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In this episode of “Lab Medicine Rounds,” Justin Kreuter, M.D., sits down with Ann Moyer, M.D., Ph.D., associate professor of laboratory medicine and pathology, assistant professor of pharmacology, and associate program director for the Pathology Residency Program at Mayo Clinic, to offer advice for residents getting started in their training programs.
A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
(upbeat music)
- This is "Lab Medicine Rounds",
a curated podcast for physicians,
laboratory professionals and students.
I'm your host, Justin Kreuter,
the Bow Tie Bandit of blood,
a transfusion medicine
pathologist here at Mayo Clinic.
Today, we're rounding with Dr. Ann Moyer,
who is an Associate Professor
of Laboratory Medicine and Pathology,
and Assistant Professor of Pharmacology,
and Associate Program Director
for the Pathology Residency Program.
And Dr. Moyer's joining us today
to talk about residents getting started
in their training programs,
kind of a follow up to a
recent podcast we've had.
So, thanks for joining
us today, Dr. Moyer.
- Thanks for inviting me to be here.
I'm excited to talk about this topic.
- Yeah, yeah.
So, you've been through
your training, both,
you're one of our double doctors, MD, PhD,
and you've gone through a lot of training,
and you've gone through it,
and now you've very much launched
a very successful
academic pathology career.
And I think that all of
our residents, of course,
are overjoyed for you
to be in this Associate
Program Director role
for the residency.
And that's why I think you're bringing
a really neat perspective here.
I'm just setting this up for our students
that are listening to
this podcast to understand
that your perspective is authentic
in a very meaningful way.
So, let's kick this off.
And so for residents who
have recently started,
now that we're recording this
the beginning of August, now,
orientation is presumably behind us.
Where should their focus be?
- I think this one's a really
hard one for a new resident,
because you're very excited.
You just got into pathology.
Hopefully it was the
specialty of your dreams.
And now you kind of feel a little bit
like a kid in a candy store.
There's all this really cool
stuff going on around you.
There's opportunities to get
involved in research projects.
You can just get in so deep into this area
that you're so excited about.
But I think the biggest
thing from my perspective,
that when you start out in
residency is even if you know
what specialty area you want to go into,
and you've got these great plans,
and you've got these opportunities
of things you can do,
it's good to really just
take a step back and realize,
wait a minute, number one,
I've gotta become a
really good pathologist.
And how are you going to do that?
I think the most important
aspect is to start
with a really strong foundation.
And so for some people,
you might've gotten to
have some experience
as a medical student,
and gotten to see some
aspects of pathology,
and some people are coming into it
where they know what pathology is,
but they haven't had as
much in-depth experience.
And in both cases,
I think making sure that both
on the anatomic pathology side
and on the clinical pathology side,
you make sure you really get
again the foundation of the basics.
So, what does that really mean?
Well, so I trained in anatomic
and clinical pathology,
but now I practice
molecular genetic pathology.
So, I'm through and through
a clinical pathologist
who happens to be trained
in anatomic pathology,
but even still, for anatomic pathology,
it's really important just
to get an understanding
of what normal histology looks like.
It's really hard to have a
framework of what's abnormal
if you don't really have
a good understanding
of what's normal.
So, having some of those textbooks
that cover a lot of the normal histology,
definitely a great place to start.
And then in addition to that,
I think having some sort of framework
about how to think about
the different cases
that you're seeing.
So, starting to understand maybe
how the disease process
works or the mechanism,
and making sure you actually understand
the clinical correlation of it too.
So, there is the whole what
we call wallpaper matching
that you might be able
to get pretty good at,
but that's not going to get you
where you need to go in pathology.
It's really having that full,
big picture understanding.
And I think to get that,
you really need the basics.
Now on the CP side of
things, as a medical student,
you've probably got some familiarity
with what lab tests you might order,
but maybe this is your first time
to come through a clinical laboratory.
So, I think the biggest place
to start there is getting a foundation
about, well, how does a
clinical laboratory work?
What are they all about?
How do the samples flow through the lab?
Who are the people in the lab?
And then in addition to that,
some medical students might
have had some opportunities
to work in a research environment,
and starting to get an
understanding of, well,
what's really different
between a clinical lab and a research lab.
