Anatomic and Clinical Pathology Boot Camps Filling Pathology-Specific Gaps in Undergraduate Medical Education Wesley Y. Naritoku, MD, PhD; Ljiljana Vasovic, MD; Jacob J. Steinberg, MD; Michael B. Prystowsky, MD, PhD; Suzanne Z. Powell, MD
Context.—The Liaison Committee on Medical Education began an initiative to change medical education across the United States in the early 2000s. With the explosion in medical science knowledge, the need arose to teach selected fundamental information both in a contextual and in an active learning manner. Objective.—To identify ways to address gaps in training and knowledge that became apparent following implementation of learner-centered teaching methods, with devotion of more time to Internet-based learning and less emphasis on face-to-face lecture time. There was a dramatic departure from or de-emphasis of many traditional courses, such as embryology, gross anatomy, microscopic anatomy, and pathology, to the integration of these sciences into system-based active learning courses. This change in medical school curricula produces a medical graduate who hopefully thinks differently but
certainly lacks subject-specific knowledge for a variety of medical specialties. Data Sources.—Pathology residency programs have developed ‘‘boot camps’’ for the initial months of residency training both to provide the necessary foundation of pathology-specific medical science and to introduce basic skills and processes required for practice of anatomic pathology and laboratory medicine. The College of American Pathologists Graduate Medical Education Committee sent a questionnaire out on the Program Directors Section Listserv; the results are discussed and 3 boot camp programs are described. Conclusions.—Boot camps have 2 purposes: (1) to teach or strengthen knowledge required to practice pathology and (2) to introduce basic skills and processes that will be used during the practitioner’s career. (Arch Pathol Lab Med. 2014;138:316–321; doi: 10.5858/ arpa.2013-0356-SA)
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of a system rather than as isolated individual facts. With the use of an active learning process, the hope is that the student will not only retain more information but learn to think in a systematic way and develop lifelong learning processes. The Liaison Committee on Medical Education accredits postsecondary education leading to the MD degree in the United States and Canada, and it is recognized by the US Department of Education in this role.1 Various reports have recommended changes in medical education in the United States, which has essentially remained unchanged during the 20th century.2 With access to the World Wide Web, and the manner in which current medical students learn, the Liaison Committee on Medical Education offered recommendations to change medical education to fit the needs of the new learner and to use many of the new technologies available. As early as the start of the 1990s, first-year medical students were instructed to purchase laptop computers rather than microscopes. Many medical schools began to replace glass slides to teach histology and pathology with 35-mm color slides, which were eventually replaced by PowerPoint presentations in multidisciplinary laboratories, and computers with LCD projectors eventually replaced multiheaded teaching microscopes. Many medical students now review gross and microscopic pathology images downloaded from their medical school’s server, and currently some schools have virtual slides with whole
dvances in medical sciences during the past few decades have made it virtually impossible for medical students to acquire a strong fundamental knowledge of all biomedical sciences, to assimilate the individual sciences into an understanding of normal system physiology and pathophysiology and then apply that integrated knowledge into clinical practice. Thus all medical specialties are faced with the challenge of supplementing medical school education with specialty-specific needs. This challenge in medical school education has resulted in the requirement for contextual learning, where scientific facts from many biomedical sciences are integrated and taught in the context Accepted for publication August 12, 2013. From the Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles (Dr Naritoku); the Department of Laboratory Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (Dr Vasovic); the Department of Pathology, Albert Einstein College of Medicine, Bronx, New York (Drs Steinberg and Prystowsky); and the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Dr Powell). The authors have no relevant financial interest in the products or companies described in this article. Reprints: Wesley Y. Naritoku, MD, PhD, Department of Pathology, Keck School of Medicine of the University of Southern California, 1200 N State St, Clinic Tower Room A7A119, Los Angeles, CA 90033 (e-mail: [email protected]). 316 Arch Pathol Lab Med—Vol 138, March 2014
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slide digital scanning technology. Some incoming pathology residents have never touched a microscope before, and seek instruction on the proper use of microscopes. Learnercentered teaching methods and team-based learning methods have been implemented, wherein the instructor and students assemble in small groups and the students are placed in the role of teacher, so that the students actively learn the subject through the process of problem solving and, occasionally, in a team-based manner. At the same time, the Liaison Committee on Medical Education recommended that medical schools significantly decrease the lecture hall learning time and replace the lecture time with independent study online. Medical schools have reduced or eliminated many lectures from subjects that were traditionally taught in the first and second years of medical school, such as embryology, gross anatomy, microscopic anatomy (histology), and pathology. As a result of this curriculum change, the experience of basic medical education has become quite variable. In another article3 in this issue of the ARCHIVES, the Accreditation Council for Graduate Medical Education pathology milestones are described, and a visit to the Accreditation Council for Graduate Medical Education Web site provides the expectations of the Pathology Milestones Working Group of what knowledge, skills and attitudes are expected of an incoming level 1 resident.4 Among many other things, it is expected that undergraduate medical education will equip the incoming resident to recognize normal anatomy and histology. The ability to assess tissues in this way is reflected in 3 of the 27 milestones: (1) patient care 3 milestone: interpretation and diagnosis; (2) patient care 4 milestone: reporting; (3) patient care 5 milestone: surgical pathology grossing. Without a solid working knowledge of gross and microscopic anatomy, the pathology resident cannot progress to level 2 or further in these 3 critical milestones. Some medical schools are now providing senior electives to allow medical students to focus studies on these fundamentals prior to graduation; in some schools, these offerings occur after a student has selected a specialty through the National Resident Matching Program. However, that practice is not common, and therefore, many pathology residency programs across the United States have developed ‘‘boot camps’’ during orientation programs at the beginning of residency to provide pathology-specific medical science knowledge building upon the knowledge acquired in medical school, and to introduce basic skills and processes required for practice of anatomic pathology [AP] and laboratory medicine. Three programs present ideas illustrating several different methods for providing pathology-specific knowledge and processes to ease the transition from medical school to pathology residency. ANATOMIC PATHOLOGY AP Boot Camps at the Los Angeles County þ University of Southern California Medical Center and The Methodist Hospital Rationale.—Provide first-year (postgraduate year [PGY] 1) residents with the necessary foundation in gross and microscopic anatomy to enhance efficiency and effectiveness on surgical pathology rotations and to develop confidence in developing pathology-specific skills for PGY1 pathology residents. Curricula designed in these programs are monitored with continuous discussion with residents to enable the programs to modify the boot camp to meet PGY1 resident needs as they change and evolve. Arch Pathol Lab Med—Vol 138, March 2014
