Residents Prepared to Signout After 4 Years?

It is actually two years of AP only (out of the four years). One can argue by saying that you can read AP during CP rotations and attend the AP conferences. This can be true but it is not like being directly engaged in the field. Moreover, most of these two years are gone for grossing. Unless you have a previous experience in pathology (as do some foriegn MDs -who are already pathologists overseas and join residencies in the States- and unless you receive intense and vigorous training during those two years, my answer to your question is a big NO.

Anyone can sign out after the residency but the more important question is about the level of accuracy of the reports. I can easily answer your Q with yes if you just want to do "any kind" of sign out.

Being confident in reading cytology INDEPENDENTLY (both Gyn and non-gyn) as well as handling surgical cases -especially the complex neoplastic ones with issuing a full report covering all things clinicians want to know plus doing frozen sections...high skills in doing all this cannot be obtained within 2 yrs only.

This has been disucssed before in another thread where it was shown that MOST of residencies do not prepare residents for real life-practice. Most of residencies are service-oriented focusing on grossing and other service work!!. This is just my opinion.

I would say that most residents in my program are ready after 4 years AP/CP and 1 year fellowship. The poster above is correct that AP only is two years, but during your CP years at most programs you will still be participating in AP conferences, reading AP books and doing AP projects. According to recent CAP stats something like 66% of trainees only do one fellowship and they tend to do just fine when they start practice (i.e. they don't get fired, etc). Granted, they are not Rosai himself after 5 years training, but they are competent and able to practice independently.

As the above poster also stated, it depends on the program. Many programs are indeed just having the residents gross the majority of their surgpath experience while some programs have you preview, dictate and polish up reports even in first year. It all depends. Ask around at your program and see if residents are getting jobs and being successful after just one fellowship. If they have been consistently doing this, then you are likely to as well. If most of the residents at your program are doing 2 fellowships, then I would definitely consider doing two fellowships. Also, in some regions of the country it is customary to do two fellowships whereas in others it is customary to do one. So there is that factor as well.

To directly answer your question, I can't evaluate whether anyone is competent to sign out and practice independently after only 4 years of AP/CP because I don't know anyone who has done that.

Good question...but honestly who cares? Only 3% of residents get jobs...the opportunity won't be there. Programs don't care...CP training at a lot of programs is proof of that. (they probable care more about AP..don't want you to screw up the gross).

The answer...depends on the individual and their comfort level. Make sure you can sleep at night. Do the fellowships if thats what it takes....you have to anyways do to the lack of jobs.

I knew a small handful of residents who I think -could- have jumped into a real sign-out job straight after residency, but to my knowledge none of them did, instead opting for at least one fellowship. I can't comment on their personal level of confidence, though (except for one who had been a pathologist overseas before and was quite confident - he still did a fellowship!). Just that I would have had confidence in them doing a good job, which includes knowing their limitations. That would've been..what..maybe 15% of residents, when I was going through?

I went into forensic path, and even after a fellowship signing my first death certificate and first autopsy report technically unsupervised was a harrowing -- though not "difficult" -- experience. It's like taking the training wheels off; no matter how jacked up and unused they had been, if anything getting in the way of you doing everything you felt you could, when they're first off it's very easy to feel like you're plummeting to the ground while doing something extremely stupid. Nevertheless, in most situations you will still have one or more elders around to keep you grounded and provide just enough of a safety net until your confidence builds.

I also absolutely agree that many/most residency programs are service oriented, with making confident independent pathologists important but still second fiddle. I would love to see more programs really -have- every resident function independently by the last 6 months or so of their final year, rather than pay lip service to it while maintaining co sign-out with them. Secondary review should be separate by that point, with questions/disagreements sent back to the resident. It -should- take longer to get a final result out, as that's part of academics.

I wonder if the perceived lack of confidece/ability in 4th year residents comes via the nature of AP training. In general, we have absolutely no responsibility until we finish residency. We never have to make a tough call. Ever. That is a direct result of attendings not being able to bill for diagnoses they do not provide themselves. Contrast that with other departments, like medicine, where residents essentially run the service and attendings are often made aware of decisions after the fact. They are definitely ready to do what they do after 3 years of training. Their attendings also cannot bill, but seem not to care (the hospital bills and it's up to the patient to decide not to pay, but the department does not get the money from what I've been told).
Why could we not have preliminary Dx like rads (or autopsy)? I think that would go a long way to help residents.

