Human Pathology (2017) 68, 34–39
www.elsevier.com/locate/humpath
Editorial
Passport to pathology: transforming the medical student pathology elective from a passive educational experience to an exciting, immersive clinical rotation 1. Introduction In the United States, third- and fourth-year medical students are exposed to a variety of rigorous clinical rotations ranging from 4 to 12 weeks in duration. Regardless of the specialty that a student ultimately plans to pursue, all medical students are required to take clinical rotations including surgery, medicine, pediatrics, obstetrics and gynecology, psychiatry, neurology, and outpatient/family practice. A student planning to specialize in psychiatry, for example, is not exempt from closing an incision in an operative case or from assisting in a laparoscopic procedure during a general surgery rotation. Conversely, a future cardiothoracic surgeon is not excused from evaluating patients with psychiatric disorders. Students enter medical school open to many possible avenues of study, and their rotation experiences often determine their career decisions [1]. Some specialties are at a significant advantage, as their rotations are graduation requirements, and they assign students definable, mandatory roles. For instance, at Harvard and Stanford, third- and fourth-year medical students must complete core rotations in internal medicine, neurology, obstetrics and gynecology, pediatrics, and surgery [2,3]. In addition, students at some institutions must complete rotations that are not typically required at other medical schools, such as radiology at Harvard. The attention afforded each specialty is in part intended to provide an opportunity for students to make informed decisions regarding career choices. It is also arguable that the breadth of exposure is necessary to ensure that all medical school graduates have at least an essential core knowledge of all aspects of the profession and—perhaps more important—that they also understand the roles played by other practitioners that they will encounter. After all, medicine is a team sport, with practitioners of many different specialties working together to provide the best care for their patients. http://dx.doi.org/10.1016/j.humpath.2017.08.031 0046-8177/© 2017 Elsevier Inc. All rights reserved.
Unfortunately, rotations in specialties like pathology are not generally required [4]. Given that medical schools are currently reluctant to allocate time to include pathology among their required rotations, pathology departments must focus on making the pathology elective experience more exciting and beneficial to attract potential rotators. Currently, nonmandatory rotations—if taken as electives—typically do not have standardized curricula. By contrast, internal medicine and surgery rotations have long-established, standardized curricula that guide students through the rotations and leave the majority satisfied with their learning experiences [5,6]. Sadly, when students do complete electives in pathology, they are often disappointed in the rotations, which tend to lack emphasis on skill building; consequently, they may choose to not pursue further study in the field [7]. In this article, we propose a standardization of the pathology clinical rotation curriculum, with the goal of elevating the pathology elective experience to the level of the required medical school clinical rotations. We include several components designed to increase student satisfaction with pathology rotations and heighten their interest in the field.
2. The current pathology rotation Before considering potential changes, it is worth describing what a present-day pathology elective often looks like for students. On the first day of a typical rotation, students arrive in the department, are given a short tour, and are assigned their own work areas, sometimes separated from the pathology residents. Each day, students might have an hour-long didactic session in which they sit at a microscope while a resident or fellow reviews the contents of a teaching slide set. Rotating students also typically attend morning sign-outs, where they similarly passively watch through the microscope as residents
Passport to Pathology Table
35
Recommendations for designing medical student pathology electives
• Deliver an introductory lecture or organize a case-based “scavenger hunt” that defines anatomic and clinical pathology and their role in clinical practice. • Assign a resident mentor for the clerkship. • Institute a “passport” case logbook that students must complete by the end of the elective. • Encourage the residents, pathology assistants, and attendings within the department to incorporate students into their daily practice. • Require students to rotate on both anatomic and clinical pathology services. • Require students to actively practice in the pathology frozen section and cutting rooms and cut in, preview, and sign out both benign and malignant cases. • Require students to work up and sign out cases and/or round on patients on a subset of clinical pathology services (eg, clinical chemistry, microbiology, hematopathology, or transfusion medicine). • Require students to attend and participate in multidisciplinary conferences to better understand the pathologist's role in the medical community. • Hold a midclerkship feedback session to assess students' progress. • Hold an exit session to review the key topics covered during the clerkship.
discuss patients with their attending physicians. During lunch, students might attend another didactic session or conference and then be left to their own devices for “independent time” during the afternoon before leaving early for home. The hypothetical scenario depicted above emphasizes the decreased ratio of active learning to passive learning in contemporary pathology rotations, which may contribute to students' lack of satisfaction [8]. Medical students' most fulfilling moments during medical school rotations occur when they actively engage with their clinical team and contribute to patient care, be it taking a history, placing a dressing, or irrigating a Foley catheter [9,10]. But unlike surgery and internal medicine—rotations that rely heavily on patient interactions—students in pathology rotations are often given few opportunities to autonomously engage with case material and present their findings to the team [11].
