Fast-Track Residency

[BlondeDocteur]

When I first started exploring the idea of fast-tracking through AP-only residency there was some skepticism here about the logistics, so I wanted to share my experience and see if anyone else out there is considering doing the same.

I'm interested in pediatric cardiothoracic pathology. I've gotten a Thoracic Pathology fellowship spot secured for 2016, so I'll be doing two years of AP, followed by Thoracic, followed by Pediatric pathology.

The combined AP/NP pathway has had this laid out for a long time, but in a nutshell-- to sit for either the AP or the CP boards, you only need 24 months of training in each. However, you're not actually board eligible until you've had three total years of training in something. And for the most part, the ACGME fellowships exclude you if you're not board eligible (i.e. had three years of training), so you can't skip a year of residency and do derm or blood bank.

This usually shakes out as having a 10+ month elective/research third year of single-track residency. But if you want, you can arrange a non-ACGME fellowship for the third year. It's kind of a free fellowship, really, and slices off a year of total training time. Obviously this is only of interest to people who are interested in becoming specialists, and is only viable in academia.

So, bottom line, I'm doing it. Is anyone else? I'd like to hear your experiences, particularly regarding boards prep and what your practice is like now.

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[LADoc00]

Pediatric CT Pathology..is that a gag? Im unclear where this is like an April's Fool thing or something.

 

[Thrombus]

Who is giving you career advice? Pediatric cardiothoracic pathology? I could take 10 groups and they may have a case they need help on once in their careers.

 

[LADoc00]

Pediatric CT Pathology, which Im fairly certain isn't even a "thing", would be the equivalent of majoring basket weaving when the actual engineers can't even find work.

I almost want to know if you simply came to one day and made that up after a particularly eventful Match.com date that involved shots of Fireball where you passed out a bar in West LA.

Im fairly unclear where you are fast tracking to? the land of no job opportunity? the land of basic science research? the land of being forced to go back and do a full surg path fellow followed by a CP stint?

 

[pathstudent]

Phil Ursell at ucsf via Columbia made a long career out of pediatric cardiac pathology. Per the sac bee state employee salary search, he makes a decent salary.

 

[gbwillner]

cardiac biopsies are 88307.... right? That's a sweet gig if you can get the volume.

 

[AZpath]

Real bad career track
You may have no job when your done unless some retires
It it best to have some general AP experience .... 4 years

 

[LADoc00]

Phil Ursell at ucsf via Columbia made a long career out of pediatric cardiac pathology. Per the sac bee state employee salary search, he makes a decent salary.

Yes and yesterday I read an article about a guy who makes his living tattooing eyeballs. Apparently he invented the technique and commands a pretty penny but that doesn't mean one should drop out of Harvard B-school to be his understudy....

Although Pathstudent if you had dug a little further that guy spent SEVEN years in training, including a full Peds residency and what appears to be a 3 year fellowship just to be able to see enough cases to be even remotely be considered an "expert." Hardly a "fast track.."

The entire U.S. has room for maybe 2-3 of such individuals. Unless the OP has some inside track about the failing health of one those in the Peds CT Path "triad" then I would think of something else...

 

[BlondeDocteur]

Thank you all for your sweet and touching concern for my future. It really pulls on the old heartstrings.

I know Dr Ursell and think he's great. Actually if you want a wide-open market in pathology, cardiac might be where it's at... the next youngest person to me who specializes in this is about 65. Supposedly I will be the first person in the US to complete this mix of fellowships; most of the largest children's hospitals have dedicated cardiac/cardiothoracic pediatric pathologists, but they've all just self-taught after completing pediatric fellowship.

Anyway, as you all know I have zero (less than zero) interest in community practice and couldn't care less if private groups out there wouldn't find me hirable. I'm an academic creature and will stay ensconced in the ivory tower for life. And that includes devoting significant time to research, GME, medical student teaching, surg path admin and the like; not to mention, of course, general service work in both pediatric surgical pathology and/or adult thoracic pathology. Mix that in with a directorship of autopsy, consultations on forensic pediatric cases re: cardiac causes of death, and so on and I think I'll be able to fill my days. Which you all know, of course, and are just being asshats.

So too bad, it doesn't seem like anyone else has taken advantage of this way to streamline your training. Well, if anyone out there is interested and is reading, it can be done.

