Pathology is the world's most civilized residency

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Vistaril is only here to troll because he hates psychiatry and his fiance cheated on him with a pathologist and left. Don't feed the troll.

Members don't see this ad.
 
No matter what specialty you do, as soon as you leave training and magically gain attending powers it's a lot more nerve-wracking. Safety net removed and all that. Most of my med school classmates are newly fledged attendings and every single one of them feels this anxiety. In surgery it's a big, big, big deal to start taking people to the OR by yourself. In OB, my friends spent all of their first nights staring at perfectly normal labor tracings, terrified that they were missing a tanking baby. Hospitalists- same, should they order a billion unnecessary tests/imaging that a month ago in residency they would have scoffed at, just in case they're overlooking something?

The big difference for path, as far as I can tell, is that no one can second-guess your work. Even radiology-- anybody can pull up the imaging themselves and look it over. Active patient management of any type-- you see the hospital chart, the labs, the vitals, you can make guesses as to what's going on. Who can second-guess path? Who can get access to the slides and look them over? Who can run molecular tests or antibody screens or whatever? Everyone has to just accept that we say, full-stop. And that's a responsibility unique in medicine.
 
  • Like
Reactions: 1 users
Anything is better than a surgery residency.

For people who are constitutionally wired to be surgeons, surgery residency is great. You have to be very concrete, very literal, very decisive, and enjoy the idea of repetition to the point of perfection.

The reason I think path is so much better is not just because of hours, it's because the workflow is so much more intelligent and interesting.
 
Members don't see this ad :)
For people who are constitutionally wired to be surgeons, surgery residency is great. You have to be very concrete, very literal, very decisive, and enjoy the idea of repetition to the point of perfection.

The reason I think path is so much better is not just because of hours, it's because the workflow is so much more intelligent and interesting.
I also think you also have to have the fortitude to withstand the surgical personality - i.e. your typical General Surgery resident.

Pathologists (IMHO) - just seem nicer, more relaxed, etc. It truly is field in which the education to service ratio is quite high just by the very nature of it. There are also great Pathology programs (you can tell a lot just by looking at their websites) out there that are great. Not to mention as you said, your input is respected. No one trying to read your slides, the way every IM and Surgery doc thinks they're radiologists.
 
  • Like
Reactions: 1 users
We'll as a clinical resident you weren't being trained to do something where you would be completely dependent on others.....so there is that. He who controls the tissue controls the world.....
You realize clinical residents are dependent on others right?
 
It's hard to take someone to the OR without a pre-op diagnosis (radiology, pathology), intra-op help (anesthesia, nursing), post-op care (an ICU with intensivists, consultants, CCRNs), a ward team, a post-op diagnosis (radiology, pathology), etc...
 
I also think you also have to have the fortitude to withstand the surgical personality - i.e. your typical General Surgery resident.

Pathologists (IMHO) - just seem nicer, more relaxed, etc. It truly is field in which the education to service ratio is quite high just by the very nature of it. There are also great Pathology programs (you can tell a lot just by looking at their websites) out there that are great. Not to mention as you said, your input is respected. No one trying to read your slides, the way every IM and Surgery doc thinks they're radiologists.

It happens a little bit though. I have seen hematologists look at marrows or smears and think they know better than the pathologist. Same thing with nephrologists and medical kidney biopsies. I hate to say it but in rare cases they may be right, if it's a pathologist without the right training.
 
It happens a little bit though. I have seen hematologists look at marrows or smears and think they know better than the pathologist. Same thing with nephrologists and medical kidney biopsies. I hate to say it but in rare cases they may be right, if it's a pathologist without the right training.
I guess it depends on the hematologist. Surprised with nephrologists though as I imagine it's rare to get a kidney biopsy. I think also right training unfortunately highly depends on the quality of the Pathology program in question. Unfortunately, Path is a residency that requires very good faculty who see residents as trainees and not nuisances. It's quite difficult to "self-study" Pathology.
 
