The Road Less Traveled By Has Made All the Difference

Hello again residents, I hope that you enjoyed the recent posts from your colleagues about their experiences at the 2014 ASCP Annual Meeting. Hopefully, we’ll see you there next year in Long Beach, CA during October 28-31, 2015 and we can celebrate Halloween together! I’ll let you know in late winter/early spring 2015 when the abstract submission period opens for those interested in being chosen to present during the oral and poster sessions. And congratulations to those residents recently appointed to various ASCP subcommittees! As always, let me know if you’d like to get more involved and I’ll pass on your info.

So I’m writing this post from the air while flying from Newark to San Francisco via a layover in Phoenix. When I arrive at SFO, I would have spent 9.5 hours today traveling. In fact, I’ve flown every month since I moved home to NJ this past July either for conferences where I presented posters or meetings for national leadership positions I hold in organized medicine organizations.

I’m tired from all the travel but at the same time excited to finally start my fellowship interviews. I postponed them until November when I’d have a month free from most of responsibilities I’ve had the last few months. The only responsibility I have this month is to serve as the ACCME/AMA monitor at the Ohio Society of Pathologists meeting for CAP. But November is actually somewhat late for interviews. Some of my PGY-3 friends who interviewed early have already matched to their fellowships because they were given offers at or shortly after their interview at programs that have rolling admissions (which is quite common).

So if you’re a PGY-2, I suggest asking to have your letters of recommendations written and ready by end of July 2015 at the latest and send out your applications in July/August or as early as the application period opens at your programs of interest. Spend early 2015 researching programs and refining your personal statement and CV so that everything is ready early. But the bottleneck most likely will be your LoRs so make sure to follow up with your letter writers to make sure they are completed in a timely fashion. Also remember to follow up with programs to make sure your applications are complete because I had lost LoRs that delayed the process, and one program that I did eventually get an interview at, never received my initial application because the email address was incorrect on their website.

If you’re a PGY-1 and unsure of what you want to do for fellowship, make yourself opportunities in 2015 to help answer this question for yourself early. For 2014, concentrate on learning on your rotations, especially surgpath/grossing. Ask to have rotations of interest or electives in your chosen subspecialty completed by second year so that you can make this decision and so that you can get letters from attending physicians in your subspecialty area. PGY-2 is also your opportunity to shine during an external “audition” elective and possibly be considered almost as an internal candidate at your top program if you schedule one early before you apply. You can even apply for a subspecialty grant from ASCP (deadline is Jan 16, 2015) to help fund your external elective expenses.

Get involved in research in your area of interest, participate in and ask to present monthly at tumor boards for your area of interest (go above and beyond the minimum!), get involved in the lab validating tests (for CP oriented folks), and attend CME meetings in your area of interest (I used to attend Chicago Lymphoma Foundation Rounds even when not on the hemepath service) – anything to learn more about and show your interest in your chosen subspecialty. Also think about getting involved in a resident leadership position within the organization that represents your interests (eg – ASCP, CAP, USCAP, Association of Molecular Pathology, etc) and take your responsibilities seriously in this role because pathology is a small specialty. Word gets around if you do your job well (and also vice versa). The connections I’ve made in these positions not only allowed me to meet inspiring pathologists who will be my future colleagues but also helped me in terms of letters of recommendation.

Well, at least all that travel and the fact that I have a credit card from a major airline, saved me in terms of paying for interview travel as most of them were paid with frequent flyer points! During medical school, I got an airline credit card at least a year before residency interviews and paid for most of my interviews that way as well. Another way I saved money on interviews back then and again now, is to rent a private room in private residencies for a fraction of the cost of a hotel through the Airbnb app. Sometimes, the programs will give you a list of hotels – remember to ask about discounts for those interviewing at that specific program. Both during residency and for fellowship interviews, some programs are paying for all my expenses except for airfare! Another way to save money is to take rides using the Uber, Lyft, or Sidecar apps especially if you can find a promotion or coupon code. And remember to keep all your itineraries organized using apps such as Tripit or Kayak.

