competitive fellowships

[anonaaa]

Any thoughts on going to a good path res program that has very competitive fellowships like GI or dermpath vs. a great program without such competitive fellowships?

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[b&ierstiefel]

Any thoughts on going to a good path res program that has very competitive fellowships like GI or dermpath vs. a great program without such competitive fellowships?

For derm, go to a strong residency program, it can only help you...but I will warn you that dermpath is one of those fellowships that don't necessarily favor in-house residents. Furthermore, dermpath is open to not only path residents but also Derm residents. Read into that what you want...just remember that your classmates that go into derm tend to have more of a gunner personality than path residents who despise those personalities. Now, that being said, derm residents when given a choice tend to gun for more popular, more lucrative fellowships such as Mohs fellowship rather than Dermpath. A residency in a strong fellowship only helps in one's efforts to land a fellowship. It's so funny to see path residents look at Dermpath as the golden fellowship whereas Derm residents don't.

 

[106174]

Now, that being said, derm residents when given a choice tend to gun for more popular, more lucrative fellowships such as Mohs fellowship rather than Dermpath. It's so funny to see path residents look at Dermpath as the golden fellowship whereas Derm residents don't.

I beg to disagree. Procedural dermatology fellowships (preferred term over Mohs because they are also taught other stuff during fellowship training) are easier to come by for Derm residents that Dermpath fellowships. Dermpath fellowships are extremely competitive even for Derm residents.

 

[b&ierstiefel]

I beg to disagree. Procedural dermatology fellowships (preferred term over Mohs because they are also taught other stuff during fellowship training) are easier to come by for Derm residents that Dermpath fellowships. Dermpath fellowships are extremely competitive even for Derm residents.

That's not what I was saying. I was making an observation about how dermpath seems more popular for path residents than for derm residents...you see a lot more pathology applicants these days flat out saying "I wanna do dermpath" than dermatology applicants. What percentage of people in path are interested in dermpath vs. the percentage of people in derm who are interested in dermpath? I would contend that the former is greater than the latter. Of course, a lot of work in dermpath involves scope work and that will tend to be more attractive for pathology-inclined folks. But I am not blind to the fact that $$$$$ is a big motivating factor. How sad is it that we have such a hard time getting into a dermpath fellowship so that we can make $$$$$ whereas derm residents have an easier time (I'm assuming you're right) getting their Mohs/procedural derm fellowships so that they can make $$$$$$$$$$$$$$?

 

[yaah]

Going to a program that has fellowships is advantageous for a few reasons. One, you have the "inside track" although as said above, this doesn't guarantee you squat. You will have to work just as hard, but your program will be more likely to recognize and reward your efforts than an outside program who knows you only as a CV or a face they met once. Two, the program has enough volume and teaching in the area to support a fellowship. Thus, the training in that field will likely be excellent, and at the very least it will be adequate. Like at my program, GI path is excellent, so I almost feel like I've done extra training in GI and I have relative expertise in it, even without extra training. Three, you do your residency and work with experts in the field, who can not only teach you but can get you involved in projects and can write you letters that will be given more respect. Because, truth be told, if you are applying for a fellowship and have a letter from a renowned expert in the field, that letter holds more weight.

The "good" news for derm-inclined people is that there seem to be more fellowship spots every year. Although it might be offset by an equal increase in applicants. The "quality" of applicant that dermpath fellowship directors get is insane. A lot of applicants seem to want to do research in it to as the primary part of their career, I guess because Melanoma is a "hot" area. So of course these applicants often get more priority.

You could also run into a situation where multiple residents in the same class are gunning for the same fellowship, however.

 

[106174]

How sad is it that we have such a hard time getting into a dermpath fellowship so that we can make $$$$$ whereas derm residents have an easier time (I'm assuming you're right) getting their Mohs/procedural derm fellowships so that they can make $$$$$$$$$$$$$$?

That is the thing, though - I am not certain that Mohs makes more money than Dermpath. I might have misunderstood them but my Derm friends and colleagues have told me that the reimbursements for Mohs have been cut dramatically. Also, Plastics compete against them. Whenever we do get into discussions about money, Dermpath seems to be better than Mohs. However, it will not take very long before Medicare cuts down on the reimbursements for 88305s, so this for sure will change in the very near future.

