How and Why To Organize Your Workday

• New-in-Practice Resources
• New-in-Practice Committee

Julie McDowell:

One of the challenging aspects of transitioning from a pathologist in training to one who is new in practice is how to organize your workday. In this podcast, Dr. Yasmeen Butt and Neha Varshney discuss this topic based on their experiences.

Dr. Yasmeen Butt:

Hi, I am Dr. Yasmeen Butt. I'm a thoracic pathologist and I work at Mayo Clinic in Arizona.

Dr. Neha Varshney:

Hi, my name is Neha Varshney. I am a GI and Hepato-Pancreato-Biliary pathologist. I work at University of Mississippi Medical Center at Jackson, Mississippi.

Dr. Yasmeen Butt:

So, today we're going to talk to you about how we organize our workdays. And I guess I'll just start out with our first question. So Neha, is every day the same for you? How would you describe an average day?

Dr. Neha Varshney:

Not really. Every day is so different for me, because we are an academic center and we have residents. Don't have fellows, but we have residents every day. I cover GI, so based on if I'm on big or small status biopsies, it's different every day. And then we cover frozens one week at a time. So it's also different based on if you are on frozen or not. And then additional teaching of medical students, and medical school, dental school, et cetera, always add on. So every day is a new challenge and different.

Dr. Yasmeen Butt:

Similar to my experience as well. We're also an academic center here, but we don't have a formal residency training program in Arizona. We certainly have pulmonary fellows, cardiac fellows, medical students who rotate with us, but our services also split up.

So on some days I'm on our pulmonary consultation service where I'm only looking at challenging pulmonary cases, but then other days we're a hybrid general subspecialty practice here. So other days I might be doing biopsies where I look at everything from lung biopsies to GI biopsies to skin biopsies. And then we also have a separate frozen section day coverage followed by I guess a big day, where we look at big cancer resection cases. Those are probably my busiest days.

So I'm with you on that. Every day is a little bit of a different challenge, so there's no one set framework on how I would say I organize my day. So I guess that gives hopefully our listeners an idea of what our services are like. So how would you organize some of these days, just to give us kind of a rundown on different services and how you organize those days?

Dr. Neha Varshney:

So I have a bigger organization and then I have a smaller organization on everyday basis. That is, every Monday I come in and I check for my whole week. I look at my calendar and I see if I'm teaching, what I'm doing for next week.

Early morning, every day I sit down and I have this cheat sheet kind of a thing. What are the things I'm doing for that day? If I'm on frozens or not, depending on that. We have set frozen days and we have also set sign-out times with the residents. So if you are on biopsy services, you are 9:00 to 10:00, and then if I have liver and hepatopancreatic, that is from 11:00 to 11:45. Bigs are 10:00 to 11:00. So it's kind of easy sometimes unless you're on frozen, if you [inaudible] all the time, then you kind of are in trouble, then you cannot finish your cases.

Also, I try to organize in a way that I want to see all the triage, the cases depending on the timeline. So 10 o'clock is our ISC cutoff. So based on that I try to organize. The other big thing I have done for myself is I do not schedule any meeting early morning till 12:00. Every meeting has to be after 12:00 unless we're absolutely required, or other people really cannot do it.

Then tumor boards are other ones, which sometimes can be in middle of your day. Those days you have to be more flexible. So I guess you've got to be more flexible based on the days, but sign out time, I try to keep them covered as much as possible.

Dr. Yasmeen Butt:

That sounds very helpful. I'm interested that you have a set sign out time with residents. So when I was at UT Southwestern prior to coming to Mayo, of course we had a huge residency program there and we never had a set sign out time. We would just sign out I guess whenever we were both ready.

So I would touch base with the residents in the morning, whoever was on service and triage the cases and decide what we needed to look at, and based off of my meeting schedules throughout the day, decide when we wanted to sign out.

I love what you said about not scheduling meetings before noon. I don't think I have quite that much control over my meeting schedules, or maybe I just have too many meetings, but I really like that idea. As much as you can control your meetings to allow you to sign out from your cases, or at least triage as much as possible in the morning.

