Serotypes and Stereotypes: the Path to Pathology

Hello and welcome back! After a hiatus for the holidays, I’m now back at school and gearing up to write about more Arbovirus-related public health endeavors. But, with projects on hold until now, I’m going to briefly depart the world of mosquito source reduction and epidemiology to discuss something that relates to my experiences in medical school. If you read my Lablogatory bio, you’ll see I spent a number of years studying and working in some of Chicago’s great clinical laboratories. In the past decade, I’ve been very close to the field of pathology and laboratory medicine. As I reach the “half-way” mark in medical school now, I have become increasingly aware of the way people across healthcare professions and specialties view laboratory clinicians. One thing that stands out strikingly is, what I argue, a potential stereotype.

Let me tell you one of my pet peeves. As a medical student, I am fortunate enough to learn and work under the guiding hands of physicians, nurses, and other educators. I work my hardest to learn how to provide the best care possible as I learn the skills needed for my future practice. In debriefing from a simulation, a good performance might spark conversation which culminates to the paramount question: “Have you thought about a specialty?” My heart set on it for a while, I often remark “Pathology” before I correct myself to “Clinical Pathology” since I’ve learned to curtail jokes about autopsies. (Disclosure: autopsies are a very important part of medicine, and the number of autopsies have experienced an unfortunate downward trend.)

As a result of my AP/CP answer, many people are often surprised, citing that I’ve been “great with the patient(s).” So that begs the question: why does my current answer surprise people? And more importantly, what perpetuates the stereotype of an introverted, microscope jockey who doesn’t want to be near patients? Yes, hyperbole, but I’ll come back to this stereotype.

While I was stateside visiting family, I coordinated some clinical shadow time with a colleague and alumnus of my medical school in her pathology residency at University of Alabama at Birmingham (UAB). I spent time rounding with their teams in derm-path, watching sign-outs for endless cases, and getting up close and personal with autopsy training with another pathology resident. Each interaction with the faculty and staff were familiar and expected—full of enthusiasm and passion about their respective field of research or clinical work. What struck me as special, however, was that I was neither questioned for my motives in seeking pathology as a specialty, nor did I surprise anyone by being social and amicable. Everyone was quite sociable and proud of their work. My interactions were limited to the anatomic and clinical pathology departments so I suspect there may have been some bias. When I was a medical laboratory science student, I recall working with other disciplines, and, though I may have been in a nascent time in school to notice any stereotypes, they became clearer as I progressed through various jobs across the city. Large trauma centers, small community hospitals, even a shadow stint at the Cook County Medical Examiner’s Office, all taught me valuable lessons on varied scope and different professional perspectives. And all the while, people seemed surprised I would be interested in such a misunderstood specialty.

On Lablogatory, I’ve enjoyed just about every post and one of my favorites is a series by Dr. Lori Racsa, “Lonely Life of a Clinical Pathologist.” Dr. Racsa discussed things about laboratory medicine I had observed in my time as a medical laboratory scientist: the critical role of pathologists on committees, the value of built-in mentorships, the [aforementioned] mystery about the particularities of the job to clinicians and laypeople alike, and the value of technologists like myself! One of the most poignant posts she wrote addressed the potential for a clinical pathologist to round with other “floor” clinicians. That was something I thought I’d dreamed up in my ambition to go to medical school, blazing a trail in Path where I could put some cracks in that stereotype. Dr. Racsa cited a great article from Critical Values by Dr. H. Cliff Sullivan where he recommended pathologists become more actively involved with fellow clinicians to directly improve patient outcomes. Having freshly attended several events at the ASCP National Meeting in Long Beach just prior to his article, I rode a wave of his “rally call” for changing the face and accessibility of pathology as a specialty. I saw myself in both his and Dr. Racsa’s stories of interdisciplinary teams, rounds, and committees and I’ve been excited ever since.

