Entry of Graduates of US Pathology Residency Programs Into the Workforce: Cohort Data Between 2008 and 2016 Remain Positive and Stable.

The pathologist workforce in the United States is a topic of interest to the health-care community as a whole and to institutions responsible for the training of new pathologists in particular. Although a pathologist shortage has been projected, there has been a pervasive belief by medical students and their advisors that there are "no jobs in pathology." In 2013 and again in 2017, the Program Directors Section of the Association of Pathology Chairs conducted surveys asking pathology residency directors to report the employment status of each of their residents graduating in the previous 5 years. The 2013 Program Directors Section survey indicated that 92% of those graduating in 2010 had obtained employment within 3 years, and 94% of residents graduating in 2008 obtained employment within 5 years. The 2017 survey indicated that 96% of those graduating in 2014 had obtained employment in 3 years, and 97% of residents graduating in 2012 obtained positions within 5 years. These findings are consistent with residents doing 1 or 2 years of fellowship before obtaining employment. Stratification of the data by regions of the country or by the size of the residency programs does not show large differences. The data also indicate a high percentage of employment for graduates of pathology residency programs and a stable job market over the years covered by the surveys.

Gender Parity in Gainful Employment and Other Gender Trends in the Job Market for Recent Pathology Graduates.

CONTEXT.­: Gender-based barriers to equal salary, career advancement, and leadership still exist in medicine. Herein we provide the first report of data comparing the experiences of men and women seeking their first nonfellowship position in pathology. OBJECTIVE.­: To identify gender trends regarding pathologists taking their first job after training and the relationship to various demographic factors, job search satisfaction, and outcome. DESIGN.­: Aggregate data from the College of American Pathologists Graduate Medical Education Committee Job Market surveys (2015-2018) were analyzed across multiple domains including residency focus, number and subspecialty of fellowships completed, and extent to which expectations were met in regard to work duties, geographic preference, benefits, and salary. These data were examined in the context of assessing gender-based differences. RESULTS.­: Comparable results were identified in all measured outcomes according to gender. There were no differences between gender and medical school type, relocation, residency training focus, number of fellowships completed, overall satisfaction with position accepted, salary, or extent to which the position met expectations. Similarly, there were also no discrepancies between gender and the geographic region in which positions were accepted, practice setting, practice subspecialty, partnership track, length of job search, or difficulty finding a position. CONCLUSIONS.­: Analysis from 4 years of job market survey data shows equivalent results between men and women looking for their first nonfellowship position in pathology. There were no significant differences with regard to difficulty finding a position, overall satisfaction with the position accepted, salary, benefits, or access to partnership track.

Development of Professionalism in Graduate Medical Education: A Case-Based Educational Approach From the College of American Pathologists' Graduate Medical Education Committee.

Professionalism and physician well-being are important topics in academic medicine. Lapses in professional judgment may lead to disciplinary action and put patient's health at risk. Within medical education, students and trainees are exposed to professionalism in the institution's formal curriculum and hidden curriculum. Development of professionalism starts early in medical school. Trainees entering graduate medical education already have developed professional behavior. As a learned behavior, development of professional behavior is modifiable. In addition to role modeling by faculty, other modalities are needed. Use of case vignettes based on real-life issues encountered in trainee and faculty behavior can serve as a basis for continued development of professionalism in trainees. Based on the experience of program directors and pathology educators, case vignettes were developed in the domains of service, research, and education and subdivided into the areas of duty, integrity, and respect. General and specific questions pertaining to each case were generated to reinforce model behavior and overcome professionalism issues encountered in the hidden curriculum. To address physician burnout, cases were generated to provide trainees with the skills to deal with burnout and promote well-being.

The Recent Pathology Residency Graduate Job Search Experience: A Synthesis of 5 Years of College of American Pathologists Job Market Surveys.

