“I spoke with the residency director of Pathology. We both agree you'll be a great fit there…Given your difficulties with communication and social cues I think it will be a much better fit.”—The Good Doctor1
“Exactly, nobody knows who you are.”—Lord Lockwell2
The profession of pathology is rapidly changing owing to an emerging combinational future.3,4 Examples include the blending growth of team and precision medicine, the paradoxical scope of practice conflicts, the ambiguity arising from escalating consolidation of health systems through mergers and acquisitions, and the insecurity caused by the extraordinary evolution of machine learning, artificial intelligence, and digitalization. These linear and nonlinear factors will require pathologists' ever-increasing attention.3,5 To channel these present and unforeseen matrixed dynamics resulting in ideal patient care, the future-oriented and top talented pathologist will be expected to be especially competent in the Accreditation Council for Graduate Medical Education (ACGME) Pathology Professionalism and Interpersonal & Communication Skills milestones. Within the professionalism milestone, pathologists will be expected to comport themselves in alignment with the discipline's ethical guidelines in a manner of the highest level of conscientiousness and accountability through self-awareness and help-seeking.6,7 Together with professionalism and with expected magnification of import, is the milestone of Interpersonal and Communication Skills. The future-oriented and team-focused pathologist must actively engage and adapt to multimodal and evolving communication avenues.
Society already expects of pathologists, as it expects of other physicians, the maintenance of the highest-level professional standards. Our difficulty meeting society's expectation is underscored when one considers that most physician behaviors that undermine a culture of safety are related to lapses of professionalism and are often referred to as “disruptive.”
Effective communication is everything as it promotes a “just” culture of safety and can prevent disruptive behaviors from occurring.5 “[I]mproved communication is unquestionably the key to our future success in today's evolving world of molecular medicine, team-focused patient care, and value-based payment dependent upon quality.”5 “We are the answer, so it has to be the right answer.”8 And that answer must be communicated fully, clearly, and accurately every time.
Historically, academic pathologists have primarily emphasized the ACGME Pathology milestones of system-based practice, patient care, medical knowledge, and practice-based learning and improvement, while subordinating professionalism and interpersonal/communication skills.9 There is a paradigm shift underway within the discipline whereby pathologists must recognize and act quickly on the actuality that “[o]ur inability to [professionally and communicatively] interact effectively and efficiently with our patients, administrators, and non-pathologist physician colleagues is today's greatest risk to our profession.”5
Nonpathologist physician disciplines, such as radiologists, have also recognized that communication skills are an essential component of high-quality medical care, indeed as important to medical care as clinical expertise, and are a critical component for successful patient-centered care10–12 and are lacking in their training programs. Some of our colleagues have already instituted robust curricula.10,11 Although pathologists have approached the development of a professionalism curriculum for trainees,9,13–17 unfortunately no nationally recognized pathology curriculum currently exists.13
The University of Mississippi Medical Center's Department of Pathology, Jackson (UMMC Pathology) contemplated the aforementioned transformation and existing training gaps and decided to formalize the milestones of professionalism and communication into a robust curriculum to prepare residents with the skills needed to become a top talented and future-oriented pathologist.
Using the Tuckman model of team development18 (forming-storming-norming-performing-outperforming and adjourning), the UMMC Pathology faculty and chief residents began setting the stage, or “forming” in April 2020, early in the coronavirus disease 2019 (COVID-19) pandemic. The faculty discussions were coordinated by the 2 coauthors during a 2-month period. The team identified the goal of developing and implementing a professionalism and communication curriculum by the beginning of the new 2020–2021 academic year (July 1, 2020). Another clinical chair who knew of the department's work asked to be invited to attend, and he contributed to the discussions. The “storming” phase, whereby conflict and tension are resolved, occurred by faculty discussing, recognizing their responsibility, and openly disclosing their individual obligations for modeling professionalism and communication. This stage of team development took place in the presence of residents. This disclosure included the planning, execution, and disclosure of the faculty completing self-reflective assessment tools regarding professionalism and communication. This storming phase built team trust and brought calm to the team while balancing the power differential between faculty and residents. With trust established, “norming and performing” appeared as the team demonstrated cooperation and shared the common reality of understanding the significance of communication and professionalism, the value in creating and providing such a curriculum, resource identification, the specifics of a year-long curriculum, the curriculum's andragogy, and considerations of trainee assessment.
During this teamwork phase, UMMC Pathology conducted a literature search and review to better understand educational approaches to professionalism by pathologists and learned they generally involved the application of strategies supporting behavior-based professionalism.6,9,13–17 These educational efforts have provided operational definitions linked to behaviors, milestones, and competencies, fitting well into the schema developed by the ACGME, which includes professionalism and communication as 2 of its 6 domains of competence.6 These approaches have been practical ones; behavior-based professionalism is in fact the dominant framework today.6 Its strength lies in “its clarity of expectations and connection to assessment.”6 Because it is based on the demonstration of behavior, it is relatively easily measured.6 “Behaviors can be defined, observed, and assessed…,” with professionalism lapses viewed as inappropriate behavior that can be identified, monitored, and hopefully corrected with a remediation plan.6 While it is a strong framework, behavior-based professionalism is unfortunately, by its nature, limited in its contribution to the development of professionalism as a trait, of professionalism as a process, or of professionalization.6
As is common in the performing stage of teamwork, UMMC Pathology developed a resident professionalism and communication curriculum envisioning a preventative, nuanced, holistic “continuous improvement” approach. The team's goal is not to react and manage professionalism problems, but rather to take a proactive posture and avoid managing professionalism lapses through education focusing on prevention while creating habits to produce lifelong continuous improvement. UMMC Pathology's curriculum, while including the framework of behavior-based professionalism, also includes the frameworks of virtue-based professionalism and professional identity formation.6 UMMC Pathology's goal is to combine behavior-based professionalism, which focuses on “doing rather than being,” with professional identify formation, which focuses on “being and becoming versus doing,” and virtue-based professionalism, which focuses on “inner habits of the heart, the development of moral character, and acting in a self-giving, ethical, caring, and humanistic manner.”6 Fundamentally, these 3 frameworks have remarkable overlap and their differences are related to semantics and connotative meanings. At a basic level, thoughts are waves of excitation at the neuronal level. Experiencing a thought can stimulate emotional (ie, feeling) states and expression of thought is revealed in verbal and nonverbal modes and can be observed by other human beings. Thought development is an epigenetic phenomenon.19 Repeated patterns of thoughts, sometimes known as automatic thinking, is the basis of habit. Human habit profiles reveal patterns of observable behavior and can be judged as “virtuous” or as an “identity formation.” Thus, the 3 frameworks described by Irby and Hamstra6 are more alike than different.
