Tag: residents

Pathologist and Pathologist-in-Training Engagement as Patient Advocates

I’m used to being surrounded by people who are passionate about transforming systems. I’ve spent many years involved in organizing grassroots movements, health advocacy, and health equity campaigns in the minority and immigrant communities. And the year before I started residency, I studied for a masters degree in public health where I focused on these same issues,  along with more scientific training in molecular and infectious disease epidemiology. But as a resident, I have had to make some tough choices.

Even though I am back in Chicago where I attended college and first got involved working with minority and immigrant health issues, my community organizing, for now, will take a back seat to my education and service duties. And even though I sometimes reminisce about and miss the electrifying momentum involved in pushing toward such social change, I know that once I’m finished my training that I can return to contributing to these movements again on a more personal level. So I’m fine with the decisions I’ve had to make. We all have to make choices about what is most important at that specific time in our lives.

And so as a resident, I’ve focused my thoughts and efforts on how to create a movement within pathology to question our role on the clinical patient care team and to engage those in our profession to respond to this question – reasons why I got more involved with ASCP and CAP. With the gradual implementation of portions of the ACA since 2008 that is now moving into a more palpable phase, pathologists, tech staff, and residents have an opportunity to show our worth to the health care team. We have the opportunity to show that we are the experts in data interpretation and that in terms of more complicated testing such as flow cytometry, cytogenetics, or molecular tests, that the pathologist would be the best person to order the most appropriate tests.

No one knows better that we do what are the costs, indications, and limits of specific tests and despite what non-pathologists may think, we were trained just as they were in how to work up a patient and differential diagnosis. So who better to choose the right test for the right patient at the right time? I know that pathologists have the reputation of being not the most vocal or interactive doctors so how do we engage not just our leaders but also pathologists in general to take more ownership of patient care decisions and to speak up? How do we train our next generation to also see this as the big picture?

In grassroots organizing, strategy requires an understanding of the power dynamics and forces involved in decision making within the system one wants to change. So what drives pathologists and pathologists-in-training and how do we light a fire within our profession not to waste this opportunity that has been provided by health care reform to redefine our role within the patient care team? How do we nurture true patient advocates? I’ve been a little frustrated with these thoughts lately so please leave a comment with suggestions on how you think that we can accomplish these goals.

 

Chung

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

Are Pathologists and Primary Care Physicians Ready for the Genomic Era and Personalized Medicine?

I was reading about the FDA’s recent crackdown on 23andme to stop marketing their saliva based whole genome testing and interpretation service. Rather than resist, 23andme decided to comply and is currently in “talks” with the FDA so that they can complete the process for FDA validation and again begin to market their kits and testing. For now, they can continue to provide their genealogy testing and whole genome sequencing without interpretations.

Currently, in some academic research centers, whole genome or exome sequencing via next generation sequencing (NGS) methods is utilized on a limited basis by researchers and clinicians to identify pathogenic mutations. NGS and bioinformatic analysis methods continue to steadily improve and costs have been decreasing. However, there are limitations and barriers to widespread use at this point. These include but are not limited to: 1) widely used databases such as the Human Gene Mutation Database (HGMD) and the Online Mendelian Inheritance in Man (OMIM) still only contain information that only covers a fraction of the human genome, 2) more research is still needed to identify more variants mutation-disease associations, and 3) most mutations identified fall under the category of “unknown clinical significance”.

Tools such as NGS, despite its improvement over previous technology, still cannot identify large deletions or copy number variations (CNV) and is a technology not accessible, cost-wise and support-wise, to most health care institutions. Despite all of this, primary care physicians, even now, still may be confronted with patients who bring them their genomic screening results, whether obtained from commercial services provided by companies like 23andme or through molecular testing through a health care institution. But today’s physicians, including primary care physicians and pathologists, were not trained in medical school to understand how this testing is performed or the significance of these results. But the time is coming, and maybe sooner than we realize, when we will have to deal with such testing on a daily basis.

So, it is imperative that we train our doctors and doctors-in-training now to be ready for when that time comes. But, my question this week is “How should we go about it?” Additionally, who should compose the health care team to provide guidance and counseling to patients once results are available? And who should regulate how testing should be done and what information should be included in results reporting? Leave me a comment if you have an opinion or any ideas.

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.