What are some tricks or tips you may have for our listeners on signing out with trainees, challenges you might face and ways you've come up with how to overcome them, if you have?

Dr. Neha Varshney:

Well, so I'm a very new pathologist. I started last year in July, so I finished one year and some few months. So initially it was hard for me to even... I thought myself more as a fellow than an attending. So that was kind of like a change, a little bit of change and that's something which just evolved itself.

I think the important thing is to learn where your residents are, like what level? So if it's a junior resident versus a senior resident, junior residents need more handholding and it's hard sometimes for them to even know what cases to triage, they would not even know.

So what I have done is I've made this five page long PDF, basically like a checklist for GI rotations, which talks about expectations, the books you've got to read and all the templates I use for GI, majority of the biopsies, and even bigs, I write everything very cookie cutter. All my reports are literally pretty similar.

I think that's helpful for them. And I ask them the feedback, is there anything I need to change? And I change as we go. I give them feedback, they give me feedback if something is not working. And the junior residents, I try to spend more time and be more patient, which is sometimes difficult if you're on other a hundred services.

Dr. Yasmeen Butt:

Honestly, I don't know if I can add much to that. I certainly echo that. My first year out I was at the same place I trained, and you're right, there's a little bit of that disconnect between you were just a fellow before the weekend and now you're an attending and many of the people rotating with you were your fellow residents or fellow fellows and now they're your students. So certainly that can be interesting.

I did something similar as well for our thoracic rotation, creating a document showing all the templates of how I would sign out my cases. And I think that's another tip that even taking residents or trainees out of the picture, having templates for your cases, it's incredibly helpful. And that's something that has really helped my workday and my organization. Even for our consult service, there are certain things that we see fairly often, and if I have a long explanation talking about LAM or sarcoidosis or something like that, rather than recreate the wheel each time is to utilize those templates where you can.

So I have found that templates have been incredibly helpful, and I also triage my cases in the morning, as you mentioned, based off of IHC cutoff time. And this I think is really important when you're on biopsies in particular, because if you can get that biopsy out before 5:00, get the state in before 10:00, we actually have the same cutoff time that you mentioned in our lab.

So certainly triaging your cases is helpful. I know when I first started practicing in my first year, so I didn't mention earlier, but I've been practicing about four years now. So in my first year when I started, I wasn't as good at triaging my cases. I would basically just have a pile and I'd work my way through the pile. So every case was a surprise. I didn't know what was coming next. But quickly I learned that going through those cases right away is really important.

Separating out what needs to happen first, what needs to happen second, if you have a case, this is a longer case, I know this is not going to get signed out today, it can wait to look at until at that 10 o'clock cutoff if you have biopsies. And couldn't agree more and echo what you said about junior residents versus senior residents and portioning out your time. Knowing that if it's a first year, you're going to have to spend more time signing out with them compared to a third or a fourth year who already pretty much has an idea of what's going on.

Dr. Neha Varshney:

The other thing I would like to add to this is I look at my list a day before, before the end of the day, and I see... So I also do liver, so I usually see the cases, if there is any transplant cases and things like that. And also I have good communication with all my clinicians. So they would text me or call me or page me, whatever form of communication they choose and let me know, okay, there's a transplant biopsy coming tomorrow. This is a question I will GVHD, can you give me a stat diagnosis like that?

So then I would just communicate that with the resident and let them know, okay, these are stat cases. And if I go in my list and see if this is a stat case, I write there, I write big bold Stat Case, show me in the morning.

And then if it's a senior resident, actually I get up at six o'clock and I don't know if it's healthy or not, but they usually start texting me, "Okay, this is the case. Do you want me to do the stain? What would you want me to do?" Because if it's stat, we can do stat [inaudible] and give a prelim. So that also have tried to do. And gradually they learn. For a second week, they ask me more questions and by third and fourth week they're great. They're good to go with triaging the cases much better. So it's very helpful.

Dr. Yasmeen Butt:

Sounds like you have a great residency program.

Dr. Neha Varshney:

Don't tell the residents that.

