The Case for a New Model for Pathology
Residency Training Requirements
Ron Domen, MD
Penn State Hershey Medical Center and
College of Medicine
Hershey, PA
Special Thanks to my Co-Author
• Jennifer Baccon, MD, PhD
• Domen RE, Baccon J. Pathology residency training: time for a
new paradigm. Human Pathology 2014;45:1125-1129
Historical Notes
• Prior to 1900 – pathology was the study of “morbid”
anatomy (autopsy)
• 1900 – AMA established “Section on Pathology and
Physiology”
– Helped to define scope and educational requirements
– 1924: Minimum training for a pathologist: preferably some
hospital experience, 2 (better 3) years of “special study
under a good pathologist in a laboratory where there is
plenty of material”
• Early 1900s – clinical physiology and clinical chemistry
increasingly became aids in disease diagnosis and
treatment and began to define “clinical pathology” as a
separate area of medical practice
Historical Notes (cont)
• In the early decades of the 20th century “clinical
pathologists” also performed AP duties (Today,
should CP more properly be called, Laboratory
Medicine?)
• Pre-WW II – growing numbers of hospital and
state-run clinical laboratories with increased
oversight by pathologists
• 1932 – ASCP designated an arbitrary time of 3
years of study for qualification in clinical
pathology (accepted by the Council on Medical
Education and Hospitals of the AMA)
American Board of Pathology
• Formed in 1936
• 1938 examination requirements (5 years)
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Clinical internship (1 year)
Clinical pathology training (1 year)
Pathologic anatomy (2 years)
Additional pathology training or practice in pathology (1 year)
1973/74 - Clinical internship year eliminated
1985 – fifth year added (intention was to be a clinical year)
2002 – fifth year eliminated
2002 – present: AP (18 months) + CP (18 months) +
Electives (12 months)
Thomas M. Peery, MD
JAMA 1959;171(15):2065-2068
“This rapid expansion of services accounts for
most of the pressing problems which confront
the clinical pathologist today. First and foremost,
we find that no one pathologist can possibly
encompass all that must be known for the
proper expansion and development of
laboratory services.”
Townsend JF, Van Peenen HJ, Senhauser DA, Lucas FV.
J Med Educ 1971;46:456-460
“Physicians preparing for academic careers
really require more than four years of
educational experience to become competent in
clinical and anatomic pathology. In the authors’
experience, they need six years. At end of that
time, they…have begun to attain depth in one
area of pathology.”
Gorstein F, Weinstein RS.
Hum Pathol 2001;32:1-3
“Remarkable scientific advances have
broadened the potential scope of practice and
have made mastery of the entire body of
pathology information an impossibility.”
Christopher N. Otis, MD
Hum Pathol 2006;37:929-931
“Aside from the basic medical knowledge in
anatomic pathology, the other areas [molecular
pathology, cytogenetics, bioinformatics,
management skills] are different angles on the
same topics necessary for clinical pathology
training…Is it time to consider an entirely new
approach to residency training in pathology, an
approach that allows for training in the basic core
competencies while providing enough latitude for
the trainee to differentiate throughout training?”
The Current State
• 2-plus-2 years paradigm of combined AP/CP training
– Minimum of 18 months in each area
– 12 months of elective time
– Up to 6 months of research
• AP-/CP-only (24 months + 12 months of electives)
• Employers increasingly want fellowship trained graduates
• >90% of residents pursue a fellowship (30-40%, 2
fellowships)*
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Required for a desired position
To enhance their skills and develop area(s) of expertise
To enhance their ability to secure employment
(top 6) surg path, cytopath, hemepath, GI/hepatic, dermpath, forensics
*2014 ASCP Survey; and, Lagwinski N, Hunt JL. Archiv Path Lab Med 2009;133:1431-36
The Current State (cont)
• What do employers want/look for:
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Diagnostic competency
Fellowship training (surg path, dermpath, cytopath, bb/tm, GI path)
Strong interpersonal and communication skills
Laboratory management and administrative competency
Professionalism (cooperation, collegiality, flexibility, knowing when to
ask for help, etc)
– Able to engage with, and understand, clinicians and can serve in the
role of consultant
– Able to work well with others at all levels, be involved with medical
staff governance, and be an advocate for pathology (leadership skills)
• Most of these are “cross over” skills that could be learned as part of
an AP-only program with 1 or 2 areas of concentration in CP
Hum Pathol 2006;37:969-73; Arch Pathol Lab Med 2007;131:545-55; Arch Pathol Lab Med 2009;133:1139-1147
The Current State (cont)
• What employers are getting:
– Nearly 1/3 of new hires have a major deficiency in a critical
area, and 71% of employers report difficulty hiring entry-level
pathologists. Why? (for example):
• Preparedness in clinical and administrative areas
• Inadequate training/experience
– Independent sign-out in surg path and clinical decision-making
– Poor technical proficiency
• Laboratory management and administrative skills
• Professionalism and Work Ethic
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Unrealistic expectations about work-load/hours
Interpersonal and communication skills
Flexibility regarding responsibilities and willingness to acquire new skills
Interpersonal interactions
Honesty and reporting/recognizing errors
• Regulatory and compliance skills/knowledge
Arch Pathol Lab Med 2007;131:545-55; Arch Pathol Lab Med 2009;133:1139-1147; and, Post MD,
et al. Employer expectations for newly trained pathologists…(manuscript submitted).
