Surviving Pathology Residency: Advice from 1st Year to 4th Year Residents

Being in my final year of pathology residency, I feel that I’ve been through a lot. I am definitely not the same inexperienced first-year resident I was when I started. I’ve gained a great amount of knowledge, as well as technical and professional skills. But how did I do it? What advice would I give my fellow pathology residents to help them survive and succeed as I have done so far? I chose to ask this question to my fellow pathology residents through a simple survey consisting of just the following two questions:

• What is your current PGY level (PGY-1, PGY-2, PGY-3, or PGY-4)?
• If you could give only one piece of advice to a fellow resident, what would it be?

The responses I received from 27 pathology residents confirmed much of what I feel about pathology residency and resonated with the lessons I have learned through my own experience. The following are the lessons I have learned from first year to fourth year in pathology residency.

Burnout Is Inevitable

The rate of burnout among pathology residents quoted in one study was found to be as high as 52.5%¹ In my experience, I think there is no doubt that every pathology resident will feel at least some degree of stress or fatigue during their residency—I certainly did several times during residency. Dr. Justin D. Richey wrote in his article Even Pathology Residents Suffer from Burnout² that long hours, learning a completely new skill set, research demands, and the under-recognized value of pathologists contribute to pathology resident burnout. It follows that we must learn to deal with burnout as pathology residents. Dr. Richey also writes that hobbies, exercise, taking a day just to relax, and volunteering can help to decrease burnout. While no single piece of advice works for everyone, we need to be attuned to ourselves to recognize when we feel burned out and take actions to avoid unnecessary—and possibly harmful—levels of stress. When I feel burned out, I find it useful to take a mental break, even if that means just taking 10 minutes to get a coffee or talking about what’s stressing me out with a trusted friend, colleague, or mentor. As one of the survey respondents put it: “Breathe.” Another said, “Get enough sleep and sun.” In the end, we need to take care of our physical and mental well-being before we can learn or do anything else in residency. In some cases, this may even mean seeking formal counseling or employee assistance.

Learn All You Can During Your Residency

It probably goes without saying that the simplest piece of advice any pathology resident should follow is learn as much as you can—that is, after all, the goal of residency. It was interesting to see through my survey that the most common of the responses was advice like: “look at as many cases as you can,” “try to see as many cases as possible,” “review cases as much as possible,” “Read a lot. Look at slides,” and “look at as many cases as you can.” Undoubtedly, any pathology residency is structured to maximize the exposure to many cases that residents need to learn to become competent practicing pathologists. The takeaway for me is not just to work hard and look at a lot of cases, but also not to take any opportunity to learn for granted. Under pressure, it can become easy to discount some opportunities and think “I don’t need to learn that, I’m never going to use it.” The truth is, every piece of knowledge or experience is valuable, and I have often come to regret not knowing something that I could have more easily learned earlier on. Some lessons are learned the hard way, but you’d be surprised how a little bit of extra effort can go a long way. For example, at one point, one of my colleagues asked me if I would like to present at a city-wide conference. Although I was busy at the time, I still dedicated a few extra hours to work on my presentation during the week leading up to it. Unexpected to me, it turned out to be one of the best and most widely appreciated presentations I gave, and I was very thankful for the experience.

You Can Never Learn it All

Working hard and learning as much as you can is good advice, but it is important to realize that you cannot and will not learn it all. There is just too much information for one person to know. Understanding this will help you avoid unrealistic expectations and burnout, as one survey respondent put it: “It is only too easy to become overwhelmed with the wealth of things to know.” One of the greatest teachers in my program tells us that despite having practiced pathology for almost 40 years, being one of the most well-respected and experienced academic pathologists, he is still learning—that by teaching us he is learning more for himself. The same pathologists once jokingly introduced himself as a “PGY-38.” Focusing on what you do not know can quickly become discouraging, but as another survey respondent says: “Don’t stress about what you do and don’t know. Just always do your best and give 100%.” Trying to imagine the infinitely deep glass of knowledge as half-full can be a difficult but necessary exercise.

Transitions Are Difficult

As doctors, residency is one of the major educational and professional transitions we encounter. Just like anything new, it takes time to get accustomed and comfortable with change. I started residency by moving to the US from Lebanon, making the adjustment even more difficult. Interestingly, the majority of survey respondents (70%) were PGY-1 and PGY-4 pathology residents, ie, those transitioning at the beginning or end of their residency. It seems that the survey question attracted the most attention from those residents, maybe those most seeking or most experienced in the advice they gave. What I can say now is that having been in residency for over three years, I feel much better and happier with each new year. Just remember, it gets better, so don’t lose hope!

