The Importance of Continuing Medical Education, at Least in Theory…

Hello again residents. It’s the wee hours of the morning and I am in Chicago O’Hare International Airport waiting for my connecting flight to Columbus, Ohio, where I will serve as an ACCME/AMA monitor for the College of American Pathologists (CAP) at the Ohio Society of Pathologists (OSP) meeting. I wasn’t allowed on my flight because I was just beyond the cutoff time even though I had rushed out of the hospital, still in my scrubs. And so I got re-routed through Chicago and spent a couple hours at a hotel in order to sleep before catching an early flight the next day.

As the junior (trainee) member on CAP’s Council on Education (COE), I was given this opportunity to monitor this CME meeting for compliance to ACCME/AMA standards and CAP representation as a joint CME partner. I’ve served on the COE since January 2014. We have four meetings a year with two of them in Chicago. I was just approved for a second term that runs until December 2015. We oversee and approve proposed projects from all the educational committees of the CAP: publications, GME, CP education, and the curriculum committee as well as some of the educational aspects of the Annual Meeting.

Despite the airport snafus (which I’m pretty good at getting myself into), it was interesting to serve as a monitor. I met an attending from the Cleveland Clinic who I remembered from my residency interviews. I also met other residents and fellow who were in attendance. The OSP had taken great care to preclude commercial bias from their meeting. They did have a few exhibitors but they were in a separate room from the lecture sessions. I heard a very informative talk on the clinical oncology applications of next generation sequencing (NGS) as well as an engaging case-based session on dermatopathology cases.

The meeting was held in a hotel in Dublin, OH, which I strongly suspect must have Irish and German roots from the names of the town, streets, and types of restaurants (Irish pubs and German-Austrian) that are common here. The hotel restaurant which had an Irish name served a buffet of Irish food (no surprise) for the participants at a discounted rate. Overall, it was a good meeting with a good balance of germane topics covered. Having been a co-chair of a national medical conference when I was in medical school, I totally can appreciate all the pre-planning that goes on behind the scenes to organize meetings such as this. I was also able to have dinner with and catch up with a friend who is a non-pathology resident at the local Ohio State University.

I know that we, as doctors, would like to believe that once we’ve passed through the gauntlet of medical school and graduate medical education training, that we know everything that we need to know and shouldn’t necessarily have to be retested or do CME, but I believe that it only makes us better doctors if do. We should be life-long learners, especially in a technology-driven specialty such as pathology (that is, if we want to remain in control of lab testing). As a scientist in my life prior to medical school, I intimately understand how even dogmas can change (at one time, people thought that protein was the genetic material of the cell!). We can always learn something new and new disruptive technologies like NGS will always arise that will transform how we diagnose, prosnosticate, and treat our patients. We may not always see patients physically but must remain present within the process and that requires us to continue to test our knowledge base. Since I haven’t graduated yet, I don’t really have the experience to say whether the current mix of CME, SAM, and MOC requirements is the way to do it but in some form, we need regulations to help push us as a profession (not necessarily as an individual if we are self-directed and pro-active) in the right direction to be the best physicians for our patients.

 

Chung

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

 

Decisions That Will Impact the Direction of My Pathology Career

So, I’m in Midway Airport in Chicago with a 2.5 hour layover back to the East Coast from my West Coast tour of fellowship programs and interviews. I flew on 5 separate flights and interviewed at 5 programs in 4 cities in 3 states over the past week. Quite a whirlwind schedule to keep even if it wasn’t exacerbated by the fact that I’ve had a wicked flu the entire time (and still am sick as I type). But I look forward to getting at least one night’s comfortable sleep in my own bed and spending some time with my kitties before I start with my first East Coast interviews (2 in 1 day) on Monday. I’m very fortunate that my program director, program coordinator, and fellow co-residents have been supportive, especially when I’ve had to switch multiple days on-call.

On the left coast, I interviewed at 3 hematopathology and 2 molecular genetic pathology programs with overlap at one program where I interviewed for both hemepath and MGP. All of the people that I met at each program were people who I felt that I would like to become colleagues with (and who will be my colleagues in the future). But despite this fact, each program was vastly different from the other and I am reminded that these next decisions about where I’ll spend my fellowship years will probably impact the direction of my career more so than any other decision thus far. The people who will touch my life will help shape the pathologist I will be!