Dr. Yasmeen Butt:

No, it sounds very positive. So what are some aspects of your day that you feel, if any, might still be a daily challenge? And I'll start with mine. And I say sometimes day to day there are what I call quicksand cases, where you don't anticipate that they're going to be a problem. And for me this is often a consult case. So you have a quicksand case where you think it's going to be quick, like, oh, it's just a small biopsy, it shouldn't take me very long to get that done. And then it turns out to be something complicated, you need to request a block, you need to call the pulmonologist. So those cases often take me by surprise and I end up potentially spending an hour on a case, where I thought it would take me five, 10 minutes. So that's something that I guess you can never really prepare for that, but I definitely have those in my practice.

And I think also sometimes you run into a case that's just really cool, and you want to photograph it, or at least I do, I want to photograph it, and then 20 minutes goes by and I'm like, gosh, I should probably stop taking pictures of this case and get onto my next cases.

So there's always that potential distraction I think for challenging or fascinating cases. So I have to constantly remind myself to stay on task sometimes. Like, okay, you've got a pile behind you, you need to get back to it. So now I have a separate pile of interesting cases that need to be photographed or something. They're of course signed out. I don't leave them. But I've created a separate pile for myself of cases I want to photograph or do something else with it for educational purposes. So that has helped me a lot. So then if I have an off service day or I have a research day, I can spend some time there to work on those, rather than let it eat up my time on a clinical day where I might have a lot of clinical work that needs attention.

Dr. Neha Varshney:

I'm working on a study set right now, so I usually, anytime I get a case, I order a recut for study purposes, and I'm putting it there. So I'm not spending time on photographs or anything, but I'm just taking a recut and putting in... I'm not writing a book like you, so I guess that's a little different, but that's what I'm doing right now, just making a study box for them.

I feel the most worrisome aspects sometimes, which are really challenging for me are additional things. Like when you are on multiple services. So I also am backup for bone and soft tissue and very recently cardiovascular. I've not covered cardiovascular as yet, but bone and soft tissue I was covering for a while now.

And then when you're covering multiple services, it becomes really hard sometimes. And then infrastructural issues, administrative issues sometimes can be a problem. Shortage of staff is a big one we're facing right now. We're short staffed, faculty, techs, all of that. That is sometimes very, very challenging because you just don't have people. You're covering multiple services, your frozen calls, everything has increased, your teaching expectations, all that, that's the one I get into trouble with.

Dr. Yasmeen Butt:

Oh yeah, I'll have to add that to my list as well then because it's challenging. Additional things add up. If you have so many meetings that you have to, oh, you're on this committee, you're on that committee, whether it's an internal committee or a national committee, and they take time and they add up, and I'm not sure how your service schedule works, but unless we have specific time off for grants or medical school teaching, if I'm here, I'm on service, so I'm always having cases. And so you don't necessarily get any extra time for extra committees and work that you do.

I always dread those days where it's like, oh gosh, I have three or four or five meetings today. It's taking up half the day. When am I going to sign out my cases? So certainly I'm grateful for Zoom on those days if I need to sign out with my camera off, but you didn't hear that from me. I think we're all guilty of that at least sometimes.

Dr. Neha Varshney:

Yeah, I mean those are definitely difficult to handle. I taught nine or 10 hours of medical students last three days, Wednesday, Thursday, Friday, and I was on GI biopsy service. And all your cases just get delayed. I mean, you just don't have a choice because you're teaching from eight o'clock in the morning. So it becomes really difficult. And we have no additional days here. Basically you assign cases every day, so we don't get any additional days. All these additional stuff just get to on top of your case file.

Dr. Yasmeen Butt:

Right. I feel you. Yeah, it definitely can be challenging. And something leading from that that I have learned over the last few years as I've become very new in practice to still new in practice but slightly less new in practice, I still feel like it was just yesterday that I started, is if it's the end of the day and I'm tired, the turnaround time is not worth signing out a case incorrectly. And I find that at least for me, I'm a morning person, I'm not an evening person. So if it's late in the day and I'm trying to get this last case pushed out, to just stop and just sign it out the next morning.

And I found time and time again that I'm more likely to make small mistakes if I'm rushing at the end of the day and I'm tired. And so to sort of unclench my hand a little bit on that turnaround time and try not to stress too much about it, because really it has to be the quality of the report and the needs of the patient.

