Our own Journal is trashing us!

[pathdoc68]

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This months (July) Archives has an article discussing "Resident preparation for practice" Basically carping about all matter of deficiencies perceived in new graduates - amazingly some of which is apparently self-reported by new graduates. This is just what we all need now- articles claiming that a significant fraction of new pathologists are incompetent. How unfortunate.

 

[yaah]

There have been previous articles like that, reaching similar conclusions. Unfortunately pathology residency doesn't lend itself to the same kind of on the job training that clinical fields do. We don't have to make as many critical decisions.

I assume (I haven't seen the article yet) it is similar to the 2007 version? http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

In that, a lot of the deficiencies were CP related. I assume that hasn't changed. Also the statement about, "more guidance and support is needed" for recent graduates. I know some residency training programs are trying to address this but I don't know with how much success.

 

[yaah]

here is the link http://arpa.allenpress.com/arpaonline/?request=get-document&doi=10.1043/1543-2165-133.7.1139

not sure if it will work for everyone

 

[2121115]

These types of articles all seem to be reinforcing certain key points.

One is that pathology residents do not have the same degree of responsibility throughout training as residents in medicine, surgery, etc. In other words, residents cannot sign out cases. We should get around this the same that radiology gets around it. At our institution radiology residents put together reports that go over into the universal electronic medical record which attendings then go back and "verify" (in other words they could change). This is a great exercise for rads residents, but other departments hate it because they might take a treatment action and then realize that the attending has changed the interpretation. IMO, in an educational institution you have to let the trainees go spread their wings a little though. As the article points out, pathology residents are basically students throughout training who one day start practicing. This whole situation, while unfortunate, at least makes sense to me.

What doesn't make sense is a couple of other points that are always made.

For instance, they always cite that graduating residents have weak grossing skills. I'm not sure what this even means. Are they too slow? Didn't sample margins? Didn't put in blocks of the tumor? I mean, seriously, what is it? Granted, at many programs senior residents haven't grossed anything in 2-3 years and maybe that has something to do with it. However, we all (meaning pathology residents in general) complain about too much grossing or how we are grossing until the late evenings every night or even (on the extreme) that residency programs exist in order to get the grossing work done. If all that is true, the lack of competency can't be due to lack of exposure to grossing. And if the grossing skills of the residents who are doing all this grossing are subpar then how is anything getting signed out at these academic centers? It just doesn't add up.

Also, I just don't understand what it means when they cite "lack of interpersonal skills". What is that anyway? Mean to co-workers? Can't get along? Too loud? Too quiet? Even the article mentions we should have programs that educate residents on interpersonal skills. WTH kind of program would this be?

 

[yaah]

T

For instance, they always cite that graduating residents have weak grossing skills. I'm not sure what this even means. Are they too slow? Didn't sample margins? Didn't put in blocks of the tumor? I mean, seriously, what is it? Granted, at many programs senior residents haven't grossed anything in 2-3 years and maybe that has something to do with it. However, we all (meaning pathology residents in general) complain about too much grossing or how we are grossing until the late evenings every night or even (on the extreme) that residency programs exist in order to get the grossing work done. If all that is true, the lack of competency can't be due to lack of exposure to grossing. And if the grossing skills of the residents who are doing all this grossing are subpar then how is anything getting signed out at these academic centers? It just doesn't add up.

Also, I just don't understand what it means when they cite "lack of interpersonal skills". What is that anyway? Mean to co-workers? Can't get along? Too loud? Too quiet? Even the article mentions we should have programs that educate residents on interpersonal skills. WTH kind of program would this be?

In terms of grossing, that's a hard thing. Residents need to take it upon themselves to actually learn how to gross. Most don't. They treat grossing, and those who do it, as scutwork. Some residents actually choose programs based on how little they will have to gross. Others just pay lip service to it, thinking it is not that important once you get the basics down. And many attendings do a poor job of teaching it (some don't even read the gross descriptions). It's not about lack of exposure to grossing, I don't think, it's about lack of a good approach to it. Both programs and residents can do better.

Lack of interpersonal skills is hard to define, I agree. It's different for everyone, I'm sure. Basically though I would think it boils down to, "is this person easy to work with." Does the person add time to others' days because they don't communicate with clinicians or ancillary staff and others have to cover their tracks? Some of it is simply attitude.

 

[Nilf]

In terms of grossing, that's a hard thing. Residents need to take it upon themselves to actually learn how to gross. Most don't. They treat grossing, and those who do it, as scutwork. Some residents actually choose programs based on how little they will have to gross. Others just pay lip service to it, thinking it is not that important once you get the basics down.

On the other hand, many programs use residents to gross the kind of specimens that their work qualifies only as scut.

 

[Pathwrath]

Did the article address the pressure to do "research" in order to get now-required fellowships? That's a huge time commitment in an already full residency.

 

[coomasie blue]

One of you should write a letter to the editor in Archives. You all make excellent points.

It is unfortunate that pathology residency training can be so different between institutions. I think part of this is due to variability of how things are signed out (the actual nomenclature).


