Is Pathology training suitable for independent practice?

[MetroPath]

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I was wondering what you all think about surgical pathology training in residency and whether it is adequate for independent practice? I understand that a lot of it has to do with experience but do you think the training is adequate to prepare you to not make any big mistakes or provide you with the confidence as a junior attending? Does your residency provide you with feeback in regards to tailoring your surgical pathology reports? Do your attendings give you feedback in regards to your diagnoses (wording, etc)?

Surgpath itself if such a broad field with a vast amount of knowledge, which requires a lot of practice looking into a microscope. Add on the material you need to know in CP for the boards, it really gives you a "jack of all trades master of none" feeling during residency.

 

[KCShaw]

Confidence is related to the individual, but, for the most part my impression is that most programs do not gear up towards completely independent practice. It may suit some people, but for the most part the expectations have changed -- there is lip service paid to making one ready for independent practice, but generally very little time devoted to allowing a resident to function truly independently. Even in practice, most people are either surrounded by or have ready access to others in their group that they can share cases with; you may find fairly quickly that you can often sway your colleagues to your line of thinking, depending on your presentation, but that's a common issue with mob mentality...there is still a degree of safety in numbers even if you're wrong, if you take due diligence to show it around even locally.

Having said that, I think the bulk of finishing residents who pass the boards can handle the bulk of cases that cross their desk without a major error. The problem is that pathology does not tolerate error very well. In IM or even surgery you can start treating based on little more than speculation, and alter diagnosis/treatment as the disease progresses with often very little negative impact on your career. Surgery for suspected appendicitis becomes surgery for a ruptured ectopic, but hey, you needed surgery anyway. In pathology you can get away with mixing up different kinds of benign perhaps, but missing cancer doesn't go over real well, and frankly that's the crux of most of our AP business. Even if you are correct 95% of the time, you're still at major risk maybe a few times a week. Those medical renal folks are probably the smart ones.

While a finishing resident probably -could- practice independently, if they were willing and able to send out fairly frequently, I'm not sure why anyone would -want- to unless the location and salary were really quite impressive, and I don't think training...for the most part...is geared towards such.

 

[Enkidu]

While a finishing resident probably -could- practice independently, if they were willing and able to send out fairly frequently, I'm not sure why anyone would -want- to unless the location and salary were really quite impressive, and I don't think training...for the most part...is geared towards such.

So is fellowship geared towards independent practice? Or are you saying that no level of pathology training is?

 

[mlw03]

I was wondering what you all think about surgical pathology training in residency and whether it is adequate for independent practice? I understand that a lot of it has to do with experience but do you think the training is adequate to prepare you to not make any big mistakes or provide you with the confidence as a junior attending? Does your residency provide you with feeback in regards to tailoring your surgical pathology reports? Do your attendings give you feedback in regards to your diagnoses (wording, etc)?

Surgpath itself if such a broad field with a vast amount of knowledge, which requires a lot of practice looking into a microscope. Add on the material you need to know in CP for the boards, it really gives you a "jack of all trades master of none" feeling during residency.

In my opinion, absolutely not. I was AP-only, passed boards on first attempt, then went into FP, but in theory, I could be signing out cyto and general surg path in a community setting with my certifications. But no, I do not believe that I (nor most residents) are ready to go out and practice solo after residency alone, thus the need for at least 1-2 fellowships and also why I think being in a group that is OK with junior faculty asking for help is crucial. I do so plenty as a new FP practitioner. More eyes looking at a tough case is almost always a good thing in any field of pathology.

 

[deleted314957]

Today, it seems the rules and regs have changed so that it is impossible for a resident to get truly indepent responsibility. 30 years ago when i was going thru it was different ( and maybe it helped because it was the military). senior residents were allowed completely indepent sign-out and it was a big help. with out that i think you are on shaky ground to go into independent private practice.

 

[KCShaw]

So is fellowship geared towards independent practice? Or are you saying that no level of pathology training is?

Fair question. I think "more" fellowships are "more" geared towards preparing one for independent practice than residency programs are. But let's face it, even in a "good" preparatory fellowship one is usually a chair or a door or two away from a quick quality consult, and even signing out with junior residents is another pair of eyes and another pair of hands showing slides around. I agree with the concept mikesheree brings up, which is that the rules/culture has changed in the last generation or so, as has the level of complexity (at least as far as the academics are concerned) for almost every kind of case.

 

[2121115]

Residency programs train fellowship applicants these days, rather than practicing surgical pathologists.

So no, residency does not prepare you. With no good surgical pathology fellowship (i.e. one that involves independant sign out) there is a steep learning curve when going into practice. This is why many groups prefer to hire candidates with surgical pathology fellowship training or with 1-2 years of experience. Residency can train you enough to not make big mistakes, but it isn't enough to hit the ground running in a complex practice.

 

[Textbookversion]

Those medical renal folks are probably the smart ones.

What's that alluding to?

 

[Enkidu]

What's that alluding to?

That they never have to call cancer, I guess.

 

[KCShaw]

Medical renal, as perhaps a bad example, ain't a lot of tumor vs non-tumor. Not that you can't be wrong and cause problems, they're just in a different category from calling a thyroid biopsy benign follicles and fibrosis when it's really invasive cancer with desmoplasia. At least those kidney patients will generally still be monitored clinically, while the "benign" thyroid walks out the door until they show back up unresectable -- i.e., somewhat more akin to the generic IM/surg vs path comparison.

 

[lipomas]

Medical renal, as perhaps a bad example, ain't a lot of tumor vs non-tumor. Not that you can't be wrong and cause problems, they're just in a different category from calling a thyroid biopsy benign follicles and fibrosis when it's really invasive cancer with desmoplasia. At least those kidney patients will generally still be monitored clinically, while the "benign" thyroid walks out the door until they show back up unresectable -- i.e., somewhat more akin to the generic IM/surg vs path comparison.