And that's something that's been challenging for me in organizing my day, because of course you end up signing out things at the end of the day. And if there's something that's complicated or unusual or it's a long template and it wasn't exactly straightforward, I have found that it's better just to maybe wait till the next morning.

And there are some people that are night people and maybe the opposite would be the case, but at least for me, I found that to be very helpful, to just tell myself to stop and take care of it the next morning. And so I have a little time built into my mornings for doing that.

Dr. Neha Varshney:

Yeah, I've given myself three o'clock cutoff. I don't sign out cases after 3:00. I look at them if there are HPs and things like that, that's different, but no difficult cases.

The other thing which I feel like writing very long comments, sometimes. I do liver, and liver you can write pages because it's all pattern based, like medical lung. So I pick up my phone and call them, say, "Okay, this is what I see, what are you thinking? What is happening? What is the clinical picture?" And we talk. They almost call me once a day and we talk every day hepatologists. We have three hepatologists here right now. So we talk every day if there is any case. And rather than writing long comments, I'd rather talk to them and tailor [inaudible] on the clinical picture more. So I find it really helpful for liver at least. Even for very certain GI cases I would. For liver I have done that a lot.

Dr. Yasmeen Butt:

Yeah, I totally agree with that. Medical lung, it's the same way. Having that clinical information, having that conversation with a pulmonologist can be incredibly helpful and definitely improves the quality of the report that you're giving them, because there are such broad differentials for things, certainly.

So we've kind of already touched on this, but our next question was are there any specific times stealers that you've found to be a challenge? Something for me is how to handle email throughout the day. And I know when we did our round table discussion on this topic, it was interesting to hear the different perspectives on how different people decided to handle their emails.

For me, I used to try to make a point to not answer every email as it comes and save it for a certain time of the day, but I actually found that that didn't work as well for me because the longer I would put off taking care of an issue, even if it was a small issue, the more they piled up.

So for me, I've actually found that it's helpful to have my email up and just answer them and take care of the issues as soon as they come up, if it's something I can do immediately. And I won't look at emails while I'm in the middle of a case, but in between cases I'll check my emails. So I don't know if that's healthy, but it seems to work well for me. I'm curious to see what your take on it is.

Dr. Neha Varshney:

Like my cases, I triage my emails, I literally triage them. If it's about patient care, if it's something stat, I'll take care of them. If it's not stat, and trust me, I was a person who has to respond right away, and I'm efficiently and forcefully trying to learn to not respond right away. Especially after five o'clock, I try not to respond. Once I'm out of here, six o'clock, whatever time I get out of here, I try not to email unless it's absolutely necessary.

And that is something I'm learning and I'm a great work in progress right now, but I do triage. If it's not important, I would not do it. I would just put a flag on it and say, "Okay, I'm going to come back to it." I don't write mass emails, I don't get involved in mass emails, and I try to only respond when it's needed. I don't try to get involved unless it's absolutely necessary.

Dr. Yasmeen Butt:

That sounds healthy, especially the mass emails. I'm with you on that. I am very hesitant to respond all to a mass email. Almost never do I do that. I think not a lot of good can come of that depending on the topic.

Dr. Neha Varshney:

Some people love it and some people love these long emails. I would rather pick up the phone and just talk to them. And I think it's more helpful because emails can be misinterpreted in a lot of ways. Also, I find it healthier to just talk to the clinicians, or if there is any issue, it just has better results.

Dr. Yasmeen Butt:

Right, I agree completely. You're in your first year, or you just completed your first year. Congratulations, by the way.

Dr. Neha Varshney:

Almost second.

Dr. Yasmeen Butt:

Almost second. So congratulations, by the way. It's the hardest in the beginning, as I say, with only minimally more experienced than you.

Dr. Neha Varshney:

I hope it gets better.

Dr. Yasmeen Butt:

It always gets better. Although I feel like the more I learn, the more I realize that I don't know, which is kind of terrifying. I think there's nothing more humbling than surgical pathology.

