Transitioning to Practice - A Residents Forum Panel Discussion

• Residents Forum

Julie McDowell:

What are some common challenges that pathologists face when they're transitioning from training to practice? This CAP cast features a panel discussion recorded during the 2021 Fall Residents Forum meeting, when , vice chair of the Residents Forum moderated a discussion on this topic with three pathologists who are early in their careers, doctors, Elizabeth Rinehart, Marcos Lepe and Juanita Evans. The panelists share their insights about how they are navigating the early stages of their pathology careers.

Dr. Abdul Abid:

This is a session that we are starting on popular demand. We call it the transition into practice panel, and I have with me two excellent panelists in person and one another excellent panelist online and I would let them introduce themselves.

Dr. Elizabeth Rinehart:

All right. Well, my name is Liz Rinehart and a little bit about myself. I started in practice in 2017, so I've been in practice just over four years now. Originally I am from Kansas. I did my medical school and training in Kansas, my residency in Boston at Brigham and Women's Hospital where I subsequently did my GI fellowship. During that time, during residency and training, I was a member of the RF ACT for four or five years. I did all the positions that I could do and I think I was chair in 2016, maybe 2016, 2017. So I've kind of been around for a while and have some things to say about transitioning into practice, so feel free to fire some questions away.

Dr. Abdul Abid:

All right. Dr. Marcos Lepe.

Dr. Marcos Lepe:

Hi everyone. My name is Marcos Lepe. I started my medical career in Mexico, where I'm from. After that I did AP/CP residency at Brown in Providence, and then I did a cytopathology fellowship and surgical pathology fellowships at Penn. I currently am an attending at Beth Israel Deaconess Medical Center in Boston, and I just passed my one-year mark as an attending. And like Liz said, feel free to fire any questions and hopefully we can get something really good at this.

Dr. Abdul Abid:

All right, Dr. Juanita Evans.

Dr. Juanita Evans:

Hi everyone. As you said, I'm Juanita Evans. I've been in practice a little bit longer. I'm going into my 10th year now, which time incredibly flies. I'm originally from North Carolina, that's where I did my med school, my undergrad, I did my AP/CP and heme path fellowships up at Penn State. And I took my first job in Michigan in the Detroit metro area and I'm still there after all this time, which I think is a little bit rare. In practice I do general pathology and I supply most of the heme path services for three hospitals. I'm also the medical director of one of our about 250, 270 bed hospitals out there. That's been an interesting new thing that I've done over the last couple of years. And like everyone else said, feel free to ask me questions, I have some thoughts on these things too.

Dr. Abdul Abid:

Well, I'm glad to hear. We'll start with Dr. Rinehart. What's your perspective or I would say, what were the biggest challenges that you felt while you were moving from your fellowship and residency training into being an independent pathologist?

Dr. Elizabeth Rinehart:

One of the things that I think I found the most challenging, is after having been at one institution for four or five years, you'd kind of worked your way through the ranks and people knew who you were, they knew your skillset, they knew your personality. You had leadership responsibilities in your residency and fellowship program, you were on hospital-based committees and doing all these various things, where you're doing your residencies and then essentially you start over brand new. And you're most likely moving to a new place, most likely people aren't going to know you and I guess I should backtrack a little bit.

So I'm actually a private practice in Connecticut. I do much like Juanita, I do a little bit of everything. I do a lot of GI, but I actually sign out every single thing possible. Friday was a bit hectic, I had eight new cancers, three prostates, one breast, two metastatic melanomas of unknown primary, a lung and that's on top of all your ditsilly stuff like your placentas and lipomas and miscellaneous things like that.

So we definitely see a lot, but transitioning into practice, it was just like I was used to people knowing who I was and knowing my character, knowing my intentions and just knowing the committees I was on and stuff and then essentially you have to start all over. And I think that was a huge struggle for me, not really knowing how do I fit in here and what should I focus on here and how do I let my skillset shine through at this new institution? So I think that was a big challenge for me, at least initially.

Dr. Abdul Abid:

What about you, Dr. Lepe?

Dr. Marcos Lepe:

Liz made some really good points. I think because the tail end of my fellowship was affected by COVID and then I started off as an attending during COVID, you just add that little nice layer of difficulty on top of an already difficult situation. You have to adapt to being a new face at a new institution and a lot of nuances and a lot of things that you think you knew and you were like, I have these things down, you just have to start over from scratch. I mean, in my specific scenario, I do GYN/GU and some cyto, how the GYN oncologists do things at BI versus how they did it at Penn, there's some nuances that you just kind of have to get used to. And once you get over that hurdle, which again, I'm only one year in, still getting used to all these nuances, but I think that's just something that you're going to have to go through

Dr. Abdul Abid:

Dr. Evans.

Dr. Juanita Evans:

I'll tag two things onto that. I think your point about not having your clinician colleagues know you as well, so perhaps you have to work a little harder to get onto their ladder of trust, is definitely true. But then I found that my co-pathologist thought I was the bee's knees and I knew everything. And I was going to come in there and bring them into the 21st century and it was kind of like, whoa, whoa, whoa, I can't take on all of this at once, let's start here and see what we can do. Because they were hiring new blood so they could hear the new ideas and just be on top of things. And don't get me wrong, they're totally on top of things, but they wanted that injection of new energy into their practice. So that was kind of hard to be like, well, these people don't trust me, but these people think I'm amazing. Trying to figure out where you think you fit and all of that was quite difficult.

I think the other piece of that, that's pretty hard when you're first starting off is personally, I had a moment of anxiety. I'm like, do I know what a tubular adenoma really is? And I would spend these long days reviewing some cases so many times. And so just coming back to understanding that, yes, you are very competent. You got through four plus years of training, you did great, you passed your boards and feeling okay about that and moving forward, it took me a while. I mean, it took me a while.

Dr. Abdul Abid:

All right. Now that we have heard some hard stuff, what's your favorite part about being an attending compared to a trainee, Dr. Rinehart?

