May 2011

Stephen N. Bauer, MD

Training, jobs, fit, and fellowships

The United States and Canadian Academy of Pathology meeting in February was excellent, as always, but my inability to be in two places at once prevented me from attending the Residents Forum. That was a real disappointment because there is always a lot happening when the residents convene. I’ve decided to put my misfortune to good purpose and devote a column to our esteemed young colleagues—what concerns them most and how the College hopes to support them.

The big issues now for residents and fellows are finding the right job or the right fellowship and changes in the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements that go into effect July 1. Many good people are putting great energy into addressing these concerns.

The graduate medical education committees of the CAP and the Association of Pathology Chairs have formed a work group on matters of mutual interest, including workforce demand for new graduates. Michael Talbert, MD, professor and chairman of the Department of Pathology at the University of Oklahoma Health Sciences Center and CAP GMEC chair, presented to a joint session of the CAP House of Delegates and Residents Forum the results of a recent survey the work group conducted. One hundred percent of survey respondents who self-identified as first-time job seekers between July 2008 and June 2010 had received at least one job offer and accepted a position, though not always in their preferred location. Those entering the market since July 2009 were more likely to report difficulty finding a job, and 94 percent of all those experiencing difficulty felt there were not enough opportunities available, but 85 percent of all job seekers were satisfied or very satisfied with the positions they had accepted. The work group plans to repeat the survey next month.

Pathologist workloads have increased substantially over the years and many practices report that new hires have difficulty adjusting to the pace and to a sudden increase in diagnostic responsibility. Dr. Talbert says that the CAP Graduate Medical Education Committee and the joint work group have been trying to get a handle on the criteria and conditions of a successful “fit” for a new associate. Their initial research indicates a broad range of expectations among hiring pathologists, program directors, and candidates, pointing to a need for better communication. Conversations at present, Dr. Talbert says, are centering on finding ways to clarify expectations for new-in-practice pathologists (for example, the workload expected and the comfort level with independent diagnosis). CAP treasurer Gene Herbek has suggested we might benefit from practice management courses that cover how to successfully integrate newly trained pathologists into our practices.

The new ACGME Common Program Requirements that take effect on July 1 include new provisions for graduated responsibility that should help by including four levels of progressively increasing responsibility with decreasing supervision, the least restrictive being after-the-fact review of decisions affecting clinical care that has already been provided. The transition to this model will be a major adjustment for residents, fellows, and supervising faculty.

Adapting to the new ACGME duty hour provisions is also complicating life within training programs. First-year residents have new requirements for supervision that may place added demands on senior residents and faculty. Training program directors are working to reconfigure the scheduling puzzles.

Four years ago, the Residents Forum made an urgent appeal for fellowship application process reform. Since then, residents, residency and subspecialty fellowship program directors, and pathology department chairs have studied, surveyed, and debated the best ways to make the experience fairer and less chaotic. It’s complicated. J. Allan Tucker, MD, pathology department chair at the University of South Alabama, who chairs the APC Graduate Medical Education Committee and the APC Fellowship Reform Task Force, relates that a well-intentioned attempt in 2008–2009 to satisfy the majority preference for a uniform application timeline without a formal match failed when 83 percent of programs reported they had not been able to hold their offers until the agreed-upon date.

Former APC chair James M. Crawford, MD, PhD, and colleagues report in the March 2011 issue of the American Journal of Clinical Pathology that 51 percent of fellowship positions are currently filled internally. The residents are deeply divided on the question of a match, and nobody is certain how it will turn out. Looking to the 2013 fellowship class, the APC initiated a pre-match survey on March 15 that will determine whether pathology can meet the National Resident Matching Program requirement that, for each subspecialty area, 75 percent of accredited programs must participate and 75 percent of all available slots must be listed through the match. A decision will be made by Oct. 1.

All of this happens in context: Residency is transformative by definition. Fortunately, our junior members are persistent collaborators and good communicators and their optimism is contagious.

Jerad Gardner, MD, a fellow in soft tissue pathology at Emory University in Atlanta and chair of the Residents Forum, built a wiki (http://pathinfo.wikia.com) last year that pathology residents own and operate. The wiki offers up-to-date information on fellowship application, training programs, and pathology group practices. Visitors to the site can review and contribute to a section on immmunohistochemistry or, on the lighter side, click on a link to “funny pathology videos.” There are discussion threads on how programs are adapting to the new ACGME duty hours and graduated responsibility requirements; residents simply sign in to add their comments. It is impossible to visit this site and not feel confident about the future of this specialty.

Although it must be a great pleasure to work so closely with this generation of residents, it takes a particular combination of high standards, creative thinking, and hard work to manage a training program. We are indebted to our training program directors and pathology department chairs, who inculcate the competencies and attitudes that enable new graduates to enter practice prepared not just for the present but for a career of transformations. They are building the skills that will frame our future.