surg path fellow without grossing?

[DocGul]

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I really enjoy surg path, want to do one more year of surgpath subspecialty or general oncology. I want to go in programs that does not require fellow to gross, or very minimum. Please help me out on this. Thanks

 

[GeoLeoX]

I really enjoy surg path, want to do one more year of surgpath subspecialty or general oncology. I want to go in programs that does not require fellow to gross, or very minimum. Please help me out on this. Thanks

what?

half of the signout is the gross description. i always feel a little queasy signing out big cases that i didn't gross myself. i appreciate the work of residents and PAs, but if i had the time i would rather do it myself (frozens, too) and follow the case all the way through. there's nothing worse then trying to recapitulate a gross from an inexperienced (and even experienced) gross tech.

i would be very suspicious of a program that minimizes the importance of grossing. besides, gross dissection is one of the skills that consistently rates high in surveys of prospective employers (http://repositories.cdlib.org/cgi/viewcontent.cgi?article=4811&context=postprints). putting together the macroscopic and microscopic picture is critical in the bigger cases. as a staff i feel like i am losing the ability to be truly responsible for my signout without getting to gross the case.

that's not to say that you couldn't just sign out cases grossed by a skilled dissector and still have a great experience, but when you are responsible for the case - your name is on the bottom line - you might have wished you grossed it yourself.

i am sure this will be a contentious topic and i am interested to hear the opinion of others.

G

 

[rirriri]

I really enjoy surg path, want to do one more year of surgpath subspecialty or general oncology. I want to go in programs that does not require fellow to gross, or very minimum. Please help me out on this. Thanks

they definitely exist. one i've heard about recently is in Hartford.....AND i've heard it's also a pretty good fellowship in the tri-state area.

 

[KluverB]

Kids today...

 

[sohsie]

what?

half of the signout is the gross description. i always feel a little queasy signing out big cases that i didn't gross myself. i appreciate the work of residents and PAs, but if i had the time i would rather do it myself (frozens, too) and follow the case all the way through. there's nothing worse then trying to recapitulate a gross from an inexperienced (and even experienced) gross tech.

i would be very suspicious of a program that minimizes the importance of grossing. besides, gross dissection is one of the skills that consistently rates high in surveys of prospective employers (http://repositories.cdlib.org/cgi/viewcontent.cgi?article=4811&context=postprints). putting together the macroscopic and microscopic picture is critical in the bigger cases. as a staff i feel like i am losing the ability to be truly responsible for my signout without getting to gross the case.

that's not to say that you couldn't just sign out cases grossed by a skilled dissector and still have a great experience, but when you are responsible for the case - your name is on the bottom line - you might have wished you grossed it yourself.

i am sure this will be a contentious topic and i am interested to hear the opinion of others.

G

I disagree. While I did not do a surg path fellowship (I did GI and am doing dermpath now), I would not want to be in a fellowship with a lot of grossing, and I am certainly past the point of ever wanting to gross every big case.

Residency is for learning how to gross (amongst everything else). You should be extremely comfortable and efficient in grossing by the time you are finished residency. Fellowship is for pushing as much glass and seeing as many different cases as you can.

Besides, one does need to learn how to understand and sign out a case based on someone else's gross description, and one needs to learn how to direct residents and PAs on how to gross and generally how to manage and teach them.

In the real world, you don't get paid to gross. You get paid to sign out cases (in between trying to get through all the paperwork, billing, administrative stuff, etc.)

I wholeheartedly encourage you to find a surg path fellowship where you are not doing a significant amount of grossing. If you are doing a lot of grossing, this means that you are at a fellowship that is treating you like a resident and doesn't really know how to design a surg path fellowship.

PS UCLA has a surg path fellowship that has only one rotation where you gross, but this rotation is at a hospital where the attendings gross all the cases. You are simply put into the grossing rotation with the attendings.

 

[GeoLeoX]

I disagree. While I did not do a surg path fellowship (I did GI and am doing dermpath now), I would not want to be in a fellowship with a lot of grossing, and I am certainly past the point of ever wanting to gross every big case.

Residency is for learning how to gross (amongst everything else). You should be extremely comfortable and efficient in grossing by the time you are finished residency. Fellowship is for pushing as much glass and seeing as many different cases as you can.