Acknowledging and Transforming Pathology Stereotypes

I find that in interactions with other specialties, even attending physicians who far surpass me in age, that many have very little idea of what pathologists do. Those who do not work closely with pathologists are the first to mention CSI, forensics, autopsies, and an office in a windowless basement morgue. In fact, I recently heard the story that when a group of attendings and residents from another specialty along with their medical students were told to meet a pathologist for a teaching session in the anatomic pathology department…that they waited outside the locked morgue door before realizing that no one was there and that the morgue was not probably not the intended meeting location.

And for those who work more closely with pathologists, there exists a spectrum of attitudes and perceptions about our profession. We have surgeons who were trained “old school” style with six months of surgical pathology during residency who will sit at the multi-headed scope during intra-operative consultations and who know more than beginning junior residents. Hematology/oncology physicians often stop by hematopathology to look over slides together or to discuss a case. And then there are those who think that pathologists exist to provide them only with diagnoses and who do not look at us as equal members of the patient care team. I’ve heard some even question a diagnosis without ever seeing the slide and others grumble or joke that pathologists take too long to render diagnoses.

I’ve more than a few times had to call attendings, residents, or fellows to recommend canceling an inappropriately ordered test or less commonly, to suggest ordering an indicated one. I found that this more often occurs when there is not a strong differential of diagnoses. Even so, I still have the person on the other end of the line bellowing at me that they just MUST have this expensive molecular test ASAP.

Recently, a medical student who is interested in pathology told me that some residents from a non-pathology rotation harassed and made fun of this student for choosing pathology as their future career. I could continue with more examples but instead I ask this question, “Why is pathology as a field not valued?” especially with respect to specialties like surgery where there is a heavy reliance on pathologists to provide them with diagnoses?

I believe part of the reason lies in lack of exposure to the practical and daily aspects of pathology as a legitimate medical field during medical school. Furthermore, those who chose pathology as a career are often not personality types who proactively engage in promoting or advocating on behalf of the profession, especially at the state and federal levels. We also subconsciously contribute to this issue. For example, we often refer to all non-pathologists as “clinicians” as if there is a difference between these types of doctors and pathologists even though we all completed four years of medical school.

So, what are other reasons do you think contribute to the undervaluing of pathology as a profession, and more importantly, what can we do to change these stereotypes and misconceptions? Let me know by leaving a comment.

-Betty Chung

What are Important Must-Haves in a Pathology Residency?

So, we’re about 1 month into our interview season for resident candidates for our 2014 PGY-1 cohort. Each year, answering prospective candidates’ questions over lunch forces me to re-evaluate what I was looking for when I was in their shoes and what opinions have changed since then. I’m always surprised at myself that some things that I thought were initially important are not so much now and vice versa. So I always tell the “prospies” (a word we used when I was in college) to try and figure out what is most important “must-haves” for them and at least make sure that the programs they are looking at have those characteristics and resources.

But as I’ve learned, as time passes, some of those things will change…while some will not. For me, coming from a research and public health background, it was important to me that I could do basic science, translational, and molecular epidemiology research during residency….and that I would have these types of opportunities and that my program and faculty would support me in these endeavors. I wasn’t as interested in the “brown stains” or case series type of research as much that I see coming out of virtually every program that also includes my own. Not because there is anything wrong with that type of research either but just that my exposure and interests weren’t along those lines.

One of the interviewees today said something interesting to me. He said that he read on the websites of the programs he is interviewing at how they supported resident research. But that when he specifically asked about it was discouraged and told that residents don’t really have time for research in between their service duties. To me that seemed contradictory to the branding that these programs’ website at least made an attempt to endorse which was interesting but not entirely surprising.

For me, “fit” was a lot more important than a prestigious name and I interviewed at some high-powered programs, too. But I wanted a program that worked with an underserved minority or immigrant population (most of my advocacy work has been with these groups), made changes based on resident feedback to improve their program (I don’t like or thrive in “top down” situations), and supported each resident’s unique needs and goals. I wanted a program that would support and didn’t limit conference attendance and participation in leadership roles, both within the program and within the profession…a program and faculty that would work with me to do those things that would benefit my professional goals and allow me these freedoms even if I was on a surgpath rotation and not try to fit residents into a “one size fits all” mentality. Don’t get me wrong, like all programs, mine has some very real kinks as well. But I think that I’ve found some great and supportive mentors, PD, and chair who allow me to create the non-traditional experience I seek.

So what did or do you are think are “must-haves” for a residency and did those ideas change over time? Leave me a comment if you like.

