Twenty-First-Century Residents

We live in a pathology world where the rate of technological evolution is ever-increasing and the volume of information available is rapidly expanding. Back in 2011, Densen predicted that medical information would have a doubling period of approximately 73 days – or 0.2 years – by 2020 (1). Presently it is 2024, and although I have yet to see another article validating this prediction, some Google searches and a litany of anecdotal ‘word-of-mouth’ conversations seem to agree that it is correct. Medical information is in overload and overdrive with no slowing down (2). It is expanding at rates faster than any physician can keep up with, and education curricular strategies must be fundamentally adapted to meet this continued expansion effectively.

In pathology, the plethora of information is augmented by the rapid progression and importance of molecular diagnostics and computational-based technologies in modern practice. Take the former, for instance; Folpe stated in 2022 that pathologists “can’t keep up” (3). We have been, are, and will continue to practice in a molecular era of precision medicine (4).

Pathologists are increasingly being asked to play integral roles in accounting for the genomic underpinnings of unique histomorphologic entity presentations (in other words, genomorphology), such as for solid, hematolymphoid, and myeloid tumors. Why? Because we understand that changes in genomorphology, even when subtle, may suggest different entity behavioral patterns and, consequently, point at unique pathology classifications with prognostic and therapy-related implications (5). 

Advances in genomorphology understanding have resulted in multiple editions of the World Health Organization’s Blue Books in every organ system (now set to include cytopathology). These resources are updated every few years to help pathologists keep up with modernized diagnostic guidance. After all, our role as pathologists in the continuum of patient-centered care is to provide the most accurate pathology diagnostic reports we can so our patients receive the best treatments for their individual conditions (6).

But, this is only the tip of the information expansion iceberg. Pathologists practice in the “digital age” of 21st-century healthcare (7). Every day, we navigate clinical information systems, like electronic health records, to provide patient-centered care. Calls for improved resident pathologist training in this discipline have been made previously by leaders in the field (8).

Catalyzed by the 2019 COVID pandemic (9), digital pathology has also advanced to a degree where these and other computational tools can be implored as pathologists‘ “physician extenders” in rendering safe, appropriate, and timely diagnostic pathology reports (10). This aspect is critically important because practicing pathologists are increasingly being asked to do more – as in, sign out more cases in less time – as workforce shortages persist (11).

Rising laboratory – and healthcare – demands for digital pathology are projected to increase the digital pathology global market value from approximately $740 million in 2021 to almost $1,739 million in 2028 (12). On top of this, artificial intelligence (AI)-driven technologies are increasingly being evaluated, validated, and integrated into digital pathology tools, such as whole slide imaging, to further enhance pathologists’ practice efficiency and delivery of patient-centered care (13). With guidance for proper use continually being put forth by organizational bodies, the ethical and evidence-based institutionalization of computational pathology techniques can be safely pursued (14).

Naturally, in the realm of graduate medical education, this means that resident pathologist training must evolve to meet the demands and trends of 21st-century healthcare, including precision medicine and digital (15). Historically, however, this change has been slow, so pathology educators, the American Board of Pathology, and major pathology organizations recently collaborated to find out “what all pathologists need to learn in categorical residency” and improve the rate of change (16). In 2021, a four-year series of surveys of new-in-practice pathologists and employers unveiled that many residency programs are inadequately preparing residents in molecular pathology (for example, genomics) and informatics, which includes computational and digital pathology, even though these are identified by both parties as important for modern pathology practice (17).

Something has got to give in modern residency training: simply adding “more” (often the instinctual human response to solving a problem) is insufficient (18). What must be addressed, then, are the daily workload models for which resident pathologists are being asked to train (19); after all, poor workload models may potentiate role conflict, burnout, and inadequate preparation for modern pathology practice (20).

Section IV.C.11.e) of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Anatomic Pathology and Clinical Pathology (updated in 2023) states, "Each resident must examine and assess at least 2,000 surgical pathology specimens" (21). Section IV.C.11.e).(3) also states that residents “must formulate a microscopic diagnosis for the majority of cases they examine grossly.” However, these suggestions do not specifically address what percentage of the 2,000 surgical pathology specimen recommendation resident pathologists should grossly (or macroscopically) examine before formulating microscopic diagnoses (21). Additionally, although the ACGME agrees that resident pathologists must have exposure to molecular pathology and informatics while demonstrating participation and competency in these areas, no explicit guidance is offered (21).

