overwhelmed

[riamo007]

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Hi All,

Im starting my path residency now and am feeling quite overwhelmed with all the material we have to know - is this normal

Its discouraging when you look at the microscope and you have no idea what the heck your are looking it - really scares me.

then you see the seniors and how good they are....

 

[zao275]

It is normal. Relax. Everyone feels like that. But you will be amazed one year from now when you look back and see how much you have learned. And you will feel the same way looking back every year after that for a long time! But that is what makes this fun.

My advice to first years: Pick up a Rosai (or your favorite surgpath book) and just flip through it each night and look at the pictures. Don't worry about reading yet. Don't misunderstand me: reading is important. But right now you need to build some mental filing cabinets to store all those facts in. For me at least, I can store much about a tumor or disease unless I have seen it (or a picture of it). Then I have something to "tag" that data to in my brain. You will probably come to find out that some of the pictures really fascinate you and there will be tumors and things you have never heard of. Then you will find yourself reading out of curiosity (and you will ENJOY it) rather than because you just feel you should read. THAT is the better way to learn.

There is some free advice from a soft tissue pathology fellow that loves teaching. Take it or leave it. Others may advise you differently. But regardless, most residents eventually adapt to the massive amount of info we must learn very nicely. So don't quit yet, ok?

 

[riamo007]

thanks for the advice..i was really starting to wonder about the enjoyment part...that is hugely missing right now..guess I have to sow that enjoyment in me...

 

[zao275]

The more you learn, the more fun it is, I think. It is a great feeling to nail a diagnosis on a rare tumor or to pick up on something important that will make a real difference for the patient. Those days will come soon enough. Hang in there!🙂

 

[Patho2009]

This quite normal and know that this might continue to an advanced stage of your training...

 

[KCShaw]

It is normal. Relax. Everyone feels like that. But you will be amazed one year from now when you look back and see how much you have learned. And you will feel the same way looking back every year after that for a long time! But that is what makes this fun.

Right on. This is almost -exactly- what I used to tell first years every year after my own first year. I honestly didn't realize how much I had learned my first year until the new first years came in and started bumbling around and stressing out.

There's a huge amount of information, and most of the surg path you just aren't exposed to in medical school -- this is in stark contrast to most other residencies. While the new residents in other programs are figuring out how to get things done on the wards, you get to learn an entirely new visual art-language..of sorts. People will always harass you about the details, but in your first year I suggest focusing on the big picture -- literally.. lower power, normal vs not normal, and loosely categorizing (epithelial/glandular, mesenchymal, vascular, etc.). I wish I had used "Differential Diagnosis in Surgical Pathology" earlier, as it addresses the very broad strokes and offers a way to categorize and narrow down to a diagnosis. You'll start finding things that interest you more than others, and you can branch your studying out from there.

Eventually you'll find a comfort zone in work and study, but it's normal to feel overwhelmed, especially early on.

 

[gschl1234]

I would check out Molavi http://www.amazon.com/Practice-Surg...=sr_1_1?ie=UTF8&s=books&qid=1279970515&sr=8-1

and Wash U SP Manual http://www.amazon.com/Washington-Ma...=sr_1_1?s=books&ie=UTF8&qid=1279970565&sr=1-1

Also try www.pathconsultddx.com which is good if you already have an idea what entity you need to look up.

Molavi is good for reading cover to cover but is does not describe some commonentities and WashU SP Manual is good for browsing "choices" by location while pathconsultddx or pathologyoutlines.com is good if you already know of a specific entity you'd like to look up. If you're going to be using WashU, I suggest you use their online version because they have their pictures embedded in the text. The print version has no pics. Good luck.

 

[TinyFish]

To the OP - I'm also a brand new first year, and feel the same way. You're definitely not alone, judging from the responses here and what I've seen in person.