Recognizing the overlay of these frameworks, UMMC Pathology involved practical applications using language labels from each framework in developing its curriculum, defining its andragogy, and informing assessment.
Ultimately, the UMMC Pathology team created a year-long curriculum, with 35 weeks concentrating on a weekly professionalism topic and subtopic and a specific communication topic and subtopic (Table).20 The remaining 12 weeks emphasize communicating differences, specifically proactive communication, cultural differences, and feedback.
The team did not advance to the “adjourning” stage of Tuckman's model of group development but rather focused on “norming and re-norming” to advance UMMC Pathology to a “just” culture where professionalism and communication are rooted and embedded with supporting values and behaviors. Some may call this an “outperforming” stage of development. This approach would be in contrast to simply a “one and done” set of lectures or assignments. The curriculum expectation is to have residents think about the 2 professionalism and communication subtopics during the week, and produce 2 role-playing videos via cell phone, one regarding the professionalism subtopic and one the communication subtopic. UMMC Pathology's New in Practice Committee, composed of faculty members who are 5 years or less out of academic training, also produce a weekly “standard video” that applies to the week's professionalism subtopic, with the goal of illustrating subtleties and nuances surrounding the subtopic. As one committee member put it, “We want to produce a role-playing video where there is no professionalism problem to be fixed, there is nothing wrong, just that with some thought the situation could have gone better. That will stimulate discussion about the nuances of that week's professionalism subtopic.”
The UMMC Pathology team opted to have weekly 2 half-hour sessions, back-to-back, occurring during the residents' noon hour, an hour dedicated solely to resident education. Four pairs of faculty members are assigned individual lecture rooms equipped with appropriate audiovisual equipment. The faculty members serving in each week's curriculum sessions meet 15 minutes prior to the sessions' beginning to view and discuss the standard video. Each half-hour session involves 2 residents and 2 faculty members. In the beginning of the session, the residents present and discuss their 2 videos for that week with the faculty members, including discussion about how the situation, even if a good one, could have gone better. Then to complete the session, the faculty members present, and discuss with the residents, the week's standard video, which had not yet been viewed by the residents. Faculty then assess the residents using a form developed by the faculty, with abundant room for handwritten comments (Figure).
As the team approaches the curriculum's half-year mark, it will soon assess the curriculum, consider the progress made, and suggest revisions for improvement of the curriculum as it enters the second half of the academic year (norming and re-norming). The team will pursue publication of its early results.
There exists a narrative that pathologists are introverts, perhaps even socially marginalized, unprofessional, and noncommunicative. But that narrative must be eliminated. It is important to remember that “Pathology is a new medical profession; pathologists were not formally recognized nationally as independently practicing physicians until 1965.”3,21 It therefore is a fallacy to consider as real any narrative about the profession of pathology as being made up of physicians who have “always” behaved or communicated in a certain way. In fact, it is more accurate to view pathology as a young, subspecialized, still evolving medical profession, with the physicians who hold themselves out as pathologists still defining their professional identities—not as physicians, but as subspecialty physicians. Given the extraordinary importance of professionalism and communication, pathologists should continue to work hard to establish their developing identities to include excellence in professionalism and communication.
Indeed, we are “progress[ing] in the brave new medical world from the ‘doctor's doctor' to the ‘patient's doctor.' Who knows? One day soon, we could be the doctors whom others consider role models for professionalism and communication!”5
The authors would like to express their sincere gratitude for the invaluable participation from UMMC Pathology Faculty: Veena Shenoy, MD (Professionalism and Communication Committee development lead); Youssef Al Hmada, MD; William Daley, MD; IJ Frame, MD; Dianne Grunes, MD; Ashley Illingworth, PhD; Sarika Jain, MBBS, MD; Sara Johnston, MD; Fariborz Rashid-Kolvear, PhD; Patrick Kyle, PhD; John Lam, MD; Xiu Liu, PhD; Venkat Mannam, MBBS, PhD; Varsha Manucha, MD; James Neill, MD; Tejal Patel, MD; Neha Varshney, MD; Xinchun Zhou, PhD. We would also like to thank UMMC Pathology Residents: Anu Abraham, MBBS; Imran Ajmal, MBBS; Aljunaid Alhussain, MD; Fahd Hussain, MMBS; Vijay Kumar, MBBS; Hansini Laharwani, MBBS; Chase Middleton, MD; Karla Perrizo, MD; Varsha Prakash, MBBS; Lakshmi Ramachandran Nair, MBBS; Akram Shalaby, MBBCh; Hardik Sonani, MBBS; Ayush Srivastava, MBBS; Anas Yahya, MBBS; and Marty Tucker, MD, chair of UMMC Department of Obstetrics/Gynecology.
The authors have no relevant financial interest in the products or companies described in this article.