Dr. Elizabeth Rinehart:

Oh man. Well, I'll say before I get to my favorite part, I thought coming out of training, I'm going to be this hot shot attending. I'm going to start my new job, I'll be able to come in, maybe not at 7:00 AM, but maybe I'll come in at 8:30, I can probably leave a little bit earlier. If I am tired at the end of the day and want to sign out my GI cases the next morning, that'll be fine. I can kind of manage my time a little bit more than I perhaps thought I did during residency and that was not the case.

I think just understanding what the expectations are in your practice before you set foot in the door is very critical and will perhaps help you out and avoid any unnecessary confrontations or situations that you may find yourself in like, "Liz, I noticed you still had eight GI cases that you didn't sign out from yesterday. Is there an issue?" And I'm like, "No, I thought I would do them this morning." So that definitely happened. So I thought that was going to be my favorite part of starting the new job, is having all this autonomy, but perhaps that is not as much as I thought it was going to be initially.

But I think once you've kind of got your foot in the door and you do start to build those relationships with your clinical colleagues and the pathologists that you work with, you do start to get that trust and people do tend to rely on you and people respect your opinion. And I got a phone call on Friday night from a clinician, "Hey, you just signed out this breast biopsy as a flat epithelial atypia. What does that mean? How do I manage that?" And so you start to have this great rapport with your clinicians and you can actually impact patient care and help guide treatment. And I think just once you get over those initial hurdles and establish yourself, those relationships with your clinicians is probably one of my favorite things.

Dr. Abdul Abid:

What about you, Dr. Lepe?

Dr. Marcos Lepe:

Oh, you talked on an interesting point, Dr. Rinehart, anxiety as an attending, yes. You really don't see it when you're a trainee, because you hand in stuff and you're double scoping cases and either you get it right or the attending says, "Well, there's some dysplasia here." And you're like, "Oh yeah, I missed it." As an attending when you're signing it out, it's your name on the report now and if you think that goes away, I don't think it ever truly, truly goes away a 100%, but you just learn to deal with it. And as it has been mentioned many times already, you're kind of getting that confidence up. That's the harsh reality.

Then again, what Dr. Rinehart said, you have this idea built up in your mind of what attending shift, if we can call it that is, just be sure that and I guess this is good advice all around. That you're very much aware of what the expectations are at a place that you're applying for a job and see if those expectations meet yours, then it's a perfect match.

Dr. Abdul Abid:

Cool. What about you, Dr. Evans?

Dr. Juanita Evans:

There's a couple of things, some are the small wins. Oh, I have my own office and it has a window and there's some trees outside of it, that kind of thing. The bigger wins is just getting to know the other pathologists, the other doctors and the staff. I've had so many great conversations, both about work and not work, with the people I see every day and it's a pleasure. Honestly, I love traveling if anyone knows me, but sometimes I miss being at work when I'm gone for too long, because I missed all of these people. And it's just nice to know that people value you, you value them and you're all working together to take care of patients. So I think that's the biggest one of being an attending, just feeling super in control of that kind of happiness and the work relationship.

Dr. Elizabeth Rinehart:

And speaking of the work relationships, I hit on the importance of the relationships with your clinical colleagues, but you have to dial that back and you have to have a good relationship with the pathologist that you work with as well. I trained at a big academic institution and we had a general sign out, but there was also some subspecialty sign out mixed in, and you've got GYN over here and breast over there and GI a block away, and you tended to kind of drift apart from each other. In practice I'm now in a private practice that has 17 ish pathologists, give or take and we have multiple subspecialty training amongst the group of us and having strong bonds and strong communication amongst the members of the practice is paramount.

We also have a fairly robust interdepartmental consultation service. So if I see a derm case and I'm like, yeah, I got nothing. I have no problem knocking on my friend's door and saying, "Hey, do you mind looking at this? It's probably just a benign little nevus, but can you hold my hand?" So if you don't have those good relationships, showing these little ditsilly cases becomes somewhat more challenging, because people will be like, "Oh, why is she showing me the third nevus today?" But if you have a good relationship with your colleagues and it's no problem, and the flip side is true, show me all your little tubular adenomas. No, that's not high grade. Yes, that is. And just having that relationship is super, super important.

Dr. Juanita Evans:

Oh, I wanted to add one other win to this. So as you become an attending, we're talking about anxiety, trying to sign out the small stuff. But as a resident and a fellow, I highly recommend everyone try to write up the report, however you think you would write up a report just to get used to, these are my words on paper. If you do that, I'm sure you've experienced when your attending goes and changes up everything and you're like, ugh, why do they have to do that? It's totally a win as an attending when you can write your words, they're your words and you can sign it out and you're just like, yes, I'm doing my job the way I want to do it. So that's also a small, but amazing win.

Dr. Abdul Abid:

That's a big flex.

Dr. Marcos Lepe:

Can I add something to that?

Dr. Abdul Abid:

Sure.

Dr. Marcos Lepe:

I mean, I try to make it a point whenever I sign out with a trainee, that there's two things. There's one thing which is truth and there's another thing which is style. As long as you write something in the report that is truth or as close to truth, because we have to be humble, because we don't get always the truth, as close to truth as we can get there, then that's a win. If I write, I don't know, some vulvar dysplasia one way and the next GYN pathologist writes it another way, as long as the clinician has actionable information, it doesn't matter that it changes somewhat and I think that's a fairly important concept to grasp. Yes, it kind of feels very disheartening as you're a trainee and you wrote up this beautiful report and to have an attending just scratch it off and then say, "No, no, no, this is how I would write it." But then again, you just have to recognize that.

Dr. Abdul Abid:

Cool. And I would invite anyone in the audience, both in person and virtually, if they have any questions for panelists.

Audience Member:

A two part question. So what kind of resources did you utilize when you were looking for a job, outlines, word of mouth? Then on top of that, do you see any challenges or benefits to being in a larger practice or a smaller practice in terms of consultating once you're finally out there?

Dr. Abdul Abid:

I think these are two important questions, we'll get everyone's perspective on that. Dr. Rinehart.

