CAP and ASCP etc recommend GME INCREASE path residency training/spots

[wp746911]

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http://www.cap.org/apps/docs/statline/gme_funding_coalition_letter_1220.pdf

forgive me if this has been posted before.

you can't make this stuff up. The CAP and ASCP along with other pathology organizations give a long list of reasons why we need to increase gme funding/spots for pathology training. Are they insane? At a time of ACOs, with pathology in a poor negiating position, after enduring the POD lab/IOP abuses- all brought about by a supply/demand problem- they want to make things worse?

 

[Path or bust]

http://www.cap.org/apps/docs/statline/gme_funding_coalition_letter_1220.pdf

forgive me if this has been posted before.

you can't make this stuff up. The CAP and ASCP along with other pathology organizations give a long list of reasons why we need to increase gme funding/spots for pathology training. Are they insane? At a time of ACOs, with pathology in a poor negiating position, after enduring the POD lab/IOP abuses- all brought about by a supply/demand problem- they want to make things worse?

These people are just simply pathetic scumbags and belong in prison for trying to defraud healthcare dollars from where they should go. They simply don't want to work, sit in their office, write BS abstract crap and don't work for 6months out of the year or ever handle a specimen.

 

[pathstudent]

It is one thing to recommend something it is another thing to pay for something.

To currently increase spots in a particular program another program at the same hospital would have to give one up. Good luck trying to get that done.

The other way is to have the acgme increase the number at a particular hospital, Then get cms to fund them (good luck with that with the dire fiscal times) and then get them slated for pathology. Not bloody likely with the current desire towards increasing primary care physicians and the assumption that specialists (which pathologists are clustered in) unnecessarily increase the cost of patient care and make too much money.

But people please stop griping about supply of pathologists. Deal with it and move on with your life.

 

[yaah]

http://www.cap.org/apps/docs/statline/gme_funding_coalition_letter_1220.pdf

forgive me if this has been posted before.

you can't make this stuff up. The CAP and ASCP along with other pathology organizations give a long list of reasons why we need to increase gme funding/spots for pathology training. Are they insane? At a time of ACOs, with pathology in a poor negiating position, after enduring the POD lab/IOP abuses- all brought about by a supply/demand problem- they want to make things worse?

They are not "insane." They are making a judgment based on the data they have. You can argue about the utility and usefulless of their data but you have to argue it with actual data, not just inflammatory language and whining. NOTE THAT THIS DOES NOT MEAN I AM SUPPORTING THEIR POSITION (I have to say that because the first reply to this will be someone saying I am an apologist or whatever).

Any increasing of pathology residency spots will take 4+ years to have any impact on supply of pathologists, this is part of the problem. If one was able to suddenly shift the supply it wouldn't be an issue. Personally, I don't get the need for increasing residency spots, I don't think that is going to solve any problems. There already is a problem with getting quality candidates into pathology - increasing spots will just increase the number of subquality candidates.

A lot of the assumptions made on this forum are a little questionable - exactly how is decreasing the supply of pathologists going to help eliminate pod labs, reduce reference lab power, etc? I am really not so sure. As we have said many times, the more quality reference labs and in office labs for which pathologists are working full time pay often better salaries than most private groups. The shoddy ones aren't employing anyone full time, typically, so it isn't really changing the job market, just giving some people extra work (not a good thing, by the way, in case any of you want to try to twist my position). A lot of the trends that people complain about are problems of medicine in general and everyone is feeling the crunch. Even those with "high bargaining power" like urologists (according to this forum) are stressed and talking about leaving the field.

Did you read the letter you linked to? Can you seriously refute their points with any real information? The point I think one could argue is the one where they say, "The number of pathology positions is insufficient to meet this demand," because I am not sure how they get there and ignore increasing efficiency and workload and such. But they also have an analysis which suggests the opposite.

So I don't know, but I don't think you know either. I find the whole thing problematic to think about because of the issue of taking five years for any change to have any effect, and the extreme difficulty in predicting what is an "appropriate" pathology workforce.

 

[2121115]

Here is the STATline report summary...

Pathology Groups Press IOM Panel on Need for GME Funding

With approximately 40% of practicing pathologists expected to retire over the next 5-10 years, the specialty needs targeted increases in Medicare funding for graduate medical education (GME), according to pathology and laboratory medicine stakeholders, including the College, in a recent letter to an Institute of Medicine (IOM) panel developing recommendations on GME financing.

The Federal government does not currently provide funding for GME, since it was frozen by the 1997 Balanced Budget Act. Lawmakers, as well as patient and health care groups, have been increasingly calling for a reform of the GME system to better align financing to address physician shortage issues. This ad hoc IOM panel is expected to release recommendations on improving GME with an emphasis on the training of physicians.

