hemepath and heme/onc

[Enkidu]

I recently spent some time in hemepath and I loved it. The combination of morphology and ancillary studies like flow, molecular, IHC, iron stain - all of that stuff was so intellectual and fun.

How much of that sort of diagnostic sleuthing goes on in clinical heme/onc? I think that heme/onc works up all of the non-neoplastic heme cases more or less without hemepath input - is that right?

Did any of you feel conflicted between hemepath and heme/onc? I hadn't really considered heme/onc before, but now that I've gotten really interested in the diagnostic side of things it's made me more curious about the clinical side. Do all of the myriad of diagnostic categories and subcategories and cytogenetic studies that appear on the path report all go into the treatment plan? Or does hemepath just spin out complicated diagnoses that really have very little clinical significance?

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[2unhigenyx]

I recently spent some time in hemepath and I loved it. The combination of morphology and ancillary studies like flow, molecular, IHC, iron stain - all of that stuff was so intellectual and fun.

How much of that sort of diagnostic sleuthing goes on in clinical heme/onc? I think that heme/onc works up all of the non-neoplastic heme cases more or less without hemepath input - is that right?

Did any of you feel conflicted between hemepath and heme/onc? I hadn't really considered heme/onc before, but now that I've gotten really interested in the diagnostic side of things it's made me more curious about the clinical side. Do all of the myriad of diagnostic categories and subcategories and cytogenetic studies that appear on the path report all go into the treatment plan? Or does hemepath just spin out complicated diagnoses that really have very little clinical significance?

I have felt very similar to what you are going through. Loved hempath and always knew i was going to be involved with hematology, mostly bench research. Almost applied to path, but then changed my mind to IM due to patient contact.

If you want to get real comparison, try BOTH inpatient and outpatient hem for a few weeks. Very different flavor and certainly worth experiencing.

i am finishing up IM residency and starting Hem/onc. I have to be honest, I would give a long hard look to IM residency if i had to do it all over again. To me, IM was just a way to get to Hem. I am hoping fellowship would be a better experience.

 

[2unhigenyx]

sleuthing is more on path side imho. if you think hempath is complicated, wait for 3-4 years and path reports would run few gb of data on each patients. for now, we may not have use for much of genetic/genomic data, we will certainly have it very near future.

mutation analyses pretty much determines the clinical outcomes and treatment, so yes most of path reports matters.

 

[Enkidu]

I have felt very similar to what you are going through. Loved hempath and always knew i was going to be involved with hematology, mostly bench research. Almost applied to path, but then changed my mind to IM due to patient contact.

If you want to get real comparison, try BOTH inpatient and outpatient hem for a few weeks. Very different flavor and certainly worth experiencing.

i am finishing up IM residency and starting Hem/onc. I have to be honest, I would give a long hard look to IM residency if i had to do it all over again. To me, IM was just a way to get to Hem. I am hoping fellowship would be a better experience.

Thanks for your thoughts. Do you wish that you had pursued pathology instead?

 

[gutonc]

I recently spent some time in hemepath and I loved it. The combination of morphology and ancillary studies like flow, molecular, IHC, iron stain - all of that stuff was so intellectual and fun.

How much of that sort of diagnostic sleuthing goes on in clinical heme/onc? I think that heme/onc works up all of the non-neoplastic heme cases more or less without hemepath input - is that right?

Did any of you feel conflicted between hemepath and heme/onc? I hadn't really considered heme/onc before, but now that I've gotten really interested in the diagnostic side of things it's made me more curious about the clinical side. Do all of the myriad of diagnostic categories and subcategories and cytogenetic studies that appear on the path report all go into the treatment plan? Or does hemepath just spin out complicated diagnoses that really have very little clinical significance?

It's kind of a weird question honestly. From a practical standpoint, here's how it goes down.

Patient comes to see me with some sort of hematologic issue (benign, malignant or unknown...usually unknown at the time I see them). I look at what has been done so far to work it up (precious little these days it seems...I saw a 65yo guy this week referred for IV iron for his IDA who'd never had a colo and has had melena for 2 years...guess what he has?) and then, based on what I think/fear might be going on, I order a metric buttload of lab tests, possibly including molecular studies (they're all send outs so the local hemepath folks rarely have anything to do with them), SPEP/UPEP, peripheral flow and, if indicated, a BMBx with flow. The hematopathologist then reads/interprets the studies, usually (but not always) in isolation from each other and then reports the findings, always including the phrase "consistent with X, recommend clinical correlation." The reports do always include an excellent DDx and are usually well referenced. The hemepath guy I work with most of the time is excellent and will usually run any additional indicated/confirmatory studies and call me if he needs more clinical info.

