December 2008
Feature Story

Anne Ford

With medical school training providing little, if any, exposure to real-world pathology practice, many first-year pathology residents today have scant histology or microscopy experience. “Your typical American medical student may have done two to four weeks of pathology training,” and even then as an elective, says chief pathology resident Christopher Morgan, DO, of the University of Tennessee Health Science Center, Memphis. Those who choose a pathology residency will also have had no more than one month of pathology.

And it’s painfully evident, say those who welcome those residents.

“When we get new residents in pathology, we—especially in recent years—discovered several things about them,” says Charles Handorf, MD, PhD, chair of pathology and laboratory medicine at UT Memphis. “First of all, many medical schools have dispensed with traditional histology programs, where you learn about normal histology, what normal looks like. So many younger folks were coming to us kind of ill-prepared, because you can’t understand what abnormal looks like if you don't know what normal looks like.”

“There are some big gaps in their knowledge of basic science,” says John K. Duckworth, MD, professor and residency program director at UT Memphis. “Some of these kids have never seen a microscope. We have to start at the beginning, and that is: Guys and gals, what does normal breast tissue look like? What does normal kidney tissue look like? What does normal liver tissue look like?”

No patient “walks into the hospital with a wristband that says, ‘I have infiltrating ductal carcinoma of the breast,’” he quips.

It was the lack of preparedness that led UT Memphis five years ago to introduce a monthlong July orientation to histology, gross anatomy, and microscopy for incoming first-year residents. Residents and faculty alike consistently praise it as an efficient means of getting new pathologists-to-be up to speed and ready to hit the ground running when residencies begin officially on Aug. 1. To the knowledge of Dr. Duckworth and his colleagues, it’s the only such program around. (Many institutions don’t offer an in-depth orientation of any kind, says Dr. Handorf: “They’re just ‘Hello, how are you, here’s your badge,’ and off you go.”)

“We’ve had nothing but favorable comments” about the orientation, Dr. Duckworth says. Even more telling, shortly after the conclusion of the first orientation, Dr. Handorf recalls, “at one of our training sites, one of the senior faculty called and said, ‘Gosh, you have much better residents this year.’ I was thinking to myself, ‘I’m not so sure we do,’” he says. “I just think that what we’ve done is get them better prepared.”

The need for resident orientation, particularly to histology and microscopy, arose in part not only because traditional histology has disappeared from the curricula of many medical schools but also because even those residents who did study histology in medical school did so four years before beginning their pathology training. “That is quite a big gap,” says Anand Kulkarni, MD, UT Memphis instructor and director of tissue services. Then, too, there’s pathology’s tendency to attract a significant number of slightly older physicians who have completed training in another specialty first and whose knowledge of normal histology is therefore that much rustier by the time they begin their pathology training. Drs. Kulkarni and Duckworth also point to the digitization of slides for teaching purposes. “The thing with digital slides is, we choose the best possible slide,” Dr. Kulkarni says. “It’s a perfect picture. The real pathology slides—none of them are perfect.”

UT’s orientation begins with an introduction to the histology laboratory, including how to score and report immunostains. “Not that we’re going to make histologists of them,” Dr. Duckworth says. Rather, as Dr. Kulkarni puts it, “The pathologist is responsible for all the things that are happening in the lab. So it’s important that the ­pathologist know each and every thing that happens there. We let them see the process, see where the possible mistakes can happen.”

Jackie Granese, MD, a UT Memphis dermatopathology fellow, found the histology orientation valuable because it has allowed her to “tell when things are being processed correctly, or when there’s room for improvement,” she says. “You’ve gone and seen how it’s actually cut, so you can tell if it’s understained or overstained, or if there’s wrinkles in the tissue.”

In addition, says chief resident Dr. Morgan, it’s a chance for first-years to learn the grossing of specimens in a comparatively relaxed environment that’s conducive to learning. “They have plenty of time to put their very first specimens through in the gross room, see how they’re processed and how histology works, and then see the slides for the first time,” he says. “There’s no time pressure; there’s no hurry to get the cases out. That is the one time in all of residency [at UT] when you have a dedicated histology learning experience.”

Just as valuable, Dr. Granese says, is the next step of the orientation: microscopy. Using that microscope consists of more than “just sitting down and looking through the eyepieces,” as Dr. Handorf puts it. “The fact is, they [first-year residents] really don’t know microscopy when they come into pathology residency, and since that’s so key to many of the things we do—not just anatomic pathology but hematopathology and body fluid analysis—we give a fairly intensive orientation.” It’s a satisfying rebuttal of sorts to the former medical school dean of his who once said, “Well, nobody looks in microscopes anymore.”

The orientation also requires each first-year resident to prepare and deliver a 15- to 20-minute talk on a topic of his or her choosing. Why? “Because a lot of pathology is effective communication,” Dr. Handorf says. “It helps us know where each of the new residents is in their ability to communicate effectively in a teaching situation. We can give them, at that point, some general help as to where to improve.”

As important as the orientation is, they don’t try to tackle too much.

“I want to emphasize that we don’t try to teach them all about pathology in that first month,” Dr. Handorf says. “Our new residents, when they begin, often feel overwhelmed, and so they want us to teach them more about one specific aspect of pathology or another. That’s really what we have to fight against doing. We don’t go into topics that they’re going to learn in great depth when they do their rotations. What we try to do instead is to prepare them to be more effective in learning when they do go to their rotations by giving them the necessary background tools.”

Anonymous evaluations from residents and faculty have helped streamline the UT Memphis program and make it even more useful. “That’s how we came to cut the actual didactic period from four to two weeks,” Dr. Handorf says. Now, in the second two weeks of the orientation, “we send each of the residents to a different training site with a senior resident as their mentor, and just give them two weeks’ immersion in what it’s like to be a pathology resident, literally following a senior resident every step of the day. By the second month they feel much more comfortable jumping into the life and duties of a resident.”

So why don’t more pathology residency programs offer similar orientations? “We don’t know,” Dr. Kulkarni says. “Probably because they just want the resident to start working from day one.”

The orientation not only boosts the confidence of new pathology residents but also reduces their overall stress, Dr. Morgan says. “Some of them have moved to a new city, some just within a week or two,” he says. “You have that time period where you’re learning the basics, that little bit of time where you have other areas of your life to sort out. I think it’s very beneficial on all those levels.”

And it isn’t only the residents who see the benefits. “It makes our lives simpler,” Dr. Duckworth says. “Suppose we started these residents right off the bat” without an orientation. “Man, my phone would be ringing off the wall.”