With only 450 to 500 new residency graduates entering the pathology workforce each year, the current number of training positions cannot meet the demand for pathologists, noted the letter, whose signors included the AMA Pathology Section Council and the Association of Pathology Chairs, among others.

In addition, there has been a decrease in the number of pathology residency training slots, with five residency program closings since 2009, according to the American Association of Medical College’s 2012 Physician Specialty Data Book. “We urge you to consider this evidence of shortage, and our consequent request to add pathology to the list of specialties recommended for targeted increases in Medicare funding for graduate medical education,” concluded the letter.

 

[pathstudent]

Again I think the authors know there is little chance pathology spots will be increased in the current political/economic climate. They are probably just advocating for an increase to prevent a decrease. Like I have written above the current push at the national level is to increase the number of primary care docs. Having to wait months to get into an internist is more dire than having to wait an extra day for a biopsy result.

If there are too few of us, don't worry we won't throw your breast biopsy or colon biopsy away, it might just take us an extra day or two to get to it.

 

[Substance]

Here is the STATline report summary...

Pathology Groups Press IOM Panel on Need for GME Funding

With approximately 40% of practicing pathologists expected to retire over the next 5-10 years, the specialty needs targeted increases in Medicare funding for graduate medical education (GME), according to pathology and laboratory medicine stakeholders, including the College, in a recent letter to an Institute of Medicine (IOM) panel developing recommendations on GME financing.

The Federal government does not currently provide funding for GME, since it was frozen by the 1997 Balanced Budget Act. Lawmakers, as well as patient and health care groups, have been increasingly calling for a reform of the GME system to better align financing to address physician shortage issues. This ad hoc IOM panel is expected to release recommendations on improving GME with an emphasis on the training of physicians.

With only 450 to 500 new residency graduates entering the pathology workforce each year, the current number of training positions cannot meet the demand for pathologists, noted the letter, whose signors included the AMA Pathology Section Council and the Association of Pathology Chairs, among others.

In addition, there has been a decrease in the number of pathology residency training slots, with five residency program closings since 2009, according to the American Association of Medical College’s 2012 Physician Specialty Data Book. “We urge you to consider this evidence of shortage, and our consequent request to add pathology to the list of specialties recommended for targeted increases in Medicare funding for graduate medical education,” concluded the letter.

I suppose the issues that one could take with this data are:

1. The retirement age for pathologists has not been well-defined. Many tend to work beyond 65, and we don't know how many, so making a large claim like that in the above statement is a bit baseless.

2. There are no good data regarding the optimal workload of pathologists. If their first point about retirement is true, that does not necessarily mean that the remaining pathologists cannot pick up the slack.

I suspect this report is more about "keeping the money you already have" than about expanding programs, kind of like how the public works department does random needless road work every year to justify their budgets.

 

[mlw03]

This article was posted to the forensic pathologist listserve I am on as well. We got into a discussion about how if there are not enough pathologist period, it'll be even tougher to recruit into FP. As much as some path residents worry about the job market, it's still few that are going into FP for whatever reasons.

I will say I think the 65 retirement age is accurate (or high) for FP, which is far more physically demanding than any other area within pathology.

 

[wp746911]

I understand they are not out to get us, I just find their logic flawed. There are many problems with the current pathology training, supply and demand is just one of them. I have read (before I posted) their entire letter, and I think it is a case of 'numbers can say anything'.
They quote the aging pathology popultion -which they say 40% will retire in 5-10 years- do you agree with that? My experience has been that most pathologists delay retiremend well beyond normal years.

They mention the idea that pathologist are some consult that can promote effective test utilization -sound warm and fuzzy, but this has not been my experience at massive medical centers and smaller community practices. Oncologist order what they want, when they want it. Yes I did get a call about what test to order last night, but that is 0.00001% of tests we see.

They do say the specimen load will increase, which it might, but they don't factor in the likely 'rationing of healthcare (less biopsies on elder patients) that comes with most socialized medicine. It might or might not.

They mention the explosion of genomic testing requiring a large pathology workfoce. Maybe, maybe not. Reasearch needs them, but day to day signout probably not. And correct me if I'm wrong by molecular reimbursement got cut/is getting cut.

I agree that any change in pathology is very slow. My father is in primary care, and he says his organizations over-react all the time. They scream that there are too many X, and the supply chain gets reduced, but then within 10 years they are screaming that there are too few X. There is such a big delay (5++ years) for any major training change to cause an impact, that no one knows how to react right now.

I think there is a major quality issue in residencies. We can't sign out any specimens, and I would argue that some smaller programs don't have the material to produce good specimens.

I'm not under the dellusion that cutting positions will make pathologys ill go away. Certainly there is more internal abuse within pathology (lack of partnerships, abusing junior staff, etc) that the GI/GU pod lab guys almost seem nice.

