Pathology career questions from a misguided radiology resident.

[TimeOptimization]

Hi path board, long time lurker first time poster, thank you for your time in advance.

I'm currently a PGY-2 radiology resident (first year rads) considering a change of pace, and wanted to learn a little more about day to day pathology as a resident / fellow / attending. I sincerely enjoyed my path rotations as a MS4, and it was a close second while applying for the match. I'm an AMG currently at a decent rads program, step 1/2/3 mid 230s.

1. What is volume like in the world of pathology? In my radiology experience, it seems volume and speed are king. Every moment not spend dictating and pre-liming reports is "wasted time." Generally speaking I have little time to look up patient history, fully evaluate the study, or learn more about the disease state I'm calling. I see this time debt magnified in higher level residents, fellows, and attendings. Is the experience similar in path?

2. What kind of impact does pathology have? Not that I went into medicine to make a difference, but it seems the majority of content within most of my rads report is more focused toward avoiding litigation than actually saying something relevant. The usefulness of my reports for clinicians seems very limited. Do pathology reports convey relevant findings to clinicians?

3. Are you still able (enough time) and willing to explore your medical curiosities in pathology?

4. What is clinical interaction like in pathology? Not to be too blunt, but I'd rather not see patients at all. I had the impression radiologists had a similar amount of patient interaction as path, but most rads spend an unfortunate amount of their day doing biopsy / drainage / arthrogram /ultrasound / flouro / IR / other garbage. I'd neither care to perform procedures nor see living patients during them. Is path actually exempt from living patient contract?

5. What is call like? As much as I enjoy learning about disease entities and being productive at work, I also enjoy other aspects of life in moderation as well. Are pathologists able to strike a balance between working and living their lives?


TLDR: In the world of path, what is volume, report impact, continued education and clinical interaction like?


Thanks!

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[ScubaV]

I'm a pathology resident at a low-mid tier hybrid academic/private program. I've also rotated at a big name academic program. The answers to most of these questions depends somewhat on the practice environment you are in. In general, big academic places are going to be lower volume and subspecialized with time set aside for mandatory teaching and research. Small community private practice (a dying breed) also seems to be lower volume, but very generalized and without the teaching and research. Larger private practice is high volume, may or may not be subspecialized, and does not have teaching or research. Most of my experience is as a resident, but I also have a family member who works in a small private practice.

1) Volume is what you make it. As an attending you will get a certain number of cases per day that have to be signed out in 1-2 business days, excepting those that are sent out or need ancillary studies. How and when you tackle them is generally up to the individual. An attending who is experienced and efficient can sign out in a couple hours the same volume that takes another the entire two working days because they dilly-dally, lack self-confidence and re-re-re-review slides, or waste time for whatever reason. As a resident, especially early on, you usually only get a fraction of the cases the attending does and can spend time (and are expected to) looking things up.

2) With rare exceptions, the tissue diagnosis is considered the gold standard and with the help of ancillary studies like immunohistochemistry, FISH, and molecular analysis provides the "final" answer. That said, clinicians often have a very good idea of what they are dealing with and are mostly looking for confirmation or getting details like subtype/grade/stage. We still heavily rely on patient history and radiology especially in areas like frozen section diagnosis. The phrase "garbage in, garbage out" comes up a lot. And like the rest of medicine, we are litigation conscious and will use phrases like "consistent with", "cannot exclude", or everyone's favorite "clinical correlation recommended", sometimes even when we are fairly confident.

3) Generally yes, see #1.

4) You can see patients during cytology procedures (if you are at a place where radiology/clinicians don't do them all) or in blood bank. Also, in some areas of the country pathologists will do bone marrow biopsies instead of the clinicians. But interaction with live patients is extremely limited. Autopsies on the other hand...

5) Call depends heavily on the program. But I believe most pathology programs do home call rather than in-house. Things like critical lab values and blood bank questions can be answered by phone and you usually only have to come in for after-hours frozens and weekend autopsies.

