anyone doing hemepath

[pathpiano]

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i wanted to know if anyone was doing hemepath.
also wanted to know if you should do ap/cp + hemepath

 

[Gut Shot]

i wanted to know if anyone was doing hemepath.
also wanted to know if you should do ap/cp + hemepath

My fellowship desires are top secret (not dermpath). You should definitely at least try AP/CP before doing hemepath. Despite being under the CP umbrella, you will need a certain amount of microscopic acumen to excel, and that will only come from AP. Yeah, it's a helluva pill to swallow, but you'll be better off in the long run.

 

[yaah]

We have a CP-only fellow doing hemepath, although this person is primarily going to be a researcher I believe.

Personally, I would do it after doing AP/CP, although even if you do AP-only you will get some molecular and hemepath exposure during training at most programs. So strictly speaking, it doesn't matter to a certain extent. You can even do internal medicine residency and a hemepath fellowship, although I don't know what you can sign out "officially" after that. I would be hesitant about any fellow who didn't do any AP training before hemepath, although no doubt there are some who can manage and do quite well.

 

[LADoc00]

I have BC in hemepath and personally I would stay away. The remibursement for flow was slashed a whopping 80-90% and although I can blab endlessly about lymphomas, the routine ones you see can be So'd by any general pathologist with ease.

Im baffled by groups who feel like they have to have a hemepath guy, they dont. Not if they have a working knowledge of modern IHC. Im very much overtrained for what I do on a daily basis.

Would stick with GU, GI and Derm, at least atm.

 

[yaah]

Well, as I have posted before, I have had my normal amount of resident hemepath training (which here is probably more than most programs, but still...) and I feel comfortable with most hemepath. I know what I don't know, at which point it would become a consult anyway.

 

[abefromann]

LADOC, what's the deal with heme reimbursement being slashed recently? I do think heme and derm are more interesting, that GI/GU, but derm's a bit competitive for me despite the research I've done. You don't think heme's a good fellowship, financially speaking? Damn shame b/c I think it's quite cool.

 

[pathstudent]

LADOC, what's the deal with heme reimbursement being slashed recently? I do think heme and derm are more interesting, that GI/GU, but derm's a bit competitive for me despite the research I've done. You don't think heme's a good fellowship, financially speaking? Damn shame b/c I think it's quite cool.

CMS slashed technical and professional reimbursement for flow about 3 years ago. Prior to that they paid x amount of dollars per antibody, and anyone with a flow cytometer would run every antibody they had on every single case and bill thousands of dollars per case. It was too good to be true, but the federal government rightfully saw that it was a reimbursement scheme that was a set up to be abused. I don't know how they reimburse it now, but it I the federal government reimburses decreasing amount per antibody or after a certain number, they won't pay you anything at all. Insurance companies structure their compensation around what medicare reimburses.

The same thing will happen with immunos on parafin. I think I once saw that medicare pays about $40 to interpret an immunostain, whether you have to study it for 15 minutes or look at it for 2 seconds and say "negative". That's a system that is set-up to be abused by unethical people also.

 

[beary]

I am planning on going into heme (though am recently having second thoughts because I love surg path too). I am a second year AP/CP resident and can't imagine doing heme as either AP or CP only.

 

[abefromann]

Why can't you "imagine doing heme as either AP or CP only"? Is it because you need both to be proficient at all aspects of heme?

 

[abefromann]

As far as the surgpath fellowships go -- what's the advantage to doing one? I thought surgpath was an integral part of AP as it is. Also, I've read on this forum that surgpath isn't like doing a specialty fellowship (i.e. a marketable one).

 

[pathresident]

Why can't you "imagine doing heme as either AP or CP only"? Is it because you need both to be proficient at all aspects of heme?

Hemepath fellowship is done after AP only tract (and even CP only) at my residency all the time. It is probably more helpful to do it after AP/CP tract in that you know more heme after CP -- but you can pick up all that stuff during the hemepath fellowship.

 

[abefromann]

The AP/Hemepath programs seem to be rare. Like, Stanford has one but who else? Also, people seem to think that the salaries are going to suck for hemepath. There's an academic guy here who's probably 55, and he pulls in about 300K. Is this a rarity, or does it seem to be about right?

 

[NKcell]

I have BC in hemepath and personally I would stay away. The remibursement for flow was slashed a whopping 80-90% and although I can blab endlessly about lymphomas, the routine ones you see can be So'd by any general pathologist with ease.

