Michael L. Talbert

Competency-Based Education for the Molecular Genetic Pathology Fellow: A Report of the Association for Molecular Pathology Training and Education Committee

The following report represents guidelines for competency-based fellowship training in Molecular Genetic Pathology (MGP) developed by the Association for Molecular Pathology Training and Education Committee and Directors of MGP Programs in the United States. The goals of the effort were to describe each of the Accreditation Council for Graduate Medical Education competencies as they apply to MGP fellowship training, provide a summary of goals and objectives, and recommend assessment tools. These guidelines are particularly pertinent to MGP training, which is a relatively new specialty that operates within a rapidly changing scientific and technological arena. It is hoped that this document will provide additional material for directors of existing MGP programs to consider for improvement of program objectives and enhancement of evaluation tools already in place. In addition, the guidelines should provide a valuable framework for the development of new MGP programs.

Assessment and Management of Professionalism Issues in Pathology Residency Training Results From Surveys and a Workshop by the Graduate Medical Education Committee of the College of American Pathologists

Professionalism issues are common in residency training and can be very difficult to recognize and manage. Almost one-third of the milestones for pathology recently instituted by the Accreditation Council for Graduate Medical Education encompass aspects of professionalism. Program directors are often unsure of how and when to remediate residents for unprofessional behavior. We used a case-based educational approach in a workshop setting to assist program directors in the management of unprofessional behavior in residents. Eight case scenarios highlighting various aspects of unprofessional behavior by pathology residents were developed and presented in an open workshop forum at the annual pathology program director’s meeting. Prior to the workshop, 2 surveys were conducted: (1) to collect data on program directors’ experience with identifying, assessing, and managing unprofessional behavior in their residents and (2) to get feedback from workshop registrants on how they would manage each of the 8 case scenarios. A wide range of unprofessional behaviors have been observed by pathology program directors. Although there is occasionally general agreement on how to manage specific behaviors, there remains wide variation in how to manage many of the presented unprofessional behaviors. Remediation for unprofessional behavior in pathology residents remains a difficult and challenging process. Additional education and research in this area are warranted.

Disaster Risks and Preparedness Planning

While it is possible to spend one’s life thinking through extreme “Katrina-like” disasters that might threaten the practice and attempting to prepare contingency plans, we believe there are probably better uses of time, provided that one has attended to certain principles and priorities. This is particularly true since no amount of simulation, drill, or other planning and preparation can enable an organization to be perpetually completely prepared for all possible overwhelming disasters.

The High-Performing Practice into the Future

We recognize that the topics and case studies up to this point have been largely based on past experience, which in some settings might not be predictive of future success given the pace of changes happening in medicine today. However, we do believe that it is not just one principle that will define a practice as successful and that regardless of the changes in the global environment of medical practice and health-care delivery, the principle of being able to effect a synergy of the various aspects covered in previous chapters will be essential to both effective health care and rewarding work as a practitioner of pathology. That said, we recognize that it can be difficult to see how these pieces come together into a cohesive solution for all the various iterations of medical practice that do or will exist. With that in mind, we have asked a number of individuals from a wide variety of backgrounds and practice settings to give us their take on what the high-performing pathology practice will look like in the future. Herewith are some of their responses.

Bringing It All Together

We have spent a good deal of time talking about people issues. Much of pathology practice management, and management in general, is about people. While people are a practice’s most valuable resource, they can also create its most vexing problems. A rift between two senior pathologists can be a greater threat to a practice than changes in Medicare payment rates. This can be compounded by our current environment of rapid change and downward pressure on payments which engenders stress and may exacerbate underlying people issues within a practice. In our experience, day-to-day people issues can demand more total time than the other aspects of practice management combined. As such, careful recruiting, early identification of problems, a focus on fairness, and a proactive approach to intervention are key. Continually evaluating culture and mood is also essential. With these warnings in mind, though, a high-functioning team of professionals is both fun to be part of and difficult to beat in the market.