 

[deleted314957]

Thank you all for your sweet and touching concern for my future. It really pulls on the old heartstrings.

I know Dr Ursell and think he's great. Actually if you want a wide-open market in pathology, cardiac might be where it's at... the next youngest person to me who specializes in this is about 65. Supposedly I will be the first person in the US to complete this mix of fellowships; most of the largest children's hospitals have dedicated cardiac/cardiothoracic pediatric pathologists, but they've all just self-taught after completing pediatric fellowship.

Anyway, as you all know I have zero (less than zero) interest in community practice and couldn't care less if private groups out there wouldn't find me hirable. I'm an academic creature and will stay ensconced in the ivory tower for life. And that includes devoting significant time to research, GME, medical student teaching, surg path admin and the like; not to mention, of course, general service work in both pediatric surgical pathology and/or adult thoracic pathology. Mix that in with a directorship of autopsy, consultations on forensic pediatric cases re: cardiac causes of death, and so on and I think I'll be able to fill my days. Which you all know, of course, and are just being asshats.

So too bad, it doesn't seem like anyone else has taken advantage of this way to streamline your training. Well, if anyone out there is interested and is reading, it can be done.

I would look out for the use of the term "just self taught". I was a "self taught" GI pathologist ( now retired and 63 y.o.) because there were no fellowships then and I can line up a few bridge foursomes of gastroenterologists who swear by me and want me to come out of retirement.

Thank you all for your sweet and touching concern for my future. It really pulls on the old heartstrings.

I know Dr Ursell and think he's great. Actually if you want a wide-open market in pathology, cardiac might be where it's at... the next youngest person to me who specializes in this is about 65. Supposedly I will be the first person in the US to complete this mix of fellowships; most of the largest children's hospitals have dedicated cardiac/cardiothoracic pediatric pathologists, but they've all just self-taught after completing pediatric fellowship.

Anyway, as you all know I have zero (less than zero) interest in community practice and couldn't care less if private groups out there wouldn't find me hirable. I'm an academic creature and will stay ensconced in the ivory tower for life. And that includes devoting significant time to research, GME, medical student teaching, surg path admin and the like; not to mention, of course, general service work in both pediatric surgical pathology and/or adult thoracic pathology. Mix that in with a directorship of autopsy, consultations on forensic pediatric cases re: cardiac causes of death, and so on and I think I'll be able to fill my days. Which you all know, of course, and are just being asshats.

So too bad, it doesn't seem like anyone else has taken advantage of this way to streamline your training. Well, if anyone out there is interested and is reading, it can be done.

 

[LADoc00]

This is fascinating. So you actually thought all this out and realized all the other self proclaimed experts are on Deathwatch in their 60s and this would be perfect time to strike.

Touche.

Tell me more of your dark plan. If this involves perhaps '50 Shades of Grey' stuff that precipitates heart attacks, perhaps leaving you as the sole national expert, then I will be truly impressed. If this is your Machiavellian plan, then I have underestimated your Kung Fu.

 

[pathstudent]

I think it is a great thing to do. When I was in residency, there were only two cardiac pathology fellowships in the country, one in boston and one in Los angeles. Every pediatric heart transplant center could use a pediatric cardiac pathologist. If it is your passion, go for it.

The secret to making a lot of money is to try to become great at something you love. If you love making cupcakes, become great at it and you will be a success. I saw a TV story about robert Kirkman. He was a nerd who loved writing comic books about zombies. He spent years living in a tiny apartment doing something that people never thought would amount to anything. Well have you ever heard of the walking dead? The dude is now worth hundreds of millions

 

[mlw03]

I can't comment on your specific career plans, but I can comment on AP-only. If you are sure of your intentions (and it sounds like you are), I don't see the downside. You save a year off training, avoid stuff you have no interest in, and this last point is a big one with the new ABP rules about MoC - you don't have to worry about recert in CP if your career is pure über-niche AP stuff such that you never see CP. Someone has to do what you're interested in - just because most folks in here do community based practice doesn't mean there isn't a place for a niche academic specialist. As an FP guy, I'd be thrilled to have someone like you in my city, and would surely ask for help in cases of possible congenital cardiac anomalies, either based on history or in-situ look at the heart-lung block. I knew I wanted an FP career and have no regrets going AP-only. With the career plans you describe, if you are sure of, go for it (et bonne chance ).

