How much does going to mid vs top tier residency impact your abillity to easily find a job in a city?

octopusprime

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Agree with MDNE--unless you have connections elsewhere, you spend 5 years getting to know the layout of the land in the geographic location in which you train, which can lead to job prospects, but "top tier" programs are often in larger cities that are flooded with annual graduates and corporate lab presence.
There are some "top tier" programs in the Midwest, but plenty of "mid tier", and the difference isn't going to land you more job prospects...often the opposite IMO (again unless you have connections or are looking in academia, in which case it doesn't matter where you go)--there's a LOT of land between the coasts, and it's not as sexy to live in flyover country but unless you're insanely lucky or wolf-of-wallstreet/LADoc-type aggressive & savvy, the coasts are much tighter markets to break into and thrive within (and repayment rates often lower, with higher COL).

If you're content living in the Midwest, training there can often lead to much better job prospects.
Personally I would rather live like a prince in the Midwest than a pauper on the coast...the former is not always a thriving metropolis but plenty of ~500k-1mil population metros with solid medical communities that can provide a great lifestyle.
 
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AZpath

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Yes
One Caveat - some of the top programs are large enough to have flooded the local market so you may still have to relocate unless you stay in academia.
Agree, there are so many training programs in some cities that supply greatly out strips demand.
Getting a good job in these area is often a matter of luck and timing.
Develop contacts in local practices.
Perhaps offer to use a vacation week to replace a path assistant etc.
 
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LADoc00

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Contacts and connections trump prestige of training program.

This is amplified 10-fold if your goal is to settle in a small rural (what is our term here? "rural deluxe"??) area.

Many groups in the rural deluxe category actively disdain elitist training programs and will reject you immediately so YMMV.
 
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octopusprime

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Contacts and connections trump prestige of training program.

This is amplified 10-fold if your goal is to settle in a small rural (what is our term here? "rural deluxe"??) area.

Many groups in the rural deluxe category actively disdain elitist training programs and will reject you immediately so YMMV.
lol I love that term--rural deluxe. and yes --unless you're from 'round these parts--a degree from MGH means nothing other than you probably really don't want to live here.
Local / regional / personally recommended applicants only.
 
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Adrian Cocot

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Not directly.

It might improve your fellowship prospects, so if you're looking at a career in academics, it will help you to go to an ivory tower for residency.

For most private practices, personality and work ethic -- things that make you a good co worker -- trump whatever institution is on your diploma. Too many of us have dealt with candidates and colleagues that look great on paper but suck to work with.
 
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LADoc00

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For rural deluxe: UTexas, UUtah, Baylor, Michigan, Ohio State, Arizona, Alabama, Creighton....definitely eschew MGH, BWH, NYU, Columbia, Dartmouth, Yale, UCSF, UW Seattle, UCLA.

Dunno, what is THE most snooty training program sure to enrage rural deluxe groups? BWH? Yale? NYU?

I know I once told a rural deluxe group I spent time in Boston and they pretty much stopped communicating with me.

Rural deluxe rage is real, choose carefully.
 
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octopusprime

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Does the 'deluxe' denote academic or just larger size/prestige midwest?
How about "Prestige Midwest" (a subsidiary of Prestige Worldwide)?

Unless said trainee went to MGH for undergrad or has since relocated to the midwest , it's more of the perception that MGH, BWH, et al are good academic places to do a fellowship and send consults but not necessarily get one's formal AP/CP training, but also from the standpoint of wanting people to commit to the area: if there's literally no indication someone has spent any time here, there's nothing to say they won't be looking to leave as soon as something better comes along.
The >95th percentile income is appealing to everyone, the location is not.
 
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I think UW Seattle might be pretty good for all the rural deluxe locations in the northwest like Idaho, Montana, Wyo, Alaska?
 