I’ll drive to most of the East Coast interviews. But this week, I have 5 West Coast interviews in 4 cities and pretty much jetting to the airport right after to catch a flight and get into the next state around midnight in time to sleep for my interview the next day. Since I have to use vacation days, I thought it best to interview every day instead of wasting a day for the bi-coastal flight. And lucky for me, I start in San Francisco and end in Seattle where I have friends to chillax with and can do the long cross-country flight back and forth on Saturdays so as not to lose a potential interview day.

I feel fortunate with respect to fellowship interviews. I’m grateful that I received invitations at most programs that I applied to unless they took internal candidates or candidates that they interviewed who submitted applications earlier than I did. I applied for two consecutive fellowships (hematopathology and molecular genetic pathology) and upfront informed programs of my intention in my cover letter. I left it up to the programs to choose in which order I’d complete the fellowships if they were interested in interviewing me for both. I’ve found that most programs were open to my proposal. Three of them even coordinated the interview so that I either had both on the same day or over two consecutive days. Among other residents that I’ve met, the popular combo this year seems to be cytopathology then molecular genetic pathology. Makes it more competitive to get a MGP fellowship as there are currently only 52 ACGME accredited positions and that does not account for those which will go to internal candidates out of that number.

I’ve never been traditional. I graduated college as a super senior (took >4 years and time off working in a biotech company), went to grad school (I have a masters in pharmacology and experimental therapeutics with a focus on transcriptional regulation and signal transduction with respect to molecular neuroscience), worked as a research scientist in molecular and cell biology and transgenics, went to med school in my 30’s, and then completed my MPH (focusing on molecular and ID epidemiology along with minority/urban health and domestic and global health policy and development) before I went to residency.

But just like Robert Frost’s poem, I think that having taken the ‘road less traveled’ has made me into the person I am today and I wouldn’t trade in my experiences for a more traditional path. Along the way, I’ve gained knowledge and skills that I think have helped me to get interviews at great programs and that hopefully will help me develop into the triple threat I aspire to be (hematopathologist, molecular pathologist, and researcher). If this is possible or too naïve a dream, time will only tell. I blog to hopefully share helpful advice or to pass on advice from practicing pathologists that I’ve met in terms of those areas of which I yet do not have experience (eg – job market). As for me, and also for you, advice is only meant to be a trigger to thought. You will need to decide what works for you and work diligently to make your personal goals a reality. As Robin Williams said in one of my favorite movies, “Carpe diem…live EXTRA-ordinary lives.” I believe that he was telling us to aspire beyond mediocrity, to push to change and not merely accept the status quo, and to create our own destiny while not dwelling on those things that we cannot change. When my fellowship interviews are complete, I’ll let you know how the journey went.

 

Chung

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

 

Reminiscing Tampa

ASCP 2014 at Tampa provided the perfect getaway for a New Yorker forced to wear fleece early October. The same attire seemed to be mocking me the moment I stepped out of the Tampa International Airport on Wednesday night. It was a pleasant surprise and I gleefully tucked it right into my suitcase.

At the hotel, I took a quick glance at the lecture schedule. Having already missed the first day, I was eager to extract the best out of the next two days. I was thrilled to see an array of topics specially aimed at residents. Also, many lectures focusing on novel or state-of-the-art techniques, including molecular methods, virtual microscopy, digital pathology, informatics, etc. It seemed to me like “The future beckons!!” Being a hard-core morphologist, it was a tough call for me, as I would have to forego a host of other good lectures. But I decided to focus on the resident review courses and ancillary techniques.

Keeping with my agenda, I set the ball rolling on day two by attending the lecture on “Automating Anatomic Pathology.” It was an eye opener for me, dealing with the scope and future of automation in anatomic pathology lab. “Anatomic Pathologist’s Role in Patient Safety” was the next. Dr. Silverman cited studies revealing that soft tissue lesions, with an error rate of 20-30%, led the list of organ specific error rates. He deliberated on the importance of second opinions in error reduction. He aptly concluded his lecture with the remark, “the pathologist is the Final Quality Assurance Officer or ‘the buck stops here.’” It was a huge wake up call for me.

