Training in Pathology Informatics:
Lecture, Project, Rotation,
Fellowship and beyond
Raymond D. Aller, M.D.
Director of Informatics
USC Pathology
20 September 2010
20 September 2010
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Acknowledgments
Dozens have contributed – I can mention
only a few here

Ramzi Cotran, Stan Robboy, Roger Cote,
Brad Copeland

Frank Elevitch,Bill Hartmann,Tom Lincoln

Mark Tuthill, Bob Miller, John Gilbertson,
Paul Catrou, Anil Parwani, Ul Balis

Wes Naritoku, John Vallone,

Alexis Carter, Stephen Hewitt, John
Sinard, Brian Jackson
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Evolution of training in pathology
informatics

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Explorers and pioneers: we have been
training for a long time
Training in general medical informatics
programs

Early adopters - OJT

ABP: informatics as a subspecialty -

Spotty coverage in residency
Sporadic fellowships
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More recently, it gets better ...
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Ongoing fellowships
General medicine rediscovers board
certification
Advertising for these skills
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The explorers
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Bill Dito, Art Rapapport, George Brecher,
Homer Warner, Phil Hicks, many others
Self taught
From basic data management to deeper
analysis
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The pioneers

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Mike McNeely, Don Connelly, Delane
Wycoff, Art Krieg,
Again, focused on facilitating lab workflow
Some – graduate degrees, MD theses,
NLM fellowships
Both explorers and pioneers passed
knowledge to colleagues via national
meeting seminars
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Informatics training: past

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1970's: informal rotations, occasional
masters and MD theses – Missouri, Utah,
Minnesota, Harvard, others
1980's: under pathology leadership, NLM
sponsored training fellowships at several
universities – plus others
–
NLM leader: Don Lindberg
–
Ohio State: Jack Smith, Oregon: Bob
Beck, Minnesota: Don Connelly, Utah:
Stan Huff, Indiana: Clem McDonald
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National pathology meetings and
resources

1970's on – Informatics seminars – ASCP, CAP,
IAP (now USCAP)

1983: AIMCL, University of Michigan

1984: Bill Dito's Informatics in Pathology journal

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1987: monthly pathology informatics coverage in
CAP Today (continues today)
Late 1980's: over half of the seminars presented
at the biennial CAP meetings are on informatics.
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User Group meetings

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Another important source of lab informatics
training
How to get more value out of a system you
already own
How to get past seeming roadblocks to improve
patient care
Many of the most relevant and practical seminars
are in this context
E.g.: Sunquest, Kontron, Medlab, Mediware,
Meditech, Cerner, Soft
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Written Resources

For many years, there was only a single textbook
in this field (Elevitch, ABCs of LIS)

Chapters in Henry

Some journal articles

CAP Today coverage

In past five years, a number of useful books have
appeared
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“Just in time” knowledge

Calling your friends

Local colleagues

Google, Wikipedia, etc

API listserv

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American Board of Pathology
proposed subspecialty
1992 Letter of intent to American Board of
Medical Specialties

Intended to be open to diplomates of any of
the ABMS boards

Appointed 5-member informatics test
committee

Test committee met for a number of years

Unfortunately, could not devise a sufficient
number of questions testing informatics (as
opposed to “bits and bytes”)
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Formal informatics training in
pathology departments.

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1993: the residency informatics rotation
described
An increasing number of departments offer
rotations
1980's-1990's: A few unique fellowship
trainings – Johns Hopkins, Michigan
CAP Foundation training grants – for
residents to attend AIMCL, APIII
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Into our own – the 2000's

A number of formal fellowships established,
fellows trained

The Association of Pathology Informatics

Description of curriculum for a fellowship

At end of decade: a few fellowships fully
active, but others lack sufficient candidates
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How is informatics information
available to pathologists today?
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National meetings: CAP, USCAP, AABB,
DR/EWC, AACC, ASM, CLMA, PI2010
National LIS user's groups
CAP Today
Occasional articles in other path journals
Articles in general informatics journals
Most recently: online J Path Informatics
Residency training in informatics required
Fellowships
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Residency rotations lacking

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Many departments/programs lack interested
faculty
In some departments, informatics does not
get academic respect
Competition for time in the general residency
training
We know how to teach surgical pathology –
we are still learning how to teach informatics
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Compensating for inadequate
training

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Residents fail to recognize the gap in
informatics training until too late.
Some apply for CAPF travel grants to
attend LabInfoTech, APIII, Pathology
Visions, or now PI2010.
Others don't do even that much.
Very few seem to take advantage of
rotations available in other programs, with
strong informatics faculty
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Leaving value on the table ...