Back to that stereotype. Those articles about pathologists’ roles in medicine reflect a distinct lack of visibility to fellow colleagues. While we all recognize that nearly 100% of cancers are lab-dependent diagnoses and 70% of patient records are tied to diagnostic laboratory data, why are nearly half the residency spots for Pathology in the US National Resident Matching Program unfilled for the past few years? According to recent surveys by the American Medical Association, Pathology has one of the lowest relative rates of physician burn-out compared to other specialties. Pathologists are earning within 15% of the average physician income, with one of the highest relative satisfaction scores to match. So with lifestyle and career quality reporting positive values, I would argue that the seeming lack of interest stems from the possible lack of exposure of pathology as a dynamic field. The stereotype I’ve been talking about might also be one of attrition—“out of sight, out of mind.” Some great pieces of work on Lablogatory focus on promoting the value of laboratory medicine as an integral part of any patient’s care. Just recently, Dr. Sarah Riley discussed CO poisoning and public health, while her bio calls for “bringing the lab out of the basement and into the forefront of global health.” I feel close to that cause myself, hopefully made evident in my previous posts. Stay tuned for next month’s where I’ll be discussing the next steps in our public health project on Sint Maarten. After celebrating a successful 2016 effort presented by the Ministry to the Global Health Securities Agenda, our team has a number of projects lined up to demonstrate effective integration of lab medicine, epidemiology/public health, and social outreach.

A friend and mentor once told me to keep a completely open mind about my medical career and let whatever specialty fits best “find me,” so to speak. I couldn’t have asked for more sound advice. I’ll admit I have my biases and comfort zones, and for now that’s what they’ll remain. In this post, I had hoped to shine some light on the disparities in career reputation between pathology versus other disciplines. Is the stereotype founded in any truths I may have missed? Don’t pathologists have the social tact to work up and down the ladder, working with lab assistants to government health officials? Have you ever been challenged for your career choices in pathology? What reasons do you think contribute to the stereotypes I mentioned? What words can you offer students like me just starting to find a foothold in their newfound careers in medicine?

Leave your comments below! Thanks!

 

ckanakisheadshot_small

Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

Show Us Some Skin

Which epidermal layer is indicated by the arrow?

  • A. Stratum corneum
  • B. Stratum germinativum
  • C. Stratum granulosum
  • D. Stratum lucidum
  • E. Stratum spinosum

Skin1

 

The answer is E, stratum spinosum. The stratum spinosum, also known as the prickle cell layer of the skin, is often several cell layers deep, and is located immediately above the stratum germinativum. Cells in this layer are polygonal, and are connected to each other by numerous desmosomes. During fixation, the cell membrane retracts around desmosomal contact points, giving the cells a prickly appearance. The cells contain many bundles of intermediate filaments as well as keratinosomes, which are membrane-bound granules thought to deposit a “toughening” layer on the surface of the cell membrane.

Skin2

 

The stratum germinativum (also known as the basal layer) is composed of a single layer of cells adjacent of the basal lamina. The cells are tall cuboidal or columnar, and are connected to the basement membrane by hemidesmosomes, and to other cells by desmosomes. Cells in the basal layer are mitotically active, and contain numerous polyribosomes and intermediate filaments.

Skin3

 

The stratum granulosum is 3 to 5 cell layers thick, and is composed of flattened, polygonal cells arranged with the long axis parallel to the basement membrane. The cytoplasm of these cells contains numerous basophilic granules, called keratohyalin granules, which are thought to be keratin precursors.

The stratum lucidum is not truly a distinct layer of skin, but rather a staining artifact. It is visible in some sections of thick skin as a glassy-appearing, eosinophilic artifact at the bottom of the stratum corneum. It is not present in this particular image of epidermis.

Skin4

 

The stratum corneum is the outermost layer of skin. The thickness of this layer varies considerably from region to region in the body. The cells of this layer are dead, flattened, and fused together, with completely keratinized cytoplasm.

Skin5

 

Krafts

-Kristine Krafts, MD, is an Assistant Professor of Pathology at the University of Minnesota School of Medicine and School of Dentistry and the founder of the educational website Pathology Student.