What are these processes
that they have in place
so that they make sure
that they're resulting out quality results
every single time?
I think some of these things
can be kind of surprising
for people that are new in pathology.
So, I think being able to, again,
just get that really solid foundation
of how everything should
work is really important.
And I guess as I mentioned earlier,
some people might have
a subspecialty in mind
when you come in.
I know I already knew that I wanted
to be a molecular genetic
pathologist from day one,
but it turns out
I actually thought all of the
rotations were pretty fun.
I even liked grossing,
and I didn't think I'd like autopsy,
but it was certainly interesting, too.
So, even if you've got a pretty good idea
of where you're going,
you can learn a lot from every
single rotation you go to.
So, I think it's helpful to
approach every single rotation
as if maybe this is the thing
that I'm actually going to do.
And even if you don't do it,
you can draw on that
knowledge in the future.
Or maybe suddenly you'll realize
that you have a passion for something
that you didn't realize
that you had a passion for
and you'll change your mind.
And, let's see, I had one
other thing in mind, I guess,
for advice for a brand new resident.
So, I think as a medical student,
you get to have a little bit of ownership
over what's going on,
and making sure that this is my patient,
and I'm going to take care of them.
But in addition,
you do a lot of things that are
a little bit more shadowing,
or sometimes you are involved,
but not the person that's
driving something forward.
So, when you're going through
your residency training,
if you can start taking
some ownership of that case.
So, you're certainly going to get help.
You're not going to be signing it out
on your own on day one,
but making sure that you know, okay, well,
this is what's going to need to happen.
Maybe I have to move
on to another rotation,
but someone's going to follow up
on some immunohistochemical stains,
or something else is
going to happen downstream
after what I've been looking at,
taking ownership to follow through on it
and make sure that you
understand what happened
for that case,
I think that can be
really helpful for people.
And part of that is not being
afraid to ask questions,
because sometimes some of
these things in pathology,
like the case will
probably get signed out,
whether you took ownership of it or not.
But if you can make sure
that you really understand
what's going on,
and if you don't, now is
really your time to learn.
In the future,
you'll have to be able to
practice independently,
but that's not what training is all about.
So, definitely just ask questions,
make sure you understand
what's going on with that case.
Pretend it's a case
that you were going to
probably have to sign out
at the end of the day.
And I think being fully engaged,
I think that'll help
you really get the most
out of your residency.
- I really like how your
answer puts us on this focus.
'Cause I totally relate to your idea
of walking into a candy store,
and you're just, like,
you're so overwhelmed.
And plus you get a lot of
trainees you probably look up to
who are your seniors who
have a lot of knowledge,
and that also can get really enticing,
but your return to focus,
if I'm hearing you right,
is that foundational information,
which paraphrasing you is this,
what's the framework we're approaching
that anatomic pathology case.
And it's kind of this
to the same extent in clinical pathology,
the framework on how do you
approach clinical issues
that come up in the laboratory.
And since this is really
a focused on our students,
I think that our physician listeners
can also kind of take this,
and use this same advice
you're giving to think about,
okay, when I have a junior
resident on service,
how can I focus on being more
transparent with my framework,
and how do I approach a case,
as opposed to maybe a more senior resident
that needs a different sort
of training focus at the time.
And then also for
laboratory professionals,
you might have students
rotating in the lab,
and sometimes it might be,
what do I do with them?
And you're kind of
highlight on contrasting
on a lot of times, people
are involved with research,
but how is this different
than a research lab?
How does the lab work on the grand scheme?
What does the forest look like?
I think are really key insights.
One thing I wanted to ask you just
to elaborate a little bit,
you talked about ownership,
and I think that's such a neat concept
that I think it's something
that is kind of in the ethers
a little bit as a topic,
where a lot of times, like,
I'm not thinking about it
because it's just happening and I feel it.
And it's sometimes maybe
with a learner who is not
taking ownership of a case.
In other words, I guess for me,
I feel like then I'm having
to step in periodically
and direct what's next
step, what's next step.
But I also am sympathetic
that maybe for a learner,
that's a little tough to
understand and come in.
And how does a first year resident work on
or start developing that taking ownership?
Do you have any advice
for what step one or two might look like
for a new resident that's just
trying to get their sea legs.
What does that look like?
