For various reasons, many surgical pathology fellowship programs no longer include “Hot Seat” training rotations. As a result, today’s residents and fellows often fail to realize – let alone experience – the intense, exhausting nature of this once-rigorous component of training. It was a program that could bring trainees to the brink of mental and physical burnout, reminiscent of military-style endurance. Yet, as I reflect on nearly 20 years of practice as a licensed surgical pathologist in both academic and private settings, I regard my Hot Seat experience during fellowship at Barnes-Jewish Hospital, Washington University School of Medicine, Missouri, US, as one of the most memorable and formative moments of my career.
After completing residency, I was fortunate to be accepted into the renowned Barnes-Jewish Hospital advanced surgical pathology fellowship. The program had a rich legacy, with legendary figures like Lauren Ackerman, Juan Rosai, Louis Dehner, and Peter Humphrey among its esteemed faculty. One of its standout features was the two-month Hot Seat rotation. Initially, I viewed it as a trial by fire – but it became one of the most valuable parts of my training.
The Hot Seat, true to its name, felt like sitting on a hot stove. This strict training model was pioneered by Lauren Ackerman, one of the giants of surgical pathology (the textbook Ackerman’s Surgical Pathology remains a staple on nearly every American pathologist’s shelf).
The setup was modest: a cramped room with a table, microscope, phone, computer, chair, and shelves filled with slide folders and a few reference books. I would start each day reviewing a heavy load of subspecialty cases (excluding OB/GYN) and entering preliminary diagnoses into the computer – visible only to supervising attendings.
As a fellow, I was treated like a junior attending and expected to work independently. After sorting cases by subspecialty – GI, hepatobiliary, pulmonary, GU, soft tissue, transplant, breast, endocrine, and more – residents would pick up their assigned cases for proofreading and discussion with attendings.
Following a brief lunch break, feedback rolled in: “The attending said your diagnosis was off,” or “You missed key grading and staging details.” I would revisit the cases, often flushed with anxiety, revising my assessment based on the attending’s feedback. Occasionally, I’d receive direct calls – sometimes impatient or stern – pressing me to justify or correct my diagnosis.
One of the most stressful scenarios involved urgent heart and lung transplant biopsies. The transplant director, often accompanied by residents and fellows, would demand immediate clarification – was this A1 or A2 rejection? The urgency, coupled with the director’s temperament, created some of the most pressure-filled moments of my training.
Most days, I’d leave dizzy, drained, and sometimes nauseated. That first week, I understood the meaning behind the Hot Seat program – I constantly felt like an ant on a hot pan. But over time, I adapted. Week by week, mistake by mistake, I learned to think critically, make better judgments, and sharpen my diagnostic accuracy. By the end of the fourth week, I found a rhythm – and even a sense of comfort – in the process.
When I returned to the Hot Seat later that year, my confidence and speed had grown. Other subspecialty rotations, and guidance from directors like Dehner and Humphrey, had strengthened my foundation. WashU’s culture encouraged open dialogue between fellows and faculty. If I disagreed with a diagnosis, I was expected to present my reasoning. If needed, a third opinion – or the director’s insight – could be sought. This atmosphere of independent thinking and real-time diagnostic refinement was an irreplaceable part of my development.
Dehner, who accepted me into the program, told us, “I don’t expect you to focus on writing articles or conducting research during this year; this advanced surgical pathology training is about high-intensity challenges that will enhance your diagnostic skills and build your confidence for any future role – be it in a university hospital, a private practice, or a group.” The Hot Seat rotation reflected that philosophy completely.
Even today, I look at how much lighter the workload and expectations are for current trainees. I feel both fortunate and a little regretful when I compare that intense experience with the variable quality of training available to pathologists elsewhere, such as in China.
The Hot Seat tested my limits, but it also taught me lessons that I carry to this day. As the old saying goes, “No pain, no gain.”
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