Human Pathology (2014) xx, xxx–xxx
www.elsevier.com/locate/humpath
Education in pathology
Pathology residency training: time for a new paradigm Ronald E. Domen MD a,⁎, Jennifer Baccon MD, PhD b a
Department of Pathology and Laboratory Medicine, Division of Clinical Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA 17033 b Department of Pathology and Laboratory Medicine, Divisions of Anatomic Pathology and Experimental Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA 17033 Received 7 January 2014; revised 18 February 2014; accepted 28 February 2014
Keywords: Residency training; Medical education; Pathology training; Pathology fellowship training; Maintenance of certification; Pathology resident training
Summary The exponential growth of the field of pathology over the past several decades has created challenges for residency training programs. These challenges include the ability to train competent pathologists in 4 years, an increased demand for fellowship training, and the structuring and completion of maintenance of certification. The authors feel that pathology residency training has reached a critical point and that a new paradigm for training is required. © 2014 Elsevier Inc. All rights reserved.
1. Historical overview Over the past 150 years, the discipline of pathology has progressively redefined itself to keep in step with changes in technology, research, diagnosis, and disease treatment. In its infancy, pathology was the study of “morbid anatomy,” but as bacteriology, physiology, and then clinical physiology, became specialty areas under the umbrella of pathology, the scope of the field continued to expand and the skills of its practitioners along with it. The ability to define, “What is pathology?” and how best to train pathologists have not been fully answered in 150 years. Indeed, in 1850, it was written: “In pathology, so complicated and various are the conditions attendant on the individual forms of disease, and their relations with idiosyncrasy, temporary condition and external agency, with organic lesions and ⁎ Corresponding author. Department of Pathology, H160, Penn State Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033. E-mail address: [email protected] (R. E. Domen). http://dx.doi.org/10.1016/j.humpath.2014.02.026 0046-8177/© 2014 Elsevier Inc. All rights reserved.
functional disturbances, that few of the most experienced pathologists can be said to understand their whole science, or to be always competent to its successful application” [1 482].
This concept has not changed. More recently in 1971, Townsend et al [2 456 and 459] stated: “The rapid expansion of medical knowledge, the changing trends in health care, and the demand for increased professional competence are primary conditions which have created an urgent need for advanced educational programs of high quality in pathology… Physicians preparing for academic careers really require more than 4 years of educational experience to become competent in clinical and anatomic pathology. In the authors' experience, they need six years.”
Finally, Gorstein and Weinstein [3 1] stated in 2001: “Remarkable scientific advances have broadened the potential scope of practice and have made mastery of the entire body of pathology information an impossibility.”
2 The reality we face in pathology is that the body of knowledge is ever-increasing and we are at a point where it would require superhuman effort for any one person to master all areas of anatomical (AP) and clinical pathology (CP). In 1900, the American Medical Association established their Section on Pathology and Physiology [4]. Over the ensuing decades, this section helped to define the scope of pathology as well as the educational requirements for the field. Physiology, as it related to pathology, began to morph into clinical physiology, and its relationship to disease diagnosis and treatment was better defined. The oversight, quality, and regulation of clinical laboratories were problematical in the pre–World War II era and became an important issue as more hospitals and physicians increasingly relied on accurate laboratory test information for patient care [4-8]. Pathologists became the logical choice to assume oversight of the growing numbers of hospital and state-run clinical laboratories. In his 1924 address, the Chair of the Section detailed the “minimum necessary training for one who would be reliable in the general diagnosis of tissues” [9 79] Basically, graduation from medical school, preferably some hospital experience, followed by 2 (or better, 3 years) of “special study under a good pathologist in a laboratory where there is plenty of material” [9 79]. With the growth of pathology as a distinct specialty within the practice of medicine in the early decades of the 20th century, “clinical pathologists” performed AP duties and, in addition, increasingly established and directed hospital clinical laboratories [10,11]. In 1936, the American Board of Pathology was formed, and the educational requirements to sit for the examination were defined [12]. After an initial “phase-in” period, the requirements in 1938 were as follows: completion of a clinical internship, 1 year of training in CP, 2 years of training in pathologic anatomy, and 1 year of additional training in pathology or practice in pathology. In addition, the board defined the areas of CP and AP that are familiar to us today [12]. The challenges that pathology faces in relation to the exponential growth of knowledge in the field are not unique within medicine. Similar problems arise in both undergraduate medical education and other graduate medical education training programs. We are truly beginning to see that there are limits to what we can expect to teach individuals in the course of their apprenticeship to become a physician. If we continue to extend years of training in order to accommodate the ever-growing archive of relevant information within our currently defined field, we run the risk of dissuading promising pathologists of the future. Beyond the scope of material to be learned, there are some who speak of the “seventh competency” that comprises problem-solving and decision making skills—that is, critical thinking—that, to date, our educational process and programs have yet to adequately incorporate into our training programs. Learning how to think critically about new information (and how to apply it) needs to be a cornerstone of future residency and fellowship training.