Hence, my big question is this: 

“Where does macroscopy education stand in the modern era of information overload, molecular entity classification, and computational practice?”

This question does not suggest that macroscopy is not essential to resident pathologist education and the formulation of final pathologic diagnoses. Proper macroscopy results in enhanced specimen sampling, tissue formalin fixation, and microscopic clarity. Additionally, poor macroscopic evaluation may result in the inability to retrospectively rectify sampling errors, even with expert histopathologic analysis (22). Also, complex resections (for example, cancer specimens) rely heavily on macroscopic examination for proper margin and section procurement to accurately complete protocol checklists which, in many electronic health record systems, are automatically interfaced with checkbox-style templates (23). Therefore, resident pathologists must have sufficient training in the macroscopic examination of surgical pathology specimens, and learn how to efficiently triage them before becoming independently practicing pathologists.

Rather, the aim of my question is to explore the extent of macroscopy versus microscopy education that resident pathologists should be experiencing as part of their daily workloads in the modern healthcare era. Should resident pathologists be grossly examining and dictating all 2,000 surgical pathology specimens before formulating microscopic diagnoses, as previously suggested by the Association of Pathology Chairs? Or should macroscopy training be only enough for sufficient, individualized demonstration of grossing competency and readiness for 21st-century pathology practice given that “the use of number-based criteria as a means to assure competency is extremely problematic” (24)? 

According to Novis, the continued perceived pathology manpower shortage in the US has forced surgical pathology groups (including residency programs) to adopt less-is-more mindsets and be innovative with the delegation of duties to other laboratory professionals (25). This includes the increased use of gross room personnel (GRP), such as pathology assistants (PAs), to assist with macroscopy, frozen sections, and autopsies (26). Importantly, these GRPs also play essential roles in helping resident pathologists gain much-needed education in many of these surgical pathology duties given that they are less frequently completed directly by attending pathologists (27). GRPs are often experts in what they do, such as gross dissection, and receive specialized education (for example, higher-level graduate certification and focused training) to fulfill their professional responsibilities as part of the continuum of patient care (28).

With increasingly high pressures by hospital administration to mitigate healthcare costs and fulfill the growing demands of pathology and laboratory medicine services in patient-centered care, pathologists – including both attendings and residents in residency programs – must rely on the help of GRPs since they are highly trained, allied health professionals (29)(30).

Many questions must be addressed and rigorously analyzed to ensure modernized resident pathologist training suitable for the demands of 21st-century healthcare and the pathologists’ evolving role as facilitators of genomorphologic diagnostics and computational practice:

• Should resident pathologists be getting significantly more education in genomorphology and navigating pathology informatics because this is where residency training is currently lacking in many programs?
• Are attending pathologists asked to perform the direct macroscopic evaluation of surgical pathology specimens within their surgical pathology groups or are these roles predominantly fulfilled by GRPs?
• Must the emphasis now be placed on creating collegial laboratory environments where pathologists and GRPs must learn to practice effectively alongside each other and learn to trust each other? Or will strain between each group of providers occur due to differing opinions, expectations, or poor communication in what each others’ professional responsibilities are?
• Is the current level of resident pathologists’ macroscopy education appropriate for meeting current and future job market demands? Should it be shifted to better meet pathologists’ modern roles in healthcare delivery?
• Is it acceptable, appropriate, and potentially best practice for resident pathologists to spend more time dictating as many final pathology reports as possible, including working up immunophenotypes, genomic studies, and billing for services with appropriate codes? Should they do so regardless of whether they performed macroscopic evaluation, so they can see as many histopathologic variants of entities as they can and be better prepared for fellowship training or post-training practice?

These and other related questions must be addressed soon. Otherwise, I fear the pathology and laboratory medicine community may continue to fall behind in its collective mission of delivering superior patient-centered care and keeping up with the demands of 21st-century healthcare.

^{Credit: Image sourced from Pixaby.com}