Philosophy And Goals
TRAINING IN ANATOMIC AND CLINICAL PATHOLOGY AT THE MASSACHUSETTS GENERAL HOSPITAL
David N. Louis, M.D., Chief of Pathology Service, Massachusetts General Hospital
W. Stephen Black-Schaffer, M.D., Associate Chief and Training Program Director
Matthew P. Frosch, M.D., Ph.D., Associate Director for Training in Research
Robert P. Hasserjian, M.D., Associate Director for Resident Recruitment
Frederick C. Koerner, M.D., Associate Director for Resident Scheduling
Esther Oliva, M.D., Associate Director for Training in Anatomic Pathology
Christopher P. Stowell, M.D., Ph.D., Associate Director for Training in Clinical Pathology
The discipline of Pathology is devoted to the definitive diagnosis and the understanding of the pathogenesis of human disease. In the Residency Program in Anatomic and Clinical Pathology at the Massachusetts General Hospital (MGH), we seek to train physicians who will become leaders in this field, whether in clinical practice, research, or a combination of these. We believe that a solid foundation of knowledge of human pathology and understanding of disease mechanisms is essential for either career goal. Both practitioners and researchers must, in addition, be skilled at synthesizing information, communicating it to others, and teaching. Our program recognizes that each distinct career path in pathology has an optimal blend of training experiences, which should be customized as much as possible within the constraints of the requirements of the American Board of Pathology and the Accreditation Council on Graduate Medical Education. We have introduced options for the individual resident, and changed the programmatic required rotations, to accommodate this learning process optimally.
The most important strengths of the MGH Pathology training programs are the high volume of challenging clinical material, the expertise and academic stature of the faculty, the daily involvement of the faculty in training the residents, the enthusiasm and high quality of our residents, the flexibility of our program in constructing individual training pathways, and the international reputation of the MGH in both clinical and research activities.
The guiding principle of our program, as in most of postgraduate medical education, is that young physicians learn best by having responsibility for patient care in a supervised, supportive setting. Responsibility motivates learning, which is focused on solving the challenging problems presented by each patient. Therefore, training in all MGH Pathology programs emphasizes active resident involvement in diagnostic services, whether AP or CP, allowing the resident to take primary responsibility for evaluating clinical specimens and communicating results to clinicians, under the supervision of more senior pathologists. In addition to independent study through reading stimulated by the cases, learning occurs at daily signout sessions, and at working and teaching conferences at which residents discuss their interpretation of pathologic findings and laboratory results with senior pathologists, present pathology and laboratory findings to clinicians, and review and present relevant literature. The faculty and fellows give formal lecture series in both AP and CP. Critically important are the innumerable informal discussions with staff and fellow residents that refine and solidify the knowledge gained.
Overall Program Educational Goals
Resident training is a professional educational process in which the resident is expected to acquire skills, knowledge, attitudes, and behaviors appropriate to a beginning independent practitioner of the medical specialty of pathology. Some of these characteristics can be acquired through a didactic process of lectures and study; others depend on modelling, mentorship, and progressively independent practice under supervision.
The two major components of our residency process are anatomic pathology and clinical pathology, the latter often referred to as laboratory medicine. These have many aspects in common, and some significant differences. The common features include that both are the medical application of a scientific and empirical understanding of health and disease, as these can be detected and assessed by laboratory parameters. This medical application is generally consultative to practitioners in other medical specialties, though it sometimes involves direct patient care responsibilities as well.
Anatomic pathology is distinguished by the patient material to which it is applied, which has structure that can be recognized and assessed morphologically. There is a continuum of scale to which such assessments can be applied, ranging from molecular and ultrastructural through cellular, tissue, and organ-based analyses, to the whole person. Recognition and understanding of the significance of structural patterns representative of health and disease is a key aspect of patient care as provided through anatomic pathology.
Clinical pathology (laboratory medicine) is distinguished by its analysis, based on scientific principles, of body fluids and constituents that are usually, though not always, based on parameters other than the morphological. Many hematology and microbiology analyses, as well as some in immunology, depend on morphological assessments, an important area of overlap between anatomic and clinical pathology. Other areas of overlap have origin in the molecular understanding of disease, as this brings together many hitherto disparate aspects of pathology, as does laboratory management, which applies to all pathology services. Furthermore, some specific areas of pathology are virtually continuous in their manifestations between diagnostic anatomic pathology and clinical laboratory medicine.
With this as background, the overall goals of residency training in pathology may be more specifically stated in terms of achievement of the following competencies, necessary for beginning independent practice.
--Medical Knowledge
The scope of necessary medical knowledge is a broadly based understanding of pathologic anatomy and pathophysiology as these relate to the laboratory-based recognition and assessment of disease.
--Patient Care
Laboratory-based patient care services require several cognitive and procedural skills. Suitably subtle, sensitive and specific pattern-recognition skills are often referred to as "having a good eye." Though the rudiments of this skill can be acquired didactically, practice in dissection, description, and diagnosis is essential to hone the skill. Other procedures and skills contribute to patient care in specific areas of pathology, including transfusion medicine and fine needle aspiration, both of which also involve the skills for direct patient care.
