Aims This is a qualitative study of the perceived learning needs of trainees for graded responsibility in histopathological training in the UK.
Methods A focus group with trainees and interviews with consultants was carried out. Participants were asked ‗What do you perceive are the learning needs of histopathology trainees to develop skills for safe and confident independent reporting in surgical histopathology?‘ Data was analysed using open coding content analysis for items relating to training content and structure.
Results Trainees and consultants perceived a need for a case load of around 100 specimens per week with a continuously variable case mix. It was thought necessary to be the principal presenter of cases at multidisciplinary team meetings. There was a perceived need for adequate amounts of supervision by consultants using double-headed microscopes and sufficient time to develop skills in microscopic visual perception through detailed feature discussion, not necessarily related to specific diagnoses. Being able to write clear histopathology reports, developing the ability to recognise normal histology and to be aware of diagnostic pitfalls were also thought to be important.
Conclusions Our findings may inform efficacious implementation of graded responsibility in histopathology departments and be used as a sound basis for further research.
- IMAGE ANALYSIS
- SURGICAL PATHOLOGY
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
As postgraduate medical trainees progress through training they are given increasing levels of responsibility.1–3 Histopathology trainees are no exception and the Royal College of Pathologists (RCPath) states that ‘graded responsibility’ is a component part of training and have outlined a framework for its implementation.4 ,5 Those that have been training longer are more likely to be ready for this increase in responsibility.3 ,6 ,7 The RCPath are currently reviewing their guidelines regarding graded responsibility.8
When a supervisor chooses to devolve diagnostic responsibility is a poorly understood phenomenon and no single assessment tool exists to aid this milestone in trainee development.9 Providing responsibility is said to be a key driver of deep learning and understanding10–13 and can have positive consequences for trainees.11 Trainees with greater levels of responsibility for decision making were found to have higher levels of motivation to learn compared with hospital-based trainees who perceived themselves to have less autonomy.11
Delegation of responsibility is a difficult process for trainers as well as trainees.1 ,14 ,15 Perceived barriers to delegating responsibility for patient management decisions may relate to legal responsibility and patient safety within the context of an increasingly litigious society.15 Histopathology is no exception and this is a reason often cited as an obstacle to graded responsibility.6 ,16 ,17 Much of the debate revolves around concern for patient safety and balancing this with the training needs of doctors.14
In a Dutch study, four elements were shown to effect the decision to devolve autonomy to perform discrete practical procedures; attributes of the trainee, the nature of the task, the supervisors and characteristics of the working environment.18 These factors were also found in a similar study of anaesthetic trainees.9 Dijksterhuis et al18 found that depth of acquaintance with the trainee was most frequently cited as the variable affecting decisions to delegate work.
Two studies examined increasing responsibility in histopathology training and both were reports based on postal questionnaires in the USA.16 ,19 The authors concluded that trainee exposure to responsibility was limited despite being perceived as making a positive contribution to developing diagnostic confidence. This was echoed in a recent American editorial.17
To our knowledge, this is the first UK study of the perceived learning needs required for graded responsibility in histopathology training. Our findings have the potential to inform RCPath guidelines and assist departments in implementing graded responsibility.
This is a qualitative study designed with reference to grounded theory.20 Nine histopathology trainees took part in a focus group from a possible cohort of 11 based in one training region in the UK that allowed graded responsibility after gaining part 2 FRCPath. Between six and eight is cited as the optimum number of participants in a focus group to yield good quality data.21 Participants were asked ‘What do you perceive are the learning needs of histopathology trainees to develop skills for safe and confident independent reporting in surgical histopathology?’ Five interviews with consultant histopathologists who had been in post for between 2 months and 5 years were conducted after the focus group to yield iterative data based on experience of reporting independently. This was done in an attempt to highlight any unperceived learning needs that trainees may have had.22
Audio data were transcribed by the author and anonymised. Emergent research design provided an open coding framework for iterative data analysis. Data were analysed with reference to the authors’ first-hand understanding of the social, cultural and professional contexts of the subject and its participants. Data relating to training content and structure are presented here.