R. E. Domen, J. Baccon
2. The current state and the role of fellowships Despite the recognition by generations of pathologists that obtaining competence in a field as large and as varied as pathology and being able to practice as a generalist pathologist is a lofty and all too often an impracticable goal, we continue to teach both CP and AP as if they are inseparable pieces of the whole. The educational requirements for pathology residency have changed little since 1936. The clinical internship year was phased out, and 2 years each for CP and AP was codified. A fifth year was added in the 1980s (ideally, this year was to be a “clinical” year of training), but because this year was ultimately defined, it essentially became a fifth year of pathology training—essentially extending AP/CP training or providing a year of research—rather than a return to a clinical year. The fifth year was subsequently eliminated in 2002, so that now we remain at a 2-plus-2 training paradigm of CP and AP. Ever-increasing numbers of graduating residents now opt for 1 and sometimes 2 or more fellowships [13,14]. The reasons for pursuing a fellowship are varied, but generally, they are sought because academic or private practice groups see the benefit of having competency and depth of expertise in certain subspecialty areas (eg, cytopathology, hematopathology, transfusion medicine, etc), and graduates appreciate the logic of focusing their expertise in a more narrowly defined area of pathology. Another reason graduates pursue fellowships is that both they and their future employers realize that the current way we train pathologists is falling short of the goal to train competent practitioners in 4 years in a 2-plus-2 combined training program. However, one apparent side effect of multiple fellowships is emerging: overqualification for jobs. Often, when an open position requires a particular area of expertise, candidates with fellowship training in that specific area plus an additional fellowship are sometimes not seriously considered. In this scenario, we could assume that practice groups do not want to hire someone who will be unhappy because they will not have adequate opportunity to use all of their fellowship skills. Another aspect related to training that has impacted the practice of pathology is the new requirements related to maintenance of certification (MOC). Maintaining competency in the broad field of combined AP and CP repeatedly for 10-year periods has proven a challenge. In both private practice and academic settings, a pathologist is unlikely to maintain competency in the broad fields of both AP and CP because their practice, by necessity, becomes subspecialized in a minimal or select number of areas. A “one size fits all” in MOC becomes problematical when one's practice for the prior 10 years has been virtually within a single subspecialty such as surgical pathology, or blood banking/transfusion medicine, or dermatopathology, and where the initial training has been a combined AP and CP program followed by 1 or 2 years of fellowship to focus one's scope of practice. Where is the logic of training a generalist in AP and CP when those
Pathology residency training skills are not likely to persist or to be needed when recertification in 10 years becomes necessary? We acknowledge that the development of the MOC process in Pathology is in its infancy, and we commend the American Board of Pathology as it continues to struggle to find the best approach to assess ongoing competency in the numerous practice patterns and knowledge areas that currently exist in the scope of pathology practice today. The MOC and training programs of the future will ideally synergize and focus on the same set of goals.