Dr. Elizabeth Rinehart:

So when I was looking for a job, I was actually signed up to do two fellowships. I was doing my GI fellowship first and then I was signed up to do heme path second. And I was in about day 10 of my GI fellowship and I got a cold email from a recruiter saying, "Hey, I've seen you, I've heard about you, I've seen you at the CAP meetings, et cetera. We have a practice in New England that is very interested in interviewing you."

And I'm like, "Dude, I just started my GI fellowship. I don't even know what is happening right now." I was not looking for a job at that time, but that felt kind of good to have somebody come out of the woodwork and say, "Hey, we have a position." So I ended up interviewing with that practice and at that point I decided, maybe I don't want to do two fellowships. I'm kind of ready to get out on my own, two fellowships is a lot.

It's definitely fine, it's fantastic if you do two fellowships, you will be super marketable if you do that. But for me, I at that point decided, hey, I think I'm going to look for a job. At that point back then, Crystal, you can correct me, but the CAP actually had this little mix and match program, where people that were looking for jobs could put their application in the pool, residents or fellows that were looking for jobs could put their applicant in the pool. There was a match.com thing that went on and you got matched with potential employers.

At the next CAP meeting, which just happened to be, I got the initial interview in July, CAP meeting in September. I ended up meeting with 12 or 13 different practices when I was at the CAP meeting and they were obviously very informal interviews and sit down talks and things like that, but I had some more formal interviews after that. So I ended up talking to about 13 different practices at that point, circle back around to the original practice. Long story short, that's where I signed, that's where I'm currently at and I am now a junior partner in the practice as of January of this year. And as of September 1st, I'm now medical director of one of our approximately 250, 280 bed hospitals in Connecticut. So that is how I got there.

I will tell you, we are actively looking for a hematopathologist or if you're just an all around amazing pathologist that's looking for a job that would like to do private practice in Connecticut, find me afterwards, I have cards. The point of me saying that is these CAP meetings and going to these meetings, you are going to be leaps and bounds above your colleagues that are back home, because this is where you establish your relationships, where you meet people. I remember as a very, very junior resident, I got my own business cards made, I walked around introducing myself and that's kind of how that all transpired. So being at these meetings is hands down, one of the best things that you can do to find a job.

Dr. Abdul Abid:

I'm going to get a card after, but then we go to Dr. Lepe.

Dr. Marcos Lepe:

I missed the first question.

Dr. Abdul Abid:

The first question was where do you look for the jobs, path outlines versus networking versus-

Dr. Marcos Lepe:

Got it. Mine was, I guess a mix. I looked for an ad in path outlines for the BI, for position that I'm currently at, and I knew someone there at the BI, so I just texted them, "Hey, is this true? What do you think? Give me your opinion." And then one thing led to another and now I've been there for a year and I'm super happy. Have we answered the second question? Sorry, what was the second question?

Dr. Juanita Evans:

It was regarding small versus large practice, how does that fit for being in your first year, asking questions, that kind of thing. Just to go back to the finding a job question. I think path outlines, CAP Career Center, whatever you can is great, but now that I've been in practice for a while and I've sat as the person trying to hire. A lot of it's we call friends and we go, "Hey, you got someone at your program, what do you think about them?" And it's a lot of word of mouth. So what Dr. Rinehart said about coming to these meetings, networking, meeting as many people as you can is so important, because we are a relatively small profession. And someone out there knows you and hopefully they're going to say amazing things about you when they get the cold call. So just to keep that in mind.

In terms of small versus large practice, when I joined my practice, we were nine members. So on the smaller side, but there were enough people there and the culture of my practice was such that we had a quite open door policy. So I felt very comfortable, tagging a couple people as my mentors essentially and going to them with certain questions. I know who's good for GI, I know who's good for breasts. I have my people who I want to talk to about cases and like I said, part of that's culture. I mean, you can be in a really, really big group, but then you only do a small chunk. Say you're only in GU and if the three other people only do GU, don't have that open culture, then that may impact how much you're able to do that thing where you want to ask questions.

So part of that's just judging who the people are that you're going to potentially work with. And the other part of that is trying to create a situation which even if they were a closed door group, you might make them open their door a little bit more. So you're going to have to work on that.

Dr. Abdul Abid:

Dr. Rinehart.

Dr. Elizabeth Rinehart:

Yeah, I think that's a very individualized decision. For me, when I started with the group that I'm with now, we were originally seven-ish pathologists. Three were retiring, they hired three of us out of training and there was an overlap of about three to four months where the older pathologists were on their way out, we were on our way in. So we had this nice little mentorship, also a nice little onboarding process. I wasn't handed a hundred part types on day one and it was like, "Here you go." It was like, "Here's a tray."

So for me, that group has since grown from about seven pathologists up to about 17-ish. A couple are part-time, but it's grown substantially even in the last four years. So I personally like having a little bit of a larger practice with multiple subspecialty expertise, because I feel very confident in those people and their subspecialty training. That if I have a very nuanced question about heme, I can go ask my heme person and that same holds true for all the subspecialties.

Dr. Abdul Abid:

Nice. Do we have any more questions, audience or online?

Audience Member:

Can you talk a little bit about the decision making process you used to determine which fellowship area or areas would be the best fit for you?

Dr. Juanita Evans:

I'm just going to be honest. Heme path lit me up when I was in residency. I super enjoyed it, I loved reading flow, I loved reading slides, I just really liked heme path. When you're rotating, if something attracts you and I was like, yep, I like that a lot. So that's why I went into heme path.

Dr. Elizabeth Rinehart:

So for me, I originally loved heme path and I originally was signed up to do my heme path fellowship. The closer I got to that fellowship, the more and more I realized I didn't like it as much as I thought I did. Everything had gone so molecular, which is fantastic, hands down, fantastic, but I don't love doing molecular and I knew that about myself. And so the closer and closer I got to the heme path fellowship, the more and more I was like, well, yeah, I still like it, but I don't like it as much as I did once like it.

And then I was actually offered the GI fellowship first and I said, "I will take it." And like I said, I was full well planning on doing two fellowships. I was planning on, I committed to this, I do still like it, I'm going to stick it out, but when the job offers started coming in, I was like, okay, I think that decision was made for me. So I just fell in love with GI, I liked the fact that it was both medical and neoplastic, so the whole spectrum of disease and I still enjoy it.

