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The need for increased clinical responsibility in pathology training programs
H U M A N PATHOLOGY
VOLUME 8 NUMBER 6 November 1977
Current Topics THE NEED FOR INCREASED CLINICAL RESPONSIBILITY IN PATHOLOGY TRAINING PROGRAMS ROBERT E. ANDERSON, M.D.,* ROLLA B. HILL, M.D.,I" REX B. CONN, JR., M.D.,.~ aND ELLIS S. BENSOX, M.D.w
BACKGROUND IndMduals are entering pathology training programs with less experience in direct patient care today than was true five to 10 )'ears ago. T h e reasons for this are complex but include a shortened medical school curriculum, disappearance o f file classic rotating internship, and a reduction in 1970 o f board eligibility in pathology from five to four years after graduation. Although some students prior to that time entered straight pathology internships man)' continued to have clinical internships. Since then, however, most students have been going directly into pathology residencies on graduation from medical school. Except for deletion of the fifth year requirement, the training requirements for eligibility for examination in pathology remain the same: For eligibility in both anatomic and clinical pathology the minim',.l requirement *Professor and Chair,nan, 1)clmrnnent of i'athology, University of New Mexico School of Medicine, Albuquerque, New Mexico. tl'rofessor and Chairman, Department of Pathology, State University of New York, Upstate Medical Center, S)racuse, New York. ~:Professor, Department of Pathology, Johns ttopkins University School of Medicine, Baltimore, Maryland. w and Head, Department of Laboratory Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota.
is two )'ears o f training in each area for a total o f four )'ears. Eligibility in either anatomic or clinical pathology requires three )'ears o f training in the respective area followed by a )'ear o f experience in a laboratory headed .by a board certified pathologist, again a total of four )'ears. Various combinations with areas o f special competence are also possible. T h e deletion o f the internship has occurred at a time when man)" medical schools have experimented with three year curriculums and other highly flexible formats, thus further decreasing the clinical experience of future trainees in pathology and in other nondirect patient care specialties. Simuhaneously pathologists in a variety o f practice settings are being called upon to make increasingly complex judgments requiring an understanding of patient care. T h e clinical thrust o f clinical pathology practice is likely to increase rather than decrease, especially with the rise of family practice and other primary care specialties. It is likely that primary care specialists will call increasingly upon pathologists for advice in utilization and interpretation o f laboratory medicine in the diagnosis and management o f patients. Candidates who are seeking combined certification in anatomic-clinical pathology will find it difficult to accommodate clinical training in their four )ear program. Yet it is precisely these candidates who will need this training, since they are likely to be spending their careers in community hospitals. Other specialties are faced with the same
597
H U M A N P A T t l O L O G Y - - V O L U M E 8, NUMBER 6 problem. This is notably true o f radiologT, anesthesiology, psychiatry, neurology, physical medicine and rehabilitation, ophthalmolog T, and preventive medicine. Each of these speciahy areas is now considering or has instituted various options, including reinstitution o f the internship requirement. If pathologists are to enter into an)" coordinated program along with other specialty groups, the time for decision is becoming very short. This crisis comes at a time whdn society through its elected representatives is asking: What do pathologists do? Why does it cost so much? Can't someone (or something) do the same thing at less expense? Thus, it is increasingly incumbent u p o n pathologists not to lose sight o f those unique services that require clinical expertise; the alternative is to risk losing a significant a m o u n t of their responsibilities to commercial laboratories or nonpathologists. Since we believe these clinical activities o f pathologists to be greatly needed, it becomes increasingly vital to resolve this problem o f clinical training with alacrity.