3. A proposal Given this state of affairs, we propose a paradigm shift in the education of students on their pathology rotations to promote active rather than passive learning, thereby promoting interest and knowledge acquisition [12]. The changes we propose would encourage active learning through integrative, case-based experiences through which students would be given supervised responsibilities for examining surgical specimens, evaluating slides, and analyzing laboratory data, thus building upon education standards promoted by other authors [4,13,14]. These changes would promote a wide range of interactive teaching opportunities involving residents, support staff, and attendings (Table). An ideal 1-month pathology rotation would include 2 weeks of anatomic pathology (AP) and 2 weeks of clinical pathology (CP) but offer the flexibility to accommodate specific student interests. At the outset of the rotation, third- and fourth-year medical students should be exposed to the fundamental aspects of and
differences between anatomic and clinical pathology. Although this information could be imparted by means of a passive didactic lecture, it would be better done as a medical “scavenger hunt” in which students are divided into small groups paired with a resident mentor, who would present a clinical case and then physically lead students through multiple areas of the department to collect data. For example, a case of a patient with colorectal cancer presenting with lower gastrointestinal bleeding would see students go from the hematology laboratory to collect data on red blood cell parameters, to the clinical chemistry laboratory to review hemolysis laboratory results, to the blood bank to type and screen the patient, to the microbiology laboratory to follow up on blood cultures, to the frozen section or cutting room to evaluate a biopsy or resection specimen, to the molecular laboratory for microsatellite instability and BRAF testing, and ultimately to the morgue for an autopsy discussion and wrap-up session. After such an orienting exercise, students would pair with their resident mentors to coordinate their schedules for the rotation. In the case of anatomic pathology, this work would consist of cutting in gross specimens and previewing slides. For clinical pathology, it would consist of working up clinical chemistry, microbiology, hematology, or molecular pathology cases, or seeing patients on the transfusion medicine service. With respect to anatomic pathology, as students gain experience, they should be encouraged to physically cut in their own cases under direct resident, pathology assistant, or attending supervision [15]. This recommendation is critical because medical students rotating on pathology often do not “gross-in” specimens, an unacceptable situation that epitomizes the passive learning environment of current pathology rotations. On the laboratory medicine services, students should interact regularly with clinical pathologists and trainees to discuss specimen processing, testing methodologies and applications, and the principles of laboratory management. Students should also be given graduated case previewing responsibilities on services that span the traditional anatomic and clinical pathology (AP/CP) designations, such as hematopathology and molecular pathology.
36 To formally codify this behavior and standardize pathology learning, students should receive a “passport to pathology,” that is, a rotation manual listing a set of skills to learn, gross specimens to evaluate, and anatomic and clinical pathology case types to preview by rotation's end, all of which should be completed under the tutelage of their mentors (Figure). Attending and resident physicians should all commit to helping students achieve the goals delineated in these rotation manuals. Just as we advocate for national standards in pathology education in the preclinical years, such “pathology passports” would standardize learning objectives for pathology clinical rotations [13]. Clearly, implementing and improving upon these standards will increase the complexity of the pathology workflow. However, the potential benefits—which include better medical student education, increased appeal to and attraction of future trainees, and fostering a future of betterinformed clinical colleagues—would more than justify the extra effort. Nevertheless, there must still be buy-in from stakeholders including medical school deans (for funding), department chairs, attendings, residents, and ancillary staff.
