Darn Radiologists :)

[EtOHWithdrawal]

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Any thoughts on the future of pathology?
In the last couple days I have read two articles that both discuss Radiology advances i.e. elastography and virtual colonoscopy. There are others.
It may be complete ignorance on my part or perhaps a massive misunderstanding of the nature of the field, but these continuing advances by radiologists seems to threaten the need for breast specialists or GI specialists, for instance, or at least limit the need for a large number of them. Or how about the HPV vaccine and it's effect on the need for cervical cancer screening in the future, hence it's effect on cytologists?
Where is the future? Molecular tests? Cytogenetics? How will pathology defend itself and maintain relevance? Will it need to?
Any thoughts would be interesting.
I don't pretend to believe these changes will happen overnight, if at all, or even affect the practice of pathology as a whole. But it must concern some others out there. Sorry if this has been addressed elsewhere.
Cheers
E

 

[salmonella]

Any thoughts on the future of pathology?
In the last couple days I have read two articles that both discuss Radiology advances i.e. elastography and virtual colonoscopy. There are others.
It may be complete ignorance on my part or perhaps a massive misunderstanding of the nature of the field, but these continuing advances by radiologists seems to threaten the need for breast specialists or GI specialists, for instance, or at least limit the need for a large number of them. Or how about the HPV vaccine and it's effect on the need for cervical cancer screening in the future, hence it's effect on cytologists?
Where is the future? Molecular tests? Cytogenetics? How will pathology defend itself and maintain relevance? Will it need to?
Any thoughts would be interesting.
I don't pretend to believe these changes will happen overnight, if at all, or even affect the practice of pathology as a whole. But it must concern some others out there. Sorry if this has been addressed elsewhere.
Cheers
E

The financial future of pathology is grim. Job prospect is bad. Here is why:
-Self referral threat. GI docs and urologists have their own pathology labs, and will hire pathologists to work for them part time and pay them low salary
-No control over patients. Pathologist's business only comes from clinicians.
-Turf battle with PhDs, especially in clinical pathology labs
-Radiologists will likely take over molecular imaging
-Tele-pathology, and potential outsourcing to other countries
-Decreasing medicare reimbursement
Unless you want to do basic science research in academic or biotechnology companies, I suggest you shy away from pathology.

 

[Gut Shot]

It may be complete ignorance on my part or perhaps a massive misunderstanding of the nature of the field, but these continuing advances by radiologists seems to threaten the need for breast specialists or GI specialists, for instance, or at least limit the need for a large number of them.

On the contrary, all these new technologies do is increase the number of biopsies that are performed. Until rads comes up with something that will replace tissue diagnosis these new modalities are just going to increase workload for path.

 

[Gut Shot]

Unless you want to do basic science research in academic or biotechnology companies, I suggest you shy away from pathology.

I'm sorry, I must have missed it. Who the f**k are you, again?

 

[EtOHWithdrawal]

Interesting. Incidental findings. "What the heck is that thing in the colon on that virtual colonoscopy? I'm not sure, but clinical follow up may be warranted. Better biopsy it."

 

[Gut Shot]

Interesting. Incidental findings. "What the heck is that thing in the colon on that virtual colonoscopy?

Considering that no definitive diagnosis would be made by virtual colonoscopy in the first place, and that any finding would require further study (i.e. biopsy), they're hardly incidental.

 

[DarksideAllstar]

Decreasing medicare reimbursement

Wow, isn't this happening in every field of medicine?

 

[f_w]

- double contrast barium enema didn't eliminate pathology
- colonoscopy didn't eliminate pathology

why would CT colonography eliminate pathology ?

On the contrary, the more accessible colon cancer screening becomes, the more polyps will be found. The more polyps are found, the more diagnostic colonoscopies are done. The more diagnostic colonoscopies, the more biopsies are done.

Same applies to the mammo field. None of the imaging modalities will eliminate the need for biopsies. There is just too much stuff growing in boobs that doesn't have a clear-cut imaging appearance.

And yes, 30-60 years from now, universal HPV vaccination of kids will sharply reduce the prevalence of the cancer relevant HPV subtypes. As a result incidence of cervical cancer and its precursors might decrease to a level that obviates the need for a screening program.

 

[djmd]

Clearly we are cross linked... where are all these non pathologist coming from??

 

[Gyric]

Self referral threat: True, this is a threat to a valuable income stream, it will not destroy the profession however. The gloves do need to come off at the legislative level though.

No control over patients: And that’s a bad thing? That is the specialist model and is almost without exception more lucrative than the gatekeeper role.

Turf battle with PhDs: This one cracks me up. It is our sandbox, we let them play in it. Many of us have PhDs also, we know how well prepared 7 years of grad school makes you for the process of clinical decision making. If you think there is a glut of pathologists, look at the PhD market. I bet I could run a whole clin lab with starving postdocs if I wanted to. In the end diagnostic information is not provided from a laboratory without physician, typically pathologist, oversight.