Dr. Abdul Abid:

Thanks. Dr. Lepe.

Dr. Marcos Lepe:

I recently had someone ask me this and I don't think it's a very clear cut answer, there's no right answer. It basically boils down to what kind of setting you want to work in. Most, not all, but most academic centers have now gone to sub-specialized sign out and most, but not all community practice, to my understanding, I could be wrong, is more of a general, we all sign out everything. So the first decision in that decision tree is what kind of setting you want to work in. And the second, like Dr. Rinehart said, if you want to just follow your passion, there's no wrong answer, just follow whatever is your passion. There's really no right answer for this. I think in reality most places are pushing for more of a, okay, we're only offering GYN, GU, GI fellowships and I've heard of personally a lot of general surgical pathology fellowships being phased out. So in that sense, the decision might even be made for you, but I don't know what the future might hold.

Dr. Juanita Evans:

Just to tag onto that, I think as practices become larger, which has kind of been the trend over the last couple of years, there is a lot more subspecialty to that. So I think in the end we're all going to be picking something that, for one reason or the other that you're going to want to do. So you're going to at least be okay with it in the long run.

Dr. Abdul Abid:

I think Janera had a question.

Dr. Reala:

Hi, I'm Dr. Reala, one of the fourth years at Orlando Health. So I have two questions. The first question is actually from one of my co-residents. She's asking, does volume matter, did you consider the volume of sign out cases before you picked the job? And if so, especially as a studying attending, do you want the volume to be lower or higher in terms of you to be able to get comfortable with sign out? And then the second question is, in terms of having support, would you have taken a job where there's less attending to sign out other subspecialties, in case you had questions like signing out in a smaller group, where you felt like you had less other subspecialties to show other cases too?

Dr. Elizabeth Rinehart:

Great questions. I mean, I can start. I'm not sure if I asked about volume per se, I just kind of figured inaccurately. I figured that most practices are busy and most practices have a high volume and most practices, everybody just kind of signs out. It turns out that that is not the case and my practice where I'm at currently is a very, very high volume practice in the private practice arena. We just recently had an overarching view of our practice, in comparison to approximately 230 to 250 other similar sized practices in the region or in the country I guess. And it turns out our practice is in the greater than 95th percentile in terms of part types that we sign out. While I say that I'm busy and everybody says that they're busy, it in fact turns out that our practice is very, very busy in terms of the part types that we sign out. I love it.

Now there are definitely days, like Friday when I'm trying to get out of there to come here and I've got eight new malignancies and calling clinicians and taking over the new medical directorship roles, and it feels like you're being pulled in 5,000 different directions. For me, I love that setting, I tend to thrive when I'm being pulled in multiple different directions, some people not so much. So I think again, you have to know that about yourself and know what setting is going to work well for you. If you feel like you can only maybe handle 20 cases a day, then perhaps looking at the volume before you sign a contract is going to be very important for you. So I think it is a good important question to ask and you just have to really reflect and know yourself and where you are going to do best.

Dr. Juanita Evans:

I would like to tag onto that, at least the volume question. I do agree, it's important to ask. Now you can ask it in a tactful way or you can be like, I can only do 2,000 cases a year, will you be able to support that? You need to be tactful about these things. So I do think it is important to ask, because different practices handle that differently and it's not just volume, it's volume and complexity. If you have 4,500 one part tubular adenoma cases a day, I mean, a year, that's probably going to be okay, 4,500 breast lumpectomies, no way are you going to enjoy your job. So you're going to want to ask about volume, complexity and distribution of the workload between your fellow members. So especially in the subspecialty kind of sign out way, and most practices are doing some version of subspecialty. Certain services will be given compensation for either the amount of volume or the amount of complexity. So I do think those are important discussions to have in your first job, but just realizing it's not just a one number game at all.

Dr. Abdul Abid:

Dr. Lepe.

Dr. Marcos Lepe:

Definitely, those are really good points. I guess in my specific situation, since I came from Penn and Penn is really high volume, I never considered, oh, maybe I'm crazy from going to one high volume place to another high volume place, but that's how it turned out. It's okay, I think I shared Dr. Rinehart's personal preference. I would much rather have a high volume being pulled in different directions kind of situation. Again, it does boil down to personal preference.

I love the way that you said how to tactfully ask for the volume without really asking for the volume. I guess other ways that you can do that is, how is this? So since I said I do GYN and GU, I asked how is the service scheduled? And then I found out that there were two GYN people at any one time. So that gives you kind of an idea that there's a lot of GYN and so there are definitely ways around that. But it also, again, as I've said before in other answers to other questions, it boils down to you really knowing, which is a really difficult thing, you really knowing what you would really be happy with.

Dr. Juanita Evans:

And on top of that, when it comes to your first job, it may not hurt to ask questions about onboarding. I'll be honest, if I had been thrown into the same volume I do today on the first day of my job, whoa, that would've not been a recipe for success. However, onboarding was halfway decent and really was able to meet the demands of our practice. So those questions are also important to ask at least. I mean, if you get a second interview, at least in that consideration of the offer kind of thing.

Dr. Elizabeth Rinehart:

Yeah, that's paramount. The onboarding process is super, super critical to your success. I think if you're talking to a practice and they ask, "Well, what is onboarding?" That might be a problem. For me, we started out and I think I mentioned we have a fairly robust consultation service within our own practice, and I think the whole first week was signing into your computers, learning how to use the LIS system. Oh, here's a tray of consults that somebody else has already reviewed. Why don't you take a look at those as well, to kind of see how consults are handled within our practice and kind of understanding how different pathologists look at things. Oh, Dr. X thinks this is a LSIL and Dr. Y thinks this is normal reactive, inflamed.

