How long before academia begins to suffer?

[rirriri]

Your disdain for "menial tasks" does not elevate the relevance or importance of your skill set above them, it just happens to coincide with the disdain others have for paying you what you're worth. Listen I don't think us out here in the trenches LIKE to do billing and other tedious "non advanced tasks"...but it's requisite to understanding the whole billing process [which, like it or not, is just as important in your department as it is mine, I just happen to have responsibility in that regard]...and it puts things into far greater perspective when you realize there is a price tag attached to your actions, both in terms of your livelihood and your impact on patients.

I don't care how happy people say they are in academics. What I care about is people pushing the idea that academics is great because one can kick back, ignore all the details and implications behind their work, yuck it up with other high minded folks over a beer at some insignificant international conference on the classification of ganglion cysts, and let the world burn around them because they're safe inside the walls of the tower.

I think the general idea is those of us who prefer academia are in it for the actual work; not the billing, practicality, financial strategies, etc. we actually collaborate about the science, develop better diagnostic criteria and treatment-based solutions, and try to expand the central scientific core of the field. The financial aspects are peripherally important but not even in the top 20 (or top 50) reasons I went into Pathology. I understand it’s important for you to do tedious (to me) tasks like billing; but it isn’t to me. In fact I have 0 interest in billing or insurance. Why? I am salaried and non-RVU based on purpose and happily am in this system for a reason because I want to concentrate on my diagnoses, my work, my research or investigative thoughts.

So let’s reinforce this point is that private practice Pathology is a MINORITY of the workforce in this country. The fact that some of you keep stating that your opinions are somehow the most realistic or relevant are wrong. Yes they are relevant to you but not necessarily to the rest of the Path workforce.

For all the ranting and raving I see here about finances, reimbursement, future projections; I haven’t seen any of you making a positive change in the Pathology lobby to fight the downward trend in reimbursements. Are you? Or do you just wish to complain and be sad and feel like a victim. Do something about it. I would gladly and happily support you if you did.

I am doing something about what *I* care about. Medical education, my subspecialty practice, and getting Pathologists more engaged in clinical aspects of medicine. If you feel strongly about the direction of path do something about it. Stand up and make your voice heard. I would gladly have your back. We are on the same side. Despite me ridiculing your passions for billing and you ridiculing my passions for discussing science; we are in fact supposed to be on the same side.

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[octopusprime]

I think the general idea is those of us who prefer academia are in it for the actual work; not the billing, practicality, financial strategies, etc. we actually collaborate about the science, develop better diagnostic criteria and treatment-based solutions, and try to expand the central scientific core of the field. The financial aspects are peripherally important but not even in the top 20 (or top 50) reasons I went into Pathology. I understand it’s important for you to do tedious (to me) tasks like billing; but it isn’t to me. In fact I have 0 interest in billing or insurance. Why? I am salaried and non-RVU based on purpose and happily am in this system for a reason because I want to concentrate on my diagnoses, my work, my research or investigative thoughts.

So let’s reinforce this point is that private practice Pathology is a MINORITY of the workforce in this country. The fact that some of you keep stating that your opinions are somehow the most realistic or relevant are wrong. Yes they are relevant to you but not necessarily to the rest of the Path workforce.

For all the ranting and raving I see here about finances, reimbursement, future projections; I haven’t seen any of you making a positive change in the Pathology lobby to fight the downward trend in reimbursements. Are you? Or do you just wish to complain and be sad and feel like a victim. Do something about it. I would gladly and happily support you if you did.

I am doing something about what *I* care about. Medical education, my subspecialty practice, and getting Pathologists more engaged in clinical aspects of medicine. If you feel strongly about the direction of path do something about it. Stand up and make your voice heard. I would gladly have your back. We are on the same side. Despite me ridiculing your passions for billing and you ridiculing my passions for discussing science; we are in fact supposed to be on the same side.

Non-academic jobs (hospital employed, corporate, contracted, private owned lab) greatly outnumber true academic jobs; groups that actually "own the lab" is a minority--that's not to suggest all private practice pathologists "own a lab". Like Pongo stated: All those outside of academia (true private practice, employed community hospital physicians, big lab employees, botique lab employees, in-office lab dwellers, etc) have much more in common with each other, and comprise the majority of the pathology workforce.

We've established you'd never do PP for the above list of reasons, and I'd never to academics for a different list of reasons (not among them is a billing fetish or preference for tedious work). I never said I don't care about academics. My point is that an understanding of the finances in pathology is requisite to speak intelligibly one way or the other on advocacy. If you don't care, don't want to care, and claim an absolute ignorance on the subject, how can you have an opinion on the positive or negative of the financial underpinnings that guarantee your paycheck?

Needless to say a willful ignorance on any other subject in life wouldn't bolster one's ability to advocate one way or the other on the laws that surround them.

I get it--academics doesn't lend one to care about the details of the financial aspect of the field, whether it's path or surgery or psychiatry. So if the discussion about the problems of the field centers on the deterioration of the financial aspect, you don't have a dog in the fight and your opinion on the subject is moot.

