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Pathology

Stanford Surgical Pathology Rotation

Description of Stanford Surgical Pathology Rotation

Background
Over a year ago, the Department of Pathology undertook an extensive strategic planning process, involving many faculty and trainees, to decide on whether to continue with our traditional “fully general” model of surgical pathology sign out or to introduce elements of “specialty sign out”. As would be expected in any highly performing group of faculty and trainees, there was considerable thoughtful discussion, and some disagreement, about which sign out model would be best for Stanford at this time in its history.
Ultimately, the current “hybrid model” of subspecialty sign out (which is described below) was adopted in light of the following considerations.
1) Major academic medical centers increasingly have moved to at least partially and often fully subspecialized surgical pathology sign out systems, in part to ensure that the most appropriate expertise is brought to bear for each specimen seen and in part because academic pathologists are increasingly choosing to specialize in particular areas of surgical pathology, both for their clinical work and research.
2) Academically-oriented residents increasingly are seeking subspecialty training before seeking jobs in academic or large private practice settings, providing another impetus to move toward a training program that incorporates some elements of subspecialty sign out experience.
3)  While Stanford has many faculty members with extensive subspecialty expertise, and who have an interest in developing a career focused on their subspecialty interests, we do not yet have the total volume of cases in each subspecialty area, or the number of surgical pathology faculty, to consider moving to a “fully subspecialized” model of surgical pathology sign out.
4) If we were to retain a fully general sign out system, in addition to missing the opportunity to provide more specialized sign out support for our clinical colleagues and their patients, we would risk losing highly performing faculty who want to develop a subspecialty-focused career to other institutions where such opportunities are available. We also would appear increasingly unattractive as a training site for academically-oriented trainees who wish to pursue careers with a subspecialty focus.
5) On the other hand, our faculty includes superb general surgical pathologists who are also well known for their particular subspecialty interests; indeed many of these individuals are acknowledged leaders in these subspecialty fields, despite continuing also to practice general surgical pathology. Such faculty members have much they can teach trainees, and more junior faculty, and they represent a tremendous asset to the department.
6) In considering modifications of our surgical pathology sign out system that would move it toward a more subspecialized model, we would seek to make each change focus on meeting three related goals: 1) enhance the quality of patient care; 2) improve the resident and clinical fellow training and career development program; and 3) improve faculty satisfaction, including for those who are seeking to develop careers based on subspecialty interests.
7) Our success in achieving these three related goals would be monitored by ongoing discussions and consultations involving faculty and trainees, including that which occurs formally in our monthly meetings of the Residency and Fellowship Committee, which includes both appointed resident members (i.e., chief residents) and elected resident members. Should modifications of the system appear to be indicated, these will be implemented thoughtfully.
Current Stanford Surgical Pathology Rotation
In light of the considerations described above, Surgical Pathology has adopted a hybrid model of subspecialty sign-out, which is now being evaluated during a period of one year. We feel it’s very important for applicants to understand some of the details of how our system works. Taking into account service size and numbers and complexity of specimens in various subspecialty areas, we are piloting subspecialized sign out for breast, gyn, and GI pathology. These services have separate sign outs in Surgical Pathology. The remaining organ systems, for example, head and neck, lung, soft tissue, and genitourinary, remain part of a general sign-out service on which all Surgical Pathology faculty rotate. As illustrated below, residents alternate between the breast/gyn/general and the GI/general services such that on their grossing day (day 1 & 4), they are either cutting in breast and gyn specimens or GI specimens, in either case they also cut in general surgical specimens that are neither breast/gyn nor GI. The residents continue to have a dedicated “preview” day (day 2 & 5) to review their cases prior to sign out. In addition to previewing their cases on days 2 and 5, the residents preview cytology cases and participate in cytology sign-out around 1pm.
Sign out Day 9 am- 12 Noon (day 3 & 6)

Resident 1 GI General  
Resident 2 Breast Gyn General

Seven residents are scheduled during each Surgical Pathology month. The 7 day schedule for each resident is as follows:


GI/GEN CYCLE (days 1-3)

BREAST/GYN/GEN CYCLE (days 4-6)

FROZENS (day 7)

The numbers of big specimens (defined as: complicated, time consuming case, typically major resections for malignancy) and total specimens assigned to each resident is capped according to level of training. Therefore, if the GI volume is high and the breast/gyn volume is low, the breast/gyn resident will cut in more of the general cases while the GI resident will focus on GI and vice versa. On their sign-out day, the residents sign out with 2 or 3 attendings, depending on their service, so that the breast/gyn resident will sign out with a breast attending, a gyn attending and a general surgical attending. The GI resident will sign out with the GI attending and then with a general surgical attending.
We think that our “hybrid model” gives trainees the best of both worlds because some of their cases are double scoped with a specialized attending with high-level expertise in that subspecialty, whereas other cases are signed out with a general surgical pathologist. Moreover, we wish to stress that our residents see the entire spectrum of surgical pathology cases each month they are on the surgical pathology service. This is because the residents alternate on the different services each month rather than month by month. That is, you will not have a month consisting of only one of the subspecialty areas. We strongly believe that our approach is preferable to an exclusive exposure to a subspecialty area for a block of time with no or limited further exposure to that area for extended periods of time during your training. Furthermore, we are developing a regular case conference in which interesting or problematic cases are shown among the residents and faculty. It is hoped that this will promote faculty level discussion about diagnostic criteria and further enhance the educational experience in our program.

Conclusion
Changes in long-standing systems can be difficult, both because change itself is often difficult and because new systems may require ongoing monitoring, re-evaluation, and modification to deal with unanticipated problems, to enhance efficiencies, or otherwise to improve processes. When all participants in the changing system also are very busy, as is the case with our faculty and trainees, accomplishing the goal of optimizing the system can be even more challenging. Working together, we can achieve the goals that prompted the department to put in place these changes in our surgical pathology sign out system.

Stanford Surgical Pathology


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