RECOMMENDATIONS
598
In attempting to address the problems posed, it is incumbent upon training directors to maintain as much flexibility as possible. Ttfis is necessary not only because o f significant differences between training programs in pathology, but also to acknowledge the need for flexibility a m o n g various trainees with different backgrounds and divergent career goals. However, it is our strong recommendation that a significant period o f direct patient care responsibility be incorporated into every pathology training program as a required part o f its core program as soon as possible. In the implementation o f this recommendation, a variety of alternatives is possible: A. A six to nine month block of full-time direct patient care responsibility. This would occur in the earl}" part o f the residency, to take maximal advantage of clinical skills gained as a fourth )'ear student, but it could profitably be preceded by a core pathology (anatomic and clinical) program to clarify the relevance of one to the other and permit a clearer goal orientation during the clinical period. T h e purpqse of a soiid block of clinical responsibility would be to develop an easy confidence and familiarity with clinical settings, allowing for growth and development in clinical consultation abilities in later }'ears o f the residency. Tiffs could be accomplished in a variety o f settings. O f these, perhaps the best possibilities include a clinical assignment to an
November 1977
affiliated community hospital, direct patient care responsibilities oil a surg-ical service (where the number o f house staff appointments can be expected to decline over the next several years), or direct ward responsibility in a department of family and community medicine (where patient care responsibilities nmy be expected to increase significantl)' over the next several years), pediatrics, internal medicine, or other primary care specialties. T h e length of this core clinical training would depend on individual circumstances, but we feel that less than three months would not be likely to produce confidence, whereas time over nine months might be redundant and should probably be directed toward other more specialized goals. B. Increased emphasis on clinical exposure throughout residency. Again such responsibility nmy assume a variety of forms. Some that come to mind most quickly are: I. Responding to consultations in rotation with residents from medicine, pediatrics, and so forth. For example, it would appear feasible to have pathology house staff assigned to microbiology (for example) or to see consults in rotation with residents from medicine or pediatrics assigned to infectious diseases. 2. Participation in subspeciall)' clinics. Again this would probably work best for house staff assigned to clinical pathology and in conjunction with departments of medicine. T h e various subspecialty clinics sponsored by departments o f medicine match tip very well with specific subspecialty areas in clinical pathology. 3. Participation in ward rounds ("work rot, nds") as the laboratory consultant on an ongoing basis. 4. Active participation in subspedalty rounds. 5. Preoperative examination of patients scheduled for surgery. 6. Study o f all suspected transfusion reactions. 7. Conferences with families regarding autopsy results (with the acquiescence o f responsible ward physicians). Traditionally pathologists have left this responsibility to t h e i r clinical brethren; such an approach has not worked well in most teaclfing hospitals where relatives get little or no feedback from the autopsy. 8. Subspecialty rotation in the department o f medicine. 9. Ongoing scheduled (one to four }'ears) patient care responsibility in selected subspecialty clinics.
CURRENT TOPICS OBJECTIVES Tile chief objective is to educate a physician-pathologist who is uniquely a n d expertly capable of consulting, advising, and interpreting illness in terms o f a b n o r m a l physiology as revealed t h r o u g h l a b o r a t o r y testing. Such a physician should be equally at home examining and talking to a patient p r e o p e r a tively as in examining the resultant surgical specimen, diagnosing and prescribing therapy for a patient with a bleeding problem, and supervising the tectmologists in the coagulation laboratory, Such a physician should be best able to prescribe the most efficient and most effective use o f tile laboratory as a clinical aid, thus r e d u c i n g medical costs. Tile wide gap that often exists between tile prinmry care clinician on the one h a n d and the laboratory m a n a g e r on the o t h e r should narrow. Personnel and fiscal m a n a g e m e n t , quality control, cost containment, and instrument develo p m e n t can all be accomplished by highly trained nonph)'sicians. Selection o f effective testing a n d translation o f test results to the clinical situation, on the o t h e r hand, are unique to the pathologist and can best be achieved by solid attention to d e v e l o p m e n t o f u n d e r standing and skills in direct patient care responsibilities.
LIMITATIONS OF AUTOPSY DATA 1N RELATING NEONATAL INTRACRANIAL HEMORRHAGE TO BUFFER THERAPY* ALAN LEVITON, M.D., S. M. EPIDEM.,"~ AND FLOYD H. GILLES, M.D.~
D u r i n g the past few )'ears chemicals to which newborn l m m a n s may be exposcd have p r o d u c e d lesions o f the brain in newborn laboratory animals." 2 Assessmcnt o f the effect o f these chemicals on thc h u m a n brain has been limited by factors associated with e x p o s u r e o f the nelmatc, as well as b)" factors that con*This stud)" was supported in part b)" funds provided b)" the United Cerebral Palsy Research and Educational Foundation (R-224-74), The Children's Hospital Medical Center Mental Retardation and Human Development Research Program (5 1'30 HDO 6276), and 5 P01 NS09704, NINCDS. tAssistant Professor of Neurology, Harvard Medical School. Associate in Neurology, Children's l-|ospital Medical Center, Boston, Massachusetts. ~Associate Professor of Neuropathology. liaryard Medical School. Neuropathologist. Children's Hospital Medical Center, Bosum, Massachusetts.
