preview time

i would think that it's not just the number of specimens, but the type. a 3cm skin lesion resection isn't going to take nearly the time to gross as a R hemicolectomy. the most important thing applicants would be interested, IMO, is whether there is enough time/help/support to finish one's grossing in enough time to have adequate preview time before signout with the attending.

 

I hate previewing. The rest of the world disagrees with me, but I think it is of limited utility for junior residents. I think it's more appropriate for senior residents who can generate a differential diagnosis. When you are a clueless junior resident, previewing is just too grossly inefficient when there's 60-80 cases to see. Another problem, which may be unique to my program, is that preview time sometimes supplants time at the scope with the attending. They think the resident has already seen the cases, so they can just sign them out. Personally, I think this is their way of being able to sign out faster without having to sit there and teach you or entertain your questions. They come back to you and tell you what they changed, but I do not think this is an effective way to learn. Ideally I think PGY-1s and 2s should not have preview time beforehand but reading time afterward, and PGY-3s and 4s should preview. Again, I know the rest of the world disagrees and thinks previewing is the most sacred thing ever, but I disagree.

 

I'll join your cause. We don't get much preview time here, and while I initially felt lost and clueless, having to blast through cases before signout has definitely helped my efficiency (and I daresay improved my pattern recognition).

 

that's actually an interesting viewpoint. i am not yet a resident but having done some surg path, i do agree that while previewing, there is potential to spend too much time looking at a given slide, esp when you're not yet schooled on what to really look for. this time could be spent reading about the dz entity (as well as an appropriate differential dx).

it's unfortunate that your attendings assume that your having looked at the slide was sufficient for learning how to work up a case (at least as a pgy 1 or 2). that's a raw deal regardless of what preview system is in place. not cool at all.

anyway, i guess i will have to let you know if i truly agree or disagree after july. although i do think you make a valid point.


what i can say is that previewing should (in an ideal world) trump grossing...in other words, you shouldn't loose preview time to gross like a machine, esp as a senior resident. again, i'm not yet a resident so maybe i'm a bit off on this one.

 

interesting thoughts - i haven't gone through this, so i'm not going to venture an uneducated opinion. it seems like your suggestion would make the first 2 years of path residentcy a very long "teaching session" in terms of of the surg path. the question is whether this would lead to strong diagnosticians down the road. at my program i get the impression that they really don't expect full diagnostic accuracy of PGY-1s, especially for zebras, and that diagnostic skills are expected to progress over the year, like in any other specialty. to me it seems like the question comes down to how the residents time is best spent: struggling through slides on their own before sign-out vs. using that time instead to read about the entity diagnoses and further study that entity via atlases and texts. i'll enjoy seeing the opinions of other current residents, from the PGY-1 level on up, on cjw's ideas.

 

Well, I for one really like preview time and as I have posted about in other threads, would not train at a place without it, knowing what I know now. I did my PSF at a place that didn't have preview time the majority of the time (although i usually found time for it) and I learned a ton more when I previewed.

You learn a ton by previewing, +/- dictating diagnoses ahead of time. You are often forced to make decisions and consider things that you wouldn't normally do in the context of a normal signout (because they don't come up or the attending blows by them). Many times I spend a lot of time focusing on something during previewing that turns out to be nothing, and I would never know it if I just saw it at signout. But when I was on my own, I sure as heck would notice it and I am likely to remember more if I thought about it a lot during preview time and then had signout. Education is not being told what is or is not true - it's figuring it out for yourself.

Previewing does take up more time commitment than just going to signout, or quickly perusing cases before signout, but it is very much worth it.

I also think it is important at all stages of your training. At the start of training, it's important because you can spend time on things and learn different trends, associations, etc. And yes, signout can then go fast afterwards but I have never sat with an attending who didn't answer every single question I brought up and take time to discuss anything I wanted to (and I ask lots of questions). As a senior, it is advantageous because you start refining your own diagnostic abilities, and you can see how efficient and how correct you actually are. As for the argument that you can spend too much time during previewing focusing on insignificant things, that's the idea. How do you know it's insignificant? Do you take someone's word for it or do you learn about it yourself and figure out why?

