Dear LADOC: FAQ thread

[LADoc00]

Each week I get numerous PMs to my inbox. I am more than happy to answer your questions about pathology, training and business even philosophy. Recently though, many of those questions have been the same and I feel that our community would be best served if I posted the questions and my reply on this thread (sticky maybe?) to allow everyone the opportunity to benefit. I am going to do my best to protect the anonymity of the people who send me letters.

8/10/06

Dear LADOC,
You seem to know alot about the private practice market and potential (or lack of). Anyway im already knee deep in this field so I was wondering what fellowship between GI and heme should I choose. Ive done some research and have a couple of contacts with some GI programs, but ive also definitely got an in with a decent hemepath spot. What is a good choice for GI on the east coast? Should I go GI and forget Heme? What about going to a place like MSKCC and spending 2 years getting specialized in something like GI after a year of surg path. What are your thoughts?
~Apprehensive Resident

Dear AR,
I personally do not advocate pure cancer centers like SK for GI training. The private practice of GI is heavily weighted towards inflammatory/non-neoplastic disease. The small amount of neoplastic GI you encounter is easily learned from any basic residency program.
In terms of GI vs. Heme, I personally no longer advocate heme fellowships. In years past, flow cytometry reimbursement was based on a per antibody charge. For a 21-antibody flow panel, total charges would be antibody interp.x21, if you charged $99 per antibodyx21=nearly $2,100/flow+morph charges on the marrow. This made heme a near equivalent of dermpath in terms of value. This changed last year, now instead of a per antibody charge you are given so much per "antibody group" and they max out: 14+ antibodies is now billed as a single $128.00 medicare charge. That is a >90% slash in the prime moneymaker of the entire subspecialty. To add insult to injury, reimbursements for doing both flow and paraffin-based IHC on the same specimen is currently being disallowed. So if you do flow on the aspirate, but then do a cyclin D1 on the core biopsy, they disallow the higher charge set, in this case the flow.
GI is enjoying a very astronomical rise to power in the current market. But realize that this isnt the same for every community. Some GI groups do endoscopy within the confines of a hospital, so although it is truly outpatient, the business is automatically going to hospital-based pathologists just like a appendix would.(pathology groups sign exclusivity agreements with hospitals that guarantee any specimen within the hospital is theirs) Hospitals have realized that outpatient procedure centers are big moneymakers and are expanding them like crazy. In other communities, GI docs do the endo's in their own office settings and consequently have the choice on where to send em. They may send them to the local hospital based group OR they may go with a national lab. That is where is GI fellowships really shine.
In conclusion, if you are considering GI, take a look at places where you want to practice and inquire whether the GI docs in those communities are office or hospital based in their endos. If you are dead set on a big city, you can almost guarantee that GI training will be highly sought after.

Dear LADOC,
I'm starting to think about fellowships and I don't know what to do. I would like to do mostly surg path and cyto in a private practice setting. Should I do a SP fellowship since my AP experience is not the best? Or just go with a SP subspecialty? I'm thinking about cyto.
~Sleepless in DC

Dear Sleepless,
From year to year I can on occasion be found to flip flop and my answer to your question may seem a departure from things Ive said in the past. Cytology is by and large widely overtrained as a subspec. There are tons of cytologists, everywhere. But Ive learned the hard way there is a reason for that, non-gyn cytology is common and although pap smears maybe dying off, they will never go away. Im not advocating becoming boarded in cyto, but having a solid background in the field will help you wherever you land.
General Sp fellowships on the otherhand have fallen out favor, mainly due to the elimination of the credentialing year by the ABP. I however do think they have instrinsic value.
For instance, lets say you match you into a so-so AP program. About 6 months into it you realize SP isnt that bad and you want to go into private practice. Applying to top-notch SP programs is now easier than it has ever been, they are practically giving slots at places like UCSF, Stanford, Hopkins and the like away. Spending a year at UCSF will effectively make you a UCSF trained pathologist in the eyes of employers, even if you spent 4 years prior at West Virginia State.
In terms of COMBINING SP and cyto, UCSD has what I consider the premier program in the country. Other ways would be to ask to split the year between general SP and cyto.