So you then got a look at how different people in the practice interpreted pathology, and that just served to help me know who I wanted to showcases to, the expectation of how cases were written up and things of that nature. So that's week one to week two, and then maybe finally all of your credentialing paperwork goes in. But speaking of which, this is a transitioning to practice talk. Do all your credentialing paperwork as soon as you get it, because in some states, Massachusetts is horrible, but in some states it takes a very long time for your licenses to go through, your insurances to be approved, hospital credentialing and you may find yourself at your practice, not being able to sign out cases because you haven't been credentialed with the insurers. So little tangent, make sure you do that paperwork as soon as you get it. But that being said, week two is like, here's a tray of cases, sign out a tray of tubular adenomas. And then week three is like, oh, here's three trays and then we kind of gradually ramped up.

My practice is one that we have three hospitals in Connecticut, two hospitals in Massachusetts, and we also do pathology for several private physician owned labs. One being a very, very large high volume GI group, which has about 50 gastroenterologists. So we're doing a ton of GI volume every year. So in terms of the onboarding process, it's like, "All right. You spent your first three weeks at our main hospital, now we're going to send you down to this other hospital, so you can learn how that system works and did a little rotation." So I think, again, going back to the point, knowing how the onboarding process works is super critical to your success.

Dr. Abdul Abid:

I believe the second question was, how important is the support at the group that you go to? For example, if someone is not comfortable with derm, do you think you should go to a place that has at least one derm person that you can show those things to?

Dr. Marcos Lepe:

So again, this is very situational. I'm at Beth Israel, so you have the entirety of Beth Israel, you have the entirety of Brigham and you have Mass General, all in the same city. And it just so happens that with my black cloud, my first week of signing out, I had a really crazy ovarian tumor case. I saw it and I said, "I've never seen this before." So I went to the senior GYN path person at BI and I showed them the case and there's always, I want to make a parenthesis. There's always that little bit of anxiety on top of the usual anxiety, where you're like, what if the other person will just see this case and say, "This is a classic example of this." But no, thankfully the other person saw it and after looking at the entire tray, they said, "I've never seen this. I don't know what this is." So I said, "Okay. Kind of a win-loss." So I took that case to the Brigham and they were kind of, "Okay. This may be this." But that was a really difficult case.

So just to bring the point home, that my specific situation is that I have a lot of internal support and then I have a lot of, quote-unquote, external support, because there are experts within the hospital, but also within the same city that are still part of, I guess the Harvard branch and in that setting, it's super helpful. Even within our department, there's a really good rapport whenever someone deals with GYN, I think vulvar dysplasia is the crux of every GYN pathologist like, oh my God, how do I deal with this? And it's kind of an in-betweener area, but the dermatopathologist at BIDMC are super cool, and I really follow them so much with vulvar. So I guess that's my take home point, it really is very dependent on each individual situation.

Dr. Abdul Abid:

Cool. Do we have any online questions? Yes.

Audience Member:

No online questions, I had a question though. So I've been practicing a few months now and I've early on I kind of made some rules for myself and I was curious if y'all had done the same thing. So one of them is, if I've never seen this or I've never made that diagnosis before, don't do it. Or if I have even the slightest bit of doubt in my mind, don't just brush it off, listen to my gut, go show somebody. Have a really low bar for showing things, even if I feel like I'm going to be embarrassed or not, but put the patient first. So just go show them, if I need to do other levels or stains, whatever, just do it, because it all comes, such your ego and pride aside. But I tried to make those rules to really low bar, don't make something, a diagnosis I've never made, just stuff like that. Did y'all come up with any rules or things that you stuck by?

Dr. Juanita Evans:

I like that rule, don't make a diagnosis you've never made before. I actually still live by that. I mean, you're going to see things that you don't recognize. And sometimes even if I'm like, well, I read this book and I read this book and these 10 articles, I'm sure it's this. I'm going to still either consult someone in my practice who has the expertise or consult an expert. I just think that's a patient safety thing, that I think is really strong.

So I agree with that. And I was in a practice, like I said before, with the culture where, yes, if I had that little tingle on the back of my neck, like woo-hoo, something might be weird about this case, I could definitely just go pass a slide real easy and it wasn't a big deal. So I strongly agree with those rules. Those are probably my two biggest and my other rule was don't be sad about working really late at first. I have time to work at that later.

Dr. Elizabeth Rinehart:

I think that's super important, never ignore that little tingle or your little spidey sense. If something seems off, it is probably off, every time I have ignored that, I have regretted that. So always, always listen to that since, if something doesn't seem right, I don't care if your practice has a strict sign your cases out the same day or within 48 hours or whatever. If you have to take your time on a case, you need to do stains, levels, send it for an expert consult, your name is on that report. So you have to do whatever is best for you and obviously the patient, because you don't want to sign something out and then come to regret it later.

In terms of other rules, for myself, I should probably set some, but luckily the practice I'm in has predefined rules. So all core needle biopsies, regardless of sight, get shown to a second pathologist, whether it's benign. But definitely, 100% of all malignancies get reviewed by at least two pathologists, all breast cores, all liver cores, any melanocytic skin lesion. In fact, I show almost all of my skin cases, unless it's like, I don't know, we even show all of our basal cells, even if it's just the basal cell. We show pretty much all of our derms get reviewed by a second pathologist, unless it's a dermatopathologist signing out the case, even they show each other all new malignancies.

So we have very predefined rules about what we are supposed to show and as a practice, we also try to hit the 20% mark. So regardless of what the number of cases or the types of cases, we have a goal of 20% of our cases get shown interdepartmentally and we review the statistics every month, look at the types of cases that were shown, the discrepancies interdepartmentally. And then also, because we're in Connecticut, a lot of our cases get referred to Yale or Hartford or things of that nature. So anytime extra departmental reviews come back, we compare, we contrast, mark the ones that are concordant, discordant, et cetera and review those on a monthly basis. So having predefined rules at your practice is also super helpful.

Dr. Abdul Abid:

Dr. Lepe.

Dr. Marcos Lepe:

I have so many rules. So have you guys seen the movie Zombieland, where the guy's basically giving rules to how to survive the zombie apocalypse? That's kind of what happens in my mind. I don't have them in order, but if anything is even a little bit out of whack, even if I don't feel a 1000% confident, I will just not do it. I will get levels, I will get stains, my trigger, my threshold rather for doing that is super, super low. If it's, again, as mentioned previously, if it's not a diagnosis that I've made in the past, I will definitely show an expert. If it's any vulvar thing that's not a SIL, I will show a dermatopathologist, just even if it's a curbside, just look at this slide, not even a formal consult, but just give me your opinion.

