Prepping Today’s Residents for Pathology’s Future
How Montefiore’s groundbreaking Pathology Residency Program sets residents up for success in 21st-century healthcare
Tiffany Hébert, Adam Cole, Bryan Harmon | | Longer Read
As an institution, Montefiore Einstein dates back over 125 years. Established to care for patients with chronic or debilitating illnesses, Montefiore has always greatly valued medical education and has trained many generations of physicians across all specialties. That vision became even stronger when the Albert Einstein College of Medicine became a part of the Montefiore Health System.
Given the constant focus on medical education, we were inspired to revamp the curriculum of our Pathology Residents Program as part of our strategic planning. We had been aware for some time of the looming retirement cliff and, therefore, a potential pathology labor shortage – a problem that may have been accelerated by the pandemic. Despite those pressures, pathology training has lengthened over the years, starting paradoxically with the shift from a five- to a four-year residency training program. Since that shift, we have noticed increasing numbers of residents feel the need to complete one or two fellowships to be marketable in the employment arena. Such delays affect people’s futures – their ability to save for retirement, start a family, and establish themselves professionally. When redesigning our residency program, we were keen to see if we could tailor training in such a way that people would feel more comfortable and confident seeking a job afterwards.
We also knew we needed a program that would address the ever-evolving professional role of the pathologist. Teamwork has always been paramount; however, the teams have diversified to include many allied health professionals and advanced practice providers. Moreover, there is a renewed focus on quality over quantity of care. We wanted to make sure our residents had the requisite adaptability to work within emerging health systems with an eye toward patient safety and quality management. Finally, we wanted the Pathology Residency Program to reflect Montefiore’s core values: humanity, innovation, teamwork, diversity, and equity.
The program in a nutshell
The redesigned program is divided into three main phases. There is a two-year foundation phase, during which residents cover core anatomic and clinical pathology rotations, and are exposed to (and involved in) lab management and clinical consultative experience. Rather than simply teaching our trainees how to recognize patterns, we instill process-oriented learning—the process in working up a case that leads to a diagnosis. This foundation prepares residents to excel in the academic environment, community hospital setting, or commercial laboratory. Over the course of the program, a wide variety of regularly scheduled teaching conferences are conducted in various subspecialties of pathology and other relevant clinical departments. And trainees also participate in dedicated daily didactic time.
The two foundation years are followed by the one-year integrative (or hybrid) phase, where residents return to some clinical pathology rotations while embedded within the clinical team in a consultative role. The hybrid rotations encompass endocrine pathology, infectious disease pathology, transplant pathology, and hematology clinical consultation – spending time in both laboratory and clinical settings that are complementary to one another. Modern medicine is (or should be) a very collaborative process, and though pathologists are, of course, diagnosticians, we feel they should be equally good communicators. And so, through this hybrid phase, our residents not only gain a deeper insight into how laboratory science impacts patient care, but also foster essential communication skills to support genuine collaboration with their clinical colleagues. Residents will round on patients with the clinical teams, serve as a liaison to the clinical laboratories, help guide test selection and present results back to the teams, follow the cases where they lead, and explore additional subspecialties.
The “Hybrid” Rotations
Centered in clinical chemistry, residents:
- Rotate in the endocrinology clinic, where they see patients and interact with clinicians.
- Rotate in the cytology-run fine needle aspiration (FNA) clinic, where they perform FNA biopsies of palpable thyroid masses and learn about performance of ultrasound-guided thyroid FNA biopsies.
- Spend time in surgical pathology, where they see resection specimens and participate in head and neck tumor and endocrinology tumor boards.
Infectious disease pathology
Centered in the microbiology laboratory, residents:
- Rotate on the hospital wards with the infectious disease clinical team during rounds and participate in infectious disease clinic visits.
- Play a critical consultative role and interact with the microbiology laboratory on behalf of the infectious disease team.
- Attend our parasitology clinic where they consult with parasitologists, visit patients, and ultimately follow up on laboratory specimens generated in the workup and monitoring of patients.
- Follow up on cases (when relevant) that proceed to tissue diagnoses.
Residents who rotate on this service during the medical school’s year-two microbiology course may also participate in teaching at the medical school in small group conferences.
Centered in surgical pathology and the human leukocyte antigen (HLA) laboratory, residents:
- See transplant biopsy protocol patients with the transplant clinical teams, learn the procedures, and follow laboratory testing in the HLA lab.
- Review surgical pathology material from our institution’s renal, liver, and heart transplant services
- Rotate with therapeutic drug monitoring in the chemistry department.
- Participate in real-time slide conferences with clinical teams in which management decisions are discussed based on pathologic findings.
As our nascent lung transplant service expands, exposure to lung transplant material will also be incorporated into this rotation.
Hematology clinical consultation
Centered in the hematology laboratory, this rotation includes a consultative role with the clinical hematology team. During this rotation, residents:
- Provide insight and guidance regarding advanced coagulation workups, peripheral blood smears, manual differentials, and routine hematology testing.
- See patients and attend grand rounds.
- Serve as an interface with the hematology laboratory for the clinical hematology team.
Finally, to address the fact that so many residents feel the need to complete numerous fellowships before moving into an attending role, we recalibrated our rotation schedule to allow for a longer-term focused fourth-year elective. The elective is used as a period of prolonged and intensive immersion in an area where the resident is likely to pursue a career – mastering skills and functioning at a higher level with graduated responsibility and scholarly activity. As a kind of “mini-fellowship” built into the residency, it helps prepare our residents to make a successful transition to becoming an attending physician.
