Another Mayo Pathology

[DigitalLove]

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Dear all,

This is the first time I have been on this site and am glad something like this exists; it would have been helpful when I was a med student. I am a resident in pathology at Mayo, and I wanted to introduce myself if anybody had any questions about the program. I suppose that you will just have to take my word for it that I am telling you at least my opinion of the truth here in Rochester.

Needless to say, I also wanted to (hopefully) clarify a little bit about our AP/frozen section bent, which basically means I am going to give you a biased opinion as I am favorably inclined towards the whole process.

To make it as simple as possible, everything that we see using the Tol Blue stain is processed the next day on standard H and E with immunos ordered up-front. For ~90% of the cases, the team (staff, fellow, and resident) feel confident giving a diagnosis. Those weird cases, which, like many other big centers, you will see plenty of at Mayo, we will "hold over" and give our diagnosis the next day. Surgeons come in and out all the time and correlate their findings.

I think of the Tol Blue stain as enabling us to get a taste of the gross specimen immediately, which is great for those who don't have long attention spans and want to see the micro immediately and then again the next day. The stain has made me better at paying more attention to architecture and fine nuclear detail. As a resident, I will gross my specimen (the big cases) and run over to the scope to see the micro and give my impression. The next day I see everything again, which can be 600 slides from the previous day.

We don't really preview anything, we are expected to give our diagnosis immediately. Reading comes afterward; actually, we probably learn by attrition; there is more seeing cases rather than reading about the differential (which itself is a great way to learn too, but different than ours). Diagnostic pathology comes first; then you do research - the staff at Mayo want to make us the best H and E morphologists that we possibly can be in the short amount of time we have.

Please feel free to post something in response, whether you agree or think I am full of it, or if you just wanted a little more info. There are a lot of great places to train, probably too many. Path residents seem very individualistic in the ways that they approach their learning - Mayo offers a variation on theme.

 

[dodobird13]

I'm familiar with the process there. It's interesting and I'd like to watch for a day, but I'm not sure how training that way can prepare a resident for everyday life at their "real" job (which, presumably, will not be at Mayo, and will thus be quite different).

 

[yaah]

Well, everyday life involves making confident diagnoses, so it does train you for that. There will be an adjustment period as you change systems, but since every single graduate of mayo's training program that I have run into says there is no problem making that adjustment, I am inclined to believe them (despite what assumptions might be).

The one thing I worried about with the Mayo system was that the residents seemed to be more of a peripheral component to the fellows - and at least in the sense of the frozen section material, were not really making a primary diagnosis very often.

 

[DigitalLove]

In response to yaah; I would agree with you to a point. First year, I did feel that way. There has been a change in frozen section in that there is more graduated responsibility for the residents.

However, if you are more timid and quiet about getting involved in the final diagnosis, you may get left behind. What residents here have been doing more and more of is communicating with the consultant that we would like to manage those cases we grossed the next day and having a chance to agree or disagree with the prior day's diagnosis.

 

[rockit]

In response to yaah; I would agree with you to a point. First year, I did feel that way. There has been a change in frozen section in that there is more graduated responsibility for the residents.

However, if you are more timid and quiet about getting involved in the final diagnosis, you may get left behind. What residents here have been doing more and more of is communicating with the consultant that we would like to manage those cases we grossed the next day and having a chance to agree or disagree with the prior day's diagnosis.

It seems like you're saying that you have to put in a lot of effort just to get the training you're supposed to be getting at baseline. Is it frustrating to have to put in that much effort just to get a crack at tissue diagnosis?

 

[Pianoboe01]

There has been a change in frozen section in that there is more graduated responsibility for the residents.

When I interviewed, I was told the graduated responsibility consisted of one hour at the scope as a first year, two hours as a second year, etc. Is this accurate or has it changed?