Im baffled by groups who feel like they have to have a hemepath guy, they dont. Not if they have a working knowledge of modern IHC. Im very much overtrained for what I do on a daily basis.

Would stick with GU, GI and Derm, at least atm.

IHC/flow/cytogenetics are great tools for hemepath. However, specifically as it pertains to lymph node pathology, the more important thing is to know its limitations, something ONLY a person with specialized hemepath training can do. For example, let's use follicular lymphoma, one of the most common lymphomas, and certainly something that a general pathologist will see in a routine practice.

IHC
- bcl-2 is negative in ~70% of pediatric cases, up to 25% in adult grade 3,
20% in adult grade 2, and 3% in adult grade 1
- bcl-2 is positive in benign T-cells, mantle cells, and marginal zone cells, all
of which can be found within the follicles, and thus be misidentified as
malignant centrocytes
- CD10 is negative in up to 50% of cases
- bcl-6 is negative in up to 25% of cases
- CD5 is positive in rare cases

Flow
- CD10 is negative in ~40% of cases
- Light chain restriction is absent in positive bone marrow biopsies in ~40%
of cases

Cytogenetics
- t(14;18) is negative in 5-30% of adult cases, and up to 90% of pediatric
cases


So yeah, this is just follicular lymphoma, but the limitations of IHC, flow, cytogenetics, and even molecular (i.e. TCR and Ig rearrangement false positivities) can be applied to all of the other lymphomas, and even MDS (the flow signout of "granulocytic dysmaturation" in a person without cytopenia and morphologic dysplasia...WTH do I do with that?) and leukemias.

So back to the original question, do AP/CP, do a hemepath fellowship. Don't worry about getting a job, because there are too many people out there who don't know anything about morphology and who think that IHC/flow/cytogenetics/molecular are the greatest thing since sliced bread, because they AIN'T. Knowing about disease processes, morphology, and the proper use, intrepretation, and limitation of different ancillary techniques are the way to go, and only a hemepath fellowship will train you adequately.

 

[ScopeHound]

I did AP/CP and Heme. That is definitiely the way to go. I always hated surg path and I was able to find a job where I do pretty much only heme and CP and minimal AP. Thats the nice thing about heme, you can control how much AP or CP you want to do. If you don't like one, you do the other. We have another heme boarded guy who hates CP and bloodbank call, so he pretty much does AP and not much CP. You don't get that kind of flexibility with many other subspecialties. And once you're a pratner, everyone makes the same, so you should really focus on doing what you enjoy and everything else (money, vacation, hookers) will come in time.

 

[LADoc00]

I did AP/CP and Heme. That is definitiely the way to go. I always hated surg path and I was able to find a job where I do pretty much only heme and CP and minimal AP. Thats the nice thing about heme, you can control how much AP or CP you want to do. If you don't like one, you do the other. We have another heme boarded guy who hates CP and bloodbank call, so he pretty much does AP and not much CP. You don't get that kind of flexibility with many other subspecialties. And once you're a pratner, everyone makes the same, so you should really focus on doing what you enjoy and everything else (money, vacation, hookers) will come in time.

Actually I would disagree. A VAST majority of private and public groups that hire want someone who signs out everything and has an expertise in heme, not heme as a primary duty. The only exception would be large corporations such as Genoptix/Ameripath or huge groups which break off areas of speciality.

Would be interested to hear what your set up is. I dont think you can hide from being completely versatile in the modern marketplace. Due to vacations, illness and other staffing issues, how could you hide from AP sign outs or have other people in the group not take CP call?

Personally, I would NEVER hire someone who couldnt do everything. It doesnt make sense in my business model.

 

[abefromann]

LADoc, how long were you in practice before starting your own business? Was this something that required a lot of venture capital, or did you take on partners with a buy-in initially?

 

[ScopeHound]

Actually I would disagree. A VAST majority of private and public groups that hire want someone who signs out everything and has an expertise in heme, not heme as a primary duty. The only exception would be large corporations such as Genoptix/Ameripath or huge groups which break off areas of speciality.

Would be interested to hear what your set up is. I dont think you can hide from being completely versatile in the modern marketplace. Due to vacations, illness and other staffing issues, how could you hide from AP sign outs or have other people in the group not take CP call?