-Betty Chung

Fellowship Choices…Choices…Choices…

So, I’m almost halfway through my PGY-2 and starting to think more seriously about what fellowship to apply for next year. According to the ASCP 2012 Fellowship and Job Market Survey, 69% of residents surveyed decided on their choice of fellowship during their PGY-3 year while only 18% decided during PGY-2. Coming from a heavy research background, I always knew I would do at least a fellowship in molecular pathology and genetics – and I totally enjoyed and rocked my molecular pathology rotation. So that told me that at least I was thinking in the right direction.

But even though I often thought about pursuing CP only, I could never commit to it for fear of not getting a job once I was done training. It was even suggested to me to change my application to CP only by an interviewer at one of the top CP programs when I interviewed for residency and even then could not fully commit. My PGY-1 RISE scores also would support that I am more CP oriented since I either scored near or greater than the PGY-4 average in most CP subjects.

But now, I’m glad I decided to go AP/CP and to wait on that decision until the end of my PGY-1. It was then and at the start of my PGY-2 that I was assigned 3 consecutive months of hematopathology. And for 2.5 of the 4 weeks of my time at the VA, my attending was on vacation so I got more autonomy and had to meet those expectations or I’d be in serious trouble. Sink or swim time. But it was a good experience and made me think about combining a hematopathology fellowship with the intended molecular pathology. Hematopathology was only peripherally on my radar coming into residency even though I enjoyed the hematopathology I did during my hematology rotation at the NIH during medical school. I actually had entered residency thinking I’d do a second fellowship in clinical microbiology and a portion of my MPH concentrated on infectious disease diagnostics, surveillance, and epidemiology in addition to molecular epidemiology.

But I was fortunate during my hematopathology rotations. Sometimes, it takes the perfect storm of unexpected experiences and mentors to really change your perspective, to see something that was always there but not so obvious…at least, not until you’re ready to see it. I didn’t realize before, even though I had done a month of hematopathology previously, that it paired so well with my interests in molecular pathology. Currently, I’m still mulling over the idea in my mind but only in terms of how some personal aspects of my life will affect my abilities to perform in certain settings. And unfortunately, these things may end up dictating my choices more than I’d like. But for now, I’ve put off the final decision to early 2014 and feel a little more breathing room because my journey has become a little bit clearer.

So, did you have a “light bulb” moment or a special person who helped you decide on a choice of fellowship? Let me know in the comments section.

-Betty Chung

What Are Better Ways to Learn and Retain New Pathology Concepts?

So, I’m curious…how are pathology concepts taught in your program and are these methods effective? We use multiple modalities in my program. We have mandatory core curriculum didactics three mornings each week, 2 days of AP and 1 day of CP. Additionally, we also have either cytology (lecture or multi-headed session) or hematopathology interdisciplinary conference on alternating Fridays. On some Tuesdays, we have invited guest lecturers for grand rounds. During PGY-1 while on our “intro to SP” rotations, we had additional histology, gross organ, and subspecialty didactics.

And even though, we have 4 sites, those who cannot be at the main site for lecture, teleconference in to the core lectures. So, our mornings are pretty full and it almost feels like we’re still in medical school during our clinical years with needing to balance service work with didactics. This year, they’ve tried to make the curriculum more interactive with more pre-assigned virtual slides or reading, occasional pre- and post-didactic quizzes, and a case-based rather than lecture-based structure.

And this is before all the tumor boards, morbidity and mortality, interdisciplinary specialty conferences, journal club, conferences, and CP call conferences that we make presentations that require prior research. So, sometimes, I’m amazed that in the midst of all this, that we can fit in all our service duties. We also make consistent use of our slide scanner – to create virtual re-cut sets for study, prepare presentations, and put together educational modules (at least our attendings do for this last one). And I didn’t realize until I met other residents at conferences, that heavy use of virtual slides isn’t the norm everywhere so I feel fortunate. And of course, there is sign-out (and sometimes, grossing) with the attending and learning from our fellows.

So in terms of the aforementioned, I expect that many programs teach utilizing a similar mix of modalities. But how do you learn on your own personal time? I’ve never been a student who would win an award for lecture attendance but since our “core” is mandatory, I attend most despite the fact that I don’t learn best in this way. I’m not a big textbook reader either – I have a decent number of books but can’t say I’ve finished any entirely. Having been graduate school trained initially, I’m much more of a journal article reader, which for me, as a CP-inclined resident, works well when I’m on CP rotations where I tend to excel more than I do on AP.

