The Importance of Supportive Mentorship and “Junior Attending” Experiences

Over the last few weeks I have spent more time revising my fellowship application personal statements than I would like. While my attendings have been a great source of feedback, it’s hard to know what fellowship directors would like to see highlighted. But going through this process, I have realized even more palpably than I had previously thought before, that two things have been important in bringing me to this point: supportive mentorship and “junior attending” experiences.

Let’s start with supportive mentorship and the definition of mentor. The word Mentōr derives from the Greek name of the friend of Odysseus and advisor to his son, Telemachus, in Homer’s Odyssey. Therefore, first and foremost, a mentor is an advisor: someone who is more expert and who guides you. But what I’ve found is that a professional mentor is more than a mere advisor.

I have been extremely blessed and grateful when it comes to my mentors. Not only do they advise me but they also think of me when opportunities arise such as a possible research project or publication or to be a member of their CAP lab accreditation team that inspects another institution’s lab. Besides building up my CV, these activities also help me to acquire skills that I will need in my future professional capacity. I at first didn’t necessarily think of including some of these experiences on my CV but after a talk with a fellowship director, realized that these are the types of experiences that they would like to know about – if I’ve had previous experience where I gained a skill, then they feel I will be faster to train in terms of skills that build on that initial skill.

This brings me to my second point: the importance of “junior attending” experiences. What I mean by this term is the opportunity to participate in patient care or directorship duties in as close to a capacity as your attending would have. This could mean initial sign-out without direct supervision (of course, attending review has to occur prior to true verification) in terms of patient cases, whether it be AP or CP cases, or the initial preview of a frozen section. In terms of lab management, this could mean participating in preparation for a CAP inspection or serving on a CAP inspection team that goes to another institution. And in terms of most CP rotations, serving as the primary consultant for primary physicians about lab tests and discussing evidence-based and cost-effective ordering of appropriate tests or developing, troubleshooting, or validating a new assay.

Whatever the attending does in the course of their daily workload is where we should focus on acquiring skills. While writing my personal statement and CV, I talked with fellowship directors, and this became clearer to me. It’s all about having the proper attitude. Yes, there can be a lot of “scut” during our training but in comparison to other specialties (and those who have to do an intern year), we are fortunate to have less of it. Either way, the work has to get done, “scut” or not, so might as well learn from it and you might be surprised how it helps you later. Our attendings are not free from “scut” in their daily work either. If we think of the “scut” as attached to a patient who is waiting for their diagnosis, it makes the work go easier and faster in my opinion.

Having a positive attitude, working hard, and becoming known for certain qualities and skills only help in terms of developing strong relationships with mentors (who will one day be your colleagues) and being given those “junior attending” opportunities. Strive to be the first person they think of in those situations. Remember we are no longer in school and the faster you acquire the characteristics, knowledge, and skills of an attending, the better off you will be when it comes to progressing to the next phase.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

 

Ebola Information for Laboratory Professionals

While it’s unlikely you will ever encounter a case of Ebola, it’s best to be prepared. The CDC has a health advisory page full of information, including specimen requirements for Ebola testing. The laboratory’s first step is to contact their state health department.

 

 

Is Your Lab Ready to Give Results to Patients?

In February I wrote about the Department of Health and Human Services regulation that amends the Clinical Laboratory Improvement Amendments of 1988 and the Health Insurance Portability and Accountability Act of 1996 in regards to reporting of patient results. The deadline for implementation is fast approaching–9/27/2014–and so I’m curious as to how prepared laboratories are for this change.

Is your lab ready? What sort of changes have you made, if any? And do you see this as a way for pathologists and laboratory professionals to become a bigger part of the healthcare team? Or is it simply going to make everyone’s life harder?

 

Swails

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

Right Test, Right Time, Right Patient: The Age of Lab Stewardship

Last week, I attended the American Association of Clinical Chemistry (AACC) conference in Chicago. I attended molecular diagnostics talks but also talks about quality improvement, the use of “big data,” and lab stewardship. I have an interest in QI as my AACC poster presentation last year was on lab interventions to reduce lab error frequency and I am also a resident on my hospital’s performance improvement committee.