 

[DigitalLove]

You have to be on your toes to be the one to make the first diagnosis, but during the day, the attending, fellow, and the resident make the diagnosis as a group. Frozen section is our opportunity to gross complex specimens, and so much care is put into gross diagnosis that for things like ovarian, pancreatic, hepatobiliary, renal, inflammatory colons and such, the gross really tees up the diagnosis. The microscopy is easy to follow, and you can take a look at the slides while the fellow and attending are also looking at the case. You just have to pick your times when to do this; for some cases it is great, for others the microscopy may not help as much (inflammatory colons and neoadjuvant cases).

I have to mention that the cases that you grossed come back to you and you basically take care of that case. This can be a lot of stuff, depending on how many things you grossed the previous day.

That comment about scope time at the sink is true; sometimes you wish it was more time, sometimes less.

 

[112641]

Dear all,

This is the first time I have been on this site and am glad something like this exists; it would have been helpful when I was a med student. I am a resident in pathology at Mayo, and I wanted to introduce myself if anybody had any questions about the program. I suppose that you will just have to take my word for it that I am telling you at least my opinion of the truth here in Rochester.

Needless to say, I also wanted to (hopefully) clarify a little bit about our AP/frozen section bent, which basically means I am going to give you a biased opinion as I am favorably inclined towards the whole process.

To make it as simple as possible, everything that we see using the Tol Blue stain is processed the next day on standard H and E with immunos ordered up-front. For ~90% of the cases, the team (staff, fellow, and resident) feel confident giving a diagnosis. Those weird cases, which, like many other big centers, you will see plenty of at Mayo, we will "hold over" and give our diagnosis the next day. Surgeons come in and out all the time and correlate their findings.

I think of the Tol Blue stain as enabling us to get a taste of the gross specimen immediately, which is great for those who don't have long attention spans and want to see the micro immediately and then again the next day. The stain has made me better at paying more attention to architecture and fine nuclear detail. As a resident, I will gross my specimen (the big cases) and run over to the scope to see the micro and give my impression. The next day I see everything again, which can be 600 slides from the previous day.

We don't really preview anything, we are expected to give our diagnosis immediately. Reading comes afterward; actually, we probably learn by attrition; there is more seeing cases rather than reading about the differential (which itself is a great way to learn too, but different than ours). Diagnostic pathology comes first; then you do research - the staff at Mayo want to make us the best H and E morphologists that we possibly can be in the short amount of time we have.

Please feel free to post something in response, whether you agree or think I am full of it, or if you just wanted a little more info. There are a lot of great places to train, probably too many. Path residents seem very individualistic in the ways that they approach their learning - Mayo offers a variation on theme.

We have a couple attendings here who use the Tol blue stains at the frozen station to get a preview while the residents and techs do the H&E and deepers on the frozen section. I wish more of them did it, it takes 20 seconds and does give you a great idea of the diagnosis.. forces you to look both at general architecture and cytology on the same slide.... and just looks cool.

I think it would be a grueling, long, nearly impossible adjustment for me to read 600 slides in a day. Other than that sounds like a great system.. When I interviewed there for fellowship the residents all seemed very happy with how things were done too.

 

[DigitalLove]

I appreciate your post, and I have a very similar opinion. It would be cool if we incorporated more H and E frozen section; and there are ways to make it quick. Some of our faculty feel the same way, but right now it is a tough time to change with so much other junk going on that doing something that would require more money and time may not get greenlit. Therefore, the system won't change anytime soon.

It is a lot of slides, which is why I think we learn pathology more by seeing a bunch of junk quickly and repeatedly rather than good previewing and forging a differential. The fellow does have to see it all. Staff that have come here from other places feel the same way as to our training - specifically, very different training philosophy here than the one at MGH.

During consult/elective rotations, you get first crack at everything and preview just like other places. There are tons of consults; I wish we could do those rotations earlier, but then again I would have no idea what I was looking at. I think there are days I prefer the preview philosophy rather than the look at it for a little and get asked "what is it?". Both modalities, I have to admit, have their advantages, and they probably get you to the same goal.

Thanks to everyone for letting me talk about Mayo a bit; this place is different. Although there are things I wish I could change, I like this place a lot, and in terms of training, I do believe that I get fantastic training and lots of attention. Most importantly, I love coming in to work.