 

[LADoc00]

I think it is a great thing to do. When I was in residency, there were only two cardiac pathology fellowships in the country, one in boston and one in Los angeles. Every pediatric heart transplant center could use a pediatric cardiac pathologist. If it is your passion, go for it.

The secret to making a lot of money is to try to become great at something you love. If you love making cupcakes, become great at it and you will be a success. I saw a TV story about robert Kirkman. He was a nerd who loved writing comic books about zombies. He spent years living in a tiny apartment doing something that people never thought would amount to anything. Well have you ever heard of the walking dead? The dude is now worth hundreds of millions

Hold it, lets be realistic. No one and no institution 5-10 years down road will pay an actual salary for a Pathologist to just do cardiac peds path or even all cardiac. Those that do this are complete dinosaurs.

There isn't a "secret to making lots of money" here. You have zero bargaining power with employers unless you have a broader set of skills than that.

Although fascinating that there is a blonde chick "black widow-stalking" old, enfeebled pathologists hoping to gain their expertise mantle, this isn't a reproducible formula ANYONE should be emulating.

And no, the secret to making lots of money is not becoming great at something you love. If that was true, there would be self made millionaires from playing COD or Destiny...it is a tad more complex than that son.

 

[WEBB PINKERTON]

About time LADoc brought us back to reality. I thought everyone agreed it's not smart to "follow your dreams" or be hyperspecialized. I couldn't believe what I was reading for a second.

I tried following my dreams in my spare time and all it got me was bilateral pulmonary emboli and a large infarction.

 

[mlw03]

Hold it, lets be realistic. No one and no institution 5-10 years down road will pay an actual salary for a Pathologist to just do cardiac peds path or even all cardiac. Those that do this are complete dinosaurs.

There isn't a "secret to making lots of money" here. You have zero bargaining power with employers unless you have a broader set of skills than that.

Although fascinating that there is a blonde chick "black widow-stalking" old, enfeebled pathologists hoping to gain their expertise mantle, this isn't a reproducible formula ANYONE should be emulating.

And no, the secret to making lots of money is not becoming great at something you love. If that was true, there would be self made millionaires from playing COD or Destiny...it is a tad more complex than that son.

She is being realistic - she's said she wants a full academic career. Teaching, research, admin duties, and the niche specialty. That seems like a not uncommon academic life, so what's the problem? I do agree that there's not a lot of leverage, but it can go both ways. Once an institution gets used to having a service available, take it away and they're not happy. I remember the uproar when the one neuropath we had on staff wanted to go on vacation to India for a few weeks to visit family. The neurosurgeons were freaking out - who's gonna read my frozen sections?! How do I know when to stop cutting?! This situation is different, but I do think there is a market for a few of these people in the job market - why not this gal?

 

[caffeinegirl]

I know of several residents who did similar non-ACGME fellowships as their third year of AP training. The challenge was board preparation, and that was met by continuing to attend general AP conferences, and micro consensus conferences during your non-ACGME fellowship. It still was challenging for those with only two years of AP training (especially in my program which was subspecialty based) to get a broad and confident overview of AP (including cytology). As an AP only resident, the final year of AP was used to solidify my knowledge prior to surgical pathology fellowship. However, I did not enter an academic track, as the OP. I would also suggest Osler courses for board prep. The goal for the OP is to be board certified in AP, not to practice general AP.

 

[thebouque]

I am a Canadian resident and here is my opinion for what it's worth. In Canada most of us do a 5 years AP only residency. Also, there are 4 years Hemepath only and 5 years neuropath only residencies (as well as 5 yrs med micro) and these residents find jobs so being subspecialized early on is a realistic career plan. However, these jobs are in academic centers and they require fellowships (usually 1-2 years), so these people spent 6-7 years in training.