Hospital billing is a little more complicated than that, but the crux of the point I think is accurate. Pathology residents, in general, handle non-billable service work, and sit in on billable work. Unfortunately that's exactly the stuff residents are -supposed- to be being primarily trained in. Not that everything else isn't important, but much of it becomes routine after a few months or so.

The argument against "preliminary" results released by residents in surgical pathology, since radiologists do it, seems to be that any physician can interpret a radiology image -- everyone is trained to to some extent, so even if the resident is wrong, the clinical attending should be looking at the images themselves and deciding if they agree. This doesn't really hold true with pathology; even if everyone had functional basic training, the majority of the time there's no easy way to see the histology image. And, unfortunately, surgeons have a tendency to be impatient and act on preliminary information, as everyone knows from chatting around the frozen-section scope.

Personally, I think creating a culture which includes pathology resident preliminary findings can work. But the culture has to depend on clinicians.

Yes, it's possible to do. There are a few "fellowships" (such as the one that I'm in now), usually filled with people right out of residency, which provides independent signout responsibilities. It has been a stressful transition, but it can be done. Some people are more ready for the role than others, but it helps to have a lot of warning in order to prepare as well as possible. For example, I spent a lot more time studying AP than CP, but fortunately passed both parts of the boards.

My understanding is that some fellowship programs intentionally avoid ACGME accreditation because CMS will not allow trainees to bill, as discussed above. Thus, those fellowships are like junior faculty positions in regards to responsibility level but have more of a safety net built in, as you can always ask the faculty if unsure of your dx. Is this essentially accurate?

gbwillner said:

I wonder if the perceived lack of confidece/ability in 4th year residents comes via the nature of AP training. In general, we have absolutely no responsibility until we finish residency. We never have to make a tough call. Ever. That is a direct result of attendings not being able to bill for diagnoses they do not provide themselves. Contrast that with other departments, like medicine, where residents essentially run the service and attendings are often made aware of decisions after the fact. They are definitely ready to do what they do after 3 years of training. Their attendings also cannot bill, but seem not to care (the hospital bills and it's up to the patient to decide not to pay, but the department does not get the money from what I've been told).
Why could we not have preliminary Dx like rads (or autopsy)? I think that would go a long way to help residents.

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Because in any instance where a prelim dx would be desired is way too important to have a trainee giving it. Radiology is more of a triage field while pathology is a definitive field. Wrong prelim dxs could cause umpteen problems in many cases. Heck ,we hear about groups that don't want anyone without five years post training experience. There is a reason for that. Even after residency we are still apt to cause problems. Imagine a 2nd year resident. Yes first year and second year rad residents can read middle of the night films, but they don't give chem or chop of limb or tell someone they have cancer based on radiology

Yes, many can and do. But many can't. I think the defining question is:

How many reports do residents write/dictate?

Note that the question is NOT "how many scribbles do residents make on post-it notes that are not directly part of the report?" In some programs, residents dictate the cases, make corrections after getting attending feedback, and the attending just hits the sign button at the end. In other (most?) programs, residents don't write/dictate reports (or they might only write autopsy reports). It is amazing that such programs (perhaps the majority of them?) are allowed to exist and hire residents as grossers and cheap pathology assistants while feeding them the "you learn all that in surg path fellowship" nonsense. No, many residents learn it from the beginning of residency and in every rotation. Why wouldn't residents write/dictate at least some reports on every rotation? It would be like an internal medicine residency requiring residents to write "what they think" on some post-it notes stuck to the patient chart, while the attending removes the post-its notes and is the only one who actually writes in the patient chart. Of course the analogy is not perfect, as an attending pathologist has to sign out the case whereas resident internists can write notes, orders, etc. That doesn't preclude pathology residents from writing reports that are then signed by an attending. The obvious question is, "why doesn't every program require residents to write/dictate reports (that are then signed by the attending)?" In other words, what *exactly* is preventing it from happening in the places where it (resident training) doesn't happen?

The short answer to the original poster's question is: if you routinely write/dictate reports that look identical (or almost identical with some non-content style changes) to what is signed by the attending, then I think you are well-prepared for practice. If you haven't done this routinely, then you're not ready yet. If you're in a program where this doesn't routinely happen, leave the program ASAP, because you are being taken advantage of as a cheap grosser. You can't change the culture, but you can get trained elsewhere.

Rodak said:

... if you routinely write/dictate reports that look identical (or almost identical with some non-content style changes) to what is signed by the attending, then I think you are well-prepared for practice. If you haven't done this routinely, then you're not ready yet.

