Learning pathology: Difference between revisions

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The goal of this resource is to make a new pathology trainee able to properly handle at least 70% of cases that are expected at an average general pathology department, including the exclusion of the most pertinent differential diagnoses thereof. Its aim is to present you at least '''one way''' of doing things that is at least adequate for a particular situation, so that although there may be various routines at various locations, adherence to these methods should not result in a worse reprimand from a senior than ''"although that was adequate, that is not how we do it here"''. Still '''ask for help''' whenever needed, such as first time you are doing something, or whenever you are not sure about what to do, especially when doing something potentially irreversible.  

* '''[[Emergent pathology]]''', mostly relating to intraoperative or frozen section consultations. This includes information that usually cannot be timely looked up on the Internet when needed.

* Proficiency in diagnosing '''equivocal or borderline cases''' where readily available sources and evidence usually deal with discrete and specific disease entities and subcategories thereof. Unusual or equivocal presentations of very common diseases and conditions are still generally more common than rare diseases, and constitutes a major workload in everyday pathology practice. However, most textbooks still give disproportionately large room for rare diseases compared to such presentations. Nevertheless, strive to '''master the common''' conditions (including the most common pitfalls) before diving into the uncommon. After all, you will get by with effectively handling the regular cases wherever you work, so that when unfamiliar cases appear, you will have time to study or ask others for how to handle them, as long as you know your pitfalls, and have an idea about your unknowns:

* '''Where to find information''' for various situations. It includes which person or which '''search engine''' is most useful for various clinical situations. See the ''Using resources'' section below for further information. Similarly, a pathologist often needs to be efficient at finding what is relevant among a large amount of information, and be able to '''integrate''' it into a decision or a relatively short report. For questions where a look-up does not readily give the answer, a new trainee usually gets satisfactory replies even from senior trainees, but the more experienced you get, the more you need to establish contacts with particular people, such as certain subspecialties, who are most likely to be able to answer your questions when needed.

*How to distinguish '''memorization-worthy''' versus '''look-up''' versus '''practically useless''' information. With the ease of access to pathology information on the Internet through smartphones and computers, those studying for the everyday practice as '''a pathologist should not waste time memorizing what can essentially always be conveniently and timely looked up when needed'''. This includes most of the content of books and web pages that are sorted by names of diseases and conditions, because if the name of a disease is already known, then it can relatively quickly be looked up when needed in such sources. When finding relevant look-up information on the Internet or local repositories, it is generally enough to remember enough of its related words in order to find it again. After all, other doctors and even laypersons can look up diseases and conditions themselves, without the need for a pathologist consultation, so the expertise of memorizing such readily available information is expendable. Similarly, electronic systems are better suited than the human brain for the storage and rapid retrieval of databases of for example immunohistochemistry and genetics results of various diseases. The topics listed in this section are already immense enough to cover a lifetime of learning. Learning pathology therefore optimally involves the memorization of where and how to find look-up information, rather than directly memorizing such information. Therefore, if you need to choose a textbook to study, then choose one that you will always be able to quickly reach through your smartphone whenever you need its look-up information. Accordingly, the final '''aim''' of this resource is to help pathology trainees to give accurate and clinically useful reports to clinicians, in '''synergy''' with the resources that are available in everyday pathology practice, and to establish routines to continue such practices. The intended end result is to help clinicians to improve the lives as much as possible to as many people as possible, even if it means forgoing the prestige of becoming a walking encyclopedia. It also means finding '''high-yield''' learning sources, for even if they may take longer time to find, you will be better prepared for real life than when you study ''low-yield'' knowledge, which includes statistics that is very unlikely to be used diagnostically, mainly because their calculations would be so complex that it is not worth it. For example, in reality you generally have a '''pattern''' of signs and other findings and you want to know the likelihood of each differential diagnosis, and for this purpose you only get limited help by knowing the reverse likelihood of what percentage each individual condition is to display the finding, because it would still be necessary to also know for example the epidemiology of each disease to calculate its likelihood. Instead, the optimal studying is generally not of diseases individually, but rather of patterns of signs and other findings and the likelihoods of each differential diagnosis thereof. Arguably the best method of acquiring such knowledge is to be involved in many real cases at a pathology department, making your own diagnostic thinking of them, and correcting your thinking based on how you differed from a senior's report. The next best method is arguably to solve virtual cases such as found in pathology qbanks.

