Implications of Changes for Readiness to Practice: Hybrid Academic/Private Practice Perspective Michael R. Pins, MD American Board of Pathology Spring Meeting with Cooperating Societies May 5, 2015 Training Requirements for Certification of Pathologists in the 21st Century:

Hybrid Academic/Private Practice Perspective - Outline Context Context  Introduce the Advocate System and Myself  Academic Affiliations “Implications of Changes for Readiness to Practice” “Implications of Changes for Readiness to Practice”  Proposed New Model  Sub-specialization  In General...  In Private Practice… Comments Comments

Hybrid Academic/Private Practice Perspective Context - Introduce Advocate System Context - Introduce Advocate System  Advocate System  10 Hospitals, including 2 Children’s Hospitals (and growing....?)  “Largest ACO in the U.S.”  Advocate Lutheran General Hospital  600+ Beds  Referral Center for Thoracic, Hematologic (stem cell transplant program) and Breast Malignancies, Melaonoma

Hybrid Academic/Private Practice Perspective Context - Introduce Advocate System (cont’d) Context - Introduce Advocate System (cont’d)  Midwest Diagnostic Pathology (MDP)  44 Pathologists (and growing....?), separate business groups  ACL Laboratories  “Largest hospital-owned laboratory in U.S. by volume  Centralized lab. for all Advocate sites  Molecular Pathology: Advocate and Aurora (southern Wisconsin) Systems

Hybrid Academic/Private Practice Perspective Context - Introduce Advocate System (cont’d) Context - Introduce Advocate System (cont’d)  Academic Affiliations  University of Illinois at Chicago College of Medicine  4 Pathology Residents (General SP)  Electives in HematoP, SurgP, MolP, CytoP, DermP and RenalP  Chicago Medical School of Rosalind Franklin University of Medicine and Science  Second year medical school course  Medical Student electives

Hybrid Academic/Private Practice Perspective Context - Introduce myself Context - Introduce myself  Chicago Native – Returning to Chicago  Massachusetts General Hospital (7 years)  Residency, Fellowships (Transfusion Medicine and Surgical Pathology)  On staff: Assistant Director Blood Transfusion Service and CVPath / Transplant Pathologist  Northwestern Memorial Hospital (11 years)  On staff: Surgical Pathology (“….too many blood bankers”)  Sub-specialization (depending on need): GU Pathology, Perinatal Pathology, Gyn Pathology

Hybrid Academic/Private Practice Perspective Context - Introduce myself Context - Introduce myself  Chicago Native – Returning to Chicago (….geographic)  Massachusetts General Hospital (7 years)  Residency, Fellowships (Transfusion Medicine and Surgical Pathology) (….marketability)  On staff: Assistant Director Blood Transfusion Service and CVPath / Transplant Pathologist (….downside to sub-specialization)  Northwestern Memorial Hospital (11 years)  On staff: Surgical Pathology (“….too many blood bankers”) (….so much for marketability)  Sub-specialization (depending on need): GU Pathology, Perinatal Pathology, Gyn Pathology (….adaptability)

Hybrid Academic/Private Practice Perspective - Outline Context Context  Introduce the Advocate System and Myself  Academic Affiliations “Implications of Changes for Readiness to Practice” “Implications of Changes for Readiness to Practice”  Proposed New Model  Sub-specialization Comments Comments

AP/CP, lab management, informatics, lab accreditation Hybrid Academic/Private Practice Perspective Implications of Changes for Readiness to Practice: Proposed new Model Implications of Changes for Readiness to Practice: Proposed new Model “Advanced” AP or CP Fellowship(s) 1 Yr (6-18 mos?) “Critical Thinking” 2 Yr (12-36 mos?) “Minutia” 1 Yr (per fellowship)  

Hybrid Academic/Private Practice Perspective Implications of Changes for Readiness to Practice: Sub-specialization - In General Implications of Changes for Readiness to Practice: Sub-specialization - In General  Breadth of knowledge required to master the disciplines of AP/CP (as defined by ABP in 1938) too great  Advantages: Better patient care (focus, consistency, state of the art, clinicians know whom to call, etc) Refs: Sarewitz SJ. Arch Pathol Lab Med 2014:138;871-2 and Domen RE and Baccon J. Hum Pathol 2014:45:1125-9