All participants gave written, informed consent to take part in the study and were able to withdraw at any time. The research was granted ethical approval by the Research Ethics Committee for the School of Postgraduate Medical and Dental Education, Cardiff University on 5 October 2013.
Six categories emerging from data analysis are presented here. Concepts relate to the accumulation of experience, supervision, recognising normal histological patterns, attending multidisciplinary team (MDT) meetings, writing reports and being aware of diagnostic pitfalls.
Accumulation of experience
Both trainees and consultants highlighted year 3 as a pivotal point in training. It was difficult for people to pinpoint exactly what had happened by year 3 but it was clear that trainees had reached a level of greater confidence in their abilities. This person tried to explain how the third year was different from the first 2 years of training:
…In the third year with no kind of pressure of exam passing and because of all of the experience of having those two years meant the third year allowed for the development of your own, of yourself, I guess.
Trainees felt that they needed adequate numbers of specimens to report on a regular basis. Some quoted numbers around 100 cases per week as being a desirable quantity. Variation in specimen type and complexity was also valued. Some individuals felt that subspecialisation ran contrary to this facet of learning needs and that they needed to see a continuously wide variety of specimens:
When I started we used to get…..a constant throughput of all the biopsy stuff; it wasn't sub-specialised so you did actually build up a better experience I think generally of……pathology as a whole. I don’t know whether training somehow is being stunted because of sub-specialisation.
Inter-disciplinary working relationships
Attendance at MDT meetings that required review of case material was perceived by trainees as being a valuable way of increasing diagnostic experience:
The best ones were where you were given the slides the day before… you were doing the MDT. That's quite a good way of learning and then if you've got to go to the MDT and present to the clinicians….that's a good way of increasing your confidence as well, I think.
MDTs were also given as an example of a necessary learning opportunity in which to develop skills in communication and team working.
I think MDTs would probably be a good way because you would get increased exposure to clinicians so they might be able to build up rapport with you…..
Comments about content and quality of histological reports were expressed by consultants only. They felt it important that trainees understood the consequences to patients of histopathological diagnoses both in terms of diagnostic thresholds that change management and overall comprehension of reports:
…. [In] an MDT, I suppose, that you actually see how your report is translated by the clinicians and sometimes it may not be what your intention was…
Also it was perceived that trainees had a need for guidance and support in clear report writing and that this was a necessary skill before assuming some responsibility:
…your report may contain everything that there has to be in it but it might not contain it in the order that you would have done it as a consultant. So trainees would describe something in about twenty lines, … come up with [differential] diagnoses but it still might not be clear [what it is] at the end of it……
Supervision and fear of making mistakes
Supervision was a recurring theme throughout the focus group and interviews. Trainees expressed a desire for close consultant supervision to prepare them for independent reporting and, largely, this means ‘double-heading’ of microscopic material. The term ‘double-heading’ refers to use of a microscope with two sets of viewing lenses to allow the trainee and the consultant to look at material at the same time. Trainees and trainers described double-heading as a highly valued and integral facet of apprenticeship-style learning:
[You] consolidate by double heading with a consultant and asking them to talk you through what you are doing, what you are looking for.
There seemed to be a reluctance to progress from this format to a situation where one takes more responsibility, at least until successful completion of the part 2 FRCPath examination:
I think in order to do [graded responsibility] you need to be ….reporting all [specimens] with the consultant even as time goes on…. to develop your skills beyond graded responsibility….until you are safe, or signed out as being safe to report.
Participants here acknowledged the inevitable end point of training with full responsibility for their own learning and were aware of the need for less direct supervision later in training. A ‘two- tiered’ approach to reporting was suggested as a potential solution. ‘Two-tiers’ refers to a trainee identifying two categories of work: a group that the trainee feels satisfied to authorise alone and a second group that the trainee would like to ‘double-head’ with the consultant. Consultants also described this process and thought it a good way of stimulating trainees to think about why they might be comfortable authorising some cases and not others. In essence, this represents a form of reflection that promotes meta-learning, that is, learning about how one learns.
