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Point/Counterpoint |
1 Department of Pathology, University of Pittsburgh, Pittsburgh, PA.
2 Department of Laboratory Medicine, Yale University, New Haven, CT.
aAddress correspondence to this author at: Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15213. E-mail wellsa{at}upmc.edu.
We welcome the dialog entered into by Luning Prak et al. concerning the proposed clinical pathology/laboratory medicine (CP/LM) 1 curriculum (1). Indeed, generation of discussion in this area was one of the major motivating forces that led to creation of that document. The CP/LM curriculum was deliberately designed as a template and not a blueprint, and as such, it is intended to be adapted to the philosophies and capabilities of the various extant programs. However, even with that open approach, we feel that we need to clarify and reemphasize aspects of the curriculum that are raised by Luning Prak et al.
First, the entire committee, comprising faculty members from over a dozen programs, felt strongly that we are educating clinicians to act as clinicians. This should not be viewed as meaning that there must be direct, face-to-face patient contact as the primary activity of the clinical pathologist, but rather that the clinical pathologist’s role is to treat the human condition of disease and health, albeit most frequently from a population-based orientation. Most often this clinical service will be provided within the "system-context" of the entire healthcare team, which includes direct patient-oriented clinical colleagues. (Although in some circumstances care may also be delivered directly to the patient by the clinical pathologist.) To function effectively in this role, the clinical pathologist must be competent in leading the operation of the laboratory in all of the critical aspects enumerated in the proposed curriculum (1). We fear that Luning Prak et al. have misunderstood this point, leading to a seeming disagreement with the emphasis of training that we do not believe is present in the curriculum document.
Second, there appears to be a philosophical schism that is suggested based on the construction of the particular curriculum. The committee that developed the proposed curriculum had extensive discussions as to whether it should reflect current capabilities of programs or be designed to capture what is generally felt to be core knowledge and skill sets. We chose the latter, whereas Luning Prak et al. appear to argue for the former. It is to be expected that not all programs can provide the entire training set, and not all residents may have an anticipated career path that will allow them to focus on all areas sufficiently to acquire the full knowledge and skill sets. Thus, programs and individuals will need to make adjustments or decide not to provide/acquire specific subsets of this training. Although such a choice may be viewed as lamentable, the proposed goal-oriented education will better ensure competency and excellence than would an adaptive curriculum based on the lowest common denominator.
Indeed, several of us have argued that the actual implementation of both anatomic pathology (AP) and CP curricula will need to consider the changing face of pathology practice as well as the realities of training. Some believe that the aims of an initial pathology training period may need to be adjusted downward from the current lofty goal of truly comprehensive competency to practice in all areas of pathology in all settings. Such an adjustment has been the subject of action in other medical disciplines as the knowledge base explodes, and may need to be carefully examined in our discipline as well. Nevertheless, in the curriculum proposal (1), we believe that it is important to define what such global competency in CP truly involves.
We fully recognize that most residents enter so-called "community-based" service environments. Although the complexity of clinical laboratory testing is reduced in such settings, the actual practice of CP might be even more challenging, given the breadth and pace of advancements. As such, limiting the base training would be counterproductive to clinical practice. Rather, a pathologist entering such an environment may choose to attain competency in a subset of CP subdisciplines, as suggested in the proposed curriculum (1). This is increasingly possible in practice, as the average size of community-based practices is now 8 pathologists and growing. This, and the increasing availability of CP specialist consultations, allows for focused and deeper consultative competencies. In short, the days of a lone pathologist running all AP and CP services are limited by the increasingly broad and detailed nature of medical practice and by the actual ongoing changes in pathology services that this fact has engendered. The committee decided that we need to teach for the future and not for the present and the past.
A minor point appears to be a simplification of the concepts of gradated responsibility and educational reinforcement embodied in what are labeled levels I and II of our curriculum. Criteria for progression from one to the other, and incorporation of the appropriate knowledge and skill subsets (some of which are almost arbitrary in sequencing but parsed anyway on the pedagogic concept of limited teaching sets), is not intended to be seniority but instead must be based on the actual acquisition of the requisite skills and knowledge. This is to be determined in real time by the program, the faculty, and the trainees.
Lastly, we fully agree with Luning Prak et al. that evaluation of competency is complex and fits no one format. We did not mean to imply that "hands-on" experiences should be in any way minimized. We state that knowledge and skill set acquisition is the main goal. In the examples provided by Luning Prak et al., we agree that this likely is best attained by hands-on training. Rather, we emphasize in the curriculum that technical performance does not replace, nor does it compensate for, clinical knowledge and competency. Problem solving, including data analysis, is often the best way to learn and to judge the extent of that learning.
In closing, we hope that others engage with us in the dialog to strengthen the CP/LM training experience, as the proposed curriculum is a living document meant for adaptation and developmental growth.
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The following articles in journals at HighWire Press have cited this article:
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  M. G. Scott and D. E. Bruns Improving training in laboratory medicine. Clin. Chem., June 1, 2006; 52(6): 915 - 916. [Full Text] [PDF]
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