SUPERVISING A COMBINED RESIDENCY/GRADUATE RESEARCH
TRAINING PROGRAM
Paul C. Stromberg
Unlike many tasks pathologists might be asked to assume, leading training programs is not one that is usually “dropped in your lap” unexpectedly. Most of us join training institutions as junior faculty members and grow into the leadership gradually with time. This means you have the advantage of experience with the system, resources, staff, faculty, current students and program activities. Pathology training institutions and programs around the world are quite diverse with respect to resources and likely have adapted over time to accomplish the goals of the program with what works best in each unique situation. So if you are growing into leadership gradually you have a big advantage when tasked with eventually leading it; you have insight into what has worked and you can change it gradually. To young recently hired faculty from outside the program, guard against trying to change too much too fast. Get to know the system, how and why it worked before doing things too radically different. Know the reason why things work and the downstream unintended consequences of changing things in a system with which you are not familiar. You can only familiarize yourself with your new institution by taking time to observe how it works and discuss with the “Old Guard” why certain things are done.
There are two fundamental types of pathology training; residency and combined residency/PhD programs. The substance, activity and demands of these are quite different. Residency training in clinical and anatomic pathology are similar to residency training in other medical specialties. The student spends 36 months engaged in learning the pattern recognition skills of their specialty under the supervision of experienced specialists. The experience depends heavily on clinical material from hospital based cases supplemented by familiarization with the textbooks and published literature and whatever formal course work exists. At the end of that time they are qualified to sit the certification examination. The merits of this system are that it is short and focuses on professional medical training.
Combined programs are very different. The student must learn enough pathology to be equally as prepared for the certification examination as pathologists in residency programs but at the same time finish a research project suitable to earn a
PhD degree in the host institution. This is quite a challenge if the experience is to
1

provide enough pathology for board preparation while at the same time learning how to conduct a high quality prospective hypothesis driven research investigation.
One side of the process is focused and often rote while the other favors independent thought, innovation, much trial and error and a little luck. It often takes 5 years or so but is efficient in that two goals can be satisfied in a shorter time than if both were pursued separately. The research experience needs creativity and perhaps a little innovation and requires time which often cannot be compartmentalized as easily as professional specialty training. So in combined programs, research must take priority which changes how we teach pathology. In addition, the extra time spent also allows a certain amount of personal growth and prolonged exposure to the pathology related activities in the program which may have a benefit in the certification process.
The most important attributes of an investigator, curiosity and imagination, cannot be taught. Students either have these attributes or they do not. They provide the motivation and desire to labor through a research problem. We can prepare the ground for such students, facilitate opportunity and lead by our own example but if the desire and curiosity are not at a threshold level, the research project becomes just another task on the road to acquire a credential and perhaps a bigger salary.
The question then is how do we find and encourage student interest in a research career? Our traditional target audience has the veterinary student body. This is where we could have the most impact to influence or encourage a career in research but it might be too late. The most we can do is demonstrate by our example, our passion, enthusiasm and satisfaction with a research career and hope that some choose to follow our example. But our real target should be undergraduate students. Because most curious, research oriented students make the choice to pursue research directly after undergraduate school and do not attend professional school. This audience is the one that should be reached and informed of the rewards of both professional training and research training.
TEACHING THE SCIENCE OF PATHOLOGY----THE EASY PART
Teaching others what we have learned about animal disease is of course what we were all trained to do. We take the clinical material that comes to us, expose our students to it and instruct them about recognizing lesion patterns, interpreting what the patterns might mean and make diagnoses. It’s what we all know how to do. We are well prepared to do it and I believe in the main we do a pretty good job of it.
It’s how I expected to spend the pathology side of my career. At its root, the science of pathology is all about pattern recognition. As pathologists become more experienced, many begin to appreciate the subtle nature of these and how
2