 

[veo1]

The job market is great!

Check out this position on pathologyoutlines:

http://pathologyoutlines.com/jobs.html#5027

"No calls will be accepted regarding this position.
Due to the amount of resumes received, we will only be able to contact eligible candidates."

You can't make this stuff up. I like the bold font they used. I'm sure this position was posted and they edited the initial listing after getting swamped with CVs.

Information about benefits, practice setting, location are conspicuously absent. Bust rest assured "The position has potential for medical directorship and other advancement"...whatever that means. Other advancement. Ha!

 

[LADoc00]

This almost feels like the Rads forum has sent someone over to mock us and report back. No one fall for this.

 

[Over9000]

The rads residents see the really cush hours of the path residents. The no call, no nights, no weekends. The high amount of sitting, and discussing, and eating. It all looks very nice from the outside.

What they don't see is how cush unemployment can be. Going into pathology is a good way to achieve that.

 

[TimeOptimization]

I really appreciate the straightforward response SubaV, thank you for making time.

LADoc, your contributions continue to be a mainstay of the path forums.

Just wanted to hear a bit more about the day to day. From what my seniors and the interweb tell me, the rads market is moving in a similar direction, but most rad graduates these days are only required to do 1 fellowship to find a bad job. They aren't quite in the dire position path appears to be.

What they don't see is how cush unemployment can be. Going into pathology is a good way to achieve that.

Point taken. Maybe I can do unemployment without all the training. From my standing, no desire for spouse/child/mortgage/travel, I make more than enough money as a resident to live my life. Perhaps I can just do fellowships until I die? Ahaha.

I suppose I'm wondering out-loud if path is better than night stocking in retail, or slinging coffee at starbucks, because those are about all I'm qualified for outside of rads/path. They sure beat clinical medicine.

 

[Ziehl-Neelsen]

Sounds like you want a Quest/Labcorp off-site slide mill job where they hand you your 5 flats of slides per day and you retire to your cubicle and sign them out. Turn-around time is king and there is no time to to indulge medical curiosity and work through an interstitial lung disease or a complicated medical liver biopsy when you have 2 mastectomies, 4 twelve part prostate biopsies, and a mountain of paps to get through. I had an ex-colleague who worked in one of these slide mill practices and was approached by the medical director after he had ordered a second round of stains on a difficult case who flatly told him to sign the case out as pending consultation and send it to Mayo as work-up of complex cases hurt TAT. And as reimbursement for anatomic pathology specimens continues to be cut, volume will have to increase to maintain salary. Plus, when your utility to an employer consists of being a semi-autonomous glass-pusher in a cubicle, it's only a matter of time before employers can find somebody who will push the same volume for less.

There is no call at a slide mill, but you'll be in on occasional Saturdays to gross or sign out because TAT is king. The same ex-colleague said he was in on weekends frequently because there was no other way to manage the volume.

Radiology sucks. There are few things more gratifying than completely blowing a radiologist's differential diagnosis out of the water with a tissue diagnosis. Outside of people who are really into procedures and want to go into IR and the physics nerds who love that part of radiology, I don't know how anybody could objectively find radiology to be a more intellectually stimulating specialty than pathology. The trade-off (IMO) has always been the better monetary compensation and job prospects offered for staff radiology positions.


It seems that most of your desires could be met by a nighthawk tele-radiology position. Or a trucker: solitude, books on tape, government-mandated 8 hour workdays, the beauty of America on display with each new day...

 

[Kilgoretrout 65]

Or a trucker: solitude, books on tape, government-mandated 8 hour workdays, the beauty of America on display with each new day...

I missed my calling. But, alas, I can't even back my Expedition into a spot in the garage without the back up camera.

 

[DrBowtie]

Hi path board, long time lurker first time poster, thank you for your time in advance.