My stance is that pathology (and radiology, and anesthesiology) is in a poor bargaining position for the shrinking medical pie. We will have a tough enough time keeping things reasonable if we have a good supply/demand. I don't think that currently we have a a good supply/demand position- which makes us more susceptible to pod labs, lack of partnerships, etc.

I don't know, but they don't either. Having recently been in the job market, and seen fellow groups recently consider hiring someone, it ain't pretty where I am. Maybe there is some pent up demand for pathologists that I've missed, but I find it very very very hard to believe. I think that at most the CAP could argue for continued funding of pathology- but increasing it flies in the face of my logic.

 

[lipomas]

I don't know how to predict this stuff. I do think that past predictions have been wrong, mostly because these past predictions were operating under flawed assumptions, such as # of specimens per pathologist! The retirement age thing is confusing, I think right now lots of people are working longer, but I don't know how much longer that will last. Reimbursement is going down, hassles are going up, I just don't see it being worth it for people on the margins of retirement. It has been for the past 10 years, but not as much now.

So I don't know, if more pathologists in the future become employees without much incentive, then will # of specimens per pathologist go down?

I really don't think there is a current shortage, I can't really tell if that letter is saying that or not. It says there will be a future shortage. Not sure if they are right or not. Also not sure which is the best side to err on. I have no doubt most of you would err on the side of having too few rather than too many, but there are downsides to that as well, many of which may actually FAVOR reference labs and in office labs.

I guess we'll all know in 20 years! I think the safest thing to predict is that all doctor salaries will be going down in the next 20 years (exception maybe cosmetics). Primary care salaries might go up slightly but I don't really think this is going to be significant. the government seems to consider giving PCPs a 5% raise a massive raise. It is much harder to predict demand and stuff like that.

 

[WEBB PINKERTON]

I understand they are not out to get us, I just find their logic flawed. There are many problems with the current pathology training, supply and demand is just one of them. I have read (before I posted) their entire letter, and I think it is a case of 'numbers can say anything'.
They quote the aging pathology popultion -which they say 40% will retire in 5-10 years- do you agree with that? My experience has been that most pathologists delay retiremend well beyond normal years.

They mention the idea that pathologist are some consult that can promote effective test utilization -sound warm and fuzzy, but this has not been my experience at massive medical centers and smaller community practices. Oncologist order what they want, when they want it. Yes I did get a call about what test to order last night, but that is 0.00001% of tests we see.

They do say the specimen load will increase, which it might, but they don't factor in the likely 'rationing of healthcare (less biopsies on elder patients) that comes with most socialized medicine. It might or might not.

They mention the explosion of genomic testing requiring a large pathology workfoce. Maybe, maybe not. Reasearch needs them, but day to day signout probably not. And correct me if I'm wrong by molecular reimbursement got cut/is getting cut.

I agree that any change in pathology is very slow. My father is in primary care, and he says his organizations over-react all the time. They scream that there are too many X, and the supply chain gets reduced, but then within 10 years they are screaming that there are too few X. There is such a big delay (5++ years) for any major training change to cause an impact, that no one knows how to react right now.

I think there is a major quality issue in residencies. We can't sign out any specimens, and I would argue that some smaller programs don't have the material to produce good specimens.

I'm not under the dellusion that cutting positions will make pathologys ill go away. Certainly there is more internal abuse within pathology (lack of partnerships, abusing junior staff, etc) that the GI/GU pod lab guys almost seem nice.

My stance is that pathology (and radiology, and anesthesiology) is in a poor bargaining position for the shrinking medical pie. We will have a tough enough time keeping things reasonable if we have a good supply/demand. I don't think that currently we have a a good supply/demand position- which makes us more susceptible to pod labs, lack of partnerships, etc.

I don't know, but they don't either. Having recently been in the job market, and seen fellow groups recently consider hiring someone, it ain't pretty where I am. Maybe there is some pent up demand for pathologists that I've missed, but I find it very very very hard to believe. I think that at most the CAP could argue for continued funding of pathology- but increasing it flies in the face of my logic.

This is probably the best post ever written on this forum.

 

[lipomas]

A lot of the assumptions made on this forum are a little questionable - exactly how is decreasing the supply of pathologists going to help eliminate pod labs, reduce reference lab power, etc? I am really not so sure. .

I am no sage of economic behavior, but shouldn't a shortage of pathologists paradoxically lead to increase power and prevalance of reference labs? Harder to find competent local pathologists so reference labs move in because they can hire the pathologists, staff them in more desirable locations to work (since it seems like 50% of pathologists want to work in a city or have a spouse that wants to live there). Harder to find local pathologists with subspecialty training. Have to pay them more so it's easier for reference labs to undercut on prices.

