Advice for Medical Students Matching Into Pathology

(upbeat music) - This is "Lab Medicine Rounds", a curated podcast for physicians, laboratory professionals and students. I'm your host, Justin Kreuter, the Bow Tie Bandit of blood, a transfusion medicine pathologist here at Mayo Clinic. Today, we're rounding with Dr. Ann Moyer, who is an Associate Professor of Laboratory Medicine and Pathology, and Assistant Professor of Pharmacology, and Associate Program Director for the Pathology Residency Program.

And Dr. Moyer's joining us today to talk about residents getting started in their training programs, kind of a follow up to a recent podcast we've had. So, thanks for joining us today, Dr. Moyer. - Thanks for inviting me to be here. I'm excited to talk about this topic. - Yeah, yeah.

So, you've been through your training, both, you're one of our double doctors, MD, PhD, and you've gone through a lot of training, and you've gone through it, and now you've very much launched a very successful academic pathology career. And I think that all of our residents, of course, are overjoyed for you to be in this Associate Program Director role for the residency. And that's why I think you're bringing a really neat perspective here.

I'm just setting this up for our students that are listening to this podcast to understand that your perspective is authentic in a very meaningful way.

So, let's kick this off. And so for residents who have recently started, now that we're recording this the beginning of August, now, orientation is presumably behind us. Where should their focus be? - I think this one's a really hard one for a new resident, because you're very excited. You just got into pathology. Hopefully it was the specialty of your dreams. And now you kind of feel a little bit like a kid in a candy store. There's all this really cool stuff going on around you.

There's opportunities to get involved in research projects. You can just get in so deep into this area that you're so excited about. But I think the biggest thing from my perspective, that when you start out in residency is even if you know what specialty area you want to go into, and you've got these great plans, and you've got these opportunities of things you can do, it's good to really just take a step back and realize, wait a minute, number one, I've gotta become a really good pathologist.

And how are you going to do that? I think the most important aspect is to start with a really strong foundation. And so for some people, you might've gotten to have some experience as a medical student, and gotten to see some aspects of pathology, and some people are coming into it where they know what pathology is, but they haven't had as much in-depth experience.

And in both cases, I think making sure that both on the anatomic pathology side and on the clinical pathology side, you make sure you really get again the foundation of the basics. So, what does that really mean? Well, so I trained in anatomic and clinical pathology, but now I practice molecular genetic pathology.

So, I'm through and through a clinical pathologist who happens to be trained in anatomic pathology, but even still, for anatomic pathology, it's really important just to get an understanding of what normal histology looks like. It's really hard to have a framework of what's abnormal if you don't really have a good understanding of what's normal. So, having some of those textbooks that cover a lot of the normal histology, definitely a great place to start.

And then in addition to that, I think having some sort of framework about how to think about the different cases that you're seeing. So, starting to understand maybe how the disease process works or the mechanism, and making sure you actually understand the clinical correlation of it too. So, there is the whole what we call wallpaper matching that you might be able to get pretty good at, but that's not going to get you where you need to go in pathology.

It's really having that full, big picture understanding. And I think to get that, you really need the basics. Now on the CP side of things, as a medical student, you've probably got some familiarity with what lab tests you might order, but maybe this is your first time to come through a clinical laboratory. So, I think the biggest place to start there is getting a foundation about, well, how does a clinical laboratory work? What are they all about? How do the samples flow through the lab?

Who are the people in the lab? And then in addition to that, some medical students might have had some opportunities to work in a research environment, and starting to get an understanding of, well, what's really different between a clinical lab and a research lab. What are these processes that they have in place so that they make sure that they're resulting out quality results every single time? I think some of these things can be kind of surprising for people that are new in pathology.

So, I think being able to, again, just get that really solid foundation of how everything should work is really important. And I guess as I mentioned earlier, some people might have a subspecialty in mind when you come in. I know I already knew that I wanted to be a molecular genetic pathologist from day one, but it turns out I actually thought all of the rotations were pretty fun. I even liked grossing, and I didn't think I'd like autopsy, but it was certainly interesting, too.

So, even if you've got a pretty good idea of where you're going, you can learn a lot from every single rotation you go to. So, I think it's helpful to approach every single rotation as if maybe this is the thing that I'm actually going to do. And even if you don't do it, you can draw on that knowledge in the future. Or maybe suddenly you'll realize that you have a passion for something that you didn't realize that you had a passion for and you'll change your mind.