 

[pathdawg]

LA,
I think this is a great idea. It reminds me of the Sports Guy (espn.com) and his mailbag. Perhaps you can make this a weekly on-line column, with witty remarks about the field, and occasionally ripping on the residents/students who write in.

 

[RyMcQ]

So if you do flow on the aspirate, but then do a cyclin D1 on the core biopsy, they disallow the higher charge set, in this case the flow.

This is not true. There is a new code modifier for charging for immunohistochemistry while simultaneously billing for flow. They might disallow repeated antibodies, i.e., CD20 on both, but reimbursement for cyclin D1 should never be denied because flow was also done. You could even occasionally make the case that the repeated marker was necessary for diagnosis.

 

[yaah]

According to the panel at the USCAP this past year, surg path fellowships are still very important - at least in terms of what employers are looking for.

 

[LADoc00]

This is not true. There is a new code modifier for charging for immunohistochemistry while simultaneously billing for flow. They might disallow repeated antibodies, i.e., CD20 on both, but reimbursement for cyclin D1 should never be denied because flow was also done. You could even occasionally make the case that the repeated marker was necessary for diagnosis.

Okay, what is the code modifier?? Tell me, Ill use it and see if I get reimbursed. You may be write about bcl-1 getting through, but I have been zapped on things like CD138 where flow the % is 1% but on core I showed it to be 70%. The core paraffin charge was denied, the bastards.

 

[LADoc00]

According to the panel at the USCAP this past year, surg path fellowships are still very important - at least in terms of what employers are looking for.

IF I was you, I would do a fellowship with Appelman and bolt out into the scene....before all the money is gone. Drying up fast now.

 

[DoubleHappiness]

8/10/06


Dear AR,
I personally do not advocate pure cancer centers like SK for GI training. The private practice of GI is heavily weighted towards inflammatory/non-neoplastic disease. The small amount of neoplastic GI you encounter is easily learned from any basic residency program.
In terms of GI vs. Heme, I personally no longer advocate heme fellowships. In years past, flow cytometry reimbursement was based on a per antibody charge. For a 21-antibody flow panel, total charges would be antibody interp.x21, if you charged $99 per antibodyx21=nearly $2,100/flow+morph charges on the marrow. This made heme a near equivalent of dermpath in terms of value. This changed last year, now instead of a per antibody charge you are given so much per "antibody group" and they max out: 14+ antibodies is now billed as a single $128.00 medicare charge. That is a >90% slash in the prime moneymaker of the entire subspecialty. To add insult to injury, reimbursements for doing both flow and paraffin-based IHC on the same specimen is currently being disallowed. So if you do flow on the aspirate, but then do a cyclin D1 on the core biopsy, they disallow the higher charge set, in this case the flow.
GI is enjoying a very astronomical rise to power in the current market. But realize that this isnt the same for every community. Some GI groups do endoscopy within the confines of a hospital, so although it is truly outpatient, the business is automatically going to hospital-based pathologists just like a appendix would.(pathology groups sign exclusivity agreements with hospitals that guarantee any specimen within the hospital is theirs) Hospitals have realized that outpatient procedure centers are big moneymakers and are expanding them like crazy. In other communities, GI docs do the endo's in their own office settings and consequently have the choice on where to send em. They may send them to the local hospital based group OR they may go with a national lab. That is where is GI fellowships really shine.
In conclusion, if you are considering GI, take a look at places where you want to practice and inquire whether the GI docs in those communities are office or hospital based in their endos. If you are dead set on a big city, you can almost guarantee that GI training will be highly sought after.

Just to add a little bit of advice, if that person is looking for GI path fellowship on the eastcoast, Mt. Sinai is probably the place to look. Like LADoc said, most GI volume is biopsies of inflammatory diseases. Mt. Sinai, I'm assuming, has the largest volume of IBD cases anywhere in the world. IBD was actually discovered in that dept.
NYC is not an area with alot of outpt endoscopy though. To much overhead with $1000/ sq foot realestate.
Also look at BID in Boston. Antonioli is a giant in GI path and has trained some great GI folks.

