How clinical of a practice can a path-trained Dermatopathologists have?

[Launcelot]

It sounds like a hyperbole, but I constantly hear people talking about how pathology can be a backdoor to a practice in dermatology, but how is the actual practice of dermatopathology for a path-trained dermatopathologist? Can you work up a general case in dermatology from start to finish? Open or join a general dermatology practice or move into practicing cosmetic dermatology as a dermatopathologist? Or are you just moving to signing out a higher number of skin specimens than the rest of your pathology colleagues?

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[mario2010]

I think it is pretty realistic but really depends on individual interest. Back in 2010 or 2011, ABD changed the derm training requirements for path trained dermpath fellows. These days you have to do eight months of half a day derm clinics and work essentially as a derm resident rather than passive observation. Every institution is different, in my fellowship year, I was seeing upward of 20 patients per day, doing procedures, prescribing medications etc. At the end of that year, I felt pretty confident with bread and butter general derm stuff. Keep in mind, most of general derm is repetitive and there are limited number of medications. In a community practice 90% of patients are for routine stuff, AKs, SCC, BCC, DNs, MM, DFs, SKs, VV, skin tags etc. On inflammatory side, prob half of the patients are for acne, than you have eczema, seb derm, rosacea etc. Of course, there will be a small percentage of complex medical derm patients, those would definitely need to be seen by a dermatologist. These will include biologics for psoriasis, immunobullous disease, SLE etc. On the other hand, keep in mind, there is more money in signing out skin biopsies rather than seeing general derm patients. A level 2 clinical encounter, roughly pays 60-100 bucks at most, whereas an 88305 pays $70-$120 depending on type of insurance. An experienced dempath can sign out 150 cases a day and still go home at 3 PM, on the other hand, no one can realistically see more than 45-50 patients a day and can still do a good job.

 

[Launcelot]

I think it is pretty realistic but really depends on individual interest. Back in 2010 or 2011, ABD changed the derm training requirements for path trained dermpath fellows. These days you have to do eight months of half a day derm clinics and work essentially as a derm resident rather than passive observation. Every institution is different, in my fellowship year, I was seeing upward of 20 patients per day, doing procedures, prescribing medications etc. At the end of that year, I felt pretty confident with bread and butter general derm stuff. Keep in mind, most of general derm is repetitive and there are limited number of medications. In a community practice 90% of patients are for routine stuff, AKs, SCC, BCC, DNs, MM, DFs, SKs, VV, skin tags etc. On inflammatory side, prob half of the patients are for acne, than you have eczema, seb derm, rosacea etc. Of course, there will be a small percentage of complex medical derm patients, those would definitely need to be seen by a dermatologist. These will include biologics for psoriasis, immunobullous disease, SLE etc. On the other hand, keep in mind, there is more money in signing out skin biopsies rather than seeing general derm patients. A level 2 clinical encounter, roughly pays 60-100 bucks at most, whereas an 88305 pays $70-$120 depending on type of insurance. An experienced dempath can sign out 150 cases a day and still go home at 3 PM, on the other hand, no one can realistically see more than 45-50 patients a day and can still do a good job.

That's extremely informative, thank you; You are saying that path-trained dermpaths do have access to the full scope of dermatology practice should they choose?

 

[icpshootyz]

That's extremely informative, thank you; You are saying that path-trained dermpaths do have access to the full scope of dermatology practice should they choose?

Technically I believe any MD can see patients and "do" dermatology. One of my clients that sends me tons of skin biopsies is just a family medicine doc that supposedly used to be a dermatologist in their original country. They didn't do a US Derm residency, just family medicine. But they basically function as a dermatologist here. Not sure why someone that went into path would want to practice dermatology, but I'm not sure there are laws or regulations against it.

 

[coroner]

whereas an 88305 pays $70 $39 - $120 depending on type of insurance

If referring to PC only per current CMS fee schedule

Technically I believe any MD can see patients and "do" dermatology.

Correct. I can also "do" brain surgery...well, not really. But, having a state medical license grants you the ability to do whatever you want legally (borderline legally though). The issues one runs into when it is outside their formal training is:

1) Will you be able to get hired by a place and granted medical privileges to perform clinical duties outside of your formal medical training? e.g. I could theoretically know how to operate on a pt. with a pituitary tumor because I did really well on my neurosurgery rotation, but that doesn't mean a hospital will hire me to do so.

2) Will you be able to get reimbursed? Assuming you will accept health insurance, you will have to apply to those companies and they will have to approve you when you bill patients who have that respective type of insurance. e.g. Going back to the previous example, if I do end up operating on brain surgery pt. and bill a couple grand, no insurance company would reimburse me. Unless you're a cash only practice e.g. like those walk-in cosmetic surgery clinics doing illegal boob jobs in FL by IMG's that get busted on 'Inside Edition'...

