A Holistic Approach

By Leslie Stainton | 2 Feb

Joe Fantone, MD, remembers how it was in the early 1980s before the University of Michigan Pathology Department had a stand-alone education division. While the department had a long and distinguished record of teaching, residency training was separate from medical student education, and there was no formal graduate program. What’s more, the medical curriculum was evolving into a more integrated, organ-system model. As the curriculum evolved, Fantone says, teaching assignments became more ad hoc and less coordinated. A course director would ask, “Joe, can you teach this?”

“And I’d say sure, happy to.  Or no, I’m too busy, but Sharon [Weiss] might.”

All that changed in 1986, when the department created its first-ever Division of Education Programs. Fantone, now Senior Associate Dean for Educational Affairs in the Department of Pathology at the University of Florida College of Medicine, was the founding director. His biggest job, he recalls, was “getting systems into place.” Systems for teaching, so that faculty were employed most effectively, capitalizing on their areas of expertise and teaching skills. And systems for documenting faculty teaching effectiveness and meeting accreditation requirements for residency and fellowship programs. Under Fantone’s leadership, the department significantly expanded its educational mission over the course of the next two decades, adding, among other things, a new graduate program in cellular and molecular pathology and multiple sub-specialty fellowships.

Today the department’s Division of Education Programs is 34 years old and under the leadership of its third director, Carol Farver, MD. A pulmonary pathologist and past director of the Pathology Residency Program at the Cleveland Clinic, Farver came to Ann Arbor last September and is already envisioning new programs and initiatives. She brings a wealth of experience with her, including a four-year tenure as Vice-Chair of Education for the Institute of Pathology and Laboratory Medicine and stints on the education committees of the United States and Canadian Academy of Pathology and the International Society for Heart and Lung Transplantation.

At Cleveland, where she also led a complex, multi-year process of transitioning the pathology department into a subspecialty program, Farver says she found herself “thinking harder and harder about the whole cycle of being an educator.” She expected to finish out her career at Cleveland. But Michigan reached out—and when a place with the reputation of Michigan gets in touch, “you’ve got to take a look,” Farver says brightly.

“I want to give those people the capabilities to all have a meaningful career.  It’s more of a holistic message around education.”

In Ann Arbor, she discovered a breadth of expertise that astonished her. “People who are faculty development people, people who measure outcomes in every possible way, people who help develop curricula. I thought, wow, you go to one big place and you have everything.”

Since joining the U-M faculty last fall, Farver has devoted herself largely to what she calls “connecting dots.” She’s met with colleagues throughout the Medical School and across campus. With faculty in the Ross Business School, School of Education, and sociology department, she’s exploring potential collaborations aimed at refining outcomes research and strengthening project development.

“The greater discussion around education, in general, these days—and not just health care education,” she says, “is that the paradigm around which one measures outcomes is not a financial one, but a capabilities one. How are we changing the lives of people who get educated? How do we measure their success? The University of Michigan has been in the forefront of trying to do that.”

Building on the work of her predecessor, Barbara McKenna, MD, who retired in 2017, Farver wants to create a division that educates everyone in U-M pathology—not just the traditional cohort of medical students, residents, and fellows, but also the more than 1,100 professionals who staff the department’s labs. “I want to give those people the capabilities to all have a meaningful career,” she says. “It’s more of a holistic message around education.”

“Barbara developed an incredibly strong core of great medical school residency and scholarship,” Farver says of McKenna. “So now the opportunities are really to extend all of that to everybody else.”

Her single most important job, Farver believes, “is making sure that people see education as important to having the best pathology department in the country.”

A Leader in Education

Faculty join the U-M pathology department knowing they’ll be expected to teach. In fact, many learn to teach as Michigan residents and fellows and then stay on to become faculty. While they’re increasingly rewarded for this work—chiefly through promotions—education has long been “a kind of poor stepchild of academic medicine,” says McKenna, who ran the department’s education division from 2009 to 2017. Typically, education doesn’t bring in the funding and reputation that research and clinical practice do, so faculty “don’t get nearly as many strokes for worrying about it,” she says. “The people who teach do it because they love it, and there’s something very special about that.”   

At Michigan, as elsewhere, physicians are being asked to learn more and more, and that poses additional challenges—among them ongoing tweaks to the medical school curriculum. It’s part of an overall push in health care, Farver says, “to achieve the best quality of care for the least amount of money. Education has to find a way to stay alive in that space.”

Unlike other medical specializations, pathology touches virtually every part of a physician’s education—basic science, classroom training, patient care. U-M medical students no longer take a stand-alone course in pathology in their second year, as they once did, but instead study pathology as part of an integrated, systems-based curriculum. While learning about the cardiovascular system, for example, they’ll be exposed to pathology in such areas as anatomy, biology, biochemistry, and physiology. From an educational standpoint, this means greater coordination is needed.

In their second year, U-M medical students now do a mandatory week-long clinical rotation in pathology. The rotation—developed by Madelyn Lew, MD, an associate professor of pathology who oversees the medical school pathology curriculum for the department—is a first for the department and possibly the first in the nation, Farver says proudly. The rotation means that instead of meeting pathologists exclusively in the classroom, students spend time in the laboratory, too.

“A lot of students don’t know what pathology looks like in terms of a clinical practice,” says Lew. “Not every medical student will opt to go into pathology, of course, but the rotation may get them to realize that pathologists are people they can talk to in order to optimize the chances of making a diagnosis, or to explore the best way to approach a sample or test.”

In both their third and fourth years, medical students can also take a four-week elective in pathology. And they can seek one-on-one mentorship with pathologists—even if they’re not planning on specializing in pathology.

