Types of Stress During Path Residency

[KeratinPearls]

---

Members don't see this ad.

I'd like to hear from the upper level residents out there. What kinds of stress do you guys experience in a path residency. CP is usually 9-5 and AP is like 8-6, sometimes longer. I'd like to prepare myself for the battlefield.

During the stressful moments, I'll think to myself .... "at least I'm not in surgery".."at least I'm not managing 10 patients at a time"..."at least I don't have to deal with all the BS in clinical medicine"..."Thank God I'm in pathology."

 

[BU Pathology]

I'd like to hear from the upper level residents out there. What kinds of stress do you guys experience in a path residency. CP is usually 9-5 and AP is like 8-6, sometimes longer. I'd like to prepare myself for the battlefield. I would think path residency is very manageable when you consider the lives of residents in other specialties (like surgery or IM).

During the stressful moments, I'll think to myself .... "at least I'm not in surgery".."at least I'm not managing 10 patients at a time"..."at least I don't have to deal with all the BS in clinical medicine"..."Thank God I'm in pathology."

This issue has actually be studied and reported in the peer reviewed literature:
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Dan Remick, M.D.
Chair, Pathology and Laboratory Medicine Boston University

 

[Napoleon1801]

This issue has actually be studied and reported in the peer reviewed literature:
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Dan Remick, M.D.
Chair, Pathology and Laboratory Medicine Boston University

Awesome! Thank you!


Addendum: I couldn't find the full article, but I did find the author's powerpoint presentation on the subject here:

http://www.apcprods.org/mtg/2007/Presentations/PRODS%20Summer 2007/Joseph.pps

Interesting insights!

 

[PathJet]

the abstract said only 6.4% replied so the rest of us were probably in the grossing room or running to an OR call


what is that saying there is no free lunch? (what does that mean anyway?)

i think medicine is hard and stressful i know radiology residents and derm residents who are stressed out.i know attending pathologists that are in the hospital from 730 am to 9 -10 pm some times ..

 

[DarksideAllstar]

I'd like to hear from the upper level residents out there. What kinds of stress do you guys experience in a path residency. CP is usually 9-5 and AP is like 8-6, sometimes longer. I'd like to prepare myself for the battlefield.

During the stressful moments, I'll think to myself .... "at least I'm not in surgery".."at least I'm not managing 10 patients at a time"..."at least I don't have to deal with all the BS in clinical medicine"..."Thank God I'm in pathology."

Multitasking is stressful. While I don't have to round or take care of 10 patients on a service, I do have 15-20 cases going at one time. For every case, I've got:
1. Stains pending (or sitting on my desk waiting to be looked at because I've been previewing and signing out other cases).
2. Two clinicians in my office asking about stains I haven't looked at or gotten from histo yet.
3. Another attending in an outpatient clinic calling me about a prelim on one of those cases.
4. A couple of cases that I need to go to pubmed for some reference about what we saw and what it means
5. A surg path resident asking me what's in the bone marrow biopsy because they got a CNS biopsy on the same patient.
6. Eight new cases that came in that I need to preview and sign out.
7. Eight cases that I just finished signing out that I need to write up.
8. An hour to an hour and a half out of my day for required didactics.

While I don't have anyone coding on me and I don't take in-house call, the day can be pretty stressful.
And yeah, I'm glad that I went into path and not clinical medicine.

 

[Arctic Char]

Multitasking is stressful. While I don't have to round or take care of 10 patients on a service, I do have 15-20 cases going at one time. For every case, I've got:
1. Stains pending (or sitting on my desk waiting to be looked at because I've been previewing and signing out other cases).
2. Two clinicians in my office asking about stains I haven't looked at or gotten from histo yet.
3. Another attending in an outpatient clinic calling me about a prelim on one of those cases.
4. A couple of cases that I need to go to pubmed for some reference about what we saw and what it means
5. A surg path resident asking me what's in the bone marrow biopsy because they got a CNS biopsy on the same patient.
6. Eight new cases that came in that I need to preview and sign out.
7. Eight cases that I just finished signing out that I need to write up.
8. An hour to an hour and a half out of my day for required didactics.

While I don't have anyone coding on me and I don't take in-house call, the day can be pretty stressful.
And yeah, I'm glad that I went into path and not clinical medicine.

sounds like fun. hectic, but fun

 

[Rosenthal]

Multitasking is stressful. While I don't have to round or take care of 10 patients on a service, I do have 15-20 cases going at one time. For every case, I've got:
1. Stains pending (or sitting on my desk waiting to be looked at because I've been previewing and signing out other cases).
2. Two clinicians in my office asking about stains I haven't looked at or gotten from histo yet.
3. Another attending in an outpatient clinic calling me about a prelim on one of those cases.
4. A couple of cases that I need to go to pubmed for some reference about what we saw and what it means
5. A surg path resident asking me what's in the bone marrow biopsy because they got a CNS biopsy on the same patient.
6. Eight new cases that came in that I need to preview and sign out.
7. Eight cases that I just finished signing out that I need to write up.
8. An hour to an hour and a half out of my day for required didactics.

