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Acad Pathol
Acad Pathol
Academic Pathology
2374-2895
Elsevier

S2374-2895(24)00041-1
10.1016/j.acpath.2024.100145
100145
Regular Article
Development of a residents’ needs assessment-based novel pathology residency boot camp designed on the graduated release of responsibility model
Bhardwaj Swati MBBS, MD
Sampson Barbara MD, PhD Barbara.sampson@mountsinai.org
⁎
Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY-10029, USA
⁎ Corresponding author. Strategic Laboratory Initiatives and Academic Affairs, Department of Pathology, Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 1468 Madison Avenue, New York, NY 10029, USA. Barbara.sampson@mountsinai.org
03 9 2024
Jul-Sep 2024
03 9 2024
11 3 1001459 4 2024
12 6 2024
15 7 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Boot camps in medical education have emerged as effective tools for addressing knowledge gaps and facilitating the integration of incoming residents into clinical training. We developed a pathology boot camp designed on a needs assessment survey, the graduated release of responsibility model, and active involvement of senior residents as educators. A comprehensive survey was administered to current first-year residents to assess educational needs to identify significant knowledge gaps and difficult areas. Based on these findings, a four-week, three-phase curriculum was developed, comprising introductory didactics, hands-on training, and mentorship under senior residents. Pre- and post-tests, as well as resident surveys, were used to evaluate the efficacy of the boot camp curriculum. Senior residents unanimously expressed the need for a boot camp, expressing challenges in histology, workflow, autopsy, and laboratory operations. Pre- and post-boot camp assessment tests showed a 15% knowledge improvement. Most pathology programs across the country have implemented structured pathology boot camps. The strengths of our boot camp included the emphasis on the previous year's residents' feedback, and the challenges that they encountered, serving as a comparison group; a graduated release of responsibility model; and the involvement of senior residents as designated mentors for the duration of the boot camp. The pathology boot camp presented here serves as a promising model for addressing foundational knowledge deficits among incoming residents. By tailoring the curriculum to meet specific educational needs and leveraging senior residents as educators, institutions can better prepare residents for the challenges of clinical training.

Keywords

Boot camp
Medical education
Pathology curriculum
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pmcIntroduction

The term “boot camp” has its origin ​in the military system, referring to a short, intensive training camp for new recruits, conducted with strict discipline. It has gradually encompassed a wider meaning including any type of training camp aimed to impart important introductory information, typically during onboarding, as a first step toward learning a new skill. The success of boot camps lies in their ability to impart training condensed in a short period of time, via a concentrated agenda. Boot camps are popular onboarding “camps” in the digital sector, sports and fitness routines, etc. The current medical school curriculum has limited opportunities for medical students to familiarize themselves with the basic aspects of pathology. Thus, unlike other clinical specialties, residents joining pathology have to overcome a vast gap in basic histology, sometimes even having to learn how to use a microscope, and other basic skills, before they actually start learning pathology. On the other hand, the Accreditation Council for Graduate Medical Education (ACGME) describes, among other things, an ability to recognize normal anatomy and histology as an expected skill from an incoming level 1 resident.1,2 This gap in actual versus expected knowledge creates an overwhelming need for a balanced and rapid pathology boot camp.

Several pathology programs have instituted boot camps for incoming residents. According to the College of American Pathologists' (CAP) Graduate Medical Education Committee's (GMEC) survey of program directors (with a 40% response rate) conducted in 2010, 57 programs already had an orientation program in place, with nearly half (43%) of them having such a program for more than 8 years.3 Several of these programs comprise about 4 weeks of didactics covering anatomic pathology (AP), clinical pathology (CP), or both.1,4,5

At our institute, while an informal training is provided for some basic topics, a formal boot camp curriculum was lacking. Previous years' trainees did not have a structured program in place for learning the basics. This learning happened as and when they rotated through various divisions, with guidance from attendings as needed. We developed a novel 4-week boot camp curriculum after surveying current first-year residents for areas of greatest difficulties. This boot camp design is unique for 3 reasons: 1) The boot camp curriculum was based on a needs assessment survey, 2) the design of the program is based on the graduated release of responsibility model (Pearson and Gallagher6) ​and Miller's pyramid of progressive responsibility,7 and 3) the model engages senior residents in basic teaching roles to serve the purpose of providing experience as an educator for senior residents. The efficacy of the boot camp curriculum was assessed using surveys and pre- and post-tests.

