Residency Program Standards

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BlondeDocteur

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I was curious if anyone here has any knowledge of the accreditation standards for pathology residencies.

We keep close track of every surge path case a resident sees during training (does everyone's program?) in a sort of 'case log.' As of now the ABP only requires the famous 50 autopsies and occasionally asks to see evidence of procedures like FNAs (occasionally)-- there are no objective standards for the number, spread, complexity and accuracy of the cases a resident sees during their training. Though I hear we're supposed to be responsible for 2000 cases over our 4 years.

This is in sharp contrast to other fields. In surgery there is a '750 major case' requirement to graduate and become board-eligible. But this can't just be any random collection of 750 cases: the resident must have performed at least a critical part of the case in order to be able to log it, and the distribution across organ systems and the type of procedure is meticulously detailed. It's logged on a central site-- every resident in every program in the US uses the same one.

(If anyone wants to see it, it's here: https://www.acgme.org/acgmeweb/Portals/0/GSNatData1213.pdf)

What would you think about adopting such a system for pathology? Obviously we see/workup many more cases than the average surgical resident would and I don't think it's necessary to break it down into every possible tumor type. I think it could help objectively assess programs and whether or not they are able to expose residents to an adequate array of specimens and cases in their training, and would be certify people to be ready to practice general anatomic pathology when they graduate. (Maybe it would work for CP-- I can see it adapted for blood bank in particular-- but that's a black box for me on which I can't comment).

If you think it's a terrible idea, how would you objectively assess which residencies are adequate and which should be shuttered?

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I think the RRC for Pathology should increase the numbers for certain procedures residents should complete in order close certain programs that won't meet them. There are tons of programs listed the "Grossing Workhorse" programs that should be effectively closed.
 
"Procedures" probably isn't the right word here, since true procedures in pathology are very limited and hardly form the crux of your educational experience. But I do agree with you; pathology residency absolutely needs to expose a resident to esoteric zebras as well as the bread and butter; reading is not sufficient IMO.

The case log we keep is very simple-- the case #, our preliminary diagnosis before signing out with the attending, and the final diagnosis.
 
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My program was beginning to institute this as I was finishing, a list of things you were required to gross in and sign out, to make sure everyone got exposure to a larynx, a whipple, large mandible resection, etc. Also had # of FNAs performed, bone marrows performed. This began to be mandated as PAs started doing more and some residents were getting less exposure. The boards required you to list a few things in terms of numbers you had done, but didn't have any requirements apart from the autopsy number. I did zero bone marrows and don't ever plan on doing them.
 
The new buzzword in pathology resident education is "milestones". Every aspect of pathology resident education is going to be evaluated (i.e. number and types of cases, diagnostic acumen with respect to PGY level, etc.). I left residency training as this was coming into existence, so I don't know where it stands presently.

I will say that grossing is one of those things that needs to be delicately balanced. You absolutely have to know how to competently handle complicated specimens to function in most pathology environments that are stable. Even if you're not the one grossing the specimen in, you're still responsible for the quality of the dissection and by direct proxy, your final diagnoses. But at the same time, a program shouldn't have residents as PA's at half cost. Perhaps, and maybe naively, I believe this is an effort to finally weed out those programs that just have residents as cheap labor.
 
Yale's path department has software that tracks resident cases and apparently serves some educational functions also, like comparing resident's vs. attending's impressions. If the ABP is counting autopsies of all things, they should absolutely be counting surgical pathology cases.
 
Exactly, that's what we do. I hope it's part of a data-gathering stage that will be the basis for setting objective standards of exposure to cases & competency. My PD sits on the Path RRC so I have reason to hope.
 
We have to do at least 10 FNA's and 10 bone marrows in order to graduate. We also have extensive credentialing documents (prior to the milestones) for each rotation of skills/knowledge that we should be competent in by the end of that rotation. They tell us that these are "living documents" that will follow us after graduation. We also log surgpath specimens but only for the first 3 of each type like everyone else has to do. And most end up with 70-80 autopsies by fourth year but that's including ME cases where we do more than just observe. And we're not a "grossing workhorse" program. For us, since most go into private practice, they want to train residents who can do everything in case they are called upon to do it.