*How to efficiently '''study for exams''' that contain questions that require direct memorization of look-up (or even practically useless) information, as long as such exams are in the way of practicing pathology. The best approach is arguably to spend enough time and effort on memorizing what is memorization-worthy, to the point where you will pass an exam even if you will fail multiple questions that require memorization of look-up or practically useless information. However, when starting pathology training, do not focus on studying for any final exams that are years away, because the content on such exams is systematically very different from what you need to know initially. For instance, you initially need to know how to handle the common types of cases, but exam makers on the other hand, in their effort to distinguish those who have studied more extensively than others, will systematically choose presentations that are not commonly encountered. {{further|Secrets}}<includeonly>''Further exam advice is found in the '''[[Secrets]]''' chapter at patholines.org.''</includeonly>

This resource is written with the intention to teach you what to do in the most common situations you are expected to encounter during your first years of pathology training, at least until the point that you are usually fairly confident about what disease or condition you have at hand, because then you know what words to use to look it up in the vast literature out there. At that point, the fastest way to get more information is generally by Googling the disease or condition name, followed by '''pathology outlines''' (which is generally the most likely to quickly give you the information you need), since Internet will always be readily available in pathology.<ref group=note>If you worry about Internet outages, then it is still much more worthwhile to purchase satellite Internet as a backup (which costs $50 to $100 per month) than to try to memorize the Internet.</ref> The most efficient method of studying to solve a case at hand is to not read articles in their entirety, but to scroll directly to the parts that are most likely to give you the information you need (generally past the first half of Pathology Outlines articles). A major skill of a pathologist is to have a good idea of what pages and texts can be skipped by only a quick glance.

*Google, and then clicking the '''Images''' tab, if you just want to see more micrographs of the disease or condition. Even when you don't have a clue what condition you are looking at, you may find something that looks similar to your case by entering words you would use for the microscopic findings that you see.

*Adding '''cancer.net staging''' in Google searches for definitions of cancer stages, for example Googling ''prostate cancer cancer.net staging''. The first search will then generally be the one from the American Society of Clinical Oncology.

*'''ClinVar''' to look up the pathogenicity of specific genetic variants/mutations.

If the above resources do not provide a sufficient answer:

*'''Googling''' what you are looking for. You may add the word '''pathology''' or equivalent if results are too clinical or layman-oriented. Before even reading the title of results, first look at the URL. If it is from a reputable organization then you may proceed to check if the title is pertinent to what you are looking for, but if it is from an unfamiliar site then you should only proceed if you don't find a better source among your search results, and you will need to look for additional proof of reliability such as authorship of the content in order to use it in the diagnostics of any case. You can generally rely on more articles for presumably well-established topics (such as anatomy, and relatively common diseases) than for potentially controversial and experimental topics, in which case you generally need to ask yourself if the author has a conflict of interest.

This resource also assumes that you will '''ask''' a colleague for advise if you see an unfamiliar presentation, and any literature lookup thereof still does not explain it. Therefore, this resource will focus on the most common presentations and the main differential diagnoses thereof, which may include rare conditions if for example the clinical management thereof would be significantly different. On the other hand, most rare conditions that generally have distinct presentations will be omitted. Therefore, keep in mind that there are many such rare conditions that you do not know about, so keep asking colleagues whenever a presentation remains strange to you.

To test your knowledge on memorization-worthy information, seek questions that present you with a possible real life situation, as well as all pertinent information you can readily look up before needing to answer the question, so to ensure that it tests you on pertinent information as per the items earlier in this chapter. On the other hand, don't waste time on questions whose answer requires memorization of look-up or practically useless information (except if you want to practice looking up the answers online). There are about 5500 questions in PathPrimer, PathDojo, BoardVitals and the ASCP Question Bank combined, so you can be picky about which questions to take and which ones to skip.

Consider the '''usefulness''' of each question before spending significant time memorizing its answers or explanations, in order to maximize the useful knowledge you will learn overall. Generally, skip questions that test you on look-up information and practically useless information. Whenever you have a question where you can not picture in what real life situation it would be relevant to remember, then you can generally assume that it never will be. For questions that consists of a useful item together with a more useless one, only learn the the useful part and move on. If you can, flag/mark questions on memorization-worthy information that you did not know, and move on fairly quick on those as well, and later revisit those questions specifically if you have the time, as repetition is generally more efficient than lingering.

A common sign that a question will deal with look-up or practically useless information is where it asks which of the alternatives is '''false or correct''' for one particular condition, and the alternatives are relatively heterogenous (such as one dealing with diagnosis and another one dealing with prognosis). The high prevalence of such questions is mainly because they are easy and quick create, because the question creator can simply look up a condition, choose some more or less random facts, and then change small details to create alternatives. It requires no real life experience in everyday pathology practice, and learning from such a question is hence generally not useful for that purpose either. The thought processes of real life pathology is generally the opposite of this, because you are generally presented with a specific location, gross appearance and microscopic appearance, and you need to practice on finding the most likely causative condition thereof among many differential diagnoses. Even other kinds of memorization-worthy pieces of information generally have a more limited scope among alternatives (like knowing the optimal staining duration in hematoxylin for a frozen section among alternative durations (see [[Emergent pathology]]). Thus, to practice your knowledge in memorization-worthy pathology, it is generally most efficient to skip false-versus-correct questions, in order to spend your limited time on something more worthwhile. Similarly, questions are in general rather low-yield whenever they deviate from the realistic direction.

 

Other signs of unrealistic and therefore rather low-yield questions include those that mention what kind of test identified the condition, but does not give you the test result (such as a case presentation that includes "Serology identified the organism").