Besides, one does need to learn how to understand and sign out a case based on someone else's gross description, and one needs to learn how to direct residents and PAs on how to gross and generally how to manage and teach them.

In the real world, you don't get paid to gross. You get paid to sign out cases (in between trying to get through all the paperwork, billing, administrative stuff, etc.)

I wholeheartedly encourage you to find a surg path fellowship where you are not doing a significant amount of grossing. If you are doing a lot of grossing, this means that you are at a fellowship that is treating you like a resident and doesn't really know how to design a surg path fellowship.

PS UCLA has a surg path fellowship that has only one rotation where you gross, but this rotation is at a hospital where the attendings gross all the cases. You are simply put into the grossing rotation with the attendings.

I knew this would be contentious and it shows the disparity of opinions that are out there. IMO it is better to be fully involved in your cases. My experience is obviously different that the previous poster - I finished residency and went on to a staff position. My name is on the bottom line, I am responsible for the case, I am responsible for the paperwork, I am responsible for the resident's (or fellow's or PA's) grossing. I don't disagree that a staff pathologist needs to be able to direct others, but I do disagree that the experience of grossing should come from residency alone.The best surgical pathology-fellowship-trained pathologists that I have known have been expert grossers.

As a former member of the ASCP and CAP Residents' Forums I can say that I have met a lot of residents from numerous programs who felt unsure of their ability to sign out cases due to the fact that they spent a lot of time grossing as a resident and not enough time being truly responsible for cases. In these instances perhaps they are well-suited to direct the grossing of cases. However, these residents tend to burn through multiple fellowships in order to gain experience (and case numbers) they didn't get as a resident, without being ultimately responsible for the cases they see. I have obviously had a different residency experience than the previous poster where I have not grossed as many cases as I would have liked to before signing them out myself. Don't get me wrong I was way above and beyond the case numbers needed to sit for the boards, but I would have felt more comfortable with greater numbers.

I also disagree that in the "real world" one gets paid to sign out cases - not that I disagree with the factual statement, but I think that signing out cases involves a lot more than "getting paid".

In the end it comes down to what you feel like you need and what experience will best prepare you for the career you envision.

G

 

[rockit]

I'd agree with the OP. Most attendings do not gross and it takes practice to read off other people's grossing and direct others to gross properly.

 

[rirriri]

well to be fair, most attendings at teaching hospitals NEVER gross a specimen. In private practice and in small practices as well as smaller community hospitals----i'm sure there is plenty of grossing being done by attendings before they sign out that same case.

I personally would never want to gross too many of my surgical cases...i'd like to SEE the specimen in larger more complex cases, but i'd like to think that i can trust residents or PAs to do a good job......this should be a TEAM effort, just a self-revolving-i-can-do-it-all-and-i-don't-trust-anything-i-didn't-do type affair....

just my input, as a current resident. maybe this'll change in the real world as an attending, when my electronic signature actually COUNTS for something! 😉

 

[yaah]

I think that too many residents and fellows minimize the importance of learning to gross properly (not just learning to gross). Being good at it improves diagnostic accuracy and efficiency. Too many residents treat it as scutwork or something else objectionable (which it can be in certain circumstances). I probably got to gross more than most residents during my training because of circumstances like doing a PSF where there wasn't much PA help, and being on services when the PAs were absent, and I really didn't get totally comfortable with it until fairly late. I don't gross much in my fellowship - only when there is no resident on the service which is rare, and then the PAs do most of it anyway.

 

[DocGul]

Grossing is big part and important part of the surgpath residency, I mean residency. If you grossed many and good at at. I don't see the point spend more than 50% of your fellowship time grossing again.

Thanks for the input everyone.

 

[exPCM]

It all depends on the type of grossing.
I spent a lot of time in residency grossing in small biopsies which was basically scutwork.
However, the time that I spent grossing in larger surgical specimens was quite worthwhile.

