INTRODUCTION

The transition from medical student to resident represents a shift from a purely educational role to one that combines learning with responsibility as a healthcare provider.1–3 This transition can have significant impacts on learner well-being.4 Most studies describing these challenges have been in patient-facing disciplines,1–3,5,6 and little attention has been paid to the factors that influence early residency transitions in non-patient-facing specialties, particularly those with minimal exposure during undergraduate medical education (UME), such as pathology.

UME curricula in Canada are defined by the objectives outlined by the Medical Council of Canada’s (MCC) examination objectives,7 which describe the attributes expected of medical graduates entering residency in Canada. Due to the generalist nature of the MCC objectives (and, therefore, UME syllabi) certain Royal College-accredited specialties are significantly underrepresented in the MCC objectives,7 corresponding to minimal foundational coverage in pre-clerkship, along with the absence of core clerkship rotations or equivalent experiences. We term these ‘non-core’ residency programs, which are distinct from ‘core’ residency programs that are well-represented in the MCC objectives and therefore well-covered in UME programs.

Diagnostic and Molecular Pathology (DMP), also known as Anatomical Pathology, is one example of a non-core residency in Canadian medical schools. DMP physicians specialize in the study and diagnosis of disease by evaluating human tissue from biopsies, surgical procedures and autopsies.8 There are foundational skills that DMP residents need to have to be successful in early training (such as basic histology knowledge and basic gross and autopsy dissection techniques), yet these skills are minimally covered in UME curricula leaving early pathology residents underprepared for residency training.9 Despite this systemic limitation, pathology training programs involve early service-based learning similar to their core residency counterparts (such as internal medicine), despite significantly less UME exposure. Although pre-UME or UME clerkship elective experiences may attenuate the learning curve associated with acquiring these novel skills, remediation to address this gap in early training remains essential for most incoming residents in pathology.

To address these issues, the authors developed a transitional curriculum to bridge the gap between UME knowledge and that required to be successful in early pathology residency training. The transitional curriculum was developed based on practical evidence that service-based learning alone is insufficient to remediate the knowledge not yet acquired by early pathology trainees.

Outline of the transitional curriculum module

The transitional curriculum was first implemented during the 2022-2023 academic year during Foundations of Discipline for DMP and Diagnostic and Clinical Pathology (DCP) residents at the University of Calgary, prior to Core of Discipline.10 The eight-week module had residents engaging in non-service based learning activities for half of their time, while the other half was spent engaging in graduated service-based learning with a modified workload.

The non-service-based learning was oriented around a weekly topic using multiple learning modalities to engage learners predominantly through retrieval opportunities.11 The multi-pronged approach included: independent study plans with clearly stated learning objectives and a list of level-appropriate resources, interactive flash cards,12 formative short answer quizzes, a live interactive quiz-based Zoom session with a senior DMP resident, weekly guided self-reflections, twice weekly lectures by a Pathologists’ Assistant on grossing and autopsy theory and techniques, and non-neoplastic gross dissection simulation of 3D printed organs. The service-based learning was either directly or indirectly supervised by a practicing staff pathologist, senior DMP resident, or Pathologists’ Assistant, and included topics such as fresh preparation of specimens, intra-operative consultations, grossing, case sign-out, and autopsies.

Study rationale

Although on-boarding initiatives for pathology trainees have been documented,13 to our knowledge the unique overarching learning challenges faced by medical students transitioning to pathology residency (or other non-core specialties) have not been well explored or documented. Therefore, in this study, we sought to explore the early transitional learning experiences of DMP residents both with and without explicit transitional supports

METHODS

Study design

We conducted a sequential exploratory realist mixed methods study using Pawson’s model of realist inquiry14–16 around the following research questions: 1) “What are the perceived learning challenges faced by early pathology residency trainees in Calgary?” and 2) “How can the perceived learning challenges faced by early pathology residency trainees in Calgary be remediated?” By exploring the experiences of junior pathology trainees who had different levels and forms of support in early training, we sought to identify “what works for whom, under what circumstances, how, and why?” The sequential exploratory realist mixed methods study17 was designed in two phases: first a survey of all DMP residents currently in the program (n*=14) regarding learning challenges and supports, from which interview questions were developed. The second phase involved semi-structured interviews (n=*8) exploring issues identified from the survey with a particular focus on what had or had not helped them and why.