Radiologist will take over molecular imaging. Come on. Maybe you have this image of an old pathologist curled up in the fetal position getting spanked by all the other medical specialties but I assure you there is a bit more backbone in most of us … in the end the tissue comes to us, it is a turf battle radiology would lose.

Tele-pathology and outsourcing: Sure this may be a threat for some specialties, but I would put pathology a lot lower on the list than radiology. Sure it may be cheaper to have that neuro frozen read in India but do you think the neurosurgeon is really going to go for that?

Decreasing medicare reimbursement: No argument there, still pathologist do a hell of a lot better than most specialties, especially per hour.

Actually I would recommend you shy away from pathology if you are sure you want to do basic science research, medicine is a much more facilitative career path in that regard, not a lot of R01 funded surgical pathologists out there.

 

[BU Pathology]

Self referral threat: True, this is a threat to a valuable income stream, it will not destroy the profession however. The gloves do need to come off at the legislative level though.

No control over patients: And that’s a bad thing? That is the specialist model and is almost without exception more lucrative than the gatekeeper role.

Turf battle with PhDs: This one cracks me up. It is our sandbox, we let them play in it. Many of us have PhDs also, we know how well prepared 7 years of grad school makes you for the process of clinical decision making. If you think there is a glut of pathologists, look at the PhD market. I bet I could run a whole clin lab with starving postdocs if I wanted to. In the end diagnostic information is not provided from a laboratory without physician, typically pathologist, oversight.

Radiologist will take over molecular imaging. Come on. Maybe you have this image of an old pathologist curled up in the fetal position getting spanked by all the other medical specialties but I assure you there is a bit more backbone in most of us … in the end the tissue comes to us, it is a turf battle radiology would lose.

Tele-pathology and outsourcing: Sure this may be a threat for some specialties, but I would put pathology a lot lower on the list than radiology. Sure it may be cheaper to have that neuro frozen read in India but do you think the neurosurgeon is really going to go for that?

Decreasing medicare reimbursement: No argument there, still pathologist do a hell of a lot better than most specialties, especially per hour.

Actually I would recommend you shy away from pathology if you are sure you want to do basic science research, medicine is a much more facilitative career path in that regard, not a lot of R01 funded surgical pathologists out there.

I would strongly urge you to enter pathology if you have an interest in basic science research. There are literally hundreds of NIH funded pathologists. Pathology encompasses far more than just surgical pathology. A rich, rewarding career awaits investigators who train in the pathology and use this information to integrate their basic science investigations and clinical problems.

One of the criteria used to judge any NIH grant is signifigance. The significance can be both at the basic science level and also at the clinical level. As a pathologist you can address both issues making a case that your studies address basic mechanisms of disease but also the clinical problem.

In my laboratory studies on sepsis we look at cells, animal models, patients and results from autopsies. My talks include autopsy photographs (de-identified of course) to emphasize the salient points about the pathophysiology of sepsis.

If your interest in pathology is driven primarily by the desire to have a non-stressful, highly lucrative lifestyle, please look elsewhere. If you want to make a significant contribution to the care of patients, or if you desire a basic science academic career with direct clinical relevance, come over to pathology.

Dan Remick, M.D.
Chair of Pathology, Boston University

 

[deleted113029]

And yes, 30-60 years from now, universal HPV vaccination of kids will sharply reduce the prevalence of the cancer relevant HPV subtypes. As a result incidence of cervical cancer and its precursors might decrease to a level that obviates the need for a screening program.

😕 I thought the vaccine addressed the four major HPV types that accounted for cervical cancer; 16, 18, 31, 33 (I believe). This altogether accounts for ~70% of all cervical cancers. This just allows more room for the other subtypes to occupy. Obviates the need for a screening program? You CRAZY! 😛

As long as women have sex with multiple partners (i don't believe this trend will decrease significantly as I have found out on my OB/GYN rotation) and SMOKE, then cervical cancer is here to stay.

 

[deleted113029]

If your interest in pathology is driven primarily by the desire to have a non-stressful, highly lucrative lifestyle, please look elsewhere. If you want to make a significant contribution to the care of patients, or if you desire a basic science academic career with direct clinical relevance, come over to pathology.

Dan Remick, M.D.
Chair of Pathology, Boston University

Good advice for people who are unsure about pathology and want to make a lot of money. I want to work next to/for people who WANT to learn and apply pathology for patients. An additional bonus is conducting research in whatever field of pathology that floats our boat so that we can understand MOD.

Sorry if I made anyone fall 😴

 

[pathdawg]

If your interest in pathology is driven primarily by the desire to have a non-stressful, highly lucrative lifestyle, please look elsewhere.

D'oh.

 

[dermpathlover]

D'oh.

PHEW!!!!!!!!!!!! I was looking for a field where I would have a stressful non-lucrative career. Good thing I found it.

