Answering the Call

Professional opportunities to practice pathology vary worldwide. In Europe and the Middle East, most positions are for either an anatomic pathologist or a laboratorian directing clinical laboratories.  Residency training reflects these opportunities. Although these career paths exist in the United States, there is also substantial opportunity to practice pathology in a community hospital – a job that requires expertise in both anatomic pathology and laboratory medicine. As a result, approximately 85 percent of pathology residents seek board certification in both disciplines.

A recent workforce analysis of American pathologists forecasts a shortage of pathologists in the next five to 10 years with current practice modes (1). The shortage results from a growing population of elderly patients with chronic diseases, a “retirement cliff” of pathologists, and no growth in training programs. The average pathology trainee takes five to six years of training, including four years of residency and one or two fellowships. Such training most often yields a subspecialist pathologist who naturally desires to practice their subspecialty – but that generally doesn’t appeal to a small (10 or fewer pathologists) community practice that needs an adaptable generalist with subspecialty expertise (2) (3).

The question of how to train pathologists to practice healthcare based on 21st-century medicine has been a frequent topic of discussion. A group of us at a recent pathology retreat took the initiative to develop a conceptual plan that redefines pathology training in line with the requirements of the Accreditation Council for Graduate Medical Education and the American Board of Pathology (4). Parts of this conceptual plan have long been in place at Montefiore Medical Center; the rest has evolved over the past three years.

Numerous surveys of pathologists (in practice and in training) reflect what respondents think was most useful in their training, which is usually determined by the skills they use in practice (5). But although practice is an important parameter, it does not fully reflect the value of training in uncommon practice areas (such as autopsy) or the communication skills required to be an integral member of a healthcare team (6). With this concept in mind, we posed two key questions: What should be the practice capability of our graduating resident? And how do we train our residents to be competent, without fellowship training, to practice in any given setting?

To address both questions, we developed a unique training plan. It begins one month prior to the new resident’s arrival with an online onboarding exercise that includes a refresher in histology, basic principles of laboratory testing, fundamentals in quality management, and acculturation to Montefiore and New York City. The preparation frees up the first few months at Montefiore for anatomic pathology processes rather than on revisiting medical school.

Let’s digress for a moment and consider a specific example: the value proposition of the autopsy as a training exercise for pathology residents. Although practicing pathologists may do few or no autopsies post-training, autopsy pathology lays the groundwork for comprehensive diagnostic capability. A successful post-mortem examination requires the resident to process the clinical history (including laboratory- and imaging-based diagnostic tests), to conduct gross and histopathologic analyses, to synthesize the findings, and to communicate them to the healthcare team. This process then segues into surgical pathology training. We expect the resident to review the clinical history before receiving the specimen, perform the diagnostic process, and render a diagnostic opinion that they report in writing and communicate verbally to the healthcare team, both directly and in conferences.

But how can we expect new trainees to perform competently if we immediately give them a full workload? They can do more – at least initially – if we treat them like technologists or pathology assistants. The problem? When we do that, we risk simply deploying them to make up for staff shortages. At our institution, we’re more interested in helping our residents become useful colleagues in the later years of training, so we have developed a teaching service in surgical pathology that works toward that goal from day one.

Each resident works as an apprentice with an experienced pathologist on a subspecialty service. They are given light caseloads until they master the process of working up a case, at which point the caseload is gradually increased until the trainee can perform a full day’s work. The residents get to that point much more quickly than in traditional training because they are in a less stressful guided learning environment. Likewise, they become comfortable with different specimen types more quickly when they have focused training in that subspecialty, as opposed to encountering specimens as they’re dispersed through a generalist surgical pathology service. By having just one pathologist teach using a single tissue type, we eliminate stylistic differences and the nuances of different tissues, enabling residents to focus on learning the basic process of making a diagnosis. As a result, the time to competency and the need for remediation are greatly reduced.

The first two years of our program focus on process and incorporating fundamental practices (7) – including basic principles of laboratory medicine (taught in the third month via a one-month chemistry rotation), communication skills (honed through filmed presentation exercises), and the ability to perform a data-driven quality management study using a unique decision support tool. The third year of residency begins to transition the resident into the role of a pathology consultant. The rotations integrate anatomic pathology and laboratory medicine, and some even place the resident on a clinical team (such as the thyroid clinic or infectious disease rounds). The entire fourth year is elective.

In our effort to make our residents market-ready, we’re also enhancing our mentoring program, which is still a work in progress. In year one it functions more as a coaching program, ensuring that each resident is on track with their learning goals. It’s our view that residents are forced to make career choices much too early in their training; we believe in the need to mentor and advise our trainees when it comes to choosing a fellowship. It’s our hope that helping residents design individualized fourth-year programs tailored to particular job opportunities will increase their fellowship opportunities and future job eligibility. For now, the fourth-year program augments the training experience for those with a particular fellowship in mind. For example, if a resident knows she’ll be doing a gastrointestinal pathology fellowship, but also knows that she wants a community practice job, she may spend more time in other surgical pathology subspecialties and specific laboratory medicine rotations during her fourth year.

There are several key factors that we considered during the development of our program, which we feel are significant to the future of pathology training in general:

1. Initiating an open discussion with faculty based on the frank acceptance that we could do a better job at training. Incorporating frequent and timely feedback into our daily routines improves both resident progress and our ability to identify areas where we can intervene to help them. Likewise, providing residents with more one-on-one time with faculty allows us to better tailor learning experiences to an individual resident’s performance level.
2. Defining the essential skills and capabilities required for our graduating residents. Using the pathology residency training competencies, milestones, and entrustable professional activities as a guideline, we focus on imparting the foundational practice habits and processes that we feel are necessary to succeed in any practice milieu. Basic practices – such as knowing how to evaluate a patient’s clinical history and correlate it with clinical and laboratory values, how to construct a cogent and succinct pathology report, and how to communicate with colleagues on the healthcare team – are the foundation of our training program. Such a strong foundation also gives trainees the skills needed to adapt to changes in practice and content that they may encounter later in their career.
3. Drawing on the collective faculty and resident experience to design a trainee-centric program with agreed-upon, desirable outcomes in mind, rather than a program aimed at the short-term goal of filling staff shortages. Investing in our pathology assistant staff is key to reaching this goal in surgical pathology. As such, we continue to increase our complement of assistants with an eye toward hiring those who are interested and invested in resident education. As residents move beyond the introductory months to their third- and fourth-year rotations, we give them more opportunities for graduated responsibilities. These include clinical-laboratory liaison in clinical rounds, frozen section hot seat, junior attending rotations in surgical pathology, and expanded duties, such as test utilization approval and transfusion medicine call responsibilities.

We’re finding that our current crop of trainees are more satisfied than their predecessors and are performing at a higher level in a shorter period of time. Even those who have not personally benefited from our curriculum can see the advantages; nearly two-thirds of residents surveyed who went through our old curriculum stated that they would choose to go through on the new curriculum if they were to start residency again. Residents view the fourth year as an opportunity to complete one or more “mini-fellowships” with the added bonus of graduated responsibilities throughout the year.  We’re hopeful that this focused training will produce more confident, market-ready residents with the requisite adaptability to work within any practice setting – and we call upon other institutions to take up the same challenge.