- Yeah, I think this is
a really good question,
because ownership looks like
something very different
when you're a fourth year resident
or a fellow even versus
first year resident.
So, I guess my approach
would be when I was on call,
let's say as a junior
resident, for example,
in clinical pathology,
first, somebody calls
you with some question,
and sometimes you're like,
I don't even know what
that test actually is.
So, you try to get as much
clinical information as you can,
figure out, well, what
exactly is their question?
Take down some notes.
And then you tell them, oh yeah,
I'll get back to you on that.
And then as soon as you hang up, well,
you've kind of got two options
of roads you can go down.
Number one, you can be like, okay,
who's the consultant or the attending,
if you're not at the Mayo
Clinic, who might be on call,
and or might oversee this laboratory,
and you can just pick up
the phone and call them
and relay the exact same
thing that you just got back,
and get the answer from them.
I don't think that's really ownership.
I would recommend taking the approach
where you take down that information,
and now you spend a little
bit of time looking up,
well, what is this test?
What is this test for?
Find out a little bit more
about how it might be used clinically,
and then try to think, well,
how would I answer that question
if I didn't have somebody
else I could call.
And then once you've kind
of got an idea in your mind
about maybe what you think
you might want to say,
then call that consultant or attending,
tell them what the
person was asking about,
tell them what you were thinking,
and then ask them for
some feedback on that.
And in some cases they might say,
"Oh, good job, you really
understood this test."
And you can feel proud
and walk away from it.
And other times they might
say, "Oh, not even close,"
but hopefully it'll be something
that then you can learn from it.
But if you don't go through those steps
of trying to figure it out
a little bit on your own,
it's harder to really get
something from that education
when it's more passive, someone
just telling you the answer.
Now, the only caveat to
that, is as a first year,
you could easily go down a rabbit hole
and find thousands of papers
to read about this topic.
I don't think you want to
go to that extreme either
because that pager's probably
gonna start going off again.
So, you really have to
find that fine balance
of learning on your own a little bit
so that you've got
something intelligent to say
about this test,
and how you're going to ask your question,
and that you've looked into
it at least to some extent,
but recognize that, again,
especially as a junior trainee,
no one's expecting you
to know the exact answer,
and it's okay to be wrong.
So, don't spend three days
trying to answer that question,
because the patient
that's on the other end,
and that provider,
they probably need an
answer sooner than that.
- I love that.
That last part of your
answer is really kind of,
for my mind, my ear,
this kind of highlights,
maintaining situational awareness.
When is it appropriate to dive in?
When is it not appropriate?
And also your answer,
it really resonates for me,
'cause that's my same
process I still follow.
When I get a difficult
therapeutic apheresis question,
I know I've got Dr. Winters on speed dial,
but always before I pick
up the phone and call him,
I'm always asking, like, okay,
if he was unreachable, or
if he doesn't pick this up,
what would I do with this?
Or if he doesn't pick up,
what will I do with this?
I think that translates
to the anatomic path, too.
If you show up as a resident
having previewed a case
with certain recommendations
on what you think this is
or what you think this needs,
and follow up for special stains,
I think that is a way.
I think you're really spot
on showing how are some ways
that as a junior can show
what ownership looks like.
- Yeah, I totally agree
with that comment, too,
on anatomic pathology,
very similar thinking about
what would the next steps be?
That's definitely a good
analogous pathway in that area.
- So, there was once a coaching book,
I get nerdy about this stuff,
there was once a coaching book,
I think it had some piece of
advice in there about kind of
like what got you here won't
get you there kind of thing.
In other words,
what you did to be successful
in medical school won't
necessarily be what you need
to focus on, or the skill set
to be successful in residency.
And so, I'm curious, in
your leadership role,
and with your experiences so far,
what's a new skill or two
that residents should really
kind of focus on developing?
- Yeah, I think that's an interesting one,
because probably a lot of the skills
that did get you here are the
things you wanna keep doing.
But definitely I think things
transition the further you get
through your training.
Again, since I really
like clinical pathology,
we're gonna go down that road,
but you can think about
how it might apply to anatomic pathology,
but as a medical student,
you think about, well,
what's the differential diagnosis?
And then you start thinking, well,
what tests might I order
to help answer my question
and get to the final diagnosis?