The question initially posed was "when are people in academics going to feel the pinch that people in the non-academic setting feel?" Like Pongo also stated earlier: Academic pathologists are lumped in with and negotiate alongside the academic center's "physician group", and tend to command much more favorable rates than those outside of academia. Academic physicians also have other responsibilities (research, teaching), which provide revenue sources outside of CPT codes. So it is understandable why an academic is less concerned about negative market forces.

If you don't understand and don't want to understand the finances, your answer to the question should be: "I don't know because I don't care."

 

[gbwillner]

Utter nonsense. People do 2 fellowships because it’s become the norm. Again show me the facts here not the jaded misperceptions you guys are marinating in.

I only did one fellowship. What is wrong with me?

 

[Med Director New England]

Well said octopus ^^

Riri - I have spent a lot of my free time advocating for pathologists. Working at the state and regional with state legislators years ago to fight client billing.

As have a lot of others in this forum - who have detailed the specifics of their endeavors.

Many of us who regularly visit and opine here believe the ever increasing numbers of pathology trainees transitioning to the work force are major contributors to the issues talked about with reimbursements. These new trainees are not easily finding jobs either.
If you disagree so be it, but medical students really do deserve this information. It is up to them to do some more due diligence to know for sure what is happening.

I also believe this type of forum is impactful, though imperfect partly b/c of the anonymity. I find the information here useful and a timely way to find out about happenings in the world of pathology - a med student considering pathology should be in the know about all aspects of the field.

Finally - in my experience when it come time for pathologists to fight (client billing for path services) or with billing issues like the BC/BS reimbursements it is ONLY non-academics who are active at all. From what I see academics simply don’t care. Just calling it how I see it.

 

[rirriri]

I only did one fellowship. What is wrong with me?

Nothing at all! Same here my friend!

 

[rirriri]

Well said octopus ^^

Riri - I have spent a lot of my free time advocating for pathologists. Working at the state and regional with state legislators years ago to fight client billing.

As have a lot of others in this forum - who have detailed the specifics of their endeavors.

Many of us who regularly visit and opine here believe the ever increasing numbers of pathology trainees transitioning to the work force are major contributors to the issues talked about with reimbursements. These new trainees are not easily finding jobs either.
If you disagree so be it, but medical students really do deserve this information. It is up to them to do some more due diligence to know for sure what is happening.

I also believe this type of forum is impactful, though imperfect partly b/c of the anonymity. I find the information here useful and a timely way to find out about happenings in the world of pathology - a med student considering pathology should be in the know about all aspects of the field.

Am very glad to hear you are trying to make an impact. This forum is a place I have not visited for years but recently decided to return to and I was horrified by the negativity hence I’ve been posting. I am glad that people like you are concerned and want to make a difference but this site firstly serves as an interface for students to enter the field and it’s irresponsible to burden them with unregulated fear as was going on prior to my arrival.

A fair perspective yes please I’d love to hear all perspectives private public and academic.

 

[rirriri]

Non-academic jobs (hospital employed, corporate, contracted, private owned lab) greatly outnumber true academic jobs; groups that actually "own the lab" is a minority--that's not to suggest all private practice pathologists "own a lab". Like Pongo stated: All those outside of academia (true private practice, employed community hospital physicians, big lab employees, botique lab employees, in-office lab dwellers, etc) have much more in common with each other, and comprise the majority of the pathology workforce.

We've established you'd never do PP for the above list of reasons, and I'd never to academics for a different list of reasons (not among them is a billing fetish or preference for tedious work). I never said I don't care about academics. My point is that an understanding of the finances in pathology is requisite to speak intelligibly one way or the other on advocacy. If you don't care, don't want to care, and claim an absolute ignorance on the subject, how can you have an opinion on the positive or negative of the financial underpinnings that guarantee your paycheck?

Needless to say a willful ignorance on any other subject in life wouldn't bolster one's ability to advocate one way or the other on the laws that surround them.

I get it--academics doesn't lend one to care about the details of the financial aspect of the field, whether it's path or surgery or psychiatry. So if the discussion about the problems of the field centers on the deterioration of the financial aspect, you don't have a dog in the fight and your opinion on the subject is moot.

The question initially posed was "when are people in academics going to feel the pinch that people in the non-academic setting feel?" Like Pongo also stated earlier: Academic pathologists are lumped in with and negotiate alongside the academic center's "physician group", and tend to command much more favorable rates than those outside of academia. Academic physicians also have other responsibilities (research, teaching), which provide revenue sources outside of CPT codes. So it is understandable why an academic is less concerned about negative market forces.

If you don't understand and don't want to understand the finances, your answer to the question should be: "I don't know because I don't care."

I have some idea of how finances work only due to my interests in administration of larger centers however I don’t claim to be an authority of any type or of any desire nor do I watch this scope on a weekly or monthly basis; only on a larger scale perspective. What I do know is that every single specialty is full of fear and paranoia about reimbursement and as much as you guys want to spread the dark cloud here, unopposed, I am only going to add that Pathology is certainly not the only one worried their heels are falling off. This type of worry and concern is endemic across all fields of medicine.

Pongo is correct about a lot of stuff; but hospital based Pathologists are still the largest population of Pathologists in this country and OF that population academic Pathologists are the largest. If we are talking the largest segment of total Pathologists it is easily and handily Academia. Pathology, in particular, is traditionally an academic field and still is fundamentally.