I moved on to my first lecture on Molecular Pathology, “Welcome to the Beginning: Molecular Pathology for the General Pathologist and Molecular Pathologist.” It was just the right one for me and helped me firm up basic concepts. In the evening I attended “Molecular Diagnostic Methods in Oncology: an update on practical aspects.” Dr. Larissa Furtado and Dr. Yue Wang from University of Chicago were simply brilliant in elucidating the role of molecular techniques in oncologic practice. The prior morning session, helped me understand the deliberations in this talk much better.

I made it a point to attend most of the Resident Review courses. Though my Board Exams are two years away, I took it as a perfect platform to acquaint myself with the “hot” topics. I spent almost the entirety of day three attending the courses. A packed audience was testimony to these sessions’ popularity. Most of the speakers were brilliant. The case based presentations followed by an interactive voting format helped keep us all fully involved. However, the lab administration and last day hematology section could have been better.

In between, I found some time to listen to one of my all time favorites: Dr. Goldblum’s trademark lecture on soft tissue pathology. He quipped in his inimitable style “Don’t hunt for lipoblasts to diagnose a liposarcoma” and warned us of the vast plethora of “pseudolipoblasts” lurking around. Rather, he stressed the importance of analyzing the entire histology in the correct clinical context.

Let’s wander into the poster sessions! We had a total of twelve posters from our program itself, probably the largest representation from a single center. I had four posters and one of them was selected as a finalist in the Best Resident Poster section. It was an entirely new experience for me. However, I did some homework to prepare myself for the judging session. The judges on both the days were very pleasant and spent a significant amount of time discussing the work with me. It was disappointing not to get the award, though I knew the competition was tough.

The evening Mixology Lab was the perfect concluding session in the backdrop of the setting sun across the scenic Hillsborough river. There was delicious food and wine as Dr. Baloch announced the various poster award winners. It was special for me for another reason, as my very good friend Shree Sharma was one of the “top 5 under 40” award winners.

Mixology Lab attendees soaking up the sun.
Mixology Lab attendees soaking up the sun

It would be so improper if there were all work and no play. Friday evening provided the perfect opportunity to explore the city. I went out with friends to the Ybor City, taking the streetcars, which surprisingly provided 50% discount to conference attendees. Ybor City was such a happening place, full of fun. While strolling along the 7th avenue, we took pictures with people celebrating Gasparilla festival, dressed as pirates. A glass of sangria at the historic Columbia Restaurant provided the perfect toast to end the day.

My trip was not to end here as I had already registered for the TRIG Genomic Pathology Workshop for Saturday. This was my first exposure to such a session in molecular technology. We were divided into small groups. In a case based approach, the workshop deliberated on teaching principles related to the development of genomic assays and result interpretation. There were four cases pertaining to single gene testing, prognostic gene panel testing, how to design a cancer gene panel and whole genome sequencing, respectively. Both Richard Haspel and Andrew Beck were simply brilliant and they took special care to approach each group separately and clarify their doubts. It was a highly stimulating experience for me and I learned a whole new facet of pathology. The utilization of online genomic pathology tools for result interpretation appealed to me. It also gave me the opportunity to work with fellow residents from other programs in a very close and interactive manner. Though the warm sun outside beckoned, I believe this was the perfect finale for three full days of extensive learning activities.

A trip to Tampa would be incomplete without a visit to the Florida Aquarium. I took a relaxed tour of the aquarium after the workshop, visiting the lovely marine friends. When I boarded the flight back to New York on Sunday afternoon, I felt very content. It was also reassuring to see that ASCP indeed cares about resident education and needs. The meeting opened my eyes towards the new horizons in pathology and how many options lie before us for shaping our careers.

 

rifatpassportpic

-Rifat Mannan, MD is a second year Pathology resident at Mt Sinai St.-Luke’s Roosevelt Hospital Center, New York.

Resident Concerns, Part 1: Boards Prep

So I’m writing this blog while taking a break from the 2014 CAP Annual Meeting (I hate high heels and my feet are killing me from standing by my poster). As a resident, one of the most enjoyable parts of every conference that I attend is meeting and speaking with other residents. It’s even better if the conference planners organize specific events, networking receptions, or a resident lounge where residents can meet and socialize with each other and other trainees and pathologists. The CAP Annual Meeting is always good in terms of providing residents such outlets.