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One program with a well established
informatics curriculum and faculty offered a
rotation for residents from other programs yet over a number of years, no one applied
or came.
While residents seem to understand the
need for slide-reading skill, they seem
clueless about managing the actual product
of their department.
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Pathologists without basic
understanding
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Recent training is no defense
Many residencies lack a meaningful
rotation
National pathology meetings offer fewer
informatics seminars than they did 15 years
ago.
National meeting seminars: they gave a
party, no one came...
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Most fellowships are undersubscribed
One university offered a fellowship, it was
never filled
Another only had four fellows in 25+ years
Others are less than half full.
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Program began trained concur durati advance faculty
so far rent on
admiss
Pitt
2000
15
1
1
16
2+6
MGH/Part
2007
2
5
1 to 2
16
14
Henry
Ford
2006
2
1
2
4
1
Johns
Hopkins
1990
4
1
1 to 2
4
1
Michigan
95/08
3
1
2
4
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Length of the fellowship
Some programs structured as one year,
others as two years
One year:

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–
–
less time away from other aspects of
pathology practice
May be easier to schedule
Two years:

–
–
More time for fellow to learn the environment,
become a productive member of the team
“Informatics projects are at least two years”
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Thoughts on structure: 2 years

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Gives a better chance for the fellow to
become a productive (net-positive-FTE)
member of the team
Lead time on position recruitment may be
18+ months
Strongly consider including a component
of case-based responsibilities
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Case-based responsibilities

Such as a rotation reading biopsies - within
the informatics fellowship.
–
to prepare our fellows for practice settings, and
–
to maintain continuity with case-based
pathology
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Thoughts on background: 1 year


For those who already have leadership
and management skills (may have been
in practice for some years)
Desire greater depth in informatics than
afforded by their (non-)rotation in
residency.
How do we ensure that they come up to
speed more rapidly, and take on
adequate front-line responsibility?
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More concerns about 1-year
fellowships:
Not long enough to learn the systems and people,
to become productive, and to have an impact.
Not enough time to develop skills; yes it gets
them out and they can start earning, but they
are very green; mainly this relates to a mature
perspective and business management and
negotiation skills
Both MGH and Henry Ford noted 2 years is just
barely enough time to develop skills

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How far in advance are fellows
appointed?

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The more successful and highly
subscribed programs designate the next
fellows about 15 months in advance.
In order to compete for candidates 18-24
months in advance, funding must be
secure a long time ahead
Otherwise, the best candidates have
already committed to another program
before the less-funded program can even
offer a slot.
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Those programs recruiting later ..


... recruit only a few months before the
program would begin.
However, the best candidates are making
a commitment for a period 18 months
through 42 months from now.
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Facilitator/administrative support

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Half time, or so
The two most successful/highly
subscribed fellowships each have such a
support person
It appears that the others (less successful
in recruiting) do not have such support.
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How many faculty?
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.. at least 40% time doing informatics
(service, research, teaching, etc)
One, one, two, two + six, 5, 14
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Faculty roles

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Program leader/director/cheerleader
Plus additional staff with special interests:
imaging ,
Adjunct contributors for management,
regulatory,
Co-directors in CP, AP, molecular,
imaging
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Number of fellows Many programs - zero much of the time
Some programs, one
Another, five
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Funding

To assure continuation of program

To increase the number of fellows
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To provide additional support for faculty
(e.g., NLM training grant at Pitt)
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Funding sources
-- Intramural/practice funds
– Laboratory revenues
– NIH training grants of various types
– One program mentioned growing beyond
the current 5 - "could easily recruit and
train 6 or more fellows next year"
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Consistent funding

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Essential to carry forward with such a
fellowship (can't recruit otherwise)
Some fellowships have been hamstrung
by inconsistent funding
However, it is often challenging to justify
existing front-line operational employees
in the informatics group - the linkage
between funding and productivity of an
informatics fellow may be more difficult
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General medical informatics
programs

Interaction with NLM funded general
medical informatics fellowship?