 

[RyMcQ]

Okay, what is the code modifier??

We got a bulletin from our billing agency about it, but I couldn't find it. I'll keep you posted.

 

[LADoc00]

8/11/06 Mailbag

Dear LADoc00,
I was wondering about other sources of revenue unique to heme. Is there much potential in coag reports, seems if you could convince hematologists or even GPs to order platelet aggregation studies on every little kid with a nose bleed that might be easy $.

Not sure how you bill this, what is the code for a profee on CP tests, how much does it reimburse? For that matter what about profeeing more blood smears, if you set your threshold for review low you can probably still say something useful about most of the smears that get kicked back ... canned text comment etc, I know they bill for that sort of thing where I am training and you can scan blood even faster than skin.
~Restless in Reno

Restless,
Making a significant profit margin on platelet aggregation studies is near impossible. First realize that "every little kid with a nosebleed" doesnt need a platelet studies and then understand that time to do this vs. reimbursement is garbage. But I'll congratulate you for trying at least to think out of the box.
In terms of billing for PB reviews, let me give you my experience and maybe RyMcQ can chime in with his. I have tried to bill for PB reviews and even in situations where it has an obvious advantage for me to look at it (ie-acute leukemias where I render a differential, do a 200-cell count etc) I have been denied reimbursement. I have recently found a modifier code and am trying it, but wont know the success of this for another 2 months or so. For run of the mill PB reviews not associated with a bone marrow or flow cytometry case, most groups do not bill. This is assumed to be part of the normal QA/QC of the clinical lab. I have yet to be in a group that bills for these, but Im sure there are some. Regardless, I wouldnt get more than 3xday/150 beds from my calculations. Not enough to really make any sort of difference. If all the sudden I changed review criteria so I was reviewing 50xday and charging, I would almost guarantee alarm bells would go off. But once again Im speculating.

 

[RyMcQ]

My thoughts on peripheral blood smear reviews:

Most are part of lab QA/QC, as LADoc says.

If a doc requests that a pathologist reviews the smear, we give the case an accession number and I write up a report with hemogram, differential, micro description, diagnosis, and comments. For all this work, the group gets reimbursed about $20, if we get paid at all. I also bill for peripheral smear review (85060) if requested with the bone marrow exam.

If the day came where I had to produce reports on more than a few PB per day, I'd be really unhappy.

 

[Wallachia]

LA,
I think this is a great idea. It reminds me of the Sports Guy (espn.com) and his mailbag. Perhaps you can make this a weekly on-line column, with witty remarks about the field, and occasionally ripping on the residents/students who write in.

LOL; thats exactly what i was thinking . . . i am a dedicated reader of the Sports Guy and would easily add LADoc00 to the list

 

[pathdoc68]

300 bed hospital in the midwest with oncology center, we do 3-10 smear reviews per day, we bill and we get paid.

 

[juddson]

My thoughts on peripheral blood smear reviews:

Most are part of lab QA/QC, as LADoc says.

If a doc requests that a pathologist reviews the smear, we give the case an accession number and I write up a report with hemogram, differential, micro description, diagnosis, and comments. For all this work, the group gets reimbursed about $20, if we get paid at all. I also bill for peripheral smear review (85060) if requested with the bone marrow exam.
.

This ought to be a crime.

Judd

 

[djmd]

This ought to be a crime.

Judd

What part of that? The fact that they get a WHOLE 20 dollars?

Or that they sometimes dont get paid or only get 20 bucks?

