Resident Preparation for Practice: A White Paper From the College of American Pathologists and Association of Pathology Chairs

Pathology's future depends on training pathologists who are as facile with new technologies as they are with the microscope. Trainees must absorb, assimilate, and be ready to apply an unprecedented breadth of scientific and technologic knowledge and concepts and apply these skills as part of the patient treatment team. During the past decade, several pathology surveys have identified gaps in resident preparation for practice. The identified gaps typically involve a minority of trainees and may be more evident in certain practice settings, such as high-volume general practice. However, as pathology practice continues to evolve, these gaps are becoming more evident and problematic. Action is needed now because the process of training a new pathologist spans 4 to 6 years (anatomic pathology [AP], clinical pathology [CP], or more commonly AP/CP, plus 1 or 2 fellowships) or 10 years if medical school education is included.Currently, gaps exist for some residents in the preresidency mastery of basic histology, anatomy and pathology, the ability to make relevant clinical decisions, life-long learning habits, interpersonal and communication skills, professionalism, ability to recognize limitations, readiness to practice independently, gross pathology skills, ability to handle high-volume surgical pathology, ability to provide competent CP consultation, and preparation in laboratory medical direction and management. Most trainees elect a fellowship, suggesting that current residency training is not adequate to prepare them for immediate practice. In its current form, the American Board of Pathology (ABP) examination is not designed as a comprehensive measure of competence and may contribute to the gaps by misdirecting the focus of residency training.Academic and private practice pathologists must be cooperatively engaged in building the bridge that connects our current path to our future road. As the largest professional organization of pathologists and the organization of chairs of academic departments overseeing training programs, the College of American Pathologists (CAP) and Association of Pathology Chairs (APC) must take a lead in addressing these issues.The CAP Board of Governors and APC Council (oral and written communication to Michael L. Talbert, MD [CAP Graduate Medical Education chair] from J. Charles Jennette, MD [APC president] on behalf of the APC Council, April 2009) recommend the following actions:In the rapidly changing health care environment, physician education must encompass a broader spectrum of skills and knowledge than in the past. The changes occurring are affected by society's emphasis on maintaining work-life balance (eg, requirements for fewer duty hours), changing attitudes of trainees about occupation versus profession, and the ever-changing milieu of federal regulations and provider payment. The expectations of employers and physician “employees” are also changing. In addition to fulfilling traditional roles as diagnosticians, pathologists must strive to meet marketplace demands to provide consultation to patients and their families and to other physicians.The practice of pathology is being shaped by rapid technologic and scientific progress, as well as market forces. Pathologists must increase their role as consultants to remain part of the clinical care team. Skills that made a pathologist successful yesterday will not be sufficient to guarantee success tomorrow. If resident education fails to evolve, trainees will be especially impacted. Recent research1–3 and anecdotal evidence suggest that many trainees may not be prepared for practice upon completion of training. Although not a universal phenomenon and strongly affected by the practice situation, these gaps in preparation will widen as changes within the profession accelerate.For the most part, closing the gaps is the responsibility of medical school and graduate medical education training program faculty. The purpose of this article is to identify some of the perceived areas for improvement and to suggest possible mechanisms to close some of these gaps.In 2004, the CAP hosted the Future of Pathology Task Force, bringing together representatives of several key pathology organizations (including CAP, the American Board of Pathology, The American Pathology Foundation, the American Society of Clinical Pathology, the American Society of Cytopathology, the Association for Molecular Pathology, the Association of Directors of Anatomic and Surgical Pathology, the Association of Pathology Chairs, the National Association of Medical Examiners, and the United States and Canadian Academy of Pathology) to discuss and explore the future of pathology. Through these discussions, the task force recognized that resident and fellow education and preparation for practice were crucial to the future of pathology. To study this issue, a survey was conducted in May 2005 of potential employers (heads of groups, members of the Association of Directors of Anatomic and Surgical Pathology, and experienced CAP fellows) with the goal of assessing readiness for practice across a broad range of skills and practice environments. Similar information on readiness for practice was also solicited from recent graduates of pathology training programs. Results of these surveys are described in detail in the Archives of Pathology & Laboratory Medicine.3 In brief, 722 CAP members identified as heads of groups, 182 Association of Directors of Anatomic and Surgical Pathology members, and 2967 CAP fellows who passed their boards between 1980 and 1994 (but were not included in the other 2 groups) were sent an e-mail link to the survey. Invitees were asked to indicate if they were responsible for hiring or supervising recent graduates. Twelve percent of the heads of groups, 21% of Association of Directors of Anatomic and Surgical Pathology members, and 9% of the experienced CAP fellows (a total of 384 respondents) completed the survey. Thirty-one percent were from academic practices, while the remaining survey respondents were from nonacademic settings. Overall, 11% of respondents who had hired recently trained pathologists reported being dissatisfied and 3% very dissatisfied with the newly trained pathologists. Thirty-three percent reported that their recent hire was somewhat prepared or only slightly prepared to enter practice. One half of respondents reported that more or much more guidance and support was necessary for the new hire as compared with 10 years ago. Thirty-one percent reported the new hire had major deficiencies in critical areas, with the most common being in the skills of management, surgical pathology, and interpersonal interactions. In general, nonacademic respondents reported less readiness for practice among new hires compared with academic respondents. Areas of least preparation were regulatory and compliance issues, clinical laboratory management, laboratory personnel management, grant application preparation, and billing and reimbursement issues.The May 2005 survey of recent graduates targeted 732 CAP junior members who finished in January 2004 or later and 200 CAP junior members who completed their boards in 2003. These individuals were sent e-mails containing a link to the survey. 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