Materials and methods

Study design

Assessment of need

A 7-question survey was designed to assess the familiarity with basic aspects of histology, autopsy, grossing, etc. and the difficulties faced in each of these aspects, correlated with the level of pre-residency experience in pathology (Supplementary Material 1). Current first-year residents toward the end of their first year were surveyed to develop a basic understanding of the unmet need for a boot camp. The results of the survey were compiled and analyzed. Curriculum content was developed on the basis of the curriculum.

Curriculum design

A 4-week, 3-phase curriculum was designed according to the graduated release of the responsibility model (Fig. 1). The boot camp was split into 3 phases, as described in the following subsections.Fig. 1 Graphical illustration of how different phases of boot camp design resulted in gradual release of responsibility. The downward green triangle shows gradually decreasing responsibility of the teacher. The upward facing green triangle shows gradual increase in responsibility of the PGY1 resident. This figure shows the example of autopsy. The phrases on the right are the classical phrases described in this model. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

A pre-test was administered to all residents on the first day of the boot camp.

Phase I: introduction, orientation, didactics, and slide-based sessions

Introductory and orientation sessions

The introduction and orientation sessions were conducted at a program level in addition to hospital-wide graduate medical education (GME) orientation sessions (covering the Health Insurance Portability and Accountability Act (HIPAA), diversity, inclusion and equity training, legal and regulatory aspects, Epic training, basic safety, onboarding training, etc.). Department-level orientation sessions included an ​introduction to the program by program leadership, introduction to digital pathology, introduction to pathology digital communication interface (PowerPath), how a tissue becomes a slide, and how to use a microscope and navigate digital slides. Legal and regulatory aspects as they pertain to pathology were covered.

Surgical pathology

The first 2 weeks included multiple didactics and slide-based sessions. Histology curriculum was taught via slide-based teaching sessions. Complex organ system histology was taught by experienced faculty members. Simpler histology sessions for types of epithelia and tissues were conducted by senior residents to utilize this as an opportunity to provide teaching experience to senior residents. In addition to slide-based histology lessons, there were 5 didactics, a mix of slide-based and presentation-based teaching for the most common diagnoses that a resident is likely to encounter in the 5 major surgical pathology specialties at our program (gastrointestinal, genitourinary, breast, head and neck, and gynecologic pathology).

Autopsy

Introductory sessions to autopsy were held in the form of didactics as well as practical hands-on training in the morgue. Basic aspects were covered in 3 “introduction to autopsy” sessions. In addition, all residents observed and participated in autopsies each day on rotation among ​each other.

Introduction to faculty mentors

Based on each individual resident's areas of interest, residents were assigned to meet with one or more faculty members for an overview to the subspecialty, including the daily aspects of practicing that subspecialty.

Clinical pathology

CP curriculum was primarily a practical orientation to the laboratories and a walking tour with a practical overview of each CP subspecialty. In addition, transfusion medicine orientation comprised 2 introductory sessions, including an introduction to blood banking and an introduction to apheresis.

Phase II: pairing with a “senior buddy”

As the second step in the graduated release of the responsibility model, teaching sessions were followed by accompanied and supervised practical training sessions of day-to-day work. For this purpose, senior resident volunteers were assigned as “senior buddies” who were accompanied by the PGY1 resident throughout the work day, including previewing cases together (on a double-headed/multi-headed scope), grossing specimens with the PGY1, and signing out cases together with the attending.

Phase III: first rotation

To ease the transition into independent learning in residency, the first-year residents were scheduled in the same subspecialty rotation that they were paired with the senior buddy in. This first rotation involved the residents working independently, with the senior buddy ​being “on call” for help and questions.

Development of a boot camp manual

A manual for boot camp was developed, which included face sheets of all faculty members, residents, and staff members and a schedule of the boot camp. The manual also included common GME ​information and resources, such as information on leave policies, book funds, travel, and educational funds. In addition, wellness resources and department and GME contacts and resources for wellness were also included.

