Cut In Required Autopsy Numbers

[exPCM]

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As noted below the required number of autopises has been reduced to 50.

"In fact, the required number of autopsies for board qualification was 75 a few years ago, but the number was reduced to 50 because of insufficient autopsy rates in many training institutions. It is now permissible for two pathology residents to share in the performance of an autopsy for the purpose of board qualification, another adjustment necessitated by low autopsy rates."
http://www.cdc.gov/nchs/data/series/sr_03/sr03_032.pdf

I disagree with the statement that the cut in numbers for board certification was "necessitated" or absolutely necessary - an equally valid fix would have been to cut the number of residents. However who would expect programs to cut back on their resident cash cows. Again it is not about education - why did people need 75 before and only 50 now if it was deemed an essential part of the education for a resident to perform at least 75 autopsies.

Now autopsy numbers are still declining in many places. What will the ABP do next: let residents share more autopsies, let residents fudge the numbers, cut the required number again, or force programs to cut their residents slots so that each resident can meet this educationally necessary requirement of 50 (which a few years ago was 75)?

 

[yaah]

It's been 50 for at least 10 years, as far as I know. ABPath has no requirements on numbers of shared cases. They just ask you on the board application how many were shared (they don't say if there is a limit). Theoretically all your autopsies could be shared and limited in some fashion. The only thing that is required is that you document 50, and they basically trust your program to certify that fact (since all you have to submit is age and cause of death, not autopsy accession number or anything like that). Individual programs have limits on how many can be shared autopsies, how many can be limited, how many can be forensic, etc. But the ABPath, to the best of my knowledge, does not.

Big hospitals used to have 3-4 autopsies every day, now they are lucky to get 3 or 4 per week.

 

[exPCM]

It's been 50 for at least 10 years, as far as I know. ABPath has no requirements on numbers of shared cases. They just ask you on the board application how many were shared (they don't say if there is a limit). Theoretically all your autopsies could be shared and limited in some fashion. The only thing that is required is that you document 50, and they basically trust your program to certify that fact (since all you have to submit is age and cause of death, not autopsy accession number or anything like that). Individual programs have limits on how many can be shared autopsies, how many can be limited, how many can be forensic, etc. But the ABPath, to the best of my knowledge, does not.

Big hospitals used to have 3-4 autopsies every day, now they are lucky to get 3 or 4 per week.

Yes, so the numbers were arbitrarily changed. Nothing to do with education - just another example of easing requirements to prevent programs from having to cut residency slots.
Look at the cytology numbers for the boards - 1500 cases. That is one months worth of cases for a typical cytotech - what a ridiculously low number.
Surgpath - 2000 cases for the boards - That is 10 weeks or less worth of cases for most pathogists I know.
The target numbers in path are very lax so that spots do not get cut.
I remember you posting about a resident who did not see an inhouse prostate biopsy in her whole residency. How about starting to strip accreditations from programs that lack basic and adequate case material.

Even enforcing the weak numbers below would help cut out some of the poor programs out there:

 

[yaah]

50 or more neuromuscular biopsy specimens? Good luck with that one. I agree most of those numbers are laughable, some for different reasons than others.

 

[gungho]

Y
Surgpath - 2000 cases for the boards - That is 10 weeks or less worth of cases for most pathogists I know.

so you're saying most pathologists you know sign out ~10K/yr? seriously? this is general surg path and not GI or derm only?

 

[levels x3]

I don't want to get into whether or not there really is an oversupply of pathologists and pathology residents in the country, but I don't see how declining autopsy rates are an indication of a need to cut residency spots. Autopsy rates say nothing about the number of pathologists needed in the workforce.

Numbers of surg path and cyto cases needed for board certification doesn't say anything about residency slots either. Those numbers are dictated simply by the amount of time within a 4 year AP/CP residency that can be devoted to those areas. If you think the numbers are too low (and you might be right), you should be making an argument for changing the structure of AP/CP training, not the numbers trained.

 

[exPCM]

so you're saying most pathologists you know sign out ~10K/yr? seriously? this is general surg path and not GI or derm only?

We do an average of about 40 cases/day x 45 weeks/yr each so about 9K per year in my group. Most of the group does gensurg path with some subspecialty expertise. I actually am at ~60 cases/day (75% dermpath, 25% surgpath) currently.

From talking to friends in other groups 40 cases/day (mixed small and large specimens) has become a pretty standard benchmark in general surgpath.

 

[TMZ2007]

We do an average of about 40 cases/day x 45 weeks/yr each so about 9K per year in my group. Most of the group does gensurg path with some subspecialty expertise. I actually am at ~60 cases/day (75% dermpath, 25% surgpath) currently.

From talking to friends in other groups 40 cases/day (mixed small and large specimens) has become a pretty standard benchmark in general surgpath.

Is that over a full 8-5 (minus lunch) workday? Just curious.

 

[2121115]

We do an average of about 40 cases/day x 45 weeks/yr each so about 9K per year in my group. Most of the group does gensurg path with some subspecialty expertise. I actually am at ~60 cases/day (75% dermpath, 25% surgpath) currently.