Study and participants

We included all levels of DMP and DCP residents enrolled at the University of Calgary in 2019-2024 who were in the Competency by Design (CBD) residency stream and had completed Foundations of Discipline (FoD). Pre-CBD stream residents were excluded from the study, as their early training schedule differed significantly from the CBD residents. Three of the resident cohorts completed FoD before introducing the transitional curriculum, while two of the resident cohorts completed FoD with the transitional curriculum. Eligible participants were recruited via e-mail. Research Ethics Board approval was obtained from the University of Calgary [REB23-1529].

Data Collection

Data were collected between January and April 2024 through an anonymous survey administered through the Qualtrics platform and distributed to CBD stream pathology residents who had completed FoD. The survey focused on developing a better understanding of the early pathology training experience with the intention of identifying issues to be followed up in the interviews (see Appendix 1). Findings from the survey were tabulated and discussed among the study team from which a semi-structured interview script was developed (see Appendix 2). The interviews were conducted by KF, audio recorded and transcribed for analysis using Zoom followed by manual checks for accuracy. Completion of both components entitled the participant to a $30 gift card.

Data Analysis

De-identified free-text survey entries and de-identified interview transcripts were analyzed using open coding followed by data homogenization and identification of context-mechanism-outcome (CMO) configurations from which demi-regularities, and finally, middle range theories were developed.14 Coding was conducted using Microsoft Word and Microsoft Excel (Microsoft Corporation, Redmond, Washington). Because of the sequential explanatory nature of the study, the realist analysis and the reporting of the findings reflects the second phase of the study.

RESULTS

A total of 14 out of 23 eligible participants (61%) completed the anonymous survey. Of the 14 participants who completed the survey, 8 of the 14 (57%) participated in a follow-up semi-structured interview. The participants attended a variety of UME institutions, including, but not limited to, the University of Calgary. Four (50%) of the interviewees had completed the transitional curriculum and four had not (50%). Below, we describe the specific learning challenges faced by early pathology residency trainees and specific aspects of the experience that seem to have a significant impact on the learner experience.

Universal under-preparedness and cognitive overload in early pathology training

Despite a variability in pre-UME (prior biomedical science exposure) and UME (i.e. institution attended and/or exposure through clerkship electives) pathology-related experiences, incoming DMP and DCP residents universally found that their UME training had not given them the “day one” knowledge they needed to function. They felt that the foundational skills learned in UME (regardless of the institution attended), were not necessarily transferable to pathology and found that there was a large and jarring gap in knowledge that had to be rapidly filled.

“A lot of the stuff that you learn in medical school wasn’t necessarily transferable to being a first year [pathology] resident, apart from being on [off-service] clinical rotations… I felt like I was starting at ground zero again.”

- Participant 3: Non-transitional curriculum participant.

“[One of the biggest challenges] is just not knowing what we’re supposed to know… I just had no idea where to start.”

- Participant 6: Non-transitional curriculum participant.

For example, early trainees struggled with the pathology-specific vocabulary they were expected to know from day one:

"One of the [challenges] was learning a language that pathologists use. [The basic vocabulary is] very different from a clinical case presentation [and] didn’t really transfer over to how you would work up a pathology case."

- Participant 3: Non-transitional curriculum participant.

Given the minimal transferrable skills from medical school and clinical rotations, learners were left feeling like a burden when engaging in service-related tasks, which contributed to feelings of being undervalued.

“I struggled with coming off [my clinical rotations] and feeling very much a part of the team… And then you come into pathology and you’re a burden as you’re just slowing everybody down… I just felt like all my responsibility was gone and then you feel less engaged.”

- Participant 3: Non-transitional curriculum participant.

In addition to universal under-preparedness related to the generalist nature of UME, all participants described immense cognitive overload when trying to address the pathology-specific knowledge gap in early training. The volume and rapidity of novel skills acquisition was daunting and overwhelming, leading trainees to feel as though they were “starting from scratch”, despite having a medical degree:

"Learning normal histology can be very daunting … but [then] you’re also being given slides that have pathology on them, and … I was expected to be trying to sign out reports. You’re also trying to navigate this EMR system and figure out how to format the reports and how to write a diagnostic line. So it’s just cognitive overload… and that’s just for the microscopy side… on top of that, you’re also learning how to fresh, how to gross and then autopsy as well… it’s almost like starting from scratch."

- Participant 4: Non-transitional curriculum participant.

While participants frequently cited individual motivation to fill their own knowledge gaps, the novel nature of the material in combination with a lack of guidance led to inefficient and suboptimal learning:

“Even finding those resources [for learning] is not always super intuitive. Half the battle sometimes is not just reading enough but reading the right stuff.”

- Participant 1: Transitional curriculum participant.