CONTEXT: - Pathology residents and fellows tailor their training and job search strategies to an actively evolving specialty in the setting of scientific and technical advances and simultaneous changes in health care economics. OBJECTIVE: - To assess the experience and outcome of the job search process of pathologists searching for their first non-fellowship position. DESIGN: - The College of American Pathologists (CAP) Graduate Medical Education Committee has during the past 5 years sent an annual job search survey each June to CAP junior members and fellows in practice 3 years or less who have actively searched for a non-fellowship position. RESULTS: - Job market indicators including job interviews, job offers, positions accepted, and job satisfaction have remained stable during the 5 years of the survey. Most survey respondents who had applied for at least 1 position had accepted a position at the time of the survey, and most applicants who had accepted a position were satisfied or very satisfied. However, most attested that finding a non-fellowship position was difficult. Despite a perceived push toward subspecialization in surgical pathology, the reported number of fellowships completed was stable. Respondent demographics were not associated with job search success with 1 significant exception: international medical school graduate respondents reported greater perceived difficulty in finding a position, and indeed, fewer reported having accepted a position. CONCLUSIONS: - Pathology residents and fellows seeking their first position have faced a relatively stable job market during the last 5 years, with most accepting positions with which they were satisfied.

Entrustable Professional Activities for Pathology: Recommendations From the College of American Pathologists Graduate Medical Education Committee.

Competency-based medical education has evolved over the past decades to include the Accreditation Council for Graduate Medical Education Accreditation System of resident evaluation based on the Milestones project. Entrustable professional activities represent another means to determine learner proficiency and evaluate educational outcomes in the workplace and training environment. The objective of this project was to develop entrustable professional activities for pathology graduate medical education encompassing primary anatomic and clinical pathology residency training. The Graduate Medical Education Committee of the College of American Pathologists met over the course of 2 years to identify and define entrustable professional activities for pathology graduate medical education. Nineteen entrustable professional activities were developed, including 7 for anatomic pathology, 4 for clinical pathology, and 8 that apply to both disciplines with 5 of these concerning laboratory management. The content defined for each entrustable professional activity includes the entrustable professional activity title, a description of the knowledge and skills required for competent performance, mapping to relevant Accreditation Council for Graduate Medical Education Milestone subcompetencies, and general assessment methods. Many critical activities that define the practice of pathology fit well within the entrustable professional activity model. The entrustable professional activities outlined by the Graduate Medical Education Committee are meant to provide an initial framework for the development of entrustable professional activity-related assessment and curricular tools for pathology residency training.

Propofol infusion syndrome or not? A case report.

BACKGROUND: Propofol is commonly used and well tolerated for induction of general anesthesia and is also used as a sedative in the intensive care unit. However, in rare cases, the agent may cause a fatal condition known as propofol infusion syndrome (PRIS). CASE REPORT: We present a case of PRIS that could have been fatal in a previously healthy male patient with multiple gunshot wounds. CONCLUSION: Because patients typically exhibit other potentially fatal comorbidities, PRIS is always a diagnosis of exclusion. The true incidence of PRIS remains unknown, and more objective criteria for its diagnosis need to be established.

The increasing incidence of remote metastasis: a case report of metastatic hepatocellular carcinoma to the rectosigmoid.

As the fifth most common malignancy worldwide, survival rates of hepatocellular carcinoma (HCC) have only slightly improved over the years due to early-stage detection. HCC is well known to metastasize to the lung, lymph nodes, and musculoskeletal regions; however, only 0.5% to 6% of HCCs metastasize to the gastrointestinal tract. In the case described here, a CT scan and subsequent colonoscopy of a 51-year-old Asian male with a history of hepatitis B and HCC revealed a mass lesion of metastatic HCC 12 cm from the anal verge. Because metastatic HCC to the lower gastrointestinal tract has only recently been reported, it is speculated that the prolonged survival of patients is also increasing the incidence of extrahepatic metastasis, giving the disease greater opportunity to spread to more distant regions of the body. This case may be the farthest metastasis within the gastrointestinal tract to date.

Lymphocytic gastritis is not associated with active Helicobacter pylori infection.