While I don't have anyone coding on me and I don't take in-house call, the day can be pretty stressful.
And yeah, I'm glad that I went into path and not clinical medicine.

😱 How do you get organized? This is getting me seriously worried. I have a hard enough time just tracking 2 things at a time.

 

[mrp]

Having just made the transition from fellow to attending at a smallish academic center, I can tell you that it only gets worse, at least in terms of stress.

I am a wreck whenever I'm on service. Total multitasking freakout, frantically busy, and no margin for errors or oversights.

 

[DarksideAllstar]

😱 How do you get organized? This is getting me seriously worried. I have a hard enough time just tracking 2 things at a time.

Its not too bad. After two days, you just can't survive without developing a practical approach. I have a designated area on the report print out where I have a list of items the case needs or are pending. I check them off as they arrive, that way when someone calls and says "what is the status on pt x?" --I don't have to kill myself for not remembering because I have 15-20 cases in progress. I find the flat with the case, look at the paperwork, see whats been written up so far, see whats back, see whats pending and tell them when they should expect a final.

I have a day to day "routine" that I go through each day, making most of the work pretty manageable. For instance, I come in at 7:30-8am, check my folder for new cytogenetic reports, check the flow from cases seen the day before, make sure that I have all stains ordered from the previous day's signout. I go to didactics at 8:30, return at 10. Look at clot sections and biopsies that came out from cases, finish them up about 11:30. About this time I start getting new aspirates and touch preps, then I just preview and write up until the attending is ready to get going. Make periodic phone calls and get additional history PRN. Its not too bad after the first couple of days--- you'll get used to knowing when to do what and who to call when x, y, or z happens.

 

[cytoborg]

I agree that it's essential to be organized & extremely detail oriented. I'm neither by nature. I've had to develop ironclad routines to avoid mistakes like forgetting to order a stain - amateurish mistakes are sort of tolerated in the first few mos, but after a certain point it just gets embarrassing and you have got to get your act together. Most people develop their own routines quickly, and senior residents are also a great source of tips on how to be most efficient.

One of my biggest sources of stress is worrying that I will make a mistake that will impact the patient: a miscommunication with a surgeon, a specimen mix-up, etc. So far I've been lucky but I am constantly hypervigilent. You can never just blow something off...I often ask "OK so just to be clear, you said..." just to make sure everyone is on the same page.

Another thing I found stressful when I was starting was catering to the personality quirks of different attendings. Some like to front-load signout with tough cases, others will get in a bad mood if they're hit with a problem case right off the bat, some like lots of sections and some don't. And of course they all have their different ways of phrasing things. Once I got to know them all pretty well, it stopped being a source of stress.

 

[deleted57552]

Having just made the transition from fellow to attending at a smallish academic center, I can tell you that it only gets worse, at least in terms of stress.

I am a wreck whenever I'm on service. Total multitasking freakout, frantically busy, and no margin for errors or oversights.

I hear ya...I sign out cases and there are so many things to worry about. It makes you quite anal and obsessive-compulsive...things I didn't have to worry about as much as a resident.

 

[yaah]

Having just made the transition from fellow to attending at a smallish academic center, I can tell you that it only gets worse, at least in terms of stress.

I am a wreck whenever I'm on service. Total multitasking freakout, frantically busy, and no margin for errors or oversights.

Yeah, path residents probably experience the least amount of "real world" decisionmaking during training as compared to any field. In any other field, you have to make important decisions and evaluations on call or without much attending input. In path, most everything ends up going through an attending (especially on AP). I mean, we get blood bank calls and have to make decisions, but a lot of times they aren't tough decisions, just annoying ones.

The only real way to get real world experience on AP is to signout cases and verify them yourselves or be responsible for calling frozens yourself, and while the latter does happen at some programs, the former doesn't happen during residency. It might happen at some fellowships, but not all.

A lot of residents, unfortunately, don't really immerse themselves in the workings of the service and really commit themselves to it. They preview cases and all that, but they don't really force themselves to see what they would do if they had to call it for real.

 

[danaphosaurus]

My biggest challenge has been dealing with the support staff, i.e. the techs in the gross room. I am not really good at dealing with hypersensitive females and passive aggressiveness. I also aggree about the stress of dealing with different attendings. I also have had to learn how not to get overwhelmed with having mutiple projects due, presentations and still running the service. It's like the survey said, you often get carried away with the work that you don't always have time to learn.