While the onus can and should be placed on individual trainees to supplement their knowledge on their own time throughout residency, participants noted that the amount of supplemental learning required by early pathology trainees may not be feasible or reasonable in addition to a full service load. In fact, participants viewed this as inefficient in gaining competence:

“Sometimes you don’t have time in your workday to read around cases, so you spend a lot of time outside of work reading around cases and I think that if we had some dedicated time it might help us not have [these large] lists of things to read… I mean, I’ll eventually get there, but if we had a little bit more protected time within our residency for learning then potentially I might grasp some things a little bit differently, maybe quicker.”

- Participant 2: Transitional curriculum participant.

Despite the learning challenges associated with transitioning to pathology residency, participants felt that transitional initiatives are a responsibility of the pathology residency training program, rather than a deficiency in the MCC objectives7 or UME curricula:

"I don’t think that’s on the medical school to have taught me those things. I think that’s more on the residency programs for their onboarding process for new residents."

- Participant 1: Transitional curriculum participant.

Attenuation of cognitive overload through protected learning time and on-ramping initiatives

We found a broad consensus that a sense of sufficient non-service educational time during working hours was integral to the early pathology training experience leading to more efficient novel skills acquisition and the solidification of skills and concepts. Residents who participated in the transitional curriculum used that protected time to work on their independent study plans, formative assessments, or to supplement knowledge encountered in their service work. This enabled opportunities to gain knowledge and reinforce concepts, which in turn led to a perceived deeper understanding of the pathology material:

"Protected [learning] time allows you to read in depth and really solidify any kind of concepts that you’re exposed to that day or that week, so I think it’s very critical in truly learning the pathological processes and reinforcing those concepts."

- Participant 7: Transitional curriculum participant.

In contrast, insufficient non-service educational time was noted to put learners at a perceived risk of knowledge gaps due to lack of opportunities for in-depth knowledge acquisition:

“[Without it], I personally would feel that I am bombarded with too many entities, and not even just feeling overwhelmed, [but] not really feeling as though I’m learning anything… [it’s like] going through the motions without really, truly understanding what you’re seeing, what the process is, and what the implication is for the patient.”

- Participant 7: Transitional curriculum participant.

Those who didn’t participate in the transitional curriculum described no time for adjustments to their chosen discipline. Rather, they were “thrown in to the deep end” of service-related tasks and senior-level learning activities, which led to overwhelm and disengagement:

“Throwing you in the water to see if you can swim… there was no shallow end… I would just spend hours poring over [this senior level activity], not getting anywhere, spinning my wheels, getting so frustrated and disengaged.”

- Participant 4: Non-transitional curriculum participant.

Participants highlighted the positive impact a structured on-ramping process can have on learner morale. The culmination of level-appropriate learning objectives and resources into categorical learning plans, as was done in the transitional curriculum, enhanced learning by providing the requisite tools needed to develop a foundational knowledgebase in an efficacious manner that one could build off for learning more complex topics; however, it was noted that more formal teaching with respect to pathology-specific terminology and vocabulary may further enhance the positive impact of structured learning plans:

“So, I feel like the weekly protected time very much enhanced my learning, but then that was in concert with guided activities [like] the weekly quizzes [and] the cards [which] provided a framework of what’s expected. We were given a larger document that kind of outlined what was expected during Foundations and resources that we could turn to. All of that was incredibly helpful… I couldn’t imagine going through foundations without the resources that I was exposed to. There’s certainly room for improvement, but I was very satisfied with the resources and structure provided during our Foundations.”

- Participant 7: Transitional curriculum participant.

Attenuation of cognitive overload through adherence to graduated responsibility

There was a variable degree of adherence to graduated responsibility described by participants in both the transitional and non-transitional curriculum cohorts. Those participants who felt that their learning adhered to level-appropriate tasks with graduated responsibility promoted learner confidence and competence when progressing from simple to more complex service-related tasks:

“We had a lecture and then direct supervision for [simple] grossing… having that we sort of hit the ground running when it came to [complex] grossing in ways that [other] cohorts did not.”

- Participant 6: Non-transitional curriculum participant.

Conversely, pre-conceived knowledge assumptions that impeded graduated responsibility resulted in unfair and unrealistic expectations for early trainees:

“I mean everybody’s going to have a different level of experience with grossing when they come in, but I was like, I don’t even know how to hold a knife [for grossing].”

- Participant 3: Non-transitional curriculum participant.

