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.

Resident Concerns, Part 3: Networking Opportunities

Just as an addendum to my previous post about fellowship applications, my suggestion would be to have everything ready to send by July 1st or earlier, if possible. I’ve found that some programs started accepting applications on July 1st. And this includes asking for letters of recommendation as early as possible so that they are ready by then as well or you may find yourself, like I have, in the bottleneck with programs emailing weekly that all they need are your letters because they have started reviewing and/or interviewing already and won’t look at your materials until its complete with letters of rec. I submitted most of my applications (minus letters of rec which still have to come) by September 9 and one of the programs had already filled for both hematopathology and molecular pathology. I would guess with an internal candidate or an early interview candidate because their website didn’t list yet that the position was filled. Some of the programs for molecular genetic pathology, in particular, have early deadlines of September 1st, so make sure you know the deadlines and have your materials ready to go way in advance.

Now on to this week’s topic: networking. Throughout our journey to and during medical school, it was often hard work and studying that got us to where we needed to be. Yes, there were the “legacy” students who got into colleges and medical school based on who their parents or families were but those are not the students that I speak of. I speak of those like myself who form the majority and who didn’t have those types of connections. But in the workplace, if we take the group of “legacies” out, we still have to deal with the power of connections but at a more palpable and potent level than previously encountered. On multiple workplace surveys, the #1 manner through which people (and pathology trainees) obtained jobs is through “word of mouth” and referrals. Having someone make a call on your behalf can be a powerful factor in helping you to obtain that fellowship or job.

With respect to fellowships or jobs, the market is tighter. There are far fewer positions available. So how do you set yourself apart from the crowd of others with similar or even, slightly better, credentials than yourself? Connections can greatly help so start early. Local and national conferences are great places to meet other residents but more importantly, other pathologists in your intended field. Make yourself business cards and give them out like there’s no tomorrow. If you impress someone, they most likely will keep your business card and remember to get in contact with you when a position opens up that you’re a great fit for. At annual meetings, there often are networking receptions for residents to meet practicing pathologists. Also at these venues, job seekers get the word out that they are available and have access to job boards. This also holds true for attending your state society or other local subspecialty meetings.

Another way to meet and make connections is through getting involved with organized medicine and advocacy organizations. ASCP, CAP, USCAP, and subspecialty organizations (like AMP for molecular pathology) often have junior positions on their committees and councils for a resident. Find one in an area of pathology that you have an interest in and apply. Many also have travel awards to their annual meetings or grants for research also set aside for residents. I’ve found that many of the people who volunteer in national leadership positions in these organizations frequently overlap so once you start meeting people, you will see them at other meetings, and it makes it easier to meet more people. So if you are able to obtain a junior member/resident position, work hard. People recognize and value hard work and enthusiasm and it’s a way to make a great impression doing work that you are passionate about. And if you apply and are not chosen, then don’t give up. These positions have many more people applying for them than positions that are available. But persistence is a virtue and when TPTB (“the powers that be”) see your name on a subsequent application, they might be impressed that you applied again.

Some of these positions are advertised and others are through referrals. As a resident, I never found it that easy to find when many of these positions have an opening so I’ll try my best to advertise through this blog when those times arise. But you can get involved early and at a more junior level first by being a representative for your program to ASCP (contact angela.papaleo@ascp.org) or a delegate to the CAP Residents Forum (contact Jan Glas at jglas@cap.org). I know that at some programs, this is through election, but even if you are not elected, you can still attend the CAP Residents Forum (you just won’t be your program’s voting delegate) and still ask to get the ASCP e-newsletter (where they advertise when new resident volunteer positions are open).

If you can decide early what you want to do when you are a pathologist (subspecialty-wise, etc), then the easier it will be for you to get involved with your specific pathology community in leadership/volunteer positions early. You can even participate in other activities such as blogging, creating podcasts, and writing for these organizations. You’ll be surprised that you meet people through these venues as well. You can write about a pathology topic of interest for CAP NewsPath which is then converted into a podcast. I blog for ASCP’s Lab Medicine Lablogatory as you all know, but we are always looking for resident bloggers. If you can’t commit to writing weekly, then contact me (chungbm@rwjms.rutgers.edu) and I’ll happily have you do a guest blog here one week! For those of you attending the upcoming ASCP Annual Meeting in Tampa, I’ll be looking for bloggers to write on their experiences at the meeting so just shoot me an email or find me at the meeting (I’ll be one of the poster judges). Check out the websites of organizations you are interested in to see how you can get involved – it does take some effort on your part but you won’t be disappointed! For positions that work through referrals (where I didn’t have one), I was still able to apply because I identified the person in charge (internet searches are your friend), contacted them, and asked. So, it never hurts to be proactive.

And in my attempt to keep you all informed of opportunities, for those of you who want to do an external/away elective or international/global elective and need financial support, the application period is now open for round 2 of ASCP’s subspecialty grants. You can find more info at the ASCP website but you need to apply by Jan 16th!

