Right track vs wrong track programs

[Rodak]

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I propose the following two true/false questions as potential discriminators of pathology residency programs that are on the right vs wrong track. I would like your ideas, critiques, input, etc.


*** EDIT *** Please see my revised questions in bold in post #7.



1. If PA's grossed 100% of the specimens and dictated 100% of the gross descriptions/frozen diagnoses, then residents on general surgical pathology would NOT routinely *directly* compose (i.e. dictate, type, or write for transcription to type) general surgical pathology reports. If true, then your program is on the wrong track. If false, then your program is on the right track.

2. This one can apply to any area, but let's specifically address it to the areas of general surgical pathology, cytology, autopsy, transfusion, and hematopathology: For the vast majority of residents in your program, they would be able to perform *independently* the VAST MAJORITY (say, over 80%) of the clinical responsibilities of one of your attendings in that area at your institution THE WEEK AFTER they finish their last rotation in that area. If true, then your program is on the right track. If false, then your program is on the wrong track.

 

[lurksalot]

I propose the following two true/false questions as potential discriminators of pathology residency programs that are on the right vs wrong track. I would like your ideas, critiques, input, etc.

1. If PA's grossed 100% of the specimens and dictated 100% of the gross descriptions/frozen diagnoses, then residents on general surgical pathology would NOT routinely *directly* compose (i.e. dictate, type, or write for transcription to type) general surgical pathology reports. If true, then your program is on the wrong track. If false, then your program is on the right track.

2. This one can apply to any area, but let's specifically address it to the areas of general surgical pathology, cytology, autopsy, transfusion, and hematopathology: For the vast majority of residents in your program, they would be able to perform *independently* the VAST MAJORITY (say, over 80%) of the clinical responsibilities of one of your attendings in that area at your institution THE WEEK AFTER they finish their last rotation in that area. If true, then your program is on the right track. If false, then your program is on the wrong track.

I'm not aware of any training program in the country that has its PAs gross 100% of specimens and frozens. Therefore, ALL programs would be on the "right" track.

Really? You want the vast majority of residents functioning as attendings the week after their last rotation in a specialty? Many of the sub-specialties you list have ACGME fellowships. I agree they should be trained at a level of competence, but I'm not sure at any program they'd be able to function as attendings in all sub-specialties.

Things that make you go.... HUH???!!!

 

[2121115]

I'm not aware of any training program in the country that has its PAs gross 100% of specimens and frozens. Therefore, ALL programs would be on the "right" track.

Really? You want the vast majority of residents functioning as attendings the week after their last rotation in a specialty? Many of the sub-specialties you list have ACGME fellowships. I agree they should be trained at a level of competence, but I'm not sure at any program they'd be able to function as attendings in all sub-specialties.

Things that make you go.... HUH???!!!

There is something to be said for getting better over time. In fact you can get better at surgpath by getting more experience doing heme or cyto or whatever because you just become a better pathologist in terms of habits, attention to detail and general experience. For example, if a first year and a fourth year do a rotation at the end of the rotation I would expect the 4th year to be much better than the first year just because they've "been in the game" longer.

However, expecting someone to do 80% of an attending's work is not an unreasonable expectation after completing a resident rotation. Most of what we do is relatively easy to pick up. It is the other 20% that is the hard part.

 

[Rodak]

1. You may have misinterpreted the first one. I probably didn't construct the question well enough. The question is not about grossing specifically, but rather about the *rest of the report*. If *hypothetically* residents stopped grossing at your program, would they directly contribute anything else to the report? I suppose an oversimplified way to ask it is: do residents dictate the final diagnosis? The basis for this question is twofold. One, surgical pathology is by far the main competency area. Two, the main work product in surgical pathology (and most of pathology overall) is the report.

2. Regarding the second question, I'm trying to get at the ultimate measurement of competency. In other words, what exactly will someone pay you to do once your done? Sure, there are fellowships in the most common core areas of pathology, but would you need to do fellowships in every area to be competent in those areas? If most graduating residents from a program are unable do most (not all) of what a pathologist does, I would tend to think that's a wrong track program. Graduating residents from many programs would answer yes (or "right track") to this minimum competency question. I don't know how common such programs are as a percentage of all programs (20? 50? 90?).

I'm not aware of any training program in the country that has its PAs gross 100% of specimens and frozens. Therefore, ALL programs would be on the "right" track.

Really? You want the vast majority of residents functioning as attendings the week after their last rotation in a specialty? Many of the sub-specialties you list have ACGME fellowships. I agree they should be trained at a level of competence, but I'm not sure at any program they'd be able to function as attendings in all sub-specialties.

Things that make you go.... HUH???!!!

 

[sirenomelia]

1) No program like that exists so irrelevent
2) This is not true either. Some aspects of path all 100% of trainees should be able to do after the last month- ie AP; while some niches- like informatics one shouldnt be expected to be an expert computer programmer after a one month cursery experience. You just need to understand basics. Other things like heme or chemistry you should come away with a good foundation but not necessarily savvy to walk in and be a medical director.