Trainees voiced insecurities about their visual perceptions and worried about missing microscopic features. Trainees used permanent marker pen to ‘dot’ items of interest on histological slides to make them easier to find on review with a consultant. This process was referred to as ‘dotting’. Trainees asked questions about morphological features not necessarily related to the pathological diagnosis. This is a learning need that could contribute to basic histological recognition patterns and could improve confidence in visual perception ability.
If you know that the consultant is gonna look at the slide you just dot it. You might not put it in the report but you'll dot it and then when you're there with the consultant you'll be able to say, “What do you think of that thing there?” That's what I always do.
Consultants felt that being able to distinguish normal microanatomy from abnormal was necessary for starting graded responsibility:
…if we spend more time….recognising normal, as soon as somebody is comfortable in recognising normal and knowing what normal is, then they are ready to start graded responsibility.
Others stated that identifying appearances that deviate from the classic description given in textbooks was a more important learning need:
They have to be able to recognise what normal is….[also] they have to understand that particular diagnosis and if there is anything that deviates from that diagnosis. It doesn’t matter what it is…. But they don't have to be able to call it “that”.
Trainees worried about entities that they had not yet encountered.
…..[Histopathology] is very similar to clinical medicine in many respects because, you know, I think it's all very down to the competence levels. You start off……unconsciously incompetent, don't you?…I think it's the same thing with reporting that until you get to that level when you know the sort of important negatives you can't really independently report.
Consultants were aware of this feeling and came up with reassurance strategies for overcoming it. Some thought it useful to compile a reference list of potential pitfall diagnoses for each of the specimens trainees would be allowed to report independently:
….when they are allowed to diagnose, I wonder if we could get a list of potential pitfalls [of] those diagnoses.
This is a small-scale study without data saturation and more research is required to identify any further themes relating to graded responsibility. However, what we have found is of importance to both trainers and trainees in histopathology. Year 3 of training was highlighted as a significant milestone in training and this has been identified by others.17 Year 3 might be the first opportunity in the curriculum for adequate time to reflect on achievements and progress made. This time might allow trainees to explore facets of learning that are identified as being more relevant and meaningful to them.
Requiring 100 cases appears to be an arbitrary figure cited by trainees without reference to evidence. The trainees request for more work may be misplaced. Some authors argue that fewer cases in combination with immediate constructive feedback, reflective practice and discussions around performance standards leads to development of professional expertise in medicine—a process termed ‘deliberate practice’.23
Concerns over subspecialisation affecting histopathology training in the UK, however, might be justified. Subspecialisation has been linked to practical difficulties in rostering and logbook omissions for certain case types.24 Furthermore, some claim that learning about rare entities can be associated with decreased motivation levels and lower levels of learner satisfaction.25
Having adequate support has been shown to be crucial to trainees in feeling confident enough to take on responsibility at work.18 ,26 Obstetrics and gynaecology trainees expressed fear at ‘being left on their own too soon’.18 Fear is thought to have a detrimental effect on learning, a situation termed ‘destructive friction’26 and should, therefore, be avoided in medical training where possible. Trainees also expressed the need to feel able to ask for help with things considered by them to be simple diagnoses, purely for reassurance. Research shows that knowing one's limitations is central to be able to know when to ask for such help.9 ,18 ,27 ,28 Reflective practice is likely to assist trainees in developing self-awareness.10 ,29–31 The data show trainee embarrassment in asking for help with cases that were perceived as potentially simple. This tension between needing support and the potential effect on ones credibility was found among trainees in other medical specialties.28 Trainees have been noted to save requests for input from supervisors about such cases for opportune moments and to rehearse a justification for asking in an attempt to preserve their professional credibility.28 Trainees need to prioritise improved performance over ego and how they appear to others for the sake of developing expertise.31 Trainers have an obligation to lead by example in this area. Trainers need to encourage safe and supportive environments for learning where discussion of cases is openly encouraged.23 ,32 ,33 Indeed, the need for an open working culture was a key recommendation of the Francis report following the Mid-Staffordshire NHS Trust public enquiry.34
Emphasis on the value of double-heading microscopic material may relate to insecurities of visual perception. The process of decision making in histopathology is complex and poorly understood.35 ,36 What a person perceives visually may alter depending upon what one expects to encounter, the so-called ‘cognitive bias’.35 ,36 What a pathologist knows of the clinical aspects of the case, how they scan over the slide, intuition and tiredness are just a few of the factors that affect their individual interpretation of what they see down the microscope.35 ,36 ‘Double-heading’ cases was described as a valued mode of teaching in histopathology and trainees suggested that this was the safest approach for patients in this study. However, there is evidence from the field of transfusion medicine to the contrary. There is debate as to whether one or two people should check blood products being hung for transfusion.37 In the absence of a randomised control trial on the subject, the evidence is still inconclusive.37 A paper by Linden and Kaplan38 crystallises the argument thus:
Not only does the passive check have significant potential for distraction, multiple responsibility itself does not necessarily enhance human performance. Unless carefully configured to prevent it, in a system in which two people are responsible for the same task, neither person is truly responsible.38 (p. 175)
Whether this problem also relates to histopathological reporting remains to be seen and is clearly an important point for further research.