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Med Director New England

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So I gotta chime in on this one more time

others have mentioned the importance of making connections, being a collegial colleague, word of mouth endorsements, etc. I do agree these are also critical to getting a good job and navigating life and work in general. I did not start residency with extensive contacts in path (I think this applies to Most kids finishing up med school) and/ or word of mouth approvals at that point. this process for most starts in residency and being at a large / upper tier place will give you a leg up on this beginning with access to an extensive network of alumni paths.

In my case - alumni of my training program are literally scattered everywhere throughout the country in every type of practice and setting imaginable. This built in network was extremely helpful for me and folks who trained around the time I did transitioning to the work force initially. Still wasn’t super easy esp for those who didn’t want to leave the immediate area. Now almost 15 years later I continue to keep up with the alumni older than me, the ones around my time and newer graduates out in the work place. So the network from my particular training program continues to be beneficial to me - I would have a much easier time relocating and finding work if I ever had to.

If one comes out of one the upper tier programs acting like an elitist A-hole - yeah you will likely turn people off. I have met a few like this but this is in my experience this is the exception.

so I still think the best move for any med student going into path is to go to the best program you get into, train in combined AP/CP — do not do AP only under any circumstance unless you are 100% committed to a career in academia and even then seriously consider AP/CP just in case —, work hard, network all you can, & don’t become an elitist jerk in the process....
 
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My experience is to train at least in the same coast as where you want to settle in (if it's East vs West coast). The practice styles are completely different and it's tough to acclimate even if you switch coasts. I would strongly recommend training close by to where you want to settle, or be ready to scramble for spots far away in the middle of the country. Definitely do AP/CP. And if you train in a big city, be ready to stay in academia if you want to stick around. Networking does pay off, but in my experience it doesn't trump geography.
 

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So I gotta chime in on this one more time

others have mentioned the importance of making connections, being a collegial colleague, word of mouth endorsements, etc. I do agree these are also critical to getting a good job and navigating life and work in general. I did not start residency with extensive contacts in path (I think this applies to Most kids finishing up med school) and/ or word of mouth approvals at that point. this process for most starts in residency and being at a large / upper tier place will give you a leg up on this beginning with access to an extensive network of alumni paths.

In my case - alumni of my training program are literally scattered everywhere throughout the country in every type of practice and setting imaginable. This built in network was extremely helpful for me and folks who trained around the time I did transitioning to the work force initially. Still wasn’t super easy esp for those who didn’t want to leave the immediate area. Now almost 15 years later I continue to keep up with the alumni older than me, the ones around my time and newer graduates out in the work place. So the network from my particular training program continues to be beneficial to me - I would have a much easier time relocating and finding work if I ever had to.

If one comes out of one the upper tier programs acting like an elitist A-hole - yeah you will likely turn people off. I have met a few like this but this is in my experience this is the exception.

so I still think the best move for any med student going into path is to go to the best program you get into, train in combined AP/CP — do not do AP only under any circumstance unless you are 100% committed to a career in academia and even then seriously consider AP/CP just in case —, work hard, network all you can, & don’t become an elitist jerk in the process....
You can be AP only and work at Quest if you’d like but I wouldn’t recommend AP only as you said.
 
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KeratinPearls

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Agree, there are so many training programs in some cities that supply greatly out strips demand.
Getting a good job in these area is often a matter of luck and timing.
Develop contacts in local practices.
Perhaps offer to use a vacation week to replace a path assistant etc.
Yup. Jobs in tight markets are by word of mouth. The groups that are high paying (But busy) can be picky and choosy who they bring on to their group. They will never advertise. So better to train in the city you want to live in.
 

LADoc00

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My experience is to train at least in the same coast as where you want to settle in (if it's East vs West coast). The practice styles are completely different and it's tough to acclimate even if you switch coasts. I would strongly recommend training close by to where you want to settle, or be ready to scramble for spots far away in the middle of the country. Definitely do AP/CP. And if you train in a big city, be ready to stay in academia if you want to stick around. Networking does pay off, but in my experience it doesn't trump geography.

THIS is incredibly good advice. Even top notch trainees from opposite coasts often do not survive the practice "culture shock" and end up leaving. Where you went to medical school is totally immaterial, where you spent your residency/fellowship is typically the prime determinant.