MGH - available, but not best option
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Some others – not available
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Making the fellowship
sustainable: not just funding

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How to reach the point where faculty time
consumed is more than made up by
useful work product of the fellows.
How do we get fellows up to a point
where they can begin to do things
independently (need to acquire a deep
understanding of existing systems)
“I just don't have any "excess" time to
spend with a fellow.”
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Impact on faculty time

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“our current fellows are experienced, all
three have prior experience with
operations and research. They are a net
positive”
“it's nearly a wash year one; very
valuable year two”
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Avoiding faculty overwhelm

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Recruit candidates who already have
management/leadership skills
If you offer a 1-year fellowship, bring in
people who can already contribute
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Effect on faculty workload

Faculty
time
Weeks -->
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Subjects covered in fellowships
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Management and workflow optimization
Administrative-type activities with the
informatics group
However, avoid "just follow me around to
meetings"
Image management, analysis, image
perception
Molecular epidemiology
Health services
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Programming?

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Understanding the use of tools is essential, but
it doesn't teach pathology informatics
for a person who already knows programming,
to simply do another programming project is not
productive.
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Operational responsibilities
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"depends dramatically on their career
goals and their experience" vs.
“Essential for a training program”
Developing new tools and approaches
Implementing systems
Innovative pathology reporting (online,
graphical, interactive)
Web-based delivery of diagnostics
information
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Fellowship projects

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Large clinical operations projects that
involve the health system and the lab
many! as many as possible; big, small; part
of team;
goal is to get them to lead a large to
medium size department project of their
own with budget, staff, planning etc.
The topics are matched to the fellows
interest and skills
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Ideas for projects

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may originate from their own idea;
more typically related to labs needs and
established plans.
As projects require capital and resources these
just don't pop up and get done.
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Informaticists should use what
they develop
In one case, a clinical pathologist “C”
developed a cytology system for his
colleagues – they seemed to think it was
fine

Several months later, one of the partners
became ill, and C was asked to take a
rotation on signing out Paps

C soon realized that the system's
workflow was awful

He fixed it, and his colleagues agreed it
was much improved.
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Implications: informatics practice
Some program directors commented on
the jobs their fellows had taken

Spending 50% time in informatics, and
50% time in a more traditional
subspecialty, has several advantages

Not only are systems better designed, but
you have more credibility if you share in
the “workload”

More opportunity for interaction with
clinician colleagues if part of your time is in
a case-based practice.
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Research time
.
Academic: 35-70% of time is protected
research time, depending on goals. Related:
opportunity to earn a graduate degree (MS,
Ph.D.)

Community -they have "research projects" and
studies they get involved in. Our shop is very
operational. I consider what they do more
proving concepts or testing solutions versus
hypothesis driven research

For the pathologist interested in the community
practice of informatics, time spent on research
means less time learning the practicalities of
informatics
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Service work
Myriad:
– system maintenance,
– issues resolution,
Training of staff and residents
No on call per se
Image analysis
Diagnostic pathology (e.g., surgical
pathology, cytopathology)
Clinical pathology (e.g., transfusion medicine)
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A different type of disease

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The surgical pathologist diagnoses a series
of patient diseases
the informaticist
–
diagnoses and treats the diseases of
systems
–
Finds ways to make work more efficient for
his/her colleagues
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How do we teach

Responsibility
–

How do we structure our organization so
that the fellow has clear operational
responsibility?
Leadership: informatics has much in
common with management – both are
difficult to teach to residents, fellows
Delegate the various tasks
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After fellowship ....
What are the next career steps for a pathologist
after fellowship?
Several: academic medical centers
Another director of lab informatics at a large
hospital in India
Some full time informatics,
more are half time informatics, half-time surgical
pathology/etc.
At least one has founded own52company
Creation of new fellowships?
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
Talked with at least four organizations that
are considering starting a fellowship::
academic, government, reference lab,
And with one well-established department
that doesn't think it's feasible
Why create a fellowship?
–
–
General clinical informatics is thinking about
board certification – need to be at the table
Recognize the need for informatics leaders
in many organizations
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Barriers to creating a fellowship
Faculty time

Funding

Facilitator (support person)

Finding qualified people
• Very very small candidate pool
• only one or two qualified
candidates per year"

Fifth wheel (Finding a role)

Free space

F ......
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Lack of qualified candidates

Not enough exposure in medical school, or
residency
–
–
Lack of training
Lack of mentors/examples
Most residents have no concept of informatics
practice

Inconsistent funding for positions – year to year,
soft money, or dependent on vagaries

Informatics fellowships are not ACGMEaccredited

Uncertainty about job prospects – marketability

Some applicants seem to want to hide in a
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backwater
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ACGME accreditation? But there
isn't an approved sub-specialty...