That being said I concede it is not 1954 anymore and private medicine blossomed at the dawn of profit-driven medicine. As the profiteering comes into question; private medicine may also. Private medicine (not just Pathology) has been falling consistently for the past 20 years with consolidation and hospital and larger private company takeovers. I think you guys suffer in the front lines of reimbursement issues more abruptly than we do and by that qualification I understand the urgency for you more than for us. Our salaries are sponsored by the medical school, by departmental funds, hospital funds, etc etc. we don’t feel it fast nor does it impact us when something new happens. Will it impact us? OF COURSE. Is telling people not to enter Pathology and to leave the field the answer? Absolutely not in fact that’s he opposite of the answer. Stand up and fight is the answer.

I am glad you are all expressing yourselves as you have the right to; and I am glad for the most part things have remained friendly in our discussions.

 

[octopusprime]

...hospital based Pathologists are still the largest population of Pathologists in this country and OF that population academic Pathologists are the largest. If we are talking the largest segment of total Pathologists it is easily and handily Academia.

The argument isn't about lab-owned, stand-alone PP groups vs everyone else...many in PP are still "hospital based" but independently contracted...IE private practice but don't bill globally, just professional.

Anyone have stats on PP vs academic? And by "PP" I'm including the aforementioned groups Pongo correctly lumped together...

Also consider that a considerable percentage of pathology departments are comprised of CP-only/super niche pathologists that have absolutely no skin in the game.

What are the stats on the numbers of surgical cases signed out at academic centers vs everywhere else? I have to say the latter constitutes a much larger volume...this goes back to what Pongo alluded to--numbers of pathologists isn't as important as their role and income streams...IE a department of 50+ pathologists at Whatever University is not the same as 50+ pathologists at a huge private lab, in terms of proximity to the realities of finances and reliance on standard CPT billing for income.

 

[rirriri]

The argument isn't about lab-owned, stand-alone PP groups vs everyone else...many in PP are still "hospital based" but independently contracted...IE private practice but don't bill globally, just professional.

Anyone have stats on PP vs academic? And by "PP" I'm including the aforementioned groups Pongo correctly lumped together...

Also consider that a considerable percentage of pathology departments are comprised of CP-only/super niche pathologists that have absolutely no skin in the game.

What are the stats on the numbers of surgical cases signed out at academic centers vs everywhere else? I have to say the latter constitutes a much larger volume...this goes back to what Pongo alluded to--numbers of pathologists isn't as important as their role and income streams...IE a department of 50+ pathologists at Whatever University is not the same as 50+ pathologists at a huge private lab, in terms of proximity to the realities of finances and reliance on standard CPT billing for income.

I agree not all Pathologists are the same; but likewise not all volumes are the same. 1 part GI biopsies are, for me, about as generic as pathology work can get. I have, in the past, signed them and don’t mind signing them but a stack of 30 GI biopsies is a piece of cake compared to 5 difficult biopsies.

“Skin in the game” has many variations. The same way you feel an academic, subspecialized pathologist doesn’t have “skin in the game” as it pertains to financial and reimbursement ramifications somebody else could claim someone not signing out the real challenging stuff doesn’t have “skin in the game” in scientific and medical terms.

That being said; I’m fairly sure good Pathologists in private practice feel they work with scientific integrity just like good Pathologists in academia try to stay aware of the current state of things. It’s not a sin to be aware and appreciate different angles.

 

[pongo]

I agree not all Pathologists are the same; but likewise not all volumes are the same. 1 part GI biopsies are, for me, about as generic as pathology work can get. I have, in the past, signed them and don’t mind signing them but a stack of 30 GI biopsies is a piece of cake compared to 5 difficult biopsies.

“Skin in the game” has many variations. The same way you feel an academic, subspecialized pathologist doesn’t have “skin in the game” as it pertains to financial and reimbursement ramifications somebody else could claim someone not signing out the real challenging stuff doesn’t have “skin in the game” in scientific and medical terms.

That being said; I’m fairly sure good Pathologists in private practice feel they work with scientific integrity just like good Pathologists in academia try to stay aware of the current state of things. It’s not a sin to be aware and appreciate different angles.

When I was a young pathologist working in academia, I too thought there was something special about the case mix I was seeing and something magical about the interpretations rendered by my department. I was wrong. As a subspecialist in an academic center, your work is enriched in "real challenging stuff". But the reason for that enrichment is that physicians outside of academia recognized these "real challenging" patients and referred them to the academic center. Patient's don't think to themselves, "I bet my lump is something unique, so I'm going to the University". So pathologists in the community, whose scope of practice is an order of magnitude more vast and complicated, are just as critical in "scientific and medical terms" for taking care of these patients. When I send a case to an academic center, it is exceedingly rare that I haven't already figured it out. Having to also pay attention to the economics of pathology does not diminish "scientific and medical skin in the game".

 

[Guest8]

When I was a young pathologist working in academia, I too thought there was something special about the case mix I was seeing and something magical about the interpretations rendered by my department. I was wrong. As a subspecialist in an academic center, your work is enriched in "real challenging stuff". But the reason for that enrichment is that physicians outside of academia recognized these "real challenging" patients and referred them to the academic center. Patient's don't think to themselves, "I bet my lump is something unique, so I'm going to the University". So pathologists in the community, whose scope of practice is an order of magnitude more vast and complicated, are just as critical in "scientific and medical terms" for taking care of these patients. When I send a case to an academic center, it is exceedingly rare that I haven't already figured it out. Having to also pay attention to the economics of pathology does not diminish "scientific and medical skin in the game".