 

[LADoc00]

8/14/06

Dear LADOC,
I'm a PGY-2 at an Ivy League program. I really want to wind up back in Southern Cal, particularly LA. I'm interested in GI path, but I don't think I have a good shot at getting it in LA (only 2 spots), from what I here it is getting hard to get. I've been busting my ass here and they say they will probably give me the GI path spot here if I apply. If I want to ultimately get a job in LA, would it be better to do GI path here, or try to get Heme-path at Cedar's or one of the other SoCal programs. Thanks.
~The New Englander

Dear New Englander,
You always be better served trying to get a fellowship slot closest to where you want to end up after its over. There are rare exceptions such as landing a GU fellowship at Hopkins or the skin Fellowship at Harvard that are such a nice feather in your cap they will help you anywhere you want to go. But generally if you want to end up in Cali, you need to try to get a fellowship in Cali. That said, bro I must level with you as the job market in LA is horrendous. Last year numerous UCLA fellows were struggling to find jobs in the area, so even if you did happen to land in Westwood or Beverely Hills, you arent a "made man". I would tho suggest applying because it wont hurt. One thing that confuses me is the hemepath at Cedars reference...why hemepath? why Cedars?
LADOC's handy Socal Fellowship rankings:
Hemepath:
1.) City of Hope (L Weiss)
2.) USC (B Nathwani)
3.) UCLA (J Said)
4.) Scripps
5.) Cedars
6.) UCI
7.) Loma Linda

If you are seriously interested in GI at UCLA or Cedars (both okay, but not at the Odze/Brigham or Appleman/UMich levels), I would inquire early, do an away elective there and try to get some research going at your school. This will help you wherever you land.

In conclusion, regardless of your situation/creds, getting a job in LA can be a real crapshoot. That said, from time to time due to my biz dealings I have a solid lead on a good job in the area, so check back with me when you are the midst of applying for real life gigs.

G'luck

 

[dermpathlover]

I think a dermpath training would make it easy to land a top-paying job in LA/SO-CAL. They only have one fellowship in the metro of 18 million, and there's dermatologists there and a lot skin cancer due to the sunny California beach lifestyle.

 

[LADoc00]

I think a dermpath training would make it easy to land a top-paying job in LA/SO-CAL. They only have one fellowship in the metro of 18 million, and there's dermatologists there and a lot skin cancer due to the sunny California beach lifestyle.

You are confused about the economics of dermpath as well as the political situation in LA and California in general. So to briefly answer your question, no a dermpath credential will not automatically land you a top paying job in So Cal. Not even close. In rural Minnesota or Arizona, maybe, but not in the greater Los Angeles area.

 

[dermpathlover]

You are confused about the economics of dermpath as well as the political situation in LA and California in general. So to briefly answer your question, no a dermpath credential will not automatically land you a top paying job in So Cal. Not even close. In rural Minnesota or Arizona, maybe, but not in the greater Los Angeles area.

If you wanted to be in SOCAL bad enough, D-path will make it easy to get a job there, and you will be among the highest paid people in the area. But like you say, if you really want to rake it in you have to go the boonies.

 

[LADoc00]

Okay...digging into my mailbag this week: 8/21/06

Dear LADOC,
As someone who hadn't given much thought to entering private practice prior to this year, I am feeling slightly overwhelmed at the idea of managing (or co-managing) what amounts to be a small business in the future. Is there anything in particular that you could suggest (aside from an MBA, of course) to help one prepare for this during residency?

Thanks and keep the cynicism coming,
~Overwhelmed in the Castro district

Welcome to the real world. The world of entrepreneurialism and adventure. Out here, we have to watch our capital cost expenditures, mind the balance sheets, negotiate with the hospital for contracts as well as insurance companies to keep reimbursements up. Add to this employee management if you are dumb enough (or ambitious enough) to start an outpatient biz. Think you can delegate all this? Think again. Doctors are well known in the accounting community as ripe juicy targets for embezzlement. Single gas groups have had millions shaved off their bottom line by malacious group management and path groups arent far behind. Your management team will thank you for working your butt through medical school, residency and fellowship to pay their healthy salaries and be dumb enough to not realize they are bilking you out of tons of $$ in addition. Hell, some of even make house calls while you are busting your ass at the hospital to bang your wife and buy your kids an ice cream cone. Now that's service.