I'm currently a PGY-2 radiology resident (first year rads) considering a change of pace, and wanted to learn a little more about day to day pathology as a resident / fellow / attending. I sincerely enjoyed my path rotations as a MS4, and it was a close second while applying for the match. I'm an AMG currently at a decent rads program, step 1/2/3 mid 230s.

1. What is volume like in the world of pathology? In my radiology experience, it seems volume and speed are king. Every moment not spend dictating and pre-liming reports is "wasted time." Generally speaking I have little time to look up patient history, fully evaluate the study, or learn more about the disease state I'm calling. I see this time debt magnified in higher level residents, fellows, and attendings. Is the experience similar in path?

2. What kind of impact does pathology have? Not that I went into medicine to make a difference, but it seems the majority of content within most of my rads report is more focused toward avoiding litigation than actually saying something relevant. The usefulness of my reports for clinicians seems very limited. Do pathology reports convey relevant findings to clinicians?

3. Are you still able (enough time) and willing to explore your medical curiosities in pathology?

4. What is clinical interaction like in pathology? Not to be too blunt, but I'd rather not see patients at all. I had the impression radiologists had a similar amount of patient interaction as path, but most rads spend an unfortunate amount of their day doing biopsy / drainage / arthrogram /ultrasound / flouro / IR / other garbage. I'd neither care to perform procedures nor see living patients during them. Is path actually exempt from living patient contract?

5. What is call like? As much as I enjoy learning about disease entities and being productive at work, I also enjoy other aspects of life in moderation as well. Are pathologists able to strike a balance between working and living their lives?


TLDR: In the world of path, what is volume, report impact, continued education and clinical interaction like?


Thanks!

Sounds like Rads isn't for you but your program isn't doing you any favors. A first year resident shouldn't be forced to crank the list. You don't know enough and you can't find what you don't know.

 

[Adloquium]

Hi path board, long time lurker first time poster, thank you for your time in advance.

I'm currently a PGY-2 radiology resident (first year rads) considering a change of pace, and wanted to learn a little more about day to day pathology as a resident / fellow / attending. I sincerely enjoyed my path rotations as a MS4, and it was a close second while applying for the match. I'm an AMG currently at a decent rads program, step 1/2/3 mid 230s.

1. What is volume like in the world of pathology? In my radiology experience, it seems volume and speed are king. Every moment not spend dictating and pre-liming reports is "wasted time." Generally speaking I have little time to look up patient history, fully evaluate the study, or learn more about the disease state I'm calling. I see this time debt magnified in higher level residents, fellows, and attendings. Is the experience similar in path?

2. What kind of impact does pathology have? Not that I went into medicine to make a difference, but it seems the majority of content within most of my rads report is more focused toward avoiding litigation than actually saying something relevant. The usefulness of my reports for clinicians seems very limited. Do pathology reports convey relevant findings to clinicians?

3. Are you still able (enough time) and willing to explore your medical curiosities in pathology?

4. What is clinical interaction like in pathology? Not to be too blunt, but I'd rather not see patients at all. I had the impression radiologists had a similar amount of patient interaction as path, but most rads spend an unfortunate amount of their day doing biopsy / drainage / arthrogram /ultrasound / flouro / IR / other garbage. I'd neither care to perform procedures nor see living patients during them. Is path actually exempt from living patient contract?

5. What is call like? As much as I enjoy learning about disease entities and being productive at work, I also enjoy other aspects of life in moderation as well. Are pathologists able to strike a balance between working and living their lives?


TLDR: In the world of path, what is volume, report impact, continued education and clinical interaction like?


Thanks!

Yo. I'll been through a similar struggle back in med school, but I chose the Path route. You sound similar to a friend of mine who also struggled with the similar decision, but chose another route. I am one of the most misanthropic and cynical people I know and I hate clinical medicine with a passion. For me, Path was the right decision. I also did all Path rotations in med school and it definitely doesn't give get an accurate idea of what residents and attendings actually do or what the job market is like. I can't give you a perfectly accurate description on what it is like to be an attending, but I can give you my perspective of what I see so far.