Personally, I would NEVER hire someone who couldnt do everything. It doesnt make sense in my business model.

Sure in our group, you have to know everything. When I take call, I sign out AP and look at cyto and do autopsies once in a while, but day to day, I do very little AP or frozens. In a group of 16 covering 24 hospitals, you can get away with doing only heme and CP because there are plenty of people who hate heme and CP and are happy to give that work to you while you give all the 88305-9's to them. Even though they are probably bringing in more money into the group then me, it is a trade off that works for everyone. Obviously, if your group size is <5 people, you cannot have a model like this.

 

[beary]

Why can't you "imagine doing heme as either AP or CP only"? Is it because you need both to be proficient at all aspects of heme?

That was my feeling from my two months of heme that I have had. Our chairman is a hemepath guy though and he says that there ends up being no difference between AP only, CP only, and AP/CP folks at the end of hemepath training.

I just meant that personally I feel like both the AP and CP training will be tremendously useful.

 

[beary]

Actually I would disagree. A VAST majority of private and public groups that hire want someone who signs out everything and has an expertise in heme, not heme as a primary duty. The only exception would be large corporations such as Genoptix/Ameripath or huge groups which break off areas of speciality.

A related question - I love surg path and heme but am planning at this point on doing just a hemepath fellowship (which is 2 years). Given that we have strong surg path training at our program, would most people consider me able to sign out hemepath and surg path? Or would people be looking for somebody who had done a surg path fellowship as well?

 

[LADoc00]

A related question - I love surg path and heme but am planning at this point on doing just a hemepath fellowship (which is 2 years). Given that we have strong surg path training at our program, would most people consider me able to sign out hemepath and surg path? Or would people be looking for somebody who had done a surg path fellowship as well?

a surg path fellowship is completely unneeded to sign out surg path, look up the history of surg path fellowships. They were an invention of the prior training scheme which required a credentialing year after they abolished the mandatory transitional year for pathology over 20+ years ago.

 

[CameronFrye]

A related question - I love surg path and heme but am planning at this point on doing just a hemepath fellowship (which is 2 years). Given that we have strong surg path training at our program, would most people consider me able to sign out hemepath and surg path? Or would people be looking for somebody who had done a surg path fellowship as well?

Most heme fellowships are only a year. Are you planning on doing one of the 2-year research tracks?

 

[beary]

Most heme fellowships are only a year. Are you planning on doing one of the 2-year research tracks?

Yeah. If I end up doing a one year heme fellowship I would probably do surg path too.

What fellowships are you interested in Cameron?

 

[yaah]

a surg path fellowship is completely unneeded to sign out surg path, look up the history of surg path fellowships. They were an invention of the prior training scheme which required a credentialing year after they abolished the mandatory transitional year for pathology over 20+ years ago.

I agree - surg path fellowships are good for a couple of situations:

1) You don't have another fellowship to do (as in a subspecialty or heme or cyto) or you want to do private practice and you are planning on being a generalist without a subspecialty area of expertise.
2) You train at a place that doesn't have great volume, experience, or teaching and you need to do a year at a bigger place to get the needed experience.

If you are doing another fellowship, doing the surg path year is nice and will be good experience but I really don't think it's necessary at all. If you look at the makeup of the average surg path fellowship it includes rotations on multiple subspecialties. To be sure, you get a lot of extra frozen section experience, but the rest is mainly just seeing more cases. I know different programs run their surg path fellowships differently, and some are better than others, but if you train at a good program and work hard during residency and use your elective time efficiently, it is unnecessary.

People doing heme + surg path or just heme get the same jobs in the end, which include jobs where you do heme and general stuff.

 

[CameronFrye]

Yeah. If I end up doing a one year heme fellowship I would probably do surg path too.

What fellowships are you interested in Cameron?

I'm also probably doing heme, although there are a couple other things that interest me.

 

[CameronFrye]

Almost everyone I have spoken to about this agrees with the above statement. You learn far more by actually working. Nothing puts your feet to the fire more than knowing your name is going to be on the diagnostic line. It is unlikely that another year of general training will change the way you approach sign out unless there are deficiencies in your pathology training program.

Yeah, I think if you need another year with a "crutch", then IMO a year as an instructor is a good way to go. Basically, you spend the year as a junior attending and sign out your own cases (but you still have all of the backup around you if you need it). However, I think these opportunities are somewhat limited.