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At my program residents dictate and write up complete reports for every case from day #1 in first year. I can't imagine not doing this and it makes me wonder what residents are doing with their time at programs where they don't do this.

zao275 said:

My understanding is that some fellowship programs intentionally avoid ACGME accreditation because CMS will not allow trainees to bill, as discussed above. Thus, those fellowships are like junior faculty positions in regards to responsibility level but have more of a safety net built in, as you can always ask the faculty if unsure of your dx. Is this essentially accurate?

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Right. We are technically junior faculty for one year. As this is a surg path fellowship equivalent, ACGME accreditation wouldn't apply anyway. There is faculty backup to ask questions, but it's not much different from a normal attending position, in that it is almost entirely at your discretion what and how much to show. I don't think I'm showing that much more than the full faculty, to be honest, except showing some more to the "junior faculty" perhaps. It is nice to be able to show difficult frozens around, though, during the workday.

Answer: zero. Or almost zero percent of residents are 4 years of combined AP/CP (ie- a mere 2 years of AP) are able to competently sign out INDEPENDENTLY general anatomic pathology.

If there is/was someoneone able to do it, I havent met them at UCSF, Stanford, Brigham, UCLA/USC, MGH, WashU or Hopkins etc...getting the picture?? Maybe Juan Rosai back in the late 60s springs to mind as a possible.

I have seen over 1/2 a dozen sorry former trainees that BELIEVED they could though and then quickly got over their heads at truly independent sign out situations, places where they are the sole provider (rural areas, small hospitals etc). They made huge mistakes that ended their careers fairly quickly.

A vast majority of people do some type of fellowship and even then spend 6+ months showing a huge number of their cases to senior partners/staff.

Heck, Ive been at places where recent trainees will walk in with 1/2 their caseload to show to people...fairly pitiful but the facts of life at the moment.

I would say the current methods employed by a vast majoriy of training programs to teach pathology are horrendous and it really shows.

Another thought... If you are not doing a general surgical pathology fellowship then you pretty much have to be ready to sign out most cases with 4 years AP/CP alone. For instance, if you do a GI fellowship you will not be any better at breast or skin pathology than when you were a 4th year resident. If you do a hemepath fellowship, cyto fellowship, GU fellowship, etc, etc, all the same situation. Basically your skills as a PGY-4 are as good as they are going to get before you start practicing.

A lot of people are capable of independent signout after four years. Generally what they lack is confidence. Programs don't do a great job of getting residents to gain that confidence. It can be gotten by taking a lot of initiative on your own and making the most of your time though.

Unty said:

Two questions,

What % of the residents in your outgoing class are prepared to signout independently and confidently after four years (in cytopath/surgpath)?

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Define "independently."

pathstudent said:

Because in any instance where a prelim dx would be desired is way too important to have a trainee giving it. Radiology is more of a triage field while pathology is a definitive field. Wrong prelim dxs could cause umpteen problems in many cases. Heck ,we hear about groups that don't want anyone without five years post training experience. There is a reason for that. Even after residency we are still apt to cause problems. Imagine a 2nd year resident. Yes first year and second year rad residents can read middle of the night films, but they don't give chem or chop of limb or tell someone they have cancer based on radiology

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I think pathstudent makes a very strong point here.

2121115 said:

At my program residents dictate and write up complete reports for every case from day #1 in first year. I can't imagine not doing this and it makes me wonder what residents are doing with their time at programs where they don't do this.

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We did the same where I was in residency, and I felt this was very useful as it forced us to commit to our diagnoses (=confidence).

pathstudent said:

Because in any instance where a prelim dx would be desired is way too important to have a trainee giving it. Radiology is more of a triage field while pathology is a definitive field. Wrong prelim dxs could cause umpteen problems in many cases. Heck ,we hear about groups that don't want anyone without five years post training experience. There is a reason for that. Even after residency we are still apt to cause problems. Imagine a 2nd year resident. Yes first year and second year rad residents can read middle of the night films, but they don't give chem or chop of limb or tell someone they have cancer based on radiology

zao275 said:

I think pathstudent makes a very strong point here.

