Your first day as an attending pathologist is the start of a new chapter. Overnight, you’re no longer a trainee and you’re now the one responsible with your name signed on the final report. It is 100% normal for this transition to feel daunting, but there are some best practices that you can use to build your practice. Here are eight strategies to help you develop your confidence, establish ideal practice habits, and build strong relationships with your colleagues.
1. Own your role – You’re a pathologist now! You’ve made it. While it might feel like you’re starting all over, it’s critical to recognize that you are a highly trained professional and valuable member of the team. Imposter syndrome can be a daily challenge, especially when we’re suddenly thrust into such an important role after being a student or trainee for literally our entire lives. Your uncertainty and anxiety is normal but you have to lean into the strength of your training. Clinicians, patients, and your colleagues now rely on you which can feel overwhelming but is also a privilege and a testament to your hard work and dedication.
2. Understand the workflow – In residency and fellowship, you’ve had time to get used to how things are done and the expectations are often very clear. When you’re only used to one way of doing things, it can be easy to assume that’s just the way they are always done. But, every lab is different in its workflow and processes. Just as you might have assumed that every department works the same as your residency program, the group that you’re joining might assume that you know how they do things. This complicated web of expectations and assumptions can make things muddier than they need to be. As much clarity as you can get about the nitty gritty details about workflow, the better. Start with the basics and understand the workflow –
- What are your daily responsibilities?
- What time are slides distributed?
- Is there an immunohistochemical stain order cut off time for same day turnaround?
- Where do you file slides?
- How are frozen sections and rapid on site evaluations managed?
3. Show cases – The trope is that pathologists are the lone, quirky scientists milling in dark hospital basements. In reality, pathology is a very interactive and collegial field. It’s very important to work with your colleagues and rely on each others’ strengths. Many new pathologists feel very anxious about showing cases. They worry that they’ll be seen as incompetent or unqualified. However, most pathologists really welcome sharing cases with each other.
Most practices have guidelines regarding case reviews for new pathologists. In some cases this is a prospective, pre-sign out review and in other cases it is a retrospective, post-sign out review. The percentage of cases varies but is generally 20-100% for 1-4 weeks. If you are unaware of the specific guidelines, be sure to inquire about them. Also, be sure to inquire about any standard institutional peer review guidelines. For example, some departments require all breast and prostate biopsies to be reviewed, any new malignancies, and any discordant or unexpected findings.
My general guideline – if the thought occurs to you to show a case to another pathologist, then you should show it. More specifically, I would focus on showing any new malignancies, diagnoses you’ve never signed out before independently, and any cases where you are perseverating and just can’t make a diagnosis.
There are some general best practices for showing cases so as to not be a bugger to your colleagues. Here’s what not to do – “I have this case and I have no clue what this is, what is it?” Here’s a better approach – “I have this case and I’m curious of your opinion as to whether this level of atypia is sufficient enough to call atypical ductal hyperplasia” or “This a new malignancy in a x year-old M/F with a history of of xyz who presented with multiple liver lesions and a lung mass. I ordered an initial round of stains but they are inconclusive, do you have any suggestions for other primary sites to consider or stains to order?”
4. Ask questions – When in doubt, ask the question. My grandmother used to always remind me “You weren’t born knowing how to do it.” You aren’t expected to know it all but you are expected to know when you need to get more information. This doesn’t just apply to diagnoses but also to questions involving the EMR, how to order molecular studies, where to file slides, how to prepare for tumor boards, when do you need to order stains for same day turnaround etc. If you don’t know, don’t ever assume. Rely on your colleagues for their knowledge about the system. Staff can be a wonderful resource as well. Always be kind and friendly to everyone, especially the support staff. They know the ins and outs of the department and can help you as you become part of the team.
5. Explore your preferred case triage style – You might have started to explore your preferred case triage style in residency but it feels very different when you’re the one now responsible.
There are two general case triage styles – 1) swallow the frog and 2) snowball.
Those who swallow the frog prefer to review the more challenging/larger/resection cases first. Those who prefer the snowball method review more straightforward/smaller/biopsy cases first. There are several factors that influence which you prefer, including immunohistochemical stain order cut off times, slide distribution times, and case allocation, but most of this preference is just personal. Neither method is right or wrong, just different.
I personally prefer the snowball method. I like to build momentum as the day goes on and reserve the cases that require more time when there are fewer cases left to review. I also prefer to save my least favorite specimens for last (cough cough…placentas, amputations). For others, they prefer to review these more involved cases earlier in the day when they feel fresher. You’re not wedded to one method or another but I’ve found that consistency when approaching a case load is very helpful for organization, time management and mental compartmentalization. Experiment and see what works best for you. One method will likely stand out as the most efficient for you.
6. Prepare for call – Be clear on the responsibilities for call. Do you have after hours access if needed? This might sound silly but the day before my first call weekend I realized I didn’t have a key either to the office or the separate frozen section room. It was a detail that had slipped through the cracks. Thankfully, I inquired about getting a key and badge access because, as luck would have it, I was called in for several frozens that weekend.
7. Give yourself grace – New jobs are challenging, whether you’re a new attending or have been practicing for 25 years. Give yourself enough time and grace to settle into your new role. Efficiency and confidence will come with time and consistent practice. An important part of giving yourself grace is knowing your limits. You could work all night but that’s rarely an efficient approach in pathology. The practice of pathology is very mentally exhausting. It’s a well-known feeling among pathologists that our diagnostic acumen decreases with fatigue – not only are we less likely to get it right but we are also less decisive rendering more “atypical” diagnoses that are not particularly helpful to clinicians. If you’re a morning person, know that your eyes are less trustworthy at the end of the day. Knowing when to stop for the day is an important skill.
8. Reach out for help – If you’re feeling overwhelmed, don’t let it compound. Reach out for assistance or to discuss any issues regarding case load and work efficiency before it gets worse. People are generally much more willing to help and guide you along if you let them know about issues earlier than later.
What are your tips for a new pathologist in practice? What do you wish someone had shared with you on your first day?
Tune in next week when we’ll discuss how to approach a case – from gross to sign out.