But guess who has to sit down and put together all the disparate info and then make the final diagnosis (often made for me by hemepath, but not always) and the treatment decision?

I could not in any way do what I do without the hemepath folks (and the surg path and the cyto path and the molecular path and the cytogenetics and...) but "making the diagnosis" is only part of the job.

Your question is kind of akin to asking a surgeon if s/he every struggled with the decision to become a surgeon or if they felt they should have been a surgical pathologist instead.

 

[Enkidu]

Your question is kind of akin to asking a surgeon if s/he every struggled with the decision to become a surgeon or if they felt they should have been a surgical pathologist instead.

Maybe you're right - The difference is that I like the process of working up patients and ordering/interpreting tests to make a diagnosis. I just find that to be really fun and interesting. IM and pathology are both possibilities for me, I'm just curious about how much of the patient workup is done by the clinician and how much is done by pathology - I'm pretty sure that surgery isn't substantially involved in this part.

Patient comes to see me with some sort of hematologic issue (benign, malignant or unknown...usually unknown at the time I see them). I look at what has been done so far to work it up (precious little these days it seems...I saw a 65yo guy this week referred for IV iron for his IDA who'd never had a colo and has had melena for 2 years...guess what he has?) and then, based on what I think/fear might be going on, I order a metric buttload of lab tests, possibly including molecular studies (they're all send outs so the local hemepath folks rarely have anything to do with them), SPEP/UPEP, peripheral flow and, if indicated, a BMBx with flow.

This helps a lot, actually. It sounds like you're ordering quite a bit of molecular tests independently of pathology - what sort of information are you looking for in these tests?

The hematopathologist then reads/interprets the studies, usually (but not always) in isolation from each other and then reports the findings, always including the phrase "consistent with X, recommend clinical correlation." The reports do always include an excellent DDx and are usually well referenced. The hemepath guy I work with most of the time is excellent and will usually run any additional indicated/confirmatory studies and call me if he needs more clinical info.

Does the hematopathologist provide a DDX for neoplastic as well as benign conditions? I would have expected a "clinical correlation" disclaimer for non-neoplastic conditions only.

Thanks a lot for your comments - sorry if my question came across as weird. I guess I consider pathology and IM to be the two most ''cerebral'' specialties and I want to get a sense of who does what in a laboratory workup.

 

[gutonc]

This helps a lot, actually. It sounds like you're ordering quite a bit of molecular tests independently of pathology - what sort of information are you looking for in these tests?

Depends on the situation. I can think of a dozen or so "molecular" tests I can order on blood that would potentially give me a diagnosis.

If you're asking whether I order mutational testing on tumor samples, the answer is "sometimes...depends on the pathologist I'm dealing with." In general, I don't have to order KRAS mutation testing on metastatic CRC biopsies, or BRAF testing on melanomas, or EGFR and ALK testing on met lung cases, because those are all standard of care. But if I have a CML case that isn't responding to imatinib, I have to ask for bcr/abl sequencing because how else would the pathologist know that's what I cared about.

Does the hematopathologist provide a DDX for neoplastic as well as benign conditions? I would have expected a "clinical correlation" disclaimer for non-neoplastic conditions only.

That's funny. If your path or rads report doesn't come with a "clinical correlation" disclaimer then I'd worry about the sanity of the people reading your studies. We laugh about it but they're making calls based on super limited information. The pathologist doesn't have the radiology report or H+P, the radiologist doesn't know what the biopsy showed, etc. It looks like CYA but in reality they're just copping to the limitations of their knowledge, which is exactly what they should be doing.

Thanks a lot for your comments - sorry if my question came across as weird. I guess I consider pathology and IM to be the two most ''cerebral'' specialties and I want to get a sense of who does what in a laboratory workup.

Pathologists don't order labs. The End. They may make suggestions, and they may run follow-up or confirmatory tests on the samples they have in hand, but they don't actually order any labs. So if I send a CBC and there are atypicals on the diff, and the tech sends it to the hematopathologist for review, and s/he says "myeloblasts noted, recommend further evaluation with peripheral flow cytometry or bone marrow biopsy," unless I do something about it, that's the end of the workup. Obviously I'm going to marrow that person (unless they're dead at that point) but unless I work them up, nothing else will get done.

You're right that path is super cerebral. It's also often immensely impractical when it comes to patient care.

 

[Enkidu]

Depends on the situation. I can think of a dozen or so "molecular" tests I can order on blood that would potentially give me a diagnosis.

That's interesting, I didn't realize that anything could be definitively diagnosed from a molecular test alone. Do you skip pathology in these cases?