The best part for me is hearing stories of other resident experiences different than my own in addition to making new friends and colleagues. So my next couple blog posts will be about some of the topics that came up as the most important from the residents I spoke with: boards preparation, the fellowship application process, and networking/engagement opportunities for residents.

So, in terms of the boards, two themes seemed to emerge. First, many felt that the Resident-In-Service-Exam (RISE) does not correlate well with what we need to know to prepare for boards. For instance, this example was given to me: a decent percentage of questions on the RISE focused on forensics while most had heard that the boards have very questions dealing with forensics. My opinion on this topic is that it depends on what your expectations are concerning the RISE. If you are hoping that the breakdown of the RISE is a simulation of the boards in mini-form, then you might be disappointed. But if you like to advocate change for a different focus for the RISE, then I’d encourage you to bring your concerns to the RISE committee at rise@ascp.org and provide a cogent argument for your views…my motto is always, “you never know, the worse that they can say is no, so it’s better to try.” It certainly is not irrational to want our in-service exam to reflect what we need to know most for the boards and for real-world practice so let the RISE committee know.

Secondly, the topic came up of what is tested on the boards in terms of breakdown. I also wondered the same thing since I need to prepare chemistry and molecular pathology podcasts for for ASCP’s Lab Medicine Podcast Series and had no clue what would be high-yield topics that I could focus on (if you have a specific topic or test in these areas that you’d like a podcast on, please feel free to let email me and I’ll try my best).

So, I asked someone I know at the American Board of Pathology (ABP) about this issue. She directed me to the APCP Exam Blueprints which outlines the overall breakdown of number of questions in specific topic areas on the most recent board exam. I’ve also been told that they will post category codes for the various exams (ie – something like a “table of contents”) to the ABP website soon.

Looking at the blueprints, I have a better idea of some of the board topic areas that I will need to concentrate on (although there is nothing listed for molecular pathology but maybe there isn’t that much yet on the boards or it’s included within other AP/CP areas like soft tissue or hematology). And apparently, this is much more info than has been previously provided. But again, if you want a more detailed breakdown or other information that you can’t find on the ABP website, I also encourage you to communicate your concerns to Dr. Rebecca Johnson, the CEO of the ABP. Remember, positive change only occurs if there is a stimulus for change, and that stimulus can be you! As attendings, we need to be pro-active in questioning and changing the status quo for the better, so why not start practicing or acquiring those skills while a resident.

 

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.

Radiologic and Pathologic Correlations

So last night I stayed later than usual after work to prepare for an interdepartmental conference that I will be giving next Friday before I fly out that night to attend the CAP Residents Forum and Annual Meeting. A radiology resident and I will be presenting two cases together to correlate their radiology and pathology, two specialties that have much in common, at least on the surface.

Both radiologists and pathologists, at least pre-ACA era and except for subspecializations like interventional radiology and transfusion medicine, do not often interact with patients directly. Therefore, both fields rely heavily on clinical observations and notes written by the primary care doctors caring for “their” patients. Both also require a broad knowledge of disease differentials, and frequently, understanding the prognostic and treatment considerations of the disorder under examination even though they are not involved in direct care of the patient. Additionally, both fields require good communication with primary care physicians.

Senior radiology residents attend a month-long course correlating radiology with the corresponding pathophysiology of diseases at the Armed Forces Institute of Pathology (AFIP) now known as the American Institute for Radiologic Pathology (AIRP). I remember during medical school trying to set up an elective at what was then called AFIP but was not able to since it is only open to radiology residents.

At both my previous and current institution, the “rads-path conference” as it is affectionately called, is informal and driven by the radiology department in terms of case choices. It’s meant to be a learning experience but generally the only pathology residents who attend are the one(s) presenting while all the radiology residents available have to attend. Seems somewhat ironic that the learning is mostly one-sided, and it’s bad that our two departments don’t do this more as a true inter-departmental conference.

Pathology and radiology are two fields that also often get left out when publications are written even though our final diagnoses, and sometimes, even images are used within publication submissions. As residents in these fields, we should make an active effort to interact with our primary care counterparts frequently. We should do this not only to be included in such scholarly endeavors but also to show that we are also equal members of the patient care team and are not forgotten when treatment discussions take place.