frequently the once black and white distinctions between entities become blurred.
Experienced pathologists begin to make intuitive diagnoses not based on step by step consideration of the pattern elements that cognitive psychologists call
“Gestalt” diagnosis. The skill is real, important and is the mark of the experienced pathologist. This is well known from studies in human medicine but how do we teach that idea to our students?
TEACHING THE ART OF MEDICINE----WHAT I DID NOT EXPECT
AND WAS NOT TRAINED FOR
While the science of medicine focuses on teaching the facts, the art of medicine deals with how we practice, on a daily basis, the collection of the facts (image patterns) and the decisions we make in acquiring, assembling and reporting the facts that ultimately lead to a diagnosis. Indeed, it may entail the distinction between objective facts and subjective interpretation of facts. This is at least as important as teaching the facts if not more so but traditionally very little attention has been paid to this. Generally, it is left up to each of us to make these discoveries on our own as our individual experiences progress. There is no body of knowledge devoted to this in veterinary medicine much less veterinary pathology and we must borrow from human medicine for guidance if we are interested to teaching this to our students. We get some insight about the art of medicine from the Hippocratic
Corpus and its most often quoted lines:
“Life is short, the art is long,
Opportunity is fleeting, experience delusive
Judgment difficult”
Hippocrates was telling us that medicine (and pathology) is too complex and too long to be mastered in a lifetime much less a 30-40 year career. We all know with the explosion of information in science how difficult it is to keep up much less master it, often even in our own specialized area. And the opportunities to study, learn and add to our knowledge are rare. When such opportunities are recognized we should act on and pursue them; publish that case report or follow up a diagnosis we made to see what happened. We all understand the value of “experience” but do we understand that it is no guarantee against errors. Although we share similar experiences we do not all have the same experience. If we did, we would always agree but we do not. Part of the divergence in medical opinion, often considerable is due to the fact we do not all have the same experience. And perhaps the most important aspect about the art of medicine is “judgment”. In the end we have to make a judgment about an image pattern to make a diagnosis and yet we hardly
3

know what judgment is much less how to teach it to our students. “
Judgment is difficult
” because often image patterns overlap or vary considerably and while experience often helps us make such judgments, it does not always lead us to the correct diagnosis. How do we teach our students to juggle the facts we see and make a difficult diagnosis that may not be agreed upon universally? Hippocrates was correct that judgment is the difficult part in medicine because it is not uniformly taught, learned or applied. This is where the science of medicine gives way to the art of medicine and is attended by all of the uncertainties we know so well.
We all recognize that image patterns have a range of variability, likely distributed around some mean or classic textbook pattern. We learn this classic pattern while training and spend the rest of our careers learning or defining for ourselves the range of variation around this mean. This learning goes on forever as we constantly refine our criteria for the non-classic but within the range of variability pattern. It requires constant feedback (verification that we were right or wrong) which we often do not get (“ Opportunity is fleeting ”).
In addition, the image patterns of some entities overlap. Undifferentiated nasal carcinomas and sarcomas can look very similar. And it is not always an “either or decision”. Spindle cell proliferations can be granulation tissue or a one of several spindle cell sarcomas or even a melanoma. How do we teach students to work through the decision tree so they will arrive at the correct diagnosis most (all?) of the time.
However much we all strive to be perfect, we must recognize that consistent perfection is unattainable. We make errors in judgment. Everyone does. Deal with it! Although there is little or no literature about this in veterinary medicine, we can borrow from exhaustive studies in human medicine. We manage this risk by knowing the cognitive traps that often lead to errors and avoiding them if possible.
Although experience in judgment is important and a real skill, it does not insulate us from errors (“ Experience is delusive ”). In fact in some cases it predisposes us to error that young inexperienced pathologists are not subject to.
Two guidelines that are useful in judgment are also used in clinical medicine.
Number one is the first rule of medicine, “ Primum non nocera ” or “ Above all do no harm ” and the second is the concept of “Total Patient Evaluation”. You should know the consequences of an error in each clinical setting or diagnostic case and you should not make a diagnosis until you have as much information about the case as possible. Although sound rules, we often are not able to take full
4

advantage of these principles. This is the art of medicine for which I was not trained to teach and did not expect to be teaching yet is a very important aspect of teaching medicine.
5