Agree. I send complicated cases to the local academic departments all the time. Doesn't mean I didn't work them up. Just that I want more eyes on the case to get the best consensus diagnosis for the patient. I love my bread and butter, 1 second/slide cases as well as the challenging, four-rounds-of-immunos cases. Not looking to give up either part.

 

[rirriri]

When I was a young pathologist working in academia, I too thought there was something special about the case mix I was seeing and something magical about the interpretations rendered by my department. I was wrong. As a subspecialist in an academic center, your work is enriched in "real challenging stuff". But the reason for that enrichment is that physicians outside of academia recognized these "real challenging" patients and referred them to the academic center. Patient's don't think to themselves, "I bet my lump is something unique, so I'm going to the University". So pathologists in the community, whose scope of practice is an order of magnitude more vast and complicated, are just as critical in "scientific and medical terms" for taking care of these patients. When I send a case to an academic center, it is exceedingly rare that I haven't already figured it out. Having to also pay attention to the economics of pathology does not diminish "scientific and medical skin in the game".

My specialty is only really practiced (in a dedicated manner) In academia as it is not about volume. Where I work is at a US top 20 hospital and medical school. Many of the outside consults I receive come with no diagnosis. The ones that do come with a diagnosis often have to be changed. Not saying anything is “magical” but people like me have the time and resources to spend on these difficult cases. I cannot imagine the average community or private practice pathologist has the time or resources to allocate on cases like this regularly.

If you’ve worked in Academia you know the deal. I don’t say it’s the best thing ever there are definitely negatives as well as positives. I can totally see why some of you decide private practice is best for you. What I cannot get behind, however, is you guys negating academic medicine and pathology.

My whole point of all of this has been; embrace the fact that there are people like me, people like you, and people who won’t follow any of these paths in Pathology. For a field to evolve one has to have a healthy respect for different pathways.

 

[octopusprime]

My specialty is only really practiced (in a dedicated manner) In academia as it is not about volume. Where I work is at a US top 20 hospital and medical school. Many of the outside consults I receive come with no diagnosis. The ones that do come with a diagnosis often have to be changed. Not saying anything is “magical” but people like me have the time and resources to spend on these difficult cases. I cannot imagine the average community or private practice pathologist has the time or resources to allocate on cases like this regularly.

If you’ve worked in Academia you know the deal. I don’t say it’s the best thing ever there are definitely negatives as well as positives. I can totally see why some of you decide private practice is best for you. What I cannot get behind, however, is you guys negating academic medicine and pathology.

My whole point of all of this has been; embrace the fact that there are people like me, people like you, and people who won’t follow any of these paths in Pathology. For a field to evolve one has to have a healthy respect for different pathways.

None of us negate academics...we all use it to some extent on a routine basis...if we're at a hospital that doesn't have/cant' afford FLOW, off it goes. If we have a medical kidney, muscle biopsy, lung transplant, off it goes. Weird sarcomas that needs either FISH or IHC or PCR test that can't perform in house, off it goes. It just makes sense to have academic centers that have the resources to dedicate to modalities or expertise that are not feasible to employ or purchase in the community. And this is certainly an aspect of academics that I didn't more explicitly emphasize in its importance. But ultimately I'm just critical of the mindset that associates non-academic pursuits with "profiteering" and greed, as if community medicine is less pure. It's smug. We can joke about PP vs academics as caricatures of modern medicine, but this thread was about reimbursements felt in the community affecting academics, and when you poo-poo such concerns as [wrongfully] only affecting a small minority and not something you bother yourself with, it comes across as disingenuous.

The debate then degenerated into tangents on the merits of PP vs academics.

Like I said, if you don't understand and don't want to understand the finances, your answer to the question should be: "I don't know because I don't care".

 

[y2k_free_radical]

9

None of us negate academics...we all use it to some extent on a routine basis...if we're at a hospital that doesn't have/cant' afford FLOW, off it goes. If we have a medical kidney, muscle biopsy, lung transplant, off it goes. Weird sarcomas that needs either FISH or IHC or PCR test that can't perform in house, off it goes. It just makes sense to have academic centers that have the resources to dedicate to modalities or expertise that are not feasible to employ or purchase in the community. And this is certainly an aspect of academics that I didn't more explicitly emphasize in its importance. But ultimately I'm just critical of the mindset that associates non-academic pursuits with "profiteering" and greed, as if community medicine is less pure. It's smug. We can joke about PP vs academics as caricatures of modern medicine, but this thread was about reimbursements felt in the community affecting academics, and when you poo-poo such concerns as [wrongfully] only affecting a small minority and not something you bother yourself with, it comes across as disingenuous.

Like I said, if you don't understand and don't want to understand the finances, your answer to the question should be: "I don't know because I don't care".

Academia charges $300 plus for consult for same case on which i receive $24.Also no free consults on indigent,self pay or illegals on which i am effectively paid less than $ 0 after billing costs.