.That's funny. If your path or rads report doesn't come with a "clinical correlation" disclaimer then I'd worry about the sanity of the people reading your studies. We laugh about it but they're making calls based on super limited information. The pathologist doesn't have the radiology report or H+P, the radiologist doesn't know what the biopsy showed, etc. It looks like CYA but in reality they're just copping to the limitations of their knowledge, which is exactly what they should be doing.

Okay. I guess I thought if pathology found a malignancy that was the end of the story. But of course, I know that benign or inflammatory conditions require clinical correlation. What would be a case where clinical information could overturn a diagnosis of a cancer?

Pathologists don't order labs. The End.

well, maybe I'm using the term ''lab'' wrong, but pathologists do order a lot of tests. I mean things like immunohistochemistry, special stains, molecular tests - things like that. That's what I like, ordering and interpreting tests. I'm not sure how the dynamic always works with some molecular tests - some come from pathology and some come from the clinician. For instance, in oligodendroglioma our neuropath would order 1p/19q all the time, but I didn't realize that bcr/abl only came from the clinician. I thought that it was part of the initial diagnostic work up.

 

[gutonc]

That's interesting, I didn't realize that anything could be definitively diagnosed from a molecular test alone. Do you skip pathology in these cases?

CML, ET, PV...I can diagnose them all from a smear review and a single molecular test. Sure...I still do the biopsy (at least for CML) because it's still in the NCCN guidelines and I get paid for it. But I don't really need to do it.

well, maybe I'm using the term ''lab'' wrong, but pathologists do order a lot of tests. I mean things like immunohistochemistry, special stains, molecular tests - things like that. That's what I like, ordering and interpreting tests. I'm not sure how the dynamic always works with some molecular tests - some come from pathology and some come from the clinician. For instance, in oligodendroglioma our neuropath would order 1p/19q all the time, but I didn't realize that bcr/abl only came from the clinician. I thought that it was part of the initial diagnostic work up.

Now you're just being pedantic. You'll make an excellent pathologist.

 

[Enkidu]

Now you're just being pedantic. You'll make an excellent pathologist.

Ouch... What was pedantic about that?

 

[Artefact]

Is it possible to do a hemepath fellowship after heme/onc?

 

[gutonc]

Is it possible to do a hemepath fellowship after heme/onc?

No.

 

[DIce3]

Why would one even want to go from a good paying specialty with an excess of positions to a totally saturated field where the income is much less?

 

[Artefact]

Why would one even want to go from a good paying specialty with an excess of positions to a totally saturated field where the income is much less?

Well, I'm not sure that hemepath income is *much* less. Do you have statistics about that?

My thought about hemepath is that it's really interesting and fun - as for the hemepath job market, who knows how things will be in the next 9 years.

 

[gutonc]

Well, I'm not sure that hemepath income is *much* less. Do you have statistics about that?

The upside for a clinical specialty will always be higher than for a non-clinical one. Starting salaries may be similar but the ceiling is much higher in hem/onc than pathology.

My thought about hemepath is that it's really interesting and fun

OK. If you want to do it, do it.

as for the hemepath job market, who knows how things will be in the next 9 years.

Nobody. But hemepath is a niche market in a market that isn't doing very well. Can you make a career of it? Sure. Would I bet the farm on it? Not if I could see myself doing anything else.

 

[Artefact]

hemepath is a niche market in a market that isn't doing very well. Can you make a career of it? Sure. Would I bet the farm on it? Not if I could see myself doing anything else.

My thoughts exactly - hence my interest in heme/onc. I just want to know if I could keep my options open in case the hemepath market opens up. I'm planning on staying in academia, so the salary ceiling is not that relevant to me.

Also - how much time does a heme/onc fellow usually spend in hemepath?

My impression is that heme/onc followed by hemepath is a technically possible way towards board eligibility in hemepath, but I don't know of anyone who has done this.

 

[DIce3]

Check out this current thread in the pathology section about the lack of any jobs in hemepath:

http://forums.studentdoctor.net/showthread.php?t=997756

 

[Artefact]

Check out this current thread in the pathology section about the lack of any jobs in hemepath:

http://forums.studentdoctor.net/showthread.php?t=997756

Oh, I've seen it - hence my interest in heme/onc as a more stable alternative

 

[gutonc]

Also - how much time does a heme/onc fellow usually spend in hemepath?

Formally? About 45 seconds. That's how long it takes to breeze through the lab and grab the smears you called to have made. Unless you do an "elective" in hemepath, in which case it's more like 3 days.

Don't get me wrong, I reviewed the living s**t out of peripheral smears and did a crapton of flow in my research but I doubt half of heme/onc fellows could coherently explain what flow cytometry is, let alone how to do it.

My impression is that heme/onc followed by hemepath is a technically possible way towards board eligibility in hemepath, but I don't know of anyone who has done this.