Previewing is a vastly different world and learning opportunity then just observing signout. Sure, you see the same cases and you get a lot of the same teaching, but you don't learn as well, IMHO.

As far as it supplanting time at the scope with the attending, that I disagree with, and that is a potential big gripe that I would raise a stink about. Do they tell you when your previewing dx was wrong? Do they know what you thought? Do they even know that you previewed or do they just trust you to do it? If, as you say, it is a way for them to get signout done in as minimal time possible, they should not be at a teaching hospital, and I would complain about this too (residents don't complain enough).

 

Ditto.

 

I will say that it depends on how you preview. If you sit down and won't go to the next slide until you feel you have the current one mastered, then you are in for a rough couple of early years. Look at stuff quick, formulate an opinion, and make sure you see as much stuff as possible. Sure, a lot of diagnoses will be wrong, but you will be able to notice trends (i.e. i keep calling atrophy prostate cancer, or i am missing lymph node mets, etc.). Then the next time you get a case like that, you will know what to concentrate on. As residency progresses the previewing will shift focus to your differentials etc. Don't underestimate previewing.

 

Yaah, you said exactly what I knew you would say. But I think part of the reason you got more out of previewing as a junior resident is that you did a PSF. For an average PGY-1, it's a couple of months of path electives and what you remember from histology to get you started on that stack of 60 cases. There is simply not enough time to QUALITY preview everything starting from ZERO knowledge, in addition to proofreading the gross description/paperwork and assigning the billing codes. The way you describe previewing, there's time to ponder things and do a little reading if you don't know what something is. I can't do this with 60 cases. It's a matter of putting the slide on the stage, writing the first thing that comes to mind (hopefully something) or the first thing in the book, and trying not to miss anything obvious while completing the associated proofing and billing. And I'm there LATE doing this. I don't consider this quality work.
Don't misunderstand, I don't advocate spoonfeeding- I don't think the attending should spend hours with you at the scope pointing out every feature of the diagnosis and discussing the differential in detail. That should be your job to sit with the book and the slides AFTER sign out to figure out *why* the attending called a lesion what they did and why it's not the other entities in the book. At least then you can focus your reading. I just think if you are clueless, it helps to be pointed in the right direction first rather than stumbling around blind.

 

I think previewing is good but I agree with the sentiment that early on, previewing more or less blindly with zero knowledge is less likely to be fruitful. But if you approach it as yaah and triguy said, then it's all good. One major issue I've observed is that some folks lack a sense of realism during their first several weeks of surg path. What I mean is this...you have two extremes of people, the obsessive-compulsive and the laid-back. The obsessive-compulsive folks will spend hours and hours previewing to try to get the "right answers" at signout the next morning. This just isn't practical and I personally think that early on in residency, it's OK to look up basic history (not going overboard), just look at the slides, admire the beauty of the H&E, come up with some thoughts, and then show up to signout. I've seen people toil over cases for extended periods of time only to see them complain that they still didn't come up with the right diagnosis the next morning. The learning curve is steep in pathology and for previewing to be of optimal benefit, some fund of knowledge is required. Once you get to this point, however, previewing has a lot of potential in helping you hone your eyes. A lot of pathology is pattern recognition too, so experience definitely helps making previewing time more efficient as well.

Another added benefit of good previewing is that it makes signout go a hell of a lot faster! You got your diagnostic reports all written up (or dictated) and you and your attending blaze through cases. But again, you don't get to this point without experience. So, when you're starting out, it's impractical to spend countless hours previewing only to find out that you were way off base on many of your cases at signout the next morning. When you preview for extended periods of time and your signouts are longer, you start a vicious cycle that leads to potential violation of work hours. And that's no good...cuz if we wanted to violate hours, we could've gone into IM or surgery

The other implication of this is the flip side...let's say that you have lots of experience, you preview efficiently, and your attendings trust your diagnostic skills. Sometimes they may even put a little more faith in you than you think you deserve...so then previewing may take a little longer because you start to get paranoid and struggle over little stuff.