Didactic Sessions.—During the first 4-week rotation at institution 1 (Los Angeles County þ University of Southern California Medical Center, Los Angeles, California), all PGY1 residents are assigned to a single site, and morning lectures are given specifically for the PGY1 class, separate from the lectures and conferences given concomitantly to the PGY2 through PGY4 residents. At institution 2 (The Methodist Hospital, Houston, Texas), these didactic sessions extend over a longer period of time (10 weeks, including limited clinical pathology [CP] introductory lectures), and all residents (PGY1–4) attend. Initial lectures include general topics such as safety; medicolegal introduction, including requirements for autopsy permission and protocols for tissue procurement for research activities; institutional review board requirements and credentialing for research; navigating the electronic health record; using the histology and frozen section laboratories; histotechniques (including various fixative types and their use, tissue processing, and sectioning); histochemistry and immunohistochemistry; and on-call procedures (AP and CP). Following the introductory sessions at institution 2, 1 to 2 hours of daily lectures organized by organ system are provided for 4 to 8 additional weeks. When appropriate, learning goals and objectives for lectures are provided to the residents on lecture handouts. Pretest and posttests are given just before the lecture and following the lecture to document progress (institution 1). As an example, pretest and posttest results for the ‘‘Introduction to Histotechniques’’ lecture are shown in the Figure. With the advent of the pathology milestones effective July 2014, pretests and posttests such as these may be a very valuable metric.4 Residents are taught normal histology at multiheaded microscopic sessions that are intended for PGY1 residents alone, although more senior residents do attend. At institution 2, this opportunity for learning is daily for the first 6 months of the year. This histology review is given for all major organ systems, except for eye and central nervous system, and may include mixed cases for variety and review of previously presented materials. Gross Dissection Skills Development Program.—On the very first day of residency, PGY1 resident orientation includes providing either recommendations for surgical pathology textbooks, or textbooks themselves at institution 2. The residency manual (goals and objectives of all rotations—required and elective, AP and CP) and procedures manuals (including grossing skills for AP and CP call manuals) are provided. Tours of the histology, frozen section, and core laboratories are given. A team approach is used for mentoring developing skills at all levels and in all areas of pathology; however, specifically for surgical and autopsy pathology, the PGY1 resident is paired with a more senior resident or fellow. At institution 1, there are 3 teams of 2, with Day 1 on the gross bench and Day 2 to preview slides and sign-out biopsies, then preview large surgical specimens to sign out on Day 3. In addition on Day 3, the resident team may have an autopsy; PGY1 residents will observe the first autopsy with minimal participation. During subsequent autopsies, the PGY1 resident is expected to participate fully in all 7 components of the autopsy.5 For 2013–2014, PGY1 residents will graduate to an alternating gross bench-sign out schedule on the second week, with the third team fully dedicated to autopsy during the second week. The third and fourth weeks, the team on autopsy will rotate back into the alternating gross bench-sign out schedule, and 1 of the teams on surgical pathology will Boot Camp—Naritoku et al 317
The results of pretest (blue) and posttest (red) on the ‘‘Introduction to Histotechniques’’ lecture for 26 residents (designated by letters) who had the boot camp experience at the Los Angeles County and University of Southern California Medical Center, Los Angeles, California. Letters A through Z represent individual PGY1 residents.
rotate onto the autopsy service. This change was implemented based on resident feedback to improve acclimation to an alternating gross bench-sign out schedule. At institution 2, each PGY1 resident is also assigned to the surgical cutting bench with a pathologists’ assistant for 1 week shoulder-to-shoulder to develop observational skills, understand and use the language of gross description, and learn appropriate and safe knife skills. Templates are not available on computer at the gross bench, but a grossing manual is always available for reference at each grossing bay with the pathologists’ assistant. A textbook on gross dissection techniques is issued to each resident at the beginning of the PGY1 year. Each PGY1 resident is required to complete a form indicating successful completion under direct supervision of the first 3 specimens of each type (as required by the Accreditation Council for Graduate Medical Education). Faculty, upper-level residents, and fellows may sign off (institution 1) and pathologists’ assistants are also given this responsibility (institution 2). During the orientation period at institution 2, all PGY1 residents are expected to view at least 1 autopsy for which they are paired with another resident. Following this observation, they will be expected to participate as a second resident on subsequent cases, where they will participate in all 7 components of the autopsy. Microscopic Skills Development Program.—When reviewing histologic slides in the first 8 weeks, PGY1 residents are paired with an upper-level resident or surgical pathology fellow at institution 2. An example pairing: Day 1, gross bench for routine large specimens or frozen section; Day 2, slide review and sign-out; Day 3, completion of signout and float for all other AP duties. During the first 2 318 Arch Pathol Lab Med—Vol 138, March 2014
weeks, PGY1 residents are given example surgical pathology reports for reference for gross and microscopic descriptions that are expected on both autopsy and surgical pathology reports. Under the supervision of the paired upper-level resident or surgical pathology fellow, PGY1 residents are given the opportunity to gradually dictate microscopic descriptions determined appropriate to their developing skills. By the end of the first 10 weeks of residency, the PGY1 resident is expected to be able to craft basic surgical pathology reports and to begin to craft synoptic reports independently. Resident Call Manual.—A residency manual with all rotation goals and objectives and an on-call manual created and reviewed annually by the chief residents are given to all PGY1 residents and incoming fellows on the first day in their respective programs at institution 2. Annual program evaluations contain a single question regarding orientation, but the question is focused on the institutional orientation program, and not the departmental orientation program. Rotation Evaluations.—Residents are provided the opportunity to evaluate anonymously their training at the end of each rotation through an online evaluation system, and annually through the annual pathology resident retreat (institution 1) and online annual survey (institution 2). From the resident retreats, the comments included: ‘‘Good experience for first years;’’ ‘‘The residents unanimously liked this experience;’’ ‘‘The residents unanimously felt that this rotation is a positive experience . . . The residents also believe the rotation provides a good basis for beginning pathology residency. Tied to this, [the] lectures are noted to be comprehensive and that they provide practical information necessary to functioning and adapting quickly to Boot Camp—Naritoku et al
Learning Goals and Objectives for the First Days in Surgical Pathology (Los Angeles County and University of Southern California Medical Center, Los Angeles, California) Goals for first grossing day: 1. Review protective gear worn for grossing in surgical specimens 2. Know where the specimen containers are placed before and after grossing 3. Know how to perform patient specimen identification; where on the requisition form important information is found 4. Know how to use the dictation system 5. Know how to gross biopsies using ‘‘swish and pour’’ and ‘‘one use, then set aside forceps for cleaning’’ techniques to diminish the likelihood of floaters 6. Who to ask for help while grossing (check previous day’s OR schedule to identify what type of specimens to expect to cut in, read Lester and the surgical pathology SOP manual on how to dissect the specimen. Follow the procedure described in the SOP manual). If you have a specimen that you’ve never cut in, get help: surgical pathology faculty members, selective (surgical) pathology fellows, and senior residents Goals for first sign-out day: 1. Know the schedule of the sign-out day 2. Where and when to get your slides 3. What to write on the worksheet (what your attending expects you to tell them) 4. What to do with the coding sheet (FS correlation, CPT code, match code) 5. What needs to be looked up before signing out with the attending (eg, previous path slides, frozen sections, history on Affinity, pertinent laboratory values for liver and germ cell tumors, pertinent radiology for CNS, bone, and oral tumors) 6. How to look up physicians’ pagers to inform them of a diagnosis 7. How to order histology, histochemical stains, immunohistochemical stains, FISH HER2/neu, KRAS, PNET/Ewing sarcoma panel, 1p19q for oligodendrogliomas 8. How to keep track of pending studies (notebook system, or ‘‘scut sheet’’) Abbreviations: CNS, central nervous system; CPT, Current Procedural Terminology; FISH, fluorescence in situ hybridization; FS, frozen section; OR, operating room; PNET, primitive neuroectodermal tumor; SOP, standard operating procedure.
