CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Valerie Neff Newitt
March 2024—Pathology trainees and training programs vary, as do first jobs, but the first year in pathology practice is generally said to be a tough one, largely because of the transition to fully independent case sign-out.
While still a resident, Levon Katsakhyan, MD, now a gynecologic pathologist with Carolinas Pathology Group in Charlotte, NC, and coauthors surveyed 12 anatomic pathology fellows from four institutions near the end of their final training year and six and 12 months into their first jobs, and their findings were published in January (Katsakhyan L, et al. Arch Pathol Lab Med. Published online Jan. 5, 2024. doi:10.5858/arpa.2023-0378-EP).
In general, he says, the results show a steady incremental increase in confidence and comfort level with all aspects of independent practice measured in the survey. “This is a first step and a starting point in trying to understand how we can support new-in-practice pathologists through this challenging transition,” Dr. Katsakhyan said in an interview. The response to all three surveys was 100 percent (12 of 12).
The anticipated and actual support from senior colleagues for their new-in-practice colleagues was reported to be strong. It was “one of the highest scores of the questions we asked,” he says. “This is encouraging, but we need larger studies to determine what specific areas of support are most helpful.”
See also: The new-in-practice pathologist
The confidence level in initiating conversations with clinicians showed only minimal incremental increases at six and 12 months. “In training,” Dr. Katsakhyan says, “we’re so focused on refining our diagnostic skills, but at the end of the day our communications skills and relationships with treating physicians are paramount. Developing those relationships early during that first year is important, and it would be good to stress it more in training in different ways.”
Once in practice, he suggests, it would be of help if the senior colleagues introduced the new-in-practice colleague to the surgeons and other physicians, whether in a multidisciplinary conference or elsewhere. This way, he says, “they can have their voices heard early and get involved early in communications with clinicians, so they can begin to develop mutual trust.”
Dr. Varshney
The main challenges the new-in-practice pathologists reported at six months were a high caseload, signing out cases in areas outside their subspecialty, time management, balancing teaching while signing out, laboratory issues, and developing relationships with clinicians. At one year the challenges were similar but for some of them diminished.
Dr. Katsakhyan and his coauthors say many of the challenges are in part rooted in a new-in-practice pathologist having to release reports and take full responsibility for them for the first time. Trainees in pathology programs accredited by the Accreditation Council for Graduate Medical Education cannot bill for final pathology reports, which means a supervising physician must perform the final case sign-out.
“It’s really challenging,” says Neha Varshney, MD, director of surgical pathology and section head of the GI and liver pathology service at the University of Mississippi Medical Center and assistant professor of pathology, University of Mississippi School of Medicine. Dr. Varshney was not involved in the survey of fellows but is a member of the CAP New In Practice Committee. “The biggest issue,” she says, “is the confidence to sign out a case. In training, you always have somebody to do the sign-out, and even if you make a mistake, somebody’s looking after you. Someone else’s name is on there. Then suddenly, overnight, your safety net is gone. That can be terrifying. That’s the biggest issue with transition.”
Graduated responsibility is discussed “from year one to year four in residency,” Dr. Varshney says, “then again in fellowship.” Programs gradually give trainees more autonomy, and “they must be given the accountability and responsibility to own their cases. There have to be benchmarks and milestones to make sure they’re ready to do that.”
Dr. Katsakhyan acknowledges that writing a final surgical pathology report fully and releasing it, within the confines of ACGME-accredited programs, may never be possible, but he suggests activities that would be of value: reporting rapid onsite evaluations for cytology, reporting preliminary diagnoses, or conversing with surgeons. “It will take effort and creativity on the part of the training programs, but there is opportunity for improvement in that area,” he says.
Mayo Clinic in Rochester, Minn., got creative in recent years with its pilot and adoption of a process in which surgical pathology fellows independently manage a subset of cases and release preliminary reports.
The aim was to increase autonomy for trainees in Mayo’s ACGME-accredited surgical pathology fellowship while maintaining safety and supervision, the authors of a recently published article write (Boland JM, et al. Arch Pathol Lab Med. 2023;147[11]:1320–1326).
A change in Mayo’s laboratory information system allowed for the release of preliminary reports into the electronic health record, they say, and it was “hypothesized that preliminary report release by trainees might be a meaningful way to provide progressive responsibility and graded supervision.” For the pilot study in 2020, four board-certified surgical pathology fellows in the final two months of their fellowship were permitted to independently manage cases sent from outside institutions for confirmatory review before additional treatment was provided at Mayo. These fellows decided whether to release a preliminary report, to share with a subspecialty pathologist in consultation and then release, or not to release a report and show the case directly to a general surgical pathology attending physician. They were instructed not to release a report on cases where they had concern about the accuracy of the outside diagnosis or the need for additional workup.
The preliminary report released to the LIS was visible in the EHR only to the patient care team; it was not sent to the patient portal until a surgical pathology attending issued the final report. A comment on the preliminary report explained it was generated by a fellow and would be converted to a final report upon review by a pathology attending. The goal for finalizing the report was two days, and fellows were instructed not to sign out a preliminary report for patients who had an appointment within two days of slide review. Any changes deemed potentially clinically significant or major pathologic diagnostic changes, or both, were communicated orally or electronically to the clinical team by the fellow or attending and documented in the LIS.