What else? For frozens, I'm not shy about, you know what, I've never seen this, I'm not used to this scenario, et cetera. Just at the end of the day, it was mentioned, it's patient care ultimately. So my ego is really, it shouldn't even come into play, at the end of the day you're dealing with someone else's livelihood. So it may be difficult, I guess for the person involved, it's more difficult for some people to shed their egos than others, for me, thankfully it's not been difficult. So I really would encourage everyone to come up with a set of rules, because I remember having this kidney biopsy situation where it was, I didn't sign it out, but I didn't order anything either. And I just came in on the weekend and just ordered stains, because my Friday night was, I was haunted by it.

And another thing about feedback with consults, I don't think I could describe it, even if I were in person. When you look at a report of a prostate core needle biopsy case that comes back from Epstein, that is anxiety. But definitely a really good idea about setting rules for yourself and following them.

Dr. Abdul Abid:

Cool. We have another question.

Fred:

Hi, I'm Fred from Allegheny General. I just have two questions. The first one for Dr. Rinehart, you said that you got your job and you had a second fellowship lined up. I was wondering, how was the process for canceling your second fellowship and going straight to your job? How did that go? And then the second question is, if you do do two fellowships, do you recommend people to have job interviews during the first fellowship, just for experience or?

Dr. Elizabeth Rinehart:

So I'll tackle the canceling my second fellowship, I was scared to death to cancel my second fellowship, because I essentially had committed to that during my second year of residency, and it was well-known throughout the program that Liz Rinehart is doing heme, et cetera, et cetera. So I was petrified. I think if you find yourself in that situation, you need to go to the director immediately or as soon as possible just to discuss, say, "Hey, this is the situation I'm in. I haven't fully committed to anything yet. I am considering dropping this fellowship."

You have to use your best judgment, knowing whoever your program director or fellowship director would be, to know how best to approach that. But I think if you give them enough heads up, I let them know in September for something that was going to happen the following July. So that was enough time obviously, to find somebody else to fill that spot and I wasn't putting anybody at a disadvantage. So I think the earlier, if you find yourself in that situation, needing to drop a fellowship, the earlier the better and I was petrified and it was fine. They were like, "Oh, we're so happy for you. Thank you for letting us know." So from my situation, it was totally fine.

Now in terms of taking interviews during your first fellowship, if you are definitely doing a second fellowship, I don't know that I would do that personally. Just because the jobs that you would be interviewing for, a year and a half to two years in advance, those jobs are going to be gone. I doubt many practices are going to sit around and wait for you for two years. Now I could be wrong, you could find yourself in that situation where they would wait for you, but I personally wouldn't take any interviews during my first fellowship, if I wasn't fully committed to taking a job at that time.

Dr. Juanita Evans:

I just want to piggyback on that. This is talking about professionalism. The same holds true for when you're actually searching for a job. You may get a job offer early on and you may accept it. You're like bird in hand, it's great, but something may come up and you want to accept a second job. Be sure that you just are really open and frank with everyone about that position. Don't just not show up to the first job that you said you were going to be at, that would be really rude, very unprofessional. And it's a small world, once again, and that kind of stuff can get out there on you, and you might find that when you come into a need for another job in the future or help or whatever, you've burnt a bridge in a major major way. So once again, I think that being open, tactful, but open about what's going on is super important.

Dr. Abdul Abid:

Dr. Lepe.

Dr. Marcos Lepe:

The timing is everything. I did the interviews for my job search at the tail end, well, not the tail end, at the middle of my second fellowship. It was kind of weird, because it was just before COVID hit, but I don't know how that job search is impacted now by COVID, that would be a little bit more interesting. I guess I don't have much more advice than just follow your heart. If you know what you're looking for and if you know yourself well enough, then you would know the right questions to ask and the right places to apply to.

Dr. Abdul Abid:

Cool. We have an online question.

Audience Member:

What component of residency and fellowship have you found to be incredibly helpful now, that was maybe undervalued during training?

Dr. Abdul Abid:

Yes. Sorry, this is something that I wanted to ask as well. It's a little bit of a repeat of this morning, that things that you knew back then. What would you emphasize now for all of us residents to learn more, let's say whenever you're going to go to practice, academic or private, some areas that you think need more work to get us ready?

Dr. Elizabeth Rinehart:

For me personally, I wish I would've paid way more attention in CP and tried way harder, because the vast majority of the questions that I feel the least comfortable with are all CP related, blood bank related. So I just wish I would've maybe retained a little bit more of that information. Particularly if you know you're interviewing or you want to find yourself in a private practice, you are going to be covering CP. You will be getting blood bank calls, you'll be getting chemistry calls, you'll be getting micro calls, you'll be getting called into the lab to look at parasites swimming in urine and have no idea what they are. So that is one thing I cannot emphasize enough. If you think you're going into private practice, pay attention in CP study. I have no financial interest, but Dan Mays has a fantastic book for CP, that will not only help you with boards, but will actually help you in your life, it still helps me today. So that's one of the biggest things.

Also, here in the last month, I found myself taking over as a medical director, I have no experience doing this whatsoever. If you have or are lucky enough to be at an institution that has any sort of leadership or management, laboratory management courses or training that you can do on an elective basis, take those, that would be very helpful. And then finally, on the AP side of things, where I trained, by and large it was just top line diagnosis, you just make the diagnosis, bam, you sign out your report. So for example, a tubular adenoma, you would say, tubular adenoma, period, sign out. Where I'm at now there's variations of that theme, depending on the clinician and who you are signing out your GI reports for, what practice you're signing out your GI reports.

