Time to Rethink How Pathologists Train

Many thanks to AC, DC, JO and RS whose experience as residency program directors and/or recent graduates with or without fellowship training contributed to this article with shared thoughts on what appears to be, in my opinion, a treacherous course for pathology and the craft we love.  The article is longer than most and perhaps my last of 2015 so I needed some extra content to fill up the time! Although every time I say this is the last post for awhile it usually isn’t. But, if it is, safe and happy holidays to everyone and will see you back on 2016!

Three years ago this month I wrote a piece entitled The Death of the General (Surgical) Pathologist and hit on some of the same issues earlier this year in April with Who is Reading Your Breast Biopsy? Or Liver Biopsy?

I had intended the more recent article to be a part of series but fell short of doing this in a more timely manner but the time that has passed since has brought to my attention perhaps a more serious problem than what I perceive as a lack of general surgical pathologists or a surplus of sub-specialists.

For the sake of argument, I think there is a general recognition in pathology that we have done our part in medical practice this century to date to train and gear our practices towards sub-specialization. Many clinical departments run this way and private groups staff themselves accordingly and have for years.  Orthopedic practices and departments have knee guys and hip guys and wrist guys (and gals).  Radiology has body, brain, breast or lung guys (and gals). Pathology has GI, liver, brain, breast, cytology, bone/soft tissue, lung and a dozen more subspecialties or perhaps, in smaller groups, generalists with interests/expertise in 1 or 2 areas if not fully subspecialized.  Many of these folks are formally trained in fellowships, some are not and have gained expertise through many years of experience and mentorship. Either pathway should suffice, but in the present era, as discussed below, pieces of paper (fellowship certificates) are driving the marketability for hire. While some of these fellowships are formally accredited, many are not.

It seems to me one became interested in a particular area perhaps by the third or fourth year of residency and perhaps considered doing a fellowship in one area or another based on exposure to many different areas over at least a couple of years.  And if not a formal fellowship, perhaps some additional time spent on electives or away electives to get an additional month on the breast service or gynecologic pathology service or the like.  For my generation, we thought about doing everything but also being able to have some expertise in one particular area, but not at the expense of the other areas in anatomic pathology and also perhaps still maintaining competency in clinical pathology.

Some folks did surgical pathology fellowships and perhaps still focused on a particular area thinking they would join a group as a generalist/laboratory medical director and be the “prostate” or “liver” guy. Surgical pathology fellowships also served as remedial training for some residents. Why do more surgical pathology when one just spent four years in a training program specifically becoming proficient in surgical pathology?

I think it is a model that worked and the way residencies were set up until a few years ago – were even enabled to make this model tenable for trainees and the needs of the market. AP/CP Pathology residencies prior to 2006 were 5 years long  and the intent was that one of the five years would be a “credentialing year”. This credentialing year could be met by a clinical internship, a research year or a year of post-residency additional training. The clinical year was the course I and my colleagues followed for those who completed military residencies and I described a bit previously in The Midnight Menu. Then you would complete 4 years or 48 months between anatomic and clinical pathology in combined programs.

After these 5 years of training, the goal and expectation, at least for us, I thought was to be able to go out into the job market, handle 85-90% of what came across your microscope, run a laboratory and deal with hospital administrators in areas of importance to your laboratory.

And I think those from my residency class and those that followed and preceded us, most of us could accomplish these goals. Occasionally someone would do a dermatopathology or hematopathology fellowship and perhaps be more subspecialized than the others after residency but still be expected to do more general anatomic and clinical pathology.

But things began to change when fewer residencies performed clinical internships and opted for additional pathology training at tail end. Folks started to do pseudo-fellowships or study for boards and try to do additional rotations in certain areas they felt they needed to cover they didn’t get in 4 years of residency. All in all, residents who trained for a total of five years in pathology generally succeeded findinga job and lofting themselves into years of experience, both in general anatomic pathology, clinical pathology and often an area that interested them.  

Now  AP/CP pathology residencies are reduced to 4 years without a credentialing year requirement and it seems that folks do not feel like they get what they need in 4 years AND are being told/think they need to do a fellowship to be marketable.  I won’t argue with the latter.  Job boards are chock full of sub-specialist listings – this is probably accurate – again – needs of the marketplace.

But I do take exception to the fact that 4 years doesn’t cover enough to be able to market yourself as a generalist and perhaps even develop some subspecialty skills that would be marketable.

Apparently future pathologists and their employers disagree with me and so now it seems nearly all residents are doing fellowships.  And in some cases more than one.  And deciding which ones within their first year.  Some are doing two to three fellowships and by the time they land a job, they are several years out from their primary training. It might be three years since they did an autopsy, performed a frozen section or read a pap smear. And in all this time, none of them have any real life experiences in the trials and tribulations of laboratory management. We are in a vicious cycle.

The fellowship selection process seems to also occur earlier and earlier in the general residency training. Second year residents are not putting applications together and starting to arrange interviews. How can one learn all of anatomic and clinical pathology in four years when a significant amount of time is spent on the fellowship application process? It is time consuming and distracting.

They are convinced they need to be “molecular dermatopathologists” or “pediatric soft tissue pathologists” or “GI cytopathologists”.  You get the idea.  

I don’t think this is a good trajectory to have pathology on right now.  I appreciate the need for a core fund of knowledge in select areas with the amount of information that is being produced to stay current.  

It’s hard doing breast and prostate and liver and cytology and microbiology and blood bank and derm. You handle what you can and refer what you don’t know.  The group has enough shared expertise to back each other up and can also all read their own frozenS and take their own calls after hours.

But to essentially admit we can’t train generalists in 4 years with some skillsets and subspecialty skills and essentially make pathology training 5 or 6 years to have folks do cytopathology or GI or pediatric pathology seems like a problem with the way we train and learn.

If this is really the case and the core competencies required to sign-out cases and be a medical director require 6 years of training we should make it such rather than trying to convince ourselves we can do it in 4 years.

Perhaps we should follow a model of what internal medicine does – offer 3 years of basics and then one of a myriad of 2 or 3 year fellowships directed towards lung, GI, genitourinary, etc… pathology and directing a lab that serves that segment of the patient market and the clinicians needs.  

You would no longer be “boarded” in anatomic and clinical pathology with additional boards in cytopathology – you would simply have the credentials “cytopathologist” or “molecular pathologist” from a specific board and have as your core competencies a very specific field, much like an invasive cardiologist or rheumatologist or allergist that deal with specific referrals related to their organ systems.

I think we in pathology are kidding ourselves offering 4 year residencies that apparently qualify you for very little while requiring sub-specialization that seems to limit what you can do.

The model seems to work in internal medicine – short residency with fellowships of equal length that are equivalent to what many of our residents are doing right now.