I have seen our future

[pathstudent]

and it is a joke

My friend just asked me to review his father's brain biopsy pathology report, excuse me I mean Theranostics report.

He has a anaplatic astrocytoma and is 82 years old. It is not resectable. Given his age he will likely be dead within 2 years and certainly within 5.

Well the university of pittsburg does

immunohistochemisty (gfap, IDH1, P53, EGFR)
FISH for EGFR, 1p, 9q, 19q,
LOH for 1p,19q,9p,pTen,p53
PCR for IDH1, IDH2, MGMT methylation

Then they have the gall to say that the patient won't do well. Well yeah, he is an 82 year-old with an unresectable anaplastic astrocytoma. I could have told you that without speding 5000 on testing. Talk about volume over value. But hey this is personalized medicine. This is the future. This is why there is no hope for healthcare.

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[Enkidu]

and it is a joke

My friend just asked me to review his father's brain biopsy pathology report, excuse me I mean Theranostics report.

He has a anaplatic astrocytoma and is 82 years old. It is not resectable. Given his age he will likely be dead within 2 years and certainly within 5.

Well the university of pittsburg does

immunohistochemisty (gfap, IDH1, P53, EGFR)
FISH for EGFR, 1p, 9q, 19q,
LOH for 1p,19q,9p,pTen,p53
PCR for IDH1, IDH2, MGMT methylation

Then they have the gall to say that the patient won't do well. Well yeah, he is an 82 year-old with an unresectable anaplastic astrocytoma. I could have told you that without speding 5000 on testing. Talk about volume over value. But hey this is personalized medicine. This is the future. This is why there is no hope for healthcare.

Apart from the fact that the patients age makes this much testing inappropriate, are these all evidence based assays? That's actually pretty awesome, I think.

 

[LADoc00]

Yup guess what, the paltry few bucks Medicare you get for a 88307-26 on a Brain Biopsy literally makes the entire field of Neuropath a joke.

Neuropath was/is a total fail, but perhaps if the NP guys are now doing some crazy FISH panel and getting 88367-26s then maybe they have found a path forward otherwise NP was a dying field IMO.

I

 

[malchik]

Apart from the fact that the patients age makes this much testing inappropriate, are these all evidence based assays? That's actually pretty awesome, I think.

What is awesome about not providing additional useful information over the simple H/E?

However, if that is 5000 dollars, that is nothing. Isn't that about what a day in the hospital costs?

 

[pathstudent]

Apart from the fact that the patients age makes this much testing inappropriate, are these all evidence based assays? That's actually pretty awesome, I think.

We get 7-10 brain tumors a week and order some of those test selectively depending on the histology and clinical scenario. They are definitely indicated but ordering a huge panel, presumably on every case is a joke and trying to game the system. I remember rotating with a transplant liver surgeon who trained at university of Pittsburgh as a medical,student and he said "the university of Pittsburg isn't just an academic medical center, it is a ruthless corporation".

Many of those test arent of use any clinical benefit in an anaplatic astrocytoma It is behavior like this that will ruin the game for all of us.

An 88368 reimburses quite well, but when they start doing this, cms will come out and say " you know what mother fers, we will pay you a 100 bucks no matter how many fish probes you order." just like they did with flow cytometry interpretation.

Racking up a bill just to rack a huge bill isn't good medicine, it is good for patients. It isn't good for the county and ultimately we will the physicians will suffer for it. On gbms We do idh1 (Ihc)' egfr (fish) pten (fish) and sometimes 1p 19q if the differential is an anaplatic oligo vs small cell gbm. But sometimes I wonder why we do any of it. Treatment options for gbm are not broad and for the few people with long term survival it had nothing to do with tumor biology or personalized medicine. They probably just had a lucky resection.

I'm all for doing ancillary testing if it dictates a different course of treatment, like in aml, or lung adenocarcinoma, but if we are going to take every cancer and spend 5k-10k working it up instead of 50-500, we're cooked. Pigs get fat. Hogs get slaughtered.

 

[WEBB PINKERTON]

Labs and drug companies are gonna use the "personalized medicine" banner to rip cancer patients off well into the future it seems.

Here is a great interview with the legendary James Watson about this subject.

http://www.redorbit.com/news/health...mes-watson-criticizes-cancer-research-011013/

"The great hope of the modern targeted approach was that with DNA sequencing we would be able to find what specific genes, when mutated, caused each cancer," molecular biologist Mark Ptashne of Memorial Sloan-Kettering Cancer Center in New York told Reuters.

After they found these specific mutated genes, researchers believed that they simply had to create a drug that would block their activity and thus hinder the development of cancer cells. However, they found that this simple solution didn't work quite as well as they had expected.

As Watson explained, the effects of most of these new therapies only lasted a few months. That's because cancer cells are clever. If a drug blocks one of their biochemical pathways for growth and proliferation, they simply activate a different pathway that works just as well, leading to a virtually endless cat-and-mouse game of ever new drugs that lead to ever new pathways.