Pathologists (IMHO) - just seem nicer, more relaxed, etc. It truly is field in which the education to service ratio is quite high just by the very nature of it. There are also great Pathology programs (you can tell a lot just by looking at their websites) out there that are great. Not to mention as you said, your input is respected. No one trying to read your slides, the way every IM and Surgery doc thinks they're radiologists.

It depends on what program you are in and your institution. If you are at an institution with a very heavy volume, and overworked attendings, PA's, histotechs, even residents (esp. if they are grossing until late at night), the education to service ratio becomes lower. Not because anyone intentionally doesn't want to teach or learn, but because everyone is too busy trying to keep pace with the load. I'm sure there are places out there that are 9 to 5 with nice pathologists who teach all the time, but it's not across the board same in every Pathology program. Also, i'm not sure how much pathology input is appreciated - sometimes I see the attendings getting frustrated because the clinician disagrees with the diagnosis/interpretation, or doesn't care to listen (not all the time of course). In renal and in heme, we do have clinicians who try to interpret the slides they send us.
 
It depends on what program you are in and your institution. If you are at an institution with a very heavy volume, and overworked attendings, PA's, histotechs, even residents (esp. if they are grossing until late at night), the education to service ratio becomes lower. Not because anyone intentionally doesn't want to teach or learn, but because everyone is too busy trying to keep pace with the load. I'm sure there are places out there that are 9 to 5 with nice pathologists who teach all the time, but it's not across the board same in every Pathology program. Also, i'm not sure how much pathology input is appreciated - sometimes I see the attendings getting frustrated because the clinician disagrees with the diagnosis/interpretation, or doesn't care to listen (not all the time of course). In renal and in heme, we do have clinicians who try to interpret the slides they send us.
Yes, there are certain programs that come to mind that are grossing workhorse programs - many of them with no fellowship programs. There are also some great programs - but are ridiculously high volume as well, so teaching just can't happen all the time, just based on the volume alone. But in Path, once you interpret it, it's your interpretation. The clinician can do what he sees fit with it afterwards. That's what is key. It's not like you're a clinical intern and you've consulted Cards and Renal on a patient and now have to find an overarching tx plan that is amenable to both consultants who see things thru their own organ system.
 
The big difference for path, as far as I can tell, is that no one can second-guess your work. Even radiology-- anybody can pull up the imaging themselves and look it over. Active patient management of any type-- you see the hospital chart, the labs, the vitals, you can make guesses as to what's going on. Who can second-guess path? Who can get access to the slides and look them over? Who can run molecular tests or antibody screens or whatever? Everyone has to just accept that we say, full-stop. And that's a responsibility unique in medicine.

Diagnoses get second guessed all the time, but not in the same way. I get clinicians calling me or coming by a lot when things don't make sense (the metastatic colon cancer forming a penile mass in a patient with no known history of colon cancer takes the cake for that one). You can head this off in many cases with preemptory phone calls when you know it's a discrepancy or it's not making sense. But every now and then you will get second guessed without anyone talking to you, usually the patient, and the slides get sent off somewhere else for another opinion. As a pathologist you sort of have to live with the fact that your diagnoses can be questioned at any time for any real reason, and part of the problem is that people can't just "see" it, like they do on imaging. You can't usually argue with a 15 cm lung mass on imaging. You can argue about what it is though. And since people and many other physicians don't have a great understanding of how we make our diagnoses it can be harder to explain it sometimes.

I have had mistakes caught by clinicians second guessing me - usually this is by providing history that they neglected to provide before, or correcting something in the history that was there incorrectly.
 
It happens a little bit though. I have seen hematologists look at marrows or smears and think they know better than the pathologist. Same thing with nephrologists and medical kidney biopsies. I hate to say it but in rare cases they may be right, if it's a pathologist without the right training.
I have RARELY seen this but when I say "would you like your name on the report" they look at me like I have a banana for a nose.
 
