What to read?

Pathology is one of the study-heavy specialties, along with others like Radiology and Radiation Oncology. The benefit of a "normal", "predictable" workday is offset by all the reading you must do on the side, over the weekend and holidays, and when family thinks that you've finished the crazy studying routine set forth in the formative years. My choice for tonight is one of the main Pathology journals, as shown above: Archives of Pathology and Laboratory Medicine. It has a resident-friendly format with, in addition to original research articles, teaching cases and a differential diagnosis approach to certain findings after imaging or microscopic examination.

Medical school certainly doesn't prepare a student for any one specialty. Of course it can't. But, surgeons may start residency having only held retractors for 10-hour long surgeries. Family physician residents may not have done simple office procedures. Emergency med residents may never have placed defibrillator pads on a live patient.

In Pathology, most of my fellow residents and I feel particularly unprepared to begin residency in this specialty. Yes, we get histology and some basic pathology during the first and second years of medical school. Perhaps we saw an autopsy or two. But we certainly didn't learn how to formulate a report for cases that we now see. Or do an autopsy mostly by ourselves and know how to pay particular attention to certain areas of the body in order to pick up key findings. For example, there are special, non-routine ways to check for pneumothorax or air embolism, if those are suspected as a cause of death. If not suspected clinically it may not be tested for and thus, not uncovered.

For Surgery, Family Practice, Internal Medicine...you are expected to be a somewhat-functioning resident as you step into the physician shoes on day 1. Hence all the training in learning to interview patients, write History and Physicals, check and interpret lab test results, and present cases to fellow colleagues on rounds or over the phone.

As for us, the Pathology, Radiology, Radiation Oncology residents out there, we generally found our field of choice by doing a rotation during medical school in our respective fields. But these were usually "litmus test" rotations so that we assured ourselves of choosing something in which we have genuine interest so we can happily practice for the rest of our career. Maybe we pick up a few useful skills, but nothing on the order of super-practical.

I am not bitter about the lack of preparation for Pathology. However, I think important improvements could be made in the way basic pathophysiology can be taught and integrated with clinical learning. One solution is the clinicopathological case (CPC) based conferences. They are of particular interest and relevance, I believe. They are the same format as those published weekly by the New England Journal of Medicine. Our teaching institution has similar conferences, but just once per month. At the Dartmouth-Hitchcock Medical Center in New Hampshire, there were weekly CPC conferences (M&M conferences). I love these types of presentations - integrations of research, pathology, clinical cases, and quality improvement. My vote: more, please!

Reaching Back and Moving On

It's markedly difficult to engender a relationship with 1400+ pieces of paper - bound and covered, mind you - but I've spent more time with this treatise than I have with much of my family over the last several years. And I am close with them.

Just about every medical student trained in this country (and countless students in the rest of the world) is familiar with this textbook, "Big Robbins". I made it through the entire text during my second year of school, covering everything from the general principles of Pathology to specific disorders of every organ in the body. As a "basic", "introductory" text, it is quite complete - something I've appreciated this year as a new Pathology resident. As I build the foundations of expertise in Pathology, I find myself turning back to Robbins more often than not. I hoped that covering every word in medical school would prepare me for moving on to something more complex this year as I build upon basic knowledge. I can point to a few reasons why I'm going back to the building blocks I obtained over four years ago.

One is the speed at which medicine progresses with the volumes of literature published every month. The understanding of old diseases and discovery of new ones divide at alarming rates. If there were enough pathologists working on Robbins, it would be (or should be!) updated yearly to reflect the massive number of changes. The edition I read is soon to be two editions old. A dinosaur in modern medicine, it lacks discussion of the human genome project, for instance.

The other reason to go back is simply the sheer amount of knowledge I've...left behind...over the years. Reading, studying, and being examined on Robbins reading wasn't enough to let my mind retain nearly enough. Just like a full-length feature film, it takes more than one time through to memorize ALL the lines.

And of course, I actually enjoy reading Robbins. I did the first time I picked it up and hope to for many years to come. Potentially I'll be comfortable with most of the content in a few years so it will remain in my library as only a consultant. Don't worry, Robbins, it's safe to say you'll always have a place in my heart. No matter how much weight you gain with future editions.

I have a 3-month block of Surgical Pathology coming up, in which I'll be rotating through several different specialty areas of Surg Path, the biggest field of a typical Anatomic/Clinical Pathology training program. January is Genitourinary/Renal/Neuro, February is Gastrointestinal, and March is Endocrine/Pulmonary/Head&Neck. Many programs are moving to specialty rotations rather than doing General Pathology (all cases bunched together). I like it because I can assume a focused method of studying and examining cases, similar to the approach of traditional medical school curricula. There's really nothing like spending a full, cold Milwaukee winter night curled up by the fire, reading about all the types of infections the prepuce can develop. Thanks, Robbins!