Am I wrong here?

 

[rollwithit]

This isn't hard to understand, folks. Nobody sits by idly when there's a money grab at stake.

I'm sure there are a lot of hospital employees on this forum. What would you do if your department management didn't lobby to protect the department's funding, even in times when you may be adequately funded in the first place? If you sit around and don't make a case for your funding, it's going to get cut.

 

[LADoc00]

Ah another academic money grab. I love these almost as much as I love gun grabs and whiskey grabs.

 

[rollwithit]

Whiskey grabs are my favorite.

 

[path24]

Confirming pathologists will always be in oversupply and that we will continue to be nothing but a commodity. Not much of a profession....just sad.

 

[yaah]

I understand they are not out to get us, I just find their logic flawed. There are many problems with the current pathology training, supply and demand is just one of them. I have read (before I posted) their entire letter, and I think it is a case of 'numbers can say anything'.
They quote the aging pathology popultion -which they say 40% will retire in 5-10 years- do you agree with that? My experience has been that most pathologists delay retiremend well beyond normal years.

They mention the idea that pathologist are some consult that can promote effective test utilization -sound warm and fuzzy, but this has not been my experience at massive medical centers and smaller community practices. Oncologist order what they want, when they want it. Yes I did get a call about what test to order last night, but that is 0.00001% of tests we see.

Those are good points overall. I think the point of the blurb you are referring to is that the "future" of health care in some circles involves greater collaboration between specialties than currently. Thus, there may be an increasing role for pathologists to play in clinical management, before tests are drawn or which ones to order, things like that. Doesn't happen like that now in most places but doesn't mean it won't happen. It would be a big change for most pathologists though. I have no idea whether these predictions are anything close to accurate. As with anything, the truth is probably somewhere in the middle.

As far as rationing, I tend to doubt that, at least for a long time. Any time anything even close to 'rationing" is mentioned the AARP and the right go ballistic. I think you would sooner see mandated screening, insurance penalties for not screening, and mandating testing before any rationing in this country.

You did say the supply/demand thing perpetuates pod labs and reference labs. I really don't think this is clear cut. An economist would probably argue that fewer pathologists would mean more consolidation (because smaller groups would become even less prevalent) and increasing penetration of reference labs. Smaller groups would become increasingly less likely to provide effective services to hospitals and medical groups because it would be hard to hire and hard to provide quality specialized care. So the reference labs would end up with the business. Pod labs I don't think really have a huge impact either - the smaller ones typically employ part time pathologists who have other jobs, and the larger ones are closer to reference labs anyway. So we can argue all we want about the evils of pod labs, but I think the link to "pathologist oversupply" is pretty tenuous. It might somewhat hold down salary but not enough to eliminate them.

 

[Enkidu]

Those are good points overall. I think the point of the blurb you are referring to is that the "future" of health care in some circles involves greater collaboration between specialties than currently. Thus, there may be an increasing role for pathologists to play in clinical management, before tests are drawn or which ones to order, things like that. Doesn't happen like that now in most places but doesn't mean it won't happen. It would be a big change for most pathologists though. I have no idea whether these predictions are anything close to accurate. As with anything, the truth is probably somewhere in the middle.

What is the current mechanism to prevent needless or inappropriate testing? Requiring that a pathologist sign off on certain tests which may be expensive or misused sounds like a pretty reasonable and minimal strategy.

Is it possible that this approach may be a natural outgrowth of ACOs? If the pool of money per patient is limited, one role for clinical pathology might be to prevent unnecessary laboratory expenses.

What other role are you imagining for pathologists to play in clinical management?

 

[Tissue issue]

"Approximately 40% of all practicing pathologists today are 55 years of age and older and will be expected to retire over the next 5-10 years."

-This is NOT data. This is a guess. There is no supporting documentation of when pathologists are retiring.

-This IS data .............. http://www.ascp.org/PDF/Fellowship-Reports/Fellowship-Job-Market-2012.pdf

 

[Enkidu]

"Approximately 40% of all practicing pathologists today are 55 years of age and older and will be expected to retire over the next 5-10 years."

-This is NOT data. This is a guess. There is no supporting documentation of when pathologists are retiring.

-This IS data .............. http://www.ascp.org/PDF/Fellowship-Reports/Fellowship-Job-Market-2012.pdf

Well... it's not really a "guess". Nearly half of all pathologists are within striking distance of retirement. Whether they retire at 65 or 75 will obviously relate to economic conditions, but they will inevitably retire.

As for the data that you linked to, that reflects the current job market. It doesn't predict the job market in 10 years.