Assessment of boot camp effectiveness

Boot camp efficacy in overcoming knowledge gaps was assessed using knowledge improvement in post–boot camp assessment compared to pre-test. In addition, feedback and comments were collected after the boot camp.

Results

Results from the needs assessment survey (Supplementary Material 1) of senior residents

All residents agreed and provided consent to participate in the survey (Q1).

Educational background of senior residents: Out of 6 respondents, 50% (3) started residency fresh out of US medical schools, 16.7% (1) graduated from a non-US medical school, 16.7% (1) had a prior residency experience in other country, and 16.7% (1) of residents had done a post-sophomore fellowship (Q2 of Supplementary Material 1). Four respondents (66.7%) had no gap between medical school graduation and residency, and one (16.7%) had a gap of one year during which they did their post-sophomore fellowship. One (16.7%) had a gap of 2–5 years, when they did their residency training (Q3 of Supplementary Material 1).

Need for boot camp: Overall, 100% of residents reported that they would have benefitted from a boot camp, with 83% of residents reporting that they would have benefitted at least in some areas (Q6 of Supplementary Material 1). Most residents (83%) reported that they needed 4 weeks to get accustomed to the workflow in their first year of residency (Q7 of Supplementary Material 1).

Difficult areas for prior residents (Q4 & Q5 of Supplementary Material 1) (Fig. 2, Fig. 3): 50% of senior residents reported that they faced difficulty with normal histology in their first month, with baseline knowledge ranging from none to below average for 50% residents, and 0.83% of residents reported facing difficulty in the daily workflow in the beginning of residency. Expectedly, 83% of residents reported having none to below-average knowledge of the basics of autopsy service. Fifty percent of residents reported facing difficulty with specimen processing and grossing in their first month. All residents reported having none to minimal knowledge of transfusion service and facing difficulties in their first month. All residents reported lack of familiarity with clinical laboratory operations.Fig. 2 Graphical representation of responses to question number 4 of the needs assessment survey (Supplementary Material 1). Question 4: How would you rate your baseline knowledge on day 1 of PGY1, in each of these aspects on a scale of 1–5 (1 ​= ​none to minimal to 5 ​= ​know fairly well to preview cases/round patients for TM/prepare case notes for lab medicine).

Fig. 2

Fig. 3 Graphical representation of responses to question number 4 of the needs assessment survey (Supplementary Material 1). Question 5: In the ascending order of difficulty faced in each of these aspects during the beginning of your first year, please rank the following areas of residency (1 ​= ​did not face any difficulty to 5 ​= ​it was very difficult to get used to it).

Fig. 3

Results from the pre- and post-boot camp survey of PGY1 residents

Pre-residency knowledge: Out of 6 respondents, 50% (3) started residency fresh out of US medical schools, 33.3% (2) had a prior residency experience in other countries, and 16.7% (1) of residents had done a post-sophomore fellowship.

Time since medical school: 33.3% of residents had no gap between medical school and residency, 16.7% had a gap of 1 year, 33.3% had a gap of 2–5 years, and 16.7% had a gap of more than 5 years since medical school. Only one resident was involved in research immediately prior to residency training.

Improvement in knowledge with post-boot camp knowledge assessment: The average score on the 20-question test administered before the boot camp was 55% (Table 1). The areas of assessment covered the didactic topics (histology, common diagnoses, and laboratory workflow). The mean score achieved on the same test following the completion of the boot camp was 70%.Table 1 Results (scores) from the pre- and post-boot camp assessment.

Table 1	Pre-boot camp assessment score	Post-boot camp assessment score	
Resident A	70	90	
Resident B	60	60	
Resident C	60	90	
Resident D	30	40	
Resident E	70	80	
Resident F	40	60	
Average	55	70	

Feedback: While all residents felt comfortable with the histology, common diagnoses, and basic laboratory workflow, nearly all residents reported difficulties with grossing, unfamiliarity with specimens on each rotation, and a feeling of having to “fend for themselves” when it came to grossing in a subspecialty-based curriculum.