But what is the best way to learn on AP rotations? As an artist, I like pictures and there are some good websites (and even textbooks out there). But most days, I come home too tired to retain anything even if I could read more than for the pre-assignment for our “core”. I have to admit…I have not figured out that secret yet and would love to hear your thoughts. How best do we learn and retain pathology concepts?

-Betty Chung

 

What Type of “Graduated Responsibility” Do We Need in Order to Gain Competency?

Building on the brief historical piece I wrote last week about the progression toward “competency-based” resident training and the ultimate outcome of evaluation by the Milestones, I’d like to ask, “How can residents achieve competency in training?”

A resident recently stated at the most recent CAP Residents Forum that true graduated responsibility means to be able to verify a case, whether surgical pathology or frozen section, and I would guess clinical pathology results were implied, without the oversight of an attending. As a PGY-2, I am not sure I can agree with that statement. But who knows, maybe closer to graduation, I might. How many of us would be a Milestones rating of “4” by the end of our funded 3 or 4 years, and therefore, competent enough to theoretically verify a case on our own?

I would like to repeat some statistics from the 2013 ASCP Fellowship and Job Market Surveys: only 16% of residents felt they were ready to sign out general pathology cases upon graduation and 95% intended to seek fellowship positions. 59% of PGY-3 and PGY-4 felt that they needed fellowship training to feel confident in general pathology and 17% to address a perceived educational deficiency. So, if this is a true, then the majority of us may not feel comfortable verifying general pathology cases, with the possibility of malpractice, even as a PGY-4.

Even though I cannot verify cases, I still feel that my program has given me the opportunity for graduated responsibility. For instance, I began to enter my diagnoses into our electronic surgical pathology reports before the end of my first month of training. Then during sign out, my attending would teach me as well as correct my diagnosis prior to verification. As I mentioned before, I learn by doing and even more so by being wrong, than by reading or being lectured to so this works for me. I have the safety net of being allowed to be a trainee while applying and improving my developing surgical pathology skills. And for me, being able to verify or not, would not change how I approach my cases or my diagnoses.

Our PGY-2 and above, are encouraged to work up a case (eg, order stains, etc) prior to sign out at our academic and VA hospitals (not sure about the community hospitals since I haven’t rotated at them yet), even if it is not our names that go on the final “dotted line.” We don’t all reach this point at the same time – it is about trust in our knowledge and skills by our attending and our initiative to broach the subject before we can do so. At the start of my PGY-2, I was ordering flow cytometry panels on cases because my attending trusted my hematopathology skills.

So, for me, at least for now, “graduated” responsibility is in the eye of the beholder and I have been nurtured to be where I need to be at this point in my training. I feel that I have the freedom to grow under our system. So, what does “graduated responsibility” mean at your institution? Let me know by leaving a comment.

-Betty Chung

CAP 2013 and My First Residents Forum

This past weekend, I attended my first College of American Pathologists (CAP) Residents Forum (RF) and Annual Meeting in Orlando, FL.

I had previously served as a delegate to the Student Osteopathic Medical Association (SOMA) House of Delegates (HOD) during medical school when I was my school’s chapter president. I was also the alternate delegate for the state of NJ at the American Osteopathic Association (AOA) House of Delegates when I was on the Council of Osteopathic Student Government Presidents (COSGP). And lastly, for the three years I served on the DO Advisory Board for the American Medical Students Association (AMSA), I wrote DO relevant resolutions for AMSA’s HOD.

In all three of my previous experiences with an organization’s HOD, I actively participated in some shape or form in voicing the opinion of those I represented – whether through writing resolutions or debating and voting on resolutions. In this manner, I, and other delegates like me helped to shape the final form of our organization’s constitution and by-laws. And this is the mindset with which I attended the Residents Forum and even ran for the position of alternate delegate to the CAP HOD on the Residents Forum Executive Council.

However, I must have misunderstood the purpose of the RF and I think it worked out that I did not win the position I ran for. What I had expected and wanted was to participate in a resident caucus to identify the consensus opinion on resident-relevant HOD resolutions similar to my previous experiences as an HOD delegate – to see my fellow residents empowered and engaged in the parliamentary process. Don’t get me wrong…I did enjoy meeting other residents at the RF – that was one of the highlights of my experience and I made some new friends who are also passionate about transforming the future of our profession.