  • Like
Reactions: 1 user
Diagnoses get second guessed all the time, but not in the same way. I get clinicians calling me or coming by a lot when things don't make sense (the metastatic colon cancer forming a penile mass in a patient with no known history of colon cancer takes the cake for that one). You can head this off in many cases with preemptory phone calls when you know it's a discrepancy or it's not making sense. But every now and then you will get second guessed without anyone talking to you, usually the patient, and the slides get sent off somewhere else for another opinion. As a pathologist you sort of have to live with the fact that your diagnoses can be questioned at any time for any real reason, and part of the problem is that people can't just "see" it, like they do on imaging. You can't usually argue with a 15 cm lung mass on imaging. You can argue about what it is though. And since people and many other physicians don't have a great understanding of how we make our diagnoses it can be harder to explain it sometimes.

"I have had mistakes caught by clinicians second guessing me - usually this is by providing history that they neglected to provide before, or correcting something in the history that was there incorrectly".
This happens too much.
 
Members don't see this ad :)
It does but there are some patients who just have the mindset that they are the ones who know more about their condition than anyone else, and that something is "being missed." So I don't get worked up about it, it's their health after all. Especially if they are paying for it. I do get a little disappointed when I see a request to send the slides somewhere shady though. Something I thought we would have to deal with more but don't end up seeing very often is patients requesting some sort of bizarre or esoteric test on their tumor. I very rarely get requests for ploidy analysis (which has no real benefit) on prostate cancers, or some other low-utility tests.
 
Pathology residency is almost too civilized. Many come out knowing nothing.

A clinical year, focusing on oncologic services, not a scut-year of ward medicine, would be welcome.

Graduated independent sign-out responsibilities in the final year of training, and dropping all of CP except for heme, would be good too.

Finally, and this is a long shot, but incorporating in-vivo micro procedures, including their acquisition, would be the most game-changing modification.
 
Pathology residency is almost too civilized. Many come out knowing nothing.

A clinical year, focusing on oncologic services, not a scut-year of ward medicine, would be welcome.

Graduated independent sign-out responsibilities in the final year of training, and dropping all of CP except for heme, would be good too.

Finally, and this is a long shot, but incorporating in-vivo micro procedures, including their acquisition, would be the most game-changing modification.

The idea that residents graduate knowing nothing is truly a time-honored idea that transcends the traditional boundaries between clinical specialties.
 
  • Like
Reactions: 1 user
The idea that residents graduate knowing nothing is truly a time-honored idea that transcends the traditional boundaries between clinical specialties.

I agree. Absolutely ridiculous. It shouldn't be that way.

We perpetuate it with outdated training (50 autopsies, CP instead of comprehensive AP training, graduated independence and upcoming modalities), a proliferation of inadequate training programs (Kendall, FL is the newest offender), and an overabundance of "warm bodies".

I remember reading applications from residents who were at low-end training programs (think Albany or any of those sketchy NY programs) trying to switch into mine because their program was 100% grossing with no preview time or teaching.

Pathology is so off-the-cuff as far as medical specialties go that oversight is probably difficult. Most of the GME executives who evaluate programs aren't pathologists, so I bet they take the word of whichever pathologist they ask as to whether a program is acceptable or not.
 
Last edited:
Diagnoses get second guessed all the time, but not in the same way. I get clinicians calling me or coming by a lot when things don't make sense (the metastatic colon cancer forming a penile mass in a patient with no known history of colon cancer takes the cake for that one). You can head this off in many cases with preemptory phone calls when you know it's a discrepancy or it's not making sense. But every now and then you will get second guessed without anyone talking to you, usually the patient, and the slides get sent off somewhere else for another opinion. As a pathologist you sort of have to live with the fact that your diagnoses can be questioned at any time for any real reason, and part of the problem is that people can't just "see" it, like they do on imaging. You can't usually argue with a 15 cm lung mass on imaging. You can argue about what it is though. And since people and many other physicians don't have a great understanding of how we make our diagnoses it can be harder to explain it sometimes.

I have had mistakes caught by clinicians second guessing me - usually this is by providing history that they neglected to provide before, or correcting something in the history that was there incorrectly.
The main difference between us and academics is that they are less likely to get their cases sent out and if you are Elaine jaffe or Robert young or Travis or Jean Simpson or Sharon Weiss if someone else disagrees with you or even if you are flat out wrong, you are still right, no matter what.
 