tribute to death, and postmortem examination.3, 4 Most recently administration o f sodium bicarbonate to infants with acidosis and respirator}" distress has been implicated as predisposing to intracranial hemorrhage. S Unlike the previous instances in which experimental laboratory evidence suggested a danger, tile evidence in this instance came from observations in humans. T h e evidence was necessarily indirect and consisted o f a comparison between the frequency o f intracranial hemorrhage f o u n d at autopsy at two periods o f time, J u l y I, 1966, to J u n e 30, 1967, and Jul)" 1, 1970, to J u n e 30, 1971. Although the authors emphasized that the two periods differed in r e g a r d to the use o f bicarbonate therapy, it may be that there are o t h e r significant differences. A n o t h e r g r o u p o f investigators related the changes in the frequency o f intracranial h e m o r r h a g e at p o s t m o r t e m examination to changes in tim use o f bicarbonate in the treatment o f respirator)" distress s y n d r o m e acidosis at their hospital in Edinburgh. n T h e y also f o u n d that intracranial h e m o r r h a g e s were m o r e c o m m o n at autops)" when bicarbonate therapy was used, but pointed out that the mortality rate in infants with the respirator)' distress s y n d r o m e fell concomitantly with bicarbonate therapy usage. An inverse relationship between tile mortality rate o f one disease and the presence o f a second potentially fatal d i s o r d e r in people dying o f the first disease follows from Mainland's principle, which states that competing fatality rates introduce bias in the
rates of autopsy fit~dings. In 1953 Mainland published a p a p e r that he viewed as an application of Berkson's principle 8 to autopsy studies. We p r e f e r to consider Mainland's principle as an axiom ill its own right r a t h e r than as an extension of Berkson's principle. Mainland emphasized that the relationship between two diseases cannot be derived from autopsy data because o f a sampling bias that he n a m e d "competing selection rates." This sampling bias is probably reflected in the a p p a r e n t relationship between bicarbonate therapy and intracranial hemorrlmge. Cornfield 9 wrote: "It is not difficult to show that even when two eventually fatal diseases have no relationship in a living population . . . . an autopsy p o p u l a t i o n . . . will nevertheless yield a negative association between them." Tile inverse relationship between the mortality rate in the respiratory distress s)'nd r o m e and the probability o f finding at autopsy evidence o f intracranial h e m o r r h a g e may be a specific example o f Cornfield's corollary. Both Mainland's principle and Cornfield's corollary apply universally to autopsy data.
599
VOLUME 8 NUMBER 6 November 1977
Current Topics THE NEED FOR INCREASED CLINICAL RESPONSIBILITY IN PATHOLOGY TRAINING PROGRAMS ROBERT E. ANDERSON, M.D.,* ROLLA B. HILL, M.D.,I" REX B. CONN, JR., M.D.,.~ aND ELLIS S. BENSOX, M.D.w
BACKGROUND IndMduals are entering pathology training programs with less experience in direct patient care today than was true five to 10 )'ears ago. T h e reasons for this are complex but include a shortened medical school curriculum, disappearance o f file classic rotating internship, and a reduction in 1970 o f board eligibility in pathology from five to four years after graduation. Although some students prior to that time entered straight pathology internships man)' continued to have clinical internships. Since then, however, most students have been going directly into pathology residencies on graduation from medical school. Except for deletion of the fifth year requirement, the training requirements for eligibility for examination in pathology remain the same: For eligibility in both anatomic and clinical pathology the minim',.l requirement *Professor and Chair,nan, 1)clmrnnent of i'athology, University of New Mexico School of Medicine, Albuquerque, New Mexico. tl'rofessor and Chairman, Department of Pathology, State University of New York, Upstate Medical Center, S)racuse, New York. ~:Professor, Department of Pathology, Johns ttopkins University School of Medicine, Baltimore, Maryland. w and Head, Department of Laboratory Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota.