From talking to friends in other groups 40 cases/day (mixed small and large specimens) has become a pretty standard benchmark in general surgpath.

I have also heard that 40 cases is standard in a busy practice.

I guess it depends on how many TA's and BCC's there are versus lumpectomies and etc to determine how long it would take to sign out that many cases.

 

[exPCM]

I don't want to get into whether or not there really is an oversupply of pathologists and pathology residents in the country, but I don't see how declining autopsy rates are an indication of a need to cut residency spots. Autopsy rates say nothing about the number of pathologists needed in the workforce.

Numbers of surg path and cyto cases needed for board certification doesn't say anything about residency slots either. Those numbers are dictated simply by the amount of time within a 4 year AP/CP residency that can be devoted to those areas. If you think the numbers are too low (and you might be right), you should be making an argument for changing the structure of AP/CP training, not the numbers trained.

I do not think you understand the point of my post. The decrease in the autopsies required in residency shows how arbitrary these numeric cutoffs are. If a resident 10 years ago had to do at least 75 then why is it 50 now? Was 75 too many or is 50 too few? It seems like the targets are not based on educational needs but based on changing numbers as needed to keep the pipeline of residents flowing at full blast.

I hope that higher standards could be established to weed out programs that do not have the sufficient and diverse volume of material needed to provide broad based training in pathology. If things continue as they are now I predict that within 3-4 years the worsening glut of pathologists will lead to complete chaos in pathology as a field. Even those who feel they have secure hospital contracts will be under pressure from lowball bidders who are desperate for work.

 

[lipomas]

I think it used to be 75 because there were loads of autopsies in hospitals until about 20 years ago, and now there are fewer. I don't think it has anything at all to do with numbers of residents. Autopsies are the weak link in pathology training - a lot of people don't care about them and just want to get them out of the way.

I think the change in target is based on the declining relevance of autopsy in general. It might as well be 25. Or just eliminate it and make autopsy/forensics its own specialty. Our group basically pays people to do our autopsies anyway since most of them are potential medicolegal issues.

 

[exPCM]

I think it used to be 75 because there were loads of autopsies in hospitals until about 20 years ago, and now there are fewer. I don't think it has anything at all to do with numbers of residents. Autopsies are the weak link in pathology training - a lot of people don't care about them and just want to get them out of the way.

I think the change in target is based on the declining relevance of autopsy in general. It might as well be 25. Or just eliminate it and make autopsy/forensics its own specialty. Our group basically pays people to do our autopsies anyway since most of them are potential medicolegal issues.

Okay why don't we eliminate the autopsy requirement? For that matter why don't we let people sit for the path boards without even needing to do a residency? Who needs standards in pathology? We can have people just learn pathology on the internet. We can churn out 10000 new pathologists per year. Any FP, IM, or peds doc could just do some pathology on the side. Sounds perfect.

 

[KeratinPearls]

Okay why don't we eliminate the autopsy requirement? For that matter why don't we let people sit for the path boards without even needing to do a residency? Who needs standards in pathology? We can have people just learn pathology on the internet. We can churn out 10000 new pathologists per year. Any FP, IM, or peds doc could just do some pathology on the side. Sounds perfect.

It seems as if you are so passionate about how the path job market sucks, etc. Have you thought about how to bring it in front of the leaders in pathology? We all can keep on citing examples of how the job market sucks, but if we dont do take action, then all the arguing/debate here on SDN is meaningless.

 

[lipomas]

Okay why don't we eliminate the autopsy requirement? For that matter why don't we let people sit for the path boards without even needing to do a residency? Who needs standards in pathology? We can have people just learn pathology on the internet. We can churn out 10000 new pathologists per year. Any FP, IM, or peds doc could just do some pathology on the side. Sounds perfect.

Eliminating the autopsy requirement would not be a bad idea, if those with forensic/autopsy training were to do all of the autopsies anyway. General pathologists used to have to have significant autopsy training because most practices required performance of autopsies. There were too many for experts to handle. Now that is at least on the verge of being no longer true, if it has not happened already. This has nothing to do with the job market or overtraining of residents (apparently you are insisting on making it so). It has everything to do with practicality and general practice characteristics. As I said, in my group there are some who like doing autopsies, but most just call the guy who does them for us because they are not worth the trouble.

Of course, that also raises the argument of why bother training in things you aren't going to use for your future career anyway, but it's hard to draw that line much beyond general AP, general CP, and autopsy.

The other criticism is that I did learn a bit during autopsy rotation about general pathology, so exposure during residency would be hard to eliminate. But could I have learned even more if I replaced those rotations with more surg path? Since you want to relate everything to the oversupply of residents, if we did this we would require FEWER residents in programs, because those covering autopsies wouldn't have to anymore.

 

[dodobird13]

We do an average of about 40 cases/day x 45 weeks/yr each so about 9K per year in my group. Most of the group does gensurg path with some subspecialty expertise. I actually am at ~60 cases/day (75% dermpath, 25% surgpath) currently.