And, let's see, I had one other thing in mind, I guess, for advice for a brand new resident. So, I think as a medical student, you get to have a little bit of ownership over what's going on, and making sure that this is my patient, and I'm going to take care of them. But in addition, you do a lot of things that are a little bit more shadowing, or sometimes you are involved, but not the person that's driving something forward.

So, when you're going through your residency training, if you can start taking some ownership of that case. So, you're certainly going to get help. You're not going to be signing it out on your own on day one, but making sure that you know, okay, well, this is what's going to need to happen.

Maybe I have to move on to another rotation, but someone's going to follow up on some immunohistochemical stains, or something else is going to happen downstream after what I've been looking at, taking ownership to follow through on it and make sure that you understand what happened for that case, I think that can be really helpful for people.

And part of that is not being afraid to ask questions, because sometimes some of these things in pathology, like the case will probably get signed out, whether you took ownership of it or not. But if you can make sure that you really understand what's going on, and if you don't, now is really your time to learn. In the future, you'll have to be able to practice independently, but that's not what training is all about.

So, definitely just ask questions, make sure you understand what's going on with that case. Pretend it's a case that you were going to probably have to sign out at the end of the day. And I think being fully engaged, I think that'll help you really get the most out of your residency. - I really like how your answer puts us on this focus. 'Cause I totally relate to your idea of walking into a candy store, and you're just, like, you're so overwhelmed.

And plus you get a lot of trainees you probably look up to who are your seniors who have a lot of knowledge, and that also can get really enticing, but your return to focus, if I'm hearing you right, is that foundational information, which paraphrasing you is this, what's the framework we're approaching that anatomic pathology case. And it's kind of this to the same extent in clinical pathology, the framework on how do you approach clinical issues that come up in the laboratory.

And since this is really a focused on our students, I think that our physician listeners can also kind of take this, and use this same advice you're giving to think about, okay, when I have a junior resident on service, how can I focus on being more transparent with my framework, and how do I approach a case, as opposed to maybe a more senior resident that needs a different sort of training focus at the time.

And then also for laboratory professionals, you might have students rotating in the lab, and sometimes it might be, what do I do with them? And you're kind of highlight on contrasting on a lot of times, people are involved with research, but how is this different than a research lab? How does the lab work on the grand scheme? What does the forest look like? I think are really key insights.

One thing I wanted to ask you just to elaborate a little bit, you talked about ownership, and I think that's such a neat concept that I think it's something that is kind of in the ethers a little bit as a topic, where a lot of times, like, I'm not thinking about it because it's just happening and I feel it.

And it's sometimes maybe with a learner who is not taking ownership of a case. In other words, I guess for me, I feel like then I'm having to step in periodically and direct what's next step, what's next step. But I also am sympathetic that maybe for a learner, that's a little tough to understand and come in. And how does a first year resident work on or start developing that taking ownership?

Do you have any advice for what step one or two might look like for a new resident that's just trying to get their sea legs. What does that look like? - Yeah, I think this is a really good question, because ownership looks like something very different when you're a fourth year resident or a fellow even versus first year resident.

So, I guess my approach would be when I was on call, let's say as a junior resident, for example, in clinical pathology, first, somebody calls you with some question, and sometimes you're like, I don't even know what that test actually is. So, you try to get as much clinical information as you can, figure out, well, what exactly is their question? Take down some notes. And then you tell them, oh yeah, I'll get back to you on that.

And then as soon as you hang up, well, you've kind of got two options of roads you can go down. Number one, you can be like, okay, who's the consultant or the attending, if you're not at the Mayo Clinic, who might be on call, and or might oversee this laboratory, and you can just pick up the phone and call them and relay the exact same thing that you just got back, and get the answer from them. I don't think that's really ownership.

I would recommend taking the approach where you take down that information, and now you spend a little bit of time looking up, well, what is this test? What is this test for? Find out a little bit more about how it might be used clinically, and then try to think, well, how would I answer that question if I didn't have somebody else I could call.

And then once you've kind of got an idea in your mind about maybe what you think you might want to say, then call that consultant or attending, tell them what the person was asking about, tell them what you were thinking, and then ask them for some feedback on that. And in some cases they might say, "Oh, good job, you really understood this test." And you can feel proud and walk away from it.

And other times they might say, "Oh, not even close," but hopefully it'll be something that then you can learn from it. But if you don't go through those steps of trying to figure it out a little bit on your own, it's harder to really get something from that education when it's more passive, someone just telling you the answer. Now, the only caveat to that, is as a first year, you could easily go down a rabbit hole and find thousands of papers to read about this topic.