I think subspecialisation is the future of pathology and eventually ''general'' pathologists will disappear and groups will be composed of people who each cover 2-3 organ systems max. However, what could be an issue in your case is the fact that you only get 2 years of AP. In my mind, and I may be wrong, it's a little short if you want to be able to take full advantage of your fellowships (maybe you're an exceptional resident and your program is particularly outstanding I don't know). Also you're saying that you'll do mostly cardiac/thoracic peds and a bit of adult lung (medical lung I suppose). However, a peds group in a pediatric hospital can always ask you to cover general peds surg path and biopsies, depending on how the cases are distributed. Chances are that you'll have to take care of peds lymphomas, bone + soft tissue, GI etc and despite your fellowship in pediatric path, an excellent basis in surg path will help you. So maybe fast tracking will make things harder for you (and I'm not going to talk about board prep since someone mentioned it above)?

Good luck with everything and congratuations for your fellowship

 

[LADoc00]

I am a Canadian resident...
I think subspecialisation is the future of pathology and eventually ''general'' pathologists will disappear and groups will be composed of people who each cover 2-3 organ systems max. However, what could be an issue in your case is the fact that you only get 2 years of AP.

1.) First off, there is absolutely no extrapolation from the Canadian healthcare market to anywhere else on earth, save for North Korea. Canada has literally no private practice period, in fact it is illegal (yes, that is right, if you charge someone 20 bucks to read a skin slide outside their system you will do time in jail, but if you sell drugs in Vancouver you are fine so it is very much like "Upside Down World").

2.) You couldnt be more wrong as to what is happening elsewhere. Pathology is being commoditized at such a rapid clip now that subspecialization is forced only where there is a market bubble: GI, GU or Derm.

5 years from now, no one will care who signs out what in Pathology as long as its done for a low price point. Efficiency, speed, block counts.

I have massive real experience watching this unfold for the last decade, not 2 years into a residency in North Korea... Dermatology practices desperate for money are willing to get anyone sign out their in-house cases assuming they will take peanuts in pay is a good example.

Outside the bubble fields where you can fill up a 40 hour week with biopsy glass, good luck to you.

Im going to leave you with this: once the Neurosurgeons are presented with the option of having a chunk of their income float a part of a salary for a NP only Pathologist, which is already happening places, you can GUARANTEE that will be day they are A-OKAY with a generalist reading their frozens...

 

[coroner]

Are you on the board of directors for Kaiser or even worse Aetna? What's your next suggestion: allow psychiatrists to start taking out people’s gallbladders because they’ll charge less than surgeons?

What this fails to take account is that with the glut of trainees nearly all of whom are fellowship trained (some in multiple), employers can afford to be selective of which specialist they hire to look down the scope because they can be due to supply and demand. So if it’s a race to the bottom to get that contract renewed, might as well load up on the subspecialists to stake your claim or at least so those groups can feel better about themselves. You’re right no one may care who signs out pathology as long as it’s done at a low price point, but they’re not the ones doing the hiring.

Still think we’re headed that way in 5 years? Let’s see how a “generalist” fares who only does a 4 yr AP/CP residency from the University of Puerto Rico without a fellowship…I don’t see them undercutting the Neuropathologists at Stanford, MD Anderson, etc. anytime soon or start doing flow and novel immunophenotyping and replace Jaffe, et al. at the NCI. For that matter, they wouldn’t even stand a chance of getting into a major metropolitan area on either coast and will probably wind up in some podunk hospital in Texarkana, AR if that…

Medicine may be headed in the era of commoditization to an extent, but this ain’t ‘Moneyball’ with Brad Pitt and quality of care and street cred still counts for something before your proposed sabermetrics/Lean method takes over. Besides, weren’t you all about uber-specializing awhile back…?

 

[thebouque]

1.) First off, there is absolutely no extrapolation from the Canadian healthcare market to anywhere else on earth, save for North Korea. Canada has literally no private practice period, in fact it is illegal (yes, that is right, if you charge someone 20 bucks to read a skin slide outside their system you will do time in jail, but if you sell drugs in Vancouver you are fine so it is very much like "Upside Down World").

2.) You couldnt be more wrong as to what is happening elsewhere. Pathology is being commoditized at such a rapid clip now that subspecialization is forced only where there is a market bubble: GI, GU or Derm.

5 years from now, no one will care who signs out what in Pathology as long as its done for a low price point. Efficiency, speed, block counts.

I have massive real experience watching this unfold for the last decade, not 2 years into a residency in North Korea... Dermatology practices desperate for money are willing to get anyone sign out their in-house cases assuming they will take peanuts in pay is a good example.