I thought that I had adequately prepared my list of questions that I carried around to each interview but I found that each interaction spurred additional new questions that I had not thought of prior to the interview. Many times, my interviewers had anticipated some of my questions and had answered them as we talked even before I asked. The current fellows I went to lunch with were very helpful in answering my questions and telling me about their lives within their fellowship programs. For me, the “fit” and culture of my working environment is important – finding colleagues who treat each other with respect and notice when others might be struggling and help each other out. I value a strong teamwork mentality as much as I appreciate a rigorous academic environment that will push me to be the best that I can be.

Having come from a graduate research training environment in what I might call some of my formative years, I also value an environment that spurs creativity. I enjoy being able to have open door policy discussions where we bounce ideas off each other and challenge each other in a positive manner to “think out of the box.” I know that research will be an integral part of my future career, hopefully along with hematopathology sign-out and molecular genetic lab directorship (even if it is not for the entire lab but possibly just the molecular hematopathology portion of it). The question for me is whether that research will be more basic science (which means I’d probably be committing to more like 80% research, 20% clinical in terms of my service duties) and on a K-R01 grant track as a physician scientist or will be more toward translational research where I can apply some of the knowledge and skills I gained during my graduate and MPH training. I was very flattered that at my first interview, the fellowship director told me that I could come back after my fellowships to do a post-doc with him and one of his mouse models of hematopoietic disease.

Mentorship for me is really big. I really want to find a program where the faculty take an interest in my career. I want mentors who look out for my future career and who will guide me toward opportunities that will enhance it. Mentors who will support me and make those all-so-important phone calls to help me get my first job, or better yet, offer me my first job. It is not far-fetched to think ahead that I might want to lay down roots where I complete my fellowships so that is an additional factor to consider when it comes time to make the final decisions.

Each program varied with respect to educational philosophy and resources. More so than I previously realized that they would even though I’ve been in two residency programs that I can compare. But right now, I compartmentalize everything I see and learn from each interview and just try to soak everything in like a sponge without assumptions or judgment. I’m placing those observations aside in my head until the time comes that I will need to think about them (which will probably be the end of this month or the very beginning of the next).

It has become very clear to me that being self-motivated and proactive to make opportunities for myself when they did not necessarily exist within the formal structure of my residency program has been a pivotal aspect of getting me this far in interviews. If your program does not have a resource available (eg – NGS for a MGP-minded person like me), then find one and gain access to it (eg – I will go to Rutgers for my last molecular pathology rotation to help with NGS clinical testing validation, and hopefully, a hematopathology elective rotation at an institution with a higher volume and diversity of cases than I can see at my own program)! If you are interested in a particular subspecialty, get involved in research, tumor board presentations, and sign-outs in that area (eg – look at hemepath cases on your free time or on the weekends if that’s what you like) from your first year as much as you can. Whining is not allowed nor is a quality that will help anyone so don’t waste time complaining about aspects of your programs you cannot change. Make your destiny happen rather than be a mere participant in it by accepting the status quo! Good luck to my fellow residents who are also on the interview trail! May we all find our future homes for the next phase of our careers very soon!

 

Chung

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

The Unsung Heroes

I have been very pleased to see our professional societies, such as ASCP, become truly active and engaged in bringing attention to the field of pathology, reminding our clinical colleagues that we are in no way the “Doctors-of-the-Lesser-God.” We certainly represent a valuable part of the healthcare team even if our care is provided in a more indirect than direct fashion.

Indeed, I applaud this effort, however, there seems to me to be another missing element that we pathologists, not just our professional society, should embrace. I would hope that we look to expand this to acknowledge the significant role our laboratory staff plays each day on behalf of patient care. The laboratory staff, whether certified MTs, MLTs, phlebotomists, or administrative personnel are the unsung heroes, often forgotten or neglected and without recognition for their much-needed skills and responsibilities. Our laboratory staff represents the legs upon which we stand.

Sadly enough, in my many years in private practice and subsequent consulting, it is apparent to me that pathologists often have very limited interaction with the staff outside of the Histology/Surgical Pathology suite. This is unfortunate as it limits us both professionally and personally. Some of my favorite memories and shining moments from my practice were those that involved getting to know and being a part of the lab team. There is nothing more rewarding than feeling you have learned and participated alongside these co-workers! And there is nothing sadder to me than hearing laboratory staff members say that they have not laid eyes upon a pathologist in weeks or see their physicians only if they seek them out.