 

[l&usibari]

Since the subject of dermpath compensation has come up, I would like to pose a question that I have been wondering about. As I understand it, there are four primary destinations for someone BE/BC in dermpath:

1) Academics: you can do a mix of clinical sign-out (in just dermpath or also general surgpath, for path people), clinics (for derm people), research and teaching. You start off as an instructor or assistant professor, just like anyone else, making no more than, say, $130,000.

2) Private practice: you join a group of other pathologists or dermatologists, and the money you bring in from signing out skins is combined with everyone else's money, and salaries are handed out from this pot based more on seniority or partnership status than on how much money you are bringing in. Starting salary is anywhere from $170,000 to $250,000.

3) Ameripath-type place: you are a salaried employee making about the same as someone in private practice.

4) Private dermatopathology lab: this is where you can make more serious money. Salaries can range from $200,000 to $400,000+, and you just sign out skins everyday.

If I am correct, most of these options don't leave you making more money than other specialty-trained people. It's only the few people who go into dermpath labs (or start their own company) who can making a killing. Am I missing something? I am interested in both dermpath and academics and don't expect to make any more money than anyone else in academics. Anyone with some experience willing to clarify?

 

[yaah]

I think you're probably right. There are probably some academic places which give a bit more compensation (perhaps as a reward or bonus for signing out lots of cases?) to dermpath as opposed to other surg path, but I don't know how common this is or if it even exists.

 

[b&ierstiefel]

That is the thing, though - I am not certain that Mohs makes more money than Dermpath. I might have misunderstood them but my Derm friends and colleagues have told me that the reimbursements for Mohs have been cut dramatically. Also, Plastics compete against them. Whenever we do get into discussions about money, Dermpath seems to be better than Mohs. However, it will not take very long before Medicare cuts down on the reimbursements for 88305s, so this for sure will change in the very near future.

That's a good point about competition from Plastics...I hadn't taken that into consideration. I wasn't aware of decreased imbursements for Mohs; it makes sense given a trend in declining reimbursements within medicine in general.

 

[schrute]

It's so funny to see path residents look at Dermpath as the golden fellowship whereas Derm residents don't.

Agreed on that...I talked extensively so some dermpath fellows from derm programs, and they expressed near regret in their choice because it's hard to find a practice that incorporates enough path opportunity to make it lucrative enough to make up for the clinic-time they lose.

 

[106174]

Agreed on that...I talked extensively so some dermpath fellows from derm programs, and they expressed near regret in their choice because it's hard to find a practice that incorporates enough path opportunity to make it lucrative enough to make up for the clinic-time they lose.

Actually, I think the opposite is true. Derm-trained dermatopathologists do dermpath to augment significantly their incomes and to have the option to see less patients (they too can only take so much of patient care). Come to think of it - they can see 10-15 patients in one half day and in that same amount of time, they can sign out more than a hundred slides. Do the math. In fact, the truth of the matter is that Derm-trained dermatopathologists gradually give up patient care over time to the point that after several years, a lot of them do not even see patients anymore.

Having said all that, I think the bottomline is that one should not pursue Dermpath just because it seems to be the most lucrative. Times are changing and Medicare is out to get all of us. There is nothing certain about the future and there is only one thing that we can all take comfort in - as long as you are doing what you truly love, you should be fine. So, pursue a fellowship based largely on genuine interest and not on potential monetary gains. It is such a cliche but it could not hold more truth, specially these days.

 

[schrute]

In fact, the truth of the matter is that Derm-trained dermatopathologists gradually give up patient care over time to the point that after several years, a lot of them do not even see patients anymore.

i can see that, but i'm not sure the majority of them want to give up that aspect of patient care...why not just do path? is it all about the green?

Having said all that, I think the bottomline is that one should not pursue Dermpath just because it seems to be the most lucrative. Times are changing and Medicare is out to get all of us. There is nothing certain about the future and there is only one thing that we can all take comfort in - as long as you are doing what you truly love, you should be fine. So, pursue a fellowship based largely on genuine interest and not on potential monetary gains. It is such a cliche but it could not hold more truth, specially these days.

i agree, and would be nervous to do a fellowship that would make my subsistence rely on 1 code.