For several of our practices, they require a microscopic description. In my training we did no microscopic descriptions, unless it was a super challenging case that had a ton of stains and you had to be descriptive and describe. But on a baseline, we were not doing microscopic descriptions. So on day one in practice, when it's like you need to write a microscopic description for your tubular adenoma, I was like, okay. So I think learning how to voice what you see on a slide could potentially be important for you as well, being able to put into words what you see is very important for our practice. So that is probably one thing I also wish I would've maybe tried a little bit more to do so in residency, is being able to be descriptive about what I was seeing on the slide. So those are probably the three big things.

Dr. Abdul Abid:

Dr. Lepe.

Dr. Marcos Lepe:

I guess a lot of people are going to cringe. I'm sorry, it's grossing, not that I didn't have a really good interest in grossing. But you just don't know unless you're working with trainees, unless you are working at an institution like mine, which through several mergers is now the final word of other hospitals and we get their consults. So you really have to get into the habit of reading a gross description and being able to, in your mind form, okay, so this is what they were going for, this is what they meant by this, this is what they meant by that. And it's that sort of point, not grossing per se, but just being able to get into the mindset of whoever is crafting someone else's report. I think like Dr. Rinehart also said, doing a microscopic description can be challenging, especially if you're really not used to it. But I think those would be the biggest points.

Dr. Abdul Abid:

Cool. Dr. Evans.

Dr. Juanita Evans:

For me, I'm going to tag onto the whole idea of becoming a section chief or a medical director. These are things that you may likely encounter in your job, you might not be the head honcho, but you're going to have responsibility and understanding quality, proficiency testing, when something's actually off versus when it's not, it's super important. I think I had great CP training, but even when I started I was like, wow, there is so much more to this. So really paying attention to some of those details would be really beneficial to you. That includes learning how to bring on a new IHC in your lab. There's so many really practical skills that you could get out of residency, learn at the hard way while you have someone protecting you and then you can bring that as a valuable asset to whatever practice you're going to be in as an attending.

So on the point that's been made about dealing with microscopics and all of that, I wish I had started it earlier in my training. But in the last year, year and a half, I started collecting examples of reports that I thought were really well written. So that I would have a treasure trove of good write-ups for the future, when I was no longer able to access all of the training logs. And I found that I still keep it to this day, I share it with all of our new hires, I just think it's really helpful. Sometimes you're like, this is not a cancer, this is nothing to worry about, but it is weird. How do I describe weirdness in a professional way? It's nice to have an example of how to do that. So I like that a lot.

And I think the third thing that I feel like I really got out of residency, that I should have maybe paid more attention to was also working with the staff. It doesn't matter if they're your histo techs or in the lab, just getting a better sense of the process of the lab, whether it's AP or CP, is so beneficial to actually being the one that they're going to knock on the door and say, "Hey, there's this problem." And you're like, "Oh well, how do we do that?" Well, if you paid attention to it more thoroughly in residency, you'd have a better idea of that. And I think that can be difficult, because at least during my training, we went from a much more holistic surge pathing to very isolated training and so you lost your sense of your place in the bigger working of everything. So I would try to get that if you're not really feeling strong in that area yet.

Dr. Elizabeth Rinehart:

The other thing that I didn't learn about much slash at all in training, was billing and coding. I did not get any of that during training, and now I'm doing at least half of the billing and coding for my practice. So that was a learning curve. So if you potentially think that might be something that you find yourself doing, although I had no idea, you might want to also learn some of the basics about billing and coding. And in fact, there are occasional board questions on billing and coding. They're very simple and straightforward board questions, but that definitely does appear. So that's the other thing that I wish I would've known more about before I started.

Dr. Abdul Abid:

Do you know any resources that we can use to learn more about basics of?

Dr. Elizabeth Rinehart:

Yeah. I mean, I have some stuff. I think if you just Google, I think the most important things, there's a website, it's like icd10data.com, I think is the website. For example, if you just Google Diarrhea ICD-10, it'll just show up as one of the top search things that you can click on. Sorry, I'm a GI pathologist. I'm sorry. Sorry guys. This is why they don't let me speak in public very often, but that's a really good web resource. The other thing is just there's various resources out there that have CPT codes. Again, if you just Google CPT, you can also find resources for that.

Also, some of the various board resource guides have lists of basic coding information that you would need obviously for boards, that is obviously applicable in practice as well. Also, your institution or your hospital will also have a billing, coding and compliance office, they would also be an excellent resource. My practice, everything I bill and code gets reviewed by a true professional coder. So if I've miscoded something, it gets kicked back, correct what I've coded and then it will formally get sent out to the insurance companies. So those are also excellent resources for billing and coding.

Dr. Juanita Evans:

Then let me plug the practice management committee. They have a ton of good resources on just the basics of billing cycle, just go onto the CAP website and you should be able to find that. And then there are a couple of professional billing companies out there that put out white papers on the regular. You could just Google and you'll find them trying to answer some of the weirder billing coding questions and so does CAP today. Every once in a while in the Q and A column, they'll tackle some of these billing and coding questions, which I have found useful in the past.

Dr. Abdul Abid:

We have another question.

Audience Member:

Hi, I'm Alex. I'm a second year medical student. But I was wondering when you transitioned into practice, I learned a lot about your relationships with clinicians and other colleagues, but what is your perspective towards trainees and where do you acquire the skills to teach other people?

Dr. Juanita Evans:

Ooh, that's a hard one. I don't know that I've ever had formal teaching, training education and a lot of it comes with practice, figuring out ways that workflow with teaching at the same time will work for you. So I don't have a good resource for that.

Dr. Elizabeth Rinehart:

I would say during your residency training, there's often ample opportunity for teaching, particularly as you progress through your training. As you become a more senior resident, there will always be junior residents to teach. Most residency programs are obviously affiliated with a medical school, so jump on any educational opportunities you have with your associated medical schools. During residency I did a ton of teaching over at Harvard Med School and I loved it. It was one of the best things, because you would be sitting there describing the most mundane thing and these little medical students, their eyes were bright and wide and you pull out a liver with a tumor and they would just be fascinated. So building your confidence by teaching medical students is also super helpful, but I found that I actually had a ton of teaching opportunities within my residency training program.

