In past blog posts, we covered responsibilities and expectations in your first few days on the job . Now that you have found the bathrooms and identified the hospital coffee shops with the shortest lines, you are ready to focus on your real job, providing accurate and timely diagnoses for your patients— the essence of what we do as pathologists. You can be good at a lot of ancillary tasks such as administrative management, informatics, or interpersonal relationships, but if you struggle with bread-and-butter diagnostics during your first year, you will find the transition to a highly valued member of the group difficult. It is important to prove yourself early in your career, as a good first impression sets you up for success down the road. Accordingly, your focus during your first year should be on diagnostic accuracy and efficiency.
Know your Cases
In most practices, a set number of your first cases are reviewed by your colleagues. You want this review period to go smoothly, which will likely necessitate late days in the office as you become comfortable evaluating your cases without the safety net of your training program. One tip: some new-in-practice pathologists find it helpful to go through their caseload and first sign out the cases they feel comfortable with as efficiently as possible. This helps you maintain a higher turnaround time on a fair number of cases, and then allows you the afternoon to show difficult cases to more experienced members of your group (when almost everyone has a little more time!). It doesn’t pay to struggle for several hours through a rare soft tissue tumor while your adenomas and cervical biopsies are gathering dust on your desk.
Similarly, you will want to learn which cases your clinical colleagues consider a priority. In many practices, cancer biopsies are the highest priority. Clinicians often schedule clinic patients with suspected malignancies within a few days of a procedure to discuss the results of the biopsy and plan treatment. You want to avoid the phone call of a clinician saying he or she has a patient in clinic and they can’t find the result of the breast biopsy they took a week ago. Get in the habit of prioritizing these important cases early on, and you will quickly gain the respect of your clinicians. They will see you as a conscientious pathologist who cares as much about patients as they do— our ultimate goal. Remember, you became a doctor before you became a pathologist so use good physician judgment when prioritizing your daily caseload.
Now, it is unreasonable to think that you will nail every diagnosis that comes across your desk in your first year of practice. I’ve never met a new-in-practice pathologist who can do this! During your case review period, when, not if, you come across a case that requires a timely but difficult diagnosis, please don’t delay showing it to your in-house expert. While the review period is used to ensure that a new colleague has good diagnostic skills, it is also used to evaluate how you deal with challenging cases. Do not just sign out a case you are not comfortable with, knowing it will be reviewed and possibly “corrected” later. Show your partners that you know your limits and can be trusted to get second opinions on the not-so-bread-and-butter stuff. Acting proactively goes a long way to build trust. At the end of the day, a slightly slow pathologist is better than a diagnostic cowboy. Efficiency is important, but accuracy always comes first.
Prepare for your Tumor Boards
Now let’s talk about tumor boards. In my experience, tumor boards are the place where a new-in-practice pathologist can either shine or go down the tubes. It is essential to learn your practice’s tumor board schedule. Resections or biopsies for malignancies scheduled for discussion at an upcoming tumor board need to be signed out on time. Nothing irks a surgeon or oncologist more than expecting to present their patient at tumor board and finding out that the pathology is not final. If there are challenging aspects to the case that preclude an on-time sign-out, send an email to the clinician explaining the issues you are sorting out so they can schedule the patient for a later discussion. This small gesture can go a long way. You will find that clinicians are very understanding of the time it sometimes takes us to finalize difficult cases. Clinicians also prioritize accuracy over speed and will often be happy to wait a few days for the correct diagnosis as long as they have a bit of a heads up.
Another aspect of tumor boards you need to be ready for in your first year of practice is presenting cases. Most likely, each pathologist in your group will take turns presenting at the various tumor boards. You are responsible for going through the cases ahead of time, so you know what to present. Get your ducks in a row before the conference. Anticipate the questions your surgeons or oncologists will ask. In most cases, they will expect you to show them any positive (or close) margins, discuss all molecular results for targeted treatments, and they will want you to demonstrate any important features that trigger decision points for the future care of their patients.
As an example, consider a stage II colon cancer resection: the oncologists are looking for any high-risk features identified on pathology that will help them decide if their patient needs adjuvant chemotherapy. Show them these features at the tumor board before being asked. Remember, they have a copy of the report. If the report documented a high-risk feature such as LVI, PNI, tumor budding, etc., show these slides right away and don’t wait for a prompt. You want to demonstrate that you speak their language from the get-go.
Finally, if you are reviewing cases for tumor board and disagree with a colleague’s interpretation, do not wait to voice that disagreement at the tumor board! Bring the matter to your colleague ahead of time, discuss the difference (maybe your interpretation is the incorrect one), and come to a mutual decision before the tumor board. Then contact the clinician about the mutually agreed upon decision BEFORE the conference, so there are no surprises. A professional courtesy like this will ingratiate you among your group and will help maintain the overall reputation of your entire department.
A Bit of Advice for Trainees
For those of you reading this blog who are still in residency or fellowship, the best piece of advice I can give you is to train how you will practice. The cases flying across your desk every day are YOUR cases. They are not your attending’s cases. Work on prioritization from day one. Put the new cancer diagnoses and STAT inflammatory pathology (organ rejection, GVHD, etc.,) at the top of the pile. Get the IHC stains needed to sign out the case as you are previewing (ER/PR/HER2). Have the radiology report in-hand for the unusual bone tumor. Come prepared with your tumor board slides and present them to your attending as you plan to present them at conference. Hand him/her the staging slide (deepest level of invasion), followed by the positive margin slide, and then the show him/her the dedifferentiated component of the tumor that will drive its biology. Then tally off all of the molecular findings you know will drive treatment decisions. Your goal should be to leave you're attending speechless. If he/she has nothing to add to your work and preparation, you will know you are ready. The harder you work now, the easier it will be to transition smoothly into your new practice.
Dr. Joshua Hanson, MD is an attending surgical pathologist at the University of New Mexico in Albuquerque. He specializes in gastrointestinal and liver pathology. When not practicing pathology, he spends his days fly fishing on the pristine trout streams of northern New Mexico.