Graduated Responsibility

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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).

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

• In our 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.