And for this reason, Watson has proposed that cancer researchers should start to consider a broader, more unified approach to treatment by focusing on characteristics that all cancer cells have in common.

 

[Enkidu]

What is awesome about not providing additional useful information over the simple H/E?

However, if that is 5000 dollars, that is nothing. Isn't that about what a day in the hospital costs?

Well, I was kind of saying that if these assays do provide additional information and their use is evidence based, then it's awesome to have that many resources to classify an astrocytoma. In the context of a really old dude, though, it's really not that useful.

 

[thebouque]

Well, I was kind of saying that if these assays do provide additional information and their use is evidence based, then it's awesome to have that many resources to classify an astrocytoma. In the context of a really old dude, though, it's really not that useful.

Unfortunately, almost nothing is evidence based in medicine, and that includes pathology. Our actions are mainly dictated by tradition, fear of getting sued, intuition, mimicking, money etc.

 

[pathstudent]

Well, I was kind of saying that if these assays do provide additional information and their use is evidence based, then it's awesome to have that many resources to classify an astrocytoma. In the context of a really old dude, though, it's really not that useful.

Those test aren't used to classify it as an anaplatic astrocytoma. They mainly have prognostic information. Some are appropriate for an oligo, some a diffuse glioma, some for gbm. Testing a grade 3 astrocytoma for idh2 is really just flushing taxpayer money down the toilet. Presumably this panel is probably done on all gliomas. We can't just do things because they are awesome or cool when we are talking about tax payer or insurance company's money. And again for gbm treatment options are limited and so what if your prognosis is closer to six months or eighteen months. Just go live the time you have left.

This reminds me of the company genotypx. I reviewed a staging bone marrow for a low grade follicular lymphoma. On their requisition they offer things like NHL FISH panel. The hematologist doesn't really understand what that means but knows his patient has NHL so he checks it. Then genotypx does FiSH for every translocation that you read about in books associated with follicular, Burkitt, marginal zone, mantle, anaplatic large cell lymphoma general IgH rearrangement, literally like 8-10 of them to add about 15-20 88368s adding about 4000 to the cost of the test. C'mon man. You are going to ruin the system for all of us.

Pittsburg can hide behind their universtiy's name and slap the title theranostics on the report, but it is the same type of behavior.

 

[WEBB PINKERTON]

Those test aren't used to classify it as an anaplatic astrocytoma. They mainly have prognostic information. Some are appropriate for an oligo, some a diffuse glioma, some for gbm. Testing a grade 3 astrocytoma for idh2 is really just flushing taxpayer money down the toilet. Presumably this panel is probably done on all gliomas. We can't just do things because they are awesome or cool when we are talking about tax payer or insurance company's money. And again for gbm treatment options are limited and so what if your prognosis is closer to six months or eighteen months. Just go live the time you have left.

This reminds me of the company genotypx. I reviewed a staging bone marrow for a low grade follicular lymphoma. On their requisition they offer things like NHL FISH panel. The hematologist doesn't really understand what that means but knows his patient has NHL so he checks it. Then genotypx does FiSH for every translocation that you read about in books associated with follicular, Burkitt, marginal zone, mantle, anaplatic large cell lymphoma general IgH rearrangement, literally like 8-10 of them to add about 15-20 88368s adding about 4000 to the cost of the test. C'mon man. You are going to ruin the system for all of us.

Pittsburg can hide behind their universtiy's name and slap the title theranostics on the report, but it is the same type of behavior.

I am amazed the whole health care industry hasnt imploded. Just look at the waste in our little world. You can make a list a mile long of labs doing excessive billing. Its pull through business as the 88305 reimbursement goes away due to client billing and cuts. Get the specimen and bill bill bill.

Wanna see something that will make you laugh? Check out how much some patients are being charged for stupid pap tests. 2000 dollars in some cases for a bunch of unnecessary BS.

http://health.costhelper.com/pap-test.html

 

[Thrombus]

Academic pathologists are running us into the ground. What a ridiculous load of tests for an 82 year old with terminal brain cancer. Nothing different than grave robbery and taxpayer extortion. If this happened to a friend of mine, a lawyer would be calling their department immediately with the next call to the CMS (who I am not fond of either).

 

[nazdar]

It's a sad thing. A neuropathologist that we have consulted with for years recently started doing a battery of tests on almost every brain tumor we send out. Most of these tests have theoretical prognostic implications. We end up eating most of the bill because we can only charge a certain amount for a neuropath consult. That's the way I understand it anyway.

 

[pathstudent]

It's a sad thing. A neuropathologist that we have consulted with for years recently started doing a battery of tests on almost every brain tumor we send out. Most of these tests have theoretical prognostic implications. We end up eating most of the bill because we can only charge a certain amount for a neuropath consult. That's the way I understand it anyway.