Editorial so that students could understand the surgical pathology workflow and witness the urgency of intraoperative diagnosis. This arrangement immensely benefits both parties. Students will General Meet with assigned resident mentor on a regular basis Attend required lectures and teaching sessions Attend multidisciplinary case conferences Attend mid-rotation feedback session Attend end-of-rotation wrap-up session General Surgical Pathology Skills Gross, fix, cut in, and preview at leas t four of the following benign specimens: Amputation Appendectomy Bowel resection Cholecystectomy Polypectomy Skin punch Splenectomy Thyroidectomy Tubal ligation Gross, fix, cut in, and preview at least four of the following malignant specimens: Colectomy Cystectomy Esophagectomy
4. Anatomic pathology
Gastrectomy Hepatectomy Hysterectomy and salpingo-oophorectomy
What behaviors should be explicitly codified? For the surgical pathology component of the rotation, students should first be introduced to the importance of safety and personal protective equipment use in the cutting and frozen section rooms. Then, prior to approaching specimens for the first time, students should review the pertinent section of a grossing manual and verbally discuss this information with their teachers at the bench. Their mentor, ideally a resident or pathology assistant, would then further explain the anatomy and physiology of the organ at hand while illustrating how to approach the dissection. Actively working in the pathology cutting room is important, as it allows students to spend time with unfixed organs, examining their external features, inner components, and connections to surrounding tissues in a way not possible in the preclinical cadaveric anatomy laboratory or any other clinical rotation. A student who has grossed-in total colectomy, hepatectomy, and Whipple specimens will never approach a living, breathing patient's abdominal examination the same way again. Their newfound anatomic knowledge will benefit their patients for the rest of their careers even if they do not pursue further training in pathology. Students should begin their cutting room experience with benign specimens, starting with straightforward cases such as appendectomies, cholecystectomies, and tubal ligations and later progressing to more complex cases such as benign hysterectomies, limb amputations, and explant lungs. Once students have demonstrated basic competency and safe practices with benign specimens, they should be provided the opportunity to work on malignant cases under direct resident supervision. These experiences would primarily take place in the cutting room but could begin in the frozen section room when possible
Orchiectomy Prostatectomy Pulmonary wedge resection or lobectomy Skin wide local excision Thyroidectomy Whipple Assist in two autopsy cases Attend two sessions in frozen section room General Clinical Pathology Skills Preview and sign out at least tw o of the following case types: Bone marrow aspirate, CSF, or peripheral blood flow cytometry Molecular pathology cases ( e.g., cytogenetics or next-generation sequencing) Serum or urine protein electrophoresis Other experiences Attend microbiology plate rounds Demonstrate knowledge of clinical chemistry analytic tests Round on patients on the tr ansfusion medicine service Pathology Knowledge Demonstrate knowledge of cancer staging Demonstrate familiarity with histolog y of the above-mentioned organ systems Demonstrate familiarity with histolog ic appearance of basic cancer types Present cases at attending sign-out Study for and pass mid- and end- of-rotation practical skills quizzes
Figure Example of a “passport” checklist for use by students on their rotations. The above “passport” is for illustrative purposes and likely contains more assignments than might reasonably be completed by a single student on a 4-week combined AP/CP rotation. These “passports” could be conceptualized as logbooks, tailored with spaces for the medical student to check off each case type (or other experience) completed; note the date, time, and location of each case; note the medical-record or pathology-accession number; and have it “signed off on” by a resident, pathology assistant, or attending. Individual clerkship directors should customize the type, number, and complexity of cases to meet the needs of their students and capabilities of their department.
Passport to Pathology learn more from hands-on experiences than they would by simply reading about those subjects in text books, and residents would improve their teaching skills while reinforcing their own knowledge of grossing. As an example, consider a hysterectomy and salpingectomy specimen from a patient with biopsy-proven, grade 1 endometrioid adenocarcinoma arriving in the frozen section room for intraoperative consultation. The resident should instruct the student in gynecologic anatomy in real time, orienting the specimen and pointing out the cervix, body, and fundus; the round ligament; the mesometrium, mesosalpinx, and mesovarium; the fallopian tube isthmus, ampulla, and infundibulum; and so forth. At the conclusion of the frozen section in the cutting room, the resident could reinforce these points and even explain clinical concepts such as the difference between version and flexion and the anatomy pertinent to the Pelvic Organ Prolapse Quantification System, which would aid students on their OB/GYN rotations [16]. Cutting in the specimen should then follow the “see one, do one” model [15]. The resident should ask the student to inspect the specimen and describe their approach to grossing it, supervise the student as he or she opens it, and demonstrate how to take sections for microscopy. The resident could take a section of the anterior cervix and lower uterine segment, leaving the posterior for the student to take under direct supervision. After finishing grossing, the resident should ask the student to read about pertinent staging guidelines, grading criteria, and histologic patterns they might see once the slides became available the following day, and then preview the slides with the student prior to sign-out with the attending, at which time the student should present the case. In addition to teaching students how to gross and preview surgical pathology cases, a successful pathology clinical rotation should train students in the practical application of cancer staging guidelines (eg, American Joint Committee on Cancer) [17]. Residents should discuss and physically demonstrate the application of staging guidelines when grossing and previewing with students. Further discussion should revolve around how a patient's medical history, radiology, and prior pathology drive the decisions pathologists make and that thoroughly understanding such information before cutting is essential for patient safety. Of note, although a gynecologic pathology case was used in the example above, a variety of case types representing “bread and butter” general surgical pathology practice would be equally appropriate. Subspecialty case exposure (eg, to neuropathology) could be supplemented based on interest and availability [18]. The anatomic pathology portion of the medical student rotation should also incorporate time in the autopsy suite. The postmortem experience is immensely valuable to students, with studies highlighting the benefits of correlating clinical outcomes and case histories with pathological features [19,20]. Students also overwhelmingly enjoy learning from gross specimens during the preclinical anatomy courses, and incorporation of time in the autopsy suite reinforces the anatomy taught during preclinical years [21]. Furthermore, the
37 autopsy suite offers students the unique experience of examining fresh rather than embalmed tissue, directly linking clinical symptoms with underlying pathologic findings. Indeed, several studies have documented student interest in incorporating autopsy into clinical medical education, a component currently lacking at most American medical schools [19]. To achieve maximum effectiveness, implementation of the ideas described above would also require a substantial component of resident education and training. Attendings and senior residents could work together to train and evaluate junior residents regarding their teaching skills and could grant increased responsibilities for medical student teaching as the residents progressed in their own skills. Ideally, this training could be formally codified as a “residents as teachers” program similar to “students as teachers” programs that combine teacher-skills training with hands-on teaching experiences [22].
