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  President’s Desk Column

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Achieving uniformity in training

September 2004
Mary E. Kass, MD

There is no such thing as paint-by-numbers pathology; our work is far too complex. Didactics are always important, but training tools extend well beyond the textbook. We teach technique, procedure, and visual inspection to develop the core competencies. While all this is going on, clinical experience draws the connections from the specimen or the test to the patient. Pathologists in training are learning to think like physicians; they are engaged in the serious business of rewiring their brains.

The transition from student to physician is not easily taught. Some programs do these things extremely well, but achieving uniformity in training is a challenge for all concerned. It’s easy to say that training falls under someone else’s umbrella, but saying so doesn’t make it true. The problem has been that residency training falls under the umbrellas of so many.

The good news is that we now have a forum where issues like these can be addressed collaboratively. I reported last month on the first Future of Pathology Meeting, a CAP-sponsored gathering of leaders from 10 pathology organizations. We agreed at that meeting to form a subgroup on residency training. The working group members consist of leaders from the CAP, the Association of Pathology Chairs, the American Board of Pathology, the Association of Directors of Anatomic and Surgical Pathology, the CAP Resident’s Forum, and the American Society for Clinical Pathology.

When we formed the working group, we knew that many of the best minds in residency education would be attending the annual meeting of the Association of Pathology Chairs in Quebec just seven weeks later. With a bit of scrambling, we were able to arrange to hold our first meeting in the same location so that leaders representing the Accreditation Council on Graduate Medical Education (ACGME), the Residency Review Committee for Pathology (RRC), and the Program Directors Section of the APC (PRODS) would be able to join us. Our instincts were right: A sit-down discussion with the leaders of those groups most intimately concerned with pathology training proved to be an excellent idea. The results were productive, positive, and dynamic.

Our working group has an action plan. The first goal is to find out if all residency programs are providing the same amount and type of training in the core competencies. To ascertain that, and to learn whether every new pathologist has sufficient experience in essential areas, we decided we would conduct an outcomes survey of private practice groups that have recently hired freshly minted pathologists. All members of the Future of Pathology group will be involved in framing the survey, which we plan to complete this year. The findings should enable us to pinpoint which skills practicing pathologists consider essential.

We also want to determine whether our procedures for inspecting training programs and our standards for accrediting them are sufficient to ensure that all pathology residents are equally well trained. Can inspectors determine whether a program prepares residents to hit the ground running in key areas, such as molecular diagnostics, informatics, laboratory management, and evidence-based diagnostics? Can they confirm hands-on experience in surgical pathology, frozen section, and gross dissection? Our group will work on strategies to address this and share them with our program directors, the ACGME, and the RRC.

Another goal is to persuade curriculum planners to give our medical students earlier exposure to pathology. More extensive exposure to pathology during medical school would encourage more interest in our specialty (because to know us is to love us). And it would demonstrate to future clinicians the value of a skilled pathological evaluation (because seeing is believing).

Finally, and perhaps most important, our residents need mentors. One thought is to create a role for clinical-teaching track attendings in residency programs. Another is to encourage mini-fellowships that would enable our residents to work with community hospital pathologists during training. These are excellent proposals and we plan to pursue them, but they do not go far enough.

I believe that every practicing pathologist has a role to play in setting quality-of-practice standards for the next generation, whether or not they teach in the traditional sense or create curricula. Our day-to-day behavior defines what a pathologist is for those who work with us. Do you call clinicians to discuss biopsy findings and offer to meet with patients to explain what you have learned? Are you hands-on active in the blood bank? Are you a visible and accessible member of the medical staff? If you can answer "yes" to those questions, then those who come to your practice out of training will rise to the expectations you have generated. In creating an environment that expects much of its pathologists, you will have been one who guided young pathologists to the highest standard of practice. The excellence of their work and their high level of engagement will be your legacy.

We have an ambitious agenda, and I promise to report soon on the findings of our survey and the progress of our working group. But setting the bar for the next generation and providing the means to reach it is a collective duty. I hope you will give me your thoughts about what more we can do to welcome and challenge future pathologists.

Dr. Kass welcomes communication from CAP members. Send your letters to her at president@cap.org.