Pathology Residency: Tips n’ Tricks

This is a slight deviation from the immigration timeline but none the less an important topic to discuss.

One of my awesome subscribers had asked for an article regarding tips on getting a Pathology Residency. I had to ponder this request for some time because I am biased in my training and opinion as I did not have much of a comparison between programs. I was not part of the match (I pre-matched when that was still in fashion), but I can certainly write about what I wish I had during my residency training and different formats of residency programs that I learned about from other pathologists and my elective rotations. Also, before I get into the tips n’ tricks, I will give a little background on my experience of getting into my former residency program and what I was looking to gain.

First, I defined goals for myself:

1.       PASSING THE BOARDS.

2.       Feel comfortable enough to sign out cases on my own.

3. Learning when to ask for in house help and when send for a consultation (knowing ones’ limits).

4.       Understanding the meaning of a diagnosis and what impact that has on a patient with respect to course of treatment (remember, they are not just tissue under glass), you have a major impact in morbidity and mortality.

5.       Picking a field to specialize in (I was, at the time, limited in my choices with restrictions from Canada).

When I was looking at my future residency position, I was a third- and fourth-year medical student. I spent my entire elective time in the Pathology Laboratory (approximately 6-8 weeks), and I involved myself in research with the then Program Director. I learned a lot about research (I had no prior experience) and the Program Director was incredibly supportive of residents working their cases up/entertaining differential diagnoses. Coming up with differentials and ordering immunohistochemical stains (even if they were the wrong stains) was supported and encouraged as you had the opportunity to learn from your mistakes. Lectures were common, including board review lectures and lectures involving “unknown” cases which were selected by the Chief residents (see more about “Unknown Conference” below).

I was verbally offered a position when I was in my third year of medical school for a residency spot beginning after graduation. I still entered the match as a backup but was then formally offered the position and pulled out of the match before I got to interview at other Pathology programs. At the time, this was a HUGE relief to not have to spend the money to fly around the country and go through the interview gauntlet. I was sure that what I had seen and observed as a medical student would translate to an excellent residency program to get me to my above listed goals.

LIFE HAPPENS

Unfortunately, the Program Director that I had worked with fell ill and had stepped down as the Program Director. He sadly died during my fourth year of medical school. The residency program pathologists shifted focus to a privatized company mindset (it was and still is an LLC) operating in a hospital, which meant education was no longer the primary focus. The staff pathologists are private pathologists working out of the hospital. As money moves the world, serving clients and turnaround time for a diagnoses became the primary goal of the residency program.

What I had initially observed compared to what I experienced in residency was vastly different. Lectures fell by the wayside and any that were given were extremely basic, not board oriented and redundant. Residents now had to either teach each other or teach themselves the information with variable guidance.

The meat and potatoes of a Pathology Residency:

When evaluating a residency program, the structure of that program is important. The main components are broken down below, but how the residency is put together (i.e. the 4 year schedule), matters.

THE GROSSING SCHEDULE:

One of the biggest draw backs was the next day turnaround time for processing a case and coming to a diagnosis. This aspect did not change from what I observed as a medical student Vs. residency; however, I did not understand its meaning until I was experiencing it for myself.

What does a “next day turnaround time” mean? For example, if you were grossing specimens on day 1, you were signing those cases out (rendering a diagnosis) on day 2 (unless it needed further work up with immunohistochemical staining, so that would be cases that would hang over for a few days until a diagnosis was rendered all the while accumulating more cases).

I have heard of programs where you could spend the day learning about your cases after grossing for a day, reading about tumors in text books, rendering your own diagnosis and then signing out on day 3 with the attending (my husband experienced a program like this).

My entire surgical pathology residency experience involved coming up with my diagnoses right at the microscope signing out with the attending and seeing the slides for the first time. By the time 4th year arrived, depending on which hospital I was rotating through, I was signing out my cases early the next morning after previous day of grossing specimens and attending would start signing out the cases about an hour after I began OR I would be signing out at the microscope with them.

A pathology residency program that has a three-day turnaround time (meaning you can proofread your gross dictations and have the time to study your cases) is a program that will make you extremely comfortable working up and signing out your cases once you graduate. These programs, from what I have heard are becoming less common and the model that I was trained in is becoming the norm.

