Robert D. Hoffman, MD, PhD
How do pathology residency programs ensure that trainees gain experience in providing consultative support for patient care during their clinical pathology rotations? That was the question that came from members of the Clinical Laboratory Integration into Healthcare Collaborative (CLIHC) workgroup, sponsored by the Division of Laboratory Science and Standards at the Centers for Disease Control and Prevention. Could we do a quick e-mail survey of residency program directors that might answer the question? they asked.
Such a survey could be written, yes, but the question is a surprisingly difficult one for residency program directors to answer in a meaningful way. Interpreting the responses might be even more difficult. What do we mean by “providing consultative support for patient care”? The Accreditation Council for Graduate Medical Education has for many years required pathology residency training programs to involve faculty and trainees in consultative activity during clinical pathology rotations. Every resident who has sat for examination by the American Board of Pathology in recent history has provided an estimate of the number of “clinical pathology consultations participated in by [trainee].” The ABP explicitly defines for applicants that a clinical consultation is “any interaction (formal or informal) between you and another health care professional regarding handling of specimens and/or interpretation of data. These consultations may be oral or written and do not have to be billable.”
A bit further into the ABP application is a boldface injunction to the trainee who is enumerating clinical pathology consultations: “Do not include written anatomic pathology reports.” The boldface text seems off topic and out of place but raises important distinctions.
In the world of anatomic pathology, important consultations happen as a matter of course and drive resident education. Patient tissues are received with a request for processing and interpretation. The judgment of the anatomic pathologist can have a profound effect on the trajectory of the patient. The clinician does not generally control the selection of tissues sampled from a submitted specimen, the ancillary studies performed, or the internal and external consultations that may be solicited before a diagnosis is provided along with detailed prognostic information. In contrast, in much of clinical pathology, the ordering clinician is often assumed to know precisely which tests to order and when, as well as to understand exactly how to use any and all information the laboratory provides. A body of information indicates that the abilities of our clinical colleagues in dealing with complex clinical laboratory testing may be overestimated (Laposata M, et al. Arch Pathol Lab Med. 2004;128:1424–1427).
What precisely is the issue about providing training in consultative support for patient care for residents in clinical pathology? Do we want to know whether residents in clinical pathology rotations are called about the type of tube required for a particular sample and test, or could we instead be holding our training programs to a higher standard? What program director would reasonably admit that a program does not ensure that trainees gain experience in providing consultative support for patient care at some most minimal level?
A better and more provocative question for program directors might be the following: Will you volunteer to show a visitor an example of how you train residents in clinical pathology to provide consultative support for patient care? In consultation with the members of and CDC liaisons to the Clinical Laboratory Integration into Healthcare Collaborative workgroup, I designed a study to observe the nature and amount of training in clinical consultation provided to pathology residents. We planned, with approval from the Institutional Review Board at Vanderbilt University, an observational study to include the 14 pathology residency training programs within a 300-mile radius of Nashville, Tenn., representing a sample of about 10 percent of all U.S. programs. To focus on disciplines where consultative practice may not have the anatomic advantage of the use of a microscope, the question was limited to consultation in blood banking, chemistry, coagulation, cytogenetics, histocompatibility, microbiology, molecular biology, and their subspecialties. Consultation in hematopathology was excluded because of its strong overlap with other areas of anatomic pathology. We sought to identify best practices and barriers to full implementation. No “right” answers were assumed to exist. Without collecting individual patient information, we looked for improvements in patient outcomes resulting from the activity. Programs were assured of anonymity for any information that would be collected.
Of 14 programs targeted in the study group, six did not respond to a personal e-mail to the program director, even after followup. Of eight programs that did respond, five declined to participate. Among the responses from this group were the following: “You would be surprised to see how little consultation there is,” “Nothing to show,” “CP people are not interested in participating,” “After two requests to CP faculty, no interest in participation,” and “Visit not feasible at this time per department leadership.”
Three programs agreed to sponsor a site visit to demonstrate how they teach residents in clinical pathology rotations to provide consultative support for patient care. The three programs focused on different disciplines and were enthusiastic about the opportunity to show their strengths. One program demonstrated a service in which residents under faculty supervision provided interpretive reports on serum and urine electrophoresis gels, using templates to ensure completeness of reports. The second program showcased a transfusion medicine service in which residents responded to clinical consultation requests, wrote notes in patient charts, and set up and monitored pheresis procedures for patients on clinical units. The third program highlighted a microbiology rapid diagnostic service, in which, in response to clinician requests, a resident and fellow would retrieve samples from operating rooms or surgical pathology, consult with clinicians to define questions, set up cultures and other diagnostic studies, and perform diagnostic procedures using frozen sections and special stains as needed, all within two hours of receipt.
A high level of trainee engagement characterized all three of the demonstrated services. In each case, I observed that the teaching activity was demanding of faculty time, because faculty not only spent time with the trainees but also, in some cases, visited patient rooms when the services were not in a central location. In one of the programs, someone shared with us that a past resident in the program—someone who had transferred from another institution—wanted to know why the rotation material couldn’t just be learned out of a book. All improvements are not well received by all concerned.
An untapped wealth of knowledge resides in our American pathology residency training programs. Pathology residency program directors have active forums, at national meetings and online, in which to share information. In addition to being able to share information indirectly in such forums, we can begin to study directly each other’s education of residents. Just as we in pathology have learned how to learn from one another to improve patient care through the peer-review model of the CAP Laboratory Accreditation Program, we have an unrealized opportunity to improve the way we train our residents by observing and learning from one another in our educational homes, and then to share what we have gained with others.
As a longtime program director and former chair of the Program Directors Section of the Association of Pathology Chairs, I have come to know the dedication and commitment to excellence of our program directors in pathology, given the different sets of resources with which we each work. Because the rules that govern the structure of our programs actually permit a great deal of variation from one another, every program must in its own way marshal a varied set of faculty talents, unique physical facilities, and the interactions of varying numbers of staff and trainees of different levels to produce a common product: the best possible pathologist we can train. We must challenge one another to seek out ways to improve our programs by identifying those who have dared to improve on training and delivery of services by reaching outside the lab to make consultation a part of clinical pathology. In doing so, we may adapt new features to clinical pathology training in our own programs.
Dr. Hoffman is vice chair for graduate medical education and director of the pathology residency program, Vanderbilt University Medical Center, Nashville.
The CDC’s CLIHC is addressing the recommendations that came from the seven institutes the CDC convened over many years on critical issues in clinical lab practice. It is focusing on gaps that must be filled to ensure that physicians can use laboratory services optimally. The co-leads of the CLIHC are Michael Laposata, MD, PhD, pathologist-in-chief, Vanderbilt University Medical Center, and John Hickner, MD, MSc, chairman of family medicine, Cleveland Clinic. Dr. Hoffman is a member of the CLIHC workgroup.