It also happens with tumor boards as well that most of the choice of cases and topics for discussion come from the non-pathology department. So what are your opinions on how we should interact with other departments for patient care discussions and inter-departmental conferences?

 

Chung

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

General Versus Subspecialty Surgical Pathology Sign-Out

I’m currently on a month of neuropathology/autopsy at our main academic center. After 2 months at a busy surgpath site with a 1-1.5 hour drive each way, it’s finally nice to be able to take a breather. Here, I’m responsible for any neuro frozen and grossing that doesn’t go to the SP resident, helping with the cutting of autopsy brains, and sign-out of neuropath cases. Since we don’t have a heavy neurosurgery service, this allows me more time to learn at my own pace and I feel that I’m able to retain more.

Not including CP rotations, I’ve always learned more, retained knowledge, and performed better on the subspecialty rotations that I’ve had – hematopathology, pediatric pathology, and now neuropathology. While I acknowledge that part of this is my own fault because when I’m on surgical pathology (we do general SP sign-outs), I read up pretty much only on my cases. I know that I need to preview them for sign-out so I read up on the SP diagnoses and differentials. But I often am not motivated to read up on general systems, so I can be real hot mess (and as one senior resident called me recently, “stupid”) during unknown conferences. In CP topics and those subspecialty areas I’ve had rotations in, I’m quite the opposite and tend to excel.

Yesterday, was the first time I’ve been at consensus conference since my first year. At the community and VA hospitals where I’ve spent most of my SP rotations during my second year, we didn’t have group consensus conferences. I remember last year thinking during consensus, “please don’t pick on me to answer a question” during the inevitable pimp sessions that evolved. But yesterday, besides the fellow, I was the only senior resident present. But I was less apprehensive and intimidated than I had been when I sat in the same place the year before. So even though I don’t consider myself a person who is good at SP, I was adequate enough and I must have learned something over the past year without realizing it.

Obviously, how we teach surgical pathology is restricted by the type of sign-out practiced at the institution we are at and this often is dictated by specimen volumes, faculty expertise, and the cultural philosophy dominant there. Even though I thought that I had taken this question into consideration when interviewing and ranking programs, I realize now that I didn’t have a complete grasp on how training styles and cultures really would affect me. Probably since I’m graduate school trained first and naturally think more like a scientist that focuses on one area and learning everything about that area, subspecialty sign-out works best for me.

Before starting residency, I had an intuition that this was true but thought that I would eventually adapt to a general sign-out format since that is how my institution practices. And I’ve adjusted, albeit maybe not progressed as quickly as my peers. It’s difficult to maintain all surgical pathology as subspecialty unless the volume is high enough and this usually means a large, well-known academic center if that’s what you need during your training. The majority of residents will end up in private practice and many often train at places where the sign-out is a more generalized one. So how do we match our learning needs with practice requirements at our training institutions with our eventual responsibilities as a pathologist in terms of sign-out? I can’t say that I have a solution for this conundrum but would welcome opinions on the topic. What works best to train our residents in surgical pathology?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Balance Between Service Obligations and Education

These past couple of days I attended the CAP Residents Forum and USCAP in San Diego. It was both an inspiring and daunting experience. Inspiring because of the breadth and depth of research and amount of scholarly expertise in the room every time I attended a lecture; daunting because of this same fact and also because of the reminder that someday soon I will need to be as expert and competent as these speakers.

With these thoughts in mind, I attended the first half of the morning of the CAP Residents Forum for their “Dating Game” panel where new-in-practice and veteran pathologists spoke about to getting and keeping your first job. It was actually an engaging panel and I learned practical information that was new to me and that will help me not only to obtain my first job but also when I apply for fellowship in a couple of months.

I attended mostly molecular pathology talks and the cytology short course that for someone who hasn’t had cytology yet, was informative. I got to hang out with friends from other programs that I met through the CAP Residents Forum and to hear how they are taught the practice of pathology. These conversations got me to thinking about whether service obligations can compromise our education.