Besides classroom and laboratory training, U-M students can take part in small group sessions in clinical pathology, and they have access to online modules and other resources “to help them get an idea of how pathology integrates into the larger picture of health-care delivery,” says Lew.

Changing technologies drive additional adjustments to the curriculum. For example, Lew was involved with delivering a new radiology-pathology correlation session within a radiologic elective. The new session integrates radiology findings with autopsy findings so that students see how radiographic images translate into actual macroscopic findings. Lew is also working with colleagues to develop toolkits involving both technological and non-technological platforms, which faculty can use to engage students more fully.

The pathology residency program has also changed. With the department’s move from the main U-M hospital to the North Campus Research Center (NCRC) in 2018, residents no longer take foundational and surgical pathology at the Veterans Administration hospital in Ann Arbor but instead commute between the NCRC and the U-M hospital.

Rotations are different too, says Allecia Wilson, MD, director of both the pathology residency program and autopsy and forensic services. Wilson works closely with co-associate program directors Kristine Konopka, MD, and Sean Li, MD, PhD, to implement pathology programs at U-M. All first-year residents participate in a brief pathology “onboarding” that introduces them to the foundations of U-M’s system—including a brief overview of both anatomic and clinical pathology and such fundamentals as basic histology and patient safety.

The Division of Education Programs hosts a weekly eight a.m. lecture series for residents, as well as a weekly unknown-microscopic slide conference conducted by faculty members or fellows. But it’s not just residents who attend. Henry Appelman, MD, a member of the U-M pathology faculty since 1969, goes to as many of these sessions as he can. “It’s great,” he says. “I get a chance to hear what other people are doing, what my colleagues are doing, what residents are learning.”

As part of its oversight responsibilities, the education division carefully monitors the number of hours pathology residents work, what they’re asked to do, and how they’re evaluated. It’s part of complying with nationally mandated guidelines, many of which were first introduced in the early 2000s in an effort to improve the quality of care.

Currently, the pathology department has 26 residents and a similar number of fellows—another area that’s changed drastically in the past two decades. When Farver was a resident, almost no one did fellowships. Today, she says, it's unusual not to do one if you want to be competitive. Farver sees fellowships as a critical pipeline for faculty hiring at U-M, in part because pathologists who train at Michigan see such a formidable volume of material—notably the kinds of tertiary, complicated, unusual cases that seldom show up outside a major research institution. “When our fellows and residents tell prospective employers about the kinds of things they’ve seen,” Farver says, “people are stunned.”

A Pathway to Advancement

Farver’s vision for the division’s future extends well beyond the foundational work of educating medical students, residents, and fellows. The department is also ramping up its role in training physician-scientists—MD/PhDs who want to focus on lab research as well as clinical practice.

Continuing medical education is also key to the division’s mission, and Farver sees new potential for growth in this area. She envisions increased engagement with pathologists and laboratories across Michigan—not just clinical interactions but also formal courses in Ann Arbor and a robust program of virtual education. “We’re probably the only pathology department in the country that has its own IT department,” she says, “and that opens up the possibility of building what every pathology department wants— more online education. Pathology is uniquely set up for it.”

Outside of Michigan, the department is partnering with colleagues in Croatia to offer continuing pathology education. And U-M faculty routinely give lectures at professional meetings around the world.

Farver is equally excited about expanding educational opportunities for the 1,100 professionals who staff U-M’s pathology labs. “Only 200 or so of them are MDs,” she says. The rest range from high school graduates to PhDs, from lab technicians and phlebotomists to anatomic pathologists and histotechnologists. Farver believes the job of the education division “is to help organize educational experiences where we can reach out to these people and help build a real pathway around advancement.”

She’s currently working with residency director Allecia Wilson* to formalize this aspect of pathology education by building official relationships with institutions like Washtenaw Community College, Eastern Michigan University, and local high schools, as well as U-M. The goal is to set up experiential internships so that high schoolers and undergrads, among others, can get exposed to pathology early in their studies. “Once they come in and do their internship, they say, wow, wouldn’t it be a great place to stay,” says Farver.

Plans are underway for the Pathology Department to offer its first-ever introductory session on pathology for an application group that will include high school students and undergrads from Michigan and elsewhere. The session will feature tours, observations, lectures, and small group sessions designed to showcase various career pathways in pathology at Michigan. “We want to show that there are a lot of opportunities within the field itself, even if you don’t go to medical school,” says Lew, who’s also involved in the program.

As she settles into her new life in Ann Arbor, Farver is newly thrilled that she chose to come to Michigan. The pathology faculty and staff are “the best,” she says. And the city is a delight. Last fall her daughter came in to visit from Chicago. “We went kayaking on the Huron River,” Farver says, “And I thought, you’ve landed in Oz.”

She cherishes being part of the Michigan tradition. That tradition includes people like Henry Appelman, who came to Michigan in 1954 as an undergraduate and is still here. People like Joe Fantone, who launched the Division of Education in 1986, and Barbara McKenna, who built on Fantone’s work by strengthening the division’s role in medical school, residency, and fellowship training. And younger faculty like Allecia Wilson, who did her residency at U-M and stayed on to become faculty. Wilson credits the pathology faculty at Michigan with having “planted the seed when I was a first-year resident. And here I am now,” she says, “planting those seeds in people’s minds and helping them to develop. Paying it forward.”

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This article was first published in the 2020 Inside Pathology magazine. To read the rest of the articles in this issue, click here. 

Some information has been updated from the previously published article:
* The residency director is currently Kristine Konopka, MD.