The Income Statement

Those responsible for monitoring the financial health of a practice (or a lab or any other business) must both understand and believe the numbers and hence information provided by an income statement. In the authors’ experience, this may require time to understand how parts of the income statement interact and to adjust categories to better reflect how the practice is operating. Each month (typically, reporting periods are monthly) as these numbers become available from your accountant or business administrator, one should look at absolute numbers for each entry, whether revenue or expense, and compare numbers with the prior month and budget. It can also be very helpful to smooth out some of the natural month-to-month variability by looking at fiscal year-to-date numbers and comparing them to both prior year-to-date numbers and budgeted year-to-date. Any significant variance should be explained. While you may learn to expect certain levels of variances in numbers such as revenue from Part B billing or supply expenses, any unexpected variances should be investigated. By investigating and explaining variances, one can decide if a variance is a onetime event or portends something more significant. It may also lead one to identify problems such as a client who no longer sends work to you, a change in denial practices by major insurance companies, or an accidental overcharge from a vendor. By identifying and explaining variances in income statement categories, one can better understand the practice, protect the practice by mitigating the impact of the changing environment, and more accurately analyze future threats and opportunities.

Technologic and Regulatory Risks

The core tools of histopathology—seventeenth-century optical microscopy and nineteenth-century aniline dye chemistry—continue to undergird the practice of pathology. However, the rapid strides in science and technology over the last several decades imperil the traditional methods and models of diagnosing disease. The threat of a “disruptive technology” that will change forever the means by which the job of diagnosis is performed (and often who does it and where it is done) seems greater today than even 5 years ago. Examples of this are easy to find and seem to appear almost daily. For example, a recent publication summarized some research with a surgical tool termed “rapid evaporative ionization mass spectroscopy” believed to be capable of detecting and differentiating tumor versus non-tumor based on the computer-analyzed signatures of gases captured from the surgical field during the course of electrocautery. If validated and suitably cost-effective, the technique would appear poised to eliminate the need for intraoperative (and potentially postoperative) margin analysis by frozen section methods. Another method with similar ability to erode or supplant a significant portion of routine pathology (although it could also be directed to augment pathology practice) is in vivo microscopy using confocal microscopy or optical coherence tomography. Some within gastroenterology have advocated that use of these tools during endoscopy could eliminate the need for pathologic evaluation of upwards of 80 % of colon polyps, currently a significant component of many pathologists’ workloads. Similar concerns related to shifts in who does the work or where the diagnostic work is done could be raised with expanded low-cost testing methods such as those offered by Theranos, a company promising inexpensive laboratory tests on small blood volumes, or the high-tech deoxyribonucleic acid (DNA)-sequencing-based “liquid biopsies” able to detect circulating tumor DNA long before clinical signs appear.

Opportunities and Entrepreneurism

Pathologists are problem solvers both inherently and hopefully by training. Beyond the realm of biopsies and analytes however, solving business problems and solving broader problems can often lead them into the realm of the entrepreneur. Here they encounter the age old paradigms of risk-reward, cost-benefit, build-buy, and me or my competitor anew. Finding the balance individually or as groups becomes either a rewarding endeavor, or a frustratingly elusive search.

Identifying and Capitalizing on Opportunities

One of the most satisfying moments in practice management comes when there is a significant positive change in a practice. In general, opportunities may be internal, such as reducing expenses or improving practice efficiency, or external, such as adding to the revenue stream through more work or better contracts, improving your competitive situation, or having novel arrangements that make your practice a more attractive place to work.

Current Major Trends and Considerations for the Future

Much of the challenge of leading the financial aspects of a pathology practice lies in adapting to national and local trends. While we currently seem to be in a time of very rapid change in pathology as well as the rest of medicine, the change is occurring unevenly across the country, and responses have varied region to region. Looking out over the next several years, multiple trends must be considered: 1. The rise of value-based purchasing (VBP) and the expansion of quality incentive programs such as the Physician Quality Reporting System (PQRS) with transition to the Merit-Based Incentive Payment System (MIPS) in 2019 2. The growth of accountable care organizations (ACO), bundled payments, and similar new arrangements of providers 3. Continued downward pressure on payments for pathology and laboratory services 4. Challenges in the workforce—numbers, training, and adaptability 5. Potential influence of technologic disrupters, for example, insourcing with digital pathology, in vivo microscopy, enhanced biomarkers for primary diagnosis and monitoring, and increasing point-of-care testing options 6. For academic pathologists, continued uncertainty in funding for graduate medical education (GME) and research