residency.’’ A resident suggested the concept of the boot camp; the curriculum was developed by the program director and faculty; another resident provided the learning goals in the Table; and with anonymous input from program evaluations, the residents have been key in providing suggestions to improve the rotation. CP Boot Camp at the Montefiore/Einstein Residency Program (Bronx, New York) Rationale.—The CP boot camp is designed to teach incoming residents the basic principles used in providing high-quality laboratory services. These principles, when taught during the first 3 months of the residency program, can then be applied and strengthened during the remainder of the training program. Learning Environment.—Montefiore Medical Center is an integrated health care delivery system and a pioneer Accountable Care Organization with greater than 50% of its patients in coordinated capitated care. Montefiore Medical Center consists of 4 hospitals (~1500 beds), a primary care network, and specialty faculty practices delivering primary, Arch Pathol Lab Med—Vol 138, March 2014
specialty, and home care to a diverse population in the Bronx and southern Westchester County, New York (~2.7 million outpatient visits per year). Pathology services are provided through a service line.6,7 Residency Program and AP and CP Boot Camp.— Postgraduate year 1 residents take the AP boot camp during the first 2 months and CP boot camp during the third month of residency training. The boot camp emphasizes basic skills and a mindset allowing residents to appreciate the importance of their opportunity and responsibility to provide treating clinicians both advice in test selection and reports that synthesize the clinical laboratory data. Training is both didactic and experiential, including laboratory management, quality assurance, problem solving, and communication skills preparing the resident to function as a laboratory director. The CP boot camp rotation aims to provide basic principles of CP with an introduction to the major laboratory services. These principles are then applied to in-depth rotations during the remainder of the residency, enabling trainees to build strong laboratory practices. The introductory program of study is structured to include didactic lectures, College of American Pathologists (CAP) initial team member training, laboratory management– related project, CP call review meeting (biweekly), and training in Clinical Looking Glass. The didactic lectures/seminars include the major rotations with the perspectives of the faculty laboratory directors, including their knowledge base and approach to the specialty, while pointing out potential pitfalls that earlystage residents commonly experience. We require residents to become CAP Laboratory Inspection Initial Team Members, which allows them to work with experienced laboratorians, skilled experts trained in the area they are inspecting with knowledge of checklist procedures (a central feature of patient safety). This training is supplemented with residents participating as mock inspectors on the service they are presently assigned to; this experience enables some residents to participate in a real team for CAP inspections at other institutions. The presentation of a laboratory management–related project generated by each division, with ongoing quality assurance projects, provides the resident with hands-on experience. The projects are completed within 2 weeks under the director’s supervision. These quality assurance projects are composed as reports, discussed by the division, and prepared for PowerPoint presentation to the residency community as a coordinated session with all residents presenting to the faculty in one session. Presentations are recorded and critiqued to teach and improve resident presentation skills. All presentations are included in the residents’ Accreditation Council for Graduate Medical Education–required portfolio. Residents are involved in consultative activities answering CP on-call questions that are discussed with a rotating attending physician. They maintain a CP call log database detailing clinical question, discussion, test approvals with a follow-up on test results, and a frequently asked questions database outlining current policies with references to consensus protocols, recommendations, and literature. Typically, a designated faculty member will review with the on-call residents and other attending residents the cases that have been logged into the on-call database. These communications and rule-rich discussions are the treasures Boot Camp—Naritoku et al 319
of medical decision making. Residents (and faculty) at all levels of training find these sessions priceless. Clinical Looking Glass is a unique Montefiore clinical information data mining tool designed to assist patient care coordination across the care system and to time-effectively organize large databases and produce opportunities to improve patient care, improve financial performance, and create advances in clinical practice. Clinical Looking Glass encourages physicians to use data to drive continuous quality improvement, leading to better patient care and outcomes.6 Training our residents to use Clinical Looking Glass was introduced to teach our residents to use data to produce information and to question protocols for test use and clinical practice. The ability to use data and add value to health care systems is an important role for pathologists in team-based medical practice. Assessment/Evaluations.—Competencies were evaluated upon conclusion of the sequence within the course curriculum. All PGY1 residents completed Boot Camp posttest/evaluations, CAP Initial Team Member posttest, and CP project presentation. An anonymous survey of the residents regarding their experience of the boot camp in improving basic knowledge and skill indicated positive feedback. Our early assessments include a CP Boot Camp residents’ focus group (n ¼ 5 responses). In general, most residents thought the CP Boot Camp was well planned and useful, especially for residents who have had little CP involvement prior to their first rotation. This feedback has enabled our educators to develop clearer learning objectives for each lecture and guided the use of a standard format for each lecture, providing the appropriate amount of basic information and process that the resident can build upon during training. Hands-on projects have been shown to be much more useful than a lecture-only format in showing residents how to manage clinical issues in CP. Many residents also realized that they needed more expertise in the art of presentation. All residents completed the CAP initial team member training course and achieved a passing score on the posttest. American Society for Clinical Pathology Resident In-Service Examination scores and CP board pass rates will be monitored for improvement. Review of the CAP Graduate Medical Education Committee Survey of Program Directors on Orientation Programs (Boot Camps) A few years ago, the CAP Graduate Medical Education Committee was allowed to use the Association of Pathology Chairs and Program Directors Section Listserv to offer a survey on orientation programs. Of the potential respondents, 57 program directors indicated that they did have a program and completed the survey (approximately 40% response rate).8 The majority of residency programs represented (almost 75%) had between 9 and 24 residents in their programs but responses included small (1–8 residents) and very large programs as well. Surgical pathology volumes at the institutions represented ranged from fewer than 10 000 specimens (2%) annually up to more than 100 000 specimens annually (3%) with approximately even volumes between 10 000 and 20 000, 20 000 and 50 000, and 50 000 and 100 000 (29%, 37%, and 29%, respectively). Sixty-eight percent of the programs 320 Arch Pathol Lab Med—Vol 138, March 2014
