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Cautionary Tales of the New in Practice

Assimilating into any new professional environment brings its own unique set of challenges and opportunities. Dr. Geoffrey Talmon collected cautionary tales and accompanying lessons that a new-in-practice pathologist may want to keep in their back pocket.

Scenario #1

On my first day of actual work on my own, I was called to do a frozen section for a margin assessment on a basal cell carcinoma. Having just completed a fellowship at a high volume referral center, I was used to seeing zebras on a daily basis and convinced that this basic lesion that I saw hundreds of times had to be a rare skin appendage tumor. I called the dermatopathologist for a consultation.…she looked at the slide, then me, shook her head, and walked out of the room.

Lesson: Although few admit it or remember it, almost every seasoned pathologist has experienced/felt what you are going through as a new-in-practice pathologist.

Scenario #2

I walked past my partner's office where he was going over one of the cases I signed out with a senior oncologist. I was taken aback. Later, when I asked my partner about it, he said that it was nothing personal or a perceived lack of ability. He had a close friendship with that clinician and whenever this person wanted to look at any case, the first stop was usually his office.

Lesson: You are joining an established culture and you need to build trust with clinicians.

Scenario #3

I joined the group at the institution where I did my residency. I noticed that for several years, my former teachers, now partners, never seemed to bring me difficult cases for my opinion. Even though I had trained with them for several years and they knew my abilities, it took time for them to build trust in me as an equal.

Lesson: There's a steep learning curve, and you need to build trust with colleagues.

Scenario #4

In medical school and residency, you are judged by how many times you are wrong, so you're conditioned to be literally afraid of errors. If an attending made a mistake, we were usually either not aware of it or never saw how it was handled. The hardest things that I had to learn during my first months is that mistakes are unavoidable and how to handle them when they happened.

Lesson: It's normal to be scared, overwhelmed, and nervous. You’ll make mistakes (and always will).

Scenario #5

When I arrived in my assigned office I had two non-functioning chairs and was told by the administrative assistant that there were no other options. Shortly after, my lab director was in my office and leaned forward while talking to me, and he tipped forward onto the floor. As I apologized profusely, I almost fell out of my chair. The next day, I had new chairs.

Lesson: Get to know everyone, particularly key influencers.

Scenario #6

Even when I'm tired, have my own cases to look at, or am annoyed, I will still look at the 50th case that the new-in-practice pathologist shows me. I expect it. If you aren't showing any cases, your partners will worry. Sometimes you'll already know the answer. That's okay, you'll build confidence……you are not annoying the seasoned pathologist, and they benefit from the experience.

Lesson: Show your cases, consult your colleagues…it's expected! The assumption is to show at least ⅓ of your cases when starting out.

Scenario #7

Trust that little voice in your head that says you probably should show this case. Every time I've listened to that voice, I was glad. If your intuition is telling you that there's something there that is significant, it probably is, and it will only help the patient if you show it to someone else.

Lesson: Trust your "Spidey Sense." Patient care trumps looking like a "diagnostic stud."

Scenario #8

We hired a new pathologist who did all of his training at the same outside institution. Many of our procedures and protocols are different than at where he trained, and almost every discussion with him started with "when I was at the University of _____, we did it this way." At first, the partners and staff were receptive to the new point of view. After about a month, whenever we heard those words, eyes would roll.

Lesson: Don't bring up previous training constantly or be overly critical of your current lab’s limitations or capabilities.

Scenario #9

Everyone wants to convert you to their side: a new ally. One of my duties when I was hired was to direct the microbiology lab. One of my techs came to me in my first week to tell me story after story about one of her colleagues and how this individual needed to be disciplined or fired. Later, I found out that these two had a "romantic entanglement," which I learned was the root of the issue.

Lesson: Don't get involved in office gossip or pit colleagues against one another.

Scenario #10

I was on a tour of the lab on my very first day and noticed that an expired reagent was being used…when I asked the supervisor, I was told that it passed QC and was okay. I disagreed. We had a great discussion about the potential effects on patient testing. She was still determined to continue, and I was determined to not use expired reagents. The lab director and I developed a plan to prevent this.

Lesson: Do not expect to make immediate or sweeping changes except in cases of serious issues i.e. patient safety, quality assurance, unethical behavior.

Scenario #11

When you first join a practice, everyone is going to try to get their hooks into the "new guy." You will be asked to serve on committees, give lectures, direct things, etc. Being eager to prove yourself, your first instinct is likely to oblige any or all of these requests. It is more than okay (and best for your patients) to say "no for right now" or "maybe in a few months."

Lesson: Don't overexert yourself to the point where your work suffers.

Scenario #12

One of the most valuable people I know is my practice manager. I come to her almost daily with things ranging from billing questions to HR issues to courier problems to issues with clients to little stuff like problems with office furniture. They get things done! As a resident, you have no idea how important this person is and how easy they can make your life, especially when you are first starting out.

Lesson: Know when and who to ask for help. Your lab managers/leads and practice manager are likely experienced and knowledgeable!

Scenario #13

When I first arrived at my new job, there were literally a couple of hundred new people between laboratory staff and clinicians that I knew that I should get to know at least their names. Whenever I went to the doctor's lounge there was always a new face that I was trying to connect with a name from a requisition or a voice from the phone; which could lead to some anxiety when I felt like I should know who that person is by now. So one of my tactics still is to look up physician faces in the online directory any name I do not recognize to help put a face to the name which helps down the road with the in-person interactions. We all know that developing rapport with our colleagues starts with these basics.

Lesson: Develop a system that works for you to get to know you colleagues.

Scenario #14

As the new pathologist to the group, I had an interaction with an established GI colleague where I used some newer terminology for an uncommon disease process that the clinician was not used to. Although I tried to be diplomatic and informative, it was objectively not the best conversation. I was concerned that I may have roughened a previously good relationship our group had with this person. I ended up discussing the issue with the chair of my department just to help decide if the department needed to take any additional steps to ensure a smooth as possible working relationship with the clinician.

Lesson: Not all clinical interactions will go smoothly. Discuss situations as appropriate with your mentor/supervisor/chair for advice or to leverage their knowledge of clinical colleagues to improve future interactions.

Geoffrey Talmon, MD, FCAP
Dr. Geoffrey Talmon is an associate professor and assistant director of the gastrointestinal pathology fellowship program at the University of Nebraska Medical Center (UNMC) in Omaha, Nebraska. He completed his residency in anatomic and clinical pathology at UNMC and his fellowship in surgical pathology at the Mayo Clinic. Dr. Talmon is the current president of the Nebraska Association of Pathologists and the Group for Research in Pathology Education.