Pathologists should be actively interacting with staff in all areas of the laboratory, whether Surgical or Clinical, fostering good relationships and also acting as ambassadors for these staff and their services. We should encourage our clinical colleagues to understand the importance of this group and utilize their expertise as part of the medical team. This helps us all to grow and learn via sometimes differing perspectives which work together to bring quality patient care.

So, while we are utilizing our professional society to grow our own outreach and highlight the important role of pathologists, let us not forget to include our laboratory staff members and what they bring to the table. Make every day the day to support one another and put our cumulative best efforts to quality safe laboratory practice and patient care.

Burns

-Dr. Burns was a private practice pathologist, and Medical Director for the Jewish Hospital Healthcare System in Louisville, KY. for 20 years. She has practiced both surgical and clinical pathology and has been an Assistant Clinical Professor at the University of Louisville. She is currently available for consulting in Patient Blood Management and Transfusion Medicine. You can reach her at cburnspbm@gmail.com.

A Bayfront Convention – ASCP 2014 in Tampa, FL

From October 8-10th this year, ASCP members met at the Tampa Bay Convention Center. The convention center overlooks the picturesque calm waters where the Hillsborough River drains into Tampa Bay, waters which are alight at night with city lights and reflections from neon-lit bridges. Opposite the convention center stands the imposing figure of Tampa General Hospital, the metropolitan area hospital at which the University of South Florida residents undergo portions of their training.

Inside, the atmosphere was quiet and relaxing on the first day. Pathologists, cytotechnologists, laboratory professionals, residents, fellows, and others mulled about, some sipping coffee and catching up on news, others hurrying to get to one of the many available lectures or seminars.

Some lectures were star-studded, others from lesser-known speakers, but they were outstanding overall in subject and quality. Dr. Richard DeMay’s lecture on cytopathology was a real treat; he interjected humor and humility into his lecture, a remarkable feature for someone with an internationally renowned series of books under his belt. It was fascinating to watch him speak, with his keen blue eyes and wavy brown hair, with a single shock of white at the front. His demeanor was poised but colloquial, brilliant but accessible. I had the pleasure of shaking his hand after and thanking him for his contributions to the field, but others were more prescient; attendees lined up afterward to get their books signed and have photos taken.

Some of the more popular lectures had standing room only, although arriving 10-15 minutes prior to the start guaranteed a seat. Pathologists – old and young – stood up against walls or sat on the floor, fumbling with beverages and notepads, to hear about Head and Neck Surgical Pathology and Medical Liver Pathology. Yet other lectures had to be missed; I regret not being able to attend what I heard was a high quality lecture given by Steven Marionneaux, MS, MT(ASCP) on the topic of platelet counts and their impact on transfusion protocols.

The resident review courses, designed for pathology residents for the purpose of board review, were well done also. They were narrower in focus than many of the other lectures, but cut into the meat of their subjects. For the fourth-year residents who attended, no doubt the reviews served as a free complement to the Osler Review courses, which began on the Sunday in Tampa following the convention.

By Thursday, the posters and exhibits were up, and the exhibit hall (Science Connections Central) was bustling with activity. Presenters from all over the country (and some international) with varied backgrounds were there, with posters on everything from laboratory media for HPV testing to the utility of peripheral blood examinations of myelodysplastic syndromes.

The exhibits were the standard fare, with laboratory hardware vendors, molecular testing services, and booksellers all present. My favorite, after meandering for some time, was the Pathology Outlines booth with Dr. Nat Pernick. He was gracious enough to share his impetus for founding his company, which was to eliminate the need to carry books when he went from site to site doing PRN work in the Northeast, He was also gracious enough to give me an autograph. I had learned my lesson from the previous day.

After rounds of lectures, and a boisterous Lab Management University graduation ceremony, ASCP 2014 began to wind down. The Friday lectures grew more sparsely attended throughout the day, but many stayed for the ending awards ceremony.