Chief Resident Advice to Junior Residents

I haven’t been able to blog as much of late. It’s been a busy year with more than its fair share above the usual crises that a chief resident is expected to handle – an “August year” for me as my program director put it. But I’ve learned a lot and have been lucky to have the support of my attendings, program coordinator, and program director to help. Even when we’ve not always agreed on what is best for our residents, I’ve always been allowed to speak up for our residents and felt as if our concerns were heard and acknowledged even if policies didn’t go our way. I think that’s the biggest strength of a smaller program–the ability to form strong relationships with mutual respect, whether it is with one’s mentors, peers, or hopefully, both–and I know we will cheer each other on when we hear of each other’s accomplishments in the future even if we won’t see each other daily as we do now because of those bonds we built during these past couple of years. The lessons I’ve learned regarding “soft skills” have been equally as important as the knowledge I’ve gained about my favorite lymphomas or molecular mutations. And four years is really shorter than one might think to fit in all we need to as AP/CP pathology residents, so see it for the gift it is–protected time to grow into the physician you want to be. I see the fruits of these lessons more clearly now as I prepare to graduate. Much of it was obtained through mentorship, formal and informal, from those more experienced and with my best interests at heart.

So here are some pearls I’d like to hand down:

  1. Know thyself as early as possible: Be honest with yourself about your strengths and weaknesses so that you can build on the one while working on the other. As we have now signed on to be life-long learners, identify what works for you early or adjust those learning habits which might have worked before but are no longer working. Designate a couple of hours on a weekend day every week to do learning above and beyond what is expected for your current rotation and consistently stick to it. If you can, designating an hour everyday would be even better and it doesn’t have to be hard core studying like our med school days—you can leisurely read a review article, watch TedMed videos, casually look over boards materials or qbanks from day 1, and so forth as long as you do set aside time consistently. Take advantage of experiential opportunities to help decide early where you see yourself as a physician (academics, private practice, commercial lab, subspecialty, etc) in the future so that you can plan as early as possible your rotations, electives, opportunities, and networking with that goal in mind. But most importantly, knowing who you are, what you believe in, how you work best, and what you want and knowing early, will help you plan and see opportunities earlier. But always, be true to yourself.
  1. Time management is key: Learning to plan early and efficiently is a skill and it takes time to learn. Honestly, I’m not the best on a daily basis unless I take time ahead of time to plan my day, which I don’t always do, but plan to be better about during fellowship. But I do know how to plan effectively to juggle multiple long-term projects with deadlines at a time. You will constantly hear about time management – whether on rotation evaluations or during fellowship interviews. I find that those who are very good at time management, all have checklists and planners (whether hard copy or digital) so maybe they’re on to something there. Whatever works for you, being a deliberate planner ahead of time will serve you well.
  1. Be proactive: In some way, we’ve all be conditioned in a passive learning style where those who are more experienced hand down information to us which we are expected to regurgitate or ruminate on and respond. During residency, we don’t have the strict structure we are used to from medical school as we may be only given loose guidelines but are expected to figure out how best to manage our time on our own. We no longer have every hour planned out for us and so the quicker you learn to plan ahead and effectively use your time while at work, the more time you’ll have for personal activities. Don’t just do the minimum but use gaps in your time during the day to study, to build relationships with mentors with whom to work on book chapters, abstract submissions (for posters/platform presentations at conferences), and publications, to attend conferences/tumor boards outside your rotation even in non-pathology departments, to work with others outside of pathology on interdisciplinary projects. In some ways, these activities are networking without our even realizing it. For the rest of our lives, we will constantly be judged and compared to others by our character and work ethic and that often will include tangible items on our CV whether this is fair or not. Challenge yourself on every rotation by trying to do as much as a junior attending would within the limits of what you are allowed to do and not just the minimum.
  1. Get involved in advocacy: Participate in leadership positions at an organized level–within our professional organizations, with interdisciplinary teams within your hospital, or with volunteer organizations in your community. Bringing about change takes time but if done with a positive goal in mind, can have such a rewarding impact on those we wish to serve as well as yourself. You might discover a previously unknown passion or skill you possess that you can share. Before residency, I was heavily involved with on-the-ground, upstream-minded health equity efforts in immigrant and minority communities. And while I took a hiatus from my work due to residency training, I know that as a future public health pathologist-scientist with both public health and research training, I will return to working to change those systemic and institutionalized societal structures that maintain health inequity within those communities. So it’s now your time to find your passion and to give back. Pay it forward for every good gesture someone has shown you.
  1. Build relationships with mentors: Since I’ve been involved with organized medicine, I’ve always heard the word “networking”. Too me, it always seemed somewhat a Machiavellian “ends justify the means” insincere word but I guess that’s all up to interpretation. What I prefer to say is focus on finding colleagues with whom you share values and passions, who you respect and would like to emulate, and with whom in the future, you might want to collaborate. If your premise is sincere, opportunities always unexpectedly follow has been my experience.
  1. Step outside your comfort zone: As busy physicians-in-training who are used to structure and consistency, it’s good every once in a while to try something new. You never know what you may find–it may even turn out to be a new passion for you. Life is too short and you want to live it without regrets. You want to say when your time comes that you lived life to the fullest and maybe even tried some things that scared but surprisingly made you happy.
  1. Recharge with some “me” time: All work and no play can make any of us dull and cranky. Set aside time to spend with friends (especially non-physician friends) and family and do non-work related activities. Especially when life is getting you down, some time away from thinking about work may be the recharge you need.

