Grossing Biopsies

[coolpath33]

Hi all,

Currently applying to Path residencies, and fortunate to be interviewing at some of the "top" programs in the country. There are some old threads from many years ago that have mentioned this, but I was hoping you all could give me some updated advice. It seems like nearly all reputable programs have stopped having their residents gross biopsies (and even some placentas, etc) and have moved that responsibility to techs or PAs - the idea being that it isn't the least bit educational and takes away from valuable learning time. Well, there was a very well-respected program that I really liked, but the residents spend usually more than 1 hr every day on surg path grossing biopsies. They have PAs and techs and I think they do some of the biopsies, but the residents are still left with a lot each day.

My question is... I should be weary of this, right? An old post called this a "red flag". I know its a great program, but I am interviewing at other top programs that I like which don't make residents do that. It's not about grossing more - I would be ok with doing more bigs - but this is just not educational. Is this a big enough deal to rank this program lower in favor of other great programs I enjoyed which simply didn't do this?

Your thoughts are really appreciated, thanks in advance!

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[malchik]

I wouldn't rank the place.

 

[LoaLoa]

If the program is otherwise strong, I wouldn't let it stop you from considering the place. But don't let them sell it to you as a plus. In the past, I've heard such chestnuts proffered as, "Grossing biopsies is the most important thing you can learn, because that's how the initial diagnoses are made." Lies--grossing biopsies is mindless scut--but no residency program is scut-free.

 

[Thrombus]

As a pathologist who gets to earn a small percentage of what he/she bills (after endless fees, regulatory shakedown, and outrageous taxation), I love grossing biopsies!

As a resident who didn't have any incentive to work hard or go surf the internet, I hated it!

Tell the program director you feel you are getting worked over for others to make money off your back. Ask them why they feel entitled to do so and if it makes them sleep well at night? Ask them why they get to keep the majority of the money that CMS pays them while you do most of the work!

 

[Johnny Sunshine]

I believe that there are way too many factors that go into determining a department workflow to know if this one thing is a sign of a problem.

The simple fact is that programs can and will use residents to reduce their needs for technical staff. Having one resident in your program gross biopsies for an hour a day doesn't sound bad at all, if indeed that is all that's going on. Just because it's a "red flag" doesn't automatically mean that the whole program is problematic. There could just be some unknown personnel issues or something.

I guess it would depend on what else you witness going on there. I agree grossing biopsies has zero educational value, but if for whatever reason they need help in the grossing room for an extra hour or two I would much rather crank through some mindless biopsies than to get involved in big cases that may follow me around for days or weeks.

 

[pathstudent]

I believe that there are way too many factors that go into determining a department workflow to know if this one thing is a sign of a problem.

The simple fact is that programs can and will use residents to reduce their needs for technical staff. Having one resident in your program gross biopsies for an hour a day doesn't sound bad at all, if indeed that is all that's going on. Just because it's a "red flag" doesn't automatically mean that the whole program is problematic. There could just be some unknown personnel issues or something.

I guess it would depend on what else you witness going on there. I agree grossing biopsies has zero educational value, but if for whatever reason they need help in the grossing room for an extra hour or two I would much rather crank through some mindless biopsies than to get involved in big cases that may follow me around for days or weeks.

ACGME is pretty clear that residents aren't supposed to be engaged in non-education activities. I think one could argue that there is nothing educational about grossing biopsies. They can hire someone off the street and train them to do that for almost nothing.

 

[Blaster1492]

That sole issue would move it down my rank list. If you're a competitive applicant there are simply other options at top programs where they use that time for educational purposes instead. Figure you spend an hour per day, 5 days a week, for 12-14 months of surg path...that's a LOT of hours of learning you could be doing instead if you used the time to read/preview. And they don't need PAs for this either...just techs. It's like having an internal medicine resident draw their own blood or take their own BPs...

 

[mlw03]

I agree with the others. This is a department not wanting to pay for additional tech support in their gross room. It wouldn't be a deal breaker for me, but it would be a huge red flag.

 

[2121115]

Red flag.

But, as mentioned above, there are no programs with zero scut work.

 

[malchik]

Well there's scut and then there's scut. Grossing biopsies is about as menial as it gets.

 

[yaah]

I may be in the minority but I still think it's important for residents to get some training and experience in grossing bits and biopsies. You learn about what can go wrong, how little things are processed and how important certain steps are. That being said, you don't need to do tons of this to learn enough. But doing none of it isn't going to help you either. So yeah, you don't want a program where you are frequently grossing in bits and biopsies.

 

[Torsed]

Switch to Derm?

 

[Pathologee]

I wouldn't let it affect your decision too greatly. If you like the residents, like the attendings, and it fits for you, rank it. It doesn't take that long to gross biopsies. It may be an hour or two of your time, it's not every single day, and you can do it while listening to an osler lecture or some smooth jazz. Also, it is not completely devoid of educational value. You would be shocked at how often a piece of skin comes in the frozen section room with one suture at a tip, and the resident looks at it like a monkey doing a math problem.

Scut work exists in all fields of medicine. Interns having to insert foleys or IVs think it is beneath them. Surgery residents take H&Ps, remove staples and change dressings. A plastics resident having to sew up some banger's face on the trauma floor think its scut and try to farm it out to surgical or ER interns, even though they are superior at it. If everything else fits, rank them appropriately. Good luck.