Two types of programs accredited
–
–
Regular subspecialty: transfusion
medicine, chemical pathology,
microbiology, etc...
Selective pathology fellowships - over 60
of them
•
•
•
Many in special areas of surgical
pathology
A few in clinical pathology
This is the area where we would apply for
accreditation of an informatics fellowship
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ACGME accreditation for fellowships

Advantages:
–
–
–

Medicare funds ½ FTE
Time in fellowship counts towards
AP/CP Board time
Time counts toward maintenance of
certification
How do we sign up?
–
–
Pathology Residency Review
Committee: program completes and
submits the Program information form
RRC evaluates the program, evaluates
the quality of the teaching.
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Accreditation – a mixed blessing?
One large program: "don't think this would be
a good thing"
A smaller program: don't really want the
paperwork hassle; it is enough to comply
with our own non-accredited fellowship
requirements in the institution.
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Accreditation 2
- If board recognition became a reality for fellows,
that might be a reasonable trade.
- “I just saw the 75 pages of &%$ our cytopath
fellow had to submit to the ACGME. Major
waste of time that had no impact on what
fellows do now versus what they did ten years
ago”
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Job prospects?




There are ads for pathologist
informaticists – but not oodles of them
In many cases over the decades,
informatics jobs have been created
(perhaps from something else) when a
candidate appeared
In other cases, a pathologist in a different
role has evolved into the informatics role
Even advertised positions sometime
specify a combination of skills that fit only
one person in the country
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Some not optimistic
“Although I believe there should be more jobs
available, especially as some of us older guys
retire, and the perceived need, at least by API
members, seems to be growing, I'm not sure
those jobs will be supported. (Locally, when I
retire, I really doubt if my position will survive).”
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Not optimistic 2
Hospital IS wants to absorb the LIS which I have
fought to keep in Pathology for the last 20
years.
I think Pathology may have lost the ability to win
the battle of ownership of pathology informatics.
Hopefully, I'm wrong.
Currently, I sense a resurgence of energy to get
pathology informatics back under pathology.
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Informatics plus another subspecialty
Maybe one idea should be to emphasize
pathology informatics not only as a primary
field, but also as a secondary field of emphasis
when recruiting residents (eg, surg
path/informatics, hemepath/informatics,
molecular/informatics, etc).
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Trailblazers, pioneers, settlers


"Today's pathologists who work in imaging
and data are like trailblazers, and the
fellows will be the earliest settlers, but it will
remain a rough world out there for a while,
before things develop. I think the
trailblazers enjoy the "risk", but I am not
certain fellows appreciate that there are not
jobs with pathology informatics as a job
description/title out there yet."
In 50 years, we will be suburbanites
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What are candidates interested
in?

“Recently, have seen increased interest
from people that want to be directors of
core labs.”

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General medical informatics
programs
In some organizations, pathology informatics
faculty spend their time with a general
medical informatics group
Examples: Utah, Oregon, Johns Hopkins,
Ohio State
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Advice to a department
considering offering a program
O: “Ramp up your faculty and your
department pathology informatics initiatives
first, the fellowship will follow naturally.”
R: “plan: money, space, time and faculty; be
aware that qualified candidates may not
surface”
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Adding informatics into other
fellowships
There may be opportunities to modify a
traditional (e.g., surgical pathology)
fellowship year to include a high
component of informatics.

–
During the elective months
–
And as ongoing responsibility during the
case-based months
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References


There are several useful articles on this
topic in the literature.
Rather than trying to jam them on several
slides, I ask that you eMail me to request
a list
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Thank you!

I appreciate your attention

raller @ usc.edu

I welcome your questions
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