February 2008
Taking off the training wheels

Jared N. Schwartz, MD, PhD

For many of us, learning to ride a bicycle is one of the first mentoring experiences. Before our parents remove the training wheels, they want to be sure of two things. First, that we can adjust as needed to stay in balance. And second, that we believe in our own ability to remain aloft. After that, the sky’s the limit. We can soar.

Last month’s column was mostly about structural supports for graduate medical education, things like outcomes-based learning environments and competency-based goals to evaluate performance. This month, I would like to expand on the role of mentors, whose contributions are less structural than visceral.

Mentoring has always been important, but never more than now, when our residents begin practice without the benefit of the clinical year. I have enjoyed the opportunity to meet many members of the next generation of pathologists in my travels as your president. They are bright, energetic, enthusiastic, and eager to practice pathology. And they are very much in need of mentors to model their responsibilities as physicians on the patient care team.

Academic studies are important, but new pathologists must also learn to walk the walk. Gregory J. Davis, MD, a professor of pathology and laboratory medicine and residency program director at the University of Kentucky College of Medicine, says that one of the best things we can do for our specialty is identify medical students who have the qualities of good teachers (lifelong learners with good judgment who like people, enjoy the workplace, and exhibit a certain esprit de corps) and bring them up through the ranks to work with residents.

Dr. Davis likes to talk about “management by walking around,” a fine concept coined in the 1940s by the founders of the Hewlett-Packard Company. In our context, it means that pathologists should be visible on the floors, interacting with patients and other specialists and modeling for residents and young pathologists the balance and confidence required to think on your feet.

In other specialties, residents start at the deep end of the pool, sometimes making life-and-death decisions in their first weeks. Surgical residents, for example, leave training with abundant experience and start scheduling surgeries. When pathology residents leave training, they have yet to face their first unsupervised sign-out. There’s something wrong with this picture.

Mentoring is a form of leadership that can be woven into the culture of an organization, as is very much the case at the CAP. Ronald D. Workman, MD, who chairs the CAP Leadership Development Committee, says leaders are made, not born, and he’s right. A properly mentored young pathologist who gets involved in laboratory operations, technology development, or customer service begins to acquire the practical experience, knowledge, and confidence to start on a leadership track.

Sometimes you don’t realize what you’re capable of doing until the right person points it out to you. I met John K. Duckworth, MD, who chaired the CAP Commission on Laboratory Accreditation many years ago, when he came to my hospital for an inspection and training. “You, Jared, will one day be a CAP leader, probably president,” he said to me then. I was 31 years old and thought he was crazy. But Dr. Duckworth was (and is) a visionary. Over the years, he has taken the time to mentor me and many others, and it has given me great satisfaction to fulfill his vision and the vision of others who encouraged me.

The CAP Council on Membership and Professional Development is looking at ways to encourage mentoring between residents and experienced physicians—pairing fellows within five years of residency and pathologists who are baby boomers and older. Robert Breckenridge, MD, who chairs the council, says studies show that residents greatly value interactions with older physicians and the benefits flow in both directions. Mentoring younger pathologists reminds us why we chose this wonderful specialty. And, Dr. Breckenridge says, it resurrects a sometimes-forgotten recognition that diagnosis is really the most important part of patient management.

Mentoring involves explaining the “why,” which makes it abundantly clear that almost everything we do directly affects a patient. Consider, too, that between 70 percent and 80 percent of all patient information comes from a laboratory under the management of a pathologist. Pathologists are truly the main drivers for the whole hospital process of patient care, and it is good to be reminded of that from time to time.

CAP Graduate Medical Education Committee chairman Michael L. Talbert, MD, department chair and residency program director at the University of Oklahoma College of Medicine, says the key to mentoring is to foster good judgment by engaging residents in problem solving and providing encouragement and guidance through the process. So much of what we do, he points out, falls under “well, it depends.” And much of teaching is about the “what ifs” and the “tweeners.” What if there is not enough tissue for a certain diagnosis, or the ancillary test isn’t diagnostic, or the government changes the Medicare rules, or your subordinate starts calling in sick once a week? What do you do next? The learning process, he says, encompasses things that the testing process cannot. In their program, there is always a supervisory faculty member, but the overriding goal is to look for ways to place a challenge before a resident and encourage that developing pathologist to rise to the challenge. For example, at the University of Oklahoma, residents learn to take responsibility for their diagnosis when they are asked, point blank, whether or not surgery should proceed.

Mentoring is about putting someone on the spot so that the spotlight can shine on their capabilities, their gifts, and their importance to our patients. Then we help them take off the training wheels so they can soar.