 

[rirriri]

None of us negate academics...we all use it to some extent on a routine basis...if we're at a hospital that doesn't have/cant' afford FLOW, off it goes. If we have a medical kidney, muscle biopsy, lung transplant, off it goes. Weird sarcomas that needs either FISH or IHC or PCR test that can't perform in house, off it goes. It just makes sense to have academic centers that have the resources to dedicate to modalities or expertise that are not feasible to employ or purchase in the community. And this is certainly an aspect of academics that I didn't more explicitly emphasize in its importance. But ultimately I'm just critical of the mindset that associates non-academic pursuits with "profiteering" and greed, as if community medicine is less pure. It's smug. We can joke about PP vs academics as caricatures of modern medicine, but this thread was about reimbursements felt in the community affecting academics, and when you poo-poo such concerns as [wrongfully] only affecting a small minority and not something you bother yourself with, it comes across as disingenuous.

The debate then degenerated into tangents on the merits of PP vs academics.

Like I said, if you don't understand and don't want to understand the finances, your answer to the question should be: "I don't know because I don't care".

I care..but I don’t have the time or interest to actually learn more about billing specifics. It’s not in my interests; except in a broader discussion of healthcare dynamics.

PP is about profits. It’s a profit driven model. Not saying that in a smug way at all but it’s the truth. Academia and hospital practices also want to make profits as well but there is a difference. There are services in academia that continuously lose money but they are necessary and they continue. Would private practice continue providing a service it loses money on?

 

[pongo]

We lose money on all kinds of services we provide. Every day. Pathologists in both sectors lie awake at night worrying about our patients, and we all draw a salary. So besides losing money on some services, which everyone does, what exactly is this "difference" in the way the two models are "driven" for profit? Trust me, your Chairperson and the bean counters in your department know all about the issues folks are discussing in these forums, in all their mundane and tedious detail. And they affect you whether or not you are paying attention. If you aren't at the table, you are on the menu. That's why I chose to leave academics - I didn't want to concede my career to the whims of questionable departmental leadership.

You really should spend some time outside of academics. The best attendings I ever worked with in academics had community practice experience. No matter how hard you try to be diplomatic, you just can't help insulting the altruism most folks in the private sector have dedicated their lives to.

 

[y2k_free_radical]

I care..but I don’t have the time or interest to actually learn more about billing specifics. It’s not in my interests; except in a broader discussion of healthcare dynamics.

PP is about profits. It’s a profit driven model. Not saying that in a smug way at all but it’s the truth. Academia and hospital practices also want to make profits as well but there is a difference. There are services in academia that continuously lose money but they are necessary and they continue. Would private practice continue providing a service it loses money on?

We would and do since we are forced to take all types of patients including the self pays,indigent and illegals.

 

[octopusprime]

PP is about profits. It’s a profit driven model. Not saying that in a smug way at all but it’s the truth. Academia and hospital practices also want to make profits as well but there is a difference. There are services in academia that continuously lose money but they are necessary and they continue. Would private practice continue providing a service it loses money on?

PP et al non-academic practice settings is about implementing current diagnostic algorithms--both anatomic and clinical--within the financial & volume-limiting constraints of either the practice or the hospital system/group that owns the lab, to give patients accurate and timely diagnoses. It's no more a profit driven model than any academic center in the country. The mere presence of an electron microscope, some obscure MD/PhDs that do research on yeast, and pathology residents (which carry their own funding) don't negate the bottom line of the department, and they don't elevate the level of your work to some higher ethical plane.

I'm no more "profit driven" than the chair of your department...what do you think "profit driven" means in the context of running a private practice vs a department, anyway? I'm genuinely curious how I run my practice that puts profit above patients...or is it simply that I don't allocate funds to purely academic ventures that qualifies my practice as "profit driven"? If I make more than an academic junior faculty does that qualify me? Or do I just have to employ modalities (with which you're familiar) that lose the practice/hospital/company money to qualify as non-profit...

I'd be curious to see the salaries of your non-profit department chair, non-profit vice-chair, non-profit university president, non-profit hospital CEO, non-profit CFOs, non-profit associate vice presidents, associates to the vice presidents, etc, etc, etc, ....how far from the pure academic nidus of your selfless ventures can one be legitimately "non-profit"?

 

[WEBB PINKERTON]

Everyone get your emotional support animal and let it go.

Bottom line that everyone agrees about is that private practice is in the dumpster and that is having an impact on the people going into this field.

 

[y2k_free_radical]

PP et al non-academic practice settings is about implementing current diagnostic algorithms--both anatomic and clinical--within the financial & volume-limiting constraints of either the practice or the hospital system/group that owns the lab, to give patients accurate and timely diagnoses. It's no more a profit driven model than any academic center in the country. The mere presence of an electron microscope, some obscure MD/PhDs that do research on yeast, and pathology residents (which carry their own funding) don't negate the bottom line of the department, and they don't elevate the level of your work to some higher ethical plane.

I'm no more "profit driven" than the chair of your department...what do you think "profit driven" means in the context of running a private practice vs a department, anyway? I'm genuinely curious how I run my practice that puts profit above patients...or is it simply that I don't allocate funds to purely academic ventures that qualifies my practice as "profit driven"? If I make more than an academic junior faculty does that qualify me? Or do I just have to employ modalities (with which you're familiar) that lose the practice/hospital/company money to qualify as non-profit...

