Hot Seat gone at Wash U!

[stickyshift]

Just found out that the place where I did my surg path fellowship no longer has the vaunted "hot seat" rotation as part of its surgical pathology fellowship:

http://pathinfo.wikia.com/wiki/Washington_University/B-JH/SLCH_Consortium_Program

In addition, attendings now sign out all frozen sections during regular working hours; fellows only sign out after hours/weekend frozens.

This is too bad: my greatest criticism of pathology training is the relatively minimal degree of responsibility residents generally assume during their training. The hot seat and frozen section rotations in the fellowship were the two best features of the fellowship, and more than anything else, made my early years in my practice successful ones. Without them my first year of practice would have been a white-knuckle experience for both myself and my employers.

Have all of the fellowship programs abandoned the hot seat?

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[Thrombus]

Fellowship doing this? Should be doing this as a 2nd year resident.

 

[LADoc00]

I was never a huge fan of a pure surgical pathology fellowship experience but the only thing I might have done was one with the Lauren Ackerman style hot seat position. Forces you make a diagnosis used in treatment. Basically a rapid fire high volume jr. attending type position.

R.I.P. Wash U Surg Path.

Probably best all the pathology training programs just start closing up though.

 

[gbwillner]

This position was not one fellows particularly liked later on. You had to preview all the slides coming out of histology, in case any physician wanted a prelim read (certain subspecialty biopsies excluded). That would be fine except volumes were huge; you were answering phone calls all day, and with increasing volumes the residents had to wait longer and longer to get their slides for review and sign out (because you had to preview them first). You could do a "hot seat" rotation as a resident, and some did.

While some of us may lament the loss of this rotation, I think overall it was more of a burden than an "on-the-spot" clinical experience. There are other ways to get responsibility for sign out at WashU, and hopefully they have continued to develop these in the absence of the "hot seat".

 

[Tiki]

I didn't do the Wash U SP fellowship but I went to another surg path fellowship that used the hot seat model and while it was grueling, it was the best experience of my training. I am efficient and can handle high volumes because of the hot seat.

Shame Wash U got rid of it.

 

[deleted314957]

I don't quite understand the "hot seat" designation. Aren't these folks "trainees" who are not allowed to do anything independently in our enlightened medical education system? To be a realist, it is only a "hot seat" if you are ALONE. Sounds like it is a busy, scut-filled "warm seat" to me.

 

[Mace1370]

Is there anything from an ACGME/CLIA standpoint that would prevent residents from putting diagnoses into the EMR that can be viewed by clinicians? I know radiologists do prelim diagnoses at many hospitals that are visible to the clinicians. Why does this not exist for path?

 

[thebouque]

Is there anything from an ACGME/CLIA standpoint that would prevent residents from putting diagnoses into the EMR that can be viewed by clinicians? I know radiologists do prelim diagnoses at many hospitals that are visible to the clinicians. Why does this not exist for path?

Because usually radz residents put in their dx at night when they're on all. I don't think they would put prelim dx on the EMR during the day when a staff is available. Meanwhile, path residents sleep at night...

 

[Mace1370]

Because usually radz residents put in their dx at night when they're on all. I don't think they would put prelim dx on the EMR during the day when a staff is available. Meanwhile, path residents sleep at night...

Many programs have pathology residents previewing the night before the case gets signed out. I have spent many nights in the hospital previewing until 11pm or midnight.

 

[stickyshift]

I don't quite understand the "hot seat" designation. Aren't these folks "trainees" who are not allowed to do anything independently in our enlightened medical education system? To be a realist, it is only a "hot seat" if you are ALONE. Sounds like it is a busy, scut-filled "warm seat" to me.

When I did the hot seat at Wash U., I had the first look at all of the general surg path cases coming through the department. Clinicians would come to me first to obtain my preliminary diagnosis, rather than the attending and resident who would sign the case out afterwards. So, in this respect, the hot seat fellow is "alone", as his diagnosis is the only one out there early on.

