner. They were also very open to feedback and incorporated our comments into refining the two week orientation “boot camp” that is given every year to new PGY-1’s. Without being overbearing, they allowed us to progress at our own pace and constantly nudged us to improve in areas where we were weak, because as a PGY-2’s at the VA and community hospitals, we would be on our own. I would hear them say this over and over but didn’t really internalize the true impact of their words until the end of my first year.
During PGY-1, I was able to attend multiple conferences where I met other residents who told me about how surgical pathology was taught at their institutions. Of course, I had appreciated and recognized the extra time our PAs, fellows, and attendings had put into our learning then but now a year later, I truly understand how lucky I was to have them because not all residents were as fortunate. The interactions that staff has with residents can have a lasting impression on what type of pathologists we become, so I’d like to start my inaugural blog with a simple “thank you.”