Don’t be Afraid to Make Mistakes and Learn from Them

As doctors and pathologists, with many of us having the type-A perfectionist personalities that got us to where we are, it can be tough to take criticism or accept our mistakes. In his article Cautionary Tales of the New in Practice³, Dr. Geoffrey Talmon writes, “You’ll make mistakes (and always will).” If that applies to pathologists just out of training, it certainly applies to the less experienced pathologists still in training. The upside is that as a trainee, you have less responsibility and expectations than you will later in your career. And it’s better to make a mistake as a trainee and learn from it than making the same error after your name is the final one on the report. I recently realized this on a case I had where I made the almost unthinkable mistake of calling a totally benign biopsy as malignant. At first, I was horrified. How could I make such a mistake and so close to the end of my training! There must be similar landmines waiting for me out there! But after I talked to some colleagues, I realized that the mistake I made is actually a potential pitfall even for some seasoned pathologists. In the end, I felt relieved that I would most likely never make that same mistake as an attending and learned an important lesson without having to bear the final responsibility for my shortcoming.

Be Prepared to Take on More Responsibility

Having the advantage of not having your name on the final report can be reassuring, as mentioned above, but at the same time should not be an excuse to be lazy or to take the easy way out by transferring all the responsibility of a case to your attending. As one survey respondent said: “Treat every case as if it were your own.” By not doing so, you may not even know when you made a mistake, and later come to regret it when you are an attending. You’ll never learn to drive if you don’t sit behind the wheel.

Develop Your Professionalism

Two key pieces of advice given by survey respondents were, “Treat your fellow residents with respect” and “Always keep a professional attitude and offer help to other residents.” This advice speaks to another important lesson in residency: learn how to be professional. Although it may not be obvious, professionalism, just like knowledge and technically-based skills, is something that you need to learn. In one instance I got in trouble for not communicating with my attending what I thought was a trivial piece of information but turned out to be much more important than I initially realized. All it would have taken me to avoid a lot of trouble was a simple email, message or phone call. Appropriate communication is one example of an essential skill that is part of being professional. I’ve learned from such mistakes I’ve made in professionalism, just as I’ve learned from mistakes on my slides and gross specimens. Indeed, a recent study found that interpersonal communication skills and professionalism were deemed highly important by potential employers, at least as much as diagnostic skills4.

Be Proud

As pathologists, we have a unique skill set that other physicians and patients rely on. However, being behind the scenes when it comes to routine interactions with patients and even other physicians puts us in a position that is easy for others to overlook, as Dr. Richey also mentions in his article on burnout.² But at least we can strive not to forget our important achievements as pathologists. Be proud that you recognized that rare or unusual diagnosis! Take time to reflect on how much you’ve learned and how far you’ve come. Enjoy your experience as a pathology resident whenever you have the chance! Indeed, enjoyment is a key part of one of our residency program’s best pathologists and mentors, Dr. Jae Ro. His essential lesson, quoted by several survey respondents in my program, is what Dr. Ro calls his “BeST.” B for “basic,” e for “enjoy,” S for “study,” and T for “think.” Dr. Ro constantly emphasizes that while the emphasis is often on the capitalized letters, not to forget that little “e” as an integral part of his recipe for success.

Realize the Importance of Networking

Being part of a professional organization gives residents many platforms to network with other pathologists. As a resident member of the CAP, I have opportunities to attend meetings, collaborate on projects, grow my professional network, enhance my communication skills, and keep up to date on new pathology knowledge. I wouldn’t even be writing this article had I not become involved with the CAP. I’ve also met many pathologists I wouldn’t have known otherwise through my involvement in professional organizations. Whereas the amount of time individual residents can be involved, even dedicating a small amount of time can open you up to unique opportunities. If you don’t always have the time to travel, virtual networking is also possible through social media like Twitter, Instagram, and Facebook. The popular hashtag #mottirl (met on Twitter then in real life) attests to this! One of the highlights of attending local and national pathology meetings was meeting fellow residents and pathologists I had engaged with online. We even took a group picture (complete with funny faces and all that friendly pathologist silliness!) A complete discussion on social media for pathology is beyond the scope of this article, but I can say that there is a huge pathology world out there on social media that is definitely worth exploring.

In the end, no one piece of advice will guarantee success in residency. There will be times when residency feels easy and rewarding, and other times that are more difficult. Maybe the best advice is not to be afraid to seek help from your colleagues and realize that you are not in this alone. We all experience similar struggles, we all need to survive residency first so that we will succeed and excel. So, hang in there and you’ll find yourself on the path to success!

References:

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–1613.
2. Richey, Justin. "Pathology Resident Burnout". August 2017. 
3. Talmon, Geoffrey. "Cautionary Tales of the New in Practice". September 2017.
4. Miriam D. Post, Kristen Johnson, Mark D. Brissette, Richard Michael Conran, Ronald E. Domen, Robert D. Hoffman, Cindy B. McCloskey, Patricia M. Raciti, Cory Anthony Roberts, Amyn M. Rojiani, J. Allan Tucker, and Suzanne Z. Powell (2017) Employer Expectations for Newly Trained Pathologists: Report of a Survey From the Graduate Medical Education Committee of the College of American Pathologists. Archives of Pathology & Laboratory Medicine: February 2017, Vol. 141, No. 2, pp. 193-202.

Ziad M. El-Zaatari, MD, is a surgical pathologist specializing in GU and medical renal pathology at Houston Methodist Hospital in Houston, Texas. Dr. El-Zaatari is past Vice Chair and currently serves as Advisor on the College of American Pathologists’ Digital Content Committee. He can be found on Twitter as @ziad_zaatari.

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