True, the hot seat fellow's diagnosis is not the final one that carries medico-legal weight, but I was always aware that clinicians presumed that my diagnoses were accurate. Every misdiagnosis hurt my credibility and reputation in the institution (as well as the care of the patient, of course). Getting used to bearing that burden was a valuable benefit of the hot seat fellowship.

Also, the sheer volume of cases that went through that place trained me to handle heavy caseloads efficiently, yet thoroughly. This was a huge boon in the private practice world.

 

[thebouque]

Many programs have pathology residents previewing the night before the case gets signed out. I have spent many nights in the hospital previewing until 11pm or midnight.

I understand, you were previewing your slides the evening/night before, but would you put in a prelim dx that clinicians could've seen? Because that's what radiology residents do when they're on call, and not only until midnight, they do it all night long.

 

[kchan99]

I understand, you were previewing your slides the evening/night before, but would you put in a prelim dx that clinicians could've seen? Because that's what radiology residents do when they're on call, and not only until midnight, they do it all night long.

Let me chime in on this as a clinician (neurology)...

The obvious difference between rads and path is the presence of images in the PACS even before the read by rads. When we are on service for neurology, we are expected to read the "films" before the prelim read by rads. If we have a question, then we page the on-call rads resident or sometimes, the attending, to discuss. If not, we may await the prelim read and then final report.

I suppose a prelim report by a senior path resident or fellow could be helpful in some cases. For instance, if a patient had a minimally invasive biopsy, and the prelim report was for malignancy, then we could start consulting a surgical service earlier to get the ball rolling and then start medically optimizing the patient for surgery while awaiting the final report. However, for certain patients during residency, I have called pathology to discuss the patients while awaiting for the final reports. These were biopsies that required multiple stains and then multiple antibodies on IHC.

 

[Mace1370]

I understand, you were previewing your slides the evening/night before, but would you put in a prelim dx that clinicians could've seen? Because that's what radiology residents do when they're on call, and not only until midnight, they do it all night long.

I definitely understand that there is a difference. I think the purpose of a path resident putting a diagnosis in that people could see would be to build confidence prior to graduation. While it is true that no one is checking on a non rush case in the middle of the night, the cases at my institution are often not fully signed out until a day or two after the resident previews them. If I was to preview a lipoma tonight and put in the diagnosis at say, 6pm, it might not be signed out by the staff until 1-3pm the next day or maybe not until the day after if they were busy with meetings or something else. That would give the clinicians a faster turn around for a diagnosis and build the confidence of the resident.

 

[thebouque]

I definitely understand that there is a difference. I think the purpose of a path resident putting a diagnosis in that people could see would be to build confidence prior to graduation. While it is true that no one is checking on a non rush case in the middle of the night, the cases at my institution are often not fully signed out until a day or two after the resident previews them. If I was to preview a lipoma tonight and put in the diagnosis at say, 6pm, it might not be signed out by the staff until 1-3pm the next day or maybe not until the day after if they were busy with meetings or something else. That would give the clinicians a faster turn around for a diagnosis and build the confidence of the resident.

That's a great system. At my institution, when we dictate a case, it remains invisible to clinicians until it is fully signed out.

 

[Ziehl-Neelsen]

Is there anything from an ACGME/CLIA standpoint that would prevent residents from putting diagnoses into the EMR that can be viewed by clinicians? I know radiologists do prelim diagnoses at many hospitals that are visible to the clinicians. Why does this not exist for path?

I definitely understand that there is a difference. I think the purpose of a path resident putting a diagnosis in that people could see would be to build confidence prior to graduation. While it is true that no one is checking on a non rush case in the middle of the night, the cases at my institution are often not fully signed out until a day or two after the resident previews them. If I was to preview a lipoma tonight and put in the diagnosis at say, 6pm, it might not be signed out by the staff until 1-3pm the next day or maybe not until the day after if they were busy with meetings or something else. That would give the clinicians a faster turn around for a diagnosis and build the confidence of the resident.

You can't be serious. You want 2nd and 3rd year residents to have the ability to miscall reactive Luschka Ducts in acute cholecystitis an invasive adenocarcinoma and have it be a part of the medical record until a staff gets around to signing out the case and changing the diagnosis?