indicated that 95% of their residents trained in both AP and CP. The majority of training program directors indicated that their orientation program had been in existence for at least 5 years, and almost half (43%) had done such a program for more than 8 years. The average length of the program was 4 weeks (46%) but programs ranged from less than 1 week to 12 weeks and from 8 to more than 80 contact hours (61% 8– 40 hours). In terms of impact on performance, those programs whose orientation program was 5 or more weeks reported a greater impact on the performance of the PGY1 residents, and results were similar for those with more than 20 versus less than 20 contact hours (ie, time matters). Methods of education used were primarily didactic lecture series and hands-on learning, with simulation videos and prescribed reading also included. A one-to-one interaction with senior residents was the most helpful method (handson learning). The individuals teaching included senior residents, faculty, and pathology assistants, with very limited education provided by histology managers, laboratory managers, medical technologists, or information technology staff (none at all or less than 4 hours total). Eighty-one percent of respondents indicated that the program included AP and CP topics, 16% AP-only topics, and 3% CP-only topics. The most common topics included in orientation/introductory curriculums were call responsibilities, AP (96%); computer systems (93%); specimen handling and acceptability requirements (93%); call responsibilities, CP (91%); patient confidentiality (89%); grossing (88%); use of surgical pathology templates, guidelines, grossing manual, checklist, etc. (88%); and autopsy/medical examiner issues (81%). The most common explanations provided for how resident performance has changed as a result of the orientation/introductory program included decreased learning curve/better preparation for specific pathology rotations (17%), increased understanding of basic processes/procedures (14%), easier transition from medical school to residency (14%), improved communication and teamwork (12%), and increased resident confidence (10%). However, very few of the programs have implemented metrics to assess the performance of the residents; 5% give pretests, 9% give posttests, and the majority (59%) have not implemented any sort of formal assessment. Overall, program directors report a wide variety of approaches and length of time dedicated to orientation of new residents. Although metrics are not used by the majority of those responding, the gestalt of these introductory programs’ impact on performance was highly rated by 92% of respondents, with only 7% indicating that there had been no perceived performance impact or only very limited performance impact. CONCLUSIONS All residency training programs are obligated to transition fledgling graduates of medical schools to competent practitioners in a relatively brief time period. Though this typically takes 3 to 6 years to achieve competency, the initial transition phase from student and predominant observer in medical school to active caregiver within our hospitals and clinics is daunting. The need to assimilate the novice, who has completed the beginner stage by medical school graduation,9 into a competent member of a highly reliable team member in the shortest time period requires not only Boot Camp—Naritoku et al
extensive oversight, but also rapid learning of prioritized, triaged tools of survival—both for patients and for the young physician. To accomplish this, an intense period of practical study (phronesis; ‘‘The key virtue in a physician’s character is phronesis, or prudence . . .’’ 10) is instituted in many specialties, with the goal of primum non nocere11— first, do no harm. Patient safety is the centerpiece driving these transitional intense courses of pragmatic learning. We use boot camps in this vein of patient safety for assimilation of newly graduated doctors into long-standing, highly reliable teams12 where medically accepted patterns of behavior and rendering care in providing entrustable professional activities are clearly and structurally delineated, as demonstrated by the Dreyfus and Dreyfus model of professional development.9 What further makes this transitional educational model important and powerful is the coupling of these do/don’t rules of engagement with active problem solving sessions from on-call episodes. This combination of pragmatic classroom interchange and dialogue; real-life, real-time instances of practice; and ultimate reflective review sessions of what went right or wrong serves as a powerful tool of educating and remembering individually, by the team, and by the community of practitioners. Boot camps are highly successful, transparent educational models that result in wellremembered lessons and low likelihood of practitioner error in those areas that are covered. With the institution of the milestones project, assessing residents for baseline performance and the defining of expectations of what undergraduate medical education has provided to incoming pathology residents, programs will likely need to create metrics to assess the value and impact of these programs on the performance of incoming residents.
The authors would like to acknowledge the contributions of the members of the College of American Pathologists Graduate Medical Education Committee, who developed and synthesized the results of the Graduate Medical Education Committee Residency Orientation Program Survey: Sterling T. Bennett, MD, MS; Noel Anderson Brownlee, MD, PhD; Jimmy R. Clark, MD; Kristin Johnson, PhD; Ronald B. Lepoff, MD; Christopher N. Otis, MD; Suzanne Zein-Eldin Powell, MD; Romualdo V. Talento II, MD, MPH; J. Allan Tucker, MD; and Michael L. Talbert, MD. References 1. Liaison Committee on Medical Education. Overview: accreditation and the LCME. http://www.lcme.org/overview.htm. Accessed May 6, 2013. 2. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med. 2010;85(9 suppl):S26–S33. 3. Naritoku WY, Alexander CB, Bennett BD, et al. The pathology milestones and the next accreditation system. Arch Pathol Lab Med. 2014;138(3):307–315. 4. Accreditation Council for Graduate Medical Education. Milestones. http:// www.acgme-nas.org/milestones.html. Accessed May 6, 2013. 5. ACGME program requirements for graduate medical education in anatomic and clinical pathology, effective July 1, 2007 with revised common program requirements, effective July 1, 2011. http://www.acgme.org/acgmeweb/ tabid/142/ProgramandInstitutionalGuidelines/Hospital-BasedAccreditation/ Pathology.aspx. Accessed May 7, 2013. 6. Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at an academic medical center. Hum Pathol. 2012;43(5):629– 631. 7. Bellin E, Fletcher DD, Geberer N, Islam S, Srivastava N. Democratizing information creation from health care data for quality improvement, research, and education—the Montefiore Medical Center Experience. Acad Med. 2010; 85(8):1362–1368. 8. Powell S. Graduate Medical Education Committee residency orientation program survey, College of American Pathologists Graduate Medical Education Committee. Presentation at: Annual Association of Pathology Chairs/Program Directors Section Meeting; July 14, 2010; Seattle, WA. 9. Dreyfus SE, Dreyfus HL. A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. City, State: Publisher; 1980. Defense Technical Information Center document. 10. Pellegrino ED, Thomasma DC. The virtues in medical practice. N Engl J Med. 1994;331:280–281. 11. Smith CM. Origin and uses of primum non nocere—above all, do no harm! J Clin Pharmacol. 2005;45(4):371–377. 12. Riley W, Davis SE, Miller KK, McCullough M. A model for developing high reliability teams. J Nurs Manag. 2010;18(5):556–563. doi:10.1111/j.1365–2834. 2010.01121.x.
Submissions Now Accepted for CAP ’14 Abstract Program Abstract and case study submissions are now being accepted for the College of American Pathologists (CAP) 2014 meeting, which will be held September 7th through the 10th in Chicago, Ill. Submissions for the CAP ’14 Abstract Program will be accepted from:
Monday, January 13, 2014 through Friday, March 14, 2014 Accepted submissions will be published as a Web-only supplement to the September 2014 issue of the Archives of Pathology & Laboratory Medicine and will be posted on the Archives Web site. Visit the CAP ’14 Web site at www.cap.org/cap14 to access the abstract submission site and additional abstract program information as it becomes available.