It was also identified that the hospital environment intrinsically impacts the ability to adhere to graduated responsibility. Tertiary care centers may be sub-optimal environments for early pathology trainees related to the complexity of clinical patients that are often seen at these facilities. Although efforts in the transitional curriculum were made to give residents level-appropriate cases, the tertiary care setting imparted an inherent complexity bias, which was challenging for transitioning residents:

“Foundations is done at [a tertiary care hospital] so when you sign out, a lot of the time they only get sub-specialty things… so you can’t actually contribute to those [complex cases].”

- Participant 8: Transitional curriculum participant.

Although Foundations of Discipline was conducted at a tertiary care center, other early learning opportunities at community-based hospitals were identified as being positively impactful in early training, as it led to meaningful engagement in service work that was more closely aligned with the resident’s knowledge base and enabled meaningful graduated responsibility in routine service work:

“[A community hospital], for example, [gets] a lot more of those community samples, which allows you to actually take that normal histology knowledge that you have and apply it and then get further instruction.”

- Participant 8: Transitional curriculum participant.

The impact of direct supervision and peer support in early training

A lack of direct supervision by superiors when engaging in pathology service work in early training was identified to contribute to learning inefficiency - misconceptions that could otherwise be resolved by brief redirection were unable to be identified in a timely manner:

“I was just told to look at standard operating procedures and just go in and do it. It wasn’t until I had been grossing a couple of months that I started to notice common themes.”

- Participant 4: Non-transitional curriculum participant.

A lack of direct supervision also propagated fears of introducing medical error when engaging in service-related tasks that was further exacerbated when they felt unsupported through lack of graduated responsibility:

“[It] was not necessarily that the expectation was for me to be competent in it, but the expectation was for me to just do it… which did not feel safe… I was encouraged to take on cases that were very challenging, even though it felt outside of my knowledge scope.”

- Participant 4: Non-transitional curriculum participant.

An emphasis on direct supervision, as was done in the transitional curriculum, provided residents with support and direction in their learning endeavors, while simultaneously acting as a safeguard for patient care. Direct supervision was particularly important for novel skills acquisition, as it allowed for real-time feedback and a direct transfer of knowledge:

“With freshing you’re paired up with a PA (Pathologists’ Assistant) and you go through things together so you have one-on-one instruction. When it [came] to grossing… there [was a PA] right there at the station to [ask] when you’ve reached the end of how far you can go.”

- Participant 8: Transitional curriculum participant.

Not only did participants note supervisory support as being important, but also the importance of feeling supported by peers in the general learning environment, particularly by near-peers. Those who perceived a power differential between junior and senior residents, noted a significant negative impact on their learning experiences. Not only was this felt to lead to learner intimidation as an early trainee, but incited tones of inter-resident conflict.

“We rely so much, as juniors, on our seniors and it can be intimidating to approach some of them when you’re new.”

- Participant 4: Non-transitional curriculum participant.

“I’ve asked questions to seniors and they’ve been like, “sorry I’m busy.” And to me that is absolutely unacceptable. If a junior works up the courage to go disrupt you and ask you a question, do better than giving them that as an answer.”

- Participant 1: Transitional curriculum participant.

In contrast, fostering a safe and collegial learning environment between junior and senior residents enhanced learning through mentorship and exchange of knowledge:

“I feel my personal experience with senior residents have been hugely beneficial… it’s a very accepting environment and there’s been a ton of education done by part of the residents… to answer any kind of questions and taking the extra step above and beyond.”

- Participant 7: Transitional curriculum participant.

While near-peer and supervisory support was not completely unique to those who engaged in the transitional curriculum, there was much more variability in the degree of perceived support from the non-transitional curriculum participants.

DISCUSSION

This sequential exploratory realist mixed methods study17 explored the challenges of entering a non-core residency such as pathology. There was a broad consensus that early pathology training encompasses a steep learning curve related to the generalist nature of UME that is extremely challenging to navigate while simultaneously engaging in service-based work. Despite variability in pre-residency pathology experiences, it seems that this challenge is relatively universal and inescapable among transitioning residents if the MCC objectives7 and UME curricula remain unchanged in their generalist nature. The issue therein is a matter of inequity in residency preparedness between specialties and how best to address the knowledge gaps for transitioning residents in less aligned residencies. If we accept the notion that UME is better at preparing learners for some specialties than others, then the onus is on the less well-aligned residency programs to fill the gaps. Indeed, participants stressed that UME curricula need not be altered to better prepare pathology residents, but that there is an inherent responsibility of pathology residency training programs to support junior learners in this knowledge acquisition. Accordingly, certain specialties such as pathology need to formally address the medical school to residency transition and ensure that they have structured transitional initiatives in place during Transition to Discipline or Foundations of Discipline. An example of one such initiative is Calgary’s transitional curriculum, which was met with a significant perceived positive response and enabled a less overwhelming transition to pathology training, while simultaneously improving perceived confidence and competence in foundational pathology skills. Given that a lack of transitional support typically leaves residents feeling overwhelmed and stressed, which can contribute to short term and long-term burnout18–20 makes this a particularly significant finding.