But I think the things
that you don't necessarily
really think about
as a medical student are the things
that end up being really
important in pathology.
And those would be things like, okay,
well what are the
limitations of these tests?
Or are there situations
when maybe I would not
want to order this test?
Or what happens when I've
got my differential built,
I've ordered my tests, and the
results just don't come out
how I expected them to have come out?
So, I think that next level
of what's the next step
of what I'm going to do,
or what could be the
limitations of these tests
that are making them give
me a different result
than I expected.
I think that's kind of
the level to build on.
And how do you really get there?
Well, I don't think
you can really get to that
level of understanding
until you've got a good understanding
of how the actual tests are working,
and how the disease processes are working.
So, a medical school prepared
you pretty well, I think,
for how the disease processes work,
but really a lot of being a resident,
at least on the clinical pathology side,
is understanding how
are the tests working,
what are their limitations,
what's the technology that's driving that?
And then if you think about it
on the anatomic pathology side,
I think it's kind of somewhat similar.
So, you have your differential
when you've got this slide in front of you
about what it maybe could be.
And sometimes you can
probably get that answer,
looking at the H and E.
And that's probably similar to
maybe what you would've seen
in a medical school
histology sort of class,
or pathology sort of class,
but then sometimes you're like,
"Hmm, I'm not really sure what this is,"
or you might need to
order some special stains
to differentiate that.
So, it's really that
next level of thinking.
And again, for figuring out what to do
in those more complex situations,
I think you just really have to have
a deeper knowledge base,
and you really can't get there
by just memorizing a lot of
factoids about these disorders.
You really have to start
fully understanding
that underlying pathophysiology.
So, I think that's probably the thing
that I would focus on the most is
the understanding the whys of medicine,
as opposed to starting
to recognize patterns,
and some of the things
that maybe you focused
on as a medical student.
So, just getting a little
bit deeper in there.
- One of the things I really
appreciate about your answer,
Dr. Moyer, is it's
something that is possible,
whatever my training
environment is, right?
So, you don't have to
have crazy things come up,
but you're talking about
that next level thinking.
So, I guess if I have a patient case
in front of me thinking
about all the permutations
about how this could be off,
and if I did get such a such a result,
or if this wasn't seen here,
if this artifact was introduced,
how would I navigate around this?
It seems like it's something
that no matter where you are
in the world and your resources,
it's something that you can do to,
I don't know if that's mentally hardening
or preparing yourself for,
you're the endurance athlete, so.
- Yeah, I think you're right, even,
so a lot of times you'll
be lucky, or unlucky,
depending on how you view it,
and you'll get those really tricky cases.
And I do think
that those are sometimes
the most educational,
because they're going to take you a while
to sort through them.
And that's when you see
when things didn't follow the textbook.
But even if things are
following the textbook,
if you've got time to read about your case
and think about your case,
I think you can start going
through some of those
various permutations, too,
to think about, well,
what would happen if this
stain did come back negative,
or what would happen
if this laboratory result didn't match
what I thought it should have matched.
So, I think that's a very good point.
- So, shifting gears a little bit.
So, we've been talking so far
about all the things that we can work on,
focus on to be successful.
I'm kind of curious about
when learners struggle,
and how can they get
help and approach that?
And I imagine that as a new resident,
it's particularly difficult to reach out.
You're probably in a new city,
in a new training environment.
This is very different than
what medical school was like
in some important ways.
And, I don't know, quite disorienting.
And so I was wondering if
you could kind of share
with the student listeners,
what do you recommend,
when you sort of realize,
you sort of look around,
you're like, geez, I'm not really being,
I don't think I'm being as
successful as I should be.
What should learners do in that situation?
- I think step one is to
stop and realize that,
and this is coming from me to you,
you're probably not alone.
Everybody has probably hit
a point where you feel like,
oh my gosh, this is really overwhelming.
I don't get this. This is confusing.
And you start worrying about, well,
maybe I'm not cut out for this,
or whatever the case may be.
They're always, everybody
hits rough patches, I think,
where you hit concerns or doubts,
or things you really need to work through.
So, I think the number
one thing is just know
you are not the only person
to have experienced this.
So, then I think that leads to number two.