The talks were also informative for many of the first-timers although most of the topics were not new to me and about content that I had heard before during my work with AMSA and my MPH studies. But that doesn’t take away from the fact that it was resident-relevant information that each delegate could take back to their programs for their co-residents. So, my experience was mixed in terms of what I had expected and what I saw as benefits for delegates who attended.

Then, I presented a poster during the CAP conference, listened to the keynote by Dr. Eric Topol (although I did not agree with everything he said, it was thought provoking and informative), attended didactics, and participated in a mock fellowship interview with one of the CAP Board of Governors. But the encounters that I enjoyed most were those when I discussed the future of our healthcare system with physicians that I met. I did end the conference on a good note as I found out that I was chosen as the resident/junior member on CAP’s Council on Education for the next 2 years.

-Betty Chung

“Light Bulb” Moments During Residency

After four months on CP rotations, I am now on a 2-month surgical pathology rotation at the VA hospital where we have a 2-day grossing schedule. While it is not as busy as the two community hospitals I will rotate in surgical pathology at in 2014, the time away from anatomic pathology brings some trepidation as I feel I’ve lost some expertise in this area. Use it or lose it. But again, it helps to have a great support staff that makes life easier by helping me out and providing me with daily laughs to make the day go by faster and almost feel like I’m not at work

While I remember being stressed when I started my 3-month “intro to surgical pathology” rotation last year as a PGY-1, a lot has changed in a short year. Last year, I felt as if there was so much that I did not know but eventually a time came, without my even realizing it, when I got most of my diagnoses correct. Clinical pathology rotations were inherently easier for me due to my research and grad school background and my comfort level in the lab setting. But since I am in an AP/CP track, its important to maintain perspective as well as skills in both disciplines.

To accomplish these goals, I approach service duties on each rotation with the same diligence. I don’t play favorites even with those rotations that I find easier, more comfortable, or more likely to be my future choice of subspecialty. There is always something I can learn and I give each rotation and every patient that same respect. Next, I learn by performing my duties with as close to the same responsibility level as my attending as I can. I find that I learn more by “doing” than by just studying. This is especially true if I interact with all members through the clinical care process – from technicians to attendings to primary care physicians and other subspecialists, not just to deliver diagnoses but to help influence healthcare decisions. This was especially true on my lab medicine rotations. But I understand that this learning style may not be the same for others.

For whatever reason, PGY-2 feels as if it has flown by more quickly, probably because I have more responsibilities and also cover night/weekend calls. But whatever what advice I or another senior gives their junior, people will only listen when they are ready to hear and have their “light bulb” moment. I know it took me a while to understand the significance of much of what I was told last year…Are you ready for your “light bulb” moment?

I will leave tomorrow to attend CAP HOD and to present a poster at the CAP conference (where I probably won’t get to visit Disneyworld). I’ll let you know how it goes in my blog post next week!

-Betty Chung

 

ASCP Annual Meeting: Empowerment and Forward Thinking

Last week, I attended subspecialty talks as well as informative sessions on policies that will affect the future and practice of pathology at the 2013 ASCP Annual Meeting in Chicago. I also attended special events such as the Keynote given by Hillary Clinton, the Raible Lecture for Residents about the “Pathology of Bliss: Searching for the Happiest Place to Work,” the Training for Residents in Genomics (TRIG) workshop,  multiple receptions, and the president’s black tie dinner. To top it off, I also presented during the poster session and saw old friends as well as made new ones.

But what I am struck by most about the myriad of experiences and conversations that I had last week is that as 21st Century physicians, we need to be forward thinking to contribute at a systems or global level. Sometimes, as Americans, we can be insulated and shortsighted, and as physicians we are not exempt. In the midst of talk of multiple technologies, often expensive and not available routinely at many institutions, focus on resident boards review sessions, and subspecialty relevant talks, it is easy to forget that we can transform the delivery of healthcare in this country and throughout the world not just by what we learn but also by what we do, especially in resource limited settings.

Currently, over 70% of diagnostic and treatment decisions are made based on the results of laboratory tests in this country.  Much needed health reform will increase coverage for all but will also place an emphasis on outcomes based compensation. Therefore, we need to build interdisciplinary interactions between lab staff, pathologists, and other healthcare providers to work on common goals, and work together to perform the “right test, for the right person, at the right time”. We just have to work smarter, not harder. Our challenge as residents is to not bury our heads in our books or go through the motions, but to see the “bigger picture.”

-Betty Chung