Another issue with the scheduling is how many months you are slated for surgical pathology and how divided that time is with clinical pathology. In my residency program, we had approximately 18-20 months of surgical pathology rotations. The first two years were set up to be “cut heavy” so you could study for your boards in the third and fourth years. Residents would cut between 6-12 months straight of their first year. This schedule I found to be incredibly overwhelming. By the time you have hit your 4th year, you have forgotten much of your gross and histology as you were just getting into the groove of being a surgical pathology resident. Additionally, with a 2-day turnaround time, your mind was probably slippery due to tiredness (I only started to get a “Velcro brain” in 3rd year). If you do find that your program is a 2-day turnaround time, see if the schedule is balanced out where you have 3-4 months maximum of contiguous grossing with breaks with clinical pathology rotations. This way you have time to process that information and study. It is not a terrible thing to have some surgical grossing in your 4th year to keep your mind fresh but not so much as it can get overwhelmingly tiresome while trying to study for board exams.

As I did not do residency in a large academic center, I did not get exposure to quite a few different fields and in fact, most of what I examine histologically during my current practice, I have rarely or never seen during my residency (heart, medical lung and liver). I currently read a lot of kidney histology as well and was fortunate to have been taught by a very knowledgeable kidney pathologist. I also was not exposed to a lot of pediatric histology, even though there was plenty of fetal autopsies. The diagnoses of the pediatric histology was in retrospect, very basic and vague. Try to find a pathology residency program that will expose you to the most organs (large academic centers) or a program that has allows for you to be exposed to a variety of cases (transplant, dermatopathology, etc.). Thankfully, my program did send the residents to the Ackerman Clinic in New York, where my dreams of becoming a dermatopathologist and subsequently finding the cure for acne…died.

“UNKNOWN” CONFERENCES:

This is a HUGE help in learning how to approach a slide that you are given extremely limited information to work with. This does, for the most part, mimic real practice as typically the history from surgeons are written as “mass”.

Typically, the Chief resident will pick slides and you get very short history (e.g. “Mass in the lung”).  You get approximately one week to research your cases, come up with differential diagnoses, come up with a battery of immunohistochemical stains, consult your peers, learn about your differential, and discuss it orally during conference. The approach to a slide and learning about the different compartments of the specimen really helped me conceptually learn pathology and helped me in fellowship to teach myself how to read slides of organs that I had no or minimal experience in. The one unrealistic aspect of this conference was that you rarely or never got to see the gross images, got a clinical presentation or radiology findings (likely because it would give you a clue as to what you were looking for thereby making the learning experience less challenging).

REGULAR LECTURES:

I have heard of pathology programs where you go through all the chapters of Rosai every year. I cannot recall which residency program this was but I do remember finding that approach interesting and very directed. Look for a program that exposes you to the nuances and caveats of tumors during lectures. Eventually they do become redundant in different parts of the body with a few unique ones.

TIPS ON GETTING INTO A PATHOLOGY RESIDENCY:

I was in Medical school during the years where the United States Medical Licensure Examinations (USMLE) resulted in a three-digit score. Pathology does not require an incredibly high score but around 210 was what I heard was the minimal cut off (this does vary from program to program). I am aware that the USMLE’s have evolved beyond the three-digit score and I believe are progressing to a pass/fail model. So, the first tip is to PASS your boards however you are evaluated!

Face time and networking: I cannot emphasize this enough. As I stated before, I spent my entire electives of third and fourth year in the Pathology Department. When the department and the residents are comfortable with you, they are more likely to hire you as they are evaluating your attitude, team effort and intelligence. Do not forget the support staff! You will be interacting with the secretaries, janitors, histo-and cytology technicians and blood bank technicians during your residency program, so treat them with the same respect you would treat a physician or boss. They can make or break your nighttime sleep during call! I do include the janitors on that list because if your morgue happens to be elsewhere in the hospital like mine was, you will need them to get you in there if you are staying past “regular” work hours or conducting a late autopsy.

I have also noticed that thank you cards are on their way to extinction. I still kick it old school and as an attending, getting a thank you card fills my heart with joy. Do not underestimate the power of a fancy piece of paper and ink, it can really make an attending’s day knowing that they made an impact on you. I still give out thank you cards to my bosses, lawyers and coworkers who have helped me along my career path in the good times and especially during times of dire straits.

TEXTBOOKS THAT I FOUND USEFUL:

One thing that I found very overwhelming in pathology was what textbooks to read. There are too many to read them all, especially when every resident tells you a book is “the best” and “this is the one amazing book”. I struggled understanding why and I never received a particularly useful answer.

I recommend the following books and I will give you reasons why I found them useful (but remember, every person is different, this is what had worked for me):

ANATOMICAL PATHOLOGY

1.       The Practice of Surgical Pathology- Molavi

This book introduces you to the bread and butter (no, not pericardial fibrosis) of what you will commonly see in anatomical pathology. It is a very thin book so going through this book is very quick and has lots of pictures.

2.       Quick Reference Handbook for Surgical Pathologists-Natasha Rekhtman and Justin A. Bishop

This book I found to be especially useful in understanding and helping to memorize the stains that you and your pathologist will be using. Once you have a grasp of this book, you will be able to understand the patterns of stains used and why. This book aids in sorting out your differential diagnosis.