What can you do? Watch your ass. You being in SF are in a perfect position to be able to zip over to Cal at night at get a finance certificate or basic accounting training. Even 2-3 accounting and basic finance courses would greatly help you. There is UC extension all over the city, look it up. Sign up and get educated.

The real residency begins once you leave the ivory tower.

 

[LADoc00]

Diggin into the mailbag real quick this afternoon, I need to still gross in a few cases today...

So LADoc, what's the deal? Is forensics really as much of a waste of time as everyone says? I've heard from a local private practice dude (who originally thought of going into forensics) that FP can be somewhat lucrative in cororner states where pathologists are paid as consultants (instead of being plugged into an ME system). Could be total bull****; I don't know. I like FP but everyone tells me I'm good at surg path and should drop it. Given the whole path mills/GU and GI docs with their own labs thing, FP is sounding better and better (although still not smelling too good!) Anyway, I might be a government worker bitch, but at least I wouldn't be a clinician/surgeon's bitch, n'est pas?
~PiMpIn

Dear Pimpin,
You are correct, some Forensics groups are in fact contractors for county governments and not employees. As such, they are free to also own a forensic toxicology lab. Because reimbursements for legal tox work is not regulated as normal CP stuff is, you can make a killing here and frankly that's where the real money is. Now, the next question would be how does one go about building a toxicology lab and that is totally different ballgame from Forensics, in fact the FP training wouldnt even begin to touch on such a project.
Purely Anatomic FPs, even if they are contractors, dont rake in tons of $ unless they can make the jump to expert witness revenue. My attorney tells me his firm pays about 500-700/hour for these guys. The downside is the work is not constant. You could make 20K one month and none for months afterward. Most pathologists have a very hard time turning it into a full time gig. And then there is the risk of burnout, where local law firms have used you so long you appear to everyone in the legal community as a "expert *****." Often they get dumped for a newer model, the cycle repeats.

All in all, not worth it IMO. Worthless? depends. In the right place, for the right person, the 150K government salary maybe enough to satisfy someone. Still, there are WAY the hell too many forensics fellowships given current demand. And add this to my general opinion that FP should be an independant medical specialty apart from any pathology training, which I feel is unneccesary.

 

[Smitty]

I totally agree that FP should be a seperate training program. Months and months dedicated to areas like cyto and BB, and for what? As far as the tox lab idea, sounds interesting, although again I wouldn't have a clue how to set it up. We have a state run ME office here with an attached state run central tox lab. I wouldn't have thought a tox lab would be a big money maker anyway (since I've always heard CP in general is not a money maker and that path gave up CLINICAL toxicology to EM long ago in part for that very reason), but what the hell do I know. There seem to be FP fellowships out there that don't get filled (or are filled my poorly qualified peeps), but I've always heard that there are tons of FP jobs out there, of course whether anyone would actually want any of these jobs is another matter. We have a FP fellow here that left good money working at a surg path mill, but pretty much hated it. He seems pretty disgusted with surg path in general, private practice, academics, or otherwise. He commented that he was tired of being a "surgeon's bitch", but I haven't really seen this kind of thing go on here. (Pathologist calls OR during frozen, pathologist says "adenocarcinoma", surgeon says "OK", pathologist says "have a nice day", end of story) What's your take?

 

[deschutes]

Dear LADoc00,

I am a program director interested in attracting sterling residency applicants to my program located in the Midwest, will setting up a dermpath fellowship solve my problems?

Sincerely,

~ Your Greatest Fan.

 

[LADoc00]

Dear LADoc00,

I am a program director interested in attracting sterling residency applicants to my program located in the Midwest, will setting up a dermpath fellowship solve my problems?

Sincerely,

~ Your Greatest Fan.

Dermpath is of such paramount importance in private practice that I question any residency that doesnt also carry the skin fellowship. From my experience, those without fellowships have little to no skin path teaching, nil consult material to learn from and without a solid academic dermpath person typically will leave you without the connections to get a fellowship elsewhere. Personally, I would like to see every pathology residency with their OWN (as in not in a dermatology program) skin fellowship, hemepath and cytology. Those are the bread and butter boarded fields. IMO, if you cant field those fellowships, then shutter the whole residency.