While it is technically possible according to the ABP it is not realistic. Time to choose.

 

[Artefact]

Don't get me wrong, I reviewed the living s**t out of peripheral smears and did a crapton of flow in my research but I doubt half of heme/onc fellows could coherently explain what flow cytometry is, let alone how to do it.

Okay, so heme/onc is expected to review peripheral smears, but doesn't get any time in hemepath?

Do heme/onc fellows get enough training to understand the IHC and flow results on the path report?

While it is technically possible according to the ABP it is not realistic. Time to choose.

Not to beat a dead horse, but why isn't it realistic in academia?

 

[Enkidu]

Formally? About 45 seconds. That's how long it takes to breeze through the lab and grab the smears you called to have made. Unless you do an "elective" in hemepath, in which case it's more like 3 days.

Don't get me wrong, I reviewed the living s**t out of peripheral smears and did a crapton of flow in my research but I doubt half of heme/onc fellows could coherently explain what flow cytometry is, let alone how to do it.

Can a Heme/Onc bill for peripheral smear reads, or do you just read the slide for your own interest, but rely on the official signout by the pathologist?

 

[gutonc]

Okay, so heme/onc is expected to review peripheral smears, but doesn't get any time in hemepath?

Do heme/onc fellows get enough training to understand the IHC and flow results on the path report?

Formal training? Minimal. Time sitting down with heme attendings going over smears? Tons of it.

And I don't know if you've read a path report lately but the vast majority of them give the diagnosis right there in black and white. It's not that hard to figure out what "Cdx2/CK20 positive adenocarcinoma consistent with colorectal primary" or "CD5+, CD20+ clonal population consistent diffuse large B-cell lymphoma" means.

Not to beat a dead horse, but why isn't it realistic in academia?

You're conflating practice and training. Sure, it's posible to find that job in academia, if you can find a program to train you. How many path programs are going to want to give away training positions for scarce jobs to non-pathologists? The number's probably not 0, but it's pretty close. It's all about turf.

 

[gutonc]

Can a Heme/Onc bill for peripheral smear reads, or do you just read the slide for your own interest, but rely on the official signout by the pathologist?

Depends on your credentialing. I can't bill for my smear reads, but I don't really care about it. That's just one more thing I don't have time for. But plenty of people can and do bill their own reads.

 

[Artefact]

And I don't know if you've read a path report lately but the vast majority of them give the diagnosis right there in black and white. It's not that hard to figure out what "Cdx2/CK20 positive adenocarcinoma consistent with colorectal primary" or "CD5+, CD20+ clonal population consistent diffuse large B-cell lymphoma

Well that's the line diagnosis, but usually in a leukemia case they also include the flow and IHC results in the report - at least where Im at. I'm just wondering if oncologists can follow the details of the report beyond the line diagnosis.

 

[gutonc]

Well that's the line diagnosis, but usually in a leukemia case they also include the flow and IHC results in the report - at least where Im at. I'm just wondering if oncologists can follow the details of the report beyond the line diagnosis.

Yes, again, it's not that complicated.

 

[johnnyb255]

Quite interesting reading this thread. In the UK/Commonwealth system haematologists are predominately dual trained pathologists and clinical physicians.

 

[bashwell]

Quite interesting reading this thread. In the UK/Commonwealth system haematologists are predominately dual trained pathologists and clinical physicians.

Same in Australia.

 

[gutonc]

Quite interesting reading this thread. In the UK/Commonwealth system haematologists are predominately dual trained pathologists and clinical physicians.

Umm...OK.

Recognize that the number of "hematologists" in the US is a tiny, tiny fraction of the number of "hem/onc physicians". Speaking only for my medium sized West Coast US city that has the only med school in the state, there are around 100 hem/onc docs in town and about 15 of them are exclusively heme mal or benign heme, all at the university. The rest of the state has another 70 or so hem/oncs, none of which are "hematologists".

Same in Australia.

Which is, of course, a Commonwealth country.

 

[johnnyb255]

Umm...OK.

Recognize that the number of "hematologists" in the US is a tiny, tiny fraction of the number of "hem/onc physicians". Speaking only for my medium sized West Coast US city that has the only med school in the state, there are around 100 hem/onc docs in town and about 15 of them are exclusively heme mal or benign heme, all at the university. The rest of the state has another 70 or so hem/oncs, none of which are "hematologists".

Yes I'm aware. There are obvious differences between the US and Commonwealth approach to haematology/oncology- in the context of the original question (discussing the fusion of pathology and clinical) I simply thought it was an interesting point that dual training is the norm in (singular) haematology training in Commonwealth systems.

No display of ignorance intended.