 

[HbyHA]

grossing small biopsies, appendicies, placentas, gall bladders = SCUT

grossing big specimens = essential to the learning process

i agree that after a few time, chop n' drop cases (breast lumps, thyroids, benign, uteri, skin ellipses) have little education yield. but those are the cases that you blast through to get to spend more time with the complex specimens. i think something is lost in the programs that allow the residents to do as little of the grossing as they want to. though i can see how residents who are so overworked that they don't get a chance to review their slides feel like they are just being glorified PAs. we are lucky in my program that we have a dedicated review day. i think more is learned when you have to put the case together from the start (when case is rec'd fresh, to cutting in, to slide review and case write up), then if you just get a tray of slides to hand to the attending.

the SP fellowship here has ZERO grossing. i guess some fellows like that, but then they only see big cases if the resident has hit their cap for number of cases and then on shadow signout.

i guess each approach has its pluses and minuses...

 

[malchik]

Grossing is a super important skill. I would like to do a 100% grossing fellowship. Which programs offer this (preferably in California)?

 

[rockit]

Grossing is a super important skill. I would like to do a 100% grossing fellowship. Which programs offer this (preferably in California)?

I suspect I'm missing some irony, but you're looking for a program called Pathology Assistant. It will get you all the grossing experience you need without that pesky tissue diagnosis clouding up your day.

 

[pathstudent]

THere is no bigger waste of a pathologist's time than grossing, unless you love doing it.

 

[GeoLeoX]

THere is no bigger waste of a pathologist's time than grossing, unless you love doing it.

Maybe you mean there is no bigger waste of a resident pathologist's time.

 

[djmd]

THere is no bigger waste of a pathologist's time than grossing, unless you love doing it.

I'm pretty sure malpractice cases would be a bigger waste of a pathologist's time.

 

[yaah]

I think the biggest waste of time is trying to track down mistakes that are made and fix them, often mistakes made from poor grossing.

 

[2121115]

I think residents have the idea that grossing is not important because they never see senior pathologists doing it in their training programs. Its is viewed as something that you "pay your dues" and then move on to "get to the reason you went into pathology". Hell you hardly see senior residents doing it at some institutions, much less attendings. The same can be said for autopsies. Ever see a senior pathologist cut up an autopsy? Not likely.

This is yet another disconnect between the world that residents live in and the world that community pathologists live in. And we wonder why surveys say that groups hiring new residents say they are not prepared. No kidding. They haven't been in the gross room for 2 years and their last year of training involved a couple months of surgpath and 10 months of random CP stuff.

 

[sohsie]

Grossing is a super important skill. I would like to do a 100% grossing fellowship. Which programs offer this (preferably in California)?

There is a surgical pathology fellowship at UCLA-Olive View in Sylmar, CA where you will gross all of the cases that you see (as do all of the attendings). The director is Dr. Nora Ostrzega, who is one of the best pathologists and teachers that I have ever met.

 

[sohsie]

I am not minimizing the need for top notch grossing skills in pathology. There is no question that every board certified pathologist ought to be able to gross any case expertly. I simply believe that that those skills should be acquired in residency. By the time you are a fellow, you should already be at an expert grossing level. (That doesn't mean that you won't sometimes need a second set of eyes on a particularly complex case, but that should be the exception, not the norm). Your fellowship time should be spent looking at slides, not being "another resident".

Grossing is a bit like riding a bicycle. I had to do a month at a hospital where I had to rotate grossing with the other attendings, and this was over one year since I had done any serious grossing, and I didn't have any problems getting right back into it.

 

[malchik]

There is a surgical pathology fellowship at UCLA-Olive View in Sylmar, CA where you will gross all of the cases that you see (as do all of the attendings). The director is Dr. Nora Ostrzega, who is one of the best pathologists and teachers that I have ever met.

Thanks, but no thanks. I only want to gross. Not only that, but I want to be trained by the world's expert grossing guru pathologist, since there is such a large difference between average grossing skills and super duper grossing skills, and there are so many fine academic pathologists who take great pride in their grossing. As was noted above, private group surveys suggest that their new hires are inadequately trained, and I am certain that they are talking about grossing skills and not histopathology. 🙄

 

[2121115]

Thanks, but no thanks. I only want to gross. Not only that, but I want to be trained by the world's expert grossing guru pathologist, since there is such a large difference between average grossing skills and super duper grossing skills, and there are so many fine academic pathologists who take great pride in their grossing. As was noted above, private group surveys suggest that their new hires are inadequately trained, and I am certain that they are talking about grossing skills and not histopathology. 🙄

If you are well trained in gross pathology, you won't even need a microscope. Back in my day, we didn't even have microscopes. We just held the gross specimen up really close to our eye so we could see it real good. Microscopes are a crutch that these younger pathologists have been trained to depend on.