My program is considered one of the "top" programs and is known for its high volume and infamously known for the long hours residents put in. The long hours are typically relegated to the surg path rotations in the 1st year (because everyone doesn't know what the f**k they are doing) and some heavy surg path rotations in the 2nd year. However, most of the year my hours are probably 8 am to 6 pm. Some rotations have even better hours than that. Path is somewhat similar to Rads in that volume and turn-around time is king. However, once you are done with your work, you leave...go home... play with your cat. There were a few rotations (usually the super heavy surg path rotations at my institution) where the volume was so high and my time was so pressed that I want to commit seppuku. However, now that I have learned to be more efficient, I have sufficient free time in the day to browse Reddit or other various unproductive shenanigans.

The only times I saw live patients was during my Cytology rotation. I go to evaluate the adequacy of a sample or perform an FNA. The latter does require verbal communication of some kind. However, it's mainly to get consent, do a time-out, and perform the procedure. Once, your sample is adequate, you can safely return to your bubble to recharge from that taxing interaction.

My main human interaction is with other physicians or healthcare people. That is usually done over the phone where I can avoid touching them or pretending like I enjoy eye contact. On rare occasions, the clinical team wanders into the Path department to review slides with us. If I can usually hold it together without having a conniption, then I assume you should be just fine with that level of human interaction.

On my AP rotations so far, I have never had be on true call. I'll start call on my transfusion med rotation and probably that's the only rotation I can think of that what most people who truly consider call (as in get out of the bed and dragging yourself into the hospital).

The Path report does hold a lot of weight with the clinician. For example, the interpretation of a histologic interpretation of a skin biopsy with a clinical impression of mycosis fungoides versus drug hypersensitivity is quite important. We do try to be defensive with our diagnostic wording especially if its complicated case with equivocal findings. However, even if our final diagnostic line could be "high grade malignant neoplasm," we usually give a microscopic description talking about our findings and our likely diagnoses.

As far as the job market, all of our recent residents (who also completed a fellowship or two) have gotten jobs and are satisfied with their geographic location. It's quite true that the "good" jobs aren't really advertised. I think a vast majority of jobs that were obtained in my program were due to the attending knowing somebody who was hiring or former upperclassmen residents being aware of an opening at their place of work. A few fellows (who weren't trained in our residency program) had a tough time finding a job, but they either had strict criteria for their job search (i.e. a very strict location) or had personality disorders. There was one former fellow who was borderline antisocial who managed to get a decent job. I'm still figuring this area out myself so I can't accurately assess what it is like as a practicing Pathologist. Talking to some former senior residents who are in private practice, they did say the volume was quite heavy and a few did still do some grossing once in a while.

Path is so broad that it's hard to find something not to enjoy learning about. That said...there are also subjects in Path that you will learn to not like so much. For example, I want Gyn Path to be set on fire.

Hopefully that helped answer some of your questions. It's late night and I'm a bit delirious, so please excuse the grammatical errors.

 

[petrina]

OP I feel like you are me. I'm a PGY1 resident in Rads and feeling like I made a mistake in choosing residencies. I considered path but ended up matching to rads. The one thing I've realized more clearly in residency so far that I didn't fully appreciate before is the intensity of call and the 24/7 demand for studies. I've also realized I don't like some of the acuity and need for urgent reports at all hours of the day.

Anyone else have stories to add about life and call in residency and beyond

 

[bochaw]

Hi. I'm in the middle of choosing my residency now. And path is my first choice. My second choice is IM.
So do you regret of choosing pathologist?How is the quality of life compared to clinical medicine that interact with patient like IM?Please give honest answer. Thanks . lol
My reason to choose path is because I like doing research and most important.... don't like to be called at night..How do you think huh?

 

[Over9000]

Hi. I'm in the middle of choosing my residency now. And path is my first choice. My second choice is IM.
So do you regret of choosing pathologist?How is the quality of life compared to clinical medicine that interact with patient like IM?Please give honest answer. Thanks . lol
My reason to choose path is because I like doing research and most important.... don't like to be called at night..How do you think huh?

