Learning in Lockdown

Erina McKinney, University of Kansas School of Medicine, Kansas City, Kansas

The COVID-19 pandemic has created many challenges in clinical medical education. To prevent disease transmission, many American medical schools placed prohibitions on externship rotations for fourth-year medical students. Externships experiences, described as “audition clerkships,” often play an integral role in the competitive residency matching process. As a residency applicant without these experiences, I was little more than a three-digit United States Medical Licensing Exam (USMLE) score to training programs. I found myself among an increasing number of American medical graduates without licenses. I knew that additional medical experience was necessary to strengthen my candidacy for the next residency application cycle – but, due to my graduation status, completing this requirement via my academic institution was impossible. Fortunately, I discovered a unique opportunity to complete a postgraduate externship with a laboratory director in private practice.

My postgraduate externship experience proved to be a valuable component of my medical education by providing the flexibility to directly participate in responsibilities generally reserved for residents-in-training. I learned to prepare light microscopy slides with the incorporation of embedded paraffin, frozen section, immunohistochemistry, and urine cytology techniques. I grossed surgical specimens, most notably a remarkably intact retained product of conception and a mature cystic teratoma, with my own hands. Clinical pathology studies, such as SARS-CoV-2 real-time reverse transcriptase PCR and serologic antibody testing, were directly available for observation.

The most significant components of my educational experience occurred during case sign-outs with the pathologist, Gang He. The ability to interpret microscopic findings to generate a comprehensive differential diagnosis is inarguably the most important skill necessary for clinical practice – making this a vital skill to develop early. Additionally, immersive exposure to the terminology used to generate diagnostic reports is necessary because it frequently involves discrepancies rarely discussed in classic textbook cases. Furthermore, engaging in a consistent coaching routine with a board-certified pathologist taught me to quickly identify and differentiate lesions under a microscope. To compensate for a relative paucity of investigational opportunities in the private practice setting, I gained experience with manuscript preparation by drafting papers covering the diagnostic decision-making processes behind interesting cases. Overall, my postgraduate externship experience provided the optimal educational environment for an aspiring pathologist-in-training because it challenged me to develop the skills necessary for successful resident performance at the “hot seat” expectations level. Additionally, I established collegial relationships with both the laboratory staff and an additional postgraduate medical student who shared my strong passion for pathology and collaborated with me on Q&A cases.

There is relatively little emphasis on pathology education in the medical school curriculum beyond the first two preclinical years. It is not a required clinical rotation at most medical schools and is often not available as a clerkship until the fourth year of education. Virtual, rather than on-site, interviews were a direct consequence of the pandemic – and removing the need to travel resulted in increased competitiveness for the specialty globally. Although there is no shortage of aspiring pathologists on an international level, medical education in the United States must increase opportunities for American candidates to explore the specialty earlier during clinical training – and learn to articulate their passion to train as physicians, teachers, and researchers.

My unique externship experience showed me exactly why pathologists are considered the “doctor’s doctor.” They provide the consultation necessary to guide the surgeon’s hand, steer the clinician’s treatment plan, and optimally influence the patient’s future. Developing the ability to independently read microscopic slides, determine differential diagnoses, and document diagnostic findings during supervised sign-outs with a variety of software strengthened my knowledge of the field and greatly impacted my future as a pathologist-in-training.

Acknowledgments: Gang He, President and Director, American Diagnostic Consultation & Services, LLC, New York, New York; Ting Zhao, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Jianyou Tan and Zhanqing Yan, NewPath Diagnostics, Flushing, New York, USA.