Outside the bubble fields where you can fill up a 40 hour week with biopsy glass, good luck to you.

Im going to leave you with this: once the Neurosurgeons are presented with the option of having a chunk of their income float a part of a salary for a NP only Pathologist, which is already happening places, you can GUARANTEE that will be day they are A-OKAY with a generalist reading their frozens...

Always a pleasure to read you. I want to point out that private practice is not illegal in Canada, and that it even exists in Quebec (Canada's french province). However, you're right, it's not as widespread as in the US. Nevertheless, OP was talking about the academic system in the US which is similar to what we have in Canada (sorry I mean North Korea).

I have a question for you internet tough guy: Do you love the smell of napalm in the morning? Does it smell like victory?

 

[LADoc00]

Folks we are talking about 2 different things: Obviously having a niche field you are good at wont HURT you. What will hurt you is ONLY doing that field.

Im making the distinction between developing an area of expertise in training you are particularly good at (which is a great idea) vs. trying to make a career ONLY doing that one thing (a tremendously bad idea).

Neuropaths in MOST groups still read general surgpath (as most US NP's dont work in academics) so keep that in the back of your mind. If you "fast track" yourself to only being able to read cardiac Peds path, even though YES I realize some Dinosaurs do this, you likely wont be able to make a living at it.

"Direct billing, whereby physicians collect payments from patients rather than from the public plan, may adversely affect access to health care services, as patients must bear the up-front cost of the care and then seek reimbursement from the public plan. Thus, in all but 4 provinces, opted-in physicians are prohibited from billing their patients directly."

REF:
CMAJ March 20, 2001 vol. 164 no. 6

• Review

The illegality of private health care in Canada

And thanks for the comments Kim Jong Un. No idea about napalm smell but I love the movie! I often wonder what life is like in the Socialist Workers Paradise of Canadian Healthcare. I assume it isnt bad per se but I would not trade self determination I have here for anything. I figure it is the difference between being a free man living on farm, working and toiling on the land to survive vs. living large in the harem of the Umayyad Caliphate.

I guess at the end of the day I prefer not be someone's little b... (Im kidding dude, no need to get bent, I do realize you guys have a pretty sweet deal up there)

 

[27G]

I think subspecialisation is the future of pathology and eventually ''general'' pathologists will disappear and groups will be composed of people who each cover 2-3 organ systems max. However, what could be an issue in your case is the fact that you only get 2 years of AP. In my mind, and I may be wrong, it's a little short if you want to be able to take full advantage of your fellowships (maybe you're an exceptional resident and your program is particularly outstanding I don't know). Also you're saying that you'll do mostly cardiac/thoracic peds and a bit of adult lung (medical lung I suppose). However, a peds group in a pediatric hospital can always ask you to cover general peds surg path and biopsies, depending on how the cases are distributed. Chances are that you'll have to take care of peds lymphomas, bone + soft tissue, GI etc and despite your fellowship in pediatric path, an excellent basis in surg path will help you. So maybe fast tracking will make things harder for you (and I'm not going to talk about board prep since someone mentioned it above)?
Good luck with everything and congratuations for your fellowship

Actually not sure if this is true anymore. There is increasing pressure to do away with subspecialization because the number of biopsies seen by some subspeicalties do not justify their existence. Didn't WASH U consider doing away with sub specialization?

 

[Over9000]

Are you on the board of directors for Kaiser or even worse Aetna? What's your next suggestion: allow psychiatrists to start taking out people’s gallbladders because they’ll charge less than surgeons?

What this fails to take account is that with the glut of trainees nearly all of whom are fellowship trained (some in multiple), employers can afford to be selective of which specialist they hire to look down the scope because they can be due to supply and demand. So if it’s a race to the bottom to get that contract renewed, might as well load up on the subspecialists to stake your claim or at least so those groups can feel better about themselves. You’re right no one may care who signs out pathology as long as it’s done at a low price point, but they’re not the ones doing the hiring.