I read through Molavi, and it definitely helped during the first couple of weeks. Plus, I think it's easy to get stressed out and overlook how much you learn on a day-to-day basis just from doing stuff and interacting with your attendings/senior residents.

re: Differential Diagnosis in Surgical Pathology --> how is it organized? Is it worth buying? Everyone has told me not to buy textbooks, but sometimes (I know this sounds strange) I want more than looking stuff up on the fly...sometimes I just want to go home and study.

 

[KCShaw]

RE: Differential Diagnosis in Surg Path: There should be -someone- in your department that has a copy somewhere. It's one of those books worth flipping through before buying, I think. (Actually, it looks like Google has scanned one in, if you do a search it's on the first page of results.)

It's particularly useful when you're actually looking at slides, though the images themselves aren't great. If you know the organ system you're in, it will give you a series of flowcharts which allow you to narrow the diagnosis based on certain described appearances. Then there's some text later in each chapter which "details" each suggested differential diagnosis (I use "details" loosely, as it's clearly not as detailed as the reference texts). I still occasionally find it a good way to find my bearings and narrow the list of likely diagnoses down to a few I can properly read up on, rather than flipping randomly through a reference text hoping I find what I'm looking at on the slide, especially since I don't take that many slides and most of them are non-tumor these days.

I do kinda agree that it's overkill to jump in and buy a buncha textbooks on day 1. Everyone has favorites, and given how expensive most of our texts are, it's wise to figure out which you like & don't like before spraying the cash. That said, try to find one of the big general surg path texts you like and get that (IMO), +/- one or two other texts that really suit you or some specific interest of yours, and -maybe- one useful CP text, and that will be more than enough for your 1st year (or 2nd or 3rd year for that matter).

 

[Gene_]

then you see the seniors and how good they are....

This should make you feel good that the residents where you are at actually learn something. You'll be there soon. Hang in there and read about your cases as much as possible - these are your patients. But, remember that residency is a marathon and not a sprint.

 

[WhtsThFrequency]

Normal 🙂

Our head gross path guy told us the first week that the first year of residency is a year of learning but also one of embarrassment (and yes, following years still have it too hah, but more learning and less embarrassment. No one knows everything...). Sure you feel out of place at say, histo rounds, and realize you called it the wrong tissue, let alone the wrong neoplasm 😳 . But like you said yourself, the senior residents are top notch - meaning that you'll be there too in a few years. And like zao said, when you have those "lightbulb" moments - and yes, the frequency of them will increase over time - it really makes you feel glad to be in such a specialty. Whenever you start feeling overwhelmed looking at a slide, figure out a system. Say you're looking at lung. Make a list of things you will look at in a certain order. Pleura, septae, alveolar spaces, bronchioles, blood vessels, etc and go about it one by one. Having those checklists in place can help you feel more organized, because you have something to fall back on and "re-set" your brain, even if you are not quite sure of the pathogenesis of what is going on.

 

[KCShaw]

...Whenever you start feeling overwhelmed looking at a slide, figure out a system. ... Make a list of things you will look at in a certain order ... and go about it one by one. Having those checklists in place can help you feel more organized, because you have something to fall back on and "re-set" your brain, even if you are not quite sure of the pathogenesis of what is going on.

Very good advice. Eventually you will start to spot recognize certain things, but I still go back to this if after I scan around I realize I'm not entirely sure what I've got. If you develop a system to at least look at, look for, and describe certain things then at worst you'll have a microscopic description -- at least half of the battle, and in some cases better than a peghole diagnosis. It's also a useful method for all that non-tumor stuff.

 

[d2d77]

To the OP
I too am a confused first year. I feel like I am running around like a chicken without a head, and I feel about as useful too.
I know all my co-interns feel the same. The past couple of weeks have been so discouraging that I have been rethinking pathology as a career because it feels like I'll never be good at it. I have no idea what I am looking at and I don't know how the seniors and attending pull a diagnosis out of their hat before I even have a chance to figure out where the sample is from.
I get some comfort from seeing and hearing that everyone at this level feels the way I do. Nevertheless is it very humbling, coming out of med school at the top of your class and feeling like you know nothing! To the point where I have actually though about switching specialties. I thought I liked path but right now it feels like I'll never be good at it. I've decided to give it a year and see where I will be then and decide. At least I can hold my own on the wards or in clinic. Doing an H&P, scrubbing for a procedure, writing a note/consult etc... are a piece of cake compared to diagnosing a frozen when the patient is on the table and the surgeon wants to know what to do next.

