How to Excel as a Generalist

Pathology is an increasingly complex field of medicine. Yet, as the pathology job market heats up, many generalists, like me, are opting out of fellowships. All the while, I hear that fellowship-trained pathologists are expected to sign out all types of cases, cover clinical pathology call, and manage professional relationships with clinicians and hospital administration. One may wonder how we are to provide the highest quality patient care while juggling so many tasks and less formal training. Here is what I do to continue learning and improving my skills as I manage my practice. 

What is excelling?

Before jumping into how to improve as a generalist, it is probably best to define "excelling." In its most basic form, we offer a service to providers to allow for the best management and treatment of patients. When we review a peripheral smear, we work to add value beyond what the computer has already provided. When we scan through a challenging case, the summation of our report should provide a framework for clinicians to manage their patients. An easy way to think of this is seen with breast biopsies. When the radiologist says there is a mass, if we don't see a mass forming lesion, we recommend a repeat biopsy. This concept applies to everything we do. So, in this article, we will define excelling as a generalist as providing the highest quality information to providers that allows for best possible management.

Start with clinicians

In our effort to provide the highest quality information to providers that allows for the best possible management, the most logical place to start is with a provider. Suppose we come across a difficult case or challenging question. Stop and ask yourself if the question you are trying to answer is even relevant to the provider. I've wasted a lot of time fretting over a ditzel, only to eventually call the provider and ask either what information they are looking for or if they would treat these two diagnoses differently. If your differential includes two ditzels that are clinically treated the same, perhaps just give them the differential and move on. Further, sometimes, when you start with the provider, you will learn details that make the decision far easier to make. This also has the added benefit of forging relationships with providers, increasing your visibility, and making you more accessible to them.

Literature review

Once we establish the question we need to answer, the next logical place to check is the literature. At this point, you likely have a source in books or online that you prefer to check. If you are in a new practice, it never hurts to ask your colleagues what they use as sources. This will lead to consistency amongst your groups' reports. The best part of reading is even if you don't get your specific question answered, you will likely learn something from your review. It is almost never wasted time.

Colleagues

Armed with the clinicians' thoughts and a fresh review of literature, yet still yearning for answers, let's turn to our colleagues. This can take many forms. I’ve worked in many settings by myself, and nothing beats a quick photo sent to your friend who subspecializes in the relevant field. If you have partners, you can bring the case to their office. In larger practice settings, you may be able to courier (or even scan in!) your case for a colleague to review and address your question. Perhaps your colleague will not know the exact answer but may still have valuable advice related to the case or how they have handled similar problems.

Consults

If you still don't have an answer and you've determined it will have clinically relevant consequences, now is the time to consult an expert at an academic practice. Draft a letter with your inquiry. If possible, recut a few H&E slides for you to keep, and perhaps keep a copy of your letter with questions on the slides, as it doesn't take long with our busy workloads to forget the nuance of the case. The most important part of a consult occurs when the results come back. Have the slides ready at your desk to review with the consultants' information. It is imperative to spend a few minutes reviewing the material to learn from experts and improve your knowledge base in the future.

Time management 

It may seem as if it takes a lot of time to manage your time. However, I’m hopeful the order of these steps will minimize the total amount of time you spend learning and improving while simultaneously providing the best information for providers to treat patients. Over time, when following these time management steps, I'm confident you will excel as a generalist. If you continue to struggle with time management, perhaps read the article, Insider Advice on Managing Time, featuring CAP members Mary Le, MD, FCAP, Adam L. Booth, MD, FCAP, and Rebecca Johnson, MD, FCAP.

Continued education

Finally, it is important for us to all incorporate some form of quality continued education into our routine. My favorite source is the Performance Improvement Program (PIPs), like this one. Not only will this keep you up to date, but it will also provide you with all the necessary CME needed to maintain certification through the American Board of Pathology.

The upcoming CAP Job Prep Bootcamp is another opportunity for generalists to continue their pathology education. The fast-paced, interactive review of pathology cases across subspecialties will take place virtually over two consecutive weekends. Register today to add more sources to your arsenal while broadening your pathology network as you excel as a generalist.

Dr. Broadwater is an AP/CP pathologist and is currently the Chief of Anatomical Pathology at Keesler Medical Center on Keesler Air Force Base. Additionally, he holds a part time staff pathologist position at Merit Health Biloxi. Dr. Broadwater graduated residency at Brooke Army Medical Center in 2021.