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Pressing The Sign Out Button: Nine Tips to Help You Bridge from Courage To Confidence

Becoming a new attending in pathology is a transition into practice unlike that of any other specialty. Most new pathologists have never pressed the sign-out button prior to completion of training. The umbilical cord of training supervision is cut, and the weight of reality becomes evident in the form of trays accumulating on your attending desk.

The following nine tips are a pathology-tailored version of personal management skills I wish I had going into practice. The tips begin with how to gather objective performance data, the best advice I have on templates and creating a signing-out routine, and ending with mindset work, specifically ideas around self-awareness. Once I truly grasped this central axis of thoughts, feelings, and actions and accepted that these are the only variables that are ever within my control, my day-to-day experience of work and life started to change.

Learn how your performance will be evaluated

Get seriously curious to learn what your group or department's core values are. Consider requesting a chat with decision makers to inquire what roles in the group need to be filled and which roles could you see me in? What does success look like for someone in my position? Additional sources of feedback include PAs, lab managers, and tumor board colleagues. The earlier you obtain this information the better given the compounding effect. The next two tips are common objective ways performance gets measured.

Turnaround time

One basic time metric is turnaround time (TAT). Ask what TAT is expected of you and learn how to query the LIS for your TAT. Do not obsess about TAT, just develop an awareness. TAT expectations often reflect clinician expectations and key performance indicators (KPI). KPIs may be reported to the hospital as part of a lab’s quality program and are easily measured and tracked. TAT expectations affect your approach to case triage and therefore affects your daily to hourly decision making around time management.

Formal and informal evaluations

If needed, learn how to solicit actionable feedback. Ideally a feedback process is in place and occurs informally at a regular cadence and formally once a year. If after an evaluation you are still unsure what steps to take to improve, don’t hesitate to ask for clarity. Brainstorm together to find a way to verify understanding. Lastly, periodically follow-up between formal evaluations to assess your progress.

Develop a system for archiving cases with learning pearls

For trainees, if you are handing cases off before the report is finalized, try saving case numbers into a spreadsheet and simulate pressing the sign-out button on your own by saving a PDF version of your report. Circle back to the case later to compare how the attending signed out the case.  While these steps require discipline, the payoff is exponential. As an added bonus, your case log can be used during hospital credentialing as an attending. Learn ways that the LIS can work for you. Eg. PowerPath allows you to create personal flags for cases which can be queried.

As a new attending and especially if in a new group, look up cases signed out by your colleagues’ including both bread and butter and zebra diagnoses. These reports can be used as a reference for examples of wording and guidance on immunostain work-up. I also keep a stash of my interesting cases saved as PDFs. The nomenclature for the file name is key to functionality. It includes part type, diagnosis, and the take-home learning point all in the file name and in order. Files can be easily sorted and searched without ever opening the document.

Of course, take care to ensure HIPPAA compliance and patient safety.

Think like a doctor

As pathology trainees, we are relatively sheltered from the graduated responsibility that other specialties employ. This may cause you to lock into the mindset of a professional student, reliant on frequent feedback and another party's ability to rely on. Try to embrace that you are seen by colleagues and other doctors, hospital administrators, etc. as being proficient in pathology. Pathology is not a standardized test with one right answer and multiple wrong answers. It can take active mental work to transition out of black-and-white thinking and into the uncomfortable grey zone of being a practicing pathologist.

On a tricky case ask yourself questions like, “what does the oncologist or surgeon need to know right now?” If it is a biopsy, “does the histologic subtype of a high-grade endometrial carcinoma on scant tissue really need to be nailed down?” The purpose is to give enough information to the care team to guide their next steps in management.

The good news is that thinking like the patient’s doctor is a skill that can be honed rather quickly. Go to tumor boards and pay attention. Attend core lab and microbiology meetings on CP rotations. Early in practice, the skill of thinking like a doctor will build on itself with every lab-tech question and clinician phone call, again by paying attention and embracing the grey zone of the next-best-step answer not the absolutely correct answer.