I think the biggest problem with my Harvard folks is they literally cant help their attitude, its like Tourette's syndrome. Hopkins trainees come off as very subdued, from what I have discerned is due to the boot camp style beat downs they endure there in Baltimore.
 
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fecalith

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For rural deluxe: UTexas, UUtah, Baylor, Michigan, Ohio State, Arizona, Alabama, Creighton....definitely eschew MGH, BWH, NYU, Columbia, Dartmouth, Yale, UCSF, UW Seattle, UCLA.

Dunno, what is THE most snooty training program sure to enrage rural deluxe groups? BWH? Yale? NYU?

I know I once told a rural deluxe group I spent time in Boston and they pretty much stopped communicating with me.

Rural deluxe rage is real, choose carefully.
Dartmouth is 'rural deluxe' on its own! Have you ever been to Lebanon, NH? lol
 

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My experience is to train at least in the same coast as where you want to settle in (if it's East vs West coast). The practice styles are completely different and it's tough to acclimate even if you switch coasts. I would strongly recommend training close by to where you want to settle, or be ready to scramble for spots far away in the middle of the country. Definitely do AP/CP. And if you train in a big city, be ready to stay in academia if you want to stick around. Networking does pay off, but in my experience it doesn't trump geography.
I'm curious, how are practice styles different? Is it composition of reports or how the daily schedule is run, or something else?
 
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I'm curious, how are practice styles different? Is it composition of reports or how the daily schedule is run, or something else?

If you don't know it by now - the practice of pathology is subjective. And, the classification and terminology of diseases varies based on the academic institution. Therefore, the alums of such institutions bring their ideology to practice, and the thresholds of what is called atypical, malignant, etc vary based on training. This is especially true in the field of dermatopathology, and I have seen it also in cytology, breast pathology and gyn pathology. I have found the starkest differences when comparing East to West coast, but even regional differences are present (and hyper local differences for example breast pathology between BWH, BIDMC, and MGH).
But pathology doesn't exist in a vacuum - the reports are read and used by oncologists, surgeons, etc. And where they trained and who they trained with also makes a difference. And if you don't fit that mold, it's tougher to acclimate. I have had experiences with clinicians who only wanted academic reads from a certain academic pathologist and disregarded the local pathologist report (ie. would always ask for a second opinion). And for many patients in large cities, they seek an academic center for treatment, and the academic pathology interpretation trumps the local pathologist. Therefore, the local pathologist has to integrate their reads with the academic style of the treating institution to avoid discrepancies. This is easier if you're already familiar with they style (ie. from the geographic region).
I'm not saying that it's impossible to switch coasts - all I'm alluding to is that it would easier to train in the same coast you want to practice as it's easier to acclimate to the regional way of practice. I wish patients would understand that their pathology report is subjective, and I hope that we could aim for a more standardized approach - I do think the strides in molecular pathology and digital pathology/AI are working towards this goal.
 
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Napoleon1801

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If I go to a top tier residency does that improve job prospects?

Thank You,

Kind of? If you're super weird, then it's going to be difficult regardless of your training program. If you can act like a normal human and be fairly competent, you have much better odds of employment.
 