  • Like
Reactions: 1 user
The main difference between us and academics is that they are less likely to get their cases sent out and if you are Elaine jaffe or Robert young or Travis or Jean Simpson or Sharon Weiss if someone else disagrees with you or even if you are flat out wrong, you are still right, no matter what.

We have a saying in my department: In every other medical specialty they practice evidence-based medicine. In pathology we practice eminence-based medicine.

My favorite pathology reports are the ones where a difficult case has been sent to multiple big names who have diverging opinions on a given entity and proceed to fight a proxy-war against each other by launching thinly veiled attacks against the alternate interpretation/classification system in the comments.

And as far as the most civilized residency thing goes... For the naturally inquisitive polymath who harbors a touch of misanthropy but is not on the autism spectrum, pathology residency is generally great (other than being wrong all the time). But residents are shielded from nasty parts of pathology. You pay the piper as a staff. SOP reviews, QA meetings, instrument validations, blood utilization reviews, techs who don't show up for work/do crappy work/harass other techs/lose specimens, clinicians using instruments in non-FDA approved settings without your knowledge, clinicians telling you what stains they want ordered... The list of little slights is endless, and it makes me yearn for a 3 hour block of time when I can shut my door, listen to some Schubert, and push some glass--which ironically was virtually every day as a resident.
 
  • Like
Reactions: 3 users
And as far as the most civilized residency thing goes... For the naturally inquisitive polymath who harbors a touch of misanthropy but is not on the autism spectrum, pathology residency is generally great (other than being wrong all the time).

Genius.

Also again, the downsides to pathology you mentioned well transcend specialty boundaries. Incompetent clinical staff (nurses occasionally but more frequently MAs and the like), incompetent ancillary services, tests that get lost, critical results you never found out about, committees, billing reviews, 'eat what you kill,' reimbursement, patient noncompliance that you end up being on the hook for, being called in to fix another specialty's gross mismanagement... it goes on, ad infinitum. It's why work is work and not compensated voluntary leisure time, you know?
 
  • Like
Reactions: 1 user
You pay the piper as a staff.
Yes, but at varying degrees depending on where one ends up...
SOP reviews, QA meetings, instrument validations,
Reviews and meetings for this stuff is overkill. Sign off on SOP manuals so you're good to go for any inspections/re-accreditations for the next year. QA can be reviewed and signed off as well, no need for meetings. Instrument validations...let the lab manager or team leader in chem handle it, that's what they're paid for.
blood utilization reviews
Again institution dependent if you're in academics or a really anal retentive hospital. Sometimes medical records departments will have more patients to "randomly" review who were out of range for blood bank products. This has to be done by the medical director per AABB guidelines, but most private groups usually designate the blood banker to do it, or they rotate that admin type stuff so each partner only does it once every couple of months.
techs who don't show up for work/do crappy work/harass other techs/lose specimens
This is pretty unavoidable, e.g. so-and-so called in sick slides and histo is down a tech...slides are out late, or the fume hood just got cleaned and slides are drying out faster and getting air bubbles so everything has to be re-cover slipped, or so-and-so accidentally put the Scott's water out of order in the stainer and the slides are streaky this morning, the list goes on...
clinicians telling you what stains they want ordered...
Usually it's the oncologists who are the culprits...I advise dumbing down tumor conference. The less they know about our esoteric ways, the better.
The list of little slights is endless, and it makes me yearn for a 3 hour block of time when I can shut my door, listen to some Schubert, and push some glass--which ironically was virtually every day as a resident.
Yes, once in awhile I yearn for my resident days when I would cut out out work early to golf, snowboard, go to the gym, etc. which I can't do anymore (and not get fired). But I bet when you compare your paycheck now to when you were a resident, I bet the yearning doesn't last very long...
 
Last edited:
  • Like
Reactions: 1 users
Don't get me wrong. I would absolutely pick pathology again were I doing it all over again. And on the whole I believe there is no more intellectually fulfilling specialty (which is what I was after). All specialties have their dross--surgeons have clinic, rheumatologists have fibromyalgia, psychiatrists have borderlines, and pathologists have laboratory administration. The trick is to know one's self well enough to know whether the "good" of a particular medical specialty makes up for the "bad".