 

[levels x3]

Interesting article though with a limited sample size to be sure. I also wonder about the selection bias created by working through prods (this was acknowleged as a flaw by the study's authors). Program directors who would be interested in this project are likely those who would be more in tune with their residents and their stressors. Why not do something like this through CAP or ASCP and their resident forums? Let them contact residents directly.

Anywho...as to the original question, I would agree that multi-tasking is a key skill, but remember that workload is extremely variable depending on the day and what service you're on. Most CP services, for example, are characterized by short, infrequent periods of excitement (i.e. work) followed by long periods of boredom (i.e. reading). Even surg path can be variable day to day and week to week. You'll hear stories of grossing till 10 pm and then having to come back in at 4 am to preview cases, etc. and sure, it happens. I've done it. We all have; but realistically, this only happens a few days a year at most programs. Just suck it up on that day and get through it. So while workload can be a stressor it isn't consistent.

By far the more consistent stressor is the one most cited by residents in the above article; inconsistent expectations of attendings. Worse still is the stress created by attending personalities. Brush up on your Axis II diagnoses because they are all out there.

 

[DarksideAllstar]

A lot of residents, unfortunately, don't really immerse themselves in the workings of the service and really commit themselves to it. They preview cases and all that, but they don't really force themselves to see what they would do if they had to call it for real.

I agree with your post-- it seems like this is the only specialty where we are given little autonomy; however, other services also have more senior residents in house with the interns and other junior residents, so there is somewhat a gradation in knowledge and the ability to seek out non-attending help, whereas in path and cp in particular its the resident with attending or fellow back up and that's it. It seems like path doesn't really have the same gradation of responsibility built into attaining "senior resident" status as other specialties, which is unfortunate as I think its important to learn how to make decisions on your own. I guess part of the problem is that most of us are more prepared to run a code after right after med school than we are to cut and read a frozen of just about anything.

Re: previewing. I should state that when I preview cases (in this case bone marrows), I write them up as I would sign them out (full micros with comments, DDxs for weird cases, plans for ancillary studies, etc). This is the only way to learn what the f**k you are doing. Sitting there and taking notes doesn't cut it.

 

[yaah]

Yeah, that's a good way to run a service - we have quite a few attendings here who like us to dictate cases fully ahead of time so they can just verify at time of signout. It seems to make a difference in terms of residents taking more ownership of the cases. It's easy to slip off into a lackadaisical attitude if this "forced pressure" isn't there. But if you don't have to dictate cases ahead of time it doesn't mean you can't still act like you have to. I agree with you - taking notes doesn't really cut it. Previewing is an important thing to have, but if you don't make good use of it it doesn't mean as much.

Another stressor I think is inconsistency amongst residents. Some residents only want to do their own work, do the bare minimum, and leave stuff for other people because it's "not theirs." It can leave other residents with a lot of work.

 

[Matte Kudesai]

Yeah, that's a good way to run a service - we have quite a few attendings here who like us to dictate cases fully ahead of time so they can just verify at time of signout. It seems to make a difference in terms of residents taking more ownership of the cases. It's easy to slip off into a lackadaisical attitude if this "forced pressure" isn't there. But if you don't have to dictate cases ahead of time it doesn't mean you can't still act like you have to. I agree with you - taking notes doesn't really cut it. Previewing is an important thing to have, but if you don't make good use of it it doesn't mean as much.

Another stressor I think is inconsistency amongst residents. Some residents only want to do their own work, do the bare minimum, and leave stuff for other people because it's "not theirs." It can leave other residents with a lot of work.

You can also compile a nice database of how specific entities are signed out by the subspecialty experts in the department. ......easy to do in copath and invaluable when you go off on your own. Especially if you trained at busy a place with lots of bread and butter as well as complicated cases/consults.

Someone should write a book on signing out succinctly with comments and everything. Indexed by entity...🙄

 

[deschutes]

I didn't explore the CoPath function because our multi-institutional program gives us exposure to Ultra, Cerner and CoPath. In the past I would just copy to a text file whenever I came across a final diagnosis, micro description or a comment that I thought had good learning points. Low-tech, but still fully searchable!

What format does the copath function export into?

You can also compile a nice database of how specific entities are signed out by the subspecialty experts in the department. ......easy to do in copath and invaluable when you go off on your own. Especially if you trained at busy a place with lots of bread and butter as well as complicated cases/consults.

Someone should write a book on signing out succinctly with comments and everything. Indexed by entity...🙄

 

[Matte Kudesai]

I didn't explore the CoPath function because our multi-institutional program gives us exposure to Ultra, Cerner and CoPath. In the past I would just copy to a text file whenever I came across a final diagnosis, micro description or a comment that I thought had good learning points. Low-tech, but still fully searchable!

What format does the copath function export into?