BACKGROUND: Lymphocytic gastritis (LG), characterized by marked intra-epithelial lymphocytosis in the gastric mucosa, has been frequently associated with both celiac disease (CD) and H. pylori gastritis. The aim of this study was to review and correlate the morphology of LG with the presence of CD and H. pylori. MATERIALS AND METHODS: Gastric biopsies diagnosed with LG from 1/1/2006 to 8/1/2013 at our institution and corresponding small bowel biopsies, when available, were reviewed for verification of the diagnosis and to assess for the presence of H. pylori and CD. Immunohistochemical (IHC) staining for H. pylori was performed on all gastric biopsies. Demographic, clinical, and laboratory data were obtained from the medical record. RESULTS: Fifty-four of the 56 cases that met inclusion criteria demonstrated significant intra-epithelial lymphocytosis as the predominant histologic abnormality; however, none were associated with H. pylori infection by IHC staining. Two cases that also showed a prominent intra-epithelial and lamina propria neutrophilic infiltrate were both positive for H. pylori and were excluded from further study. Of the 36 small bowel biopsies available, 19 (53%) showed changes in CD. CONCLUSIONS: LG is not a distinct clinicopathologic entity, but a morphologic pattern of gastric injury that can be secondary to a variety of underlying etiologies. When restricted to cases with lymphocytosis alone, LG is strongly associated with CD and not with active H. pylori infection. However, cases that also show significant neutrophilic infiltrate should be regarded as "active chronic gastritis" and are often associated with H. pylori infection. A morphologic diagnosis of LG should prompt clinical and serologic workup to exclude underlying CD.

The optimal number of biopsy fragments to establish a morphologic diagnosis of eosinophilic esophagitis.

OBJECTIVES: Eosinophilic esophagitis (EoE) is characterized clinically by dysphagia, chest pain, and food impaction, and morphologically by increased numbers of intraepithelial eosinophils and marked basal hyperplasia of the squamous mucosa. The consensus criteria for a diagnosis of EoE include the presence of ≥15 eosinophils/HPF in biopsies from both proximal and distal esophagus in the absence of other causes of esophageal eosinophilia, and the lack of clinical response to proton pump inhibitor therapy. Because of the variability in the distribution of intraepithelial eosinophils among biopsy fragments and the lack of standardized biopsy practices, we sought to determine the optimal number of esophageal biopsies from the mid and distal esophagus needed to reach the minimum morphologic criteria of ≥15 eosinophils/HPF. METHODS: From 5 January 2009 to 26 September 2011, 771 patients were diagnosed with EoE at our institution. From that patient population, 102 sequential cases were chosen for further study, all of whom had biopsies taken from the mid and distal esophagus. Cases with only gastric mucosa present and biopsies taken from patients with a previous diagnosis of EoE were excluded. The original H&E-stained slides were reviewed, and the number of biopsy fragments containing squamous mucosa was recorded. By using a × 40 objective and × 10 oculars (field diameter=0.52 mm, field area=0.21 mm(2)), the number of eosinophils per high power field (EOS/HPF) in up to three HPFs was counted in each biopsy fragment. RESULTS: The EOS/HPF were counted in 1,342 biopsy fragments. The number of biopsy fragments obtained from the mid esophagus ranged from 1 to 20 (mean 7; median 7) and those obtained from the distal esophagus ranged from 1 to 18 (mean 6; median 5). There was no significant difference between the mean number of EOS/HPF from the mid (26) and lower (25) esophagus or between the mean peak number of EOS/HPF from the mid (69.1) and lower (60.4) esophagus. The probability of one, four, five, and six biopsy fragments containing >15 EOS/HPF was 0.63, 0.98, 0.99, and >0.99, respectively. CONCLUSIONS: From these data, at least four biopsy fragments should be submitted from the mid and/or proximal esophagus to optimize the chances of a positive diagnosis of EoE in populations not known to have undergone previous proton pump inhibitor therapy. However, the yield is not increased beyond six biopsy fragments. In order to morphologically exclude a diagnosis of reflux esophagitis as the cause of intraepithelial eosinophilia, distal esophageal biopsies, if obtained, must be accompanied by more proximal biopsies (i.e., mid esophagus or higher).