--Professionalism, Interpersonal and Communication Skills
These start with the consultative basis of laboratory-based clinical care. Effective consultation requires good communication, and this in turn is based on the pathologist's ability to identify first with clinical practitioners directly caring for the patient, but ultimately with the patient him- or herself. Recognizing the patient's interests as primary in the care process is at the heart of a professional attitude to care, while understanding the clinical practitioner's needs and circumstances are essential to serving the patient effectively in a consultative role.
Beyond this ability to identify with, understand, and effectively communicate about the needs of the individual patient and his or her clinical practitioners, modern laboratory-based clinical care is a team endeavor. The pathologist must have the managerial and leadership skill to maintain and advance the operation of a laboratory team, including infrastructure, finance, operation, and personnel.
--Systems-Based Practice
Laboratories provide their services in the context of a health care community. This may be a local hospital, a regional health care delivery system, or as a reference laboratory resource, anywhere from local to international in scope. The pathologist's responsibility is to understand the needs and resources of this system, and to ensure the quality, appropriateness, and availability of services.
--Practice-Based Learning and Improvement
To serve their healthcare communities' needs, pathologists must be scientific as well as empirical practitioners of diagnostic medicine. This entails translational skills in evaluating and appropriately implementing new technologies as medical understanding advances, as well as involvement in and understanding of the practical realities of the availability of societal resources for the provision of healthcare services. To achieve this, the pathologist must establish a habit of seeking out new knowledge and critically assessing current practices, starting with his or her own practice and practice environment. A pathologist with these skills, attitudes and behaviors will acquire and maintain the knowledge needed to be a valued and contributory member of his or her healthcare community and, more importantly, of the larger society it serves.
Competency |
An unsatisfactory resident demonstrates: |
An outstanding resident demonstrates: |
Medical Knowledge |
Limited knowledge of basic and clinical sciences; poor understanding of diagnostic criteria and of relevant patterns and mechanisms of disease; minimal interest in learning |
Exceptional knowledge of basic and clinical sciences; comprehensive understanding of diagnostic criteria and of relevant patterns and mechanisms of disease; highly resourceful in development of knowledge |
Patient Care Anatomic Pathology |
Incomplete or inaccurate gross descriptions, microscopic diagnoses, and reviews of clinical data; incomplete or incompetent application of diagnostic criteria and performance of gross dissections and other procedural services; fails to analyze clinical data and consider patient implications when making medical decisions |
Superb, accurate, comprehensive gross descriptions, microscopic diagnoses, reviews of clinical data, and procedural skills; always makes medical decisions using sound judgment, considering patient implications and available evidence |
Patient Care Clinical Pathology |
Incomplete or inaccurate review, interpretation, and assessment of clinical and laboratory data and performance of history and physical examinations; incomplete or incompetent application of diagnostic criteria and performance of clinical duties including on-call responsibilities; fails to analyze clinical and laboratory data and consider patient implications when making medical decisions; medical judgment is poor |
Superb, accurate, comprehensive review, interpretation, and assessment of clinical and laboratory data, performance of history and physical examinations, and application of diagnostic criteria; exceptionally able performance of clinical duties including on-call responsibilities; always makes medical decisions using sound judgment, considering patient implications and available evidence |
Interpersonal and Communications Skills |
Does not establish even minimally effective medical relationships with co-workers and clinical colleagues; does not demonstrate ability to build relationships through listening, narrative, or nonverbal skills; does not provide education or advice to co-workers and clinical colleagues |
Establishes highly effective medical relationships with co-workers and clinical colleagues; demonstrates excellent relationship building through listening, narrative, and nonverbal skills; excellent education and counseling of co-workers and clinical colleagues, always "interpersonally" engaged |
Professionalism |
Lacks respect, compassion, integrity, honesty; disregards need for self-assessment; fails to acknowledge errors; does not consider needs of patients, families, co-workers, and clinical colleagues; does not display responsible behavior |
Always demonstrates respect, compassion, integrity, honesty; teaches/role models responsible behavior; totally committed to self-assessment; willingly acknowledges errors; always considers needs of patients, families, co-workers, and clinical colleagues |
Practice-Based Learning Improvement |
Fails to perform self-evaluation; lacks insight, initiative; resists or ignores feedback; fails to use available resources to enhance patient care or pursue self-improvement |
Constantly evaluates own performance, incorporates feedback into improvement activities; effectively accesses and utilizes resources to manage information for patient care and self-improvement |
System-Based Practice |
Unable to access/mobilize outside resources; actively resists efforts to improve systems of care; does not use systematic approaches to reduce error and improve patient care |
Effectively accesses/utilizes outside resources; effectively uses systematic approaches to reduce errors and improve patient care; enthusiastically assists in development of system improvements |
|