I'd be curious to see the salaries of your non-profit department chair, non-profit vice-chair, non-profit university president, non-profit hospital CEO, non-profit CFOs, non-profit associate vice presidents, associates to the vice presidents, etc, etc, etc, ....how far from the pure academic nidus of your selfless ventures can one be legitimately "non-profit"?

We also don't receive tax payer subsidies for training

 

[YBNJay]

I care..but I don’t have the time or interest to actually learn more about billing specifics. It’s not in my interests; except in a broader discussion of healthcare dynamics.

PP is about profits. It’s a profit driven model. Not saying that in a smug way at all but it’s the truth. Academia and hospital practices also want to make profits as well but there is a difference. There are services in academia that continuously lose money but they are necessary and they continue. Would private practice continue providing a service it loses money on?

Given the current climate, I would say that private practice is more about survival than profit. Starting salaries for new pathologists, after 6 years of training (two fellowships) are on par, or just under what a starting family med attending makes. I know someone who took a PP job for 155k/yr.

 

[gbwillner]

Given the current climate, I would say that private practice is more about survival than profit. Starting salaries for new pathologists, after 6 years of training (two fellowships) are on par, or just under what a starting family med attending makes. I know someone who took a PP job for 155k/yr.

This seems more like a random anecdote and not likely reflective of the field as a whole. There are data published every year from surveys of hundreds or thousands of pathologists, and $155K/yr in PP does sound like a tremendous outlier. This would be low for a starting academic salary in most places.

 

[gbwillner]

Everyone get your emotional support animal and let it go.

Bottom line that everyone agrees about is that private practice is in the dumpster and that is having an impact on the people going into this field.

Thanks for that and agreed. I think the issue here is that there are real issues worth having a discussion on, and there is room for different opinions from different perspectives. However, there are so many threads on this forum on the current status of the field, many of which paint an unreasonably dark or accusatory picture, that it is easy for many of us who frequent this forum to project past discussions to the current one.

I am not in academics, although I was for many years, and get triggered when I see things like "flee now" or "it's all CAP/ACADEMIA/DEEP STATE's fault that things are bad!!!" Let's discuss the actual issues if it helps and think of practical solutions.

 

[y2k_free_radical]

Thanks for that and agreed. I think the issue here is that there are real issues worth having a discussion on, and there is room for different opinions from different perspectives. However, there are so many threads on this forum on the current status of the field, many of which paint an unreasonably dark or accusatory picture, that it is easy for many of us who frequent this forum to project past discussions to the current one.

I am not in academics, although I was for many years, and get triggered when I see things like "flee now" or "it's all CAP/ACADEMIA/DEEP STATE's fault that things are bad!!!" Let's discuss the actual issues if it helps and think of practical solutions.

So you do not believe the major cause of our negotiating weakness with payers is the over production of pathologists ?

 

[gbwillner]

So you do not believe the major cause of our negotiating weakness with payers is the over production of pathologists ?

I frankly don't know if it is a "major" or "not-major" cause. I do believe that it is a factor. In my experience payors do not apply their leverage that way. First, there is Medicare, which does not take this into account at all. CLFS is entirely driven by PAMA so even Medicare has no ability to do this. On the PFS maybe there is more leverage but Medicare just doesn't operate this way. Most private insurers just pay a percentile (above or below) Medicare, so it is hard to say that oversupply has a direct impact on this. Sure they can say "we pay 25% CMS rate, if you don't take it, your competitor will" but I don't know if this actually happens. For example, if there was a deficiency of pathologists is Missouri, do you really think Anthem would NOT have made the cuts they have proposed? I would bet it didn't even factor into their calculation.

Where I see there IS a more direct impact is on client-bill relationships, in-office labs, private hospitals, and other situations where non-pathologists leverage access to the patient to take a cut of path services. If there was a deficiency of pathologists out there I think it would be harder for these groups to exploit paths and have to pay them a fairer share. I think this is really why PP complains so much more about this- this is typically how a lot of PP actually works. I think (and have said it on several occasions) that the bigger issue here is the lack of direct patient access, not # of paths. But that does not mean I don't think it's an issue.

/my 2c

 

[dukeresident]

Most competent pathologist leave academics like it’s on fire after a short stint. The ones that stay are stuck.... they get sub-specialized and can’t look at anything except their thing. Academic pathology is broken big time. Most ancillary and molecular testing is sent out to commercial entities so in-house is IHC and just good ole H&E. The ACGME has such a low bar for allowing fellowships many crappy programs develop subpar fellowships with insufficient material or expertise .
What exactly has “academic”pathology accomplished of note in the last 15-20 years. All the PDL-1, ROS-1 etc molecular testing was developed by non pathologists. No one cares about another case report on some random entity or another variant of a polyp or large brown stain series. The majority of academic programs need to be shut down and the faculty fired. Immediately before our field goes completely down the toilet.

Agreed!

 

[dukeresident]

Not saying that at all. What you described isn’t wrong about how an academic career would evolve; but there is more to life than money. I look at myself and yes I have a lower salary compared to some of my private practice peers but what I do have is contentment and a lack of stress about funding, money, reimbursement, or all the stuff I see constant paranoia about from people in private practice.