 

[exPCM]

i can see that, but i'm not sure the majority of them want to give up that aspect of patient care...why not just do path? is it all about the green?


i agree, and would be nervous to do a fellowship that would make my subsistence rely on 1 code.

Gastroenterologist: 75-80% of income dependent on one procedure: 45378 colonoscopy
Interventional Cardiologist: dependent on coronary cath/stenting
Urologist: cystoscopy, prostate biopsy
Anesthesiology: anesthesia units
General Surgery: gallbladder, hernias
Family Practice: 99213 established patient office visit most commonly used code
General Sugical Pathology: 88302, 88304, 88305, 88307, 88309 (5 main codes)
Any and all codes can have their rembursements cut at any time.

 

[mlw03]

getting back to the original question, it depends on your long-term goals. if you want a competitive fellowship, going somewhere they have it is worth strongly considering.

 

[pathstudent]

Having said all that, I think the bottomline is that one should not pursue Dermpath just because it seems to be the most lucrative. Times are changing and Medicare is out to get all of us.

Medicare can't make dermpath unlucrative relative to the rest of pathology, and dermpath isn't inherently more lucrative. It is because of the way medicare reimburses biopsies. They are typically coded as 88305 and you get paid about $35-40 every time you sign one out depending on where you practice. Insurance companies will give you a percentage of medicare, typically 100-120%. If you order special stains or immunos you can earn even more for interpreting them.

By comparison a more involved specimen like a lumpectomy is coded as an 88307 and pays around $60-65. And then a much more involved one like a pancreatoduodenectomy or mastectomy is coded as 88309 and pays around 100, I think.

A gross only is an 88300 and pays $4.

You can sign-out 20 biopsies in the time it takes you to read out a lumpectomy. That's why biopsy rich practices are more lucrative. It is not just dermpath.

To be more reasonable and 88309 should probably pay more like 500 and an 88307 should pay more like 300. Then there would be more balance and people wouldn't be fighting like dogs over the 88305s.

 

[schrute]

Gastroenterologist: 75-80% of income dependent on one procedure: 45378 colonoscopy
Interventional Cardiologist: dependent on coronary cath/stenting
Urologist: cystoscopy, prostate biopsy
Anesthesiology: anesthesia units
General Surgery: gallbladder, hernias
Family Practice: 99213 established patient office visit most commonly used code
General Sugical Pathology: 88302, 88304, 88305, 88307, 88309 (5 main codes)
Any and all codes can have their rembursements cut at any time.

Ok, wise guy, I understand, but you can't even come close to comparing urology or gen surg with dermpath in terms of narrowness.

 

[Nilf]

Medicare can't make dermpath unlucrative relative to the rest of pathology, and dermpath isn't inherently more lucrative. It is because of the way medicare reimburses biopsies. They are typically coded as 88305 and you get paid about $35-40 every time you sign one out depending on where you practice. Insurance companies will give you a percentage of medicare, typically 100-120%. If you order special stains or immunos you can earn even more for interpreting them.

By comparison a more involved specimen like a lumpectomy is coded as an 88307 and pays around $60-65. And then a much more involved one like a pancreatoduodenectomy or mastectomy is coded as 88309 and pays around 100, I think.

A gross only is an 88300 and pays $4.

You can sign-out 20 biopsies in the time it takes you to read out a lumpectomy. That's why biopsy rich practices are more lucrative. It is not just dermpath.

To be more reasonable and 88309 should probably pay more like 500 and an 88307 should pay more like 300. Then there would be more balance and people wouldn't be fighting like dogs over the 88305s.

This whole spiel about coding gives me serious retching. Scrap this socialistic system and let free market decide how much doctors bill for their work... every other profession does that.

 

[mlw03]

why do so many threads have to turn into a discussion about dermpath and/or money? there are plenty of those. let's instead focus on the original question, which is a very important one for those of us to consider as we evaluate residency programs.

as i see it there are 2 answers to the question, one if you KNOW you want a competitive fellowship and another if you don't. if you know you do, then i think that yes, it might be worth going to an overall less desireable fellowship if you think that by doing so you'll have an in for that fellowship. that's a big contingency, and i don't know how you go about determining that. if you don't know what you want, then i think it gets tougher - there are arguments to be made on both sides, but personally i'd go to the program i liked better overall and then take my chances for fellowship.