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Context.—The Liaison Committee on Medical Education began an initiative to change medical education across the United States in the early 2000s. With the explosion in medical science knowledge, the need arose to teach selected fundamental information both in a contextual and in an active learning manner. Objective.—To identify ways to address gaps in training and knowledge that became apparent following implementation of learner-centered teaching methods, with devotion of more time to Internet-based learning and less emphasis on face-to-face lecture time. There was a dramatic departure from or de-emphasis of many traditional courses, such as embryology, gross anatomy, microscopic anatomy, and pathology, to the integration of these sciences into system-based active learning courses. This change in medical school curricula produces a medical graduate who hopefully thinks differently but
certainly lacks subject-specific knowledge for a variety of medical specialties. Data Sources.—Pathology residency programs have developed ‘‘boot camps’’ for the initial months of residency training both to provide the necessary foundation of pathology-specific medical science and to introduce basic skills and processes required for practice of anatomic pathology and laboratory medicine. The College of American Pathologists Graduate Medical Education Committee sent a questionnaire out on the Program Directors Section Listserv; the results are discussed and 3 boot camp programs are described. Conclusions.—Boot camps have 2 purposes: (1) to teach or strengthen knowledge required to practice pathology and (2) to introduce basic skills and processes that will be used during the practitioner’s career. (Arch Pathol Lab Med. 2014;138:316–321; doi: 10.5858/ arpa.2013-0356-SA)
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of a system rather than as isolated individual facts. With the use of an active learning process, the hope is that the student will not only retain more information but learn to think in a systematic way and develop lifelong learning processes. The Liaison Committee on Medical Education accredits postsecondary education leading to the MD degree in the United States and Canada, and it is recognized by the US Department of Education in this role.1 Various reports have recommended changes in medical education in the United States, which has essentially remained unchanged during the 20th century.2 With access to the World Wide Web, and the manner in which current medical students learn, the Liaison Committee on Medical Education offered recommendations to change medical education to fit the needs of the new learner and to use many of the new technologies available. As early as the start of the 1990s, first-year medical students were instructed to purchase laptop computers rather than microscopes. Many medical schools began to replace glass slides to teach histology and pathology with 35-mm color slides, which were eventually replaced by PowerPoint presentations in multidisciplinary laboratories, and computers with LCD projectors eventually replaced multiheaded teaching microscopes. Many medical students now review gross and microscopic pathology images downloaded from their medical school’s server, and currently some schools have virtual slides with whole
dvances in medical sciences during the past few decades have made it virtually impossible for medical students to acquire a strong fundamental knowledge of all biomedical sciences, to assimilate the individual sciences into an understanding of normal system physiology and pathophysiology and then apply that integrated knowledge into clinical practice. Thus all medical specialties are faced with the challenge of supplementing medical school education with specialty-specific needs. This challenge in medical school education has resulted in the requirement for contextual learning, where scientific facts from many biomedical sciences are integrated and taught in the context Accepted for publication August 12, 2013. From the Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles (Dr Naritoku); the Department of Laboratory Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York (Dr Vasovic); the Department of Pathology, Albert Einstein College of Medicine, Bronx, New York (Drs Steinberg and Prystowsky); and the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Dr Powell). The authors have no relevant financial interest in the products or companies described in this article. Reprints: Wesley Y. Naritoku, MD, PhD, Department of Pathology, Keck School of Medicine of the University of Southern California, 1200 N State St, Clinic Tower Room A7A119, Los Angeles, CA 90033 (e-mail: [email protected]). 316 Arch Pathol Lab Med—Vol 138, March 2014
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slide digital scanning technology. Some incoming pathology residents have never touched a microscope before, and seek instruction on the proper use of microscopes. Learnercentered teaching methods and team-based learning methods have been implemented, wherein the instructor and students assemble in small groups and the students are placed in the role of teacher, so that the students actively learn the subject through the process of problem solving and, occasionally, in a team-based manner. At the same time, the Liaison Committee on Medical Education recommended that medical schools significantly decrease the lecture hall learning time and replace the lecture time with independent study online. Medical schools have reduced or eliminated many lectures from subjects that were traditionally taught in the first and second years of medical school, such as embryology, gross anatomy, microscopic anatomy (histology), and pathology. As a result of this curriculum change, the experience of basic medical education has become quite variable. In another article3 in this issue of the ARCHIVES, the Accreditation Council for Graduate Medical Education pathology milestones are described, and a visit to the Accreditation Council for Graduate Medical Education Web site provides the expectations of the Pathology Milestones Working Group of what knowledge, skills and attitudes are expected of an incoming level 1 resident.4 Among many other things, it is expected that undergraduate medical education will equip the incoming resident to recognize normal anatomy and histology. The ability to assess tissues in this way is reflected in 3 of the 27 milestones: (1) patient care 3 milestone: interpretation and diagnosis; (2) patient care 4 milestone: reporting; (3) patient care 5 milestone: surgical pathology grossing. Without a solid working knowledge of gross and microscopic anatomy, the pathology resident cannot progress to level 2 or further in these 3 critical milestones. Some medical schools are now providing senior electives to allow medical students to focus studies on these fundamentals prior to graduation; in some schools, these offerings occur after a student has selected a specialty through the National Resident Matching Program. However, that practice is not common, and therefore, many pathology residency programs across the United States have developed ‘‘boot camps’’ during orientation programs at the beginning of residency to provide pathology-specific medical science knowledge building upon the knowledge acquired in medical school, and to introduce basic skills and processes required for practice of anatomic pathology [AP] and laboratory medicine. Three programs present ideas illustrating several different methods for providing pathology-specific knowledge and processes to ease the transition from medical school to pathology residency. ANATOMIC PATHOLOGY AP Boot Camps at the Los Angeles County þ University of Southern California Medical Center and The Methodist Hospital Rationale.—Provide first-year (postgraduate year [PGY] 1) residents with the necessary foundation in gross and microscopic anatomy to enhance efficiency and effectiveness on surgical pathology rotations and to develop confidence in developing pathology-specific skills for PGY1 pathology residents. Curricula designed in these programs are monitored with continuous discussion with residents to enable the programs to modify the boot camp to meet PGY1 resident needs as they change and evolve. Arch Pathol Lab Med—Vol 138, March 2014