 

Chung

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

The Importance of Truly Internalizing Feedback and Learning From It

Recently, I’ve felt a shift in the timeline. Part of this I can attribute to having less time to myself as I ease into chief resident duties. Time I would’ve spent doing (or postponing) other activities is now relegated to this new role. But this increased demand on my time is not the only factor. Time feels like it is more rapidly passing with each year of residency, and more accelerated as of late.

Taking the annual RISE this time of year also contributes to this. I’m reminded that I should have reached some invisible bar on the meter stick in terms of my knowledge base and hope that I am commensurate with where I should be at this point in my residency. Because sooner than I may feel comfortable with, I will be expected to be “competent” enough to serve as a junior attending during my fellowships. And even though I’ve put it off until a later date, I know that I should also start composing a study plan soon for my boards because time is short between now and graduation.

Lately, probably because it was my most recent rotation, I’m reminded of my surgpath fellows during my PGY-1 telling me that I would learn the most from my cases, both AP and CP. Even though I was listening, I don’t think that I quite understood the depth of those words until my third year. During residency, we often don’t have much time to think because our service duties occupy much of that time. And the desire and need for sleep occupies much of the remainder of the time. But the light bulb moment has gone off so to speak in terms of what they meant by “learning from my cases” – be deliberate and start early.

For much of my first two years, as I’ve previously written, I’ve had a love/hate relationship with surgpath. Maybe those words are too strong, because I neither loved nor hated it, more like was ambivalent toward it. I naturally gravitated toward those subspecialties (obviously not surgpath) that I felt more comfortable with because of my previous training and interests – we all do.

But now I find that grossing is more meaningful and less of a chore to get through for me because I truly understand now how important it is that I do it well – be able to identify the important lesions and sections (90-95% of the diagnosis is off the gross, after all), cut thin and deliberate sections that look like “sushi” as one resident described my grossing, and understand how the sections I provide contribute to staging in the case of cancers. I understand these aspects better now because my grossing skill was called into question during my 2nd year. Since then, I’ve put a good amount of effort into correcting any deficiencies. Even the rotation director who originally brought up this issue, joked about the disasters of my first day on surgpath at his hospital at every end-of-the-rotation evaluation I had since then. His method of feedback may have been dramatic at the time but he really did provide me with a defining moment that changed my outlook and approach and for that I am grateful.

But it’s necessary to be deliberate and start early whatever rotation you’re on. Even though I read about the diagnoses for most of my big resection cases or at least did a quick pathology outlines search each time, I really wish that I would’ve spent even more time really reading up on those cases besides the cursory skim to come up with a diagnosis earlier in my residency. These days, I try to read a little every day, whether it be from a textbook or a journal article. And I’ve found that my knowledge, understanding, and skills improve at a faster rate. But I do wish that I had started this process from my PGY-1 so that I wouldn’t feel like I’m behind where I should be in terms of being ready for boards…so that I didn’t feel like I’m going to have to cram like I used to during college and med school for boards or wonder how to retain info that I learned two years ago on a rotation I haven’t had since PGY-1.