I don't think you want to go to that extreme either because that pager's probably gonna start going off again. So, you really have to find that fine balance of learning on your own a little bit so that you've got something intelligent to say about this test, and how you're going to ask your question, and that you've looked into it at least to some extent, but recognize that, again, especially as a junior trainee, no one's expecting you to know the exact answer, and it's okay to be wrong.

So, don't spend three days trying to answer that question, because the patient that's on the other end, and that provider, they probably need an answer sooner than that. - I love that. That last part of your answer is really kind of, for my mind, my ear, this kind of highlights, maintaining situational awareness. When is it appropriate to dive in? When is it not appropriate? And also your answer, it really resonates for me, 'cause that's my same process I still follow.

When I get a difficult therapeutic apheresis question, I know I've got Dr. Winters on speed dial, but always before I pick up the phone and call him, I'm always asking, like, okay, if he was unreachable, or if he doesn't pick this up, what would I do with this? Or if he doesn't pick up, what will I do with this? I think that translates to the anatomic path, too.

If you show up as a resident having previewed a case with certain recommendations on what you think this is or what you think this needs, and follow up for special stains, I think that is a way. I think you're really spot on showing how are some ways that as a junior can show what ownership looks like. - Yeah, I totally agree with that comment, too, on anatomic pathology, very similar thinking about what would the next steps be? That's definitely a good analogous pathway in that area.

- So, there was once a coaching book, I get nerdy about this stuff, there was once a coaching book, I think it had some piece of advice in there about kind of

like what got you here won't get you there kind of thing. In other words, what you did to be successful in medical school won't necessarily be what you need to focus on, or the skill set to be successful in residency. And so, I'm curious, in your leadership role, and with your experiences so far, what's a new skill or two that residents should really kind of focus on developing?

- Yeah, I think that's an interesting one, because probably a lot of the skills that did get you here are the things you wanna keep doing. But definitely I think things transition the further you get through your training. Again, since I really like clinical pathology, we're gonna go down that road, but you can think about how it might apply to anatomic pathology, but as a medical student, you think about, well, what's the differential diagnosis?

And then you start thinking, well, what tests might I order to help answer my question and get to the final diagnosis? But I think the things that you don't necessarily really think about as a medical student are the things that end up being really important in pathology. And those would be things like, okay, well what are the limitations of these tests? Or are there situations when maybe I would not want to order this test?

Or what happens when I've got my differential built, I've ordered my tests, and the results just don't come out how I expected them to have come out? So, I think that next level of what's the next step of what I'm going to do, or what could be the limitations of these tests that are making them give me a different result than I expected. I think that's kind of the level to build on. And how do you really get there?

Well, I don't think you can really get to that level of understanding until you've got a good understanding of how the actual tests are working, and how the disease processes are working. So, a medical school prepared you pretty well, I think, for how the disease processes work, but really a lot of being a resident, at least on the clinical pathology side, is understanding how are the tests working, what are their limitations, what's the technology that's driving that?

And then if you think about it on the anatomic pathology side, I think it's kind of somewhat similar. So, you have your differential when you've got this slide in front of you about what it maybe could be.

And sometimes you can probably get that answer, looking at the H and E. And that's probably similar to maybe what you would've seen in a medical school histology sort of class, or pathology sort of class, but then sometimes you're like, "Hmm, I'm not really sure what this is," or you might need to order some special stains to differentiate that. So, it's really that next level of thinking.

And again, for figuring out what to do in those more complex situations, I think you just really have to have a deeper knowledge base, and you really can't get there by just memorizing a lot of factoids about these disorders. You really have to start fully understanding that underlying pathophysiology.

So, I think that's probably the thing that I would focus on the most is the understanding the whys of medicine, as opposed to starting to recognize patterns, and some of the things that maybe you focused on as a medical student. So, just getting a little bit deeper in there. - One of the things I really appreciate about your answer, Dr. Moyer, is it's something that is possible, whatever my training environment is, right?

So, you don't have to have crazy things come up, but you're talking about that next level thinking. So, I guess if I have a patient case in front of me thinking about all the permutations about how this could be off, and if I did get such a such a result, or if this wasn't seen here, if this artifact was introduced, how would I navigate around this?

It seems like it's something that no matter where you are in the world and your resources, it's something that you can do to, I don't know if that's mentally hardening or preparing yourself for, you're the endurance athlete, so. - Yeah, I think you're right, even, so a lot of times you'll be lucky, or unlucky, depending on how you view it, and you'll get those really tricky cases.

