Prelim year for path??

[raspberry009]

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I just wanted to throw this one out there. My attending (surgery attending, mind you) and I actually got into a dispute over this question:

Should pathologists do a prelim year? or rotate in internal medicine or surgery for at least three months.

My defense: (though my thoughts running mostly on the "that the last thing I want to be doing is working 80+ hours a week doing *that*"-while rolling my eyes) I think the best pathologists have good communication skills and know their surgeons well (if you work in surg path).

My attending's side was (and a few other attendings jumped on board - I really was a minority in this conversation), that pathologists really need know the outcome of what they are reporting back. "Most" of the time (as the attendings repeatably said), the answers are so vague its frustrating. For example: inflammatory bowel disease, most pathology reports won't commit to Crohn's or UC, when clearly it should be one or the other...

My defense once again: Communication!! I think medical school has given me enough background, and I do not feel that I need to piddle around in a preliminary residency spot to know outcomes of my diagnosis... am I wrong? But I will have to admit, I did look pretty dumb at the end of this conversation.

 

[gbwillner]

I just wanted to throw this one out there. My attending (surgery attending, mind you) and I actually got into a dispute over this question:

Should pathologists do a prelim year? or rotate in internal medicine or surgery for at least three months.

My defense: (though my thoughts running mostly on the "that the last thing I want to be doing is working 80+ hours a week doing *that*"-while rolling my eyes) I think the best pathologists have good communication skills and know their surgeons well (if you work in surg path).

My attending's side was (and a few other attendings jumped on board - I really was a minority in this conversation), that pathologists really need know the outcome of what they are reporting back. "Most" of the time (as the attendings repeatably said), the answers are so vague its frustrating. For example: inflammatory bowel disease, most pathology reports won't commit to Crohn's or UC, when clearly it should be one or the other...

My defense once again: Communication!! I think medical school has given me enough background, and I do not feel that I need to piddle around in a preliminary residency spot to know outcomes of my diagnosis... am I wrong? But I will have to admit, I did look pretty dumb at the end of this conversation.

I would rather do 6 months of medicine/surgery than have current ACGME curriculum that has all path divided up by months rather than specimens. My problem with it is that it becomes so inflexible because of the sheer number of time necessary. Why can't we just sign out a certain number of all important types of specimens? Some places get 3-4 times the volume of other places, but they fill the same requrements. I feel that if our training was split up by volume rather than time, we could fit in more free time or weird things like surgery and medicine, provided you are at a high-volume place.

 

[yaah]

My attending's side was (and a few other attendings jumped on board - I really was a minority in this conversation), that pathologists really need know the outcome of what they are reporting back. "Most" of the time (as the attendings repeatably said), the answers are so vague its frustrating. For example: inflammatory bowel disease, most pathology reports won't commit to Crohn's or UC, when clearly it should be one or the other...

My response to this would be that perhaps the clinicians should spend a little time in pathology. Do they know why the answers are sometimes vague? Have they seen some of the biopsies? We got a liver biopsy yesterday with two atypical cells on it (at the edge of a biopsy, in a scar) and they wanted to know if it was metastatic carcinoma or not.

There are innumerable articles about the diagnosis of inflammatory bowel disease and how it cannot often be undertaken without appropriate clinical information, and how there are many overlapping cases which do not fit into one of the two categories. Clinicians will oftentimes do a colonoscopy and do one biopsy in the ascending colon and ask us to diagnose crohn's disease. Unlikely. See here for example.

If some clinicians spent more time actually learning what pathologists do and talked to the pathologist about their biopsy, they might learn something. Many do, and they are often better clinicians for it (just like pathologists who interact more with clinicians).

It's like getting a transbronch with a single granuloma on it, and asking why we can't make a definitive diagnosis as to infection vs sarcoid vs hypersensitivity vs other.

 

[Sean2tall]

I agree that the yield of doing a whole year of that sort of thing would be pretty low. I would even say that the 3 months of surgery during medical school plus going to tumor boards etc. has been enough to give me some perspective on what the clinicians are looking for. (Probably as much as I can get without being a surgeon for a while.) Even if you did a surgery/medicine internship, it wouldn't consist of making treatment decisions with the surgeons and oncologists, it would consist of replacing people's K and writing pointless notes. (And then maybe if you have time and you're not frowned upon for shirking your duty too much you can sneak away to tumor board and see how the treatment plans are being made.)

If we did have to do such a year, I think the most logical would be 50/50 medicine and surgery to tie in the effects Path has on surgery, medical oncology, and regular medicine. And I don't know of any such prelim that would let you do a mix like that. Additionally, to get the most use out of it, it would have to be more of a shadowing the attending experience rather than "Oh good, we have another intern to take some of the work load off of us."