3.       Differential Diagnosis in Surgical Pathology-Gattuso et. al

I unfortunately did not discover this book until my 3rd year, but this book is Gold and should be read during your surgical pathology years. It has color images of the pathology (gross and histology) and breaks down the gross, histology and main points that makes that tumor unique. It also tells you what other tumors to consider as they may look similar. I used this book in conjunction with the American Society of Clinical Pathology (ASCP) lectures to supplement what I was reading.

4.       Surgical Pathology-Rosai and Ackerman or Sternberg (pick your camp, this is a style choice)

I ended up in the Rosai camp and I regretted it. Both books are your reference guides for more information and are especially useful for unknown conference. I read a chapter from both books to compare, but apparently in the Sternberg book, the dermatopathology chapter was not that great. Peruse each book to its entirety to see which style of reading you like better and how the books are “set up”. Are you someone who enjoys charts? Sternberg is heavy on them. If you like books with a lot of small font and texts, then Rosai is the book for you.  These books are expensive, choose wisely.

5.       Anatomic Pathology Board Review-Lefkowitch

With all that reading, do you really know your stuff? This book was extremely helpful for board review, both for the slide component and the written component. This book you should start using in your 2nd-4th years.

Cytology

1.       Cytology Diagnostic Principles and Clinical correlates-Cibas and Ducatman

2.       Practical Principles of Cytopathology-DeMay

3.       Cytology websites (there are many out there with libraries of slides with descriptors)

I really enjoyed the DeMay book because it had plates of cytology photographs that were high quality and a paragraph of the unique features to look for to distinguish that cytology from another. The Cibas had more practical information that you would see on your written portion of the boards.

Autopsy pathology

1.       Forensic Pathology Principles and Practice-Emma Lew, Evan Matsches

This book is a great read as it is a story book with cases and caveats, do’s and don’ts. This book was the fastest read that I had, and I read the book to its entirety (you can do this during your forensic rotation). This book is more than enough to pass the forensics portion of the boards. I still use this as one of my reference books in my current practice and during fellowship.

2.       Handbook of Pediatric Autopsy Pathology-Enid Gilbert-Barness et al.

This book teaches you the more “in depth” measurements required of a pediatric or fetal autopsy and gives you essential charts for average weights. This book is also full of the congenital anomalies that one likely has forgotten since the first year of medical school. I did not read this book cover to cover, but certainly select chapters to refresh my memory on interesting or difficult cases. It was mostly used for the weight charts.

CLINICAL PATHOLOGY:

I found the most useful books were the ASCP Clinical Compendium and the accompanying question book. Be sure to do the question book as it will help you apply your knowledge, especially in microbiology and blood bank.

Other books/resources that I perused and used but never read to their entirety:

1.       The World Health Organization (WHO) books are divided by organ systems, thus there are several volumes. I found these useful for the unknown conferences. Every entity that afflicts that organ will be found in that organ specific volume and redundancies can be found in common structures (like vascular and soft tissue tumors).

2.       John’s Hopkins Surgical Pathology Unknown conference (online and free)- lots of images to put into your mental library, especially cases that you do not see often.

Miscellaneous but important resources:

1.       The Resident In-Service Examination feed back

These questions are the most like the boards and expand on your knowledge and differentials from the answers that you see.

2.        The Washington Manual

Chalk full of information! This book is incredibly useful for the multiple-choice questions section of the boards. I found this book to be the most useful once you have the images burned into your brain. As there are no pictures in this book, it is most useful for learning the information as a final review rather than starting off with this book in first year. I still use this book in practice now if I do encounter a tumor; however, a more important resource as a forensic pathologist is a good surgical pathologist who sees tumors on a regular basis.

3.       Pathology outlines

This is an online library edited by pathologists and for pathologists. This website is to be used with extreme caution and only as a guideline. I do use this resource on occasion for descriptors and verbiage that is fading when describing tumors in my practice. This website I also found useful for unknown conferences as it did give differentials to entertain.

4.       Robbins Pathology

Surprisingly, this book is more useful in forensic pathology that I initially thought but I had to write this one down. If you are really at a loss, this is the book I started with and served as a backbone for the rest of the information. The baby Robbin’s is not quite equivalent to the Washington manual with respect to content, but by concept. It gives you the most salient information about the tumors and you can build more information on top of your knowledge once you have images burned into your brain.

The resources for pathology are vast and frankly overwhelming. Knowing your learning style is an essential part of your success in a residency program. I am sure many pathologists out there have their own favorite resources, but the above listed textbooks and resources got me to the next stages of my career.

Good luck and congratulations on making it to the next chapter!