What happens the first time an overzealous resident tells a patient they have cancer (when they don't) or (God forbid) initiates treatment based on this preliminary diagnosis?

 

[Mace1370]

You can't be serious. You want 2nd and 3rd year residents to have the ability to miscall reactive Luschka Ducts in acute cholecystitis an invasive adenocarcinoma and have it be a part of the medical record until a staff gets around to signing out the case and changing the diagnosis?

What happens the first time an overzealous resident tells a patient they have cancer (when they don't) or (God forbid) initiates treatment based on this preliminary diagnosis?

No, I don't want that. I think it would be a good system for senior residents (4th years in their last month or two of surg path). I also think that it should be limited to certain specimens, such as easy to diagnose ditzels. Also, the residents wouldn't be telling the patient anything. It would go on the medical record as the path residents prelim opinion. It would be the treating clinicians choice to run with that or not.

 

[cmz]

No, I don't want that. I think it would be a good system for senior residents (4th years in their last month or two of surg path). I also think that it should be limited to certain specimens, such as easy to diagnose ditzels. Also, the residents wouldn't be telling the patient anything. It would go on the medical record as the path residents prelim opinion. It would be the treating clinicians choice to run with that or not.

No... just no. While I don't believe any responsible oncologist or surgeon would aggressively act on a "prelim" from a resident pathologist, it will certainly create a lot of confusion and lead to erroneous and inefficient management decisions.

 

[icpshootyz]

No... just no. While I don't believe any responsible oncologist or surgeon would aggressively act on a "prelim" from a resident pathologist, it will certainly create a lot of confusion and lead to erroneous and inefficient management decisions.

Agreed. We do not want clinicians starting chemo on patients that turn out to have benign diagnoses. I am perfectly fine with the fact that our diagnoses are not official until we are attendings. Heck, even as an attending there are times my "prelim" reads are simply wrong, especially on tough cases I send for consult opinion.

 

[gbwillner]

It's all about experience, responsibility, and trust.

As a 2nd/3rd year resident I called in frozen results (on my own) to the OR- but only after I had enough experience that the attending trusted my ability, and usually when it was after hours. On another frozen rotation, the residents and fellows call in the results without the intervention of the attendings (they review what you did that evening/the next day).

I agree you don't want oncologists/surgeons acting on prelim diagnoses from 1st year (or many 2nd year) residents. But at some point, they need to be put to the test. You probably don't want 1st year ER/IM residents placing central lines in you either, and you REALLY don't want them to do it in July, but it happens all the time.

 

[Mace1370]

I am a little shocked that a lot people here think that a senior pathology resident with only one month left of surgical pathology training is unable to sign out a lipoma or a skin tag. We aren't talking about complicated cancer cases.

This type of responsibility would have to be earned, I think. It wouldn't be automatic. Furthermore, knowing your limits is a huge part of practicing medicine. Wouldn't you rather discover that a resident doesn't know their limits before they graduate rather than after?

 

[Kilgoretrout 65]

Many programs have pathology residents previewing the night before the case gets signed out. I have spent many nights in the hospital previewing until 11pm or midnight.

I thought you had to have 10 hours between shifts? So you must go into work at 10 am to abide by those ACGME rules, right?

 

[Mace1370]

I thought you had to have 10 hours between shifts? So you must go into work at 10 am to abide by those ACGME rules, right?

That is only for PGY1s. Here is a quote from the ACGME guidelines:

"Intermediate-level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty."

 

[NuclearDust]

I have to say that I don't entirely understand the need for the general surgical pathology fellowship. Isn't pathology residency supposed to prepare residents for general surgical pathology? I mean it is "general surgical pathology" and therefore by definition, not a SUB-specialty. I thought fellowship training was for subspecialization? Frozen section seems like something that the average pathologist does on a fairly regular basis. It doesn't seem unreasonable to expect the basic specialty training to prepare you for what the average practitioner will encounter on a regular basis, right?