Why Change the Current Training Model?
• Knowledge is rapidly increasing and changing
• Current graduates are not optimally prepared
• Maintaining competency in all areas of AP and LM/CP (shortand long-term) is unrealistic
• Many/most graduates are currently pursuing fellowships and
specializing/sub-specializing
• Community practices are increasing in size allowing
for/requiring more specialization – changing practice patterns
(impact of ACA?)
• Acquiring the basic LM/CP skills needed in community
practice can be obtained in both AP- and CP-only programs
either as part of core training or during a focused fellowship
• Tailoring MOC requirements should become easier
Why Change? (cont)
• Is length of training less important than subject mastery?
Achievement of defined competency and outcome
goals/Milestones?
• Does a “one size fits all” approach to length or content of training
make sense in light of the current gaps in training, knowledge
explosion, and employer needs?
• Could changing the training paradigm offer more standardization of
content and increased educational opportunities across all
residency programs (large vs small programs)? Role of technology?
• Future of reimbursement for GME?
• Impact of student loan debt on career choice and length of training
• Pathology is ever-changing and expanding and more tailored
approaches to training are called for
Proposed Changes in Residency Training
APC Park City Report on Combined
AP/CP Residency Training (Oct 1988)
• 3 years combined AP/CP training to include overlap
areas (molecular pathology, computer science,
management)
• 2 years of additional training which could include:
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General AP and/or CP
A subspecialty of pathology
Research
A clinical year (IM, Peds, etc)
• AP/CP ABPath certification after 5 years of training
• Up to 1 year of subspecialty training during the 5 years
could count towards certification in that subspecialty
• AP- and CP-only training would still be offered
Wells A, Smith BR
Clin Lab Med 2007;27:229-240
• More and more community practices are getting
larger where specialty-based practice can more
easily occur
• Many (most?) residents choose AP/CP training
because most will go into community practice
(where <20% of their time will be spent on LM/CP
issues)
• Full global skills in LM not required and targeted
expertise in 1 or 2 areas of CP could be obtained
Wells A, Smith BR. The goals of resident training in laboratory medicine in combined anatomic
pathology/clinical pathology programs: an overview. Clin Lab Med 2007;27:229-240
Rethinking Pathology Residency Training
(Domen RE, Baccon J. Hum Pathol 2014;45:1125-1129)
Core AP/LM(CP) Training
AP-Only Track
Fellowship
(1-2 years)
Cytopathology
Dermatopathology
Forensic Pathology
Hematology
Medical Microbiology
Molecular Genetic Pathology
Neuropathology
Pediatric Pathology
Surgical Pathology
Selective Pathology
Clinical Informatics
Research
24 months
12 months of AP and CP rotations or other
clinical rotations tailored to resident’s
career plans
LM(CP)-Only Track
Fellowship
(1-2 years)
BB/TM
Chemical Pathology
Hematology
Medical Microbiology
Molecular Genetic Path
HLA
Selective Pathology
Clinical Informatics
Research
Barriers Against Change
• Impact on residency training programs?
• Impact on patient care/pathology work-flow in hospital?
• Significant changes in current ABPath and RRC policies (and
Milestones)?