On Friday evening, at the cusp of dusk, drinks and hors d’ouvres were served, and sharply dressed laboratory professionals watched as ASCP President Dr. Steven Kroft thanked everyone for coming, and the poster awards were handed out. The international award recipient gave an excellent improvisational speech, telling the assembly that he was honored to be studying in the United States, and that he looked forward to becoming “stronger together,” a nod to the ASCP’s newly minted motto. Yet my favorite award recipient was Dr. Kun Jiang of Moffitt Cancer Center, one of my attending physicians and in my considered opinion one of the most talented pathologists in the country. With his characteristic humility, he gave no speech and hurried off the stage too quickly to be photographed, but we were glad to see recognition of his hard work and talent. He was the recipient of much hand-shaking and back-slapping when he returned to his table.

Dusk came over the bay, but the convention was not yet over. Residents were invited to a classy meet-and-greet reception at Jackson’s Bistro, an upscale restaurant just a short walk away. Dr. Kroft appeared again to remind the residents that we are the future of pathology, and to inspire us to embrace the legacy we were being left with. Dr. Rebecca Johnson was there also, and it was interesting talking to her. I learned that the pathology board exams are not scaled with a Gaussian distribution, with the necessity of a certain number of exam failures, but are structured using a standards-based approach. This ensures that minimal criteria are met, and failure is not essential to the examination model. So, theoretically, everyone can pass on the first time. That knowledge was perhaps as inspirational as Dr. Kroft’s parting words.

The music popped on and residents mingled with residents, students, attendings, and a few others who showed up. It was a lively and convivial atmosphere with swimming lights, laughter, and good times. Smiling faces abounded as a room full of stressed and overworked people took at least one night out of the year to live a little. They also exchanged stories and news, cards and numbers. It was one of those moments of being caught up in l’esprit de temps, not as part of a country or a movement, but as part of a select group of people who have dedicated their lives to the accurate diagnosis of disease. We are a truly unique group in these modern times, caught between the legendary accomplishments of our forebears and a growing world of scientific modernity. I looked over the water for a moment, over the orange and white dots and the neon streaks, and I wondered, what will our future be?

 

markow

-Michael Markow, MD is a third-year resident at the University of South Florida, Tampa, FL

ASCP Annual and Resident Council Meetings from the Big Guava

I just spent most of this past week at the ASCP Annual Meeting in Tampa. Even though many of us had just met, every night we socialized over food and drinks (and for some, over a hockey game because the arena was just across the street from the convention center). Inevitably, our conversations would touch on our training, boards, fellowships, and the job market…slightly different journeys to similar destinations.

This past January, I served as the resident on the Annual Meeting Steering Committee Education Working Group. At that time, which was freezing in Chicago, I was glad to be in warm Tampa (during Gasparilla, their quasi-Mardi Gras-like pirate festival). Since I worked half a day and flew in late, I had missed the tour of the convention center and USF’s Center for Advanced Medical Learning and Simulation (CAMLS). But I was there representing the resident voice when we finalized and scheduled all the educational sessions that attendees enjoyed this past week at the Annual Meeting. Since I had also helped with making sure that the marketing was more resident-focused, I was glad to see many residents in attendance. It’s always nice to see the final product of the fruits of one’s labors so attending this past week meant a lot to me.

I usually don’t visit too many posters at conferences because I’m usually presenting a poster. But this time as a member of the AMSC EWG, I served as a poster judge and was able to speak with many of the poster presenters, even international ones from Spain and France! It was surreal to be on the other side and asking questions and thinking thoughts that judges probably once thought of me. Some even came up and asked for feedback after the judging was over and I hope I helped with my comments.

I also was able to be a resident attendee as well. I attended the Thyroid Ultrasound FNA CAMLS and performed ultrasound-guided FNAs of silicone slabs filled with “olives” as nodules. And I found that it’s much harder that I previously realized. But I was able to use my newly learned skill when I performed a breast FNA this week. Most of the talks I attended focused on hematopathology and molecular pathology topics. I also attended Dr. DeMay’s ‘basics of cytology’ session which was jam packed and even asked him to autograph my copy of “baby DeMay” after his talk (gosh, I’m such a groupie) which I had with me since I’m on cytology now. Others took selfies and pictures with the cytopathology rock star.