I mean, honestly, what is CAP supposed to do? The present pathology workforce is old, and we are producing fewer pathologists than we used to. They are projecting an increase in demand, for a lot of good reasons, at the same time that the population of pathologists is shrinking. Their projections may ultimately turn out to be wrong, but they're not just "guesses".

 

[Tissue issue]

Well... it's not really a "guess". Nearly half of all pathologists are within striking distance of retirement. Whether they retire at 65 or 75 will obviously relate to economic conditions, but they will inevitably retire.

As for the data that you linked to, that reflects the current job market. It doesn't predict the job market in 10 years.

I mean, honestly, what is CAP supposed to do? The present pathology workforce is old, and we are producing fewer pathologists than we used to. They are projecting an increase in demand, for a lot of good reasons, at the same time that the population of pathologists is shrinking. Their projections may ultimately turn out to be wrong, but they're not just "guesses".

It makes a big difference whether pathologists are retiring at 65 or 75. There are approximately 500 new pathology residents each year- a ten year difference means 5,000 or so more pathologists in the pipeline.
The current data indicates a less than optimal job market for pathologists. If people are going to start trumpeting a future shortage of pathologists (which btw has occurred in the past only to turn out to be very incorrect) then they should be very diligent in collecting facts. Facts such as when are pathologists actually retiring, how many more specimens is the individual pathologist signing out now versus 10 years ago, how are pathology groups/hospitals/corporate labs reacting to the large 88305 TC cut, etc.

 

[Enkidu]

It makes a big difference whether pathologists are retiring at 65 or 75. There are approximately 500 new pathology residents each year- a ten year difference means 5,000 or so more pathologists in the pipeline.
The current data indicates a less than optimal job market for pathologists. If people are going to start trumpeting a future shortage of pathologists (which btw has occurred in the past only to turn out to be very incorrect) then they should be very diligent in collecting facts. Facts such as when are pathologists actually retiring, how many more specimens is the individual pathologist signing out now versus 10 years ago, how are pathology groups/hospitals/corporate labs reacting to the large 88305 TC cut, etc.

Look at it like this - according to the AAMC data there has been a net loss of pathologists in the last 10 years. This means that the current number of pathology trainees per year is outstripped by the number of pathology retirees. But the rate of retirement will increase as those pathologists age, at the same time as there is a net loss of pathology training spots - meaning that pathology will continue to contract at an increasing rate. Given that our population is growing overall and the population of insured is also growing, demand is also growing.

 

[deleted314957]

Maybe this adds a little. I am one of the most "productive" paths in my situation and I am doing about ~10,000 accessions/year general community hospital real heavy on gi. we have let people go. i can easily do 12-14K of the same mix i am doing. i will be doing more because we are dropping the dead wood. pathologists will have to get off their asses and start working. and as an aside-i make orthopod money but i earn it. i am 61 and will work till ~70 if my health allows. i would work till i die but i don't think my wife would like that. i do not need money as a motivator to work. it is my hobby. i am not alone.

 

[Enkidu]

Maybe this adds a little. I am one of the most "productive" paths in my situation and I am doing about ~10,000 accessions/year general community hospital real heavy on gi. we have let people go. i can easily do 12-14K of the same mix i am doing. i will be doing more because we are dropping the dead wood. pathologists will have to get off their asses and start working. and as an aside-i make orthopod money but i earn it. i am 61 and will work till ~70 if my health allows. i would work till i die but i don't think my wife would like that. i do not need money as a motivator to work. it is my hobby. i am not alone.

So mike is part of the generation of pathologists that is heading towards retirement - lets assume he has 10 more years. when he retires how many new pathologists will it take to handle his workload? not only is the total number of pathologists decreasing, but the pathologists that are retiring may also be the most productive.

Lets say that it takes 5 years to train a pathologist for their first job - how productive and independent will they be?

So if pathology associations are looking at the loss of all the "Mikesherees" in the next 10 years, are they justified in worrying about an undersupply? Particularly since the rate of pathologist production is not even sufficient to keep the current pool constant and demand is expected to go up. I'm not saying that their predictions are right - any prediction could be wrong - but their concerns are not unfounded.

 

[Path or bust]

So mike is part of the generation of pathologists that is heading towards retirement - lets assume he has 10 more years. when he retires how many new pathologists will it take to handle his workload? not only is the total number of pathologists decreasing, but the pathologists that are retiring may also be the most productive.

Lets say that it takes 5 years to train a pathologist for their first job - how productive and independent will they be?

So if pathology associations are looking at the loss of all the "Mikesherees" in the next 10 years, are they justified in worrying about an undersupply? Particularly since the rate of pathologist production is not even sufficient to keep the current pool constant and demand is expected to go up. I'm not saying that their predictions are right - any prediction could be wrong - but their concerns are not unfounded.