So, what exactly is “big data?” It’s a word that we are hearing more often in the media these days. It’s also a term that is increasingly being used in our healthcare systems. In 2001, analyst Doug Laney defined “big data” as the “3 V’s: volume, velocity, and variety” so that’s as good a point as any to start deconstructing its meaning.

Volume refers to the enormous amounts of data that we can now generate and record due to the blazing advancement of technology. It also implies that traditional processing matters will not suffice and that innovative methods are necessary both to store and analyze this data. Velocity refers to the ability to stream data at speeds that most likely exceed our ability to analyze it completely in real-time without developing more technically advanced processors. And finally, variety refers to the multiple formats, both structured (eg – databases) and unstructured (eg – video), in which we can obtain this data.

I’m always amazed at the ability of the human mind to envision and create something new out of the void of presumed nothingness. Technology has always outstripped our ability to harness its complete potential. And the healthcare sector has usually been slower to adopt technology than other fields such as the business sector. I remember when EMR’s were first suggested and there was a lot of resistance (in med school, not that long ago, I still used paper patient charts). But now, healthcare players feel both pressure from external policy reforms and internal culture to capture and analyze “big data” in order to make patient care more cost-effective, safe, and evidence-based. And an increasing focus and scrutiny (and even compensation) on lab stewardship is a component of this movement.

I often find myself in the role of a “lab steward” during my CP calls. The majority of my calls involve discussing with, and sometimes, educating, referring physicians about the appropriateness of tests or blood products that they ordered…and not uncommonly, being perceived as the test/blood product “police” when I need to deny an order. But lab stewardship goes both ways. And these days, the amount of learning we need to keep up with to know how to be a good lab steward is prodigious, daunting, and sometimes, seemingly impossible.

So do you believe in this age of lab stewardship that it’s the job of the pathologist to collect and analyze “big [lab] data” and to employ the results to help ordering physicians to choose the right test at the right time for the right patient? Or is it a collaborative effort with ordering physicians? With patients? How do you foresee that the future practice of medicine needs to change from standards of practice currently?

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

First-RISE

There had been talk about it for some time. We even discussed the topic during the meeting of an ASCP committee that I served on previously. It’s the First-RISE. So, all of us senior residents know the RISE but this month, ASCP administered a slightly different test that is meant to test the new PGY-1 in their baseline knowledge compared to what is required for AP/CP training. Sometime next month, they will receive their test results just as we did our RISE scores this past spring.

I know that the First-RISE is not merely giving the RISE that we all know and love/hate to the first years…and that there are some topics on there that we just don’t see on our version of the RISE. But the idea is the same – to identify areas of strength versus weakness. Programs and residents can then take this information to devise personalized study plans or lists of topic areas to focus on more intently.

For those of you who are checklist people and/or disciplined studiers who stick to their “plans”, what is the best way to study? Do you think that First-RISE will assist program directors in helping to start off their first years on the right track? Do you think that First-RISE is meaningful?

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Part of the Healthcare Team

The laboratory is often considered a separate entity from the healthcare team. We are the “black box” that provides information and so some equate us with the healthcare IT department. Instead of being isolated with our instruments and microscopes while we crank out data like a big computer, we should be an integrated member of the team and involved in patient care. Imagine the benefits to the patient if a laboratory professional were included in patient rounds. Questions such as: “Can we test for that? Is that test performed on-site? What kind of sample do they need?” would have immediate answers. Laboratory professionals could also provide guidance in test selection and differential diagnoses.

Laboratory professionals and pathologists should work toward this level of involvement. And it doesn’t need to start by leaping into the middle of someone’s rounds. It can start as simply as expanding on an answered question. For example: the transplant team requests a STAT tacrolimus level, but tacrolimus is only performed once a day by tandem MS. Asking to speak with the transplant about tacrolimus testing can actually open many doors. Not only does everyone on the team now understand how tacrolimus testing works, the session also introduces the laboratory professional to a variety of healthcare providers. These providers now have a face to put with a name and a laboratory contact to call in the future when new questions arise. This initial contact could lead to cooperative efforts on other fronts. A rope bridge has been started, and it can become a freeway. All that’s required is to recognize opportunities, and get the laboratory professionals out of the lab and into the healthcare team.

