Department of Pathology

Pathology's Revamped Residency Program

 Preparing Trainees to Practice 21st Century Medicine

Drs. Samer Khader, faculty mentor; Gloria Ramos-Rivera,
cytopathology fellow; Angela Baldwin, PGY-1; and Sophie Cameron, PGY-2

Angela Baldwin, MD, MPH, has long been interested in the field of pathology. “TV shows like CSI and House made it look really cool,” she smiles. Today, Dr. Baldwin -- a Stanford graduate and former Navy flight surgeon who holds an MD degree from Howard University Medical School and an MPH from University of California, Berkeley -- is a first-year pathology resident at Montefiore Einstein and an aspiring medical examiner. Click for feature story

Dr. Baldwin and her fellow first-years - Ridin Balakrishnan, MDMohammad Barouqa, MD; and Lin Wang, MD, PhD - entered the Montefiore Einstein pathology training program at an auspicious time. The four-year program is undergoing a makeover aimed at a longstanding problem in the field: Most pathology residents graduate without the solid grounding in the advanced practical skills they need to function effectively as professionals in the real world. TiffanyHebert
Dr. Tiffany M. Hébert, Associate Director, Anatomic Pathology Education.
They usually complete one or two fellowships before they can be considered job-ready.

“Pathology is different from other medical disciplines in that medical schools typically don’t expose students to the day-to-day responsibilities of a pathologist,” explains Tiffany Hébert, MD, associate program director for anatomic pathology education. “Our residents just get to observe rather than having opportunities to do the work.”

Employers, says Dr. Hébert, “lament that graduates who start out working for them aren’t prepared to meet the challenges and do what’s needed in practice.” And the graduates themselves? They’re eager to get on with their lives, she says, and are frustrated by the prospect of deferring their dreams of a career in medicine for another five to six years. 

Rising to the Challenge

Dr. Michael B. Prystowsky, right, Pathology Chair,
with Dr. Jacob J. Steinberg, Residency Program Director.

“Pathology is an endlessly challenging, rewarding area of medicine,” says Michael Prystowsky, MD, PhD, professor and University Chair of Pathology. “We pathologists play a unique and essential role in research and clinical practice across all medical disciplines.” Yet, he notes, the traditional training model discourages many medical students from choosing pathology as a career path -- and is a major reason for the looming nationwide shortage of pathologists.

Dr. Prystowsky is determined to change all that. In 2013, he and Jacob Steinberg, MD, residency program director, set about revising and updating Montefiore Einstein’s pathology residency curriculum to reflect the demands of today’s ever-changing healthcare environment. An environment in which pathologists, who have traditionally worked behind the scenes, are increasingly called upon to collaborate with clinicians -- and, in some cases, patients -- as integral members of the healthcare team.

View Video of Dr. Prystowsky: Residency Program Overview 


View Video of Dr. Steinberg: Montefiore Einstein Mission  

Drs. Prystowsky and Steinberg invited Dr. Hébert, an anatomic and gynecologic pathologist and a 2007 graduate of the Montefiore Einstein residency program, and James Faix, PhD, director of Montefiore’s Clinical Chemistry Laboratory, to work with them to develop a revised curriculum designed to: 1) reduce the time required for pathology residents to enter practice and, 2) better equip graduates to work in a community healthcare or academic setting.
Dr. Adam M. Cole, Associate Director, Clinical Pathology Education.

The revamped curriculum launched in 2016, making the current group of second-year residents the first to cycle through the new program.

Today, Dr. Hébert works with Adam Cole, MD, director of Montefiore’s Clinical Laboratory and associate program director for clinical pathology education, to oversee and implement the new curriculum. Dr. Cole is a 2008 Einstein graduate; he completed both his residency and fellowship training at Montefiore Einstein.

“Our goal is to have our residents leave the program with the confidence and adaptability to function independently and effectively,” says Dr. Hébert.

New Curriculum Design

The revised curriculum includes the following components: 

Onboarding. A computer-based study program focused on basic principles of pathology. Consists of a series of questions and materials that provide baseline information on issues such as quality control and quality assurance. Trainees receive the study program one month prior to their arrival at Montefiore. In addition, they receive practical information to help them acclimate to their new environment, including tips on housing, transportation and enjoying life in New York City.