Same way... copy and paste text then use access or word to make a searchable database (or HTML with links). Nothing fancy shmancy. Its nice because it can be tailored to the attendings style while you are doing your residency and help you develop your own.

I still think someone should write a book of signout options including synoptics, immunos, comments for each subspecialty. Or better yet one that incorporates the "expert" in each area signout methodology.

That would be fun and would probably piss alot of people off. Get_____ (Insert famous persons name) to do the GU part and exclude________ (other famous person).

Or better yet make the book with a section devoted to every famous person for each entity. That would be sweet.



Better yet standardize everything so we can just check boxes and hit print at the end. Have it tied to all the appropriate coding and acceptable standard of care for immunos. None of this individual flowery prose crapola.😉

 

[yaah]

I got an email about an ASCP survey for residents on stress. A good idea, except for the fact that a bunch of the statements I had to respond to had the word "recipient" in there. Like, "Dealing with your recipient increases your stress level." 😕 I had no earthly clue what that meant. Who is the recipient? The patient? The clinicians? Anyone I deal with on a day to day basis who is the target of my interaction? There was no option at the end of the survey for comments. It was almost like whoever wrote the survey had no idea what word to pick and they went to a thesaurus but picked the wrong synonym.

So my survey results, and I'm sure many others, will be basically invalid. Unless I'm the only one who can't figure out who the recipient is. I just clicked "never applies" for any statement with "recipient" in it.

It's a shame when an otherwise well intentioned and useful survey has a characteristic like this that basically renders it worthless. 🙁

 

[mcfaddens]

I got an email about an ASCP survey for residents on stress. A good idea, except for the fact that a bunch of the statements I had to respond to had the word "recipient" in there. Like, "Dealing with your recipient increases your stress level." 😕 I had no earthly clue what that meant. Who is the recipient? The patient? The clinicians? Anyone I deal with on a day to day basis who is the target of my interaction? There was no option at the end of the survey for comments. It was almost like whoever wrote the survey had no idea what word to pick and they went to a thesaurus but picked the wrong synonym.

So my survey results, and I'm sure many others, will be basically invalid. Unless I'm the only one who can't figure out who the recipient is. I just clicked "never applies" for any statement with "recipient" in it.

It's a shame when an otherwise well intentioned and useful survey has a characteristic like this that basically renders it worthless. 🙁

I got the same survey. Seemed like a business school project, I looked at the top and it mentioned something like the recipient could be anyone in your department that breathes. I couldn’t make up my mind if I felt tired or discouraged due to attending or patients (cases) or the 150 degree resident room. At the end of the survey the computer system at the hospital had a problem with the site so the survey wasnt able to go thru security. Yeah time well spent.

 

[LJJoseph]

Hi
I am Dr.Joseph, assistant pathology residency program director at BU, who is teaming up with ASCP trying to gather additional data on pathology resident stress that we have been studying for three years now.

The term recipient in the current survey would include primarily the patient, the end recipient of your care. It can also include the physicians that you deal with on a regular basis. The survey is a formally validated instrument and so we could not edit the terminology too much. Sorry about the confusion. We will be mailing out another round of the emails requesting responses next week. We hope you will encourage your friends to participate. We plan to bring your comments posted here as well as the responses to the survey to the program directors meeting in July this year.

The goal is have all of your voices heard.

 

[Ale]

Hi
I am Dr.Joseph, assistant pathology residency program director at BU, who is teaming up with ASCP trying to gather additional data on pathology resident stress that we have been studying for three years now.

The term recipient in the current survey would include primarily the patient, the end recipient of your care. It can also include the physicians that you deal with on a regular basis. The survey is a formally validated instrument and so we could not edit the terminology too much. Sorry about the confusion. We will be mailing out another round of the emails requesting responses next week. We hope you will encourage your friends to participate. We plan to bring your comments posted here as well as the responses to the survey to the program directors meeting in July this year.

The goal is have all of your voices heard.

Why you never send this things to fellows?
Training does not end in residency and since 80% of residents can't find a job or decide to do fellowship, it would be good to ask ASCP to include fellows. Also, I think it would be more meaningful

 

[raspberry009]

Maybe it's just me, but grossing in seems that hardest. Remembering to cover every inch of the specimen and properly cut sections in a logical manner. Maybe its because I just haven't had enough experience yet in dictating, but I was always missing things like saying "no cystic lymph node seen" in a gall bladder removal, which you would think would be the easiest thing in the world. Maybe this sounds completely backwards from what I'm hearing from everyone, but my favorite time of the day is sitting at the microscope. It always amazed me how some attendings would even call certain things depending on their mood. Granted, I was usually wrong on my diagnosis, but I enjoyed watching attendings discuss with each other on things that you would think would be textbook (like cervical cancer). Then you learn that in some cases the text does not apply. The whole process just fascinates me.