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NuclearDust

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Looking for advice/thoughts/perspective from anyone out there on the topic of decisiding on a practice setting after fellowship training in dermpath.

Background: I am an AP/CP resident that will be completing Dermpath training at a large academic institution. I generally like all of pathology practice, but I do like dermpath the best. I want what is best in terms of stability, finance, and a well balanced life for myself and my family while producing high quality diagnostic work for patients and clinicians.

Looking at the current and potential future landscape of pathology and dermatopathology I am having a difficult time feeling really strongly about subspecialty only vs. general practice after fellowship. Below are some questions that have recently popped into my head, I don't know the answers...maybe you do, please help:

Dermpath Only Considerations:
1. It seems like many medium-to-large pathology groups practice in a subspecialty format anyway (absolutely true for academics and seems like becoming more common in private groups)
2. In some geographic regions it seems like the only choice is to practice in a dermpath only setting, as the dermpath material was separated into single dermpath-subspecialty practices long ago. So dermpath training is not needed/valued in general practices in some regions.
3. Will practicing Dermpath-only make me vulnerable to job instability?
4. Will the changes instituted by MACRA in 2019 result in derm biopsies being shifted to other institutions largely without the control of referring dermatologists?
5. Will these changes by MACRA make subspecialty pathology practices viable practice models?
6. Will subspecialty practice become tiresome as time goes on? (I have heard other subspecialists say this, but I feel that derm does have a little more variety than some of ther other subspecialties in general.)
7. If I had any thought to consider adademics initially would dermpath-only be my only choice if I decided later to move to private practice.

General Practice Considerations:
1. Some people say that it is foolish to tie all your reimbursement to such a few number of billing codes. General practice may insulate from some coding changes by diversifying your income streams and bringing value to contracting hospital organizations in other different ways.
2. Will practicing in a general setting give me enough exposure to derm to keep up the skills learned in fellowship (this seems very variable depending on group).
3. Are there legitimately large differences in compensation between general practice and subspecialty dermpath only?
4. Are there legitimately large differences in the quality of care that I will be able to provide as a subspecialist vs a generalist?
5. Will large acedemic centers and/or corporate labs pull material out of the hands of small and even medium sized general groups in the name of "higher-quality" integrated care?

If any of you have any insight into these thouhts or other different perspectives/ideas on this topic please reply. Thanks.
 

NuclearDust

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Bump. Is there an SDN mentor, or just someone with some experience out there or insight into actual practice that could help? Thanks
 

mario2010

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You will be better off in long term practicing some general surg path along with dermpath, it will make you more marketable in future. A lot of consolidation is happening right now and will continue in future, the trend is towards subspecialty based sign out in large private groups but even in these places everyone takes call and cover frozens. It will be difficult to cover frozens if you end up doing 100% dermpath for several years right after training. On the flip side high volume dermpath only jobs pay more as compared to hospital based positions, so you will be losing money during those years, there are pros and cons for both.
 

jp123ok

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To expand on what the previous poster said, most of the dermpath jobs that I've seen advertised over the last couple of years have been for combined general path and dermpath. Therefore, if your ultimate goal is a job in private practice, only signing out dermpath in an academic setting would be a mistake. If you are lucky enough to be offered a dermpath-only private practice job then that would be a different matter. This is what happened to me - I accepted a dermpath only private practice job 2-years ago, after completing fellowship. I can confirm that the lifestyle is pretty good and the pay is better than general surpath jobs. Dermpath is a very interesting area and, although I see plenty of mundane cases, I also see enough unusual cases to keep me interested. Whether my decision to specialise in dermpath will prove to be a mistake in the long-term is hard to say. I don't think it will be though because I work hard in my spare time to ensure that I retain my skills in general surpath.
 

NuclearDust

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To expand on what the previous poster said, most of the dermpath jobs that I've seen advertised over the last couple of years have been for combined general path and dermpath. Therefore, if your ultimate goal is a job in private practice, only signing out dermpath in an academic setting would be a mistake. If you are lucky enough to be offered a dermpath-only private practice job then that would be a different matter. This is what happened to me - I accepted a dermpath only private practice job 2-years ago, after completing fellowship. I can confirm that the lifestyle is pretty good and the pay is better than general surpath jobs. Dermpath is a very interesting area and, although I see plenty of mundane cases, I also see enough unusual cases to keep me interested. Whether my decision to specialise in dermpath will prove to be a mistake in the long-term is hard to say. I don't think it will be though because I work hard in my spare time to ensure that I retain my skills in general surpath.

Thanks to both you and mario2010 for your thoughtful thorough input. I appreciate you taking the time to reply. That helps I have some thinking to do, I guess I'll just have to see how it goes.
 

dr.weiner

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I'm biased, because I took a general SP + dermpath job, but I think this is the best option for people just out of training. If you are in a partner-track position it's often more lucrative, especially over the long term, and gives you a much more versatile skill set (frozens, cytology, CP lab stuff), so you will be more marketable with more options if/when you decide to change positions. I've learned how to become a competent generalist while still maintaining the DP expertise. I also feel like an important part of my group rather than a corporate employee at the bottom of the totem pole.

You always have the option to narrow your focus to derm only later (although corporate labs may look down on your volume output), but much harder the other way around.
 
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