Making the transition
Whenever significant change is required (or simply attempted), the most difficult task is usually generating buy-in from all stakeholders; fortunately, we were blessed with strong support from our chair and other administrators. When we identified the changes we wanted to make, we reached out to rotation heads and residents to seek their feedback and expertise to vet the project – this collaborative approach was key to later success. We also needed a complete shift in mindset – away from time spent on a rotation and toward looking at what constitutes acquisition of competency for a given rotation. In particular, we had to consider what experiences needed to be available for residents to attain those skills; for example, can they serve in a consultative capacity to endocrinology on the most appropriate tests to use in the workup of a patient?
As you might imagine, COVID-19 was a major challenge for our residents. Though it disrupted many of our normal services, it also presented an opportunity. For example, for several months in 2020, much of the outpatient work came to a halt – severely decreasing our biopsy and surgical specimen volumes. At the same time, we had to quickly validate new COVID-19 assays across our Rapid Response, Core, and Virology Labs, and we also created a command center to help triage and process COVID-19 testing while admissions skyrocketed. The residents were integral to these efforts and it was a (hopefully) once-in-a-lifetime learning experience for them. Going forward, we are still doing many things remotely because we are avoiding large group gatherings; however, there is hope that we are at the tail end of this pandemic; by next year, we might be back to normal...
On top of the unique structure of the curriculum, the racially, ethnically, and culturally diverse patient population sets Montefiore’s Pathology Residency Program apart from others. The Bronx is home to over 1.4 million individuals – and when you walk around the hospital or down the surrounding streets, you pass people who come from all over the world and from all sorts of different backgrounds. With such a large and diverse population, residents training at Montefiore get to learn firsthand about a staggeringly wide variety of diseases. Pathogens – such as malaria – that may be quite uncommon in other US training programs are all but guaranteed to be seen by our residents throughout their training at Montefiore.
The Bronx is also one of the most underserved counties in the country; many of our patients come to us without a history of regular and easy access to appropriate medical care. As a result, many present with advanced and complicated pathologies that provide unique challenges and educational opportunities for our trainees. One example of how our residents – and the whole department – are committed to the Bronx community is the “See, Test, and Treat” program, a community outreach event that offers uninsured and underinsured women in the Bronx free breast and cervical cancer screenings, rapid results, and free follow-up care, if needed.
No wrong turns on the path to pathology
There is no one “right” path to pathology – we have seen people in our residency program take many roads to get here, illustrating that anyone can find their way to the field. Some have even had full-blown careers in other sectors before even turning to medicine. One particularly interesting example from the past few years is Angela Baldwin, who was a navy flight surgeon prior to joining our residency program! During her time in our program, she also did some journalistic work in television as a contributor to the ABC News Medical Unit, and is now completing her forensic pathology training at the New York City Office of the Chief Medical Examiner.
Once in medicine, we have had people come over from other specialties and prior clinical careers before realizing their true calling was pathology, particularly international medical graduates who face significant hurdles to complete graduate medical education in the US. Having observed candidates take many different routes, we can confidently say you are never too old to do what you really want to do! Varied experiences color what a person brings to pathology, making the field all the more exciting.
Why Montefiore? Beyond the unique program in a diverse setting, Montefiore cultivates a very nurturing environment; indeed, it is our great strength. As well as being supportive, our culture is very collegial, kind, and generous – and we look for candidates who reflect our own values.
Fortunately, we receive hundreds of impressive applications to our residency program each year so we can afford to be picky! Those individuals who are offered an interview are guaranteed to be bright and accomplished; beyond that, we are looking for team players, empathic individuals, and motivated candidates who are committed to their professional development and to serving our diverse community. On top of that, we also value curiosity. Pathology is a broad field, and so those candidates who have an open mind and a thirst to learn new things find their way to the top of the list.
Certainly, we’re looking for the best candidates, but it’s a two-way street – and so we know we must offer the best in return! Our program delivers a wonderful overall training experience and the opportunity to serve a community that desperately needs our services, while maintaining a collegial work environment and family-friendly atmosphere. There are many fine training programs out there and, although candidates need to figure out which programs will put them in the best position to reach their professional goals, they should strongly consider which program feels like the “best fit” for them on a personal level.
If you are looking for a program that values interdisciplinary patient care, a focus on providing opportunities for residents to pursue their interests, and a culture of compassion and support, then Montefiore is the right place for you. Our advice for getting a place? Take an elective in pathology – the field is vast and what you learn in your typical, basic sciences pathology courses often does not reflect the reality of life as a practicing pathologist devoted to patient care. Once we look beyond the numerical metrics of a candidate, the single most important criterion is the person’s passion for and understanding of what it means to be a pathologist. This may well be your career for the rest of your life, and we want it to be something that you feel will bring you happiness. So, explore your scientific curiosity, get involved in research projects that interest you, and continue to contribute and be of service to your community.
- MB Prystowsky et al., “Prioritizing the Interview in Selecting Resident Applicants: Behavioral Interviews to Determine Goodness of Fit,” Acad Pathol, 8, 23742895211052885. PMID: 34722866.
- TM Hébert et al., “Training the Next Generation of Pathologists: A Novel Residency Program Curriculum at Montefiore Medical Center/Albert Einstein College of Medicine,” Acad Pathol, 6, 237428951984809. PMID: 31192299.
- WS Black-Schaffer et al., “Training Pathology Residents to Practice 21st Century Medicine – A Proposal,” Acad Pathol, 3, 2374289516665393. PMID: 28725776.