As far as DDx in surg path goes...where are these flow charts??? I've bought the book but I guess I don't know how to use it. I cannot find a single flow chart and it's driving me nuts! All I see at the beginning of the chapters is a table of contents. Any help??

 

[WhtsThFrequency]

I have no idea what I am looking at and I don't know how the seniors and attending pull a diagnosis out of their hat before I even have a chance to figure out where the sample is from.

That's why they are seniors - they have had years and years doing this - don't feel like you have to measure up to them as a brand-new first year. It's extremely disconcerting, I agree - being the newbie and feeling like you know nothing. When I'm on the necropsy floor with 4 horses, 2 cows and a few dogs I am running back and forth between, covered in guts with students throwing q's at me or messing things up, (don't flay that f*ing liver! I need that for virology! lol) , I feel like I have to check everything with the pathologist on the floor because many things I simply have not SEEN enough to know what is pathologic and what is incidental/age-related/normal for that species, and that's ok (same goes for my surg path cases as well).

Remember though, that those seniors were *just like you* when they started.

The first year of a path residency is almost like playing catchup. You'll feel useless, silly, etc. But as the months progress, you'll notice that you see trends. You start recognizing a fibrosarcoma from a peripheral nerve sheath tumor. You'll look at a slide and 5 Ddxes will pop into your head. It just takes time 🙂

(NB: Yeah, I'm a vet anatomic path resident, and technically speaking this is an MD path forum....but if I'm "allowed" if ya will, to contribute 😉..... appreciate it )

 

[WhtsThFrequency]

And to add a little piece of insight....I think the hardest path of path is recognizing the normal and the incidental. Try learning one new things every day. E.g., in my field, yesterday I learned that mineral deposits in the canine lung are age-related and normal. Day after that, I learned melanotic lesions in equine jejunum is also incidental. Learning the "normals" and the "non-pathologics" can be the hardest thing.

 

[mmt2010]

Thanks to the original poster and really helpful responses. I just started too and was having the same thoughts. The other first years here though don't seem to be as bothered as I am and I was starting to get worried I might be the only one who felt this way, so it's nice to know I'm not alone and that if I just keep chipping away at it, things will get better.

 

[TinyFish]

Thanks to the original poster and really helpful responses. I just started too and was having the same thoughts. The other first years here though don't seem to be as bothered as I am and I was starting to get worried I might be the only one who felt this way, so it's nice to know I'm not alone and that if I just keep chipping away at it, things will get better.

I agree. At my program, some people seem more bothered, and some less bothered (even overconfident). I think most, if not all, of us feel a bit overwhelmed right now - it's just that no one wants to look insecure, and some of us are better at hiding our feelings than others are. 🙂

No worries, I think we'll get it. We've survived 20+ years of difficult education. Probably the best thing to do is enjoy what we're doing, and with enjoyment will come learning. Good luck!

 

[KeratinPearls]

Some words of advice:

1. If you don't know what you are doing ask for help. You can seriously screw something up.

2. You will make mistakes. I did. Learn from it and try not to repeat the same mistakes.

3. Don't throw a specimen away. That is the absolute worst thing you can do. Before you throw anything away, make sure there is no specimen on it that you or someone else had on that diaper, towel! When working with a small specimen, keep the tissue ABOVE your workspace (countertop).

4. Bone up on histology. This is the year to do it. Read about the cases you encounter.

5. Workflow. Ask you senior resident how you can manage your workflow better to become efficient. Triage cases.

6. Again ask for help!

Things are going to go slow at first but once you progress on in your training you will become more efficient. Remember you are in a training program,

Good luck!