 

[gungho]

My response to this would be that perhaps the clinicians should spend a little time in pathology. Do they know why the answers are sometimes vague? Have they seen some of the biopsies? We got a liver biopsy yesterday with two atypical cells on it (at the edge of a biopsy, in a scar) and they wanted to know if it was metastatic carcinoma or not.

There are innumerable articles about the diagnosis of inflammatory bowel disease and how it cannot often be undertaken without appropriate clinical information, and how there are many overlapping cases which do not fit into one of the two categories. Clinicians will oftentimes do a colonoscopy and do one biopsy in the ascending colon and ask us to diagnose crohn's disease. Unlikely. See here for example.

If some clinicians spent more time actually learning what pathologists do and talked to the pathologist about their biopsy, they might learn something. Many do, and they are often better clinicians for it (just like pathologists who interact more with clinicians).

It's like getting a transbronch with a single granuloma on it, and asking why we can't make a definitive diagnosis as to infection vs sarcoid vs hypersensitivity vs other.

agree w/yaah for the most part. one of the attractions i had (mistakenly) toward path from fam med was a (perceived) lack of ambiguity-needless to say, i was wrong. but it has been interesting seeing both sides. and a lot (most?) of clinicians can be clueless about the work of a pathologist. for example, i remember when i left my last job before starting residency, my supervisor was an internist about my age. when i told him i was leaving to start pathology, he said, "now, what is it you'll be doing? you'll be in a lab all day, right?" that's fine with me-the more mystique, the better, as long as they realize we are indispensable.

 

[docbiohazard]

My defense once again: Communication!! I think medical school has given me enough background, and I do not feel that I need to piddle around in a preliminary residency spot to know outcomes of my diagnosis... am I wrong? But I will have to admit, I did look pretty dumb at the end of this conversation.

Your first mistake was trying to have a discussion with surgeons. Don't you know that they are the chosen of God, and infalliable? 🙂

The pathologists I've worked with seem keenly aware of the outcomes based on different diagnoses... if anything, like Yaah said, it's the surgeons lack of understanding of what constitues a good specimen or why diagnosis might be difficult that is the bigger problem. They just want a black n white answer so they can go slice-n-dice and bill the patient... 🙂

BH

 

[gbwillner]

Your first mistake was trying to have a discussion with surgeons. Don't you know that they are the chosen of God, and infalliable? 🙂

The pathologists I've worked with seem keenly aware of the outcomes based on different diagnoses... if anything, like Yaah said, it's the surgeons lack of understanding of what constitues a good specimen or why diagnosis might be difficult that is the bigger problem. They just want a black n white answer so they can go slice-n-dice and bill the patient... 🙂

BH

Yeah, but isn't that really our job? To consult with Surg/Medicine and explain things to them?

 

[docbiohazard]

Yeah, but isn't that really our job? To consult with Surg/Medicine and explain things to them?

Yep. So I guess like raspberry said, it comes down to communication. They've got to listen, too.

Everyone's got to appreciate everyone else's role in everything, and talk AND listen... then we can all sit around, sing kumbaya, and eat cake. 😉

BH
ps. The cake is a lie...

 

[Dr. McDreamy]

I was under the impression that until a few years ago, you were required to do an intern year in medicine or surgery before doing 4 years of path. this requirement was recently changed partially in an effort to make path a more appealing residency because the field was having difficulty attracting good candidates. This is what a pathologist told me but it could be totally wrong!

 

[DarksideAllstar]

The issue I have with the prelim year (or transitional, if you will) is that a lot of the treatment modalities and regimens change rapidly. Doing an internship now maybe you get exposed to how patients with UC are currently treated. It doesn't mean that 2, 3, or 5 years from now you will still be up to date with current therapies. Understanding the difference in treatments between disease X and disease Y now doesn't mean you'll know about the subtle changes in 5 years (hell, maybe we'll decide there isn't a difference). Tell your surgeon to get back into the OR and just get decent margins. And tell him the cautery artifact don't lie.

 

[DarksideAllstar]

And admitting patients in DKA doesn't help you be a better pathologist.

 

[yaah]

Yeah, but isn't that really our job? To consult with Surg/Medicine and explain things to them?

I think many pathologists do not do a good job of interacting with clinicians. They receive the case and paperwork and issue a diagnosis. They may look up some clinical info but often don't discuss the case with clinicians to figure out the most important issues, etc (i.e. they think they can figure it out). There are lots of things to be gained by good communication. But, as said, it is a two way street. Clinicians can't complain about poor communication from pathology if they give in a requisition form on a patient that says "35 year old man with neck mass" as the clinical history.