Didactic Sessions.—During the first 4-week rotation at institution 1 (Los Angeles County þ University of Southern California Medical Center, Los Angeles, California), all PGY1 residents are assigned to a single site, and morning lectures are given specifically for the PGY1 class, separate from the lectures and conferences given concomitantly to the PGY2 through PGY4 residents. At institution 2 (The Methodist Hospital, Houston, Texas), these didactic sessions extend over a longer period of time (10 weeks, including limited clinical pathology [CP] introductory lectures), and all residents (PGY1–4) attend. Initial lectures include general topics such as safety; medicolegal introduction, including requirements for autopsy permission and protocols for tissue procurement for research activities; institutional review board requirements and credentialing for research; navigating the electronic health record; using the histology and frozen section laboratories; histotechniques (including various fixative types and their use, tissue processing, and sectioning); histochemistry and immunohistochemistry; and on-call procedures (AP and CP). Following the introductory sessions at institution 2, 1 to 2 hours of daily lectures organized by organ system are provided for 4 to 8 additional weeks. When appropriate, learning goals and objectives for lectures are provided to the residents on lecture handouts. Pretest and posttests are given just before the lecture and following the lecture to document progress (institution 1). As an example, pretest and posttest results for the ‘‘Introduction to Histotechniques’’ lecture are shown in the Figure. With the advent of the pathology milestones effective July 2014, pretests and posttests such as these may be a very valuable metric.4 Residents are taught normal histology at multiheaded microscopic sessions that are intended for PGY1 residents alone, although more senior residents do attend. At institution 2, this opportunity for learning is daily for the first 6 months of the year. This histology review is given for all major organ systems, except for eye and central nervous system, and may include mixed cases for variety and review of previously presented materials. Gross Dissection Skills Development Program.—On the very first day of residency, PGY1 resident orientation includes providing either recommendations for surgical pathology textbooks, or textbooks themselves at institution 2. The residency manual (goals and objectives of all rotations—required and elective, AP and CP) and procedures manuals (including grossing skills for AP and CP call manuals) are provided. Tours of the histology, frozen section, and core laboratories are given. A team approach is used for mentoring developing skills at all levels and in all areas of pathology; however, specifically for surgical and autopsy pathology, the PGY1 resident is paired with a more senior resident or fellow. At institution 1, there are 3 teams of 2, with Day 1 on the gross bench and Day 2 to preview slides and sign-out biopsies, then preview large surgical specimens to sign out on Day 3. In addition on Day 3, the resident team may have an autopsy; PGY1 residents will observe the first autopsy with minimal participation. During subsequent autopsies, the PGY1 resident is expected to participate fully in all 7 components of the autopsy.5 For 2013–2014, PGY1 residents will graduate to an alternating gross bench-sign out schedule on the second week, with the third team fully dedicated to autopsy during the second week. The third and fourth weeks, the team on autopsy will rotate back into the alternating gross bench-sign out schedule, and 1 of the teams on surgical pathology will Boot Camp—Naritoku et al 317
The results of pretest (blue) and posttest (red) on the ‘‘Introduction to Histotechniques’’ lecture for 26 residents (designated by letters) who had the boot camp experience at the Los Angeles County and University of Southern California Medical Center, Los Angeles, California. Letters A through Z represent individual PGY1 residents.
rotate onto the autopsy service. This change was implemented based on resident feedback to improve acclimation to an alternating gross bench-sign out schedule. At institution 2, each PGY1 resident is also assigned to the surgical cutting bench with a pathologists’ assistant for 1 week shoulder-to-shoulder to develop observational skills, understand and use the language of gross description, and learn appropriate and safe knife skills. Templates are not available on computer at the gross bench, but a grossing manual is always available for reference at each grossing bay with the pathologists’ assistant. A textbook on gross dissection techniques is issued to each resident at the beginning of the PGY1 year. Each PGY1 resident is required to complete a form indicating successful completion under direct supervision of the first 3 specimens of each type (as required by the Accreditation Council for Graduate Medical Education). Faculty, upper-level residents, and fellows may sign off (institution 1) and pathologists’ assistants are also given this responsibility (institution 2). During the orientation period at institution 2, all PGY1 residents are expected to view at least 1 autopsy for which they are paired with another resident. Following this observation, they will be expected to participate as a second resident on subsequent cases, where they will participate in all 7 components of the autopsy. Microscopic Skills Development Program.—When reviewing histologic slides in the first 8 weeks, PGY1 residents are paired with an upper-level resident or surgical pathology fellow at institution 2. An example pairing: Day 1, gross bench for routine large specimens or frozen section; Day 2, slide review and sign-out; Day 3, completion of signout and float for all other AP duties. During the first 2 318 Arch Pathol Lab Med—Vol 138, March 2014
weeks, PGY1 residents are given example surgical pathology reports for reference for gross and microscopic descriptions that are expected on both autopsy and surgical pathology reports. Under the supervision of the paired upper-level resident or surgical pathology fellow, PGY1 residents are given the opportunity to gradually dictate microscopic descriptions determined appropriate to their developing skills. By the end of the first 10 weeks of residency, the PGY1 resident is expected to be able to craft basic surgical pathology reports and to begin to craft synoptic reports independently. Resident Call Manual.—A residency manual with all rotation goals and objectives and an on-call manual created and reviewed annually by the chief residents are given to all PGY1 residents and incoming fellows on the first day in their respective programs at institution 2. Annual program evaluations contain a single question regarding orientation, but the question is focused on the institutional orientation program, and not the departmental orientation program. Rotation Evaluations.—Residents are provided the opportunity to evaluate anonymously their training at the end of each rotation through an online evaluation system, and annually through the annual pathology resident retreat (institution 1) and online annual survey (institution 2). From the resident retreats, the comments included: ‘‘Good experience for first years;’’ ‘‘The residents unanimously liked this experience;’’ ‘‘The residents unanimously felt that this rotation is a positive experience . . . The residents also believe the rotation provides a good basis for beginning pathology residency. Tied to this, [the] lectures are noted to be comprehensive and that they provide practical information necessary to functioning and adapting quickly to Boot Camp—Naritoku et al
Learning Goals and Objectives for the First Days in Surgical Pathology (Los Angeles County and University of Southern California Medical Center, Los Angeles, California) Goals for first grossing day: 1. Review protective gear worn for grossing in surgical specimens 2. Know where the specimen containers are placed before and after grossing 3. Know how to perform patient specimen identification; where on the requisition form important information is found 4. Know how to use the dictation system 5. Know how to gross biopsies using ‘‘swish and pour’’ and ‘‘one use, then set aside forceps for cleaning’’ techniques to diminish the likelihood of floaters 6. Who to ask for help while grossing (check previous day’s OR schedule to identify what type of specimens to expect to cut in, read Lester and the surgical pathology SOP manual on how to dissect the specimen. Follow the procedure described in the SOP manual). If you have a specimen that you’ve never cut in, get help: surgical pathology faculty members, selective (surgical) pathology fellows, and senior residents Goals for first sign-out day: 1. Know the schedule of the sign-out day 2. Where and when to get your slides 3. What to write on the worksheet (what your attending expects you to tell them) 4. What to do with the coding sheet (FS correlation, CPT code, match code) 5. What needs to be looked up before signing out with the attending (eg, previous path slides, frozen sections, history on Affinity, pertinent laboratory values for liver and germ cell tumors, pertinent radiology for CNS, bone, and oral tumors) 6. How to look up physicians’ pagers to inform them of a diagnosis 7. How to order histology, histochemical stains, immunohistochemical stains, FISH HER2/neu, KRAS, PNET/Ewing sarcoma panel, 1p19q for oligodendrogliomas 8. How to keep track of pending studies (notebook system, or ‘‘scut sheet’’) Abbreviations: CNS, central nervous system; CPT, Current Procedural Terminology; FISH, fluorescence in situ hybridization; FS, frozen section; OR, operating room; PNET, primitive neuroectodermal tumor; SOP, standard operating procedure.
