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January 2008 Jared N. Schwartz, MD, PhD It is a miracle that curiosity survives formal education. —Albert Einstein Changes in how educators think about graduate medical education have begun to restructure pathology residency experiences. Training programs are incorporating competency-based goals and moving toward outcomes-based education. At the same time, the accelerated introduction of new technologies has made lifelong learning more important than ever. Each of us must be at once teachers and learners, mentors and mentees. The CAP Graduate Medical Education Committee, or GMEC, chaired by Michael L. Talbert, MD, is addressing challenges related to the degree of preparation of residents and recent graduates for existing and evolving practice settings. The GMEC is working to identify opportunities for improvement in pathology training and developing suggestions for interventions, interactions, and products to enhance the ability of future graduates to practice pathology. Dr. Talbert has a mantra that captures it: knowledge, skills, attitudes. As department chair and residency program director at the University of Oklahoma College of Medicine, he knows that book-learning is only the beginning. The “knowledge piece,” he says, is the conceptually easy part. Tomorrow’s pathologists will need the skills to apply what they know in a variety of systems, an evangelist’s enthusiasm for explaining clinical implications, and a deep sense of responsibility to their patients and society. They must know what they know, they must know how to use it, and they must be eager to share it. The College will continue to foster partnerships between educators, residents, and practicing pathologists that will promote outcomes-based thinking about how we teach and how we assess learning. Our program directors, the American Board of Pathology, the Residency Review Committee for pathology, department chairs, and subspecialty societies are already working on it. Oliver Wendell Holmes said that while the young know the rules, the old know the exceptions, which is why mentors are so important to this endeavor. In a fundamental sense, it’s not what you know, it’s whom you know. I have met with residents in training programs across the country, and one theme comes up each time. Our residents are looking for mentors who can model skills related to pathology practices centered on patient care concerns. Fred Gorstein, MD, professor and chair of the Department of Pathology, Anatomy, and Cell Biology at Thomas Jefferson University Medical Center in Philadelphia, likes to say that the pathologist is the conscience of medicine, the physician who not only bridges basic science and clinical care but, in addition, provides objective input about resource utilization and management expertise. The Jefferson training program places a lot of emphasis on hands-on learning, professionalism, and systems-based approaches to error reduction. Dr. Gorstein advocates telepathology to provide residents in smaller training programs better access to a variety of teaching, high-complexity laboratory operations, and opportunities for simulated learning experiences. Young pathologists still close to the early practice experiences can help to identify attitudes and opportunities that foster competence. John W. Turner, MD, who completed his dermatopathology fellowship at Duke University Medical Center not long ago, believes that if training is to nourish leaders it must also encourage flexibility and self-advocacy. Trainees and new partners should be comfortable about raising questions, suggesting new methods, and taking initiative. They must also have the confidence to take on new tasks and to search out what they need to know. And while Dr. Turner agrees that young pathologists need mentors, he believes that they need not be one-on-one relationships. Larger practices can organize around the mentorship responsibilities, assigning training in specific disciplines to each partner. Jackie Granese, MD, who chairs the CAP Residents Forum, completed three years of a general surgical residency before choosing pathology; she is now a dermatopathology fellow at the University of Tennessee. Dr. Granese describes her surgical and pathology residencies as “night and day.” Surgical residents make life-and-death decisions independently, she says, and that experience gives residents confidence in their ability to make decisions on their own. Dr. Granese suggests that pathology training programs allow qualified fourth-year residents to take the “hot seat” (that is, undertake unsupervised diagnosis of specimens), and permit younger residents to take clinical pathology call. Nicole Prall, MD, a dermatopathology fellow at the University of Pittsburgh Medical Center who just completed a two-year term on the CAP Council on Scientific Affairs, is among many residents who are concerned about career development training. As she looks toward graduation, Dr. Prall finds little information about how to locate, evaluate, and pursue position opportunities. In a similar vein, Richard E. Horowitz, MD, a clinical professor of pathology at the UCLA and USC Schools of Medicine, Los Angeles, and a member of the GMEC, has observed that many newly minted pathologists enter practice with few business, management, or interpersonal skills. Dr. Horowitz proposes that training programs recruit retired community pathologists to present tutorials on critical nonmedical aspects of pathology practice for the residency training programs. I opened this column with that quote about curiosity because I had just read an interview with General Electric CEO Jeffrey Immelt, who mentioned curiosity (good) and mistakes (not bad) in the context of leadership and success. “At GE, we tolerate failure, but we don’t tolerate a lack of learning,” he said. “So, basically, we only let you make the same mistake once. That’s the only way you can learn, I think, in a successful company of any kind.” Competence-based approaches to graduate medical education will continue to prompt fresh ideas. They will also teach the next generation to pursue their curiosity, to take risks, and to make mistakes. For all of those reasons, I think Einstein would approve. Dr. Schwartz welcomes communication from CAP members. |