If you can recognize that, and
believe me when I say this,
I've hit periods of time, too,
when there's things
that I just don't really
know what to do about them
and feel a little overwhelmed,
but it makes it a little bit easier
to do what I think is important,
which is to reach out to other people.
And if you can recognize
that, you know what,
I bet they've hit a hard point
at some point in their life too,
it makes it a little bit easier
to feel like maybe it's okay to ask.
So, I think what I would
do is think about, well,
who can I reach out to?
And I think you have a lot of options.
So, if you haven't found a mentor yet,
I would definitely recommend
trying to find somebody
that you click with.
They can either be someone
that's in an area of pathology
that you would like to
go into in the future,
or maybe they have some attributes
that you would like to emulate,
or maybe they just were
friendly that first day
when you met them,
and you can chat with
them a little bit more.
So, they don't necessarily
have to be someone
that's doing the exact career path
that you are planning on doing,
but someone that you feel
comfortable talking to.
And the other person
that you could potentially talk
to is your program director.
In general, program directors
are there to help you out.
That's their goal is they want
to see residents be successful
at the end of the day.
And if someone is struggling
and they never tell their
program director about it,
they'll have no idea that
you're having a hard time.
So, program directors,
associate program directors,
rotation directors, they all, like,
we wouldn't be doing
this educational thing
if we didn't want what's
best for our trainees.
So, if you're feeling a little
intimidated by those people,
even though they're totally there for you,
they've got your back,
they're senior residents
at most programs also,
perhaps some fellows,
some of those people can
help give you some tips, too.
And they've been in that
position that you were in,
not really that long ago, like,
especially think about
a third year resident.
They probably still
remember what it was like
to be a first year resident.
And even for me,
it's been a little while since
I was a first year resident,
but I definitely remember being like,
I don't even know what that
word is that they just said,
I'm gonna have to go Google that later,
or look at a textbook, or what was that?
So, I think just finding people
that you can reach out to
to kind of ask them, well,
how did you get through this?
Or what ideas do you have for me?
And if you've got something very specific,
that's a hard thing that
you're working through.
There's also at a lot of institutions,
people who are academic success coaches,
and they might have different
styles of studying, perhaps,
that you could apply, or different
techniques you could use.
And I guess if the other
thing to think about, too,
is probably spending some time reflecting
on what exactly is going on.
And this is maybe the first thing
that you would even actually
want to do after realizing
that you're probably not the first person
to experience this.
I guess this is the insert
before you talk to the other
people, maybe think about,
well, okay, what am I
really struggling with?
Am I just feeling a
little bit overwhelmed?
Because as a first year,
it's like you're drinking
from a fire hose,
and there's so much new stuff.
And I'm actually doing okay,
it just feels overwhelming.
In which case, if I keep
studying, I'm going to be okay,
I'm gonna get through this.
Or am I truly struggling in one
specific area, one rotation?
Am I not spending enough time reading?
Am I reading, but not understanding?
Kind of really feeling out
what exactly you're worried about,
because then when you do talk
to those people who are there to help you
and are going to be sympathetic,
and want what's best for you,
they'll be able to better help you
and direct you to any
resources that you might need.
Or sometimes they might
just need to be there
to be a supportive, friendly face,
while you explain what's going on.
And maybe you just need some reassurance.
But I think there are a
lot of different scenarios
that people run into as a resident.
And sometimes things outside
of work life can get in the way
of some things sometimes, too,
because we're all people
outside of being doctors.
So, kind of thinking through
all of the various permutations
of what might be inhibiting me
from doing as well as I would like to do,
because they're also resources
for all of those other things
outside of pathology, too.
But again, no one can really help you
if you don't ask for help,
because it's hard to see from the outside
what someone's going through.
So, never be afraid to reach out
because everybody wants
what's best for you
at the end of the day.
- It's an important message.
And I think another thing is
what you're answering there,
it really resonates for me in practice
in that I guess I've got a division chair
that I go and have a meeting with.
It might be most similar to
having a residency director.
But it's that same process
of I'm reflecting in
between these meetings,
and what am I struggling with,
what do I need help with?
These are things that are skills
that kind of continue
with you going forward
in your professional career.
How do you recommend
residents kind of approach
those meetings with
their program director?
I mean, sometimes there's meetings called
for a specific reason,
but there's also kind of periodic meetings
that are scheduled.