is two )'ears o f training in each area for a total o f four )'ears. Eligibility in either anatomic or clinical pathology requires three )'ears o f training in the respective area followed by a )'ear o f experience in a laboratory headed .by a board certified pathologist, again a total of four )'ears. Various combinations with areas o f special competence are also possible. T h e deletion o f the internship has occurred at a time when man)" medical schools have experimented with three year curriculums and other highly flexible formats, thus further decreasing the clinical experience of future trainees in pathology and in other nondirect patient care specialties. Simuhaneously pathologists in a variety o f practice settings are being called upon to make increasingly complex judgments requiring an understanding of patient care. T h e clinical thrust o f clinical pathology practice is likely to increase rather than decrease, especially with the rise of family practice and other primary care specialties. It is likely that primary care specialists will call increasingly upon pathologists for advice in utilization and interpretation o f laboratory medicine in the diagnosis and management o f patients. Candidates who are seeking combined certification in anatomic-clinical pathology will find it difficult to accommodate clinical training in their four )ear program. Yet it is precisely these candidates who will need this training, since they are likely to be spending their careers in community hospitals. Other specialties are faced with the same
597
H U M A N P A T t l O L O G Y - - V O L U M E 8, NUMBER 6 problem. This is notably true o f radiologT, anesthesiology, psychiatry, neurology, physical medicine and rehabilitation, ophthalmolog T, and preventive medicine. Each of these speciahy areas is now considering or has instituted various options, including reinstitution o f the internship requirement. If pathologists are to enter into an)" coordinated program along with other specialty groups, the time for decision is becoming very short. This crisis comes at a time whdn society through its elected representatives is asking: What do pathologists do? Why does it cost so much? Can't someone (or something) do the same thing at less expense? Thus, it is increasingly incumbent u p o n pathologists not to lose sight o f those unique services that require clinical expertise; the alternative is to risk losing a significant a m o u n t of their responsibilities to commercial laboratories or nonpathologists. Since we believe these clinical activities o f pathologists to be greatly needed, it becomes increasingly vital to resolve this problem o f clinical training with alacrity.
RECOMMENDATIONS
598
In attempting to address the problems posed, it is incumbent upon training directors to maintain as much flexibility as possible. Ttfis is necessary not only because o f significant differences between training programs in pathology, but also to acknowledge the need for flexibility a m o n g various trainees with different backgrounds and divergent career goals. However, it is our strong recommendation that a significant period o f direct patient care responsibility be incorporated into every pathology training program as a required part o f its core program as soon as possible. In the implementation o f this recommendation, a variety of alternatives is possible: A. A six to nine month block of full-time direct patient care responsibility. This would occur in the earl}" part o f the residency, to take maximal advantage of clinical skills gained as a fourth )'ear student, but it could profitably be preceded by a core pathology (anatomic and clinical) program to clarify the relevance of one to the other and permit a clearer goal orientation during the clinical period. T h e purpqse of a soiid block of clinical responsibility would be to develop an easy confidence and familiarity with clinical settings, allowing for growth and development in clinical consultation abilities in later }'ears o f the residency. Tiffs could be accomplished in a variety o f settings. O f these, perhaps the best possibilities include a clinical assignment to an
November 1977
affiliated community hospital, direct patient care responsibilities oil a surg-ical service (where the number o f house staff appointments can be expected to decline over the next several years), or direct ward responsibility in a department of family and community medicine (where patient care responsibilities nmy be expected to increase significantl)' over the next several years), pediatrics, internal medicine, or other primary care specialties. T h e length of this core clinical training would depend on individual circumstances, but we feel that less than three months would not be likely to produce confidence, whereas time over nine months might be redundant and should probably be directed toward other more specialized goals. B. Increased emphasis on clinical exposure throughout residency. Again such responsibility nmy assume a variety of forms. Some that come to mind most quickly are: I. Responding to consultations in rotation with residents from medicine, pediatrics, and so forth. For example, it would appear feasible to have pathology house staff assigned to microbiology (for example) or to see consults in rotation with residents from medicine or pediatrics assigned to infectious diseases. 2. Participation in subspeciall)' clinics. Again this would probably work best for house staff assigned to clinical pathology and in conjunction with departments of medicine. T h e various subspecialty clinics sponsored by departments o f medicine match tip very well with specific subspecialty areas in clinical pathology. 3. Participation in ward rounds ("work rot, nds") as the laboratory consultant on an ongoing basis. 4. Active participation in subspedalty rounds. 5. Preoperative examination of patients scheduled for surgery. 6. Study o f all suspected transfusion reactions. 7. Conferences with families regarding autopsy results (with the acquiescence o f responsible ward physicians). Traditionally pathologists have left this responsibility to t h e i r clinical brethren; such an approach has not worked well in most teaclfing hospitals where relatives get little or no feedback from the autopsy. 8. Subspecialty rotation in the department o f medicine. 9. Ongoing scheduled (one to four }'ears) patient care responsibility in selected subspecialty clinics.
