Peer-to-Peer: Ivan Damjanov Interviews Andrea Deyrup

Andrea Deyrup is Professor of Pathology at the Duke University School of Medicine where she also serves as Director of Pathology in the multidisciplinary course Foundations of Patient Care 2 and Director of Undergraduate Medical Education in the Department of Pathology.

In addition to her early work in molecular biology and biochemistry, followed by several years devoted to the study of soft tissue and bone tumors, Deyrup is best known for her work in medical education. Together with Drs. Kumar, Abbas, and Aster, she is an editor of the Robbins & Kumar Basic Pathology and Robbins Essential Pathology books – which stand as required reading in most US and Canadian medical schools, as well as many other countries worldwide. Over the past few years, Deyrup achieved nation-wide attention for her writing, lecturing, and activism against racism in medicine.

Ivan Damjanov sat down with Deyrup to learn more about her career and commitment to educating the world’s future physicians. 

From listening to your podcasts and observing your media appearances, it’s clear that you love teaching medical students. Were you recruited into your current role to solely teach, or was this always meant to be part of many responsibilities?
 

My job at Duke Pathology is definitely my dream job! I’m a fourth generation PhD and that’s what the Deyrups do: we teach! I was recruited after retiring from the University of South Carolina-Greenville to be the course director for the Duke School of Medicine pathology course. My entire focus at Duke is on teaching with no clinical responsibilities. I became the director of Undergraduate Medical Education a few years later as the department expanded engagements and programs for medical students.

Can you tell us more about your role at Duke, specifically your educational and administration tasks?
 

My responsibilities change depending on the time of year, but everyday I’m working on something that contributes to our educational mission. This can be updating course materials, presenting at outside institutions, working on course administration, developing additional teaching resources, supporting undergraduate education at Duke University, or engaging in advocacy work. I also mentor premedical students, medical students, residents, and junior faculty. I like to have a diverse portfolio of activities that inform, support, and energize each other.

Our integrated course is 20 weeks long with five small groups, each headed by an attending and a resident. Each attending teaches for 10 weeks, which is challenging considering the large amount of material we cover. Therefore, my role has been to generate instructional materials so my instructors can enjoy their teaching and be well prepared. Over the past decade, I’ve created numerous supplementary materials, including videos for our gross specimens, explanations for our website cases, and more than 80 video lectures that align with our textbook, Robbins & Kumar Basic Pathology.

Creating those videos was a massive undertaking. Usually, a course director will ask colleagues to give lectures in their own specialty and I don’t know of any other curriculum where a single person lectures on all the material. However, since I had just finished editing the textbook, I was well versed in the subject matter. I wanted to ensure the content had a consistent tone, and addressed issues of race-based medicine appropriately. The project was a lot of fun and I learned so much in the process.

I created a similar video series for my YouTube channel to make high-quality medical information accessible globally for free. Unlike typical short internet videos, these focus on clarifying the pathophysiology of disease, which is essential for future physicians. I want to help students who are seeking a deeper understanding, beyond simple word associations or mnemonics.

You mentioned providing educational resources to support your faculty. What else do you do to help sustain their effort?
 

My experience at multiple institutions and from conversations with colleagues is that undergraduate medical education is typically not well supported. There seems to be an attitude that since teaching is fun, you shouldn’t need to pay anyone to do it! At many institutions, the load is distributed quite evenly: nearly everyone in the department gives a lecture or two or participates in a laboratory session.

As I mentioned, at Duke we have 10 attendings who each teach for 10 weeks in our 20-week course. In those 20 weeks, we cover ALL of Robbins & Kumar Basic Pathology, which is a LOT of material! This is a heavy lift for our faculty and since only a small part of our department is involved in teaching medical students, it is critical that we take care of them. In addition to providing as many resources as I can to simplify their job, I advocate strongly for financial support for their effort, either as a pay supplement or as time off from service. Interestingly, my faculty are very reluctant to take time off service since they recognize the additional burden on their colleagues. It’s not like working in a clinic where there is a limit to the number of patients seen each day: when the slides come, they have to be diagnosed! I work closely with my Chair, our Chief Administrative Officer, and the School of Medicine to ensure that we can support the outstanding faculty contribution to our educational mission.

Why do you think it is important to include residents in medical student teaching?
 

Our residents are an essential component to our curriculum. For one thing, they are much closer in age to our medical students – often only a few years older. As “near-peers”, it’s easier for students to relate to residents rather than faculty. Attendings can also be a bit intimidating to medical students, simply because of the hierarchical organization of medicine. Students are often more comfortable approaching a resident than an attending and enjoy the perspective of someone who was recently in their shoes.

On the flip side, our residents also benefit tremendously from their time teaching medical students. Each resident teaches for one to two months each year of residency and is responsible for half the teaching cases and gross specimens each day. This provides them with an opportunity to review the pathophysiology of disease in the context of their expanding understanding of anatomic and clinical pathology. I’ve heard from multiple graduates that the material they learned while teaching was relevant to Board questions or cases they encountered in fellowship. I also support residents who are interested in a career in medical education by expanding opportunities for them to explore the possibilities.