And I'm kind of curious for your thoughts
on how do residents make
the most of those meetings?
- I think it depends on
what exactly is going on
at that point in time for the resident.
So, if you are having a
difficult time with a rotation
or a situation, or
something's going on in life,
and it's something
that maybe you could use
some additional resources
or some help with,
definitely come into the
meeting feeling ready
to talk about those sorts of things.
It can be hard to talk about it,
but I think that's an important thing,
because that's, again,
how you get the help if you need it.
If it's more that maybe
you've got some questions,
you're not really sure
how do I go about
applying for a fellowship?
How do I go about figuring out
what I'm going to do during this elective?
How do I start thinking about
I don't know what specialty
or subspecialty I want to go into?
How do I figure those sorts of things out?
I think if there are things
rolling around in your mind
that are bothering you,
sometimes it's hard to at
first put them into words,
but again, by doing
some reflection up front
and figuring out what those things are,
if you can come to your mentor
or your program director
with more specific questions,
it's definitely a little
bit easier to guide someone,
but if you're having a hard
time putting it into words
and there are things that are,
you're still trying to figure out,
even just going in and
talking to your mentor
or your program director
with an open mind,
sometimes they'll know
what questions to ask you
to be able to help sort
out those sorts of things.
So, I think being very
much willing to talk,
being open with the person
that you're working with
that's there to help you,
and being able to have some
specific questions ready to go,
if you've already got specific
questions, can be helpful.
But then beyond that,
if you're meeting with
a mentor, for example,
I think some of the things that
you could be thinking about
if you're not really sure, well,
what am I gonna talk
about with this mentor?
I've got this lined up.
Well, some of the things that
I think are really important,
especially as a junior resident
is thinking through, well,
what are my short term goals?
Do I just wanna get through
step three, for example,
and how am I going to do that?
And you can ask your mentor questions
about maybe how you could
be preparing for that,
or when a good time is to
do that during the year.
But then as a junior resident,
you probably want to start thinking
about some of those long term goals, too.
You don't have to know
the answer right away
about what area of pathology,
or what type of practice,
or anything you want to go into,
but start exploring, well, okay,
these are the things that I really like.
These are the things that
maybe aren't my favorite.
And if you start to get a sense
of what direction you're
headed, then again,
that mentor or program
director can start steering you
towards maybe other people,
and doing some networking,
and people that they think, oh,
you should probably talk to this person,
because they can give you a better picture
about what that subspecialty looks like.
Or you could talk to this person
because they might have a good insight
of what it feels like to work in industry,
because I don't know that,
I work in an academic
setting, for example.
So, I think coming in
with some of those specific
questions can be helpful,
but really just being open minded,
because sometimes you'll come in,
and you might have some questions,
and then your mentor might
start asking you some questions.
And sometimes I think
you know subconsciously
what you want to do,
or what the best path forward is,
but your brain is telling
you something else.
And if they're asking
you the right questions,
sometimes you realize
that the advice you're getting isn't quite
what you expected.
And if you're open to it,
you might ultimately
get to a better solution
than you were originally thinking about.
So, I think just being open
to share with your mentor
and open to their feedback makes
for a really good partnership.
I guess the other thing
I didn't really mention
at the beginning, though,
is sometimes just having some goals.
If you've got a formal mentor,
for example, figuring out,
well, what are the things, like,
what's the goal of this
mentoring relationship
that can really help steer things, too?
'Cause you'll probably keep
meeting with them long term.
And so maybe one time
that you meet with them
can lead into the next.
But I think there's a
lot of different things
that can be gleaned
from meeting with them
during these meetings.
So, just being prepared and ready to talk.
And usually it's a pretty
fun and pleasant experience.
- Wise words, deliberate words.
We've been rounding with Dr. Moyer.
Thanks for talking with us about
how can resident learners
really have success after orientation.
And to all of our listeners,
thank you for joining us today.
We invite you to share your thoughts
and suggestions via email.
Please direct any suggestions
to mcleducation@mayo.edu,
and reference this podcast.
If you've enjoyed "Lab
Medicine Rounds" podcast,
please subscribe.
And until our next rounds together,
we can encourage you to
continue to connect lab medicine
in the clinical practice through
insightful conversations.
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