And I do think that those are sometimes the most educational, because they're going to take you a while to sort through them. And that's when you see when things didn't follow the textbook. But even if things are following the textbook, if you've got time to read about your case and think about your case, I think you can start going through some of those various permutations, too, to think about, well, what would happen if this stain did come back negative, or what would happen

if this laboratory result didn't match what I thought it should have matched. So, I think that's a very good point. - So, shifting gears a little bit. So, we've been talking so far about all the things that we can work on, focus on to be successful. I'm kind of curious about when learners struggle, and how can they get help and approach that? And I imagine that as a new resident, it's particularly difficult to reach out. You're probably in a new city, in a new training environment.

This is very different than what medical school was like in some important ways. And, I don't know, quite disorienting. And so I was wondering if you could kind of share with the student listeners, what do you recommend, when you sort of realize, you sort of look around, you're like, geez, I'm not really being, I don't think I'm being as successful as I should be. What should learners do in that situation?

- I think step one is to stop and realize that, and this is coming from me to you, you're probably not alone. Everybody has probably hit a point where you feel like, oh my gosh, this is really overwhelming. I don't get this. This is confusing. And you start worrying about, well, maybe I'm not cut out for this, or whatever the case may be. They're always, everybody hits rough patches, I think, where you hit concerns or doubts, or things you really need to work through.

So, I think the number one thing is just know you are not the only person to have experienced this. So, then I think that leads to number two. If you can recognize that, and believe me when I say this, I've hit periods of time, too, when there's things that I just don't really know what to do about them and feel a little overwhelmed, but it makes it a little bit easier to do what I think is important, which is to reach out to other people.

And if you can recognize that, you know what, I bet they've hit a hard point at some point in their life too, it makes it a little bit easier to feel like maybe it's okay to ask. So, I think what I would do is think about, well, who can I reach out to? And I think you have a lot of options. So, if you haven't found a mentor yet, I would definitely recommend trying to find somebody that you click with.

They can either be someone that's in an area of pathology that you would like to go into in the future, or maybe they have some attributes that you would like to emulate, or maybe they just were friendly that first day when you met them, and you can chat with them a little bit more. So, they don't necessarily have to be someone that's doing the exact career path that you are planning on doing, but someone that you feel comfortable talking to.

And the other person that you could potentially talk to is your program director. In general, program directors are there to help you out. That's their goal is they want to see residents be successful at the end of the day. And if someone is struggling and they never tell their program director about it, they'll have no idea that you're having a hard time.

So, program directors, associate program directors, rotation directors, they all, like, we wouldn't be doing this educational thing if we didn't want what's best for our trainees. So, if you're feeling a little intimidated by those people, even though they're totally there for you, they've got your back, they're senior residents at most programs also, perhaps some fellows, some of those people can help give you some tips, too.

And they've been in that position that you were in, not really that long ago, like, especially think about a third year resident. They probably still remember what it was like to be a first year resident. And even for me, it's been a little while since I was a first year resident, but I definitely remember being like, I don't even know what that word is that they just said, I'm gonna have to go Google that later, or look at a textbook, or what was that?

So, I think just finding people that you can reach out to to kind of ask them, well, how did you get through this? Or what ideas do you have for me? And if you've got something very specific, that's a hard thing that you're working through. There's also at a lot of institutions, people who are academic success coaches, and they might have different styles of studying, perhaps, that you could apply, or different techniques you could use.

And I guess if the other thing to think about, too, is probably spending some time reflecting on what exactly is going on. And this is maybe the first thing that you would even actually want to do after realizing that you're probably not the first person to experience this. I guess this is the insert before you talk to the other people, maybe think about, well, okay, what am I really struggling with? Am I just feeling a little bit overwhelmed?

Because as a first year, it's like you're drinking from a fire hose, and there's so much new stuff. And I'm actually doing okay, it just feels overwhelming. In which case, if I keep studying, I'm going to be okay, I'm gonna get through this. Or am I truly struggling in one specific area, one rotation? Am I not spending enough time reading? Am I reading, but not understanding?

Kind of really feeling out what exactly you're worried about, because then when you do talk to those people who are there to help you and are going to be sympathetic, and want what's best for you, they'll be able to better help you and direct you to any resources that you might need. Or sometimes they might just need to be there to be a supportive, friendly face, while you explain what's going on. And maybe you just need some reassurance.