You're assuming that clinicians are going to keep biopsing. Confocal microscopy and invivo microscopy is here and WE WILL see a decline in biopsy work no doubt.

 

[MetroPath]

You're assuming that clinicians are going to keep biopsing. Confocal microscopy and invivo microscopy is here and WE WILL see a decline in biopsy work no doubt.

Really? This is the real deal? Confocal microscopy/in vivo microscopy trumps the inexpensive H&E?

 

[Enkidu]

You're assuming that clinicians are going to keep biopsing. Confocal microscopy and invivo microscopy is here and WE WILL see a decline in biopsy work no doubt.

Well, technically I'm not assuming anything. I'm just trying to say that CAP and ASCP aren't as stupid or corrupt as everyone seems to be claiming. I don't know what factors they considered when they projected increased demand.

But I actually don't agree with you anyway. Let's see what happens with in vivo microscopy. We're talking about a significant increase in training time for GI docs to learn the technique, investment in the appropriate technology, and a huge increase in liability. It may not even be economical. And even if it is, will it improve patient outcomes by enough to make it worthwhile?

I mean, how confident are early-career pathologists in signing out independently with access to an entire array of IHC, molecular tests, and whatever else? Will GI docs want to make final calls with much less training and fewer resources, when they could just take a biopsy anyway and get a definitive diagnosis and avoid personal liability?

I don't really know, but there is certainly "doubt" that this technology will be as disruptive as you seem to think. It may never even come to fruition.

As for confocal microscopy - that's been around for a long time. It's more of a research technique, unless there is another thing called "confocal microscopy" that I've never heard of. You would still need to take a biopsy to use the thing that I'm thinking of.

Edit: Also, as long as there are Pod labs I don't see any incentive whatsoever for GI docs to adopt this technology

 

[Path or bust]

Yes I already read what you wrote in previous posts 4 times already.

There really is no argument to make, this technology will be coming out in the future regardless of your "doubts". There are mountains of published data supporting this and comparing it to biopsy results, it looks pretty promising. Why do you think CAP is making the move to "transform pathology". Changes are coming...

http://www.stanford.edu/group/liaolab/Publications/PDF/Confocal Bladder In vivo optical biopsy.pdf

http://www.sciencedirect.com/science/article/pii/S0016510709024262

http://www.nature.com/modpathol/journal/v18/n2/abs/3800303a.html

http://archderm.jamanetwork.com/article.aspx?articleid=480754

http://grupopedrojaen.com/wp-conten...ctance-microscopy-of-basal-cell-carcinoma.pdf

Well, technically I'm not assuming anything. I'm just trying to say that CAP and ASCP aren't as stupid or corrupt as everyone seems to be claiming. I don't know what factors they considered when they projected increased demand.

But I actually don't agree with you anyway. Let's see what happens with in vivo microscopy. We're talking about a significant increase in training time for GI docs to learn the technique, investment in the appropriate technology, and a huge increase in liability. It may not even be economical. And even if it is, will it improve patient outcomes by enough to make it worthwhile?

I mean, how confident are early-career pathologists in signing out independently with access to an entire array of IHC, molecular tests, and whatever else? Will GI docs want to make final calls with much less training and fewer resources, when they could just take a biopsy anyway and get a definitive diagnosis and avoid personal liability?

I don't really know, but there is certainly "doubt" that this technology will be as disruptive as you seem to think. It may never even come to fruition.

As for confocal microscopy - that's been around for a long time. It's more of a research technique, unless there is another thing called "confocal microscopy" that I've never heard of. You would still need to take a biopsy to use the thing that I'm thinking of.

Edit: Also, as long as there are Pod labs I don't see any incentive whatsoever for GI docs to adopt this technology

 

[Enkidu]

Yes I already read what you wrote in previous posts 4 times already.

There really is no argument to make, this technology will be coming out in the future regardless of your "doubts". There are mountains of published data supporting this and comparing it to biopsy results, it looks pretty promising. Why do you think CAP is making the move to "transform pathology". Changes are coming...

http://www.stanford.edu/group/liaolab/Publications/PDF/Confocal Bladder In vivo optical biopsy.pdf

http://www.sciencedirect.com/science/article/pii/S0016510709024262

http://www.nature.com/modpathol/journal/v18/n2/abs/3800303a.html

http://archderm.jamanetwork.com/article.aspx?articleid=480754

http://grupopedrojaen.com/wp-conten...ctance-microscopy-of-basal-cell-carcinoma.pdf

Well what is your point? If I'm supposed to read all these papers to guess it, then I suppose it will remain unknown forever. Does this technology provide superior patient outcomes? Is it economic given the training time and equipment cost?