 

[f_w]

😕 I thought the vaccine addressed the four major HPV types that accounted for cervical cancer; 16, 18, 31, 33 (I believe). This altogether accounts for ~70% of all cervical cancers. This just allows more room for the other subtypes to occupy. Obviates the need for a screening program? You CRAZY! 😛

The math behind screening programs requires an incidence high enough to justify the rate of false positive screening exams. Currently, the considerable expense of cervical cancer screening can be justified based on the high incidence of the disease, if it went down by 70% this issue would have to be revisited.
What is the biological mechanism you suppose to increase the prevalence of the other serotypes ?

As long as women have sex with multiple partners (i don't believe this trend will decrease significantly as I have found out on my OB/GYN rotation) and SMOKE, then cervical cancer is here to stay.

Last time I checked, it was the guys who spread around the virus from one female (or other male) to the other.

 

[PathOne]

Pathology is no blockbuster field, but it's certainly not going the way of the dinosaurs either:
- Rads. Yes, at my previous job, we had a bone conference once a week. The rads people but up fabulous 3D spinning colored images on the screen. At the end of the day, however, it was the verdict of the Pathologist, based on the biopsy, that decided the treatment options.
- Molecular medicine. Know a thing or two about that too, having spent two years in one of the top3 molec path labs in the country. Apart from heme and some rather exotic sarcomas, there's just basically no dx of a major malignant disease that can be performed solely on the molecular level, despite 20+ years of research.
- Screening. Lots of false positives (and true positives) that must invariably be confirmed based on a biopsy.
- Demographics. People get older. More treatment. More dx'ing.
- Medical advancement. Increased subspecialization. 30 years ago, derms read their own slide. Some still do. They're an endangered species.

I also once thought that molecular dx would take away the need for pathology. I'm pretty convinced it won't happen in my professional lifetime.

 

[deleted113029]

The math behind screening programs requires an incidence high enough to justify the rate of false positive screening exams. Currently, the considerable expense of cervical cancer screening can be justified based on the high incidence of the disease, if it went down by 70% this issue would have to be revisited.
What is the biological mechanism you suppose to increase the prevalence of the other serotypes ?



Last time I checked, it was the guys who spread around the virus from one female (or other male) to the other.

Well as to your first question, what do you know about Hib vs. nontypeable Hi? increasing incidence of CAP by nontypeable strains after the Hib vaccine.

As to your second question, it doesn't matter who spreads the disease because doesn't the woman have the cervix?!

Anyway...

 

[yaah]

PHEW!!!!!!!!!!!! I was looking for a field where I would have a stressful non-lucrative career. Good thing I found it.

Way to miss the point once again.

 

[mlw03]

Well as to your first question, what do you know about Hib vs. nontypeable Hi? increasing incidence of CAP by nontypeable strains after the Hib vaccine.

Of course vaccine programs will change disease demographics - ask any pediatrian about this topic. While the 16,18, 31, and 33 strains of HPV are the most common causes of cervical CA, I don't think anyone expects this program to eliminate the disease, especially in less developed nations. But it should certainly reduce the incidence and mortality from this.

Regarding the HPV vaccine, I've heard it referred to as "the first vaccine to prevent cancer" but I've always countered that the HepB vaccine deserves that title, as HepB is a major non-substance-related cause of hepatocellular carcinomas. So HepB vaccine can prevent cancer. Someone please correct me if I'm wrong in my argument.

 

[deleted113029]

Of course vaccine programs will change disease demographics - ask any pediatrian about this topic. While the 16,18, 31, and 33 strains of HPV are the most common causes of cervical CA, I don't think anyone expects this program to eliminate the disease, especially in less developed nations. But it should certainly reduce the incidence and mortality from this.

Regarding the HPV vaccine, I've heard it referred to as "the first vaccine to prevent cancer" but I've always countered that the HepB vaccine deserves that title, as HepB is a major non-cirrhotic cause of hepatocellular carcinomas. So HepB vaccine can prevent cancer. Someone please correct me if I'm wrong in my argument.

i'm not arguing about the HPV vaccine anymore...😴

I don't understand what you mean about HepB being a NON-CIRRHOTIC cause of HCC, because it is a CIRRHOTIC cause of HCC. 😉

 

[mlw03]

i'm not arguing about the HPV vaccine anymore...😴

I don't understand what you mean about HepB being a NON-CIRRHOTIC cause of HCC, because it is a CIRRHOTIC cause of HCC. 😉

sorry - i mis-stated. what i was trying to say was that HepB is a major non-alcohol related cause of HCC. for whatever reason i still think of substance versus viral causes of cirrhosis in a different light. although i do realize that from a histpathologic perspective, they're not. in fact now that i think about it more, i explicitly remember a pathologist teaching us "cirrhosis is cirrhosis is cirrhosis." so thank you for the correct - i'm going to go back and edit my previous post.