The reality of it is that you just might not see certain specimens if you don't have an active service in that area (eg - laryngectomy/ENT) at your hospital. And just because you graduate doesn't mean you won't end up grossing, even placentas which we all find to be a bloody mess....I met multiple practicing pathologists at the CAP conference last week who are older than me (so its not just because they're just fresh out of fellowship), who still do their own grossing and sometimes on Saturdays. So if you can't gross well, you might get fired if your partners expect you to gross or to tell your PA's how to gross their complicated specimens. Most people want to go into private practice but unless you train at a place that has a private practice hospital, you may not really understand how the pressures are different than working in an academic center which is where the majority of us train. Sure, there are private practices with a lot of $ that may pay techs to do those things you don't like, like grossing biopsies and placentas, but then you better be good to get those jobs because from what I've been hearing, its a tight market out there with multiple pathologists doing locums or working for pod/private GI/GU labs that I know.
 
The case log we keep is very simple-- the case #, our preliminary diagnosis before signing out with the attending, and the final diagnosis.

How can you possibly track all of the cases you see? There would be thousands upon thousands.
 
That's how. You just write them all down, each day. It takes all of 2 minutes.
 
That's how. You just write them all down, each day. It takes all of 2 minutes.

How many do you see in a day? Where I trained it would have been hundreds and virtually impossible to log them all.
 
At my program, the LIS had a place for the resident's name to go. This made logging quite easy.
 
How on earth are you signing out hundreds of cases a day? These are the ones you're actually responsible for, the slides you preview & sign out with an attending.
 
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How on earth are you signing out hundreds of cases a day? These are the ones you're actually responsible for, the slides you preview & sign out with an attending.

Ok, maybe "hundreds" was an overstatement. But 50 wouldn't be. Do you really hand log all that data for 50 cases per day?
 
Ok, maybe "hundreds" was an overstatement. But 50 wouldn't be. Do you really hand log all that data for 50 cases per day?

I tend to agree with this sentiment. Towards the end of my residency my program wanted to better track grossing, and required all cases grossed to be logged. The way our program was structured, that was anywhere from 1 to 4 cases most days on surg path rotations. Even that was somewhat time consuming. I'm not doubting you BD, rather just saying that I can see it being a fair onerous task to log (whether by hand or on computer) every single case you preview and are responsible for. On biopsy heavy services such as GI or gyn, I have no problem believing a resident previews 60 or more cases each day. Logging those, even at 30 seconds per case, is real time. That said, in the modern world if it's not in writing, it didn't happen. It's a tough balance for PDs.
 
Hmmm... what standards? do you mean whether or not pathology residencies have a standard to meet? According to ACGME RRC for Pathology, they do have some standards that are supposed to apply to the program like for the material that is available at the institution and to the PD who works with the residents. I don't think that ACGME applied the minimum standards to Mount SInai Medical Center's Pathology program because Firpo-Betancourt was kicked out of Puerto Rico pathology department and from his dean job after multiple litigations for employment discrimination and government contract issues. Fipro-Bentacourt then apparently somehow got a job at AFIP, just before it shut its' doors. He said he had some government defense contracts, probably this had to do with writing some bogus book on bugs or whatever. In any case, Firpo was not practicing pathology but he still has a job as a program director... scary, if ACGME is actually following any standard here, which it appears they are because they haven't stepped in to stop this appointment. As for Cordon-Cardo, the NIH sunk what must have over 20+ million dollars over the past 20 years into his lab that lead to some bogus lab known as Aureon and some shady lab in Spain too. In any case, is there a standard for pathology residency programs, the answer is maybe, but if you were to review Mount Sinai Medical Center in New York, the answer is a no and they fail because Cordon-Cardo and Firpo-Betancout, these people got their jobs because there are no standards.
 