It would be awesome to standardize our field with specific global diagnostic terminology (like the CAP). A consensus group should write a book on specific diagnostic lingo that is used UNIVERSALLY with recommended IHC panels, when to do flow, when to do molecular based on evidence and not eminence.
That way from day one new residents can start categorizing entities specifically with proper set immunostains, flow, molecular etc. THis can be reinforced throughout residency everywhere.

 

[dodobird13]

what an interesting article. i don't look at it as one of our own "trashing us". much of what the article states is very accurate.

i have a bit of an issue with groups complaining that new hires aren't up to speed while in the same breath complaining they don't recognize their own limitations. while pathology training in general may be lacking in some areas, there is no other experience that will prepare one for independent sign-out than just that. you want your new pathologist to not rush and to not make rash decisions. it's a time of transition and a steep learning curve.

i like the points made regarding the dissonance between the demands of "real life" vs the demands of boards. we do spend an inordinate amount of time cramming minutiae for the boards that could be better spent in the lab, dealing with personnel issues or new test validation. however - in my experience most residents think their time is too valuable to be wasted on such trivialities, not realizing that those experiences are richly educational.

i would be curious to see similar studies from other specialties. i agree in that residents, in general, are alarmingly narcissistic and their work ethic questionable, but i don't know if this is a generational thing (i suspect it is and other specialties have similar complaints about their new grads).

 

[KluverB]

It is unfortunate that pathology residency training can be so different between institutions. I think part of this is due to variability of how things are signed out (the actual nomenclature).

It would be awesome to standardize our field with specific global diagnostic terminology (like the CAP). A consensus group should write a book on specific diagnostic lingo that is used UNIVERSALLY with recommended IHC panels, when to do flow, when to do molecular based on evidence and not eminence.
That way from day one new residents can start categorizing entities specifically with proper set immunostains, flow, molecular etc. THis can be reinforced throughout residency everywhere.

Good luck with that. Eminence trumps all.

Then again, I don't believe that's so much the problem, as it simply is the caliber of the residents themselves. Even "competitive" programs often go down far their rank lists. I may not be top of my class, and God knows I have plenty to learn, but there are oodles of residents (and fellows) I work with every day who are not even aware how terribly bad they are at what they do. Never mind even the laziness, like not previewing; I'm talking everything from basic histology, through grossing ability, all the way to their poor interpersonal and communication skills, and the absence of professionalism. No amount of standardized nomenclature will help these schmucks; and yet, they are about to be unleashed on the world.

So, no, I'm not surprised that we, unfortunately as a group, are being bashed.

 

[Pathjob]

Good luck with that. Eminence trumps all.

Then again, I don't believe that's so much the problem, as it simply is the caliber of the residents themselves. Even "competitive" programs often go down far their rank lists. I may not be top of my class, and God knows I have plenty to learn, but there are oodles of residents (and fellows) I work with every day who are not even aware how terribly bad they are at what they do. Never mind even the laziness, like not previewing; I'm talking everything from basic histology, through grossing ability, all the way to their poor interpersonal and communication skills, and the absence of professionalism. No amount of standardized nomenclature will help these schmucks; and yet, they are about to be unleashed on the world.

So, no, I'm not surprised that we, unfortunately as a group, are being bashed.

It's part of the job shortage. You see, the idea is blame the victim of the job shortage rather than determine some sort of cure. Ever since I was in training, long ago, there were complaints about inadequate pathology trainees, oft made by quite inadequate private practitioners who were partners.

 

[yaah]

It's part of the job shortage. You see, the idea is blame the victim of the job shortage rather than determine some sort of cure. Ever since I was in training, long ago, there were complaints about inadequate pathology trainees, oft made by quite inadequate private practitioners who were partners.

I don't think you can totally blame it on the job shortage though. Pathology is being short-changed even more in med school every year, and students rarely even get a chance to find out what it is. What they do know is often rumors or false (like all pathologists do are autopsies, or all pathologists are antisocial losers). Other fields have similar problems with residents being less competent and requiring more hand holding when they finish. I know ER attendings who hate hiring new graduates because their skills and/or confidence are inappropriate for the level of responsibility they have. When a smaller group hires a new graduate, they require a lot of attention and are not often trusted to be left on their own.

However, I do agree that the job issue has a lot to do with attracting many quality candidates. That, and the existence of a lot of residency training programs that just aren't that great.