residency.’’ A resident suggested the concept of the boot camp; the curriculum was developed by the program director and faculty; another resident provided the learning goals in the Table; and with anonymous input from program evaluations, the residents have been key in providing suggestions to improve the rotation. CP Boot Camp at the Montefiore/Einstein Residency Program (Bronx, New York) Rationale.—The CP boot camp is designed to teach incoming residents the basic principles used in providing high-quality laboratory services. These principles, when taught during the first 3 months of the residency program, can then be applied and strengthened during the remainder of the training program. Learning Environment.—Montefiore Medical Center is an integrated health care delivery system and a pioneer Accountable Care Organization with greater than 50% of its patients in coordinated capitated care. Montefiore Medical Center consists of 4 hospitals (~1500 beds), a primary care network, and specialty faculty practices delivering primary, Arch Pathol Lab Med—Vol 138, March 2014
specialty, and home care to a diverse population in the Bronx and southern Westchester County, New York (~2.7 million outpatient visits per year). Pathology services are provided through a service line.6,7 Residency Program and AP and CP Boot Camp.— Postgraduate year 1 residents take the AP boot camp during the first 2 months and CP boot camp during the third month of residency training. The boot camp emphasizes basic skills and a mindset allowing residents to appreciate the importance of their opportunity and responsibility to provide treating clinicians both advice in test selection and reports that synthesize the clinical laboratory data. Training is both didactic and experiential, including laboratory management, quality assurance, problem solving, and communication skills preparing the resident to function as a laboratory director. The CP boot camp rotation aims to provide basic principles of CP with an introduction to the major laboratory services. These principles are then applied to in-depth rotations during the remainder of the residency, enabling trainees to build strong laboratory practices. The introductory program of study is structured to include didactic lectures, College of American Pathologists (CAP) initial team member training, laboratory management– related project, CP call review meeting (biweekly), and training in Clinical Looking Glass. The didactic lectures/seminars include the major rotations with the perspectives of the faculty laboratory directors, including their knowledge base and approach to the specialty, while pointing out potential pitfalls that earlystage residents commonly experience. We require residents to become CAP Laboratory Inspection Initial Team Members, which allows them to work with experienced laboratorians, skilled experts trained in the area they are inspecting with knowledge of checklist procedures (a central feature of patient safety). This training is supplemented with residents participating as mock inspectors on the service they are presently assigned to; this experience enables some residents to participate in a real team for CAP inspections at other institutions. The presentation of a laboratory management–related project generated by each division, with ongoing quality assurance projects, provides the resident with hands-on experience. The projects are completed within 2 weeks under the director’s supervision. These quality assurance projects are composed as reports, discussed by the division, and prepared for PowerPoint presentation to the residency community as a coordinated session with all residents presenting to the faculty in one session. Presentations are recorded and critiqued to teach and improve resident presentation skills. All presentations are included in the residents’ Accreditation Council for Graduate Medical Education–required portfolio. Residents are involved in consultative activities answering CP on-call questions that are discussed with a rotating attending physician. They maintain a CP call log database detailing clinical question, discussion, test approvals with a follow-up on test results, and a frequently asked questions database outlining current policies with references to consensus protocols, recommendations, and literature. Typically, a designated faculty member will review with the on-call residents and other attending residents the cases that have been logged into the on-call database. These communications and rule-rich discussions are the treasures Boot Camp—Naritoku et al 319
of medical decision making. Residents (and faculty) at all levels of training find these sessions priceless. Clinical Looking Glass is a unique Montefiore clinical information data mining tool designed to assist patient care coordination across the care system and to time-effectively organize large databases and produce opportunities to improve patient care, improve financial performance, and create advances in clinical practice. Clinical Looking Glass encourages physicians to use data to drive continuous quality improvement, leading to better patient care and outcomes.6 Training our residents to use Clinical Looking Glass was introduced to teach our residents to use data to produce information and to question protocols for test use and clinical practice. The ability to use data and add value to health care systems is an important role for pathologists in team-based medical practice. Assessment/Evaluations.—Competencies were evaluated upon conclusion of the sequence within the course curriculum. All PGY1 residents completed Boot Camp posttest/evaluations, CAP Initial Team Member posttest, and CP project presentation. An anonymous survey of the residents regarding their experience of the boot camp in improving basic knowledge and skill indicated positive feedback. Our early assessments include a CP Boot Camp residents’ focus group (n ¼ 5 responses). In general, most residents thought the CP Boot Camp was well planned and useful, especially for residents who have had little CP involvement prior to their first rotation. This feedback has enabled our educators to develop clearer learning objectives for each lecture and guided the use of a standard format for each lecture, providing the appropriate amount of basic information and process that the resident can build upon during training. Hands-on projects have been shown to be much more useful than a lecture-only format in showing residents how to manage clinical issues in CP. Many residents also realized that they needed more expertise in the art of presentation. All residents completed the CAP initial team member training course and achieved a passing score on the posttest. American Society for Clinical Pathology Resident In-Service Examination scores and CP board pass rates will be monitored for improvement. Review of the CAP Graduate Medical Education Committee Survey of Program Directors on Orientation Programs (Boot Camps) A few years ago, the CAP Graduate Medical Education Committee was allowed to use the Association of Pathology Chairs and Program Directors Section Listserv to offer a survey on orientation programs. Of the potential respondents, 57 program directors indicated that they did have a program and completed the survey (approximately 40% response rate).8 The majority of residency programs represented (almost 75%) had between 9 and 24 residents in their programs but responses included small (1–8 residents) and very large programs as well. Surgical pathology volumes at the institutions represented ranged from fewer than 10 000 specimens (2%) annually up to more than 100 000 specimens annually (3%) with approximately even volumes between 10 000 and 20 000, 20 000 and 50 000, and 50 000 and 100 000 (29%, 37%, and 29%, respectively). Sixty-eight percent of the programs 320 Arch Pathol Lab Med—Vol 138, March 2014