3. Recommendations for redefining pathology residency training Several articles have been published over the past couple of decades lamenting the fact that graduates of combined AP and CP residency programs are not adequately prepared to enter the practice of pathology, particularly private practice [15-19]. This realization helped to fuel the morphing of the reintroduction of a clinical year in the 1980s, allowing residents to structure a fifth year of pathology training in place of a truly clinical, direct patient care experience. Calls for reform in pathology education have been voiced for at least 30 years [20,21]. However, the primary stakeholders in this issue—the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the American Board of Pathology (ABP), the Association of Pathology Chairs, other professional organizations, and private practice interests—have not been able to agree on how best to effect the needed changes. We feel strongly that reform in our pathology training programs is badly needed and has reached a critical point for the specialty. Few concrete suggestions have been made within our profession, and we feel that for pathology to maintain its identity in the patient care environment and to meet the growing demands of MOC, technological advancement, and subspecialty expertise, we must come together in a concerted effort to effect the necessary essential changes. The most consistent recommendation for redefining pathology training over recent decades has been the suggestion that the first phase (1-3 years) of training be devoted to a core composed of AP and CP training followed by 2 to 3 years of concentrated training in AP or CP, with or without additional training in a subspecialty area. It should be noted that in surveys of community pathologists, the only consistent skill requirement was for young graduates to have knowledge of clinical medicine and be able to use the laboratory to solve clinical problems (except for the blood bank where greater depth of knowledge was felt to be important) [16]. Other important areas in CP included the following: consultation, testing strategies, and test interpretation; administrative oversight; inspection and accreditation oversight; and transfusion and coagulation testing expertise [16]. In essence, in-depth knowledge in blood banking/
3 transfusion medicine (including coagulation), laboratory management, clinical consultation and communication skills, inspection and accreditation knowledge and skills, and laboratory medicine problem solving (critical thinking) are the most important attributes for the clinical pathologist in the private practice setting. These skills are no less important for the anatomical pathologist and could be incorporated into both AP- and CP-only training tracks as well as into other “fast track” or “focus-track” options. So, why are trainees still being required to memorize obscure microbiology organisms and culture reactions, chemistry trivia, rare neuropathology findings, and so on, for high stakes certifying examinations of the ABP (including future MOC examinations)? Such attention to minutiae might contain some logic in a CP-only or AP-only program, but it is difficult to support for the average combined AP/CP training program. Likewise, the CP-only pathologist who limits their practice to the subspecialty area of microbiology, for example, should not be expected to take the same type of MOC examination in CP as someone who subspecializes in hematology. The same logic would be true for the AP/CPtrained pathologist whose practice for the past 10 years has been limited to cytopathology and perhaps some general CP administration. Some American Board of Medical Specialties specialty boards have addressed the varying practice characteristics of its board-certified physicians by offering tailored MOC examinations based on an individual's practice profile while also allowing the diplomate to also retain their general or primary certification (eg, see the American Board of Radiology's MOC program). The training of the pathologist of the future will require, in our opinion, a tailored approach that is more responsive to, and more reflective of, the ever-changing role of the field. It is time that we, as a profession, recognize the whole field of pathology as multiple free-standing and unique parts and to structure our training programs accordingly. We propose 1 year of combined AP and CP training to provide a broad overview of the field with an opportunity to learn the basics of surgical and autopsy pathology, and laboratory management and informatics. For the AP-only or CP-only residents who know upfront that they will be practicing only AP or CP, this year could be structured in an 8 months/4 months format in order to allow concentration in either AP or laboratory medicine (CP). After this initial year, the resident would then spend the next 2 years in either AP or laboratory medicine per their preference and future practice goals. After these 3 years, the resident will be eligible to sit for the AP or the CP (laboratory medicine) board examination, depending on which area their last 2 years was spent. Fellowship training would remain the same as currently structured. Such a program would provide a minimum of 30 months of training in AP or CP (assuming the first year is 6 months each of AP and CP) as compared with the current 18 to 24 months each of AP and CP in the combined AP/CP training format. For residents who know from the onset that they want AP- or CP-only, then the first year could be structured to allow