 

[GeoLeoX]

Thanks, but no thanks. I only want to gross. Not only that, but I want to be trained by the world's expert grossing guru pathologist, since there is such a large difference between average grossing skills and super duper grossing skills, and there are so many fine academic pathologists who take great pride in their grossing. As was noted above, private group surveys suggest that their new hires are inadequately trained, and I am certain that they are talking about grossing skills and not histopathology. 🙄

wow, really? irony can never be overused.

i understand that it may seem like grossing is just slice and dice. stuff something into a cassette and then magically slides appear. if you are lucky you get to preview before the staff (who for the most part has not yet been involved with the case) is then responsible for commenting on a margin or something that you as a resident think that you sampled adequately. That is, until the patient develops disseminated disease because you called it a T2 tumor rather than a T4.

despite what you think there is a clear difference between "average" grossing skills and "super duper". perhaps your skills are already "super duper". if that's the case then you are on your way to a successful surgical pathology career. but i have dealt with many residents and PAs whose skills were not. one of the major differences between the two groups is experience. IMO (as was clearly stated at the beginning of this thread) is that there is no substitute for experience both in viewing and interpreting slides and approaching large complicated specimens at the grossing bench.

 

[Thrombus]

experience. IMO (as was clearly stated at the beginning of this thread) is that there is no substitute for experience both in viewing and interpreting slides and approaching large complicated specimens at the grossing bench.

Very few private jobs have you sitting in front of large complicated specimens at the grossing bench more than 1-2 times per month/year. If and when that happens, usually there are more than 1 pathologist at the bench and there is ample time to get out a resource.

Most private jobs you are sitting at your scope reading out biopsies which requires 100% accuracy and some degree of efficiency. THAT is what should be the goal of RESIDENCY programs nationwide. However in most it is not and instead there is this ridiculous notion that people need 1+ fellowships to be employable. Good grief 4 years of training should be more than enough to get competent but unfortunately the ABP and ACGME have us bogged down in learning the 15 types of tumors that can be found in Carney complex, the 100+ different hemoglobinopathies, etc. etc.

 

[yaah]

Very few private jobs have you sitting in front of large complicated specimens at the grossing bench more than 1-2 times per month/year. If and when that happens, usually there are more than 1 pathologist at the bench and there is ample time to get out a resource.

Yes but most private jobs will have you go back to specimens already grossed in to correlate any unexpected findings (like a 12 cm renal tumor that you are calling T2). That is, unless you want to always take the grosser (who may not have the same clinical history you do or questions) at their word. Or unless you are an individual who has the opinion that the grossing of the specimen is not your responsibility, just what is on the slides. Kind of a risky attitude though.

 

[GeoLeoX]

Very few private jobs have you sitting in front of large complicated specimens at the grossing bench more than 1-2 times per month/year. If and when that happens, usually there are more than 1 pathologist at the bench and there is ample time to get out a resource.

Most private jobs you are sitting at your scope reading out biopsies which requires 100% accuracy and some degree of efficiency. THAT is what should be the goal of RESIDENCY programs nationwide. However in most it is not and instead there is this ridiculous notion that people need 1+ fellowships to be employable. Good grief 4 years of training should be more than enough to get competent but unfortunately the ABP and ACGME have us bogged down in learning the 15 types of tumors that can be found in Carney complex, the 100+ different hemoglobinopathies, etc. etc.