 

[Dermbound00]

Pathology training needs to be reformed. First, you need to choose AP or CP. What track do you want to pursue? You are not going to be an expert in both AP/CP no matter where you train, how cocky you are, or even how long you spend training in both. You definitely do not need 2-3 months of chemistry, microbiology, coagulation, molecular, and even blood bank. The only CP rotation worth anything for a person deciding to do AP (which are the majority of pathology trainees) is heme. Outside of that do a week or two at the most of the others. Get a general idea of CP, what is involved, and where to find the information if asked by a clinician. Otherwise you need to spend your time in AP. Just mastering AP is a challenge in the time frame you have for residency/fellowship. Much less splitting your time between AP and CP and being shuttled back and forth. For those of you in subspeciality signout, just ask your GI pathologist about a nueropathology case and they will laugh at you. Our field is very challenging. We need to focus on training competent pathologists who are able to sign out the majority of cases without problem efficiently and effectively. Making residents waste their time watching a micro tech plate a urine is completely insane. Taking a board examination where someone asks you what tissue has the most resistance in ohms is crazy. Forget the stupid premedical and medical school issues like how much stupid, pointless information can you memorize. We all can memorize plenty. Ask the important questions like staging, implication of a diagnosis in a particular organ, and common lesions that you will encounter everyday. Once the AP/CP boards are over, most of that CP stuff for AP oriented people hemorrhages out faster than you can imagine. Wouldn't that time be much better spent mastering surgical pathology? Instead we focus on having an average knowledge base across the board rather than being very good at the work we will be hired to do.

 

[yaah]

Well, that may be true for people going into academics, but in the private world CP is important and it's not really practical to hire someone to do each CP task and run the labs for you.

 

[HbyHA]

I don't think you can totally blame it on the job shortage though. Pathology is being short-changed even more in med school every year, and students rarely even get a chance to find out what it is. What they do know is often rumors or false (like all pathologists do are autopsies, or all pathologists are antisocial losers).

what, you don't appreciate a good "virtual anatomy class"? it's just as good as the real thing, right?

and i don't know about you, but i'm definately an antisocial loser😀

 

[KeratinPearls]

Pathology training needs to be reformed. First, you need to choose AP or CP. What track do you want to pursue? You are not going to be an expert in both AP/CP no matter where you train, how cocky you are, or even how long you spend training in both. You definitely do not need 2-3 months of chemistry, microbiology, coagulation, molecular, and even blood bank. The only CP rotation worth anything for a person deciding to do AP (which are the majority of pathology trainees) is heme. Outside of that do a week or two at the most of the others. Get a general idea of CP, what is involved, and where to find the information if asked by a clinician. Otherwise you need to spend your time in AP. Just mastering AP is a challenge in the time frame you have for residency/fellowship. Much less splitting your time between AP and CP and being shuttled back and forth. For those of you in subspeciality signout, just ask your GI pathologist about a nueropathology case and they will laugh at you. Our field is very challenging. We need to focus on training competent pathologists who are able to sign out the majority of cases without problem efficiently and effectively. Making residents waste their time watching a micro tech plate a urine is completely insane. Taking a board examination where someone asks you what tissue has the most resistance in ohms is crazy. Forget the stupid premedical and medical school issues like how much stupid, pointless information can you memorize. We all can memorize plenty. Ask the important questions like staging, implication of a diagnosis in a particular organ, and common lesions that you will encounter everyday. Once the AP/CP boards are over, most of that CP stuff for AP oriented people hemorrhages out faster than you can imagine. Wouldn't that time be much better spent mastering surgical pathology? Instead we focus on having an average knowledge base across the board rather than being very good at the work we will be hired to do.

AP/CP is a requirement if you want to do private practice.

 

[Dermbound00]

AP/CP is a requirement if you want to do private practice.

Absolutely. However, do you really need to do 2-3 months of microbiology, chemistry, and watch paint dry on other CP rotations? I was thinking doing 2-3 weeks of most CP rotations, eliminate wasted time and use the other time to act as junior attendings (be allowed to sign out cases on your own, with/without attending support). Your time training in pathology is limited. The only thing you really need to know on CP is what are the common questions, gain a general understanding of the different rotations, and know where to go to look things up. Otherwise AP is challenging enough.

 

[dermpathdoc]

Absolutely. However, do you really need to do 2-3 months of microbiology, chemistry, and watch paint dry on other CP rotations? I was thinking doing 2-3 weeks of most CP rotations, eliminate wasted time and use the other time to act as junior attendings (be allowed to sign out cases on your own, with/without attending support). Your time training in pathology is limited. The only thing you really need to know on CP is what are the common questions, gain a general understanding of the different rotations, and know where to go to look things up. Otherwise AP is challenging enough.

Every single job i applied for here in the west coast asked..do you have CP certification? as well as do you read cytopathology and have you taken the GYN cyto proficiency...

that is the reality as well as how you communicate with the docs who send in their specimens..I have had experience with pathologists who only want to read thier cases and leave....that is not life...

 

[Torsed]

Did the article address the pressure to do "research" in order to get now-required fellowships? That's a huge time commitment in an already full residency.

I concur, doing research and writing papers took a lot of time, but I got my fellowship. I'll let you know if was worth it....

 

[Torsed]

what, you don't appreciate a good "virtual anatomy class"? it's just as good as the real thing, right?

and i don't know about you, but i'm definately an antisocial loser😀

I'll join the anti-social loser crowd. Concerning short changing path, my dept switched from FULL Robbins text to the Basic Robbins text, a markedly condensed version in the hope that student's would "read it this time." Sigh. 👎