4 up to 8 or 9 months in AP or CP. We propose this structure in lieu of the current 36 months for AP-only or CP-only because of the often-stated perception that the fields of AP and CP have something to teach each other, and for the truly undecided resident, this first year would offer an opportunity to peruse the field. It will be anticipated that residents will opt for a fourth year of fellowship training to complement their AP- or CPonly training. All trainees in AP or CP would be expected to be competent in such areas as laboratory administration and management, basic informatics, consultation, and accreditation. Thus, the AP-only pathologist in a smaller private practice would have the basic competencies to manage a clinical laboratory. In essence, our proposal recognizes that expecting residency graduates to be knowledgeable in the entire field of AP and CP and also be ready for private practice and to maintain this broad knowledge base over the MOC timeline is not realistic. We anticipate that one of the biggest adjustments in our proposal will need to occur in the private practice of pathology. Private practice groups may need to either hire greater numbers of CP-only pathologists to oversee the clinical laboratories or certain sections of the laboratory (eg, transfusion medicine) or hire AP-only graduates who have also completed subspecialty training in an appropriate fellowship (eg, microbiology, clinical informatics, hematology, or molecular pathology). By separating the fields of AP and CP, we also feel that a more realistic MOC program can be established, including one that can be tailored to the practice characteristics of the individual pathologist. For example, the MOC of an AP-only pathologist whose practice is 90% cytopathology might be heavily weighted toward assessing cytopathology competency and skills and only minimal amounts of surgical pathology, laboratory administration, consultation, and accreditation. The ABP may want to consider changing the name of the basic certification to “General Pathology— Anatomic Track” and “General Pathology—Clinical Track,” or something similar. In addition, there are other themes that have emerged in the national discussion of residency program structure, including inclusion of a preliminary year, creation of a “fast-track” research–focused option to train more physician-scientists, as well as other potential fast-track options in either emerging/ increasing areas of need (eg, molecular pathology, clinical informatics, quality improvement) or for those residents who simply want to focus their training in a particular subspecialty area of AP or laboratory medicine. It will be productive in ongoing discussions to consider these components and how they can relate to customizable training programs.
4. Conclusions For more than a century, the field of pathology has internally struggled to maintain the many parts that make up
R. E. Domen, J. Baccon our specialty. Now is the time to give serious consideration to how best to redefine the way we train our residents so that they are best prepared to enter the practice of pathology and to achieve meaningful MOC. Because of the number of stakeholders that would be affected by our proposal, we suggest that a task force of representatives from the key organizations (ABP, Accreditation Council for Graduate Medical Education, Association of Pathology Chairs, College of American Pathologists (CAP), American Society for Clinical Pathologists (ASCP), etc) be formed to produce a white paper addressing a new paradigm for pathology residency training and MOC (including the possible incorporation of clinical rotations in the curriculum). The represented organizations would agree up-front to adopt and implement the recommendations of the task force within a reasonable amount of time after the publication of the white paper.
Acknowledgment The authors would like to thank Fred Gorstein, MD, for critically reviewing the manuscript and providing helpful suggestions and comments and for providing a copy of Ref. [20].
References [1] Bigelow J, Channing W, Ware J, et al. Practical views on medical education. Boston Med Surg J 1850;42:481-4. [2] Townsend JF, Van Peenen HJ, Senhauser DA, Lucas FV. The education of physicians for specialties in laboratory medicine. J Med Educ 1971;46:456-60. [3] Gorstein F, Weinstein RS. Rethinking pathology residency training and education. HUM PATHOL 2001;32:1-3. [4] Bierring WL. The need of medical cooperation in laboratory work. JAMA 1907;49:289-90. [5] Christian HA. Certain phases of recent work in pathology and physiology. JAMA 1906;47:549-50. [6] Henderson Y. Clinical physiology—an opportunity and a duty. JAMA 1911;57:857-9. [7] Kolmer JA. State licensure applied to laboratories. JAMA 1922;79: 861-3. [8] Moore JJ. Standardization of clinical laboratories. JAMA 1922;79:863-7. [9] Lynch KM. The specialist in pathologic anatomy. JAMA 1924;83: 79-81. [10] Sanford AH. The role of the clinical pathologist. JAMA 1930;95: 1465-7. [11] Alter NM. The function of the full time pathologist in hospitals. JAMA 1934;103:1189-92. [12] Approved examining boards in medical specialties. JAMA 1940;115: 726-51. [13] Wells A, Smith BR, Sacks DB. The challenge of training pathologists in the 21st century. HUM PATHOL 2006;37:932-3. [14] Lagwinski N, Hunt JL. Fellowship trends of pathology residents. Arch Pathol Lab Med 2009;133:1431-6. [15] Horowitz RE. The successful community hospital pathologist—what it takes. HUM PATHOL 1998;29:211-4. [16] Horowitz RE. Expectations and essentials for the community practice of pathology. HUM PATHOL 2006;37:969-73.
