Volume and selecting a residency

[pathology4me]

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Just wanted to get anyone's opinion on the importance of volume during residency for those of us applying this year- are there any major institutions that don't see enough/see way too much and thus affect learning/ability to be well trained and competent? Does it really matter, ie. should volume and breadth of cases influence your decision? Any perspective would be really welcome.
Thanks.

 

[Entgegen]

I'm just another med student and I'm sure residents can offer opinions on institutions that make them feel overwhelmed with too many specimens, but as for too little I would just take a look at the actual numbers the program sees, provided the variety is there. If you have to put a cut-off number on it, I've heard that you really want to have >20,000 surgicals/year (not including cyto/paps). But then again if you have a little less than that it may be okay if the program takes only 2 residents a year.

 

[oldfatman]

I'm just another med student and I'm sure residents can offer opinions on institutions that make them feel overwhelmed with too many specimens, but as for too little I would just take a look at the actual numbers the program sees, provided the variety is there. If you have to put a cut-off number on it, I've heard that you really want to have >20,000 surgicals/year (not including cyto/paps). But then again if you have a little less than that it may be okay if the program takes only 2 residents a year.

Doesn't matter how high the volume is if the attendings don't show the slides.

 

[KeratinPearls]

Doesn't matter how high the volume is if the attendings don't show the slides.

I agree. You can have huge volume, but if cases are taken from you and signed out by the attending then you aren't going to learn. You have to be able to handle your cases and give an opinion before the attending see the slides.

You may not see all the interesting cases when you are on the bench. You have to ask fellow residents to tell you when they get something interesting so you can learn from it. Also, interesting cases are brought to gross conference.

 

[lurksalot]

Residency is when you need to see EVERYTHING. You absolutely want volume, volume, volume. However, that must be balanced with appropriate preview time, being able to follow your cases all the way through, and graduated responsibility as you become more senior.

IMHO, even the highest volume places don't over-work you these days. The horror stories you hear about some notorious programs pre-date ACGME work hour restrictions. True, you'll still work your butt off at these programs, but personally I think working that hard for four years is well worth the preparation you'll get for your career. Of course I trained in the pre-ACGME work hour restriction era, so YMMV.

 

[longlakeboy]

Choosing a program based on the number of specimens is like giving the batting title to the guy with the most at-bats. If a place has, say, a volume of 25,000, that could mean a lot of things.

Is it a program with 15-20 residents and no fellows? Or is it a program with 30 residents and a bunch of fellows?

Is it a program where there are weekly histo conferences in place so the interesting cases get shared?

Do the residents handle all the cases, or are there things that the attendings take care of without the residents?

It seems like most programs are in the 20-35K range for specimens. There's no reason that you wouldn't see enough with that range. It's just a matter of whether the program is set up to allow the residents to take advantage of the volume, and whether the residents themselves take advantage of it.

 

[pathstudent]

It is also worth pointing out that I have heard talk from my surgical and medicine co-attendings that there is talk of putting interns on a 68 hour work week rather than an 80 hour one. If this is true and affects path, it will change a lot of things about how surgical pathology rotations are run.

 

[TinyFish]

Residency is when you need to see EVERYTHING. You absolutely want volume, volume, volume. However, that must be balanced with appropriate preview time, being able to follow your cases all the way through, and graduated responsibility as you become more senior.

IMHO, even the highest volume places don't over-work you these days. The horror stories you hear about some notorious programs pre-date ACGME work hour restrictions. True, you'll still work your butt off at these programs, but personally I think working that hard for four years is well worth the preparation you'll get for your career. Of course I trained in the pre-ACGME work hour restriction era, so YMMV.

Agreed with everything said here. I'm at a pretty high volume program (>70k surgicals, >50k cyto, ~ 25-28 AP residents), and you do work your butt off, but it's doable, we preview all of our cases, and we share cases/have interesting case conferences all the time. It's still not like we all see every single case that passes through our department, though, and the quality of our experience is also largely dependent on our faculty, so thinking about quality vs. quantity of cases, and thinking about faculty-resident interactions is definitely important.

I guess the point of my post is, don't get scared off by high-volume programs. Just make sure it's somewhere that you'd be happy to be.