 

I understand your points, I still disagree though. As was said above, the purpose of previewing will vary depending on your stage and level or training. At the beginning, it's more getting a general opinion (is it cancer or not, can you tell what organ you're in, etc). While some attendings may be unreasonable in their expectations of new residents, most understand that it is a steep learning curve. Here, for example, we are told if we don't have enough time to preview everything, that's fine.

The other paperwork stuff, I agree, is time consuming, but it has to be done. If you wait to do it during signout, it just makes signout longer. A lot of making previewing more efficient comes from good instruction from senior level people - i.e. what should you be paying attention to, what is less important, etc.

And IMHO, you become a lot better quicker at pathology if you are previewing and trying to figure things out on your own. You will stay later, yes, but it will be worth it in the end. And as said above, worrying about the exact right answer is not as important. Think about basic things - for example if it's a liver tumor, is it cancer? And what are the important things for signout? Well - margins, size, etc (see template). Focus on those.

 

This whole debate is rather silly. How much preview time is optimal will depend on your level of training, personal style of learning, and the idiosyncracies of your attending du jour. There is no one-size-fits-all solution.

 

i don't think it's silly. cjw suggested a pretty radical change from the current model of pathology education and it's an interesting and worthwhile discussion. the exact amount of preview time a resident needs is of course dependent on how experienced they are, and how good, so yeah, that's a silly discussion. but the discussion of whether it's worth previewing at all in the first 2 years of residency versus assigning that time for reading is worth having because maybe it is better and maybe it isn't, but to figure that out informed opinions should be debated.

 

I think one factor that isn't quite defined in the discussion is the nature of previewing time at each individual institution.

At the U and at the county hospital (two of four places our program spans), it's a two-day cycle. Day 1 = Gross, Day 2 = biopsies coming out in the morning, larges coming out in the afternoon.

At the U, previewing if any basically entails scanning L3 of the biopsies quickly while putting the paperwork together while triaging which might potentially need special stains/IPs. Previewing larges usually consists of picking out the bluest slide or the key margins listed in the summary of sections before it's off to the multi-headed scope.

At the county, all the slides for the day would end up in your mailbox. But because it was lower volume and relatively less complex cases (e.g. no teeny transbronchial biopsies for evaluation of rejection), it made sense that we were required to preview and enter final diagnoses even if it was our 2nd month as a surg path resident.

I'm heading for high-volume private-practice surg path next month as a resident, so we'll see how things go there. I know residents dictate the finals there.

Additionally, not all of G1/G2 is going to be surg path. I would say after 4 - 5 months of double-scoping on a two-day surg path cycle, I felt more equipped to formulate Final Diagnosis lines. Slow, but like cjw0918, I was also starting from zero. I couldn't be counted on to spot a plasma cell at 10x. That came with double-scoping. We can't all be like yaah

Formulating final diagnoses are also somewhat dependent on how comfortable attendings are with your skillz. At the beginning of my 4th month of surg path, the SP director at the county hospital told me that I should work towards previewing and entering diagnoses into the computer on my own, and he proved to always be available if I had a difficult case and didn't know where to start. It helps too that both hospitals I've been at have computer shortcuts in CoPath and Cerner to insert CAP protocols into the final report.

On the other hand, there are attendings who won't trust you, whether a G1 or a fellow, to enter anything into the computer. C'est la vie.

~

The original poster asked about grossing.

Yesterday I did a prostate (entirely submitted), a simple and a radical mastectomy, a coupla explanted lungs, a prophylactic TAH/BSO and a colon. Average, for a day that had two hours of conferences.

 

I don't think there is really a solution either, other than to have it as an option. The optimal amount of time is "as long as it takes," which also varies. For some people, a couple of hours will suffice. But not for others. Not all departments are willing to provide the extra day of turnaround time for most cases, mine does, and I am grateful. If you don't want to use it significantly, you don't have to. We have people at my program who either don't preview much or who only do the minimum, or do that once in a while if they are busy with something else. The preview time is provided as an educational tool (that, and some cases don't finish getting processed and stained until late afternoon anyway) which is an important part of our training and which everyone appreciates having.