Hybrid Academic/Private Practice Perspective Implications of Changes for Readiness to Practice: Sub-specialization - In General (cont’d) Implications of Changes for Readiness to Practice: Sub-specialization - In General (cont’d)  Disadvantages:  Marketability of younger Pathologists  Certification: Sub-specialty MOC exams?  Distinction between AP/CP/MP, other becoming blurred  : NGS ECOG-ACRIN clinical trial not organ specific  Ex: NGS ECOG-ACRIN clinical trial not organ specific  : Hematology – Hematopathology – Transfusion Medicine  Ex: Hematology – Hematopathology – Transfusion Medicine  : AP-Research Tract vs. CP-Research Tract  Ex: AP-Research Tract vs. CP-Research Tract Refs: Sarewitz SJ. Arch Pathol Lab Med 2014:138;871-2 and Domen RE and Baccon J. Hum Pathol 2014:45:1125-9

Hybrid Academic/Private Practice Perspective Implications of Changes for Readiness to Practice: Sub-specialization - In Private Practice Implications of Changes for Readiness to Practice: Sub-specialization - In Private Practice  How will small groups sub-specialize?  Develop networks  De facto – System Mergers  Telepathology  Undergo training or recruit sub-specialists  : NeuroP: One MD, PhD “go-to person” in our system  Ex: NeuroP: One MD, PhD “go-to person” in our system  : Microbiology: Central PhD - MALDI-TOF  Ex: Microbiology: Central PhD - MALDI-TOF  : MolP: ACL Lab, MD; MD, PhD; PhD  Ex: MolP: ACL Lab, MD; MD, PhD; PhD Refs: Sarewitz SJ. Arch Pathol Lab Med 2014:138;871-2 and Domen RE and Baccon J. Hum Pathol 2014:45:1125-9

Hybrid Academic/Private Practice Perspective - Outline Context Context  Introduce the Advocate System and Myself  Academic Affiliations “Implications of Changes for Readiness to Practice” “Implications of Changes for Readiness to Practice”  Proposed New Model  Sub-specialization  In General...  In Private Practice… Comments

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”) One (or two) Fellowships One (or two) Fellowships Whom Would I Hire Today? Whom Would I Hire Today? What Advice do I Give My Residents? What Advice do I Give My Residents?

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”) Core Competencies: 1. Patient Care 2. Medical Knowledge 3. Practice-Based Learning 4. Interpersonal 5. Professionalism 6. Systems-Based Practice “7th” Critical Thinking AP/CP, lab management, informatics, lab accreditation 1 Yr (6-18 mos?) “Critical Thinking” 

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”)  Chicago Medical School Experience: Fewer residency positions (all specialties) than U.S. graduates  Case studies  Medical School Elective Credit (Advanced Placement Model)  Harvard Medical School Anecdote  Reliance on Board exams (NBME, ABP, MOC, etc) undermines fostering critical thinking skills

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”) One (or two) Fellowships One (or two) Fellowships  My opinion: “Readiness to Practice” in new model requires Fellowship - “Over qualification”  Survey: Horowitz, RE Expectations and Essentials for the Community Practice of Pathology Hum Pathol 2006:37:  Choosing the best fellowship  DermP, CytoP, Trans Med, GIPath (Ref)  Deficiencies  “Lack of clinical context”

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”) One (or two) Fellowships One (or two) Fellowships Whom Would I Hire Today? Whom Would I Hire Today?  “Critical Thinkers”: My only hire out of Fellowship was a past Resident of ours  Capable (and willing) to help with the RenalP service with mentoring (adaptability)  Adaptability: My most recent hire job description (70% CMS; 30% service [system PulmP])

Hybrid Academic/Private Practice Perspective: Comments Critical Thinking (“7 th Competency”) Critical Thinking (“7 th Competency”) One (or two) Fellowships One (or two) Fellowships Whom Would I Hire Today? Whom Would I Hire Today? What Advice do I Give My Residents? What Advice do I Give My Residents?  Do your Fellowship (67% do 1 [72%] or 2 [27%]), but.. ..maintain your general AP/CP skills  Consider Academics (68% desire PP) for a few years, but.. ..maintain your general AP/CP skills Refs: Lagwinski N and Hunt JL. Fellowship Trends of Pathology Residents. Arch Pathol Lab Med 2009:133;1431-6

Hybrid Academic/Private Practice Perspective - Outline Context Context  Introduce the Advocate System and Myself  Academic Affiliations “Implications of Changes for Readiness to Practice” “Implications of Changes for Readiness to Practice”  Proposed New Model  Sub-specialization  In General...  In Private Practice… Comments Comments