Hmmm... what standards? do you mean whether or not pathology residencies have a standard to meet? According to ACGME RRC for Pathology, they do have some standards that are supposed to apply to the program like for the material that is available at the institution and to the PD who works with the residents. I don't think that ACGME applied the minimum standards to Mount SInai Medical Center's Pathology program because Firpo-Betancourt was kicked out of Puerto Rico pathology department and from his dean job after multiple litigations for employment discrimination and government contract issues. Fipro-Bentacourt then apparently somehow got a job at AFIP, just before it shut its' doors. He said he had some government defense contracts, probably this had to do with writing some bogus book on bugs or whatever. In any case, Firpo was not practicing pathology but he still has a job as a program director... scary, if ACGME is actually following any standard here, which it appears they are because they haven't stepped in to stop this appointment. As for Cordon-Cardo, the NIH sunk what must have over 20+ million dollars over the past 20 years into his lab that lead to some bogus lab known as Aureon and some shady lab in Spain too. In any case, is there a standard for pathology residency programs, the answer is maybe, but if you were to review Mount Sinai Medical Center in New York, the answer is a no and they fail because Cordon-Cardo and Firpo-Betancout, these people got their jobs because there are no standards.

<deleted> Never mind, read post history.....
 
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Yes-- it's pretty bare-bones. Case #, residents dx, final dx.
 
As I alluded to above, some places have a program that talks to the LIS so logging is basically automatic. If you look at the case and enter preliminary diagnosis, the data is stored and no additional time is required. Every program should use something like this.
 
In the program I have seen, accuracy can be tracked, and can be broken down by specialty to see where one's weaknesses are. Great tool.
 
Based on my experience, the whole idea of ACGME is to minimize the ACGME residency program requirements for accreditation in the fake world of accreditation standards versus real compliance measures for obtaining billions in medicare funds; and also, ACGME allows reduction of compliance necessary thru their guidelines for compliance to some imaginary standard (because I think that unaccredited programs can still receive federal medicare funding dollars for residency programs), I talked to the ACGME lawyer and some lady Beane who were totally not on point about the role of ACGME. They told me that they can basically go around doing whatever they want, as long as the complainant is not a white male of some sort. I also know that they typically only take complaints from non-minorities seriously because they most certainly did not care about any of my concerns or my well-being but they did fight for the white guy/girl when they complained to ACGME and protected his/her identity. I thought that they (ACGME) was extremely disrespectful towards me and it appeared that they were trying to actually push me around for even contacting ACGME about my concerns.

I think that a lot of other people had the exact same experience when they had dealt with ACGME. This organization is irrelevant in dictating the competency and relevance of medicare funded programs because they simply do not comply with a set of standards that they already purport to have. ACGME oversees residency programs and they need to oversee how well the programs are staffed and what kind of supervisors like program directors and chairs of departments that the residents in residency programs are being exposed to because I most certainly should not ever have been exposed to, let alone work at all in any capacity as resident in a pathology residency with Fipro-Betancourt or Cordon-Cardo as these people are incompetent in Pathology and just terrible human beings. Firpo-Betancourt was retired from medicine for years and he is not practicing for a good reason. Cordon-Cardo has never done a pathology residency, is not qualified to make any diagnosis or supervise any physicians in the residency program, and is not even qualified to be a chairman of a pathology department, especially one with a residency program.

The standards to be a pathology program director is relatively strict because I know that Fallon was totally unqualified to be a program director as much as he wanted to be one. He didn't have the requisite requirements such as the necessary board certifications. Although, simply having board certifications also does not qualify you to be a program directly. Unfortunately, he was given the chairman position at a residency program, despite the fact his certifications were sketchy. I worked with him directly and I know that he didn't show up to work regularly and he didn't sign out his cases because he didn't want to come in to work. It appears that he didn't want to pay for the daily parking passes since he didn't get the yearly passes (http://www.nytimes.com/2006/06/02/nyregion/nyregionspecial2/04cteye.html?pagewanted=print&_r=0) Apparently, Lento, former program director at mount sinai medical center/ hospital in new york city, who apparently was banned from various activities for his misconduct, is actually working with Fallon now, not surprising at all. These pathologist are unbelievably crazy!
 