For someone who is CP-oriented, I am at a program that is heavy on the surgical pathology (we do 17 months; previous classes did many more). And most of us are trained at academic institutions but my program also has rotations at a VAhospital and two community private practice hospitals. Life is different at the community hospitals but I hear that most residents will go on to practice in this type of setting. The volume can be high, there may be many tumor boards/conferences to present at or attend, and the turnover time is so strictly adhered to that you might not always be able to get protected preview time – even if eventually you do get to sign-out with the attendings after they’ve verified a case.

But does it matter about protected preview time if you don’t look at the verified diagnosis before you sign out with your attending? Does your program have CP residents covering autopsy call? Do your residents gross on Saturdays? Just what constitutes service obligations interfering with resident education in your perspective? Working in a clinical setting, patient safety and service obligations can take on a predominant role, but the quality of our work cannot suffer. So what makes for the right balance between service obligations and resident education and what can we do to ensure that resident education is made a priority?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Resident Didactic Training – How Do You Learn Best?

Lately, I’ve been thinking about what I need from my residency training to become a competent pathologist when I graduate and how I learn best. I’ve never been a good audio learner so I don’t learn as much from a purely lecture-based education. And truth be told, I often skipped classes during medical school but wasn’t reprimanded probably because I did fine in my classes. It’s taken me years to realize but I learn best by making connections. Maybe it’s the scientist in me but I remember more, and can figure out the concept again if I forget it, if I understand mechanisms than by rote memorization. So for me, what I need most is time that often is not afforded in a live lecture. I often prefer to watch video recordings on pathology topics because I can stop the recording and think (or jot down a note or two). The “flipped classroom” concept works better for someone like me.

And so, this brings me to resident education. Unlike other specialties, we spend a lot of time on didactics. But there are many different permutations to how programs accomplish this objective. At my program, we have a lot of live lectures or multi-scope sessions. I faithfully try to attend (especially since we have a 90% attendance policy), but most of my attendings know that this is not how I learn best. Anything I have to learn by hearing on the spot has never been my strength.

But, I’ve found two methods at my program that do fit my learning style. First, we have a whole slide scanner. It’s great because we are allowed to scan slides to build our own virtual slide sets for repetitive study later if we so choose. Also, our surgical pathology director has given much of her time to annotating slides for us to use for “unknowns.” She can even compile data such as tracking how long it takes us to find an important required feature on the slide as well as our movements on the slide. She can also compare our scores from year to year if we use the same slide set (which we found didn’t significantly increase our knowledge if tested on the same subject the following year so we’re no longer required to do so).

With digital slides, I like having the option to go back and look over the slides as many times as I need. I didn’t realize how fortunate we were to have a slide scanner at our disposal until I presented some of this data at USCAP during my first year – many residents and attendings that stopped by my poster told me that they didn’t have access to digital slides or a slide scanner at their institutions. But looking at whole slide imaging (WSI) is a skill we all need to master since up to 2/3 of our AP boards can be digital (not glass) slides so I’m glad that I’m exposed to it early and throughout my training.

The second method that I found that really helps me to learn surgical pathology is the unknowns conference conducted at one of our four hospitals. We’re given four slides (which is the perfect number to cover in up to an hour) a couple of days in advance and the residents work together to come up with a differential and diagnosis. Since our attending always gives us papers on the diagnoses, we often read articles while we are working up the differential – which for someone who is used to reading journal articles and reviews, is right down my alley! We take turns during the conference driving at the scope and describe what we see at low then high power and then we give our differential and begin to narrow it down.

After each slide, our attending will reveal the correct diagnosis, point out salient morphologic features (especially with mimickers that can confuse us), and ask us about appropriate ancillary tests and expected results before giving us articles to read on the diagnosis. I’ve found that the interactive approach really helps but more so than that is the visual learning (ie – reading books and articles, googling on the internet) that I did to prepare for this conference. More important than getting the right diagnosis by “wallpapering” (ie – matching up a picture with the slide to reach a diagnosis) is the thought process to narrow down the differential.

And lastly, this is not specific to my program, but I am a strong supporter of open sourcing and sharing of free online didactics. I’ve often found great videos from other programs online or on YouTube to supplement my learning. So how do you learn best? Does your program provide all the tools that you need?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.