 

[b&ierstiefel]

Going to a program that has fellowships is advantageous for a few reasons. One, you have the "inside track" although as said above, this doesn't guarantee you squat. You will have to work just as hard, but your program will be more likely to recognize and reward your efforts than an outside program who knows you only as a CV or a face they met once. Two, the program has enough volume and teaching in the area to support a fellowship. Thus, the training in that field will likely be excellent, and at the very least it will be adequate. Like at my program, GI path is excellent, so I almost feel like I've done extra training in GI and I have relative expertise in it, even without extra training. Three, you do your residency and work with experts in the field, who can not only teach you but can get you involved in projects and can write you letters that will be given more respect. Because, truth be told, if you are applying for a fellowship and have a letter from a renowned expert in the field, that letter holds more weight.

I agree with this 100%. Why make life harder for yourself so early in the game by going to a place where you will NOT have this?

The "good" news for derm-inclined people is that there seem to be more fellowship spots every year. Although it might be offset by an equal increase in applicants. The "quality" of applicant that dermpath fellowship directors get is insane. A lot of applicants seem to want to do research in it to as the primary part of their career, I guess because Melanoma is a "hot" area. So of course these applicants often get more priority.

That's the funny thing. Most of the dermpath fellowships are in academic centers so as an applicant, that's what you're SUPPOSED to say. However, do a lot of these people go into research? Do these people do postdocs? Not many. Many go off to simply practice and they lock in some sweet deals.

 

[l&usibari]

That's the funny thing. Most of the dermpath fellowships are in academic centers so as an applicant, that's what you're SUPPOSED to say. However, do a lot of these people go into research? Do these people do postdocs? Not many. Many go off to simply practice and they lock in some sweet deals.

While I agree that there is some element of game-playing to the application process, a reasonable way to separate the game players from the people who are genuinely interested is their track record. If they're already doing research (and not just case reports), I think there is a good chance they will continue to do so. And I don't think going the postdoc route is necessary to contribute academically, particularly if you are interested in more translational/clinical projects than basic science.

 

[b&ierstiefel]

While I agree that there is some element of game-playing to the application process, a reasonable way to separate the game players from the people who are genuinely interested is their track record. If they're already doing research (and not just case reports), I think there is a good chance they will continue to do so. And I don't think going the postdoc route is necessary to contribute academically, particularly if you are interested in more translational/clinical projects than basic science.

Unfortunately, a lot of these game players are MD/PhDs who have a strong publication record. These folks hold the cards.

Agreed regarding postdoc...you don't need one. Thing is, dermpath seems to be hurting for people who do basic science. At the major academic programs, they do want a lot of folks who are basic science oriented. Interestingly, dermpath gives people good options (good job security and money) that lure them away from the basic science track (hard times due to decreased NIH funding and more years of low pay).

The whole thing is hilarious to me actually. Basic science is hurting; unfortunately, the higher-up's don't want to invest the energy to fix the problem and expects the problem to fix itself.

 

[b&ierstiefel]

Another way is to offer it as a two year fellowship and make the first year a mandatory research year.

That's an idea...unfortunately, I don't think that's going to fix the problem...

Fine, somebody has to wait 2 years to get to the cash camel rather than 1 year. Also, I think there are some dermpath fellowships out there that are 2 years in duration. I don't see how that really discourages people. Plus, it gives the dermpath fellow an extra year of "protected" time to search for and find the right job

 

[exPCM]

Any thoughts on going to a good path res program that has very competitive fellowships like GI or dermpath vs. a great program without such competitive fellowships?

I would DEFINITELY recommend going to programs that have the fellowships on site. When I was applying to fellowships there were programs that sent me emails saying that they were taking an internal candidate and not conducting any interviews.
Just do the math:
Dermpath ~60 slots per year
Dermatologists have been getting 50% of these slots
That leaves 30 slots for pathologists.
There are greater than 500 pathology residents now graduating each year.
That means there are only enough spots to allow 30/500+ or 6% of graduating pathology residents to get into dermpath. The 6 percent number is a rough estimate since you must consider that there are also surgpath fellows and practicing pathologists applying for these slots.