Do IM. More freedom.

 

[coroner]

Hi. I'm in the middle of choosing my residency now. And path is my first choice. My second choice is IM.
So do you regret of choosing pathologist?How is the quality of life compared to clinical medicine that interact with patient like IM?Please give honest answer. Thanks . lol
My reason to choose path is because I like doing research and most important.... don't like to be called at night..How do you think huh?

The good news if you go into Path is that you won't have to talk to patients and your English will be about as good as your colleagues...

 

[bochaw]

haha one pathol, one IM

 

[VenuSN]

The path job market I heard is poor these days.
The IM job market not at all. Besides, there are plenty of fellowships you can follow that could offer you more flexibility in choosing where to practice.

Path isn't about physician-patient interaction.
IM is all about that interaction. So it depends on your preferences, as well.

 

[bochaw]

@VenuSN and the salary is higher for IM too i think..lol
Which one is more competitive ?

If I don't get any job after finishing my residency as a pathologist, are there any other country that acknowledge my degree?

 

[yaah]

I would be very cautious about using the potential (underline potential because things change over the multiyear period of residency) job market as a significant factor for your specialty choice. Sure, it matters. But it doesn't matter as much as being in a career you hate or love. Remember that the thing about jobs in pathology is that this is still a relative thing. This is not like graduating from law school and trying to find a job. Actual unemployed status among pathologists is quite low, and most of that is by choice. Many graduates have to take jobs that either are in an area they wouldn't prefer, or are the type of job they wouldn't prefer. Typically not both at the same time. This is part of the reason why many new hires leave their job within the first few years of starting - because one opens up where they really want to be. So yes, there is doom and gloom and all that, but yet most other professions in this country would love to have this status.

Income is declining. Reimbursement continues to fall. I don't know the specifics of other specialties, but it's probably similar. Although the trends may be a bit more magnified in pathology.

Volume totally depends on your work environment. I work in a private large hospital lab. We are not hospital employees, we are contracted. This presents some uncertainty of course. I see a wide variety of things. I see cases every day. I don't have days off for "research" or whatever like in academics. I see surgicals every day which can range up to 200 slide equivalents (one case can be one slide or up to 30-40 slides rarely). Some days it's half that. I direct two offsite labs. I sit on several committees and meet frequently with clinicians and other administrators in addition to lab people. I do CP stuff including the lab direction and some heme and immunology stuff. Call involves staying late to cover frozens (late frozens happen a couple times a week, sometimes having to drive to a smaller offsite facility). Call also involves pages about lab issues, blood bank, new leukemias, unlabeled specimens, critical values that the ordering physician is not retrieving. Call is humane. We take call a week at a time, I typically only get woken up in the middle of the night 2-3 nights. On saturdays when I am on call I am at work for 2-3 hours. That's it unless there's a frozen.

Path is not about physician-patient interaction but it definitely involves physician-physician interaction. This can run the gamut. The vast majority of interactions are respectful, colleague to colleague. Occasional interactions are unpleasant, either because what you're telling the MD is a problem (i.e. we lost your sample) or it's because the MD is an dingus.

Pathology is hugely important for clinicians. You said a lot of rads reports seem to be aimed at minimizing litigation, but that isn't accurate. Radiology reports are hugely important to clinicians. The pathology report is often, however, considered the definitive diagnosis on whatever is wrong for the patient, so you have to get it right. There is a lot of pressure there. You learn how to hold the line between being definitive when the findings are there and not being definitive when they aren't (even when clinicians pressure you). It very much helps to work in a group with competent and respectful colleagues who can guide you through the early years of your training as well as be there to discuss and show challenging cases.

Pathology is changing with the increasing bloat of hospital administration. Administrators have higher expectations and want to do more things, some of which MDs are not trained to understand or deal with. Another reason to hitch yourself to a competent group.