The Mixology Lab where the poster and oral presentation as well as the 40 under 40 winners were announced was a great hit – good food, free drinks, and a fun time where attending physicians and trainees mingled next to the azure, calm Hillsborough River. And the fun didn’t end there as we closed the conference with a Resident Reception at the sushi bar across the river that was attended trainees, attending physicians, lab professionals, and friends/spouses of attendees. I even saw a Conga line composed of attending physicians, resident council members, and fellow trainees!

After the meeting, I stayed for the ASCP resident council meeting. It always inspires me to see those committed to organized medicine (or any cause) at work. Everyone was passionate, not afraid to speak up, and brought different skills and experiences to the table. ASCP is always looking for new leaders. But I realize that it’s not always easy to find opportunities to become involved with so I’ll try to advertise those I hear about here on this blog. Feel free to email me to pass along your name within the organization. I promise that getting involved with organized medicine is always rewarding and you will develop leadership skills that will help for when you are a pathologist without even realizing it.

Fellow readers, for the next few weeks, I’ll be taking a break and you’ll be hearing from other trainees about their experiences at the Annual Meeting and with ASCP.

 

Chung

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

Thoughts from Pathology Job Market Conversations

So, as you know, I recently attended the 2014 CAP Annual Meeting in Chicago. In addition to meeting with residents, I also had many interesting conversations and meals with non-trainees. I met new-in-practice pathologists who had completed two or three fellowships who were unemployed and were at the meeting networking with potential job prospects. I met veteran pathologists who were working in part-time or locums tenens positions while searching for a more permanent position. And finally, I met pathologists who were currently working but who told me that over the years, the amount of work that they have had to do for the same or less pay had significantly increased.

These conversations left me wondering how we can address this issue. How do the reports that this country would see an impending shortage of pathologists in the near future fit in with these first-hand stories? Most, if not all, of the reports about a pathology workforce shortage were based, at least partially, on survey data. This can be influenced by selection bias, volunteer bias, or both depending on how the survey was conducted. Also the modeling applied, at best, can only make estimates about future occurrences based on the data available now. It cannot take into account unforeseeable game changers (eg – Affordable Care Act) that may significantly alter the practice of medicine compared to the practice today. I’m not saying that we should discount these reports, just that we should be aware of how to critically analyze the conclusions from them.

I do believe that there is a pathologist shortage in terms of misdistribution geographically and subspecialty-wise, but this is a trend that holds true for most medical specialties. We may not have enough pathologists per person (aka a shortage) in this country but we definitely have a surplus in many urban settings where it may be more popular to practice. Certain popular and well-paying subspecialties, like dermatopathology, could have a surplus but don’t because the number of fellowship positions are limited. But other popular subspecialties like hematopathology seem to be saturated in terms of positions near cities that are popular to live in from my anecdotal experience.

And even though an impending shortage is always the battle cry to increase the number of residency spots, our community is polarized on this issue. Some residents and pathologists I’ve spoken with feel that we should, like other specialties have done in the past, limit the number of residency positions we have. Without more data, I can’t really say which side of the argument I agree with but I do acknowledge that we are at a crossroads. The decisions we make now about how we train our residents and what roles pathologists should fill (eg – molecular diagnostics) will affect our future, patients’ futures, and our profession’s future.

But regardless, the problem does remain that the job market currently seems tight and that pathologists have had to perform more work than they have had to in the past. So, what is your take on the situation and your suggestions for a possible solution? And how can we incentivize to address misdistribution of pathologists to address a shortage in more underserved areas?

 

Chung

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

 

Confirmed Case of Ebola Diagnosed in the United States

CNN is reporting that a patient in Dallas, Texas is the first person diagnosed with Ebola Virus in the United States.

According to the CDC, the patient traveled to the United States from Liberia on 9/19-9/20. The patient exhibited symptoms on 9/24, sought care on 9/26, and was admitted to the hospital on 9/28. Today, the CDC received and tested samples from the patient and confirmed the presence of the Ebola Virus by PCR methodologies.

The CDC and the Dallas County Health and Human Services will conduct contact interviews to determine if the patient may have had contact with anyone while infectious. If any contacts are identified, they will be quarantined and monitored for 21 days (the longest known incubation period for the virus).

CDC director Tom Frieden, MD, MPH says, “I have no doubt in my mind that we will stop it here.”

Be that as it may, it doesn’t hurt to be prepared. Lab professionals and pathologists should be familiar with the CDC’s Ebola information page.