But I think there are a lot of different scenarios that people run into as a resident. And sometimes things outside of work life can get in the way of some things sometimes, too, because we're all people outside of being doctors. So, kind of thinking through all of the various permutations

of what might be inhibiting me from doing as well as I would like to do, because they're also resources for all of those other things outside of pathology, too. But again, no one can really help you if you don't ask for help, because it's hard to see from the outside what someone's going through. So, never be afraid to reach out because everybody wants what's best for you at the end of the day. - It's an important message.

And I think another thing is what you're answering there, it really resonates for me in practice in that I guess I've got a division chair that I go and have a meeting with. It might be most similar to having a residency director. But it's that same process of I'm reflecting in between these meetings, and what am I struggling with, what do I need help with? These are things that are skills that kind of continue with you going forward in your professional career.

How do you recommend residents kind of approach those meetings with their program director? I mean, sometimes there's meetings called for a specific reason, but there's also kind of periodic meetings that are scheduled. And I'm kind of curious for your thoughts on how do residents make the most of those meetings? - I think it depends on what exactly is going on at that point in time for the resident.

So, if you are having a difficult time with a rotation or a situation, or something's going on in life, and it's something that maybe you could use some additional resources or some help with, definitely come into the meeting feeling ready to talk about those sorts of things. It can be hard to talk about it, but I think that's an important thing, because that's, again, how you get the help if you need it.

If it's more that maybe you've got some questions, you're not really sure how do I go about applying for a fellowship? How do I go about figuring out what I'm going to do during this elective? How do I start thinking about I don't know what specialty or subspecialty I want to go into? How do I figure those sorts of things out?

I think if there are things rolling around in your mind that are bothering you, sometimes it's hard to at first put them into words, but again, by doing some reflection up front and figuring out what those things are, if you can come to your mentor or your program director with more specific questions, it's definitely a little bit easier to guide someone, but if you're having a hard time putting it into words and there are things that are, you're still trying to figure out,

even just going in and talking to your mentor or your program director with an open mind, sometimes they'll know what questions to ask you to be able to help sort out those sorts of things. So, I think being very much willing to talk, being open with the person that you're working with that's there to help you, and being able to have some specific questions ready to go, if you've already got specific questions, can be helpful.

But then beyond that, if you're meeting with a mentor, for example, I think some of the things that you could be thinking about if you're not really sure, well, what am I gonna talk about with this mentor? I've got this lined up. Well, some of the things that I think are really important, especially as a junior resident is thinking through, well, what are my short term goals? Do I just wanna get through step three, for example, and how am I going to do that?

And you can ask your mentor questions about maybe how you could be preparing for that, or when a good time is to do that during the year. But then as a junior resident, you probably want to start thinking about some of those long term goals, too. You don't have to know the answer right away about what area of pathology, or what type of practice, or anything you want to go into, but start exploring, well, okay, these are the things that I really like.

These are the things that maybe aren't my favorite. And if you start to get a sense of what direction you're headed, then again, that mentor or program director can start steering you towards maybe other people, and doing some networking, and people that they think, oh, you should probably talk to this person, because they can give you a better picture about what that subspecialty looks like.

Or you could talk to this person because they might have a good insight of what it feels like to work in industry, because I don't know that, I work in an academic setting, for example. So, I think coming in with some of those specific questions can be helpful, but really just being open minded,

because sometimes you'll come in, and you might have some questions, and then your mentor might start asking you some questions. And sometimes I think you know subconsciously what you want to do, or what the best path forward is, but your brain is telling you something else. And if they're asking you the right questions, sometimes you realize that the advice you're getting isn't quite what you expected.

And if you're open to it, you might ultimately get to a better solution than you were originally thinking about. So, I think just being open to share with your mentor and open to their feedback makes for a really good partnership. I guess the other thing I didn't really mention at the beginning, though, is sometimes just having some goals.

If you've got a formal mentor, for example, figuring out, well, what are the things, like, what's the goal of this mentoring relationship that can really help steer things, too? 'Cause you'll probably keep meeting with them long term. And so maybe one time that you meet with them can lead into the next. But I think there's a lot of different things that can be gleaned from meeting with them during these meetings. So, just being prepared and ready to talk.

And usually it's a pretty fun and pleasant experience. - Wise words, deliberate words. We've been rounding with Dr. Moyer. Thanks for talking with us about how can resident learners really have success after orientation. And to all of our listeners, thank you for joining us today. We invite you to share your thoughts and suggestions via email. Please direct any suggestions to mcleducation@mayo.edu, and reference this podcast. If you've enjoyed "Lab Medicine Rounds" podcast, please subscribe.

And until our next rounds together, we can encourage you to continue to connect lab medicine in the clinical practice through insightful conversations. (upbeat music)