Still think we’re headed that way in 5 years? Let’s see how a “generalist” fares who only does a 4 yr AP/CP residency from the University of Puerto Rico without a fellowship…I don’t see them undercutting the Neuropathologists at Stanford, MD Anderson, etc. anytime soon or start doing flow and novel immunophenotyping and replace Jaffe, et al. at the NCI. For that matter, they wouldn’t even stand a chance of getting into a major metropolitan area on either coast and will probably wind up in some podunk hospital in Texarkana, AR if that…

Medicine may be headed in the era of commoditization to an extent, but this ain’t ‘Moneyball’ with Brad Pitt and quality of care and street cred still counts for something before your proposed sabermetrics/Lean method takes over. Besides, weren’t you all about uber-specializing awhile back…?

View attachment 189179

i wish your exertions were correct. the fact that one of my coworkers is a non boarded, non board eligible temporary foreign worker from a third world hellhole who cant even diagnose a polyp would

Are you on the board of directors for Kaiser or even worse Aetna? What's your next suggestion: allow psychiatrists to start taking out people’s gallbladders because they’ll charge less than surgeons?

What this fails to take account is that with the glut of trainees nearly all of whom are fellowship trained (some in multiple), employers can afford to be selective of which specialist they hire to look down the scope because they can be due to supply and demand. So if it’s a race to the bottom to get that contract renewed, might as well load up on the subspecialists to stake your claim or at least so those groups can feel better about themselves. You’re right no one may care who signs out pathology as long as it’s done at a low price point, but they’re not the ones doing the hiring.

Still think we’re headed that way in 5 years? Let’s see how a “generalist” fares who only does a 4 yr AP/CP residency from the University of Puerto Rico without a fellowship…I don’t see them undercutting the Neuropathologists at Stanford, MD Anderson, etc. anytime soon or start doing flow and novel immunophenotyping and replace Jaffe, et al. at the NCI. For that matter, they wouldn’t even stand a chance of getting into a major metropolitan area on either coast and will probably wind up in some podunk hospital in Texarkana, AR if that…

Medicine may be headed in the era of commoditization to an extent, but this ain’t ‘Moneyball’ with Brad Pitt and quality of care and street cred still counts for something before your proposed sabermetrics/Lean method takes over. Besides, weren’t you all about uber-specializing awhile back…?

View attachment 189179

Good to see a megadeth fan on here.

I wish you were right. Quality is lip service. Case in point: one of my colleagues is a non-boarded, non-eligible temporary foreign worker who can't even diagnose a polyp.

 

[coroner]

Good to see a megadeth fan on here.

If I had a colleague who couldn't diagnose a polyp, but listened to Megadeth, I might be willing to overlook that...

 

[Ziehl-Neelsen]

Just like the Pied Piper, led rats through the streets.
We dance like marionettes.
Swaying to the symphony...

I bet Dave Mustaine could diagnose the hell out of a polyp.

 

[gbwillner]

I liked Megadeth... then they got all Jesus-y.

 

[coroner]

That's because Dave Mustaine became a born-again Christian. Plus, their music got worse over the past 20 years (like Metallica)...

Seems like there is a sub-community of metalhead pathologists out there. We should have our own dinner/reception at the next USCAP meeting

 

[gbwillner]

yup, Megadeth died for me after the Youthinasia album.

Metallica still puts out good music though. The 'Death Magnetic' was pretty good and had some great riffs. They had really down years with pretty craptastic albums like 'St. Anger'- just a bunch of noise if you ask me. Must be hard to fathom that not all you put out is gold.

 

[WEBB PINKERTON]

Metallica has been complete crap since the early 90s.

Most people are afraid to put out a good album anymore because Tom Petty will sue claiming you plagiarised his work.

 

[coroner]

yup, Megadeth died for me after the Youthinasia album.

Metallica still puts out good music though. The 'Death Magnetic' was pretty good and had some great riffs. They had really down years with pretty craptastic albums like 'St. Anger'- just a bunch of noise if you ask me...

Check out 'Endgame' by Megadeth from 2009. It was more old school than anything they've put out in the past twenty years and their best effort since 'Countdown To Extinction'.

Metallica has been complete crap since the early 90s.

I agree with gb that 'Death Magnetic' was ok, but the rest of their stuff after the Black Album was crap.

 

[Mace1370]

Pediatric CT Pathology..is that a gag? Im unclear where this is like an April's Fool thing or something.

Haha, this was my initial response. I'm just a resident though, so what do I know?