5. Clinical pathology What behaviors should be explicitly codified for the clinical pathology portion of the rotation? The skills to be learned on this rotation are arguably more varied because of the wide breadth of the clinical pathology subspecialties. Using clinical chemistry as an example, students should be trained in all aspects of specimen processing, from start to finish. First, they should spend a half day with the hospital's phlebotomists to familiarize themselves with sample collection and transport. They should accompany samples to the clinical laboratory, where they could familiarize themselves with the analytical machinery, learning the practicalities (eg, turnaround times) and science behind sample processing. An ideal rotation would also have the residents talk the students through the common preanalytical, analytical, and postanalytical errors of which all clinicians should have knowledge. Additional active learning opportunities are afforded by the chance to preview, present, and sign out various clinical pathology laboratory-based case types (eg, bacterial and fungal unknowns, coagulation studies, flow cytometry, hemoglobin and serum protein electrophoresis, transfusion reaction workups) under the tutelage of physician mentors. Exposure to the hybrid AP/CP subspecialties such as hematopathology and molecular pathology, both of which emphasize the integration of traditional surgical pathology methods with ancillary techniques such as cytogenetics, flow cytometry, and nextgeneration sequencing, may be particularly useful for solidifying the notion of pathology as a remarkably diverse yet unified field of medicine. Exposure to molecular pathology in particular would help to introduce students to the concepts of personalized or “precision” medicine, which seeks to classify patients according to susceptibility to specific diseases or responses to particular therapies, so interventions can target only those individuals who would most benefit from them, investment in which has been heavily promoted by the federal government [23,24].
38 As before, this arrangement could benefit both students and residents. Students would gain interest and take away more knowledge from the rotation by participating in hands-on case management, and residents would reinforce their own knowledge while bolstering their teaching skills, which are unfortunately often underused in residency training.
Editorial Paras S. Minhas BS Department of Neurology and Neurological Sciences Stanford University School of Medicine, Palo Alto, CA 94305 Imarhia E. Enogieru BA Harvard Medical School, Boston, MA 02115 Richard N. Mitchell MD, PhD Department of Pathology Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115
6. Revitalizing the pathology rotation The ideal pathology rotation should encourage students to attend multidisciplinary conferences to experience the role of the pathologist within medicine. Students could also be required to present a case as an educational activity, expanding on an interesting or illustrative case that they saw during the rotation and bringing in the most recent pathobiology or diagnostic updates regarding some aspect of the case. In addition to regular informal daily feedback, attendings should host a midclerkship feedback session to assess student performance and review students' progress in learning the skills set forth in their rotation manuals. At the end of the pathology rotation, a review and summary session should be held, distilling key points from the clerkship as well as highlighting potential applications of the pathology skills and knowledge acquired to clerkships in other disciplines. The disconnect between students' current experiences and desired activities on their elective pathology rotations has implications far beyond merely increasing student interest in careers in pathology [4]. If the quality of pathology electives were improved and standardized to include more hands-on, active learning, then it is likely that more students would elect to take them. We acknowledge that an inherent challenge of our proposal is that it would be rather work intensive for residents and faculty, which in small departments may limit the number of times such an elective could be offered. Nonetheless, the improved educational opportunities for pathology residents and medical students alike may ultimately warrant the increased effort. More exposure to pathology would positively affect the way that future surgeons, internists, psychiatrists, and neurologists view the field of pathology and care for their patients. Too often, clinicians and surgeons send specimens to pathology without having any idea of what becomes of them after they leave the clinic or operating room. Never having seen the process themselves, they have no idea of the timeline for receiving, fixing, cutting, and processing a specimen, or of the turnaround time for ordering immunohistochemistry or other ancillary studies such as cytogenetics or genetic sequencing. A clinical curriculum with strong instruction in pathology would ensure appropriate use of pathology services by future clinicians, thereby benefitting patients everywhere.
Acknowledgment The authors would like to thank Jeffrey W. Craig, MD, PhD for his valuable comments and suggestions to improve the manuscript.
Douglas A. Mata MD, MPH Brigham Education Institute and Department of Pathology Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115 E-mail address:
[email protected] Web address: http://scholar.harvard.edu/dmata
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