CURRENT TOPICS OBJECTIVES Tile chief objective is to educate a physician-pathologist who is uniquely a n d expertly capable of consulting, advising, and interpreting illness in terms o f a b n o r m a l physiology as revealed t h r o u g h l a b o r a t o r y testing. Such a physician should be equally at home examining and talking to a patient p r e o p e r a tively as in examining the resultant surgical specimen, diagnosing and prescribing therapy for a patient with a bleeding problem, and supervising the tectmologists in the coagulation laboratory, Such a physician should be best able to prescribe the most efficient and most effective use o f tile laboratory as a clinical aid, thus r e d u c i n g medical costs. Tile wide gap that often exists between tile prinmry care clinician on the one h a n d and the laboratory m a n a g e r on the o t h e r should narrow. Personnel and fiscal m a n a g e m e n t , quality control, cost containment, and instrument develo p m e n t can all be accomplished by highly trained nonph)'sicians. Selection o f effective testing a n d translation o f test results to the clinical situation, on the o t h e r hand, are unique to the pathologist and can best be achieved by solid attention to d e v e l o p m e n t o f u n d e r standing and skills in direct patient care responsibilities.
LIMITATIONS OF AUTOPSY DATA 1N RELATING NEONATAL INTRACRANIAL HEMORRHAGE TO BUFFER THERAPY* ALAN LEVITON, M.D., S. M. EPIDEM.,"~ AND FLOYD H. GILLES, M.D.~
D u r i n g the past few )'ears chemicals to which newborn l m m a n s may be exposcd have p r o d u c e d lesions o f the brain in newborn laboratory animals." 2 Assessmcnt o f the effect o f these chemicals on thc h u m a n brain has been limited by factors associated with e x p o s u r e o f the nelmatc, as well as b)" factors that con*This stud)" was supported in part b)" funds provided b)" the United Cerebral Palsy Research and Educational Foundation (R-224-74), The Children's Hospital Medical Center Mental Retardation and Human Development Research Program (5 1'30 HDO 6276), and 5 P01 NS09704, NINCDS. tAssistant Professor of Neurology, Harvard Medical School. Associate in Neurology, Children's l-|ospital Medical Center, Boston, Massachusetts. ~Associate Professor of Neuropathology. liaryard Medical School. Neuropathologist. Children's Hospital Medical Center, Bosum, Massachusetts.
tribute to death, and postmortem examination.3, 4 Most recently administration o f sodium bicarbonate to infants with acidosis and respirator}" distress has been implicated as predisposing to intracranial hemorrhage. S Unlike the previous instances in which experimental laboratory evidence suggested a danger, tile evidence in this instance came from observations in humans. T h e evidence was necessarily indirect and consisted o f a comparison between the frequency o f intracranial hemorrhage f o u n d at autopsy at two periods o f time, J u l y I, 1966, to J u n e 30, 1967, and Jul)" 1, 1970, to J u n e 30, 1971. Although the authors emphasized that the two periods differed in r e g a r d to the use o f bicarbonate therapy, it may be that there are o t h e r significant differences. A n o t h e r g r o u p o f investigators related the changes in the frequency o f intracranial h e m o r r h a g e at p o s t m o r t e m examination to changes in tim use o f bicarbonate in the treatment o f respirator)" distress s y n d r o m e acidosis at their hospital in Edinburgh. n T h e y also f o u n d that intracranial h e m o r r h a g e s were m o r e c o m m o n at autops)" when bicarbonate therapy was used, but pointed out that the mortality rate in infants with the respirator)' distress s y n d r o m e fell concomitantly with bicarbonate therapy usage. An inverse relationship between tile mortality rate o f one disease and the presence o f a second potentially fatal d i s o r d e r in people dying o f the first disease follows from Mainland's principle, which states that competing fatality rates introduce bias in the
rates of autopsy fit~dings. In 1953 Mainland published a p a p e r that he viewed as an application of Berkson's principle 8 to autopsy studies. We p r e f e r to consider Mainland's principle as an axiom ill its own right r a t h e r than as an extension of Berkson's principle. Mainland emphasized that the relationship between two diseases cannot be derived from autopsy data because o f a sampling bias that he n a m e d "competing selection rates." This sampling bias is probably reflected in the a p p a r e n t relationship between bicarbonate therapy and intracranial hemorrlmge. Cornfield 9 wrote: "It is not difficult to show that even when two eventually fatal diseases have no relationship in a living population . . . . an autopsy p o p u l a t i o n . . . will nevertheless yield a negative association between them." Tile inverse relationship between the mortality rate in the respiratory distress s)'nd r o m e and the probability o f finding at autopsy evidence o f intracranial h e m o r r h a g e may be a specific example o f Cornfield's corollary. Both Mainland's principle and Cornfield's corollary apply universally to autopsy data.
599