Incidence of diagnostic change in colorectal polyp specimens after deeper sectioning at 2 different laboratories staffed by the same pathologists.

OBJECTIVES: To calculate the incidence of nondiagnostic (ND) colorectal (CR) polyp cases in which deeper tissue sectioning rendered new diagnostic information--particularly adenomas--in 2 laboratories staffed by the same pathologists. METHODS: After initial diagnosis, 100 ND CR polyps from each laboratory were reexamined with 3 deeper levels to establish rates of diagnostic conversion based on biopsy specimen location and original observation(s). RESULTS: Deeper sectioning rendered new diagnostic information in 43 (21.5%) of 200 biopsy specimens and specifically adenomas in 16 (8.0%) of 200 biopsy specimens. CONCLUSIONS: These results support routine ordering of deeper levels on ND CR polyps to improve adenoma detection rates, especially those cases without any histologic abnormality. If another biopsy in the same case already is adenomatous, examination of deeper levels may not be necessary, as it may not have any significant effect on the clinical management of the patient.

Esophageal lichen planus: a case report and review of the literature.

Esophageal involvement by lichen planus (ELP), previously thought to be quite rare, is a disease much more common in women and frequently the initial manifestation of mucocutaneous lichen planus (LP). Considering that the symptoms of ELP do not present in a predictable manner, ELP is perhaps more under-recognized than rare. To date, four cases of squamous cell carcinoma in association with ELP have been reported, suggesting that timely and accurate diagnosis of ELP is of importance for appropriate follow-up. In this case report, a 69-year-old female presented with dysphagia and odynophagia. She reported a history of oral LP but had no active oral or skin lesions. Endoscopic examination revealed severe strictures and web-like areas in the esophagus. Histologic examination demonstrated extensive denudation of the squamous epithelium, scattered intraepithelial lymphocytes, rare eosinophils and dyskeratotic cells. Direct immunofluorescence showed rare cytoid bodies and was used to exclude other primary immunobullous disorders. By using clinical, endoscopic, and histologic data, a broad list of differential diagnoses can be narrowed, and the accurate diagnosis of ELP can be made, which is essential for proper treatment and subsequent follow-up.

Immunohistochemical expression of beta-catenin in solitary fibrous tumors.

CONTEXT: Immunohistochemical staining for beta-catenin may be used as an indicator of the integrity of the Wnt signaling and beta-catenin degradation pathways. Among mesenchymal tumors, aberrant nuclear localization of beta-catenin is seen in desmoid-type fibromatoses but has not been described for solitary fibrous tumors that may mimic the former lesions, especially in small biopsy samples. OBJECTIVE: To study the immunohistochemical expression of beta-catenin in solitary fibrous tumors. DESIGN: We performed immunohistochemical staining for beta-catenin in 12 solitary fibrous tumors, one of which showed histologic features of malignancy. RESULTS: All the tumors showed strong and diffuse reactivity for beta-catenin. Four tumors (33%) showed nuclear staining for beta-catenin, whereas the remaining tumors showed either a membranous or mixed membranous and cytoplasmic pattern of staining. The only histologically malignant tumor of the group showed a mixed membranous and cytoplasmic pattern of staining for beta-catenin. CONCLUSIONS: Immunohistochemical staining for beta-catenin in solitary fibrous tumors does not show a consistent pattern, which may be due to differences in tumorigenesis. Larger studies with clinical follow-up are required for estimating the impact of the variable staining pattern on clinical behavior of these tumors.

Intraoperative cytologic diagnosis of breast sentinel lymph nodes in the routine, nonacademic setting: a highly specific test with limited sensitivity.