Data from this study implies a reluctance of trainees to take responsibility for their reports and this might relate to fear of making mistakes, a phenomenon previously reported in anaesthetic trainees.11 It might also be due, in part, to a misunderstanding that trainees will not be able to ask for help and or ‘double-heading’ when they feel they need it if they take on graded responsibility. Without effort and the motivation to improve and self-assess, trainees will take longer to develop the expertise they need to perform as consultants23 and they need encouragement to become self-directed learners.39
Evidence suggests that deep learning takes place when trainees are just outside their comfort zone12 ,13 ,26 and taking on responsibility for one’s own work can stimulate this process.9 ,11 Trainees themselves usually report not feeling uncomfortable or unsafe performing just above their level of competence in other medical disciplines.9 Histopathology trainees might become more willing to step outside their comfort zone if they received regular positive, timely and constructive feedback.40 ,41
As with all qualitative research, the findings from this work are not intended to be generalisable to the wider population of histopathology trainees. Data analysis aims to accurately reflect the views of those who took part and to provide an informed context for their meaning and implications. The findings of this research study may help inform efficacious implementation of graded responsibility and be used as a sound basis for further research.
In summary, for trainees to develop autonomy in histopathology reporting they need to accumulate at least 3 years experience with a wide variety and sufficient number of cases in their portfolio. They need to be able to recognise normal histology and have an awareness of diagnostic pitfalls. Being able to write a clear, concise pathology report and being able to present cases at MDT were perceived as essential learning needs, as was adequate consultant supervision, particularly using double-headed microscopes. The medical literature suggests that promoting feedback-seeking behaviour in a safe learning environment with reflective practice and clearly defined performance standards are also key requirements for developing expertise.23
Take home messages
There is a perceived need for close supervision by double-headed microscopy, variable case mix of sufficient quantity, an awareness of diagnostic pitfalls, normal histology and how to write good reports. Three years of experience and building relationships with clinical colleagues was also thought important.
Training programmes need to provide an open learning culture, incorporate reflective practice and promote feedback-seeking behaviour to ensure timely development of expertise.
AF would like to thank the Association of Clinical Pathologists (ACP) for a Career Development Award in support of this work. The ACP played no part in choosing the topic of the research and did not influence the research process.
Handling editor Cheok Soon Lee
Contributors AF conceived of the project subject and wrote the manuscript. LA is the guarantor of the work and contributed significant suggestions for refinement and references.
Competing interests AF is a practising histopathologist who teaches trainee histopathologists. AF received a career development award from the Association of Clinical Pathologists (ACP) which contributed to tuition fees for a Masters degree in Medical Education at Cardiff University. The ACP took no part in choice of subject or research process. LA is the Director of Medical Education in the School of Postgraduate Medical and Dental Education at Cardiff University.
Ethics approval Postgraduate Medical and Dental Education Research Ethics Committee, Cardiff University.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Original data transcripts are kept for 5 years by Cardiff University following completion of the MSc thesis.