 

[Gut Shot]

Dermpath is of such paramount importance in private practice that I question any residency that doesnt also carry the skin fellowship. From my experience, those without fellowships have little to no skin path teaching, nil consult material to learn from and without a solid academic dermpath person typically will leave you without the connections to get a fellowship elsewhere. Personally, I would like to see every pathology residency with their OWN (as in not in a dermatology program) skin fellowship, hemepath and cytology. Those are the bread and butter boarded fields. IMO, if you cant field those fellowships, then shutter the whole residency.

My med school path department was trying to get a derm fellowship up and running, but it's a total bitch to get academic dermpath faculty these days. Somehow making a fraction of private practice salary doesn't appeal to many folks.

 

[yaah]

My med school path department was trying to get a derm fellowship up and running, but it's a total bitch to get academic dermpath faculty these days. Somehow making a fraction of private practice salary doesn't appeal to many folks.

Hence part of the problem, as I said earlier - most dermpath programs prefer to train those who are going into academics, but most people with a predominantly financial interest in dermpath don't want to go into academics. And ne'er the twain shall meet. Perhaps there are a couple of programs that come right out and say "We train community dermpaths" but not many.

 

[LADoc00]

Hence part of the problem, as I said earlier - most dermpath programs prefer to train those who are going into academics, but most people with a predominantly financial interest in dermpath don't want to go into academics. And ne'er the twain shall meet. Perhaps there are a couple of programs that come right out and say "We train community dermpaths" but not many.

You arent seeing true correlation. See, dermpath spots are SO limited that in essence youve created an artificial supply vs. demand imbalance. In its essence, the biz aspects of dermpath from my end are no different than say GU or GI or any outpatient biopsy speciality. If the number of spots was increased to the point where the skill set saturated the marketplace, THEN trainees would begin filtering back into the academic centers to set up fellowships. Its a total catch-22!! The number is so low that they lack the capacity to increase training, thereby ensuring the number permenantly stays low. The solution would be to hyper-expand current fellowships by 3-4x the number of seats for 5 or so years. That would kickstart the process toward market balance.

 

[dermpathlover]

Hence part of the problem, as I said earlier - most dermpath programs prefer to train those who are going into academics, but most people with a predominantly financial interest in dermpath don't want to go into academics. And ne'er the twain shall meet. Perhaps there are a couple of programs that come right out and say "We train community dermpaths" but not many.

Well then you say your going into academics and then change your mind once you are in.

Yeah it might be a little uncomfortable, but once it is too late it is too late.

And I am sure there are many dermpath directors that are happy to train great dermpath people to go into community practice as derm experts. Plus it provides them with a guaranteed referral base for more cases. As we saw the two guys at UCSF aren't doing too badly, making 1.5 million apiece (who is interested in $$$$ now?) . How can a guy who is operating a ruthless business machine and making 1.5 million a year bust your nuts for wanting to make a fair living in private practice rather than starting in academics at 150K a year?


The same could be said for plastic surgery residents. There are so few integrated plastic spots. They are all at top academic centers, and so many alpha medical students want to get in them. I know damn well that the people that I knew that landed plastics won't spend one day in academics once they are done, but they are savvy enough to walk the walk and talk the talk while they have to. If derm is what you want to, you got to do what you got to do to do it.

It is the kind of stuff that we all do all the time. When you want to get in a girl's pants, you got to make your best impression. The hotter more out of reach the chick (dermpath), the more you got to bring to the table.

 

[yaah]

Are you really this superficial in real life? Do you even know what a hidradenoma is? And don't google it because I'll know.

 

[dermpathlover]

Are you really this superficial in real life? Do you even know what a hidradenoma is? And don't google it because I'll know.

Yeah I know. It is a proliferation of sweat glands/ducts (benign).