From talking to friends in other groups 40 cases/day (mixed small and large specimens) has become a pretty standard benchmark in general surgpath.

i do 40-60 surgicals a day but most are small. well don't let that fool you since one inflammatory dermatosis or agonizing breast case can totally jack you up. anyway plus 40-60 paps and a few non-gyns (<20). it's a 8 to 12 hour workday depending. not a lot of time for dillydallying but that's ok.

 

[Gyric]

i do 40-60 surgicals a day but most are small. well don't let that fool you since one inflammatory dermatosis or agonizing breast case can totally jack you up. anyway plus 40-60 paps and a few non-gyns (<20). it's a 8 to 12 hour workday depending. not a lot of time for dillydallying but that's ok.

That is useful to know. A few more questions to the practicing pathologists, if you don't mind.

What percentage of your cases are delayed by immunos? Do you get them same day? How many of those are bone marrows? How many cases in an average month would you send out for consult? How much CP do you fit into that day?

 

[yaah]

I have sent out one consult in 2 months since i started. Usually do immunos on an average of one case every two days, usually do not get them the same day. I don't do many bone marrows, they rotate among us and there are usually 1-2 per day total, sometimes more (which means 2-3 per week each, although some people get more than others). CP varies. It's more of an on call responsibility unless we are covering heme stuff or blood bank during the day. Today I did a lot of CP. Spent a couple of hours troubleshooting/validating a molecular test, spent an hour or two on flow cases, and had a bone marrow and a couple of peripheral smears. I also had about 15 cytology cases and only ended up with about 7-8 surgicals, although they were almost all 10+ slides (prostates mostly).

 

[2121115]

I also had about 15 cytology cases and only ended up with about 7-8 surgicals, although they were almost all 10+ slides (prostates mostly).

Are your cyto cases paps and exfoliative or FNA?

 

[Gyric]

Thanks yaah!

 

[yaah]

I don't do paps and I don't perform FNAs.

 

[dodobird13]

That is useful to know. A few more questions to the practicing pathologists, if you don't mind.

What percentage of your cases are delayed by immunos? Do you get them same day? How many of those are bone marrows? How many cases in an average month would you send out for consult? How much CP do you fit into that day?

well define "delayed"... if everything goes the way it's supposed to I'll get my immunos the next day... pretty standard. I do not do bone marrows. in 2 1/2 months of working i've sent maybe three or four cases out for consult. CP can be hit or miss. days go by and i won't have to deal with it at all but then one random phone call can really put you back an hour or two.

 

[pathstudent]

I don't do paps and I don't perform FNAs.

Redacted. None of my business

 

[2121115]

It sounds like you are in a community hospital Don't you miss being in an enviroment where all your colleagues are experts in their areas? Is the extra money really worth the lack if intellectual exploration and the joy of training medical students residents and fellows and the joy being mentored by the best and the brightest in a particular subspecialty?

Are your hours worse or better than an academics?

Would love to hear the answer to this. 🙄

 

[pathstudent]

Would love to hear the answer to this. 🙄

Nevermind it is none of my business

 

[yaah]

I am in an environment where my colleagues are experts. I am also in an environment where my colleagues are not pretentious. And it is very intellectually stimulating, probably more so than many academic institutions. Unfortunately I am not forced to prove my intellectual worth by publication, so I guess it doesn't matter.

 

[pathstudent]

I am in an environment where my colleagues are experts. I am also in an environment where my colleagues are not pretentious. And it is very intellectually stimulating, probably more so than many academic institutions. Unfortunately I am not forced to prove my intellectual worth by publication, so I guess it doesn't matter.

Ok. I got to bite. Do you means experts like applman, odze, demay, jaffe, barnes, weiss, unni, Fletcher, zaloudek, burger, vardiman? Because those people don't do cyto and bone marrows and cp and surgicals every day. They are focused like a laser beam on one single target.

 

[KluverB]

Ok. I got to bite. Do you means experts like applman, odze, demay, jaffe, barnes, weiss, unni, Fletcher, zaloudek, burger, vardiman? Because those people don't do cyto and bone marrows and cp and surgicals every day. They are focused like a laser beam on one single target.

experts like ... = The Noble Lie.

 

[yaah]

Ok. I got to bite. Do you means experts like applman, odze, demay, jaffe, barnes, weiss, unni, Fletcher, zaloudek, burger, vardiman? Because those people don't do cyto and bone marrows and cp and surgicals every day. They are focused like a laser beam on one single target.

No. There are other kinds of experts. And by the way, most of the people you listed are excellent at multiple areas in pathology. Not all, but most.

 

[BrainPathology]

Ok. I got to bite. Do you means experts like applman, odze, demay, jaffe, barnes, weiss, unni, Fletcher, zaloudek, burger, vardiman? Because those people don't do cyto and bone marrows and cp and surgicals every day. They are focused like a laser beam on one single target.

Why is Fletcher the only one who deserves his name properly capitalized?

I wonder if people who can have the kind of tunnel vision that you suggest (which they don't btw, at least the three from that group that I've met) will exist for long now that we all have to recertify every 10 years (and the super specialized retire.. which they will all do about 5 years ago I think). I also wonder if they should.