• Affect on billing, hospital contracts, CLIA regulations, etc?
• Impact on community practice; small groups vs large(r) groups?
• Job market concerns in general? Academic vs private/community
practice?
• Would pathology become too fragmented and lose
control/distinctness as a specialty?
• Planning the future - change is usually not sought out or embraced
until pressures or incentives force it to happen (run the risk of being
“too little, too late”)
Additional Recommendations
• All trainees would be expected to be competent in
overlapping areas: laboratory management and
administration, basic informatics, clinical consultation,
regulatory and accreditation, molecular pathology,
quality improvement, professionalism, interpersonal
and communication skills, problem-solving/critical
thinking skills, etc
• Formation of a task force with representatives from key
groups – ABPath, CAP, APC, PRODS, ASCP, ACGME/RRC,
community pathologists, etc – to formulate a White
Paper with a binding plan for recommendations and
implementation
References
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Domen RE, Baccon J. Pathology residency training: time for a new paradigm. Hum Pathol
2014;45:1125-1129
Wells A, Smith BR. The goals of resident training in laboratory medicine in combined
anatomic pathology/clinical pathology programs: an overview. Clin Lab Med 2007;27:229-240
Talbert ML, Ashwood ER, Brownlee NA, et al. Resident preparation for practice: a white paper
from the College of American Pathologists and Association of Pathology Chairs. Arch Pathol
Lab Med 2009;133:1139-1147
Peery TM. Horizons in pathology. JAMA 1959;171:2065-2068
Weinstein RS (chair), et al. Park City Report on Combined AP/CP Residency Training. October
1, 1988
Townsend JF, Van Peenen HJ, Senhauser DA, Lucas FV. The education of physicians for
specialties in laboratory medicine. J Med Educ 1971;46:456-460
Horowitz RE. Expectations and essentials for the community practice of pathology. Hum
Pathol 2006;37:969-973
Horowitz RE. The successful community hospital pathologist – what it takes. Hum Pathol
1998;29:211-214
Kass ME, Crawford JM, Bennett B, et al. Adequacy of pathology resident training for
employment: a survey report from the Future of Pathology Task Group. Arch Pathol Lab Med
2007;131:545-555
References
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Otis CN. Residency training in anatomic pathology: looking forward in the 21st century. Hum
Pathol 2006;37:929-931
Lagwinski N, Hunt JL. Fellowship trends of pathology residents. Arch Pathol Lab Med
2009;133:1431-1436
Gorstein F, Weinstein RS. Rethinking pathology residency training and education. Hum Pathol
2001;32:1-3
Frank K, Wagner J. ASCP Fellowship & Job Market Surveys: A Report on the 2014 RISE, FISE,
FISHE, NPISE, PISE, and TMISE Surveys. www.ascp.org
Editorial. Clinical pathology and modern medicine. JAMA 1932;99:1430-1431
Magath TB. The importance of clinical pathology to modern medicine. Science
1932;76(1972):333-336
Chemistry and its relation to medicine. The Lancet 1890;135(3466):260
Dreschfield J. The relations of pathology and its study. Br Med J 1886;2(1337):323-326
Approved examining boards in medical specialties: American Board of Pathology. JAMA
1940;9(115):737-738
Post MD, Johnson K, Brissette MD, Conran RM Domen RE, et al. Employer expectations for
newly trained pathologists: report of a survey from the Graduate Medical Education
Committee of the College of American Pathologists. (manuscript submitted for publication)
References
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Wells A, Smith BR. The challenge of training pathologists in the 21st century. Hum
Pathol 2006;37:932-933
Sanford AH. The role of the clinical pathologist. JAMA 1930;95(20):1465-1467
Alter NM. The functions of the full time pathologist in hospitals. JAMA
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Blumer G. Pathology and practice. JAMA 1935;105(17):1311-1312
Wahl HR. The responsibility of the pathologist. JAMA 1928;91(7):441-443
Wood FC. The relation of pathology to practice. JAMA 1919;73(8):569-570
Bishop LF. The relation of clinical pathology to actual practice. Boston Med Surg J
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Shattuck FC. Specialism, the laboratory, and practical medicine. Boston Med Surg J
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Henderson Y. Clinical pathology – an opportunity and a duty. JAMA
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