 

[Tissue issue]

Look at it like this - according to the AAMC data there has been a net loss of pathologists in the last 10 years. This means that the current number of pathology trainees per year is outstripped by the number of pathology retirees. But the rate of retirement will increase as those pathologists age, at the same time as there is a net loss of pathology training spots - meaning that pathology will continue to contract at an increasing rate. Given that our population is growing overall and the population of insured is also growing, demand is also growing.

I'm curious- have you talked with the pathology residents and fellows at your institution about this upcoming pathologist shortage?

 

[Path or bust]

If I'm supposed to read all these papers to guess it, then I suppose it will remain unknown forever.

Yeah thats what I thought, just another loud mouth. Im not going to give you the answers, you can read for yourself.

For everyone else, this is from our own pathology literature:
In conclusion, near-infrared reflectance confocal microscopy stands as a useful adjunct technique to the study of hepatic parenchyma offering details equivalent to, if not surpassing traditional light microscopy.

http://www.nature.com/modpathol/journal/v18/n2/abs/3800303a.html
1Wellman Laboratories of Photomedicine, Massachusetts General Hospital, Harvard University, Boston, MA, USA
2Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Harvard University, Boston, MA, USA

Having this information, why would anyone want to injure the patient by slicing into their liver? The standard of care might be changing before our very eyes. It might take another 10 years to get this going, but it will come.

 

[WEBB PINKERTON]

You could easily see this technology during your careers. It is coming and pathologists will be left out. Of course the medical device tax could plunge us into a dark age as well and kill off innovation. So who knows.

Not just technology will be reducing biopsies. Look at all the new guidelines in recent years. Prostate, breast, cervical and probably more to come. We are doing more harm with overtreatment than good it seems. Prostate screening and treatment is one of the biggest cons out there.

 

[Enkidu]

Yeah thats what I thought, just another loud mouth. Im not going to give you the answers, you can read for yourself.

For everyone else, this is from our own pathology literature:
In conclusion, near-infrared reflectance confocal microscopy stands as a useful adjunct technique to the study of hepatic parenchyma offering details equivalent to, if not surpassing traditional light microscopy.

Seriously? You can't be bothered to tell me your point, but "for everyone else" you sum up your views by copying the abstract of a paper?

Well, I read that abstract already, but since it didn't relate to anything I had said it didn't strike me as particularly relevant.

Beyond the abstract, this paper specifies that in vivo application of this technology is limited to the most superficial portions of the liver (200-300 um) with poor resolution and only speculates that it may be useful in imaging inflammatory processes and post-clamp ischemia. Half of that paper is actually using ex vivo material anyway, which also seems to be where the technology is "superior" to traditional light microscopy, because the biopsied tissue can be analyzed with sucrose or acetic acid treatment before it is processed for traditional histology

 

[Path or bust]

Seriously? You can't be bothered to tell me your point[/U]

No, because you're an a$ $hole.

 

[mlw03]

Nice to see this discussion is remaining respectful and mature.

While folks here enjoy these discussions (or so it seems), they don't really change much of significance. But since we're just spouting air anyway largely, there are other assumptions I wonder about the accuracy of, namely that every pathologist trained in the US will enter the US workforce in diagnostic pathology. I think that's false for 2 reasons. 1) there are a few of us that do other stuff, such as FP, BB, med renal, pure research, or pure CP. 2) not everyone stays in the US anyway, whether it's to leave for the whiter and greener pastures up north or to return to home countries in South America, Middle East, Africa, etc. I'll grant these two combined are probably a small percentage of US path residency outcomes.

I've been on this forum a number of years now, and my views are starting to change, although my view is that of a semi-informed outsider really. As an FP I know a bit more about the situation than a psychiatrist, but I'm certainly not in there day to day like many of you. Nonetheless, I know no qualified, socially normal pathologist struggling to find good jobs. And that fact, even with the admittedly small n, makes me wonder about those who come on here karping about their own inability to obtain gainful employment as a pathologist.

 

[pianoguy05]

You could easily see this technology during your careers. It is coming and pathologists will be left out.

Who's going to read the confocal microscopy/in vivo? I hardly think any surgeon is going going to risk the malpractice of trying to diagnose cirrhosis or evaluate the extent of disease...or learn the grading/staging criteria for HCC? Let the technology come; it's a moot point to the relevancy of properly trained diagnostic pathologists.

 

[scienceguy19]

INCREASE residency spots? I think I'm going to faint...

 

[2121115]

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

 

[Arctic Char]

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

This is a first . . . 😱

 

[rollwithit]

This is a first . . . 😱

Trolling.

 

[Path or bust]

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

bwhuahahaha, love it. 🙂

 

[scienceguy19]

May I ask what region of the country your group is in? Is it some remote rural area?

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

 

[Tissue issue]

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

People he's joking 🙄. See how ridiculous those statements seem?