So really listen to the feedback from those more experienced then you. It probably took them longer than they would’ve liked to get to that light bulb moment. That is probably why they are making it a point to bring up that pearl of wisdom to you that they should’ve and wished they could’ve known then.

 

Chung

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

The Passing of the Gauntlet

Time passes in cycles. And the time has come for the passing of the gauntlet. Two weeks ago, anxious and eager fourth year medical students found out what their fates would be in terms of internship or residency (in the case of pathology, where we don’t do an intern year) for the coming year. Those of us who are newly appointed chief residents either have already transitioned or are starting our terms soon. And as chief resident, I’ve made that last connection to loop in the new and been in contact with our incoming first years and new CP only senior.

Two weeks ago in Boston at our ASCP Resident Council meeting, I listened to a presentation by the CEO of USCAP and a resident working with him and ASCP on the development of our resident engagement strategy. It was a thoughtful presentation and I wondered to myself as the resident presented his experiences with engagement entitled “From the View of a Chief Resident” whether there would have been any difference in how he felt whether he had been chief resident or not. And I can’t say that I know the answer yet to that question.

I’ve always been pretty proactive and I can be mad vocal sometimes, especially when it comes to ethical, policy, and health equity issues that I feel affect marginalized populations that often don’t have a voice. I’ve spent decades organizing and advocating for health equity for the minority and immigrant communities so I’m quite passionate about improving health for these populations. Part of my MPH study was dedicated to this. And I went to medical school after spending significant time in biomedical research so I am much older than the average resident. So I’m not always sure if I see things differently because of those things about me or that I would’ve anyway despite them.

But the gauntlet has been passed. My two co-chiefs this past year were great. They were organized and dealt with much more than was perceptible to the eye. Since our program is small, they so did much more than make our schedules and sign off on our leave of absence forms – they were masters of conflict resolution. They had many additional meetings in addition to their rotation duties. They were responsible for teaching and guiding the first years in grossing and through their first year of residency and for solving the frequent quality improvement issues that would come up between technical staff and house staff and between our residents and our distant off-site hospital that we also rotate at.

So, I guess as a chief resident, I might see things differently, or have no choice but to. I’ve never been the best about being early but I know that I need to be a role model now. So even though it’ll be tough for me, I’m going to have to do things that I normally wouldn’t do. My schedule will need to be more conducive to this new role – like I will have surgpath in July so that I can train the PGY1 in grossing. And since I signed contracts for two consecutive fellowships last year, I won’t need to dedicate any of my PGY4 to interviewing and should have more time to mentor the PGY1. Chiefs set the tone for resident culture which can be especially important for incoming PGY1.

I’m not sure if my thinking will magically change. And because I have no co-chief, I can see that my life will change drastically in terms of what I take into consideration when I make decisions since I will have more responsibilities that will demand my time.

Regardless, it does seem like we’ve passed a moment. The PGY4 are now focused on studying for their boards since they’ve passed on their chief duties. The PGY2 are starting to think about fellowship interviews and setting up audition rotations. And the PGY1 are now starting to feel less like the newbies and more comfortable in their residency duties and rotations. One thing is certain, time does keep on moving.

 

Chung

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

 

Match Day Musings

I remember my match day. I actually didn’t go to the ceremony because I was two years behind having done a year of PhD before quitting and was in the midst of my MPH at Columbia the year after graduating medical school. So my original class had matched two years before and I was in NYC during exam period on Match Day and not in South Jersey. So I didn’t experience all the “bells and whistles” associated with Match Day festivities. But I do remember the anxiety of wondering at first if I would match, and then after that fateful Monday after I found out that I matched somewhere, wondering where that would be. It’s stressful and yet at the same time, a relief once you get your match results.