But I would say in terms of managing your workday, what do you think was the hardest right in the beginning, and how did you handle that? If you were to give advice to someone who's a fellow now, who's just about to start their first year?

Dr. Neha Varshney:

As a first year, I think you are hesitant to say no, which mine was the biggest challenge. It took me time to start saying no because I was so totally overwhelmed or not ready for it. It took me some time to do that. I guess you've got to learn to choose and delegate and say, "No, I can't do it," if you really can't, because obviously the patient care comes first.

That was a very big challenge I had. Then I did a search path fellowship in GI, so frozen was not a big challenge at the beginning, but there will be times some of the bone and soft tissue frozens, or some neuro frozens and things like that when I still had... Or a weird ENT case, which where I still had questions.

Asking for help and understanding your limitations basically I thought was important. Initially, organization, trying to understand how the system works and organizing around that helped me a lot. And also building a rapport with all your colleagues, even residents and your clinicians takes time and you just have to be okay with it, that it'll take some time.

Dr. Yasmeen Butt:

Yeah, all excellent advice. I think for me, when I first started, part of my case triage involved, when I figured out I should be triaging my cases, which I figured out quite quickly, part of my case triage involved cases that I knew I was going to have to ask to share one of my colleagues. And I think that is something you have to, one, allow yourself to do. Realize that you're going to share a much higher percentage of your cases in your first year. You should be sharing a higher percentage of your cases in your first year until you really get on your feed and realize where your knowledge base is and what you need to share and what you don't need to share.

So figuring that out early on in the day was helpful for me in terms of organizing my day, especially in the very beginning, because different colleagues come in at different times. They have different things that they may be doing throughout the day. They may have availabilities, early availabilities later. So figuring that out and managing that landscape I think was really important and a little challenging in the beginning because you're also balancing signing out with residents, signing out with fellows. So that I think can be challenging.

But I think ultimately knowing that you're going to put out the best report you can with the best information you can, figuring out which cases you need to share and sharing them earlier in the day if that colleague is more of an early person, I thought was really important.

And then I'll also echo what you said about learning to say no. I think learning to say no is really, really hard in the beginning. And in fact, you probably shouldn't be saying no to a lot of things in the beginning. I'm with you. I did the same thing my first year. It's like, do you want to do this? Of course. Can you do this? Of course I can. And so really soon you're saddled with a whole ton of things, which is a double-edged sword because on the one hand you start to gain experience and you gain it quickly. And personally, I was very grateful for the first two years that I practiced and everything that I learned from all of the responsibilities that I had.

But it also can be challenging to work on your own personal, I guess, development. Whether it be research or writing or just becoming better at your specialty, it can be challenging to balance that with all of the various committees and directorships and things that you may want or may not have wanted.

So I think being a little strategic, as much as you can in the beginning about what you agree to, can be very helpful in organizing your day. Because it can be very easy to be quickly saddled down with tons of meetings and tons of other things that take up your time, and you have to figure out for yourself because the answer is different for everybody, what is most important to furthering your career and making you a better pathologist?

Dr. Neha Varshney:

Yeah, I totally agree with all whatever you said.

Dr. Yasmeen Butt:

So do you have anything else you want to share with our new and practiced colleagues on organizing the workday? I think we touched on a number of topics. I think triaging stains, triaging is really, really important. Organizing your meetings as much as you can. We don't always have control over these meetings, especially if they're multiple people in the meetings on multiple time zones, even potentially if they're not internal meetings. But trying to control those as much as you can. And then also having a very open line of communication with your clinicians for your cases I think is actually very useful for organizing your day. And then knowing when to share cases and getting that taken care of right off the bat. So I think those are some of the things, kind of summary of what we talked about, but if there's anything else you can think of that you'd like to share.

Dr. Neha Varshney:

Well, so I think having a good team is really important and critical. That when you have a good team and you can show cases anytime or ask any kind of questions or even advice about any kind of meeting, should I get on this committee or not, or things like that. Having some people in your corner is very helpful, because they have been there for a while and they know better. So picking a few senior people who are very wise helped me a lot.