Huh? Poor analogy. Medical renal is much more stressful than thyroid stuff. Thyroid FNAs are known to have fairly low sensitivity. Acute renal failure biopsy, they want you to tell them which of 3 mutually exclusive treatment options they need to start RIGHT NOW and if you are wrong the patient is on dialysis for life.

 

[lipomas]

In my opinion, absolutely not. I was AP-only, passed boards on first attempt, then went into FP, but in theory, I could be signing out cyto and general surg path in a community setting with my certifications. But no, I do not believe that I (nor most residents) are ready to go out and practice solo after residency alone, thus the need for at least 1-2 fellowships and also why I think being in a group that is OK with junior faculty asking for help is crucial. I do so plenty as a new FP practitioner. More eyes looking at a tough case is almost always a good thing in any field of pathology.

You can make yourself ready after residency training. But it can take work. Programs do variable jobs of training residents, some train them better to be independent. But ultimately it seems to me like it's up to the individual person. You can just skate by, get good evaluations, but never really challenge yourself. Or you can take extra time and challenge yourself, look at lots of extra cases, treat things like you are making the final call, you will be a lot more prepared. I felt prepared but I started to get nervous round about the end of third year of residency and made it a specific point to do as much as I could to be ready.

 

[mlw03]

You can make yourself ready after residency training. But it can take work. Programs do variable jobs of training residents, some train them better to be independent. But ultimately it seems to me like it's up to the individual person. You can just skate by, get good evaluations, but never really challenge yourself. Or you can take extra time and challenge yourself, look at lots of extra cases, treat things like you are making the final call, you will be a lot more prepared. I felt prepared but I started to get nervous round about the end of third year of residency and made it a specific point to do as much as I could to be ready.

Well, we'll have to agree to disagree. I think even the best residents (which I'm not claiming to have been) cannot act truly autonomously for reasons discussed many times on here, and for that reason the leap upon becoming an attending is huge.

 

[path24]

Residency programs train fellowship applicants these days, rather than practicing surgical pathologists. QUOTE]

👍 Pathology residency is glorified shadowing while learning a skill (grossing) that most pathologists don't do. (and of course CP is just a joke...just like in private practice) The "leaders" of pathology have literally started pathology training to go backwards. Do not go into pathology people...the current state is crap and the future is super crap. Become a physician that is an asset and not a pawn to be used by admin, surgeons, gi, uros...etc.

 

[KeratinPearls]

Residency programs train fellowship applicants these days, rather than practicing surgical pathologists. QUOTE]

👍 Pathology residency is glorified shadowing while learning a skill (grossing) that most pathologists don't do. (and of course CP is just a joke...just like in private practice) The "leaders" of pathology have literally started pathology training to go backwards. Do not go into pathology people...the current state is crap and the future is super crap. Become a physician that is an asset and not a pawn to be used by admin, surgeons, gi, uros...etc.

I would have to agree. It is my impression that CP training at most of the smaller or mid sized programs is a joke. If you want serious CP training, you need to go to a large program with a big lab and a hands-on approach. Sitting around surfing the internet or leaving at 2 pm while on CP. Yes, it doesn't have to be a joke if you are proactive about it. At the end of the day, CP is all about studying and passing the board exam. I think more time should be dedicated to heme and cyto during residency since you may be required to signout in these areas when you start a job.

 

[member0007]

Pathology training is about learning a set of skills that residency programs could help with, if they are not malignant. If you are at a program that does not provide you with the adequate materials, adequate support, and allows rampant unfair treatment, retaliation, and discrimination against you that compromises your safety and dignity, then it will be more difficult. This should be reported to ACGME. Anyway, no one will teach you everything so just follow up on the cases in your own time. But once again, for this to happen you have to work at a non-malignant program.

 

[LADoc00]

I was wondering what you all think about surgical pathology training in residency and whether it is adequate for independent practice?

Not even close. In fact I have never heard of a single case of guy who tried this succeeding in the long term.

And I have seen at least 1/2 dozen attempts to do it. All either total implosions or career ending disasters.

At a minimum, I would think 2+ years of professional sign out and business experience prior to going solo anywhere, even in a low vol. environment.

 

[thebouque]

Come and do your residency in Canada. Most programs are 5 years AP only (including a clinical year) and more than half of the grads start practicing right away. The other half goes through 1-2 fellowships and practices in academia.

 

[mlw03]

Come and do your residency in Canada. Most programs are 5 years AP only (including a clinical year) and more than half of the grads start practicing right away. The other half goes through 1-2 fellowships and practices in academia.

Sorry, but don't think that's a great suggestion for folks. While I agree 4 years of pure AP-only path is better prep than the US model, your suggestion just isn't an easy one to accomplish. Americans face barriers to doing residency in Canada. Truthfully, it's probably easier to train in the US and then come up here, although that doesn't solve the preparedness problem. Plus, it's just not realistic for a lot of people.

This is a fundamental problem of US pathology training, and there is no easy solution. Autonomy is extremely limited in pathology residency.

 

[LADoc00]

Come and do your residency in Canada. Most programs are 5 years AP only (including a clinical year) and more than half of the grads start practicing right away. The other half goes through 1-2 fellowships and practices in academia.

this is funny.

I will be do you one better, come and do your training in NORTH KOREA. Guaranteed rice for each graduate and a job.

 

[thebouque]

this is funny.

I will be do you one better, come and do your training in NORTH KOREA. Guaranteed rice for each graduate and a job.

Right 😉