Discussion

The requirements for boot camps in pathology residency training in particular are multifold. First, as addressed by Naritoku et al.,1 the undergraduate medical education curriculum has changed significantly in past years, creating gaping holes in the pathology knowledge base of residents with an increased emphasis on clinically oriented curriculum. While this has served extremely well the needs of most patient-facing specialties, it has also created a greater need for an introductory course for incoming pathology trainees. Second, even with sufficient exposure to pathology in medical school, there are a number of basic pathology skills that have a learning curve in residency, such as grossing, laboratory workflow, and familiarity with the laboratory information system.

The design of the boot camp was based on the knowledge deficiencies and areas of difficulty reported by senior residents. This allowed the assessment of the most painful areas in getting accustomed to residency. Only a small number of programs have adopted measures to evaluate the residents' performance after a boot camp,1,5 with 5% program administering a pre-test, 9%, a post-test, and 59% not administering any assessment for boot camps.1 The quantitative results of our post-boot camp assessment showed improvement (15%) in knowledge about the content covered in the boot camp. Pairing up with senior buddies helped in overcoming the first month’s challenges in getting used to workflow.

The duration of most pathology boot camps implemented across the country is 4 weeks,1,5,8 with a range of 1–12 weeks. We implemented a 4-week boot camp based on our survey of previous year's residents who reported an average time of 4 weeks to get accustomed to training and workflow, in addition to successful boot camps with a 4-week model.

The uniqueness of our boot camp design was that we based it on the requirements of previous years’ residents. Lack of a control group has previously been reported as a deficiency for some boot camps.5 While we were not able to completely overcome this deficiency by a direct comparison of the knowledge base, the experience of senior residents served as a comparison group to match experiences in the classes before and after the implementation of boot camp.

Another strength of the design is a graduated release of the responsibility model. A graduated responsibility model has been effectively utilized for boot camps in the past.5 We utilized a different design to implement this model. While the first 2 weeks were comprised of didactics only, the next 2 weeks comprised following a “senior buddy” and were structured to mostly observe and take on limited responsibility. Following this, the residents were scheduled on the same subspecialty to take on more responsibility of the cases. Inclusion of senior residents in the training model as “senior buddies” gave more teaching responsibilities to senior residents, in accordance with Halsted's model.9

The limitation ​of this boot camp design, as reflected in residents’ feedback, was a lack of structured grossing curriculum. While phase II of boot camp with the involvement of a senior buddy was designed to have a senior resident demonstrate and teach grossing skills, the lack of structured time and dedicated topics for grossing left room for improvement.

The design of this boot camp is widely applicable. With the introduction of newer, readily accessible resources such as the Histology Primer by the American Board of Pathology, the histology training part of most boot camps across the country has been adequately addressed. However, the graduated responsibility model and the needs assessment–based model make ​it very malleable and customizable to current resources and deficiencies.

In conclusion, the necessity for pathology residency boot camps is evident due to evolving medical education curricula and skill gaps. Our boot camp design, shaped by senior residents' feedback, showcased a 15% knowledge improvement. Implementation of a 4-week model aligned with residents' needs and prior successful practices. The design's strength lies in its graduated responsibility model, though limitations such as the lack of structured grossing curriculum were noted. However, the model's adaptability and widespread applicability make it valuable for addressing current training needs.

Funding

The article processing fee for this article was funded by an Open Access Award given by the Society of ‘67, which supports the mission of the Association for Academic Pathology to produce the next generation of outstanding investigators and educational scholars in the field of pathology. This award helps to promote the publication of high-quality original scholarship in Academic Pathology by authors at an early stage of academic development.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary data

The following is the Supplementary data to this article:Multimedia component 1

Multimedia component 1

Acknowledgments

The authors thank the faculty, Dr. Amanda Krausert, Dr. J.D. Paulsen, Dr. Brandon Veremis, Dr. Vesna Najfeld, Dr. Brett Baskovich, and Dr. Francine Dembitzer for participating in the boot camp; residents, Dr. Lakshmi Kowtha, Dr. Avi Kandel, Dr. Joshua Onuiri, Dr. Maryam Kooshesh, and Dr. Nicholas Scibetta for volunteering to be senior buddies for the boot camp; and Dr. Aiswarya Irri and Dr. Avi Kandel for their help in implementing the boot camp.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.acpath.2024.100145.
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