 

[pathstudent]

The thing about the first year of pathology is that it is amazing. You will learn 90% of everything you will ever know and spend the rest of your life learning the other 10% of everything you will know

 

[yaah]

Part of the problem many new residents have in every field, not just pathology, is that they feel the need to know everything right away. Some attendings and senior residents will contribute to this, probably unwittingly. You don't have to know everything right away. Ask questions. Learn as you go.

 

[KCShaw]

I had an attending who was well and truly stupefied that we didn't already have Robbins essentially memorized by the time we started residency. For a while I thought he was joking just to put a little light-hearted pressure on us, but it didn't take long to realize he was stupefied anytime we didn't already know ANY given thing if it was in text anywhere in the world, though he was somewhat more forgiving when it came to the art side of the job (pattern recognition, etc.). Later in residency I found an attending who pulled out Robbins on a somewhat regular basis to look certain things up, and I finally stopped feeling so bad about not having it memorized. By the end of residency I was reviewing Robbins yet again for board preparation.

If only I had memorized it during medical school I wouldn't have needed that dang residency anyway....

I also had at least two different senior residents who were exceptional, one in part because of being very driven and having already been a physician in another field for many years, and the other because of having been a practicing pathologist overseas for years but his credentials weren't recognized so he had to start over at residency. Both were sometimes awesome resources, but both also had a knack of overtalking everyone else at the scope, spurting out diagnoses before anyone else had a chance to see what tissue we were looking at, and arguing with faculty about why something was or wasn't X. One had a tendency to actually quote page numbers from the WHO books or other reference texts, and was WELL known for sighing dramatically and saying "bah, if you would simply read the book, you would know, it is OBVIOUS..", and teaching by doing everything for you then pointing and going "SEE? Like THAT," and offering a politely paternal "gah, what a *****" look. More frustratingly, they were almost always "correct," if not ideal in their methods, even in academic arguments with faculty.

Point is, yes -- almost certainly you'll run into some attendings &/or other residents who will contribute to your feeling of drowning in a sea of your own ignorance. But that too shall pass, and eventually you'll be able to respectfully mock them on the internet.

I mean, page numbers. Really? REALLY??

 

[lipomas]

Just remember that at one time, everyone who is supervising you was an idiot too. No one crawls out of the womb knowledgable about their careers. Some people pick things up quicker, but that doesn't generally correlate with how good a pathologist they are. The problem is that many of these people completely forget that they were once idiots themselves. Any supervising physician (resident or attending) who would badmouth someone in their first few months of residency for not knowing a lot is not only an idiot, but someone who you probably won't learn too much from.

I always remember back in med school when we had our intro to histology class and the instructor showed us a picture of a carcinoma and asked us if anyone knew what the definition of a carcinoma was. We were clueless. I had no idea that carcinoma did not have an equivalent meaning to "cancer" and I didn't know the difference between a sarcoma and a carcinoma. I always remember that episode everytime I am faced with a trainee who seems clueless.

 

[zao275]

Just remember that at one time, everyone who is supervising you was an idiot too. No one crawls out of the womb knowledgable about their careers.

Well, I think Juan Rosai sprung forth fully formed from the mind of Virchow. But other than that, I agree with you.

 

[yaah]

Well, I think Juan Rosai sprung forth fully formed from the mind of Virchow. But other than that, I agree with you.

I heard he emerged from the jungle like Ramanujan and started creating new disease categorizations and recognizing new entities before he even knew what they were.

 

[levels x3]

And then your first year out in practice will be nearly as overwhelming as your first year of residency...so you do have that to look forward to.

 

[mmt2010]

Just wanted to say thanks again to everyone for sharing their experiences. I'm starting on my second month of surg path and your comments have helped me put things into perspective and also put some air back in my tires. 🙂