Just because you don't value what I value: a great job that earns great money doing something that I love, doesn't make me superficial.

 

[LADoc00]

Are you really this superficial in real life? Do you even know what a hidradenoma is? And don't google it because I'll know.

He is starting to reek of troll IMO.

 

[Cabbage Head]

Are you really this superficial in real life?

His sig says it all.

 

[yaah]

Just because you don't value what I value: a great job that earns great money doing something that I love, doesn't make me superficial.

Dude. Everybody values that except die hard communists and sadomasochists. And even the sadomasochists actually love what they do, paradoxically, even though they hate it.

 

[deschutes]

He is starting to reek of troll IMO.

The only thing all doctors (and all med students) have in common is good grades and the ability to wow the admissions committee.

 

[b&ierstiefel]

The only thing all doctors (and all med students) have in common is good grades and the ability to wow the admissions committee.

...on paper.

now in person...well it's not about "wow"-ing. it's about getting your nose so far shoved up your superior's chocolate starfish...

 

[LADoc00]

New from Ladoc's Mailbag:

Hey LADOC. I'm a pgy-2 AP/CP in New England. I hope to come back to CA to practice. I originally was planning on staying in New England for GI, but lately I've been seriously thinking about a surg path fellowship. I'm 100% set on getting a PP partnership track gig. Seems like a lot of the GI jobs out there are in POD labs, Quest, Labcorp and the like, which I have no interest in. It would be great to do a GI and a surg path year, but as you have pointed out in the past, the lost salary by doing a 2nd fellowship is probably a poor financial decision in the long run. So, I was considering a solid surg path fellowship in CA, like Stanford or UCLA(Westwood). I've even thought about the UCLA olive view or UCSD surg path spots with the community slant. With my career goals in mind, would I be better off doing a solid CA surg path fellowship rather than GI and if so any advise on which program? Thanks.

First off all GI programs are not created equal. Im not a fan of ANY GI programs here in Cali. UCLA WAS good, but has lost alot of its luster. Also, UW Seattle was fantastic but lost their key man in an assassination.

Coming to Cali is a BIG decision. The first thing you need to realize is that it will be 10x more competitive to get a solid partnership track position than the midwest or south.

Where do you want to end up? Do you have a specific place in mind? San Diego? San Fran? Sacramento? Far northern Cali?

Where you want to end up will play a big factor in where you want to go for a fellowship because each residency program has a political "Area of Influence" within the state.

Im a fan of programs like UCLA Olive View because they allow you much more independance than a ***** hand-holding fellowship, but the program doesnt have the prestige of Stanford or UCSF.

Also realize that large geographic areas of the state are controlled by specifc power bosses:
Sacramento county is dominated by DPMG and hires mostly out of state people
LA Metro is dominated by Memorial Path Medical Group and hires mostly people trained in So Cal
San Diego has a few different groups including those associated with Sharp and hires different types
Central California coast is dominated by Central Coast Path and hires predominantly Stanford
San Fran City is dominated by CPMC and hires UCSF and Stanford
the Cali Central Valley (Modesto, Turlock, Stockton etc.) is dominated by a few groups the biggest of which is Yosemite Path, which favors Stanford and UCSF but hires different types.
places like the far Northern Coast: Medicino, Chico, Ukiah, Eureka, Shasta etc. are controlled by small, tight knit groups that do probably better business than anyone else due to the very low penetration of managed care.
Places like the Inland Empire and Palm Springs are pretty much in flux the last time I checked.

 

[LADoc00]

Also from my xmas mailbag:

LADOc, I know you have lots of experience about hemepath training. I am interviewing for hematopathology fellowship position now. I have to decide between UPenn, MDA, and NCI in a very limited time. I am living in NYC and my family is there too. What's your opinion about these 3 programs? (reputation, diagnosis/volume, job placement, etc.)

