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Put it on the Board, 6/14

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For trainees, information ‘gaps are closing’

A special honor for a vision and the Vanderbilt team’s feats

Cancer care and patient demands

FDA OKs Qiagen Therascreen KRAS to guide treatment, Artus C. diff kit

Beckman Coulter’s phi named in NCCN guidelines

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For trainees, information ‘gaps are closing’

With the dismissal of residents from training programs having led to well-known tragedies, the most recent in pathology just a year ago, attention is being paid to the importance of ensuring residents’ well-being and properly handling remediation, probation, and dismissal.

The Accreditation Council for Graduate Medical Education has strengthened its requirements for what kind of information residency programs must share about residents’ performance. The ACGME’s common program requirements, last revised in June 2013, say “a program director must provide timely verification of residency education and summative performance evaluations for residents who may leave the program prior to completion.”

Dr. Domen

Dr. Domen

That is an important step, says Ronald E. Domen, MD, a member of the CAP’s Graduate Medical Education Committee and former associate dean for graduate medical education at Penn State Hershey Medical Center and College of Medicine. He is a former residency program director, and he currently directs two fellowship programs at Penn State, one in blood banking and transfusion medicine and the other in clinical informatics and quality.

“The ACGME’s requirements are now much stricter,” Dr. Domen says. “At least there’s some effort to be sure that certain things are being looked at with these applicants. In the past, that wasn’t necessarily true. Somebody could be passed off from a program and have all kinds of issues there and nobody really said anything. The ACGME is trying to ensure there’s plenty of opportunity to document any issues that have come up.

“The gaps are closing,” he adds. “It’s still imperative upon program directors to make sure they do their due diligence on why an applicant is leaving after, say, two years in another program. Are there issues I need to be aware of that someone’s not telling me? It’s a really tough situation,” he says, pointing out that the potential for tragedies like those seen in pathology is always present.

It was on May 12, 2013 that Anthony Garcia allegedly killed a Creighton University pathologist and his wife in their Omaha, Neb., home. Authorities also allege that in 2008 Garcia killed the son and housekeeper of another Creighton pathologist. Prosecutors say Garcia’s actions were retribution for the pathologists’ role in his 2001 dismissal from Creighton’s pathology residency program. A judge last month ruled Garcia competent to stand trial.
Dr. Domen is the author of an article published this month in the American Journal of Clinical Pathology that outlines what program directors should consider when dealing with residents who require remediation, probation, or dismissal (2014;141:784–790).

According to the article, remediation plans should identify the specific issues involved, define expectations for improvement, detail how progress will be evaluated and assessed, set a timeline for completion, and detail the consequences for failure to satisfy the goals. Each step in the process should be documented thoroughly, and residents should get help in identifying support networks, such as employee health assistance programs or faculty and resident mentors, the article says.

Sometimes residents struggle to become competent in performing their clinical duties, but other times the problem is one of unprofessional behavior. The latter will be the focus of a July 10 session at the Association of Pathology Chairs’ annual meeting in Boston. CAP Graduate Medical Education Committee chair Suzanne Zein-Eldin Powell, MD, and former GMEC chair Michael Talbert, MD, will lead a 90-minute discussion for program directors, titled “Remediation of Residents’ Unprofessional Behavior: A Hard Nut to Crack.” The session will include case studies to help program directors think through the best strategies to use in dealing with these challenges.

The process of screening the men and women who want to be physicians begins with medical school. John E. Prescott, MD, chief academic officer for the Association of American Medical Colleges, says criminal background checks are done for all medical school applicants and notes that the evaluation process looks beyond applicants’ raw brain power.

“Every year, we have students who are at the top of their class, with the highest MCAT scores, and yet no medical school picks them up,” Dr. Prescott says. “For some reason, there’s a feeling they are not a good fit for a particular school, or there is some other issue that identifies them as not being right for medicine.”

Academic medical centers have a responsibility to ensure that trainees’ well-being is monitored, Dr. Prescott says.

“We owe it to ourselves in the profession to reach out to people who are trained to be physicians to see if there’s something we can do to assist them,” he says. “With these tragedies, we have to do everything we can to prevent them.”

The ACGME’s requirements say that sponsoring institutions “must provide residents/fellows with access to confidential counseling and behavioral health services.” Some organizations have taken that a step further, with a proactive approach to promoting trainees’ well-being.

One of these is the University of Washington, itself the scene of tragedy. In 2000, second-year pathology resident Jian Chen—distraught after his termination from the UW program—shot and killed his pathology professor mentor before turning the gun on himself.

The tragedy sparked a service aimed at helping residents handle the stress, burnout, and depression that often accompany their long hours and demanding duties. It is not enough to offer mental-health counseling, says Mindy Stern, a social worker who runs UW Medicine’s Wellness Service.

“There’s a mountain of evidence in the literature that mental health declines during the training years,” she says. “You need to create a whole culture of wellness.”

The program offers social events for residents and a weekly newsletter to let them know about fun, low-cost activities in the Seattle area. Stern says such outreach has helped earn the wellness program an 85 percent rate of self-referrals—as opposed to referrals by program directors or other officials.

“We have completely normalized the process of reaching out when someone’s under stress,” she says. 

—Kevin B. O’Reilly

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A special honor for a vision and the Vanderbilt team’s feats

A rousing speech that documented Vanderbilt University Hospital’s use of laboratory expertise to improve test ordering and patient care while cutting costs earned Michael Laposata, MD, PhD, a standing ovation unprecedented in the nearly two-decade history of the Executive War College.

The cornerstone of the Vanderbilt approach, Dr. Laposata explained, is the diagnostic management team. These are collaborations among clinicians and pathologists to develop disease-specific, algorithm-based reflex test ordering. These standard operating protocols are derived from evidence-based guidelines.

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