Because I would go literally for advice like, okay, this thing happened, what do you think about that? Or should I be part of this? Or what should I do? Is this okay for me? And not just that, even my fellowship director and other people from before, I usually communicate with them even now and talk to them and say, "Okay, so I've been offered this directorship position. What do you think about that? Is this something I can do or not?"

Having a good network in and outside is helpful morally, emotionally, and of course professionally.

Dr. Yasmeen Butt:

Totally agree. I think that's excellent advice. I've also found that especially in your last years of training and in your first years of practice, observing your older colleagues, your more experienced colleagues, how do they organize their day? How do they deal with their cases? How do they deal with trainees? Is incredibly valuable. And we learn by observation. So I could not agree more. Having a good mentorship in place and a good network of people that you can go to and ask questions, who just have more experience underlies so much of what makes a successful new practice pathologist, just is good mentors and good colleagues. So totally agree on that.

Dr. Neha Varshney:

And understanding your limitations, that these are my limitations and not taking... I know people who work till nine o'clock or 10 o'clock or 11 o'clock in the night, and who are coming on Saturday and Sundays. I don't find that healthy for me. I try to be more efficient on the days I'm here and finish everything, especially the important triage cases, and I do whatever best I can and be okay with what I can't.

Dr. Yasmeen Butt:

Yeah, I have to echo that as well. I think when I first started, I was guilty of what you said, staying late, coming in on the weekends and you burn out pretty quickly. So our topic isn't burnout today, but a well-organized workday helps you avoid burnout.

Dr. Neha Varshney:

Kind of intertwined there, see?

Dr. Yasmeen Butt:

Yes, there's a lot of topics intertwined here, so I'm certainly not going to pretend that I have it all figured out, but I'm with you. It's like I'm not going to sign out late in the day. I let myself sign out until 5:00 or 5:15, but three o'clock seems really mentally healthy and maybe I can try that.

Dr. Neha Varshney:

No, I do everything else, all my new things, everything or additional work I do after that. I mean, I don't sign out. I look at the stains, I just don't because I feel like I'm exhausted. I get up at 5:30 in the morning, so by three o'clock my battery's totally dead.

Dr. Yasmeen Butt:

It's about out. Yeah, I feel my stuff start to fade around 4:00 or 5:00, so I'm with you. I try not to sign out too late in the day and leave things for the morning. You also have to find out I think what's important for you and what unique factors in your practice might alter organization of your day.

If you're in private practice and maybe you cover multiple hospitals, part of your day might involve courier systems. So we actually have two campuses. So we have couriers that carry slides between the campuses, and if I'm covering frozens, I'm out at the hospital and so our histology lab is here at the clinic. And so those days I have to account for that because I know that there's going to be a delay in slides getting to me. So there's certainly going to be unique challenges in each practice environment and in each group. And I think identifying those issues early on is best. And just sitting down with someone and asking them, "Hey, what's the best way to organize my day?" Because it may be different than what you're thinking.

And it's very different than when you're a trainee. And I think that's something that really struck me, because ultimately as a trainee, at the very end of the day, however senior you are, if you're a fellow, you're almost ready, you're not actually signing out those cases. I think sometimes there's a little bit of disconnect of what your attending is doing afterwards, before the sign out button is hit there. Knowing that there is a difference and ultimately the cases are yours, you'll change the way you organize your day.

Dr. Neha Varshney:

Somebody gave me a very good advice and said, "When you start a job or any new job or any new thing, wait for a few months, take three to six months and just observe what's going around you and then accordingly decide." Because it's too quick to decide before that, and then you just organize and be a patient accordingly.

Dr. Yasmeen Butt:

That's excellent advice, observation first. I like it. Well, thank you so much for talking with me today. Hopefully this was useful to the people listening.

Dr. Neha Varshney:

Thank you for having me. Thank you.

Julie McDowell:

Thank you, Dr. Varshney and Dr. Butt. If you are a pathologist early in your career, please visit the new and practice section under the member resources tab on cap.org.

Thank you for listening to this CAPcast. To listen to our other episodes, find us on the MyCAP app, available for CAP members, as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, Spotify, and Amazon Music. Just search for CAPcast from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss new CAPcast episodes.

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