3) Malpractice insurance. Some carriers will flat out reject you if you are too much of a risk e.g. No malpractice insurance company would provide me coverage to do brain surgery. Without that, you will essentially have flushed your career down the toilet at the first hint of a lawsuit. Not to mention the field day lawyers would have knowing you were practicing outside of your scope of formal training. Although dermatology from dermpath wouldn't be that much of a stretch, you will probably be able to get coverage; but, you may (not sure) have higher premiums practicing clinical derm coming from a path + dermpath background vs straight derm.

4) Patient safety. That's what it's all about in the end right? As mario said earlier, a path + dermpath may feel comfortable with a lot of bread and butter clinical derm, but comfortable enough to know they are providing equivalent care the pt. would receive if there were going to see a dermatology trained physician? e.g. Even in the wildest scenario, given the above barriers, I somehow finagled to "do" neurosurgery somewhere on somebody, I never would because they would be receiving inferior treatment vs going to someone who was formally trained it it. Again, clinical derm from the path + dermpath route is very similar, but only you can judge if you think the pt. is getting equivalent and optimal care.

 

[Launcelot]

If referring to PC only per current CMS fee schedule


Correct. I can also "do" brain surgery...well, not really. But, having a state medical license grants you the ability to do whatever you want legally (borderline legally though). The issues one runs into when it is outside their formal training is:

1) Will you be able to get hired by a place and granted medical privileges to perform clinical duties outside of your formal medical training? e.g. I could theoretically know how to operate on a pt. with a pituitary tumor because I did really well on my neurosurgery rotation, but that doesn't mean a hospital will hire me to do so.

2) Will you be able to get reimbursed? Assuming you will accept health insurance, you will have to apply to those companies and they will have to approve you when you bill patients who have that respective type of insurance. e.g. Going back to the previous example, if I do end up operating on brain surgery pt. and bill a couple grand, no insurance company would reimburse me. Unless you're a cash only practice e.g. like those walk-in cosmetic surgery clinics doing illegal boob jobs in FL by IMG's that get busted on 'Inside Edition'...

3) Malpractice insurance. Some carriers will flat out reject you if you are too much of a risk e.g. No malpractice insurance company would provide me coverage to do brain surgery. Without that, you will essentially have flushed your career down the toilet at the first hint of a lawsuit. Not to mention the field day lawyers would have knowing you were practicing outside of your scope of formal training. Although dermatology from dermpath wouldn't be that much of a stretch, you will probably be able to get coverage; but, you may (not sure) have higher premiums practicing clinical derm coming from a path + dermpath background vs straight derm.

4) Patient safety. That's what it's all about in the end right? As mario said earlier, a path + dermpath may feel comfortable with a lot of bread and butter clinical derm, but comfortable enough to know they are providing equivalent care the pt. would receive if there were going to see a dermatology trained physician? e.g. Even in the wildest scenario, given the above barriers, I somehow finagled to "do" neurosurgery somewhere on somebody, I never would because they would be receiving inferior treatment vs going to someone who was formally trained it it. Again, clinical derm from the path + dermpath route is very similar, but only you can judge if you think the pt. is getting equivalent and optimal care.

Yes, I understand that completely, and for all those reasons stated those examples are not actually feasible in reality (no one will actually hire you, grant you privileges at a facility, cover you in terms of insurance; an FM-trained MD/DO has no real chance at being hired for a position in neurosurgery). The question was mostly answered by mario2010, but restate the question precisely, I am specifically asking whether is it acceptable/normal/typical/feasible for path-trained dermpaths to be hired for a dermatopathology position with some clinical responsibilities or to take on some of the patient load in general dermatology?

 

[mario2010]

Yes, I understand that completely, and for all those reasons stated those examples are not actually feasible in reality (no one will actually hire you, grant you privileges at a facility, cover you in terms of insurance; an FM-trained MD/DO has no real chance at being hired for a position in neurosurgery). The question was mostly answered by mario2010, but restate the question precisely, I am specifically asking whether is it acceptable/normal/typical/feasible for path-trained dermpaths to be hired for a dermatopathology position with some clinical responsibilities or to take on some of the patient load in general dermatology?

Yes- It is feasible. Not common though. The usual scenario is working within a derm group with some clinical responsibilities and also signing out dermpath for the group. I have mostly seen that in Florida and California, within large derm groups with multiple locations. A lot of these practices are skin cancer heavy, most of the time you are doing skin cancer screenings, biopsies etc. Which you are actually trained to to do in fellowship.

