Fellowship Advice (Surgical Pathology)

[ScubaV]

I am a PGY2 resident thinking about fellowship applications. My career goal is to work in private practice, preferably in a community setting rather than a large lab or pseudo-academic place. To that end I want to do a more generalist type of fellowship. I ruled out hemepath pretty early on, although I know I need to be able to sign out basic/common heme things. And while I don't mind cytology, I'm not passionate about it enough to where I'm willing to be the go-to cytology person in a small-medium group.

That seems to leave surg path plus/minus a second year of some organ system (GI, breast, GYN, etc.) I'd much rather just do one year, but I realize that doing a second fellowship is more and more common. I also know that I learn best by doing, so I want to find a fellowship where I can have as close to independent sign-out as possible. I absolutely do not want to be an observer that watches a national figure sign out zebras. I care much more about my learning experience and post-fellowship confidence than a name brand for my CV even if it does hurt my job search some.

Does anyone know of good surg path fellowships where I can be more independent? I've gotten a few suggestions from attendings at my program, but I'd like to have a larger list to research without having to go program by program. Any other general advice would also be appreciated. Thank you.

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[tiredguy]

The surgical pathology assistants/fellows at Johns Hopkins are extremely independent, as essentially they are junior faculty who are responsible for signing out their own cases, making frozen diagnoses, and taking calls from day #1. These are typically not co-signed reports; you are the attending. I am not sure how many others are structured in a way that allows as much independence but others will chime in.

That being said, what's the market these days for a newly trained pathologist without subspecialty training?

 

[ScubaV]

Yes, that is the big one I've heard most about. I'm a little leery of being thrown into the pool without much of an adjustment period, but if that's what I have to do so be it. As you say, I'm not sure how much it helps my job prospects, but surg path is basically what I want to do in my career. The stuff I like the most is getting a stack with a little bit of everything and just working through it. I do have a personal connection that might help me get a job, and doing surg path at least checks off that I've done some kind of post-residency training. If that falls through, I figure I can do a second fellowship of some kind. I see openings posted all the time.

 

[Tissue issue]

I'd suggest lining up your second fellowship (surg path subspecialty) now. Scrambling and possibly moving is no fun. It seems private and academic departments prefer candidates with both surg path and subspecialty fellowships. Everyone is asking "what's your specialty?" these days. Older folks like me used to be able to say "pathology".

 

[tiredguy]

I think the point of an independent fellowship is to have an adjustment period before you are thrown into the pool. At some point you have to be thrown into the pool.

If you are confident with your general surgical pathology training, are from a program where employers will perceive your general surgical pathology training to be adequate, or have a connection that can guarantee you a job without doing an SP fellowship, then perhaps you can do without it. Maybe it is better to focus on a common subspecialty at which you are weak instead. As Tissue issue states, larger groups may prefer someone who can at least partially cover a subspecialty area. In a smaller group or when colleagues are on vacation, you will likely need to be comfortable in multiple areas (as you mentioned, being able to sign out basic things).

In my experience, many consultations are sent for common entities with diagnostic issues (e.g., is this tumor invasive? can you make a more definitive diagnosis on this limited tissue? is this cancer or not?) rather than zebras, since zebras by nature are rare. So I don't think this is a legitimate concern in most instances. But I suppose in some areas (like soft tissue) you may see more zebras.

 

[coroner]

Wow, tiredguy been a member for nearly 10 years with eight posts...it's like a bigfoot siting

I agree with the above that I would not do a surg path fellowship unless A) you're significantly improving your CV e.g. if you were in residency at the University of Puerto Rico and then went to do a surg path fellowship at Hopkins B) You are already at a well reputed program but want to improve your general abilities.

Since your goal is to work in PP with a small-mid size group, surg path is certainly relevant, but they would probably have more use for boarded subspecialties that are commonly encountered in small groups e.g. Cyto, Heme, Derm. Non-boarded subspecialties come more into play in mid-larger groups because usually they already have the personnel with boards in the aforementioned fields and then it becomes nice to have a go-to person for GI, GU, Breast, etc. That's not to say a Gyn fellowship would exclude you from getting hired by a small group, but they would have more use for you fulfilling the duties in commonly encountered fields that are board-certifiable. That being said, I know of some private pathologists who think that groups that need to hire someone with a GI fellowship are *****s because these private pathologists look at so many GI bxs on a regular basis than any academic does in a given year. Not to mention they didn't even exist as fellowships 30+ years ago.

But since you don't want to do cyto or heme, I would consider derm before the other subspecialty organ systems for the sake of marketability. Unless you happen to really be passionate about one of them in particular. But it seems based on your post you are emphasizing employability over personal interests. The other boarded subspecilaties Peds, Neuro, Molecular, etc. aren't going to be useful in the setting of small-mid sized private groups. If none of these pan out, or interest you, then I would go for surg path at the most well known/reputable program that you can get into even if you're already a resident there.