This increase in visibility could feasibly become vital to the survival of the laboratory in the future. As healthcare dollars shrink, it’s incredibly important that the public and our healthcare colleagues understand just how much of their care is predicated by information the laboratory provides. It’s our job as laboratory professionals to help them understand. The doctors of pharmacology (PharmDs) led the way with this type of paradigm shift; now it’s time for laboratory professionals to follow suit. The laboratory can become one of the many faces of medicine rather than its most hidden profession.

 

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-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Pre-July 1st Reflections

So, July 1st is fast approaching. It is that date each year when new residents officially start their employment. And for us senior residents, even though it may not be as momentous as our first, it still is the start of our next year of rotations and a great time for reflection. As I sit here amidst an apartment full of unpacked and half-packed boxes as I prepare to move cross-country to start my new residency, like many of the PGY-1’s, I’m reflecting on what I’ve learned, what I should’ve learned but haven’t yet, and the journey that is to come at my new residency.

First, I’d like to congratulate all the graduating seniors and fellows! You finally are on to the next phase, whether that means fellowship or employment. Most of you have put the dreaded beast of boards behind you and have reached a milestone that says you are assumed to be ready for practice with less supervision. Gone is the safety net of having your attending verify the cases but you are not completely on your own because you will still have more veteran physicians who can help you. I know that there is a lot of negativity, especially on the internet, about the current job market and decreasing reimbursement codes, but persevere. There are pathologists and advocacy organizations lobbying for our profession. It’s easy to become disillusioned but uncertainty about our future can also be looked at in a ‘glass half-full’ view – we can shape how that future evolves because nothing is set in stone as of yet. In my grassroots organizing experiences, I have seen the underdog aka ‘the little guy’ win but only when they believe that they can bring about change, mobilize and organize together with like-minded individuals, and fight for what they believe is right.

Next, I’d also like to congratulate the incoming PGY-1 again for surviving that beast we call med school. You should be very proud. I know you are probably moving cross-country now and excited about what is to come. There’s a lot to learn but it’s a great time for you. My guess is that most of you will start with an introductory surgical rotation, although I do have some friends who are starting with a CP rotation. Either way, you have probably started your orientation and/or ‘boot camp’ so you can get acquainted with your hospital’s medical record system, dictation system, and pathology basics. Although I know that some of you won’t get a boot camp and will start on rotation immediately after orientation. Don’t despair…every first year in your program with you is in the same boat. And even if some people start off ahead of others on the learning curve, what I’ve seen is that by the end of first year, most people are caught up and at the same place. The thing that may set others apart is more the effort that they put in once residency starts.

So, what is essential during residency, not just for newbies but for all of us? Here’s some surgpath advice that can also apply to other rotations:

  1. Comfortable footwear: I can’t stress this enough, especially on rotations where you may standing for all or most of the day. I personally like Merell’s but I know that Dansko clogs are also popular – these may be expensive and sometimes not the prettiest but oh so worth every penny when your feet are not killing you at the end of the day.
  2. Teamwork: Working long hours with high expectations where your work will impact a patient’s health can be daunting. This element really can make things easier or much harder for you. So, be observant of your peers when they are having a hard time, don’t just point out that they “are getting slammed,” offer to help (eg – gross, take pictures for a conference they need to give soon but are stuck grossing, etc) and hopefully, they will return the favor. Sharing resources with each other is also helpful. Think of the Golden Rule.
  3. Responsibility: Pathology is one of those specialties where our hours can be reasonable and we do not have overnight call or night float. It’s also one where residents can feel as if they can leave the hospital early (especially on CP rotations) and no one will notice. But your attending will notice, especially if you are on call (eg – autopsy) and you’re not there when a task does come up. Make sure that you really take ownership of your assigned tasks. People want to know that you are reliable and keep your word (implied and explicit). And be honest…people don’t like liars who say they completed a task when they haven’t.
  4. 100% commitment: There will always be a task/rotation that we are not thrilled about (eg – performing/writing up autopsies) but remember that for each task, there is a patient attached to it. Even with autopsy, there is the patient’s family. There is always someone waiting for your diagnosis so take that responsibility seriously even though we may not feel the same urgency as those in fields who take care of the patient in person. Don’t cut corners (we all know what this means and have seen residents who do this even while we were in med school). Do things right the first time and you won’t have to repeat and waste resources.
  5. Make a plan and set aside dedicated study time: It helps if you have a (mental) checklist (eg – read one chapter or half of one in Robbins/your book of choice, work on writing that publication, etc) of tasks and a consistent time that you devote to it each week (eg – every Sunday night), otherwise, it’s very easy to get distracted…and behind…and it will just get worse as more time passes until you re-commit to doing this. But if at first you don’t succeed, you can always try again until you perfect your discipline and time management. A few trusted sources that fit your learning style is better than having too many sources. The internet is great for this (but also make sure that the info you get is correct and from a trusted source).
  6. Never stop reading: In addition to studying, you need to keep up on what’s current, whether via hard copy or the internet. This will help you in your daily work and also help develop yourself as a lifelong learner.
  7. Find a good mentor and learn from them: Learn from their experience and knowledge but also develop rapport with them as these are the people who will ‘go to bat’ for you and give you recs when you apply for fellowship or a job. Be a role model and give them good things to say about you through the quality of your work and dedication. And also don’t be afraid to ask for advice or help but be humble.
  8. Get involved: Whether it’s research, the GME council, a pathology advocacy organization, or something else, participate. It will enrich your experience and also help prepare you for when you are in these types of leadership roles as an attending.
  9. Learn to tie in the clinical with the practice of pathology: Make sure you know the clinical history, radiology, and previous pathology on your patient and tie them together. Get the previous slides or lab results for your patient (eg – biopsies) and compare the diagnosis with what you are seeing now. It usually matches up but occasionally you may get a surprise. Understand what’s needed for staging and the implications (eg – surgery, radiation, amputation, etc) of our diagnoses for our patients.
  10. Double check your work and QA yourself: One of my attendings has this method and I find it useful for surgpath – “skim” your slides to get a “feel”, then look at them again more closely and fill out your diagnosis, and finally, QA yourself after you’ve written in the diagnosis to confirm and to check for anything you’ve missed.
  11. Fix well and cut good sections: I have attendings who for cancer specimens will have you prep the specimen but fix overnight (and others who say cut fresh). Believe me, the specimen cuts better if fixed well and if you cut with skill (and a fresh sharp scalpel blade) but not force, especially with friable lesions. If you cut good sections, then you get good slides.

Above all, put the patient first and stay positive!

 

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.

The Poisoner’s Handbook by Deborah Blum–Book Review

I recently read The Poisoner’s Handbook by Deborah Blum, a book about poison and forensic investigation in Jazz-age New York City. Dr. Norris and Dr. Gettler transformed death investigation from a good-old-boy coroner system to one based on science and data analysis. Blum weaves several cases into a narrative that covers several poisons used during the 1920s and ‘30s. Over time, poisoning deaths decreased due to public awareness as well as the realization that murderers were increasingly likely to get caught. Blum discusses Prohibition at length and its contribution to poisoning deaths in New York City. I found this particularly fascinating; not only were people willing to risk their lives to drink alcohol, the government tried to dissuade people from drinking by actively poisoning the supply.

Several of the reviews of this book note Blum’s lack of chemistry knowledge, and I can’t disagree. While my own knowledge base isn’t wide, even I notice a few inaccuracies (HCN isn’t a “potent” acid, for example). One must remember that Blum is a journalist, not a chemist; I tend place blame on the publisher’s fact-checker as well as the author. Because this book is about the evolution of the public perception of forensic toxicology and not just the science behind it, I could overlook the scientific stumbles.

As a laboratory professional, I loved reading about the early days of forensic science and forensic toxicology. While these professions existed in Europe well before 1920, Norris and Gettler forever changed how we treat death, murder, and justice in this country.

 

Swails

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

 

 

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.