We also found that the standard residency approach of engagement in service work from day one places a significant extra load on transitioning residents that may be ethically and procedurally unsuitable for the transitioning pathology trainee, both for the individual trainee (due to overwhelm and psychological injury) and patients (due to potential patient harm). In contrast to other core disciplines where early trainees can independently perform many service-related tasks due to extensive UME exposure (such as taking a history, physical examinations, basic clinical procedures, etc.), most pathology service work is novel to the early pathology trainee; therefore, while early independence may be appropriate for certain core residency programs, it is suboptimal and inappropriate for certain non-core residencies such as pathology. With respect to potential solutions, our findings identified several key aspects of transitional learning experiences that are positively impactful for the early pathology trainee. Notably, the culmination of level-appropriate learning objectives and resources into categorical learning plans with formative assessment opportunities enabled learners to target their conceptual efforts in a more directed, practical, and meaningful way, thereby enhancing efficiency in gaining competence rather than getting ‘lost in the weeds’ of less practical topics. Direct supervision in novel skills acquisition improved efficiency through the relaying of immediate and actionable feedback to the learner, while simultaneously serving as a safeguard for patient safety; therefore, while direct supervision may be an initial time investment on the department’s behalf, it pays dividends in the form of increasing efficacy in obtaining service-related competence.

Overall, our findings challenge the traditional model of residency training for pathology trainees wherein trainees are predominantly engaging in service from day one of residency. Instead, our results emphasize the importance of dedicated time as ‘learner’, as opposed to ‘healthcare provider’ in early pathology training. Failure to do so results in residents feeling as though they are “going through the motions” (Participant 7), rather than truly gaining competence in foundational skills. One may also assert that by giving dedicated learning time up front, the inevitable shift from primary learner to primary healthcare provider may be smoother, while simultaneously reducing learners’ feelings of being overwhelmed and at higher risk of medical error. Importantly, we advocate for sufficient time during working hours for residents to engage in transitional initiatives. If learners are left to complete these types of initiatives in addition to a full-service schedule, we feel this would only further contribute to learner overwhelm and potentially undo any benefits. While we do not refute the concept of early service work or workplace-based training, it is imperative that the work is modified (reduced in load), directly supervised, and graduated in nature.

Limitations

This study is limited to data from participants at a single institution with a relatively small sample size, and only in DMP and DCP training programs. While we postulate that these findings may be relevant to other pathology or non-core residency training programs, the results gleaned from our chosen methodology is rooted in the specific context of our institution’s training programs. Further studies will need to be done to confirm our results in similar contexts and in a larger sample size. We hope that other non-core programs (examples may include neuropathology, hematopathology, medical microbiology, and diagnostic radiology) may reflect on our findings and incorporate them as seen fit.

The retrospective nature of our study has the potential for recall biases, particularly of accounts from more senior residents whose responses may have been confounded or influenced by their current experiences rather than specifically reflecting on their early learning experiences.

Finally, this was a qualitative, rather than a quantitative exploration of a foundational learning initiative. While quantitative analysis on objective learner competence prior to, and after implementation of a transitional initiative may be of value in the future, we rather opted to use our intervention as a means of exploring “what works for whom, how, and why”15,16 during the early transition to pathology training. Based on the very successful pass rates of DMP residents in their Royal College certifying examination,21 long-term objective competence does not seem to be a significant issue, rather the characterization and attenuation of challenges early pathology trainees face seemed to be of the utmost interest and importance.

CONCLUSIONS

A sequential exploratory realist mixed methods study of early DMP and DCP trainees enabled qualitative exploration of the transitional experiences early pathology trainees face. Our study showed that current UME curricula (across multiple institutions) are leaving Canadian graduates underprepared for residency training in pathology (and other disciplines), resulting in very steep learning that can be challenging to navigate with concurrent service responsibilities resulting in significant learner overwhelm and stress. Although this reality seems to be somewhat inescapable based on the current MCC objectives,7 structured on-ramping procedures with appropriate near-peer and supervisory support can mitigate and attenuate these challenges. Although this study was specific to the early pathology training context at a single institution, these results are likely generalizable and informative for other institutions and non-core disciplines.