Pathology residency training [17] Otis CN. Residency training in anatomic pathology: looking forward in the 21st century. HUM PATHOL 2006;37:929-31. [18] Kass ME, Crawford JM, Bennett B, et al. Adequacy of pathology residency training for employment: a survey report from the future of pathology task group. Arch Pathol Lab Med 2007;131:545-55. [19] Talbert ML, Ashwood ER, Brownlee NA, et al. Resident preparation for practice: a white paper from the College of American Pathologists
5 and Association of Pathology Chairs. Arch Pathol Lab Med 2009;133: 1139-47. [20] Association of Pathology Chairs. Park City report on combined AP/CP residency training. October 1, 1988. [21] Burke MD, Lundberg GD, Nuzzo J, Hill RB. Special report: ASCP Colorado Springs conference: the future content and structure of residency training in pathology. Am J Clin Path 1990;93:706-11.
www.elsevier.com/locate/humpath
Education in pathology
Pathology residency training: time for a new paradigm Ronald E. Domen MD a,⁎, Jennifer Baccon MD, PhD b a
Department of Pathology and Laboratory Medicine, Division of Clinical Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA 17033 b Department of Pathology and Laboratory Medicine, Divisions of Anatomic Pathology and Experimental Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA 17033 Received 7 January 2014; revised 18 February 2014; accepted 28 February 2014
Keywords: Residency training; Medical education; Pathology training; Pathology fellowship training; Maintenance of certification; Pathology resident training
Summary The exponential growth of the field of pathology over the past several decades has created challenges for residency training programs. These challenges include the ability to train competent pathologists in 4 years, an increased demand for fellowship training, and the structuring and completion of maintenance of certification. The authors feel that pathology residency training has reached a critical point and that a new paradigm for training is required. © 2014 Elsevier Inc. All rights reserved.
1. Historical overview Over the past 150 years, the discipline of pathology has progressively redefined itself to keep in step with changes in technology, research, diagnosis, and disease treatment. In its infancy, pathology was the study of “morbid anatomy,” but as bacteriology, physiology, and then clinical physiology, became specialty areas under the umbrella of pathology, the scope of the field continued to expand and the skills of its practitioners along with it. The ability to define, “What is pathology?” and how best to train pathologists have not been fully answered in 150 years. Indeed, in 1850, it was written: “In pathology, so complicated and various are the conditions attendant on the individual forms of disease, and their relations with idiosyncrasy, temporary condition and external agency, with organic lesions and ⁎ Corresponding author. Department of Pathology, H160, Penn State Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033. E-mail address: [email protected] (R. E. Domen). http://dx.doi.org/10.1016/j.humpath.2014.02.026 0046-8177/© 2014 Elsevier Inc. All rights reserved.
functional disturbances, that few of the most experienced pathologists can be said to understand their whole science, or to be always competent to its successful application” [1 482].
This concept has not changed. More recently in 1971, Townsend et al [2 456 and 459] stated: “The rapid expansion of medical knowledge, the changing trends in health care, and the demand for increased professional competence are primary conditions which have created an urgent need for advanced educational programs of high quality in pathology… Physicians preparing for academic careers really require more than 4 years of educational experience to become competent in clinical and anatomic pathology. In the authors' experience, they need six years.”
Finally, Gorstein and Weinstein [3 1] stated in 2001: “Remarkable scientific advances have broadened the potential scope of practice and have made mastery of the entire body of pathology information an impossibility.”