None of those 3 places will do you wrong. UPenn has Adam Bagg in molecular hemepath. MDA has gods of flow cytometry. NCI has Jaffe, a world class traditional morphologist. When deciding these things, the first thing to ask is WHERE do you want to end up practicing? WHAT type of practice do you want to be in: academic, private practice partnership track or corporate/managed care?

MDA will send you to job opportunities primarily in the South and Southwest.

NCI will hook you up in the DC metro area and the Southern Coast.

Penn will place you in New England in a state near NYC with lots of job options.

None of the places will exclude you neccessarily from penetrating the market in the Upper Midwest and Plains areas.

FOR ME, I would favor UPenn, by that my own personal opinion having spent minimal amounts of time at each place.

Thank you very much for quick reply. UPenn lost hemepath director Jay Hess in 2005. Right now, Dr. Wasik, a very research oriented pathologist, is a director. Do you think it would be a major impact (bad or good) on residency training? In addition, Upenn had very good job placement record according to their website. Does this change affect the job also?

Yes, it appears Penn does have an acting director. It also doesnt have a clear faculty list on the website.
http://pathology.uphs.upenn.edu/Education/FellowshipPrograms/edu_fellow_prog_hema.aspx

That makes me weary. Still, it is UPenn and is close to NYC. You have a tough decision. MDA is renowned for Hemepath with a faculty that is deep as it gets in the heme section. Have you been accepted to all three?? Maybe the decision will be made for you.

 

[LADoc00]

That's great info. I think I will end up doing a Surg path fellowship (maybe with a GI focus) in CA. I'd prefer to get a job in the LA/OC area if possible, but I would be happy with anywhere in CA. What would be the best surg path fellowship for connections for the LA/OC area? I know of UCLA, USC, UCI, and Cedars. Any of those programs stand out as better than the others?
~East Coast Pathguy

THE easiest route for a job in So Cal is to do derm. I would definitely stay away from UCI, although I really like their Gyn guy. USC has been nearly 100% FMGs for quite awhile, but dont neccessarily let that discourage you. Having spent time at LA County, I have to say its a very very rough place to work so I would tend to pass. Cedars just got a new chief and is really revitalizing their program. In terms of LA, Cedars has by far the best "hospital" reputation. I have been in the UCLA ER where people were sobbing while asking to be taken to Cedars..I would too.

but UCLA has the most options. If memory serves me right, Cedars was also trying to get a GI rep as well.

OVERALL tho, in terms of actually landing a job, go to the LA Path Society Meeting at Good Sam. Chat people up and make connections.

 

[LADoc00]

Hey LADoc00,

Thanks for all of your informative and often-times comical posts!
I'm applying this year and am looking almost exclusively in NYC. I've interviewed at Columbia and Cornell and am deciding which of the two to rank first (I have to be in NYC for personal reasons). I think i'm generally interested in academics but that's as far as I've decided. I plan on practicing in the NYC area after residency/fellowship. Do you have any words of wisdom to help me in my decision-making?
Hope you had a great holiday season.

Academics in NYC is rough, almost as rough as it gets in terms of goals. If you told me you instead wanted to make 500K/year and drive a MC12 Maserati, I would have a much easier time giving you helpful advice.

In NYC people do tons of fellowships, mainly in a circling pattern until they get a job offer. NYC itself is heavily penetrated by corporations like Genzyme and large robber-baron types who have carved up profitable sectors to create their financial empire.

Your best bet is to be a stand out at either Cornell or Columbia. Personally I favor Cornell. I would keep your eye on the prize: A "high value" fellowship at MSKCC.

In terms of going the academic route, you will need to pad your CV with lots of bells and whistles.
Things like top notch research post docs, trips through Cold Springs or Woods Hole, KO8 grants and Howard Hughes are not optional. IMO, academics only works one of two ways:
1.) tenure track with research focus where you have 2-3 weeks/month off service and have a very very confined service scope, something like heme or derm or molecular or a CP area.
2.) pure service work with a focus in derm or GI where your consult load will provide the leverage to get a decent salary out of the med center. [LeBoit at UCSF makes over 1.5 million/year for ~2weeks/month of service work.]