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If you don't know it by now - the practice of pathology is subjective. And, the classification and terminology of diseases varies based on the academic institution. Therefore, the alums of such institutions bring their ideology to practice, and the thresholds of what is called atypical, malignant, etc vary based on training. This is especially true in the field of dermatopathology, and I have seen it also in cytology, breast pathology and gyn pathology. I have found the starkest differences when comparing East to West coast, but even regional differences are present (and hyper local differences for example breast pathology between BWH, BIDMC, and MGH).
But pathology doesn't exist in a vacuum - the reports are read and used by oncologists, surgeons, etc. And where they trained and who they trained with also makes a difference. And if you don't fit that mold, it's tougher to acclimate. I have had experiences with clinicians who only wanted academic reads from a certain academic pathologist and disregarded the local pathologist report (ie. would always ask for a second opinion). And for many patients in large cities, they seek an academic center for treatment, and the academic pathology interpretation trumps the local pathologist. Therefore, the local pathologist has to integrate their reads with the academic style of the treating institution to avoid discrepancies. This is easier if you're already familiar with they style (ie. from the geographic region).
I'm not saying that it's impossible to switch coasts - all I'm alluding to is that it would easier to train in the same coast you want to practice as it's easier to acclimate to the regional way of practice. I wish patients would understand that their pathology report is subjective, and I hope that we could aim for a more standardized approach - I do think the strides in molecular pathology and digital pathology/AI are working towards this goal.
We definitely adapt how we sign out our reports at our community hospital based on how the big academic centers nearby sign out their cases. Because we know our case will get reviewed downtown at the major cancer centers and we will get dinged if our reports are too different from theirs. The oncologists and surgeons at those centers go off the reports of their pathologists, not us. We know that and have adapted accordingly, for better or worse.
 
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We definitely adapt how we sign out our reports at our community hospital based on how the big academic centers nearby sign out their cases. Because we know our case will get reviewed downtown at the major cancer centers and we will get dinged if our reports are too different from theirs. The oncologists and surgeons at those centers go off the reports of their pathologists, not us. We know that and have adapted accordingly, for better or worse.

Well, it is nice to see nothing changes. It’s cool, just as long as it is THEM that has to muck around with the tumor board and prep that entails.
 

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I've only been on the east coast, so I was imagining something like west coasters writing long narrative reports or something instead of line diagnoses +/- comments. The only place I've seen doing microscopic descriptions was a pediatric academic center. I guess they have time for stuff like that.
 

Guest8

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Well, it is nice to see nothing changes. It’s cool, just as long as it is THEM that has to muck around with the tumor board and prep that entails.
As for tumor boards it's a mixed bag. Years ago I'd say yes, they did most of that as the surgeons and oncologists were at the major centers and wanted things presented there. Over time the big centers have spread their tentacles so now our oncology and surgery departments are a mix of our community docs and docs from the major centers, more of the latter each year. So more and more stuff gets presented here. Wouldn't be too surprised if path is the next area to see those tentacles spread.
 
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mikesheree

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As for tumor boards it's a mixed bag. Years ago I'd say yes, they did most of that as the surgeons and oncologists were at the major centers and wanted things presented there. Over time the big centers have spread their tentacles so now our oncology and surgery departments are a mix of our community docs and docs from the major centers, more of the latter each year. So more and more stuff gets presented here. Wouldn't be too surprised if path is the next area to see those tentacles spread.

That was just starting to happen at my place about 6 months before i retired. just did not have time for that crap.
 

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There is not much benefit of doing residency from a top tier busy program. You will only end up grossing more/taking more night blood bank calls to get the same board certification. It is better to do it from a less busy place, write a lot of articles, make connections, do a fellowship at one of these places, network more and use the same brand name as a "fellow" to get a good job with half the trouble. Once you are a sub specialty "trained" pathologist, you can cover most of your weaknesses in other sub specialties, trade cases, do what the surgeons at your workplace want etc and survive. This is the MO of more than half of pathologists in the country. You don't need to be a rock star in this field! ;)
 

LADoc00

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Would be VERY interesting to see income vs. training program. My prediction there is no correlation whatsoever.
 

Dave CX

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We definitely adapt how we sign out our reports at our community hospital based on how the big academic centers nearby sign out their cases. Because we know our case will get reviewed downtown at the major cancer centers and we will get dinged if our reports are too different from theirs. The oncologists and surgeons at those centers go off the reports of their pathologists, not us. We know that and have adapted accordingly, for better or worse.
A few years ago I dx'ed a 42 year old woman with a small focus of well diff adeno associated with Barrett's. It was a super tough call. She goes to Duke for treatment. Their pathologists (5 of them) in one daily conference disagreed with me, no dysplasia or carcinoma. The Duke GI doc repeats the biopsy anyway. They dx well diff adeno, and the patient is told that that my dx was still wrong and it was just a coincidence that she cancer anyway (she did'nt buy that load of crap). A-holes. Patient is fine I see her follow ups post surgery.
 