2 The reality we face in pathology is that the body of knowledge is ever-increasing and we are at a point where it would require superhuman effort for any one person to master all areas of anatomical (AP) and clinical pathology (CP). In 1900, the American Medical Association established their Section on Pathology and Physiology [4]. Over the ensuing decades, this section helped to define the scope of pathology as well as the educational requirements for the field. Physiology, as it related to pathology, began to morph into clinical physiology, and its relationship to disease diagnosis and treatment was better defined. The oversight, quality, and regulation of clinical laboratories were problematical in the pre–World War II era and became an important issue as more hospitals and physicians increasingly relied on accurate laboratory test information for patient care [4-8]. Pathologists became the logical choice to assume oversight of the growing numbers of hospital and state-run clinical laboratories. In his 1924 address, the Chair of the Section detailed the “minimum necessary training for one who would be reliable in the general diagnosis of tissues” [9 79] Basically, graduation from medical school, preferably some hospital experience, followed by 2 (or better, 3 years) of “special study under a good pathologist in a laboratory where there is plenty of material” [9 79]. With the growth of pathology as a distinct specialty within the practice of medicine in the early decades of the 20th century, “clinical pathologists” performed AP duties and, in addition, increasingly established and directed hospital clinical laboratories [10,11]. In 1936, the American Board of Pathology was formed, and the educational requirements to sit for the examination were defined [12]. After an initial “phase-in” period, the requirements in 1938 were as follows: completion of a clinical internship, 1 year of training in CP, 2 years of training in pathologic anatomy, and 1 year of additional training in pathology or practice in pathology. In addition, the board defined the areas of CP and AP that are familiar to us today [12]. The challenges that pathology faces in relation to the exponential growth of knowledge in the field are not unique within medicine. Similar problems arise in both undergraduate medical education and other graduate medical education training programs. We are truly beginning to see that there are limits to what we can expect to teach individuals in the course of their apprenticeship to become a physician. If we continue to extend years of training in order to accommodate the ever-growing archive of relevant information within our currently defined field, we run the risk of dissuading promising pathologists of the future. Beyond the scope of material to be learned, there are some who speak of the “seventh competency” that comprises problem-solving and decision making skills—that is, critical thinking—that, to date, our educational process and programs have yet to adequately incorporate into our training programs. Learning how to think critically about new information (and how to apply it) needs to be a cornerstone of future residency and fellowship training.
R. E. Domen, J. Baccon
2. The current state and the role of fellowships Despite the recognition by generations of pathologists that obtaining competence in a field as large and as varied as pathology and being able to practice as a generalist pathologist is a lofty and all too often an impracticable goal, we continue to teach both CP and AP as if they are inseparable pieces of the whole. The educational requirements for pathology residency have changed little since 1936. The clinical internship year was phased out, and 2 years each for CP and AP was codified. A fifth year was added in the 1980s (ideally, this year was to be a “clinical” year of training), but because this year was ultimately defined, it essentially became a fifth year of pathology training—essentially extending AP/CP training or providing a year of research—rather than a return to a clinical year. The fifth year was subsequently eliminated in 2002, so that now we remain at a 2-plus-2 training paradigm of CP and AP. Ever-increasing numbers of graduating residents now opt for 1 and sometimes 2 or more fellowships [13,14]. The reasons for pursuing a fellowship are varied, but generally, they are sought because academic or private practice groups see the benefit of having competency and depth of expertise in certain subspecialty areas (eg, cytopathology, hematopathology, transfusion medicine, etc), and graduates appreciate the logic of focusing their expertise in a more narrowly defined area of pathology. Another reason graduates pursue fellowships is that both they and their future employers realize that the current way we train pathologists is falling short of the goal to train competent practitioners in 4 years in a 2-plus-2 combined training program. However, one apparent side effect of multiple fellowships is emerging: overqualification for jobs. Often, when an open position requires a particular area of expertise, candidates with fellowship training in that specific area plus an additional fellowship are sometimes not seriously considered. In this scenario, we could assume that practice groups do not want to hire someone who will be unhappy because they will not have adequate opportunity to use all of their fellowship skills. Another aspect related to training that has impacted the practice of pathology is the new requirements related to maintenance of certification (MOC). Maintaining competency in the broad field of combined AP and CP repeatedly for 10-year periods has proven a challenge. In both private practice and academic settings, a pathologist is unlikely to maintain competency in the broad fields of both AP and CP because their practice, by necessity, becomes subspecialized in a minimal or select number of areas. A “one size fits all” in MOC becomes problematical when one's practice for the prior 10 years has been virtually within a single subspecialty such as surgical pathology, or blood banking/transfusion medicine, or dermatopathology, and where the initial training has been a combined AP and CP program followed by 1 or 2 years of fellowship to focus one's scope of practice. Where is the logic of training a generalist in AP and CP when those
Pathology residency training skills are not likely to persist or to be needed when recertification in 10 years becomes necessary? We acknowledge that the development of the MOC process in Pathology is in its infancy, and we commend the American Board of Pathology as it continues to struggle to find the best approach to assess ongoing competency in the numerous practice patterns and knowledge areas that currently exist in the scope of pathology practice today. The MOC and training programs of the future will ideally synergize and focus on the same set of goals.