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Member0007:
"Based on my experience, the whole idea of ACGME is to minimize the ACGME residency program requirements for accreditation in the fake world of accreditation standards versus real compliance measures for obtaining billions in medicare funds; and also, ACGME allows reduction of compliance necessary thru their guidelines for compliance to some imaginary standard (because I think that unaccredited programs can still receive federal medicare funding dollars for residency programs), I talked to the ACGME lawyer and some lady Beane who were totally not on point about the role of ACGME. They told me that they can basically go around doing whatever they want, as long as the complainant is not a white male of some sort. I also know that they typically only take complaints from non-minorities seriously because they most certainly did not care about any of my concerns or my well-being but they did fight for the white guy/girl when they complained to ACGME and protected his/her identity. I thought that they (ACGME) was extremely disrespectful towards me and it appeared that they were trying to actually push me around for even contacting ACGME about my concerns.

I think that a lot of other people had the exact same experience when they had dealt with ACGME. This organization is irrelevant in dictating the competency and relevance of medicare funded programs because they simply do not comply with a set of standards that they already purport to have. ACGME oversees residency programs and they need to oversee how well the programs are staffed and what kind of supervisors like program directors and chairs of departments that the residents in residency programs are being exposed to because I most certainly should not ever have been exposed to, let alone work at all in any capacity as resident in a pathology residency with Fipro-Betancourt or Cordon-Cardo as these people are incompetent in Pathology and just terrible human beings. Firpo-Betancourt was retired from medicine for years and he is not practicing for a good reason. Cordon-Cardo has never done a pathology residency, is not qualified to make any diagnosis or supervise any physicians in the residency program, and is not even qualified to be a chairman of a pathology department, especially one with a residency program.

The standards to be a pathology program director is relatively strict because I know that Fallon was totally unqualified to be a program director as much as he wanted to be one. He didn't have the requisite requirements such as the necessary board certifications. Although, simply having board certifications also does not qualify you to be a program directly. Unfortunately, he was given the chairman position at a residency program, despite the fact his certifications were sketchy. I worked with him directly and I know that he didn't show up to work regularly and he didn't sign out his cases because he didn't want to come in to work. It appears that he didn't want to pay for the daily parking passes since he didn't get the yearly passes (http://www.nytimes.com/2006/06/02/nyregion/nyregionspecial2/04cteye.html?pagewanted=print&_r=0) Apparently, Lento, former program director at mount sinai medical center/ hospital in new york city, who apparently was banned from various activities for his misconduct, is actually working with Fallon now, not surprising at all. These pathologist are unbelievably crazy!
Last edited: Saturday at 7:30 AM"


These are very interesting observations from a keen observer with what appears to be standing on this matter and I wonder what or if anything, ACGME will do to follow up on these issues.
 
The only way you are going to become even borderline competent is if you have a thirst for knowledge. Read the books as if your life depends on it, because it does. Seeing the slides of 2,000 cases in residency is laughable. Try 20.000.
 
Thanks Blondie for the interesting thread. I've been saying for years that the way the ABP approaches resident teaching and experience is bone-headed. Right now we are only required to spend a set amount of time in surgical and clinical pathology rotations (aside from the 50 autopsies), and there is no standardization of what should be included in that time. This is at the heart, IMHO, of the discrepancies between institutions. The ABP recommends (it is NOT required) that a resident sees ~4000 surgical cases prior to completion of residency. Some places just barely see or fail to see that volume/resident; others see that volume in less than one year. Is there any wonder then, why there is such differences in quality of trainees and opportunities at the end of training?

I think there should be a list of major types of surgical cases that need to be seen, and that for each subspecialty you should have to record a certain number of them. For example, you should do at least 10 radical prostatectomies and 20 prostate biopsies. Graduated responsibility is great, but you need to be exposed to the meat of the business. I remember as a second year resident (having seen >4K surgicals in my first year) I was horrified by the lack of knowledge of many of the fellows who came to my institution for a surgical pathology fellowship. We should set a standard number of necessary cases per year as well as a checklist of necessary specimens, so residents don't get stuck seeing 3000 gallbladders or TAs.
 
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