 

[lipomas]

Nonetheless, I know no qualified, socially normal pathologist struggling to find good jobs. And that fact, even with the admittedly small n, makes me wonder about those who come on here karping about their own inability to obtain gainful employment as a pathologist.

Same here

Most of the people posting seem to have jobs too. I don't recall seeing anyone who is unemployed coming to post and complain. It's a lot of conjecture and assumption. There's also a lot of exaggeration and selective fact picking about the benefits of other fields of medicine.

What I have seen in real life is quite a few people who can't find the job that they really want. I don't really know whether that is a lot of wishful thinking or what though. If people could design their dream pathology job would it actually exist for the salary they want? Probably not. It's still a problem for the field though, but is reducing # of pathologists going to fix it? I doubt it. It might raise salaries a trifle but really not that much. Saying the problems are because of oversupply is a bit ignorant and simplistic. Most of the REAL problems relate to society and healthcare in general - too many administrators, too much oversight but at the same time too many behemoth corporations willing to take a loss to get more market share, society's unwillingness to pay for healthcare yet insistence on everything being done.

A lot of it seems to me like general complaining about life. My wife works outside of medicine and she complains a lot about her job and how it would be better elsewhere but there just aren't a lot of opportunities.

 

[path24]

In my group, we currently have more work than we can reasonably handle, since we've been seeing an increase in outpatient and hospital specimens. We've been trying to hire a new pathologist for a while, but due to the shortage we haven't been able to find anyone. If anyone knows someone looking for a job, let me know. We are now offering recruiting incentives due to the shortage. There is way more work out there now than there are pathologists.

What is something that has never been said or will ever be said? I will take Pathology Fantasyland for 800, Alex.

Just entertaining myself. The joys of pathologist oversupply.

 

[gbwillner]

Most of the REAL problems relate to society and healthcare in general - too many administrators, too much oversight but at the same time too many behemoth corporations willing to take a loss to get more market share, society's unwillingness to pay for healthcare yet insistence on everything being done.

THIS. Everyone wants everything done, especially since they don't really have to pay the bill in the end- it's medicare/medicaid/insurance footing 99% of the bills. We are up the creek much of the time because we cannot deny services just because someone can't pay. And there is no real market since the prices are pre-set by medicare. It's a catch-22. Or course I am not talking about Path but all of medicine.

I think it's also a cultural problem- when people are really sick and dying, even those with terminal chronic disease- they insist on being full code and wasting resources. We should be teaching people to die in peace at home. No one dies at home anymore- they all die in the ICU now.

/end rant

 

[2121115]

And there is no real market since the prices are pre-set by medicare.

Which is good for pathologists (and doctors in general) because if prices were truly set by a free market we'd all be broke. Nobody is going to pay $36 to have their biopsy read plus a few $42 charges for immunostains. Not for a doctor they never see. Good luck collecting that in a free market.

 

[Enkidu]

Which is good for pathologists (and doctors in general) because if prices were truly set by a free market we'd all be broke. Nobody is going to pay $36 to have their biopsy read plus a few $42 charges for immunostains. Not for a doctor they never see. Good luck collecting that in a free market.

I dunno - not getting a diagnosis would pretty much preclude any treatment. Once the patient realizes that they'll be willing to pay their $120 or whatever. If attorneys can collect that for spending 30 minutes in the library without any noticeable result - then I think pathologists will be able to collect it for a report.

 

[WEBB PINKERTON]

Pathology and health care is full of waste thanks to insurance and the lack of transparency. We have harmed a lot of patients from excessive screening. There is NO doubt about that. "Personalized medicine" is the next con. Spend thousands for some molecular tests followed by a new drug so grandpa might live another month and half.

 

[KCShaw]

..snip..
I think it's also a cultural problem- when people are really sick and dying, even those with terminal chronic disease- they insist on being full code and wasting resources. We should be teaching people to die in peace at home. No one dies at home anymore- they all die in the ICU now.
..snip..

I get the point, but I also see a tremendous number of people who die at home &/or hospice with chronic disease/terminal conditions, with relatively little health care expenditure beyond painkillers and enough care to administer said painkillers and keep them fairly clean.

That said, most of this was made more clear to me in training when a blood bank tech explained how their entire year's budget vanished in January as some poor soul received Novoseven (or somesuch expensive factor(s)) by the gallon to stave off an incurable coagulation problem (I don't even remember what the underlying cause was); after a few days/week or so of this the patient finally asked whether he was gonna get better, and when the truth was explained, the patient was the one asking why they were wasting their time, and ultimately asked them to stop. But it was on the order of millions gone -- not exactly cost effective, even if temporary life has no price in the eyes of a loved one. And there's the rub. Individuals can have a very hard time making decisions about individuals, even if from a broad societal point of view the decision can seem easier.