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Interesting, because although I feel I understand the argument, I don't really agree. If you don't think imaging is "definitive" in terms of determining the next step in management, ask someone who gets their skull, chest, or abdomen opened when it turns out there was nothing to treat. And, really, I've seen and heard many cases where imaging + clinical correlation = cancer diagnosis, without bothering with a tissue diagnosis -- mostly individuals with other problems who generally go straight to palliative care, but that's a pretty significant decision in and of itself, no? I do, however, think that most surgeons/physicians performing a significantly invasive procedure without waiting for a final report (trauma, acute hemorrhage/perforation, etc.) take at least a half second to look at the images themselves before sinking steel into flesh. They may be wrong or the images misleading, but they share responsibility. In pathology they often don't, despite the common comment "clinical correlation is recommended" or in this case "preliminary interpretation only, final results are pending."

Of course, I also think that with rare exceptions a "prelim" pathologic diagnosis can and should be ignored by clinicians for immediate treatment purposes until a "final" is released. It's NOT that hard to NOT tell a patient "there's no tumor!" until the final is actually available, but it still allows clinicians to begin to mentally prepare for a possible next step -- exactly what, I think, prelims are for. If the final is that important to them, they'll call, and give residents all the more opportunity to learn what to do (and not to do) for next time.

That pretty much leaves frozen sections and peripheral smears in some circumstances, where a rapid confidently accurate interpretation makes a significant difference, which I think can be addressed without cutting the legs out from under pathology residents trying to become independent pathologists.

Do programs with "hotseat" rotations make residents more comfortable pulling the trigger on diagnoses though? I thought the concept of those programs was to alleviate this issue.

There is actually an interesting white paper discussing resident training from the Archives of Pathology.

I dunno about any formal results, but hotseat helped -me- a lot. Although, it wasn't quite as I had envisioned it.. I had about the same time to look at a case as usual before the attending swung by anyway, sat down, and tried not to say anything but usually failed. It felt more collegial and less on-the-spot? Something like that. So although everyone else didn't treat it much differently, mentally thinking of myself as being on the hotseat actually made a difference. It may have been different because I already had a forensic path fellowship lined up and was focused more on passing AP/CP at that point than trying to free myself solely as a burgeoning surgical pathologist.

In retrospect, a 3rd year hotseat rotation may have been more useful and a better kick in the pants. By 4th year the relationship with most of the attendings was already pretty informal and collegial, answering questions more than telling me what to say or do.

I did my surg path fellowship at Wash U, and I really believe that it gave me a lot more confidence in signing out cases when I finally became an attending. Knowing that I was accountable (if only for a day or two) to clinicians to nail the diagnoses for dozens of cases every day really pulled my training together: not only did I have to know what I was looking at, I also had to know what to say to the clinicians, how to say it, how to convey any legitimate uncertainties, etc. The hotseat rotation is what everyone talks about at Wash U., but the frozen section rotation also did a lot to season me: our rotation had two fellows and a senior resident, and we never had to show a case to an attending unless we wanted to. Lots of opportunities to screw up, but the responsibility made us grow up fast.

KCShaw said:

Interesting, because although I feel I understand the argument, I don't really agree. If you don't think imaging is "definitive" in terms of determining the next step in management, ask someone who gets their skull, chest, or abdomen opened when it turns out there was nothing to treat.

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Touche'. ;-)

I think that we truly need MUCH more in the way of hot-seat, REAL graduated responsibility, etc to make training more robust and adequate. So I agree with you, but am trying to play Devil's advocate. I guess I am saying that I do understand the reticence of those who object to the idea of prelim diagnoses of cancer. That is just not built into the thought process and thinking at many institutions. As was stated above, it really is not a problem in and of itself, provided the culture is changed so that surgeon and others realize this is the way things are being done. I imagine that at WashU everyone understands the concept of a prelim diagnosis, correct?

I'm definitely with you on the hot-seat/true graduated responsibility.

And..y'know, I do get some of the rationale for concerns about path prelims. I probably should add that, were they widely utilized, the culture on the pathology side needs to include some adaptation too -- learning hot-button issues which should be carefully worded on prelims, and so forth. Not least because those will be the same diagnoses/specimens that will always need particular care, prelim or not.

I've received some answers (see below) to my question in my previous post: The obvious question is, "why doesn't every program require residents to write/dictate reports (that are then signed by the attending)?" In other words, what *exactly* is preventing it from happening in the places where it (resident training) doesn't happen?

PS This question of having some real responsibility or a resident-centric service could apply to any rotation or service (AP, CP, etc) instead of having work go directly to the attending and bypass the resident.