Private practice is fading not just in Pathology but in virtually every field of medicine. Yes it will still exist but the market forces are against it. That’s not Pathology’s fault but that’s the fault of where our savagely broken, profit-driven system has taken us.

My academic career summarized? I have never “applied” for a job I have been recruited since my fellowship, my jobs have not been RVU based. I have been able to get involved and help transform medical education for the better. I am able to present at international meetings. I have received international recognition for my work. I love teaching residents. I get to work on projects I find “interesting”. I have never done any work in relation to billing codes nor am I involved in any matters pertaining to billing. I am constantly being recruited for bigger roles at other institutions but it’s not in my interest at the moment. On top of all of that I work in a small sub specialty solving cases that others cannot and wouldn’t attempt to. It is certainly satisfying to ME but yes not for everyone.

I agree academia is not for everyone; but the fact is that Pathology, like almost every other field of medicine, is heading towards a hospital-based or institution-based growth rather than a private sector growth. There are also plenty of opportunities in the industrial setting and biotech. I would like to hope that 10-20% of pathology stays private practice because it’s good for the field; but i feel its an upward battle at the moment.

Eventually we may go back to the model of hospitals who use contracted groups; a practice which was much more widespread 10+ years ago but at the moment all the momentum is with hospital-based and academic groups.

Regardless of the type of practice some of you are in; we should respect others choices and types of practice. I sympathize with the inner city community hospital pathologist just like I sympathize with a small private practice. We are all Pathologists at the end of the day and the goals should be the same—-to make the field robust and strong rather than weaken it by bickering.

You sound more and more like a lone voice in the wilderness. Why might that be?

 

[dukeresident]

Most people in academia are (very) happy to be in academia. Have no idea why you’d say “reluctantly”. It’s easy to chase money; much harder to chase one’s true interests. I know very few people who left academia for private jobs the ones I do know left for private biotech jobs.

Tenure track? Non-tenure has become the new standard for the past many years. Research depends on people; some do more some do less. I know plenty of Pathologists that are 50% research. There are also people like myself who are working on research and largely clinical.

I don’t understand private practice very well but I do understand academia fairly well. You can surely educate me about your work rather than focusing on dragging academia down.

And you know most are happy how? Please explain.

 

[y2k_free_radical]

I frankly don't know if it is a "major" or "not-major" cause. I do believe that it is a factor. In my experience payors do not apply their leverage that way. First, there is Medicare, which does not take this into account at all. CLFS is entirely driven by PAMA so even Medicare has no ability to do this. On the PFS maybe there is more leverage but Medicare just doesn't operate this way. Most private insurers just pay a percentile (above or below) Medicare, so it is hard to say that oversupply has a direct impact on this. Sure they can say "we pay 25% CMS rate, if you don't take it, your competitor will" but I don't know if this actually happens. For example, if there was a deficiency of pathologists is Missouri, do you really think Anthem would NOT have made the cuts they have proposed? I would bet it didn't even factor into their calculation.

Where I see there IS a more direct impact is on client-bill relationships, in-office labs, private hospitals, and other situations where non-pathologists leverage access to the patient to take a cut of path services. If there was a deficiency of pathologists out there I think it would be harder for these groups to exploit paths and have to pay them a fairer share. I think this is really why PP complains so much more about this- this is typically how a lot of PP actually works. I think (and have said it on several occasions) that the bigger issue here is the lack of direct patient access, not # of paths. But that does not mean I don't think it's an issue.

/my 2c

Good point but some groups ,such as ophthalmology recently,have forced BCBS to rescind cuts but refusing en mass to accept them.

 

[gbwillner]

Good point but some groups ,such as ophthalmology recently,have forced BCBS to rescind cuts but refusing en mass to accept them.

That may be but if true this would be the exception rather than the rule.

 

[LADoc00]

Your thought process on this is all wrong. Maybe never.

Think about this: how much do academics that study niche transgender/women's studies/ethnic studies make?

Academics is for right now, totally divorced from all realities of any free market that exists on our world.

My own feeling is the very concept of a "university" is doomed and will be replaced by online/e-learning tools for a price point VASTLY below current levels with a much much higher quality that is standardized. But that could be awhile.

 

[Med Director New England]

No better way to scare off potential applicants than to tell them they have virtually no shot at a private practice career. Any applicant we, as a field, would want is smart enough to figure out how unsavory academic medical practices can be. For those of you who don't know, the traditional academic career in pathology (or most other medical specialties) goes like this.