 

[Thaitanium]

I would be very cautious about using the potential (underline potential because things change over the multiyear period of residency) job market as a significant factor for your specialty choice. Sure, it matters. But it doesn't matter as much as being in a career you hate or love. Remember that the thing about jobs in pathology is that this is still a relative thing. This is not like graduating from law school and trying to find a job. Actual unemployed status among pathologists is quite low, and most of that is by choice. Many graduates have to take jobs that either are in an area they wouldn't prefer, or are the type of job they wouldn't prefer. Typically not both at the same time. This is part of the reason why many new hires leave their job within the first few years of starting - because one opens up where they really want to be. So yes, there is doom and gloom and all that, but yet most other professions in this country would love to have this status.

Income is declining. Reimbursement continues to fall. I don't know the specifics of other specialties, but it's probably similar. Although the trends may be a bit more magnified in pathology.

Volume totally depends on your work environment. I work in a private large hospital lab. We are not hospital employees, we are contracted. This presents some uncertainty of course. I see a wide variety of things. I see cases every day. I don't have days off for "research" or whatever like in academics. I see surgicals every day which can range up to 200 slide equivalents (one case can be one slide or up to 30-40 slides rarely). Some days it's half that. I direct two offsite labs. I sit on several committees and meet frequently with clinicians and other administrators in addition to lab people. I do CP stuff including the lab direction and some heme and immunology stuff. Call involves staying late to cover frozens (late frozens happen a couple times a week, sometimes having to drive to a smaller offsite facility). Call also involves pages about lab issues, blood bank, new leukemias, unlabeled specimens, critical values that the ordering physician is not retrieving. Call is humane. We take call a week at a time, I typically only get woken up in the middle of the night 2-3 nights. On saturdays when I am on call I am at work for 2-3 hours. That's it unless there's a frozen.

Path is not about physician-patient interaction but it definitely involves physician-physician interaction. This can run the gamut. The vast majority of interactions are respectful, colleague to colleague. Occasional interactions are unpleasant, either because what you're telling the MD is a problem (i.e. we lost your sample) or it's because the MD is an dingus.

Pathology is hugely important for clinicians. You said a lot of rads reports seem to be aimed at minimizing litigation, but that isn't accurate. Radiology reports are hugely important to clinicians. The pathology report is often, however, considered the definitive diagnosis on whatever is wrong for the patient, so you have to get it right. There is a lot of pressure there. You learn how to hold the line between being definitive when the findings are there and not being definitive when they aren't (even when clinicians pressure you). It very much helps to work in a group with competent and respectful colleagues who can guide you through the early years of your training as well as be there to discuss and show challenging cases.

Pathology is changing with the increasing bloat of hospital administration. Administrators have higher expectations and want to do more things, some of which MDs are not trained to understand or deal with. Another reason to hitch yourself to a competent group.

Sounds like you are in a good group. When you talk about administrators having higher expectations and wanting to do more things, what exactly are you talking about?

Thanks for your input.

 

[Silent Cool]

You can do it:

 

[coat0023]

Not in radiology myself, but I'm a prelim internal medicine intern who matched into another field and I'm strongly considering voiding my contract to apply to path next year. I was really waffling last year when I applied and I'm starting to think that I chose poorly going with hands on clinical medicine. The hard part is differentiating this from the standard intern slump.

 

[yaah]

Sounds like you are in a good group. When you talk about administrators having higher expectations and wanting to do more things, what exactly are you talking about?

Thanks for your input.

Administrators want more and more control of thing, including things that previously were the domain of physicians. They are proliferating with rabbits and all of them need something to do and oversee and committees to run. A lot of physicians get fed up and disengage. So then administrators start doing more of the things physicians use to do. Committees, quality stuff, safety issues. Part of it is just conforming to regulations which have become more complicated so you almost need a full time job to understand them. And then they start paying physicians less. Vicious cycle.