The answers so far have been:

1. Blame the residents: "Our residents aren't capable enough to do that." Circular reasoning. How do you know they aren't capable? Or put another way, "If you think you need more exposure, then you should do a fellowship (even though most/all our residents do fellowships because they are unemployable coming out of our program!)."

2. Blame the budget/unions: "We don't have enough histology people or equipment or transcriptionists to get reports or slides out early enough for meaningful preview or report writing and still make turnaround time."

3. Blame the attendings' perceived increased work demand of correcting residents: "What work will it save me? I'll still have to look at everything myself, and I'll also have to correct reports, lots of reports, and do (more) teaching in addition to what I'm already doing now." I can't wrap my brain around how incomprehensible this rationalization is, but I heard it from more than one person as an attending rationalization.

4. Combination of the macho continuation of the cycle of abuse and fear of grossing skill atrophy: "Residents really need to gross as much as possible to be well-trained. When I was a resident, I would gross 96 hours straight everyday and I didn't eat, drink, use the bathroom, or breathe anything other than formaldehyde. So you should too. If you can't handle simple grossing, your amateur hands definitely aren't allowed to try to (gasp) write a real report for me to sign."

5. My all-time favorite: "You learn that (i.e. practicing pathology) in fellowship (or during the first few years as a junior attending)." i.e. not in 1300+ days of apprenticeship!

Rodak said:

1. Blame the residents: "Our residents aren't capable enough to do that." Circular reasoning. How do you know they aren't capable? Or put another way, "If you think you need more exposure, then you should do a fellowship (even though most/all our residents do fellowships because they are unemployable coming out of our program!)."

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Residents are not capable to dictate a diagnosis line or a microscopic description? No way.

Rodak said:

2. Blame the budget/unions: "We don't have enough histology people or equipment or transcriptionists to get reports or slides out early enough for meaningful preview or report writing and still make turnaround time."

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This may be true, but other programs don't seem to have this problem. Not sure how to address that one.

Rodak said:

3. Blame the attendings' perceived increased work demand of correcting residents: "What work will it save me? I'll still have to look at everything myself, and I'll also have to correct reports, lots of reports, and do (more) teaching in addition to what I'm already doing now." I can't wrap my brain around how incomprehensible this rationalization is, but I heard it from more than one person as an attending rationalization.

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This is the most bogus reason. Having someone dictate a report for you speeds you up even if they are wrong. Even if they are wrong the skeleton of the report is already in and you just have to edit the details. If they are so wrong that they can't even set up the report in the correct format, all you have to do dictate to transcription to just delete everything there and start over. This takes virtually no additional time and after residents have learned at least how to set up the report (i.e. after a couple of weeks) it actually saves time.

Of course, if residents are not getting enough meaningful preview time to dictate anything, then there is a whole other issue at play here that needs to be addressed.

Rodak said:

4. Combination of the macho continuation of the cycle of abuse and fear of grossing skill atrophy: "Residents really need to gross as much as possible to be well-trained. When I was a resident, I would gross 96 hours straight everyday and I didn't eat, drink, use the bathroom, or breathe anything other than formaldehyde. So you should too. If you can't handle simple grossing, your amateur hands definitely aren't allowed to try to (gasp) write a real report for me to sign."

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When you here practices complain about hiring recent trainees it is not because the recent trainee is having to show them too many gross specimens.

Rodak said:

5. My all-time favorite: "You learn that (i.e. practicing pathology) in fellowship (or during the first few years as a junior attending)." i.e. not in 1300+ days of apprenticeship!

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LOL.

stickyshift said:

I did my surg path fellowship at Wash U, and I really believe that it gave me a lot more confidence in signing out cases when I finally became an attending. Knowing that I was accountable (if only for a day or two) to clinicians to nail the diagnoses for dozens of cases every day really pulled my training together: not only did I have to know what I was looking at, I also had to know what to say to the clinicians, how to say it, how to convey any legitimate uncertainties, etc. The hotseat rotation is what everyone talks about at Wash U., but the frozen section rotation also did a lot to season me: our rotation had two fellows and a senior resident, and we never had to show a case to an attending unless we wanted to. Lots of opportunities to screw up, but the responsibility made us grow up fast.

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WashU surgpath is the business.

I sat in on 1 resident/fellow conference where the attendings road the trainees so hard there was crying, now THAT is a training program. Old School

LADoc00 said:

WashU surgpath is the business.

I sat in on 1 resident/fellow conference where the attendings road the trainees so hard there was crying, now THAT is a training program. Old School

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At least they finally stopped hitting us when we got incorrect Dx's!