1. Get an appointment as a clinical track assistant professor with pay at the 25-50th percentile as compared to your private practice peers, but still doing just as much work as them with the added pressure of teaching. While academic departments will say you only have to "participate" in research as it is only a few percentage points of your job's trinity of Service, Teaching, and Research, reality is you have to publish in sufficient quantity (even if you're not tenure-track) to get promoted. You will also be granted the distinction of doing all the things that all your older colleagues don't want to do (i.e. medical school teaching, resident lectures, tumor boards, etc.). You'll also get all of the terrible call schedules that no one wants. Basically, you're the department's work horse and your entry level academic job is to bill waaaaaaaaaay more than what they're paying you to support the inflated salaries of the department chair and full professors (effectively the "partners" of the department).
2. After you work as an assistant professor with either no or marginal pay raises for a minimum of 7 years in most departments, you become eligible for promotion to associate professor, which in pathology only adds an additional $20-30k boost in pay from what I see in perusing multiple public academic salary databases.
3. Get promoted to associate professor so you can finally buy a house and car that's better than middle middle-class as your student loans are still weighing you down. As an associate professor, you have a little more say in what specialties and services you can (and won't) do - but not by much mind you. Again, even though you're clinical track, guess what - you still have to publish even more (and it helps if you network too). Keep in mind, the promotion requirements vary greatly from dept to dept with sometimes nebulous and/or capricious standards depending on who the chair is and how much they like you.
4. After another minimum 7 years of being an associate professor, you can come up again for promotion to full professor. Sounds great in name, but all it means is that you get only another modest boost in pay (anywhere from $30-40k). The real benefit in being professor is you now get the ability to effectively work less than what you're being paid. You've earned the right to subside off another's labor. This is where you can now make a career cataloging toenail diseases and be grossly overpaid for it.
5. If you're really, really lucky and have done a good job of networking and making a name for yourself by publishing or as a well respected speaker, you can get a chairmanship which effectively boosts your pay to what an average private practice partner in pathology would make. Candidates for chairmanships have been in the field for 20+ years and have a reputation that usually proceeds them.

For those of you who are reading this and going "Geez, that's a myopic, uninformed, and pessimistic view of academic practice", just ask yourselves how many start out as assistant professors and make it all the way up to full professor. The rate of attrition is horrendous in academia, and for good reason. Most of it has to do with not wanting to be either party or subjected to the megalomaniac designs of department chairs and their chief lieutenants, the full professors. There are of course exceptions to the above - there are always exceptions. But as our field tends to aggregate the rather unexceptional as of late, academic departments don't have to treat new hires with any special privilege or perks.

And if you think I'm painting a bad picture of academia in general, I'm not. I'll give the following anecdote I saw with my own eyes in community practice just recently. A very well established oncology surgeon was not happy in his private practice job and the regional academic center in the same city just happened to be needing someone with this surgeon's experience. The surgeon applied for the job and the conversation with the surgery chair went something like this:
Chair: You're going to do general surgery cases as well as your oncology case load.
Surgeon: Nope. I'm only doing my oncology cases.
Chair: That's not what the posted job description is.
Surgeon: That may be what you're looking for, but that's not what I'm looking for. And last time I checked, no else in 1500 miles with my experience and expertise is looking for that either.
Chair: OK. But you're still taking general surgery call.
Surgeon: Guess again. I'm only doing my cases and call related to them.
Chair: Fine. We'll just adjust your pay to match the work.
Surgeon: Nope. I'm not taking a pay cut either. Figure it out or good luck getting someone else before your accreditation comes under the chopping block.
Chair: Hired.

Now I ask, anyone see that happening in a pathology academic department???

Wow- chuckle
Great post.
This is really spot on.
My only edit - you forgot the 1-2 Yrs as instructor (esp at higher tier depts). You still might be able to sneak into university sponsored events serving free food and booze, shmooze with residents and fellows b/c your status and pay is still low enough to qualify.

 

[deleted314957]

Wow- chuckle
Great post.
This is really spot on.
My only edit - you forgot the 1-2 Yrs as instructor (esp at higher tier depts). You still might be able to sneak into university sponsored events serving free food and booze, shmooze with residents and fellows b/c your status and pay is still low enough to qualify.

You think that is clout? The clout that (non exclusive spine, craniotomy types) neurosurgeons have as regards coverage/call at major trauma centers where their(near) immediate availability is required for accreditation is unbelievable. That “little” retainer is more than many pathologists make.

 

[rirriri]

Your thought process on this is all wrong. Maybe never.

Think about this: how much do academics that study niche transgender/women's studies/ethnic studies make?

Academics is for right now, totally divorced from all realities of any free market that exists on our world.

My own feeling is the very concept of a "university" is doomed and will be replaced by online/e-learning tools for a price point VASTLY below current levels with a much much higher quality that is standardized. But that could be awhile.

You think a healthcare system run by profiteering middle-businesses (aka insurance) is a “free market”?

please...

there are no “free market” physicians anywhere in the US. We are in a semi and quasi-controlled industry where there are many hands juggling the same 3 balls. A true free market industry would be in more material objects or services which are direct to consumer. We are not fiscally working in a direct to consumer manner.

we don’t even determine reimbursement rates or patterns.

 

[Torsed]

You think a healthcare system run by profiteering middle-businesses (aka insurance) is a “free market”?

please...

there are no “free market” physicians anywhere in the US. We are in a semi and quasi-controlled industry where there are many hands juggling the same 3 balls. A true free market industry would be in more material objects or services which are direct to consumer. We are not fiscally working in a direct to consumer manner.

we don’t even determine reimbursement rates or patterns.

Bravo.

 

[WEBB PINKERTON]

Plastics and Lasik surgery about as free market as health care gets.

 

[Med Director New England]

Plastics and Lasik surgery about as free market as health care gets.

Maybe also concierge model for primary care....