 

[tiredguy]

I think it is inappropriate for pathologists to practice clinical dermatology regardless of fellowship training. Pathology is not a backdoor into becoming a dermatologist.

I wish I could say that I feel the same way about the opposite scenario.

 

[pianoguy05]

I agree with you, but also I’ll say the opposite. I would never send my biopsy to a Derm-trained DP. Everyone of them that I’ve encountered has no decent appreciation for histopathology.

 

[mario2010]

I have trained with both derm-DPs and path-DPs. Some of the best dermatopathologists, I have worked with are derm trained DPs. For inflammatory lesions, I would actually prefer a derm-DP to share my consultation cases and as a disclaimer I am a path trained-DP. I think people don't realize that dermpath and dermatology are intricately related, unlike all other sub-specialties in pathology. To become a good dermatopathologist, a good grasp and experience in clinical dermatology is absolutely essential. It makes a big difference, if you have seen the patient yourself and looked at rash/ lesion in person and taken the complete clinical history. As we all know, there are subtle histologic differences in inflammatory derm cases. I have been teaching derm and path residents for past seven years, generally speaking derm residents have better grasp of dermpath as compared to path residents, the reason is just the sheer amount of time they spend on dermpath and at scopes. 25% of dermatology residency curriculum is dermpath; derm residents get 6 months of dermpath training as compared to 4-12 weeks of dermpath rotations for path residents. Regarding pathologists doing clinical work, I beg to differ. I am in favor of more involvement of pathologists in direct patient care, whether it is in form of path trained dermpaths doing clinical dermatology as part of dermcare team or in other ways like stand alone pathologists operated US guided FNA clinics or infusion centers run by path trained BB/transfusion medicine guys or in future may be in-vivo microscopy for GI. Its a jungle out there, whoever controls the patients....rules! We cannot just sit back and keep hiding behind our microscopes while other specialties keep chopping away parts of our profession.

 

[jupiterianvibe]

I think it is inappropriate for pathologists to practice clinical dermatology regardless of fellowship training. Pathology is not a backdoor into becoming a dermatologist.

I wish I could say that I feel the same way about the opposite scenario.

this attitude is why pathology can't have any nice things.

 

[tiredguy]

Its a jungle out there, whoever controls the patients....rules! We cannot just sit back and keep hiding behind our microscopes while other specialties keep chopping away parts of our profession.

So clinical dermatology is/was part of pathology and dermatologists are chipping away at our profession by practicing clinical dermatology? You've already pointed out that you feel that derm-trained DP's are some of the best DP's you've encountered. Is your idea to let them sign out all the biopsies and have the pathologists see all the patients?

 

[tiredguy]

this attitude is why pathology can't have any nice things.

I'd rather feel otherwise but can't say that derm-trained DP's are worse than path-trained DP's.

 

[jp123ok]

I think that derm trained dermpaths are generally better at inflammatory dermpath and path trained dermpaths are generally better at neoplastic dermpath. Having said that, I think that the dumbest thing that dermatopathologists ever did was to allow dermatology residents into dermpath fellowship programs.

 

[AZpath]

I think you have to keep in mind that FP, NP, PAs all do general derm.

A dermpath that actually gets some specialty training would likely be better trained.
This county has been shifting away from real doctors seeing patients.
My gut tells me that a pathologist is more like to know what they don't know faster.
Mostly likely they would be practicing with other derms in the same group.
This not true of primary care doctors.

 

[WEBB PINKERTON]

Pathology has to go interventional or it will go extinct. Too many people in this field want to stay chained to their scope pushing glass all day. Well good luck with that when technology has rendered you obsolete.

 

[coroner]

I think that the dumbest thing that dermatopathologists ever did was to allow dermatology residents into dermpath fellowship programs.

Agree. It cut the field in half for pathologists who could've entered the specialty.

Too many people in this field want to stay chained to their scope pushing glass all day.

Most people intentionally went into this field because they did not want to do procedures nor deal with patients.

Well good luck with that when technology has rendered you obsolete.

I agree, technology will render us obsolete. But it won't happen in your lifetime or mine...

 

[icpshootyz]

I agree with you, but also I’ll say the opposite. I would never send my biopsy to a Derm-trained DP. Everyone of them that I’ve encountered has no decent appreciation for histopathology.

I have to disagree with this. I'm a path-trained DP, but I've worked with many derm-trained DPs and they were definitely not worse than the path-trained ones. If anything at the start of fellowship they are often far ahead, as a large chunk of derm residency is spent learning dermpath, while only a tiny portion of general AP residency involves dermpath. They're just as good from what I've seen. Unfortunately.