Intraoperative determination of metastatic breast carcinoma in sentinel lymph nodes (SLNs) by cytologic methods has been proposed as highly specific and sensitive. Much of these data are derived from academic institutes with highly trained personnel and without axillary dissection occurring as a direct result of the intraoperative interpretation. This prospective study was undertaken to assess the sensitivity and specificity of cytology in the routine, private-practice, intraoperative setting. A total of 207 SLNs from 96 breast carcinoma patients were evaluated by intraoperative cytologic preparations by general surgical pathologists; positive results led to axillary lymphadenectomy. Ten nodes were positive by intraoperative cytology (IC). Permanent section analysis confirmed the presence of carcinoma in the IC-positive cases and documented carcinoma in 19 of the IC-negative cases. IC sensitivity and specificity were 34% and 100%, respectively. False-negative IC interpretations occurred in nodes with occult micrometastases (12 of 19 nodes) and lobular carcinoma (6 of 19 nodes). Only one of eight grossly positive sentinel nodes resulted in a false-negative IC. While near-perfect specificity and high sensitivity can be achieved with grossly positive sentinel nodes by IC, sensitivity is quite low in cases with micrometastatic and lobular carcinoma.

Interpretive disparity among pathologists in breast sentinel lymph node evaluation.

BACKGROUND: Immunohistochemical staining on breast sentinel lymph nodes (SLN) is controversial. METHODS: Twenty-five SLN cases were reviewed by 10 pathologists (three academic, seven private) including 5 negative by both hematoxylin and eosin (H&E) and immunohistochemistry, 11 micrometastases (<2 mm) negative by H&E but positive by immunohistochemistry, and 8 micrometastases and 1 macrometastasis (>2 mm) positive for both H&E and immunohistochemistry. Answers included "positive," "negative," and "indeterminate" for each slide. RESULTS: The mean number of incorrect responses was 6.6 for immunohistochemistry and 5 for H&E. Twelve percent of cases were correct by all 10 pathologists; 80% of positive IHC cases had at least one pathologist score it incorrectly. As tumor cells decrease in number, incorrect responses increase. When tumor cells numbered less than 10, more than 30% of pathologists answered incorrectly. CONCLUSIONS: As tumor cells decrease in number pathologists' ability to recognize them decreases. We propose adding "indeterminate" to "positive" and "negative" when tumor cells number less than 10.

Asymmetric cardiac hypertrophy at autopsy in patients who received FK506 (tacrolimus) or cyclosporine A after liver transplant.

BACKGROUND: Cardiotoxicity has been described in a group of pediatric patients receiving FK506 as a part of immunosuppression for orthotopic liver transplantation (OLT). Information regarding the cardiac pathology related to this agent is limited. METHODS: Among the first 975 liver transplants at our institution (1985-1995), autopsy hearts were available for 19 patients (14 adults and 5 children) who received FK506 for a minimum of 1 week prior to death. Patients with excessive alcohol use, significant coronary artery disease, valvular disease, diabetes mellitus, or pretransplant hypertension were excluded from analysis. We compared heart weight (HW), heart weight-to-body weight ratio (HW/BW), ventricular septal (VS) thickness with left ventricular (LV) thickness ratio (VS/LV), and cardiac histologic findings of 12 OLT patients (7 adults, 5 children) who received FK506 with a group of 75 OLT patients (48 adults, 27 children) who received Cyclosporine (CsA) and 20 (10 adults, 10 children) age-comparable control patients without OLT. RESULTS: All FK506 and CsA children and adults had cardiomegaly by HW, HW/BW (P(FK506 peds) <0.024, P(CsA peds)<0.028, P(FK506 adults) <0.017, P(CsA adults)<0.006) and increased VS/LV ratio 1.25(FK506) (P <0.006) and 1.23(CsA) (P <0.006)(pediatric) and 1.09(FK506) (P <0.0122) and 1.21(CsA) (P <0.0009)(adults), compared with control. CONCLUSION: Cardiomegaly by HW, HW/BW, and histology was uniformly present in both FK506 and CsA adult and pediatric OLT patients at autopsy. A relatively greater VS hypertrophy than LV was present in both transplant groups. We found no gross or histologic cardiac finding that separated these FK506 from CsA OLT patients at autopsy.