For me, it is simply a pleasure to work with our residents and contribute to their goals and aspirations.

Most US medical schools have seen a reduction of teaching hours for pathology – has this happened at Duke? Have you seen a change in emphasis of your course to pathophysiology as a result?
 

The time that we spend at Duke is essentially the same as it has always been. When I began as course director, during the five-month long course, we had small group pathology teaching twice each week for two hours at a time – spending time looking at gross specimens and working on website cases.

When we went to remote teaching with the pandemic in 2020, we asked students to complete assignments before class and continued this approach once we could meet in person again. Since we increased the students’ time outside of class, we reduced the amount of in-class time: now students meet for one hour to examine gross specimens and the next day spend two hours working on cases. This pre-work gives students confidence in their preparation before class and feedback has confirmed they gain more from in-class time with this approach.

All pathology is taught by pathologists, though some material is also covered by clinicians in their teaching. We have a robust system of pathology education at Duke, which is reflected in how well our students do on Step 1: before the National Board of Medical Examiners (NBME) switched to pass-fail, 62 percent of Duke students scored higher in pathology than the national average. Since the switch, we’re still about 40 percent over the national average and this is for a 5-month course in an 11-month preclinical curriculum! I deeply believe that a strong foundation in pathophysiology is essential for physicians and that is where we focus much of our time.

What approach do you take to teaching histopathology, and how much reliance is placed on microscopes?
 

Before I joined the faculty, Duke had already moved to virtual microscopy for histology and histopathology teaching. We do have histopathologic images on our quizzes and exams, though our goal is not to train students to be pathologists. We focus on aspects of histopathology that relate to pathogenesis, such as the acantholysis seen in pemphigus and the “starry sky” seen in Burkitt lymphoma. We also want students to be conversant in the terminology since many of them will participate in multidisciplinary tumor boards where histopathology is reviewed.

In 2023 you received the Michele Raible Distinguished Achievement Award in Undergraduate Medical Education, from the Association of Pathology Chairs (now the Association for Academic Pathology). What did that award mean to you?
 

It was truly an honor to receive this award, particularly knowing Raible’s extraordinary history as an educator. This recognition really confirmed my belief that if you focus on what you’re passionate about, you will excel. There have been times in my life when I have been advised to “do more immunohistochemistry papers to buff publication numbers” or “if you do this program, it will help you when it’s time for promotion.” I don’t believe in checking off boxes or jumping through hoops. I essentially have three motivations: a drive to excel, a desire to help others, and above all, having fun! I’m very grateful that my work in undergraduate medical education has met all three of those criteria.

All my projects over the past few years – from editing Robbins Pathology to creating educational video series, and collaborating with the Association for Academic Pathology to create a resource for essential laboratory test teaching – have posed various challenges, but have all been extremely rewarding.

Looking forward, what challenges do you see for medical education?
 

There are several concerning trends in medical education, but one that stands out is the NBME's decision to make Step 1 pass/fail. This change aimed to reduce student stress, as residency directors were using scores to filter applications. However, instead of reducing stress, students are now focused on taking Step 1 earlier in their education just to “get it out of the way.” We’ve seen students spending less time on understanding disease pathophysiology, learning professionalism, and developing diagnostic and treatment skills. Students spend a lot of time on marathon sessions of practice questions, which don't reflect the complexity of real clinical practice.

Many of us worry that medicine is shifting away from its art toward a formulaic approach, driven by algorithms. If students don’t truly understand disease processes and rely on simple word associations to make diagnoses, they won’t be prepared to provide the excellent, thoughtful, and compassionate care that patients need.

Moreover, Step 2 clinical knowledge has become perceived as the “filter” and now students are highly anxious about taking that exam. The stress just got bumped down the road apiece. Students are anxious to find a way to stand out from the pack of applicants and aren’t quite sure what to do. One more research year, hoping for a publication? An additional course of study like a Masters of Public Health? Without a clear pathway, students seem even more stressed than before!

What do you recommend for educators who want to expand their expertise and experience?
 

First and foremost, I think it is essential for undergraduate medical educators to join the Association for Academic Pathology! This association has a section completely dedicated to UME and it is one of the most welcoming, supportive, and extraordinary groups I have ever worked with. There is a deep sense of a shared mission and a desire to help everyone from newbies to experienced educators up their game. The annual meeting is a great place to connect, develop skills, and attend workshops that allows educators to try different pedagogical methods and approaches.

There are some key resources that have helped me develop my pedagogy. Even though it is geared towards K-12 educators, I find the Teach Like a Champion resources, headed by Doug Lemov, to be eye opening. Make It Stick by Henry L Roediger III, Mark A McDaniel, and Peter C Brown helped me understand that we have a responsibility to not just teach students the material, but also to help them learn how to learn. Some “tried and true” methods are really ineffective and can be frustrating to our students.