Progressive Autonomy

Recognizing the limits imposed by law and ACGME requirements on the degree of autonomy permissible for a trainee, pathology faculty will strive to provide as much independence and responsibility as possible, commensurate with the abilities and progress of a given resident.  The pace of this increasing autonomy will vary from resident to resident, depending on individual progress, and to some extent on the comfort level of individual faculty.  However, by completion of training, all residents are expected to have attained the capacity to function entirely independently (although all cases will ultimately be reviewed by a member of the faculty).

Philosophically, from day one, residents are encouraged to take ownership of the case material for which they are responsible, i.e., shepherd cases from accession to completion, ensure that high standards of quality are met at every stage of the process, and think of themselves as integral parts of the health care delivery team.  Residents are encouraged to “act like attendings,” during their training, thus building habits of thought and behavior to enable a smooth transition to post-training practice.

Sequential Example

The following is an example of a reasonable sequence of acquisition of progressive autonomy in the context of surgical pathology.  Note that the stages are not intended to directly correspond to PGY year.

Stage 1

Upon starting in surgical pathology as a PGY1, preview time will be relatively limited, as extended preview time is of limited value without a foundation of surgical pathology knowledge.  Required special studies will be communicated to the resident by the faculty in the course of signout.  Residents will essentially be expected to transcribe what their attending staff communicates regarding the microscopic description and diagnosis, and will be expected to proofread their reports to ensure accuracy.

Stage 2

As a foundation is gained, residents begin to preview at greater length, begin to formulate differential diagnoses and impressions, and come prepared to provide those to the attending.  The attending transitions to conveying the salient features of a case without giving specific word-for-word dictation of the wording of the microscopic description, diagnosis, or comment.  Special studies continue to be discussed and ordered in the context of signout.

Stage 3

Residents dictate descriptions and diagnoses during preview and make corrections following signout based on discussion during joint review.  Basic special studies are ordered during preview.

Stage 4

Residents perform a complete work-up independently.  Completed cases are delivered to the attending staff.  As appropriate, at the discretion of both the attending staff and the resident, signout can be abbreviated to focus on cases in which the attending staff substantially modifies the trainees report and/or there are specific teaching points the attending would like to discuss or specific questions the resident would like answered.