Now, it’s three years later. I’ve matched to two fellowships for 2016-2019 at my first choice program and I have one year left during which I will serve as Chief Resident. Match Day seems like a lifetime ago, really. So fellow, future pathology residents, enjoy this time. If you do want to do some prep because you just *have* to study, then brush up on your histology at your leisure. You can’t learn the abnormal if you don’t know the normal solidly. The first six months is the steepest in terms of learning curve and it will be expected that you already know your histology. You don’t want to fall behind because you will be learning so many new things from the get-go. Or start prepping to get your Step 3 out of the way as early as possible because the further we get out of med school, the less we will remember patient care practices and procedures that we do not practice in every resident life.

Senior residents, think back to what you wish you had known or wish that someone would have impressed upon you as to its importance when you were a first year. These are the things to pass down to your incoming juniors to help them with the transition from medical student to pathology resident. I believe that things happen in this life for a reason. So match day will bring us in contact with each other, to somehow touch each other’s lives in some way – whether it is to teach or to support each other or to work together to advocate for and transform our profession. We’ve started the journey to July 1st when we the circle of resident life begins anew.

Chung

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

CAP Inspections and the Resident

Hello, fellow blog readers! It’s about 4 weeks since we communicated last. Since my first half of the year was loaded with lighter CP rotations to allow me to complete interviews for two successive fellowships, this half of the year is surgpath heavy and so that’s why I took a short hiatus from posting.

Well, I have a 4 week reprieve before I have another surgpath rotation and I am on what we refer to as our “comprehensive CP” rotation. Basically, it’s a combination chemistry-microbiology rotation. Since both of those rotations don’t always have enough work to require a resident to remain at the hospital for the usual 8-5 schedule, we cover both rotations simultaneously. We also have 11 comp CP rotations throughout the 4 years at my new program which is quite a lot but after the initial 2 months of “wet lab” rotating through all the stations in the chemistry and microbiology labs, we have the flexibility to tailor our comp CP rotation. And so, right now, I write as I sit in a hotel in Baltimore about to meet for our third preparation meeting before my attending and I go inspect a new molecular genetic pathology laboratory for the College of American Pathologists tomorrow. Since this is this lab’s first inspection, unlike the usual CAP inspection, this one is announced – they know we are coming and can prepare for our visit. The two of us will complete the entire inspection; my program counts this as rotation duties even though I am off-campus.

This is the second CAP inspection that I’ve been asked to assist with since I transferred to my program as a PGY-3. I think it’s great that my program gives our residents this opportunity since as attendings (whether we are AP or CP), we will also have to either assist in or enforce adherence to CAP or other accreditation standards and supervise preparations for lab inspections every other year and self-inspections on the alternate off-years. At my program, residents assist in both the preparations for CAP and off-year inspections. I’ve said it before, but residency is the transition from passive learning to active learning where we should participate in the daily responsibilities that our attendings oversee and that we will have in the future.

So, this inspection will be much more work than when I inspected the chemistry and special chemistry sections with my last team. Since there are only two of us, we are responsible for splitting the duties for the lab director, general, common, and molecular pathology accreditation checklists. CAP suggests a “ROAD” approach: read (through their binders of policies, SOP’s, etc), observe (a sample from receipt in the lab and though processing and interpretation of results), ask (open ended questions), and discover.

Well, I guess it’s time for me to go inspect but before I leave, I’d like to encourage all trainees (residents and fellows) to apply to serve as a junior member on one of the CAP’s committees or councils. You need to be a junior member but membership is free as a resident. Each committee or council (that oversees multiple committees in a topic area) usually has one junior member on it, very rarely, two. I’m currently serving my second year as the junior member on the Council on Education and I can say it has been a very rewarding experience where I have met many role models who definitely take an interest in what I have to say about the trainee opinion and who also think of me when opportunities arise that they think might be good for me. You can access both the instructions to apply (which includes a list of the committees/councils with junior member positions opening up in 2016) and the junior member application here – you will need a letter of recommendation from your program director and email in your app before the deadline of March 31st. Good luck guys! If you have any questions, feel free to email me.

Chung

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