 

[nimzi57]

I think it is pretty realistic but really depends on individual interest. Back in 2010 or 2011, ABD changed the derm training requirements for path trained dermpath fellows. These days you have to do eight months of half a day derm clinics and work essentially as a derm resident rather than passive observation. Every institution is different, in my fellowship year, I was seeing upward of 20 patients per day, doing procedures, prescribing medications etc. At the end of that year, I felt pretty confident with bread and butter general derm stuff. Keep in mind, most of general derm is repetitive and there are limited number of medications. In a community practice 90% of patients are for routine stuff, AKs, SCC, BCC, DNs, MM, DFs, SKs, VV, skin tags etc. On inflammatory side, prob half of the patients are for acne, than you have eczema, seb derm, rosacea etc. Of course, there will be a small percentage of complex medical derm patients, those would definitely need to be seen by a dermatologist. These will include biologics for psoriasis, immunobullous disease, SLE etc. On the other hand, keep in mind, there is more money in signing out skin biopsies rather than seeing general derm patients. A level 2 clinical encounter, roughly pays 60-100 bucks at most, whereas an 88305 pays $70-$120 depending on type of insurance. An experienced dempath can sign out 150 cases a day and still go home at 3 PM, on the other hand, no one can realistically see more than 45-50 patients a day and can still do a good job.

Thank you. Will private insurance or medicare easily reimburse path-trained dermatopathologists for clinical dermatology though?

 

[Vicinal]

I have trained with both derm-DPs and path-DPs. Some of the best dermatopathologists, I have worked with are derm trained DPs. For inflammatory lesions, I would actually prefer a derm-DP to share my consultation cases and as a disclaimer I am a path trained-DP. I think people don't realize that dermpath and dermatology are intricately related, unlike all other sub-specialties in pathology. To become a good dermatopathologist, a good grasp and experience in clinical dermatology is absolutely essential. It makes a big difference, if you have seen the patient yourself and looked at rash/ lesion in person and taken the complete clinical history. As we all know, there are subtle histologic differences in inflammatory derm cases. I have been teaching derm and path residents for past seven years, generally speaking derm residents have better grasp of dermpath as compared to path residents, the reason is just the sheer amount of time they spend on dermpath and at scopes. 25% of dermatology residency curriculum is dermpath; derm residents get 6 months of dermpath training as compared to 4-12 weeks of dermpath rotations for path residents. Regarding pathologists doing clinical work, I beg to differ. I am in favor of more involvement of pathologists in direct patient care, whether it is in form of path trained dermpaths doing clinical dermatology as part of dermcare team or in other ways like stand alone pathologists operated US guided FNA clinics or infusion centers run by path trained BB/transfusion medicine guys or in future may be in-vivo microscopy for GI. Its a jungle out there, whoever controls the patients....rules! We cannot just sit back and keep hiding behind our microscopes while other specialties keep chopping away parts of our profession.

This all sounds wonderful but the CAP and ASCP are clowns when it comes to supporting patient based path. US-FNA was a possibility but will only work in a few niche settings. The best path forward is to massively review residency programs and scrutinize CP training hardcore. The problem with pathology is training institutions and their relationship with federally subsidized residency spots. First a huge audit needs to happen to likely split AP and CP in a way that makes sense. Then massively cut positions to about 1 resident per 10K specimen. At most. After that happens and things equalize for about a decade then real fellowships can be offered that are actually teaching people to work, understand the business side of pathology and save the field from being destroyed.

 

[y2k_free_radical]

This all sounds wonderful but the CAP and ASCP are clowns when it comes to supporting patient based path. US-FNA was a possibility but will only work in a few niche settings. The best path forward is to massively review residency programs and scrutinize CP training hardcore. The problem with pathology is training institutions and their relationship with federally subsidized residency spots. First a huge audit needs to happen to likely split AP and CP in a way that makes sense. Then massively cut positions to about 1 resident per 10K specimen. At most. After that happens and things equalize for about a decade then real fellowships can be offered that are actually teaching people to work, understand the business side of pathology and save the field from being destroyed.

Don't hold your breath.

 

[HeyDalaron]

I have to disagree with this. I'm a path-trained DP, but I've worked with many derm-trained DPs and they were definitely not worse than the path-trained ones. If anything at the start of fellowship they are often far ahead, as a large chunk of derm residency is spent learning dermpath, while only a tiny portion of general AP residency involves dermpath. They're just as good from what I've seen. Unfortunately.

I agree. Not to mention dermatology trained DPs are well ahead of the curve on clinicopathologic correlations.