3. Recommendations for redefining pathology residency training Several articles have been published over the past couple of decades lamenting the fact that graduates of combined AP and CP residency programs are not adequately prepared to enter the practice of pathology, particularly private practice [15-19]. This realization helped to fuel the morphing of the reintroduction of a clinical year in the 1980s, allowing residents to structure a fifth year of pathology training in place of a truly clinical, direct patient care experience. Calls for reform in pathology education have been voiced for at least 30 years [20,21]. However, the primary stakeholders in this issue—the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the American Board of Pathology (ABP), the Association of Pathology Chairs, other professional organizations, and private practice interests—have not been able to agree on how best to effect the needed changes. We feel strongly that reform in our pathology training programs is badly needed and has reached a critical point for the specialty. Few concrete suggestions have been made within our profession, and we feel that for pathology to maintain its identity in the patient care environment and to meet the growing demands of MOC, technological advancement, and subspecialty expertise, we must come together in a concerted effort to effect the necessary essential changes. The most consistent recommendation for redefining pathology training over recent decades has been the suggestion that the first phase (1-3 years) of training be devoted to a core composed of AP and CP training followed by 2 to 3 years of concentrated training in AP or CP, with or without additional training in a subspecialty area. It should be noted that in surveys of community pathologists, the only consistent skill requirement was for young graduates to have knowledge of clinical medicine and be able to use the laboratory to solve clinical problems (except for the blood bank where greater depth of knowledge was felt to be important) [16]. Other important areas in CP included the following: consultation, testing strategies, and test interpretation; administrative oversight; inspection and accreditation oversight; and transfusion and coagulation testing expertise [16]. In essence, in-depth knowledge in blood banking/
3 transfusion medicine (including coagulation), laboratory management, clinical consultation and communication skills, inspection and accreditation knowledge and skills, and laboratory medicine problem solving (critical thinking) are the most important attributes for the clinical pathologist in the private practice setting. These skills are no less important for the anatomical pathologist and could be incorporated into both AP- and CP-only training tracks as well as into other “fast track” or “focus-track” options. So, why are trainees still being required to memorize obscure microbiology organisms and culture reactions, chemistry trivia, rare neuropathology findings, and so on, for high stakes certifying examinations of the ABP (including future MOC examinations)? Such attention to minutiae might contain some logic in a CP-only or AP-only program, but it is difficult to support for the average combined AP/CP training program. Likewise, the CP-only pathologist who limits their practice to the subspecialty area of microbiology, for example, should not be expected to take the same type of MOC examination in CP as someone who subspecializes in hematology. The same logic would be true for the AP/CPtrained pathologist whose practice for the past 10 years has been limited to cytopathology and perhaps some general CP administration. Some American Board of Medical Specialties specialty boards have addressed the varying practice characteristics of its board-certified physicians by offering tailored MOC examinations based on an individual's practice profile while also allowing the diplomate to also retain their general or primary certification (eg, see the American Board of Radiology's MOC program). The training of the pathologist of the future will require, in our opinion, a tailored approach that is more responsive to, and more reflective of, the ever-changing role of the field. It is time that we, as a profession, recognize the whole field of pathology as multiple free-standing and unique parts and to structure our training programs accordingly. We propose 1 year of combined AP and CP training to provide a broad overview of the field with an opportunity to learn the basics of surgical and autopsy pathology, and laboratory management and informatics. For the AP-only or CP-only residents who know upfront that they will be practicing only AP or CP, this year could be structured in an 8 months/4 months format in order to allow concentration in either AP or laboratory medicine (CP). After this