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.

The End of the Rotation

Since my program is on a monthly rotation schedule, last Thursday was the last day of my 2-month surgpath rotation at our busiest site, which is private practice at a community hospital that serves a more middle class and affluent patient population than our main academic hospital. So, it seems appropriate to finish my “Adventures in Grossing, Part I” post from 2 weeks ago now. As I think I mentioned in that previous post, my first day at this site (right after I just had gotten back from almost 10 hours of traveling due to layovers coming back from USCAP and getting a migraine during my flight to boot), was a disaster to say the very least.

I had made the mistake of jokingly saying to my rotation director that I was the most CP oriented of those in my year (I’m the last 2nd year to rotate at this site this year)…and he had mistakenly heard my statement as “I dislike surgpath and because of that probably wouldn’t work hard at this rotation.” We were reminiscing about it today as we had our face-to-face end of the rotation evaluation about how much has changed since that first day.

Communication is very important and sometimes that also entails knowing what not to say in a situation, especially if it can be misinterpreted. Luckily for me, after I had another talk with my rotation director, he was willing to ‘start fresh’ and see whether his initial impression of me held true. We did not work together again until the end of the month as I was assigned to other attendings during the interim. But by the time, we were assigned together again, he was “happy” with what he had heard about me from the other attendings.

As a first year, I had heard rumors about how hard this site and some of the attendings were…the stuff of legend so to speak. First years do not rotate at this site as we need to build up our grossing and time management skills to be able to adequately manage the higher volume of grossing at this site. We have a three-day schedule that includes two days allotted to finish grossing and a third intra-operative consultation day which includes frozen sections, sentinel node touch preps, and intra-op gross examination of specimens.

I still need to work on my grossing speed and time management skills but after two months of instruction and experience at this site, I do recognize that I have improved. It’s almost the end of my second year and I generally do fine with diagnoses at sign-out because they are either things I’ve seen before or things that I have some time to read about prior to sign-out. But when it comes to unknown conferences or my RISE surgical pathology scores for the past two years, I know that I am horribly deficient and need some work.

In two months, I will be transferring to a much smaller program in my home state for personal family reasons. My medical school friend will be one of the chiefs next year and one of their incoming first years is also from my medical school. Plus, they rotate mainly at one site and do 1-2 rotations/year at another site that is near where my parents live and where I went to medical school. So it will be different than my current program which has 27 residents that rotate at four sites. The culture also seems very different and I worry that I may be behind the curve in terms of my surgical pathology (SP) knowledge. I’m not worried about CP as my strengths and background are in CP.

So, I’ve been wondering…what are some good resources to learn SP and some good approaches to learn while busy on rotations? I still haven’t found a good solution to these questions yet.

 

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.