The only litmus test of a program on the right track that matters is:
1) Do they get good jobs where they want to be
2) do they pass boards.

 

[gschl1234]

The only litmus test of a program on the right track that matters is:
1) Do they get good jobs where they want to be
2) do they pass boards.

I couldn't agree with *that*. A crappy pathologist can still find a job *somewhere*. And passing the boards doesn't have much to do with day-to-day pathology so I wouldn't say that seems like a measure of a good pathologist either.

 

[Rodak]

1) No program like that exists so irrelevent
2) This is not true either. Some aspects of path all 100% of trainees should be able to do after the last month- ie AP; while some niches- like informatics one shouldnt be expected to be an expert computer programmer after a one month cursery experience. You just need to understand basics. Other things like heme or chemistry you should come away with a good foundation but not necessarily savvy to walk in and be a medical director.

The only litmus test of a program on the right track that matters is:
1) Do they get good jobs where they want to be
2) do they pass boards.

OK, scratch my original questions. I'll replace them with:

1. Do residents substantially *directly* write reports? For example, in surg path, do they dictate the final diagnosis? Does this happen at all? If so, how often? Apply the same question to all areas: AP subspecialties, cytology, protein sign out, transfusion reports, hemepath, etc. Things that do *NOT* qualify for a "yes" to this question: writing gross descriptions, writing autopsy reports, informally scribbling your ideas down that are not then used for the report, or being "around" when the attending/fellow does the composing/dictating and verbally saying what you think. I'm not even asking how often you are correct.

2. Upon finishing your residency, can you do 70% of what a practicing pathologist does in the core areas (AP: sp, autopsy, cyto; & CP: BB & HP)? 70%. Not 100%. Not 90%. 70% seems utterly reasonable.

On the second question, I didn't say informatics, neuropath, etc. I think the most core areas (SP, Aut, cyto, BB, HP) are more important for most people as a minimum competency level. I think good programs consistently graduate people who can do at least 70-80% (not all) of what a practicing pathologist does. If you can't do 70-80% of what a practicing pathologist does, that seems like many opportunities for responsibility were either not provided or not taken (i.e. they were provided as things you "may do" but are not required to pass/graduate). Not everyone does a fellowship. And even if you do, a fellowship in one area will not radically improve your performance in other unrelated areas.

My intents are to help candidates applying to residency assess progarms and to help current residents assess their own program (for potential reforms, remedies, transferring, etc). And a more long-term wish is to potentially (maybe) someday help raise the bar of minimum competency with the goal of significantly increasing the percentage of competent graduating pathology residents. This could happen by attrition/closing of bad programs or by reforming/consolidating bad ones or through other methods. The main point is that I don't see the long-term benefits for anyone of graduating and certifying a significant percentage of, to be blunt, inadequately trained pathologists who can't do most (not all!) of what a general pathologist does (in the core areas, not all!) and who haven't performed (either at all or minimally) the most important responsibilities that an attending performs (i.e. write reports). I want to hire and work with solid people.

To be clear, I'm referring to residency programs, not fellowships.

 

[KluverB]

1. Yes.
2. Yes.

 

[sirenomelia]

I couldn't agree with *that*. A crappy pathologist can still find a job *somewhere*. And passing the boards doesn't have much to do with day-to-day pathology so I wouldn't say that seems like a measure of a good pathologist either.

The OP was critquing programs not pathologists. Alot of the core sub-specialty training experience itself is irrelevant also. If you're not going to do autopsies in the future or supervise a pheresis center than limited exposure/ skills in those areas won't preclude a pathologist from being competent and successful. From the trainees perspective, the signs of a poor program are board fails and lack of trainees' attainment of fellowships/ jobs whatever the person's next step is.

 

[gschl1234]

The OP was critquing programs not pathologists. Alot of the core sub-specialty training experience itself is irrelevant also. If you're not going to do autopsies in the future or supervise a pheresis center than limited exposure/ skills in those areas won't preclude a pathologist from being competent and successful. From the trainees perspective, the signs of a poor program are board fails and lack of trainees' attainment of fellowships/ jobs whatever the person's next step is.

Eh. I still think that there are plenty of programs where "everyone passes the boards and lands a job," but churn out barely competent pathologists. Ultimately, the trainee wants to be competent, right? You not only have to get the job, but perform, right? In my personal experience, I have never heard of anyone finding it impossible to secure a job *somewhere*. And I've only met 1 person who failed CP boards. I've never met or even heard of anyone who failed AP boards. The bar is being set too low if the only criteria are passing the boards and getting a job.

 

[2121115]

1. Yes.
2. Yes.

You're on the right track, baby, you were born this way.

 

[Pathologee]

I like the two question format. In medical education, less is more. I don't see why we even need the ACGME's services.