indicated that 95% of their residents trained in both AP and CP. The majority of training program directors indicated that their orientation program had been in existence for at least 5 years, and almost half (43%) had done such a program for more than 8 years. The average length of the program was 4 weeks (46%) but programs ranged from less than 1 week to 12 weeks and from 8 to more than 80 contact hours (61% 8– 40 hours). In terms of impact on performance, those programs whose orientation program was 5 or more weeks reported a greater impact on the performance of the PGY1 residents, and results were similar for those with more than 20 versus less than 20 contact hours (ie, time matters). Methods of education used were primarily didactic lecture series and hands-on learning, with simulation videos and prescribed reading also included. A one-to-one interaction with senior residents was the most helpful method (handson learning). The individuals teaching included senior residents, faculty, and pathology assistants, with very limited education provided by histology managers, laboratory managers, medical technologists, or information technology staff (none at all or less than 4 hours total). Eighty-one percent of respondents indicated that the program included AP and CP topics, 16% AP-only topics, and 3% CP-only topics. The most common topics included in orientation/introductory curriculums were call responsibilities, AP (96%); computer systems (93%); specimen handling and acceptability requirements (93%); call responsibilities, CP (91%); patient confidentiality (89%); grossing (88%); use of surgical pathology templates, guidelines, grossing manual, checklist, etc. (88%); and autopsy/medical examiner issues (81%). The most common explanations provided for how resident performance has changed as a result of the orientation/introductory program included decreased learning curve/better preparation for specific pathology rotations (17%), increased understanding of basic processes/procedures (14%), easier transition from medical school to residency (14%), improved communication and teamwork (12%), and increased resident confidence (10%). However, very few of the programs have implemented metrics to assess the performance of the residents; 5% give pretests, 9% give posttests, and the majority (59%) have not implemented any sort of formal assessment. Overall, program directors report a wide variety of approaches and length of time dedicated to orientation of new residents. Although metrics are not used by the majority of those responding, the gestalt of these introductory programs’ impact on performance was highly rated by 92% of respondents, with only 7% indicating that there had been no perceived performance impact or only very limited performance impact. CONCLUSIONS All residency training programs are obligated to transition fledgling graduates of medical schools to competent practitioners in a relatively brief time period. Though this typically takes 3 to 6 years to achieve competency, the initial transition phase from student and predominant observer in medical school to active caregiver within our hospitals and clinics is daunting. The need to assimilate the novice, who has completed the beginner stage by medical school graduation,9 into a competent member of a highly reliable team member in the shortest time period requires not only Boot Camp—Naritoku et al
extensive oversight, but also rapid learning of prioritized, triaged tools of survival—both for patients and for the young physician. To accomplish this, an intense period of practical study (phronesis; ‘‘The key virtue in a physician’s character is phronesis, or prudence . . .’’ 10) is instituted in many specialties, with the goal of primum non nocere11— first, do no harm. Patient safety is the centerpiece driving these transitional intense courses of pragmatic learning. We use boot camps in this vein of patient safety for assimilation of newly graduated doctors into long-standing, highly reliable teams12 where medically accepted patterns of behavior and rendering care in providing entrustable professional activities are clearly and structurally delineated, as demonstrated by the Dreyfus and Dreyfus model of professional development.9 What further makes this transitional educational model important and powerful is the coupling of these do/don’t rules of engagement with active problem solving sessions from on-call episodes. This combination of pragmatic classroom interchange and dialogue; real-life, real-time instances of practice; and ultimate reflective review sessions of what went right or wrong serves as a powerful tool of educating and remembering individually, by the team, and by the community of practitioners. Boot camps are highly successful, transparent educational models that result in wellremembered lessons and low likelihood of practitioner error in those areas that are covered. With the institution of the milestones project, assessing residents for baseline performance and the defining of expectations of what undergraduate medical education has provided to incoming pathology residents, programs will likely need to create metrics to assess the value and impact of these programs on the performance of incoming residents.
The authors would like to acknowledge the contributions of the members of the College of American Pathologists Graduate Medical Education Committee, who developed and synthesized the results of the Graduate Medical Education Committee Residency Orientation Program Survey: Sterling T. Bennett, MD, MS; Noel Anderson Brownlee, MD, PhD; Jimmy R. Clark, MD; Kristin Johnson, PhD; Ronald B. Lepoff, MD; Christopher N. Otis, MD; Suzanne Zein-Eldin Powell, MD; Romualdo V. Talento II, MD, MPH; J. Allan Tucker, MD; and Michael L. Talbert, MD. References 1. Liaison Committee on Medical Education. Overview: accreditation and the LCME. http://www.lcme.org/overview.htm. Accessed May 6, 2013. 2. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med. 2010;85(9 suppl):S26–S33. 3. Naritoku WY, Alexander CB, Bennett BD, et al. The pathology milestones and the next accreditation system. Arch Pathol Lab Med. 2014;138(3):307–315. 4. Accreditation Council for Graduate Medical Education. Milestones. http:// www.acgme-nas.org/milestones.html. Accessed May 6, 2013. 5. ACGME program requirements for graduate medical education in anatomic and clinical pathology, effective July 1, 2007 with revised common program requirements, effective July 1, 2011. http://www.acgme.org/acgmeweb/ tabid/142/ProgramandInstitutionalGuidelines/Hospital-BasedAccreditation/ Pathology.aspx. Accessed May 7, 2013. 6. Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at an academic medical center. Hum Pathol. 2012;43(5):629– 631. 7. Bellin E, Fletcher DD, Geberer N, Islam S, Srivastava N. Democratizing information creation from health care data for quality improvement, research, and education—the Montefiore Medical Center Experience. Acad Med. 2010; 85(8):1362–1368. 8. Powell S. Graduate Medical Education Committee residency orientation program survey, College of American Pathologists Graduate Medical Education Committee. Presentation at: Annual Association of Pathology Chairs/Program Directors Section Meeting; July 14, 2010; Seattle, WA. 9. Dreyfus SE, Dreyfus HL. A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. City, State: Publisher; 1980. Defense Technical Information Center document. 10. Pellegrino ED, Thomasma DC. The virtues in medical practice. N Engl J Med. 1994;331:280–281. 11. Smith CM. Origin and uses of primum non nocere—above all, do no harm! J Clin Pharmacol. 2005;45(4):371–377. 12. Riley W, Davis SE, Miller KK, McCullough M. A model for developing high reliability teams. J Nurs Manag. 2010;18(5):556–563. doi:10.1111/j.1365–2834. 2010.01121.x.
Submissions Now Accepted for CAP ’14 Abstract Program Abstract and case study submissions are now being accepted for the College of American Pathologists (CAP) 2014 meeting, which will be held September 7th through the 10th in Chicago, Ill. Submissions for the CAP ’14 Abstract Program will be accepted from:
Monday, January 13, 2014 through Friday, March 14, 2014 Accepted submissions will be published as a Web-only supplement to the September 2014 issue of the Archives of Pathology & Laboratory Medicine and will be posted on the Archives Web site. Visit the CAP ’14 Web site at www.cap.org/cap14 to access the abstract submission site and additional abstract program information as it becomes available.
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