 

Chung

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

Generation Gap from a Resident’s POV

I was talking with my attending and fellow this week and was struck by the generation gap in terms of how we were/are trained. When my attending was in residency, he had to handle over 100+ CP calls in a week – he even keeps one of his call sheets to back up his stories. In some ways, we are spoiled because we can just say that there is an APP to do many of the calculations he had to do then and so we’re not even paged on these types of calls. These days, I may average 10+ CP calls/week at the same institution where he trained at. He also said that they didn’t have PAs back then and it wasn’t unusual to gross until close to midnight…and the grossing resident also covered all frozen sections at the same time, too. His is not the first attending story that I’ve heard like this. Obviously, this was before we had work hour reform. But I wonder what we’ve lost in training since his time?

I’ve often heard residents complain that we have too many service duties and that they feel that service duties supersede our education. Most of the time these complaints revolve around not having enough time to read and too much “scutwork” including grossing routine specimens. I’m no expert by any means but I feel that for me, I’ve learned more when I’ve had to do things as opposed to reading textbooks. And by doing things, I mean performing those duties that are required of my attending as close as possible to the real experience. And yes, that does include lots of reading, not just textbooks but also journal articles and other resources, but is not limited mainly to reading.

Gone are the days where I could skip (or attend) my medical school classes and watch a video of the lecture and read the textbook and do well on exams. The more important difference is that now the consequences of my actions can more directly harm patients so it’s vitally important to gain “attending skills” as well and as soon as I can. And even after graduation, I know that it will still take a few years before I am comfortable in my clinical competency. I know that I’ll be more stressed and OCD about details because it will be my name at the end of the report that is responsible for patient care decisions and also liable for medico-legal action. But I want to be as prepared as possible when that time comes.

Residency is the time when we should transition from passive learning (ie – learning mostly by reading textbooks) to active “on the job” learning. Sure, if no one at your program wants to teach you, then you may be stuck with textbooks and online resources. But I’ll take a bet that even at the most “malignant” programs, there is always at least one golden mentor (including non-attendings) who wants to teach. And remember, that during fellowship, your attendings will expect that you have most of these skills in your portfolio and that you have good time management skills. No one expects that we have knowledge of everything (even our attendings don’t have that), but they will expect that we know how to approach that situation if we find ourselves unsure.

Anyway, that’s not my most important point. I find that complaining just wastes my energy that can be directed to a more useful endeavor. Yes, if I feel something is truly unjust, I will be one of the first to say something. But I realize that the patient is the center of my training and not me, their needs supersede mine, and yes, there will always be scut but it depends on how I approach it what I get out of it. Plus, I realize that compared to other specialties, I didn’t have an intern year and don’t have to do overnights, so I’m thankful that my residency experience is not as bad as it could be.

A generation gap exists where our attendings can’t understand why we complain and where we don’t feel our attendings understand us. But I think that there is a middle ground. I don’t think that we should go back to unregulated work hours where we are dangerously fatigued and never get to see our family and friends. But I also don’t believe that residency training is there to spoon-feed me. It is the time for me to spread my wings (with supervision, of course) and learn how I’d navigate my clinical duties as a future independent attending.

For those going into surgical pathology, you may still end up working at a hospital where you may need to gross or at least, look at specimens or teach how to gross. The end of residency doesn’t necessarily mean the end of grossing (or insert you least favorite aspect of residency here). A friend was telling me that he overheard attendings at a networking reception complaining about a new hire they had who didn’t know how to gross. If that was at a private practice, I would expect that after a short time allowed for remediation, that if that new hire didn’t improve, s/he would be fired. There may be more leniency at an academic or VA institution, but I also believe that if a better replacement could be found, that person would still be fired.

So residency is the time to make sure we gain competency in skills like grossing, lab management, billing, CLIA regulations…even if these are usually the things that we find to be boring. Sign-out is not even half of what will be required of us when we are full-fledged attendings, especially if you want to work in private practice, which is where most of us end up since the compensation is greater.

Getting involved in leadership positions, whether at your hospital, state society, or within a national advocacy organization in my experience opens doors to many practical opportunities as well. For instance, I’ll be going with my hospital’s CAP lab accreditation inspection team this month to help inspect the hematology section of a lab in another state. Because my department chair knows I have an interest in hematopathology and because I performed well on my first CP rotation here, I was given this great opportunity. I’m now certified as a CAP inspector and will have a better idea of lab management issues after this experience. Due to my involvement as the junior member on CAP’s Council on Education, I’ve also been given the opportunity to serve as the ACCME/AMA compliance monitor at a joint CME activity of CAP and a state pathology society in the near future. I see this as active learning and a step toward gaining the competencies that I will need.

Right now, we are buffered from much more than we realize. Probably as a fellow, we will understand the end game better, just how much our attendings’ days are filled with more than just sign-out. I suggest reading the article, “Adequacy of Pathology Resident Training for Employment: A Survey Report from the Future of Pathology Task Group” that outlines specific competencies that employers wanted and that residents did not possess adequate competencies in. It goes on to state that 50% of employers felt that new graduates that they hired needed more support and guidance than was required 10 years ago. So what can we do now during training to ensure that we are not those new graduates who are perceived as needing “more” supervision at our first job?

 

Chung

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

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.