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I have several stories like yours Dave - the academics are not always right. However, the culture of medicine still maintains that they have the diagnostic authority - for better or for worse.
In that same vein, I would venture to say that there is no relationship between income and training program - and that there may be an inverse relationship, as the "better" training programs train and attract those that pursue academics as a career. Therefore, the average salary of a graduate from those programs is less than of those that graduate private practice pathologists.
 
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mikesheree

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A few years ago I dx'ed a 42 year old woman with a small focus of well diff adeno associated with Barrett's. It was a super tough call. She goes to Duke for treatment. Their pathologists (5 of them) in one daily conference disagreed with me, no dysplasia or carcinoma. The Duke GI doc repeats the biopsy anyway. They dx well diff adeno, and the patient is told that that my dx was still wrong and it was just a coincidence that she cancer anyway (she did'nt buy that load of crap). A-holes. Patient is fine I see her follow ups post surgery.

In my experience, most patients can tell when there is ass-covering going on.
 
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LADoc00

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It MIGHT even be an inverse correlation because the big name folks disproportionately go to academics which pays less than most other situations.

Yup, yup...funny.
 
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These "consensus" conferences at academic places are prone to a lot of groupthink and/or one person domnating the opinion and everyone else goes along with it because they have no skin in the game, no benefit in disagreeing, and hey it's time for coffee. If the note says 5 academics disagreed, it is more like one disagreed and the others went along for the ride for a variety of reasons. And it's getting worse with digital/Zoom consensus conferences by the way.
 
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mikesheree

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These "consensus" conferences at academic places are prone to a lot of groupthink and/or one person domnating the opinion and everyone else goes along with it because they have no skin in the game, no benefit in disagreeing, and hey it's time for coffee. If the note says 5 academics disagreed, it is more like one disagreed and the others went along for the ride for a variety of reasons. And it's getting worse with digital/Zoom consensus conferences by the way.

As Azzopardi called it: “the principle of divided and diminished responsibility “. If you get a bunch of folks to agree then no one is really on the hook and no one person feels responsible
 
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LADoc00

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These "consensus" conferences at academic places are prone to a lot of groupthink and/or one person domnating the opinion and everyone else goes along with it because they have no skin in the game, no benefit in disagreeing, and hey it's time for coffee. If the note says 5 academics disagreed, it is more like one disagreed and the others went along for the ride for a variety of reasons. And it's getting worse with digital/Zoom consensus conferences by the way.

Holy hell this maybe the most insightful comment I have ever read on this website in 20 years....
 
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I agree with the groupthink trap. Got suckered into a few diagnoses after showing cases at the multi-head, felt like I couldn't back out afterward. You need to find people to trust and give them the case to look at their own.
 
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mikesheree

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It was always kinda drilled into me and i almost always practiced it. That is, regarding external consults; You pick ONE consultant. No shopping the case around. You can find anybody to make any call you want. Just know your consultants.
 

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It was always kinda drilled into me and i almost always practiced it. That is, regarding external consults; You pick ONE consultant. No shopping the case around. You can find anybody to make any call you want. Just know your consultants.
Young pathologists need to find a position where you have access to experienced pathologists you can show your cases to.
 
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Young pathologists need to find a position where you have access to experienced pathologists you can show your cases to.

Agreed. Groupthink however exists both in and out of academia and is totally real. In an ideal situation, a job applicant can assess the practice just as much as the practice assesses the applicant. Red flags are lots of junior pathologists, a high case consult referral rate, and lack of cooperation between pathologists (ie. not showing cases around). If you're just out of fellowship, you need to be somewhere where you can be guided for the first year or so. However, this isn't always the case depending on available jobs. Many times it is trial by fire.
 
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