Create space around the sign out button

Implement a personal and mindful pause before clicking the sign-out button. Develop a habit of remembering one teaching point from the case. Use this as a gratitude practice, a chance to acknowledge your competence and growth diagnostically.

The examples of self-insights can range from the mundane to the clinically critical. “I identified endometriosis without stains.” “I promptly recognized the need for levels on this breast biopsy and found ADH.” “I independently called isolated tumor cells for this post-therapy patient.” “I caught new blasts on the peripheral smear and ordered the flow cytometry.” Noticing all of the ways you have progressed generates confidence and thus speed.

Befriend the voice in your head

You have grit and the willpower to succeed; however, willpower is a mental muscle that fatigues.

A voice coached you to do a few extra board preparation questions. The same voice will encourage you to order more stains as an attending to your benefit and the patient’s. While that voice sometimes saves the day on a diagnosis, when left unchecked it can also offer unhelpful critical thoughts especially under stress. Although your internal critic is trying to protect you from negative feelings, the end result can be net-negative in the long term if you don’t slow down and bring attention to the underlying thinking.

The circumstances-thoughts-feelings-actions-results (CTFAR) model was developed by Brooke Castillo. It is one tool that helped me early in my self-awareness practice with identifying circumstances defined as neutral, verifiable facts (work cases, queue length, colleague relationships, family circumstances), separating these from associated thoughts generated all day long, learning how to physically feel feelings - a concept I had never contemplated before, and began to understand how those factors culminated in results in my life.

Experiment

Different organizational methods may be helpful at different points in your career. Play around with new ideas as needed.

For example, organizing pending cases into piles of slides with color coordinated sticky notes and labeled shelves might feel good short-term, but may actually serve as a form of procrastination. One day I noticed more than one mid-career colleague was utilizing an organization method I affectionately call “one big pile.” All time-sensitive work including slide trays, TEG print outs, and administrative paperwork is stacked in a single location. Less time-sensitive responsibilities are placed elsewhere. Utilization of physical desk space is lean. I have adopted the "one big pile" method for intake and disposition of work. I find it helps with streamlining case triage and getting into a flow to hammer through a long queue. I acknowledge experience in practice and/or my specialty may contribute to what makes this strategy successful, but this is what is currently working for me.

In contrast maybe taking time to read for one case would move the needle more for you in that diagnostic area. Regardless, the pearl here is that if your routine is not leading to the result you want - building knowledge and expertise, feeling more confident, improving your efficiency, etc. - pause before doubling down on your process as you may need to pivot. Try something different. There are a million productivity resources out there: bullet journals, time-task tracking apps, and one-on-one coaches. Like other life adages, the best ideas may be right in front of you.

Find and follow your red threads

On my reading list is Love + Work by Marcus Buckingham. For a quick glance into his methods, I cannot recommend the HBR Idea Cast featuring Buckingham highly enough. In the interview, he outlines how to identify your work-loves, analogous to red threads woven throughout the canvas of your day and makes a strong case for taking them seriously. By anchoring into our work-loves, we intentionally hardwire healthy neural pathways that enable us to branch into new territory.

On a final note, the human brain desires to feel confident before starting something new, because new feels scary and confidence feels awesome. However, your brain will struggle with trying to feel confident when it has no evidence you can achieve a goal or complete a task, which generates cognitive dissonance. True confidence comes AFTER you have achieved your goal, not before. In summary, a goal like signing-out with confidence involves a lot of variables that are within your controls including managing your own mind. Hopefully, these tips will help you keep moving forward.

Jaclyn Rudzinski, MD, FCAP is a member of the New in Practice Committee, Liaison, Council on Education, Board certified in AP/CP, and Cytopathology, Laboratory Medical Director at Baylor Scott & White Medical Center - Lake Pointe.

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