It's hard to do anything significant other than correcting gross descriptions and making sure the sections can be interpreted if you only have an hour and 60 cases to preview.

In terms of grossing, we see everything we gross (as it is subspecialty based) unless it is grossed on the last day or two of the month when you won't be signing it out because it will be signed out at the start of the next month. Our load varies tremendously based on service, OR, day, and how much PA help there is that day. Today I grossed nothing. A couple of days ago I grossed two mastectomies and three oriented lumpectomies. Two weeks ago I had a day where I grossed in 3 bladder/prostates, 2 prostates, and 2 kidneys.

 

When on surgicals, I receive specimens every 3 days. On those days, I get anywhere from 7-15 specimens.

Like yaah's dept, our dept has negotiated with the clinicians to allow for one extra day in the turnaround time to allow for a day of previewing. Slides come out in the early afternoon which leaves ample amount of time for previewing all the cases.

Of course, your previewing will depend on how you gross...are you the type of person who likes to oversubmit sections? If so, your previewing time will be longer. Of course, I think it's OK to entirely submit every breast with a history of DCIS...I loooove looking at 400 slides of boob every day!

 

I'm now learning a second way of grossing a prostate since the only way I've ever known is to "entirely submit". I'm looking forward to seeing one-tray prostates the next day.

 

Yeah, I don't entirely submit prostates anymore. 2-4 slides for the nodes (if applicable) and 16 slides max for the prostate sections. What I submit depends on what I see grossly (in most cases the cancer is invisible) and if the prior biopsy documented extensive cancer, I'm conservative in what I submit. I will only consider submitting the whole thing if the prior biopsy was for instance a 3+3=6 grade cancer seen in 10% of 1 core. Going back to the bucket is like kryptonite for me.

 

Ya think it's by choice that I torture myself and the histotechs like this??

It's a damned one-year-new prostatectomy protocol that was put into place through some sort of research collaboration with the urology department.

 

Baby want her bottle?

 

After almost a year of residency, I have found that I can sign out about half of my cases (dictating) on my own fairly quickly with only minor errors. These are the everyday specimens that I have seen a lot of like breasts, colons, kidneys, prostates etc. I spend the rest of my preview time working through the rest of my cases, usually with great difficulty. I miss things, the attending points it out, and then I'm pissed about missing it and vow to myself to never miss that again. If a resident can't sign out at least some cases reasonably well by the end of first year they either aren't seeing enough, aren't reading enough, or aren't being taught well.

 

You're opening your mouth but all I hear is "bla bla bla..."

 

I agree with yaah. I've been making diagnoses, filling out synoptics, and measuring margins since my very first sign-out. There's just no substitute for struggling with cases and agonizing over unimportant things. For example, in the beginning, examining lymph nodes for metastases would almost kill me, b/c I would be scrutinizing every germinal center or funny looking histiocyte. Now, I can buzz through lymph nodes without making a mistake.

I am finishing up my first year and I am now getting a vast majority of my cases correct, I order immunos up-front while I'm previewing, and the attendings will listen to my opinion if I don't completely agree with their diagnosis. None of that would be possible if I hadn't been thrown into the fire from the very beginning. I can't imagine just starting to preview as an upper level.

cjw, do you not sit down and sign out with the attendings? I find that unacceptable. My previewing may be detailed, but I always look at every case with the attending.

 

You made a good point. I also have to admit it is attending dependent. The good ones would provide insightful feedback, and help sharpen your diagnostic skills. The others may just simply ignore your questions, in which case we don't lose anything...Given the time I put in, I found preview is very helpful, esp the large cases and bx.

 

Yep, I'm finishing my 1st year too, but don't have much fortune of ordering immunos. Our program has a long history of focusing on morphology only.

 

You have a busy service up there, given the number of large specimens. No wonder you felt well equipped to formulate final dx. We've PA gross junks, and have 3-4 big cases a day/cycle.