 

[icpshootyz]

Like others have said, volume is important but it isn't everything. A high volume program should theoretically give you more access to more interesting cases and more repetitive interaction with the common types of cases. However, there's other factors at work, like how many residents are in the program, how many PA's, whether there are uncovered services that only attendings run, etc. For examples, there could be two programs with the same number of surgicals, but one program has no PA's and one has 2-3. That would maybe free up the residents from grossing non-essential cases to give them more previewing/reading time. There's a lot to think about when choosing a program. I happen to be at one w/ no PA's, and we do all the grossing except basic biopsies, which our path "techs" do. It gets a little old. But, I've had great training there, and I never really came close to breaking work hours or anything, so it was doable.

 

[KCShaw]

I pretty much agree with previous responses, which include a lot of good points one should probably ask about during interviews.

If a program is accredited, it sees "enough" volume. But top quality programs get multiple specimens of various types, don't have a void of "common" bread & butter specimens, and efficiently use what they have to teach. Try to get a feel for programs that have a specific plethora or dearth of certain specimen types.

 

[Euchromatin]

I totally agree with previous comments concerning the way the workflow is structured. Available preview time before attendings get the cases, conferences in which interesting cases are shown, and balance of resident grossing and PA support to allow for reading time are all just as essential as the actual volume.

I just wanted to further explore the issue of specimen variety. In addition to all the bread and butter specimens that each program would be expected to have in abundance (GI, Gyn, GU, breast, etc.), you might want to ask how the program ensures that residents are exposed to derm, bone/soft tissue, placentas/pediatric specimens, medical kidney/liver, and any other unusual specimens. Some programs might not see enough (or any) of these specimens, requiring either outside rotations or only covering them through lectures.

 

[lurksalot]

I just wanted to further explore the issue of specimen variety. In addition to all the bread and butter specimens that each program would be expected to have in abundance (GI, Gyn, GU, breast, etc.), you might want to ask how the program ensures that residents are exposed to derm, bone/soft tissue, placentas/pediatric specimens, medical kidney/liver, and any other unusual specimens. Some programs might not see enough (or any) of these specimens, requiring either outside rotations or only covering them through lectures.

An excellent point, and one I probably should've expanded on in my first response. Generally speaking, the high volume places will have these types of specimens as well. All things to think about as you look at programs.

 

[KCShaw]

It is also worth pointing out that I have heard talk from my surgical and medicine co-attendings that there is talk of putting interns on a 68 hour work week rather than an 80 hour one. If this is true and affects path, it will change a lot of things about how surgical pathology rotations are run.

Maybe at a handful of places -- not for most places, at least as far as I gather from chats with other residents over the years as well as personal experience. I only occasionally hit 60+ hrs in a week and don't think I ever hit 70+ even with weekend work, during residency, though weekends were generally limited to half of one day as I recall. I probably went a little longer in fellowship, mainly because the weekends I was on were closer to regular workdays and I had to be there for both days. Of course, unlike medicine/surg where there is generally an endpoint to the workload (get thru X admissions/surgeries, write Y orders, go home), one can preview and pontificate until dawn, especially early on when you might read or take additional notes as you try to figure out what you're looking at.

 

[HbyHA]

. Of course, unlike medicine/surg where there is generally an endpoint to the workload (get thru X admissions/surgeries, write Y orders, go home), one can preview and pontificate until dawn, especially early on when you might read or take additional notes as you try to figure out what you're looking at.

very true.

I had previoulsy heard about the lower number of work hours (<80) directly from our PD at the time. Work hours for Path is so much harder to assess than for other specialties (i'm referring to mostly Surg Path). Our work is so much more self-directed. Should it matter that it takes me half the time to gross the same amount of specimens as another resident or twice as long to preview the same stack of slides? It happens! Where do you draw the line? Is previewing slides "Direct Patient Care" or does that only apply to grossing/signout which MUST happen while previewing SHOULD happen for your education but isn't necessarily an absolute need for the patient. We're trying to jam Path into guidelines designed for the "usual" specialties. Square peg round hole, much?

A new work hour change that would screw my former program is that one free weekend in four AVERAGED over a month would go out the window and go to one day off in seven (including home call). This is probably great for clinical residents but we usually only took 1-2 call weekends/3 month block which is not overly stressful. if we adhered to this same schedule, we'd now be breaking the rules and have to split those days up which would just suck more as pagers would be handed off, etc. STUPID!