My goal for posting in this thread was to disabuse residents of the idea that "staffdom" is a never-ending surgical pathology rotation where you know most of the diagnoses, get to set your own schedule, and don't have to humor the pecadilloes of weird or malignant attendings at the double-headed scope. There is a ton of managment/lab administration, and I think the way residents are shielded from laboratory administration makes staffdom somewhat of a rude awakening and contributes to all of the CAP/ASCP surveys of pathology groups that hired recently graduated residents where the groups complain about how bad the newbies are at lab admin. What bothers me the most though is the surprisingly high number of ignorant, contemptuous, and dismissive attendings from other specialtie who seem unable to fathom that the pathologist might be the expert on laboratory/diagnostic issues.

Finally, private practice is very different from the military (not that I'm whining. I made my choice and I'd make the same one again--I'm just saying...). A solo pathologist at a military hospital is responsible for every one of the duties I listed above plus pushing glass with the added bonuses of working for the government and being the boss of unionized federal employees without any real authority over those same empolyees. And my first year as staff I made 35k more than I made as a resident
 
There are many reasons why I think it might be advantageous to reinstitute a clinical internship before path residency, but chief among them is that after doing one you would simply realize how good you have it. I'm not talking just about hours or lack of call or the lifestyle/laziness factors, but rather how maturely you're treated and how optimal the workflow is. Do you have any idea how many times in surgery I would just pray for 30 uninterrupted minutes to actually get some work done? Or how you were rewarded for being an efficient multitasker, but not for being a smart doctor?

In path you can work whenever you get the slides-- if you want to stay late previewing and writing up your findings, and saunter in the next morning at 9 AM, you can. You're treated deferentially by faculty and consulting services (I have been *shocked* by this thus far). Vacations are scheduled, not assigned. You can take an afternoon off to go to the dentist or take your kid to the pediatrician. These might sound like small things but they are utterly anomalous (obviously you can't round on your patients 'the night before,' or see the next day's clinic patients ahead of time). The learning is incredible-- and you have the luxury of being able to be interested in something, read about it, and actually attend your lectures & didactics without the pager going off 100 times or needing to get your notes done or whatever. And of course the field is both very broad and very deep.

If you're someone who loves learning, who loves the cerebral side of medicine, who wants to be treated as an adult and have the rights & privileges accorded to most other kinds of jobs, who likes the idea of knowing everything and being consulted as an expert by everybody, then this is the most amazing field in medicine.

And I couldn't have appreciated it as deeply as I do unless I'd seen the other side.


yes, but will you have a job?????
 
While I appreciate your detailed, trenchant analyses of the pathology job market gleaned from your first FIVE DAYS of medical school... yes, yes, I will.
 
  • Like
Reactions: 3 users
And congrats Sulfinator! Job interview slide test went well, eh?

No, hasn't happened quite yet. I was just saying that I will have a job based the the prospects that seem to be turning up. I have little to no doubt of it.
 
  • Like
Reactions: 1 user
You people have the most amazing gig in the world. The balance of service: learning is like 1:100. .
Please don't let cms get word of this. We are begging them for more spots because there won't be enough pathologists. Hard to buy our argument if we spend 99% of of times a book and only 1% helping patients.
 
Last edited:
Aww, that's cute. You think "learning" means "reading and studying on your own time" and "service" means "diagnosing, grossing, and otherwise doing clinical work." That right there shows how amazing this job is. In the rest of the medical universe "service" means "non-MD essential scut" like filling out SNF forms in triplicate, transporting patients, or starting IVs, whereas "learning" means the practice of medicine, broadly defined.
 
  • Like
Reactions: 1 user
In the real world service doesn't equal scut. Service means work that benefits patients directly. Education benefits the physician and potentially benefits future patients she will be in service of.

So perhaps you would have been said pathologys had 1% the scut rate od other fields of medicine
 
Last edited:
Yeah but in the real world a lot of that scut is being farmed out to non-physicians. And someone has to pay them, and the money is probably going to come from physician compensation. Pathology has less scut, although there are a lot of technical type jobs which are similar in a $-distribution kind of fashion.
 
Top