initial year, the resident would then spend the next 2 years in either AP or laboratory medicine per their preference and future practice goals. After these 3 years, the resident will be eligible to sit for the AP or the CP (laboratory medicine) board examination, depending on which area their last 2 years was spent. Fellowship training would remain the same as currently structured. Such a program would provide a minimum of 30 months of training in AP or CP (assuming the first year is 6 months each of AP and CP) as compared with the current 18 to 24 months each of AP and CP in the combined AP/CP training format. For residents who know from the onset that they want AP- or CP-only, then the first year could be structured to allow
4 up to 8 or 9 months in AP or CP. We propose this structure in lieu of the current 36 months for AP-only or CP-only because of the often-stated perception that the fields of AP and CP have something to teach each other, and for the truly undecided resident, this first year would offer an opportunity to peruse the field. It will be anticipated that residents will opt for a fourth year of fellowship training to complement their AP- or CPonly training. All trainees in AP or CP would be expected to be competent in such areas as laboratory administration and management, basic informatics, consultation, and accreditation. Thus, the AP-only pathologist in a smaller private practice would have the basic competencies to manage a clinical laboratory. In essence, our proposal recognizes that expecting residency graduates to be knowledgeable in the entire field of AP and CP and also be ready for private practice and to maintain this broad knowledge base over the MOC timeline is not realistic. We anticipate that one of the biggest adjustments in our proposal will need to occur in the private practice of pathology. Private practice groups may need to either hire greater numbers of CP-only pathologists to oversee the clinical laboratories or certain sections of the laboratory (eg, transfusion medicine) or hire AP-only graduates who have also completed subspecialty training in an appropriate fellowship (eg, microbiology, clinical informatics, hematology, or molecular pathology). By separating the fields of AP and CP, we also feel that a more realistic MOC program can be established, including one that can be tailored to the practice characteristics of the individual pathologist. For example, the MOC of an AP-only pathologist whose practice is 90% cytopathology might be heavily weighted toward assessing cytopathology competency and skills and only minimal amounts of surgical pathology, laboratory administration, consultation, and accreditation. The ABP may want to consider changing the name of the basic certification to “General Pathology— Anatomic Track” and “General Pathology—Clinical Track,” or something similar. In addition, there are other themes that have emerged in the national discussion of residency program structure, including inclusion of a preliminary year, creation of a “fast-track” research–focused option to train more physician-scientists, as well as other potential fast-track options in either emerging/ increasing areas of need (eg, molecular pathology, clinical informatics, quality improvement) or for those residents who simply want to focus their training in a particular subspecialty area of AP or laboratory medicine. It will be productive in ongoing discussions to consider these components and how they can relate to customizable training programs.
4. Conclusions For more than a century, the field of pathology has internally struggled to maintain the many parts that make up
R. E. Domen, J. Baccon our specialty. Now is the time to give serious consideration to how best to redefine the way we train our residents so that they are best prepared to enter the practice of pathology and to achieve meaningful MOC. Because of the number of stakeholders that would be affected by our proposal, we suggest that a task force of representatives from the key organizations (ABP, Accreditation Council for Graduate Medical Education, Association of Pathology Chairs, College of American Pathologists (CAP), American Society for Clinical Pathologists (ASCP), etc) be formed to produce a white paper addressing a new paradigm for pathology residency training and MOC (including the possible incorporation of clinical rotations in the curriculum). The represented organizations would agree up-front to adopt and implement the recommendations of the task force within a reasonable amount of time after the publication of the white paper.
Acknowledgment The authors would like to thank Fred Gorstein, MD, for critically reviewing the manuscript and providing helpful suggestions and comments and for providing a copy of Ref. [20].
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