 

[coolpath33]

Hi everyone, thank you for the thoughts so far. Seems like most people consider it a red flag / reason to lower ranking, but not everyone agrees. Of note (because a few people mentioned it being just 1 resident or not every day...), every resident on surg path that month (about 5 or 6) grosses the biopsies for more than an hour every day of the work week... in case that changes anyone's opinion.


PS - I agree that residents in all fields have to do scutwork, but at least inserting Foleys or suturing is providing patient care regardless of how banal it is. I think "grossing" biopsies is more akin to asking a clinical resident to take q4 vitals, draw blood for morning labs, get a copy of a patient's insurance card, etc... something that is not *practicing medicine*. Anyways, thanks for the thoughts!

 

[Eostar]

The way things are headed with reimbursements, you may be begging for a biopsy-grossing position in 5 years.

 

[Autopsy101]

I think "grossing" biopsies is more akin to asking a clinical resident to take q4 vitals, draw blood for morning labs, get a copy of a patient's insurance card

Until you have been a resident or PA whose name has been associated with a lost patient biopsy specimen while grossing, I would not equate these tasks to grossing a biopsy. You can almost always draw more blood and get similar results, have another person repeat the vitals, or make 2 copies of the insurance card just to make sure that one is not lost. Many times the biopsies are of small lesions that are only present in the biopsy specimen, and that is the one chance for the diagnosis to be made. The actual process of grossing a biopsy is not that complicated and can be easily learned, but the errors that can occur when things go wrong (lost tissue, tissue contamination, specimen mix ups) can sometimes result in grave consequences to the patient.

 

[coolpath33]

Auyopsy101,
Totally agree with you... My point was not to diminish the importance of a biopsy or their workflow/acessioning to patient care. In fact I think maybe doing some biopsies during the 1st month of surg path would be worthwhile for the reasons you mentioned. But I think it becomes noneducational after that. So maybe it wasn't fair to compare it to taking vitals, but for instance, I don't think medicine residents routinely walk the biopsies that they/their attending performed to the lab so they can first hand experience the workflow or how a lost specimen would impact the patient.

Until you have been a resident or PA whose name has been associated with a lost patient biopsy specimen while grossing, I would not equate these tasks to grossing a biopsy. You can almost always draw more blood and get similar results, have another person repeat the vitals, or make 2 copies of the insurance card just to make sure that one is not lost. Many times the biopsies are of small lesions that are only present in the biopsy specimen, and that is the one chance for the diagnosis to be made. The actual process of grossing a biopsy is not that complicated and can be easily learned, but the errors that can occur when things go wrong (lost tissue, tissue contamination, specimen mix ups) can sometimes result in grave consequences to the patient.

 

[turtle1966]

I may be in the minority but I still think it's important for residents to get some training and experience in grossing bits and biopsies.

I second this opinion. Grossing is a very, very valuable skill. I am surprised by someone even questioning this. You can make diagnosis, in large proportion of cases, by gross examination only. It goes without saying that you must do micro reading of what you have grossed. I have seen pathologists struggling with frozen slides by virtue of not having grossly examined frozen specimens.

 

[malchik]

The issue is grossing small biopsies for more than one hour a day. Can you diagnose 3+4 on a large proportion of prostate cores on gross exam?

 

[coolpath33]

Turtle, I wholeheartedly agree that grossing is an essential skill and that a lot of diagnoses can be made grossly. And again I am ok with the idea of spending a small amount of time doing biopsies upfront to learn. But surely you're not saying you can make a gross diagnosis on biopsy specimens - little flecks of colonoscopies biopsy tissue?! This is why I'm drawing the distinction between biopsies and other specimens. In terms of the opportunity to add clinical value to the specimen as an MD pathologist thAt a tech or PA couldn't.

 

[2121115]

Here is what you need to know about grossing biopsies - put the right tissue in the right cassette.

Ok, now you are done. Move on to more complex stuff.

 

[Johnny Sunshine]

Having 5-6 residents spending over an hour each day doing biopsies? Okay, that I would have a problem with.

But they unfortunately can't just hire someone "off the street" to do the biopsies. There are certain certifications which are legally required to handle gross specimens, regardless of how simple they are, and this takes time and money to get people certified and keep them up to date with their certifications. One of my lab's histotechs sometimes helps out with biopsies, but she is only one of about 8-9 histotechs who can legally do so.

It's a bizzarre world.

 

[Gasparilla]

ACGME is pretty clear that residents aren't supposed to be engaged in non-education activities. I think one could argue that there is nothing educational about grossing biopsies. They can hire someone off the street and train them to do that for almost nothing.

In fact, the ACGME is quite clear that residents are not required to be engaged in educational activities at all times. Residency is an apprenticeship. Some of it is educational, some of it is just work. You need to look at the program as a whole and decide if the balance between the "work" and the "education' parts are reasonable.

 

[pathstudent]

In fact, the ACGME is quite clear that residents are not required to be engaged in educational activities at all times. Residency is an apprenticeship. Some of it is educational, some of it is just work. You need to look at the program as a whole and decide if the balance between the "work" and the "education' parts are reasonable.

Yes but there are rules/guidelines on the type of work you can do. Spending hours a week cassetting biopsies is certainly eyebrow raising.

Grossing a biopsy here and there after hours is ok as part of patient care. But systemically using residents for menial tasks is not.