- Joined
- Sep 9, 2004
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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 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 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.
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.