Also, anytime that you can present at conferences, you can just help build your educational and speaking skills and I think things like that are super helpful. Now where I'm at in private practice, we obviously don't have an affiliated residency program in pathology per se, but there's definitely family medicine residents that rotate through. We do get some students that are interested in pathology that rotate through. So I still find that even in a private practice, I'm still able to do a ton of teaching and honestly, the clinicians don't know a lot of pathology. So oftentimes you are doing a ton of teaching, as I mentioned, that phone call with the clinician, "Hey, how do I treat flat epithelial atypia?" "Oh, hey, let's talk about that." So I think there's ample opportunities. I never got any formal training myself, but if you're just going through your residency, any opportunity that you can get to explain something to maybe a junior resident, take it.

Dr. Abdul Abid:

Dr. Lepe.

Dr. Marcos Lepe:

This is a hard question. As you progress through your residency, you're given a lot of examples as to everyone else's teaching style. I would say that the best advice is take the best examples of each of your mentors and just fuse it with your own style, with your own flavor and just basically be the teacher that you would've wanted to have, if you didn't have it. At least that's what I try. Like I said, it's difficult because we're thrown sometimes into the role of educators. That's just one of the hats that we get to put on, but we're never really formally taught this.

So definitely, all the experiences that Dr. Rinehart has already mentioned would help to accumulate that experience. But I think if you teach someone with kindness and empathy, slowly you'll accumulate the skillset that you need. And I think people on the other side of the scope would sense that you're trying to perform this act with empathy and kindness. And to the point where, yeah, maybe this person is really new and they're not explaining this in the best way possible, but they're being very patient with me. And so that creates this whole different ambiance, where the information flows more freely. I don't know, that's my opinion.

Dr. Elizabeth Rinehart:

I like your answer, man.

Dr. Abdul Abid:

Cool. Do we have any last question?

Audience Member:

Do you have any advice on creating tools to be more efficient as a new attending, macros, dictation software, templates and the like?

Dr. Juanita Evans:

I'm a big fan of macros, I use them all the time, it makes my reports go a lot faster, and then knowing your style will help you go a lot faster. I don't really have other technological tools other than macros, either through Word or through Dragon. But I also try to, in the best of my ability, arrange my day in a way in which my brain will be the most efficient for whatever type of work I'm doing for that day and I find that quite helpful. Just being aware of when is a good time for you to do hard work and when is a good time for you to do the easy stuff? So that's me.

Dr. Elizabeth Rinehart:

Yeah, that's excellent advice. I think for me, I usually start my day and if I have a tray of core biopsies, I go through them quickly and I'm like, what stains do I need to order to get the ball rolling on this? So I try to go through my cores pretty quickly, write up my consult sheets, get my orders in, and then set those aside or distribute them to the people who are going to be looking at my consults. That way, say that's 8 cases, 10 cases, whatever it is, set those aside and then tackle the more routine bread and butter stuff. Sign out your GI cases, sign out your tubular adenomas, lipomas, placentas and things that you can go through at a quicker pace.

So you get through more volume and then later, I don't want to say late in the day, but later in that afternoon, come back and circle around to your difficult cases and start to go through them with a little bit more time and attention to detail. And if it takes you a little bit longer to work through a few more difficult cases, that's better than the flip side of spending your whole day working on 8 difficult cases and you still have 65 cases sitting in your queue when you leave for the day. And then the next day it grows and it's scary and daunting and you get yourself in that circle and it can be very hard to get out of.

Dr. Abdul Abid:

Dr. Lepe, any last words of wisdom?

Dr. Marcos Lepe:

Let's see. That is excellent advice. I would say yes, prioritize stains, anything you can do quickly. I type quicker than I talk, so I also do macros. Like I've said before, I'm not shy about the fact that I show some cases and so I have this part of my day where if I'm with a trainee, I say, "Hey, let's see everything that would require stains first." We go through them really quickly just to order them, get that out of the way. And then I look through the rest of the cases kind of quickly, at least that's what I've tried to do now and say, "What's going to go into my show pile?"

And after I organized, okay, these are cases that I definitely will need to show and these are the cases that we can handle, then we just go ahead and start the sign out. It boils down again to personal preference, if you would much rather dictate than type, if you would rather type and there's some form of performing macros at your institution. Our LAS has software called Softpath, which has I think very useful customizable macros. So I have my own way of doing everything, I just type in three, four letters, hit tab and it automatically outputs a lot of text. Basically finding out your workflow that works for you in your setting.

Dr. Abdul Abid:

Cool. Thank you very much, Dr. Rinehart, Dr. Lepe, Dr. Evans. I think it was very useful for everyone and feel free to ask them any questions after, once we're done and I think that's our session. Thank you very much.

Dr. Juanita Evans:

Let me make one plug. So my friends, my colleagues from the new practice committee worry on Tuesday, if you're going to be here Tuesday at 8:00 AM in the morning, we're doing a two-hour session, a lot on transition to practice. This is going to be things like trying to pick the right, setting your workflow in your day, how to deal with difficult people, we're going to try to cover the gambit of all of these things. So if you're here, please show up, we'd love to talk more about this.

Dr. Elizabeth Rinehart:

And the last thing that I will say, is the most important thing when you start in a new practice is you have to be flexible. You can't go into a practice being rigid or this is how we did things where I was at. There's some degree where that is acceptable, if you have a new or better way, but you have to be very, very careful how you approach that. You may want to wait a while before you say, "Oh, I have an idea." But never go in there blazing thinking, oh, I'm going to do this and I'm going to do that.

You have to learn to be very flexible and even if you may not necessarily agree with how things are being done or run, et cetera. I think initially you just need to go with the flow, you need to learn where you fit in the practice, because if you go in there wanting to change things up, I think you're going to burn some bridges before you can actually get started. So that's my last little piece of advice, is just be flexible, do whatever they ask you to do and we're looking for heme path persons.

Julie McDowell:

Thank you for listening to this CAPcast. To listen to our other episodes, find us on the My CAP app, available for CAP members, as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, Spotify and Amazon Music. Just search for CAPcast from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button, so you don't miss new CAPcast episodes.

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