Graduated Responsibility

Although nearly everyone agrees that "graduated responsibility" is a good thing during pathology residency training, the definition of "graduated responsibility" is vague and unclear. One of the best ways for residents and attendings to learn about graduated responsibility is to see concrete examples of how graduated responsibility is incorporated into other training programs. If you could answer the following questions below (and please feel free to cite which program you are in if you are comfortable doing so), it would greatly help other programs that are still struggling with how to incorporate graduated responsibility into their pathology residency training.

In your own words, how would you define "graduated responsibility"?

• Allowing a resident to have more and more responsibility as they progress from PGY-1 to PGY-4, so that as a PGY-4, the resident is able to commit with confidence to their diagnoses (or to seek consultation as needed). Ideally, this would allow PGY-4 pathology residents to sign out cases (eg - frozen sections) on their own without faculty oversight, although sadly the ACGME does not allow this (which is to the detriment of our training).
  • Does ACGME forbid resident sign out? Source?
• Graduated responsibility includes three necessary elements:
  • 1) The trainee performs attending-level tasks.
    • Observing, while potentially suitable for some beginners, is not doing.
  • 2) The attending trains the trainee to perform those tasks.
    • Training includes adequate supervision, timely corrective feedback, assistance when overwhelmed, and supplementation for low-volume case types.
  • 3) Over time, the scope, quantity, and quality of #1 is maximized as #2 is minimized.
    • If an external limitation is applied such as "the trainee can't bill for that specific task without an attending co-sign," then the goal of maximizing still remains. That is, the maximally-responsible trainee does everything else the attending does except for that limitation (e.g. everything except the co-sign that is required for billing).

A list of concrete examples/stories of how graduated responsibility is applied in your residency program:

THE METHODIST HOSPITAL (HOUSTON, TX)

• Residents (and fellows) preview and predictate all surg path slides before sign out with the attending. Thus the resident is required (beginning in the PGY-1 year) to look at the slides and form their own diagnosis, and then to commit to that diagnosis by dictating it. However, this is not a high pressure environment, and for a difficult case, the resident is encouraged to go and ask the attending (or a senior resident or fellow) for guidance before dictating. This setting also encourages lots of interaction and teaching between the upper and lower level residents, which is good for everyone. An example of our surg path schedule:

• Day 1 - Gross Routine Specimens.

• Day 2 - Sign Out Routines. Slides (from day 1 grossing) come out in AM. Resident previews and predictates and then signs out with attending in afternoon.

• Day 3 - Frozen Sections (dedicated day for doing frozens). Gross the frozen cases and add additional sections at the end of the day.

• Day 4 - Sign Out Frozens. (similar to day 2)

• Day 5 - Biopsy - slides out in AM, preview and predictate, then sign out with attending in afternoon.

• As the resident progresses over time, the resident may predictate and then give the case to the attending to sign out without sitting with the attending again for sign out. This allows upper level residents to gain additional autonomy. Of course, attendings are always happy to look at any case with the resident (especially if there is a difficult case, or some question for staging, etc). This system works very well and gives the best of both worlds (in my opinion) allowing autonomy and teaching to be complementary to one another.

• We also have Frozen Section Conference, where residents take turns in the hot seat and must commit (in front of the whole room) to the diagnosis that they would give at the time of frozen section (ie - they could say "spindle cell neoplasm, margins free, defer to permanents for final diagnosis" instead of "synovial sarcoma, margins free"). This is very useful to have the hot seat approach. Of note, the attendings are not malignant about it (don't berate residents for a wrong diagnosis), but it still provides added pressure to have to make the diagnosis in front of everyone and to commit to it.

• During conference, if I see an unknown and think I know the answer only to find out I am wrong when they tell us the answer, I make it a point personally to let everyone know the wrong answer I was thinking (if the conference is interactive) and to ask why my answer was wrong or how to distinguish between the 2 diagnoses. This allows me to have extra pressure to get the diagnosis correct (and helps clearly show myself my areas of deficiency), allows me to learn how to not make that mistake again, and hopefully encourages the junior residents by showing them that even upper levels make mistakes (and do so frequently...which hopefully encourages the juniors).
• Some of our attendings will also openly admit when they internally thought an incorrect diagnosis (ie - the peritoneal fluid was metastatic adenocarcinoma but the attending in the audience thought it was just reactive, etc). This level of honesty and humility is immensely helpful for residents to see that not all things are black and white, and that it is acceptable and encouraged to be open about diagnostic uncertainty. I have learned a lot from attendings who are willing to expose themselves like this, and I hold them in very high regard because of it. This is not graduated responsibility per se, but it pertains to the same goal of independent diagnostic decision making.

UNIVERSITY OF IOWA

• When I was a post sophomore fellow at this program (I assume it is still this way), senior residents and fellows got to be on the 'hot seat." In this rotation, they preview all surgical cases for the day and come up with a preliminary diagnosis. All phone calls from clinicians go directly to the resident or fellow on the "hot seat." The resident or fellow would then give a preliminary diagnosis to the clinician. Faculty were always available for questions of course.
• In the same vein, residents and fellows always went back to the OR if called by a surgeon, and usually the faculty let them have first 'crack" at a frozen section under supervision.
• All residents and post sophomore fellows alike were given preview time and allowed to dictate their own descriptions and diagnoses much like The Methodist Hospital.

UNIVERSITY OF MIAMI - JACKSON MEMORIAL HOSPITAL

1. ON CALL: Every day there is a first year resident on call, supported by a senior resident (PGY-2 to PGY-4). The PGY-1 resident is the primary responder for all calls (anatomic and clinical pathology). However, every case / call is consulted with / assisted by the senior resident and the attending pathologist.
2. SURGICAL PATHOLOGY - GROSSING: PGY-1s have direct supervision, provided by a senior resident or a pathologist, for the first THREE specimens of the same class (eg. prostatectomy, lumpectomy, Whipple resection, etc). After the third case, supervision is immediately available upon request. Pathology Assistants are also available.
3. SURGICAL PATHOLOGY - PREVIEWING: From day one PGY-1 residents are expected to preview all cases corresponding to their rotation (subspecialty) and render a diagnostic impression. Expectations are proportional to the level of experience.
4. SURGICAL PATHOLOGY - FROZEN SECTION: Initially, the on call pathologist performs the initial evaluation of the specimen, renders the diagnosis and communicates it to the clinical team. Subsequently, the resident performs the initial evaluation alone, and is allowed to give a verbal diagnosis to the clinician. The resident also goes to the Operating Room and interacts with the surgical team on a regular basis.
5. AUTOPSY:The first three autopsies are directly supervised from beginning to end. After the third case, the resident does the external examination, evisceration and dissection of the thoraco-abdominal block and then performs the organ review with the pathologist.
6. TRANSFUSION MEDICINE: Approval of blood products, transfusion reaction investigation, DAT work-ups and consultations for therapeutic pheresis are always handled by the resident. The attending pathologist discusses every pheresis case and transfusion reaction investigation with the resident(s). The attending also reviews all approvals and provides feedback to the resident.
7. LABORATORY MANAGEMENT: The first week of the rotation the resident attends meetings and regular sessions with the attending. After the second week the resident gets involved in a specific project or task (e.g. development of a new Standard Operating Procedure - SOP).

MISCELLANEOUS PROGRAMS

1. Variant of predictation: Resident writes up surgical pathology diagnoses directly in the LIS (at our institution, diagnoses are not dictated). At time of signout, attending copy-pastes diagnosis from "resident impression" field into "diagnosis" field and makes any necessary changes.
2. Senior residents serve as autopsy attending for 1-2 weeks in their final years of training.