Boot camp. A month-long orientation held in July. Features lectures and hands-on laboratory sessions led by senior teaching faculty assisted by chief residents. The teaching service, which continues until the end of September, consists of 12-14 core faculty devoted exclusively to teaching residents. Each trainee is paired with one or two faculty members.

Third year. Trainees begin to integrate the foundational knowledge they have acquired, applying all diagnostic pathology -- both anatomic and clinical – along with clinical information, to making a diagnosis.

Fourth year. Trainees demonstrate that they can assimilate the knowledge they have gained and function at a more advanced level, similar to a fellow or junior attending. They have the opportunity to hone their skills in a particular area such as surgical pathology or clinical chemistry, and to tailor their educational focus to their chosen individual career path.

A Holistic Approach

Dr. Baldwin performs a frozen section
as Dr. Sun Chung guides her through the process.

Continuous interaction. In the old curriculum model, each resident interacted with a faculty member only once a month, making it difficult for the mentor to assess the trainee’s progress based on their past experience. In the new model, residents do a month of service in surgical pathology, for example. Working exclusively with one attending, the trainee learns the process of making a diagnosis. This includes: understanding the clinical history and reasoning for surgery, performing gross exams and microscopic analyses, doing frozen sections, developing a diagnostic opinion, communicating with the healthcare team and presenting at tumor boards. Working as a team in the cutting room, and throughout the diagnostic process, allows the attending to help the trainee build on his or her previous progress.

Integrating surgical and clinical pathology. In the past, residents might learn something about surgical pathology but not clinical pathology. In contrast, the new model focuses on diagnostic pathology: taking all clinical and diagnostic information into account when rendering a diagnostic opinion.

View Video of Dr. Cole: Integrating Surgical & Clinical Pathology 

Hybrid rotations.DrsSzymczakAndDickinson
Dr. Wendy Szymczak, Associate Director, Clinical
Microbiology Lab, with Dr. Gregory Dickinson, PGY-2.
In the third year, residents return to the core clinical pathology rotations as part of “hybrid” rotations incorporating interaction with clinical teams and anatomic pathology services. These rotations focus on integrating clinical laboratory findings and anatomic pathology results; connecting those results to the in-person findings with the clinical team. In addition to the time spent in pathology, residents interface with clinical teams in a consultative role. They also attend the clinical services’ grand rounds and relevant didactic sessions during the rotation.

Stressing communication skills. The new model also fosters the development of excellent communication skills. Residents have opportunities to teach medical students at Einstein and participate in monthly tumor boards. They also get to practice public speaking by delivering informal talks, on any subject of their choosing, before an audience made up of their classmates and faculty members. The talks are captured on video, which the speakers later review.

View Video of Dr.Hébert: Communication Skills 


Measuring Trainees’ Progress

A series of benchmarks has been set up to assess each trainee’s progress.  

One metric is “entrustable professional activities” (EPA’s): tasks or procedures a well-prepared trainee can be entrusted to perform competently, without supervision. Developed by the Graduate Medical Education Committee of the College of American Pathologists,EPA's are a cornestone of competency-based medical education in Pathology.  

Dr. Hebért meets individually with PGY-1s in mid-September to review their state-mandated Pathology Milestones. Trainees take written and performance-based pre- and post-tests “to see if the information we hoped to transmit was transmitted.”

The residency program committee, which meets monthly, is in the process of comparing the speed of acquisition of milestones by Montefiore Einstein PGY-1s and PGY-2s versus the PGY-3s and PGY-4s, who have received the more traditional curriculum.

View Video of Dr. Hébert: Progress of First-Years 


Work in Progress

Still in its early stages of implementation, the curriculum design is a work in progress.

Drs. Hébert and Cole solicit informal feedback from residents at the end of each phase of the program. So far, they have received positive feedback from first- and second-years regarding boot camp, the teaching service and the onboarding process.

“Exams are nice,” says Dr. Hébert, “but more than that, we’d like to see our residents take on a more attending-like role as they’re finishing residency training. We want to hear from employers or fellowship directors that our graduates have the adaptability and confidence to function independently.”

As the Montefiore Einstein pathology residency program continues to evolve, Dr. Prystowsky and his colleagues would like to see the new curriculum become a model for others in the field.

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