All of which begs, why do a surgical pathology fellowship in the first place? I am a board-certified AP/CP pathologist with a job at a large academic medical center, I sign out a couple thou cases a year, and I have no fellowship training. I certainly can get by. Your argument about what the goal of RESIDENCY is absolutely accurate and I cannot agree more. I feel like my residency did prepare me to get by. However, that's not what we are talking about. We are discussing specialty training, the level at which those interested in academic medicine should be trained. I don't think that the goal of a surgical pathology fellowship is to be competent at signing out surgical pathology cases, but rather the academic extension of surgical pathology through teaching, research, authorship, etc. It is in this scenario that I think that grossing is important - teaching residents how to gross, correlation of gross and microscopic findings, and improvement of grossing technique.

For example, say I was interested in dermatopathology but I don't want to see patients or I was interested in molecular pathology but didn't like bench work. It's a valuable part of the experience and you critical to your success in both passing the boards and your practice.

 

[malchik]

I think all would agree that it is critical and not always easy to appropriately describe, measure, and sample a specimen. The OP asked a question about which fellowships don't involve grossing, and got instead a sermon on the virtues of grossing and a suggestion of a program with plenty of grossing in response to a facetious post. Anyone have suggestions, as I would also be curious to know.

 

[Thrombus]

Yes but most private jobs will have you go back to specimens already grossed in to correlate any unexpected findings (like a 12 cm renal tumor that you are calling T2). That is, unless you want to always take the grosser (who may not have the same clinical history you do or questions) at their word. Or unless you are an individual who has the opinion that the grossing of the specimen is not your responsibility, just what is on the slides. Kind of a risky attitude though.

If you can't handle a kidney tumor with ease after residency you are either at the wrong residency or in the wrong business. The specimens i am worried about are multiorgan resections, big neck dissections, etc. etc. With some resources and a phone call to the surgeon +/- collegial help from other path's, and it should be manageable -- granted you are in a place where this is rare (>90% of private jobs).

 

[Thrombus]

All of which begs, why do a surgical pathology fellowship in the first place? I am a board-certified AP/CP pathologist with a job at a large academic medical center, I sign out a couple thou cases a year, and I have no fellowship training. I certainly can get by. Your argument about what the goal of RESIDENCY is absolutely accurate and I cannot agree more. I feel like my residency did prepare me to get by. However, that's not what we are talking about. We are discussing specialty training, the level at which those interested in academic medicine should be trained. I don't think that the goal of a surgical pathology fellowship is to be competent at signing out surgical pathology cases, but rather the academic extension of surgical pathology through teaching, research, authorship, etc. It is in this scenario that I think that grossing is important - teaching residents how to gross, correlation of gross and microscopic findings, and improvement of grossing technique.

For example, say I was interested in dermatopathology but I don't want to see patients or I was interested in molecular pathology but didn't like bench work. It's a valuable part of the experience and you critical to your success in both passing the boards and your practice.

I agree, but almost all jobs REQUIRE fellowships which in my view are completely unneccessary if one works hard in residency. This is a product of the current glut.

 

[GeoLeoX]

I agree, but almost all jobs REQUIRE fellowships which in my view are completely unneccessary if one works hard in residency. This is a product of the current glut.

unfortunate. and i completely agree.

 

[LADoc00]

the ? I have is how long do you think you need to do it to master grossing?

Some of us are slow and need lots of time, others are quite adept, can do it a few times and have no issue.

Grossing in fellowship is therefore quite a personal decision, I knew I didnt need it, therefore wanted to concentrate more on other things like billing, flow, newer IHCs etc.

To each his own.

 

[green mantis]

This may be off topic, but I think it's related to the subject of grossing during fellowship. I think that something that's equally important is reading your gross descriptions after they've been transcribed. I can't believe how many errors I come across when I'm reviewing cases for tumor boards or other conferences. Some of the errors I've seen were in biopsies. While I can understand not having perfect grammar at the grossing bench, you should have an opportunity to make any corrections prior to the case being signed out.


----- Antony

PS: At my SP fellowship, we gross 16 weeks (4 rotations) at the cancer center. We get to sign out most of the cases that we cut in.

 

[Gene_]

how long do you think you need to do it to master grossing?

I think it takes longer to master now then say 25 years ago, when some experienced staff pathologists were still grossing and teaching residents at the bench (I've never heard of this happening anywhere currently). Now, the teaching seems to be primarily delegated to senior residents, fellows, and PAs. Being competent at grossing is one thing, but knowing how best to gross to speed up signout is another.