Reframing Pathology Resident Training

Leaders in pathology education scramble to design curricula that keep pace with the science of medicine without losing sight of either their trainees’ need for hands-on experience or the practical constraints that can limit the flexibility of their clinical and administrative partners. Pathology training program directors juggle to ensure that every resident gets a solid foundation while absorbing a mind-boggling amount of information. Residents struggle to keep pace, get some sleep, and stop thinking about the board exam. Both seek an individualized learning experience. One program director offers a snapshot of not-unwelcome challenges pathologists in training and their educators encounter. Can reframing pathology training benefit patients, colleagues, and administrators?

Charles F. Timmons, MD, PhD, FCAP, has been a professor of pathology and director of resident and fellow education at the University of Texas (UT) Southwestern Medical Center in Dallas since 2002. His current and former residents successfully nominated him for the 2017 CAP Resident Advocate Award. During the nomination process, residents described "an amazing mentor" who not only listened to them but also acted on their feedback, which could be one reason UT Southwestern has been so fortunate in filling its pathology training slots.

Dr. Timmons has a handful of rules: 1) Treat everyone as an individual; 2) Remember that pathology is all about teaching; 3) Attend to the fundamentals; 4) Offer rapid exposure to the many practice options in the specialty; 5) Create opportunities for trainees to interact with clinicians on the front lines of care; and 6) Take the time for what is worth the time.

Dr. Timmons embarked on a career path in academic pediatrics, entering MD/PhD training at the University of North Carolina, Chapel Hill. He had done research in genetics. His advisor was a pediatrician. It all made sense.

Yet, in medical school, he found himself more engaged by disease processes than hands-on patient care. "I enjoyed the puzzle of the diagnosis more," he said. "So I thought, maybe something in the laboratory aspects of medicine would be a good choice for me; it was kind of a guess."

Dr. Timmons was a clinical pathology resident just long enough to experience the autopsy service (he volunteered to assist when they were short-handed) and switch to AP/CP. Then a late rotation in pediatric pathology revealed the perfect fit.

"My dissertation had been in pediatric disease, but I hadn’t realized that pediatric pathology existed," he says now. "On paper it looks like a normal progression; but in fact, at each step along the way I really wasn’t very sure of where I was headed."

All of which explains why he so ferociously guards his trainees’ right to make informed choices about their futures. "It’s very important to me to let them explore and change their minds," he says. "In constructing my own curriculum here at Southwestern, I have kept it extremely flexible because I needed that myself."

Dr. Timmons has concerns about the impact of structural changes in medical education—most notably, the near-demise of the sophomore pathology course and diminished availability of the post-sophomore year pathology fellowship. Both compromise the visibility of pathology as a career choice. Plus, without the sophomore pathology course, clinicians may not get sufficient exposure to fundamentals of pathology to grasp the implications of critical diagnoses—or the knowledge base to articulate what they don’t understand.

Dr. Timmons, who is board certified in anatomic, clinical, and pediatric pathology, serves on the CAP’s Graduate Medical Education Committee. He is also immediate past chair of the Association of Pathology Chairs (APC) Program Directors Section (PRODS), and a member of the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Pathology. He has many commitments and clearly enjoys them all. Charles Timmons is a thoughtful person for whom certain priorities are typically front of mind. Time for learning and exploration is one. The value of the autopsy is another.

For example, he says, their trainees are able to explore opportunities within their specialty because UT Southwestern gives them outstanding institutional support. Without denying that he has lobbied relentlessly for that support, no amount of advocacy would have been successful had physicians and administrators not been willing to set aside traditional assumptions about service responsibilities of residents to entertain the tradeoffs involved. While all work can be educational, his goal is to identify those work experiences that will be the best use of the residents’ time.

Over years of back-and-forth, administrators at UT Southwestern came to agree that it would make sense to ask anatomic pathology assistants and laboratory technologists to help with grossing, act as morgue attendants, and assist with autopsies. On the clinical pathology side, laboratory professionals could help to manage apheresis patients and perform differential counts on bone marrow cells. The cost of bringing midlevel professionals on board to do these (and other) things, he said, was readily justified by what residents now had time to learn and do. Projected laboratory test utilization improvements alone justified it. The UT Southwestern solution will not work at every institution, Dr. Timmons hastens to add; his is fortunate. But it can be used to change how institutions think and talk about house staff responsibilities.

A second item on his mind is the decline of the autopsy, a powerful teaching tool and a proven way to refine clinical practice. "You’ll see people justify the autopsy with statistics of how many autopsies had unexpected findings," Dr. Timmons says. Statistics are useful. "But the real value is less concrete and tangible. It’s the communication with the clinicians about the knowledge."

To sum up Dr. Timmons’ core convictions on maintaining a vibrant pathology residency program: To grow your team, never forget that all pathologists are teachers. When you teach, respect your students’ individuality. Think about how you communicate. And make time for what is worth the time.