Only use consultants that will bill the insurance company and take wheatever they get from it. For an 88307, 88331 and 88334 you are only getting reimbursed to the tune of 160 dollars from the CMS. That is what the consultant would be charging you for one FISH probe.

Burger at Hopkins would be an excellent alternative. Hopkins takes all insurance, except of course Medicaid (other than Maryland Medicaid).

 

[scienceguy19]

Some people order FISH and a huge battery of immunos on autopsy slides.

 

[KluverB]

Some people order FISH and a huge battery of immunos on autopsy slides.

In academic centers, sure, and they eat the cost of that testing. It's not passed on to the patient's family, and to the taxpayers only very indirectly (as residency education costs, etc.).

 

[scienceguy19]

I guess the extra tests for the autopsy could provide 'prognostic information' that could bring the families peace of mind. (FISH tests shows a highly aggressive variant of a tumor..

Interpretation: Patient was destined to die soon. There is nothing the doctor could have done.)

 

[pathstudent]

I guess the extra tests for the autopsy could provide 'prognostic information' that could bring the families peace of mind. (FISH tests shows a highly aggressive variant of a tumor..

Interpretation: Patient was destined to die soon. There is nothing the doctor could have done.)

You can't bill Medicare or insurance for doing medicine on the dead. Our hospital gives us 2k for each one we do but we still hate doing them. Fortunately we only do 4-5 a year. Back in the day my group did 250-300 a year unassisted. Literally 1-2 per day and they didn't get paid anything. It was just a service to the medical staff.

You also can't be sued for medical malpractice for screwing up an autopsy as you can't practice medicine on the dead. Even if you do an autopsy without a consent. You can be charged with desecration of a corpse, but that would be unlikely.

 

[deleted314957]

You can't bill Medicare or insurance for doing medicine on the dead. Our hospital gives us 2k for each one we do but we still hate doing them. Fortunately we only do 4-5 a year. Back in the day my group did 250-300 a year unassisted. Literally 1-2 per day and they didn't get paid anything. It was just a service to the medical staff.

You also can't be sued for medical malpractice for screwing up an autopsy as you can't practice medicine on the dead. Even if you do an autopsy without a consent. You can be charged with desecration of a corpse, but that would be unlikely.

If you do a post without consent you will almost certainly not face criminal charges but you sure as hell can face a civil suit (tort) and a good trial atty can evoke lots of sympathy from your typical jury regarding your unauthorized "mutilation" of "grandpa" and his inability to enter into heaven because of your "atrocity". even M.E.'s who have some statutory backing have to be careful and pay attention to religious sensibilities, etc. to a reasonable extent, particularly if it appears to be a straightforward "natural" death as opposed to a homicide where you would have essentially total freedom within professional guidelines.

 

[LADoc00]

Autopsy pathology is dead. Pun intended. No one should be doing these anywhere unless they are involved in very specific IRB approved research groups or in LE.

Not at 2K a case, not at 5K a case and definitely not for free. The ABP needs to eliminate Autopsy just like they eliminated the need for specific hands on for Renal Bx's for trainees.

Forenics needs to separate out from Path and become its own field away from Medicine, like a Master's or something that doesnt require full medical training.

This whole thing is insane. The fact that people go to undergrad, medical school, full path residency, get boarded AND then do a Forensic fellowship only to be paid crap wages under a local sheriff is absurd.

 

[Enkidu]

Forenics needs to separate out from Path and become its own field away from Medicine, like a Master's or something that doesnt require full medical training.

Do you think that a master's degree would actually be enough? To understand the medical history, do the gross pathology, and do the histology?

This whole thing is insane. The fact that people go to undergrad, medical school, full path residency, get boarded AND then do a Forensic fellowship only to be paid crap wages under a local sheriff is absurd.

It seems like what you're saying is that forensic pathology needs to be better reimbursed, not that it doesn't require medical training. But I don't even think that even forensic pathology is reimbursed more poorly than family medicine or peds.

I'd probably suggest a (3?) year combined AP/FP program, similar to AP/NP, if one doesn't exist already. I bet that cytopathology and hemepath don't come up too often in forensic practice. Probably most tumor pathology doesn't come up either, so 3 years might be reasonable.

Also - are medical examiners under the local sheriff? I thought that they were under the coroner, who is an elected county official. It might be a conflict of interest if the medical examiner actually worked *for* the sheriff, since the sheriff would obviously have an interest in the results of the examinations.

 

[pathstudent]

Autopsy pathology is dead. Pun intended. No one should be doing these anywhere unless they are involved in very specific IRB approved research groups or in LE.

Not at 2K a case, not at 5K a case and definitely not for free. The ABP needs to eliminate Autopsy just like they eliminated the need for specific hands on for Renal Bx's for trainees.

Forenics needs to separate out from Path and become its own field away from Medicine, like a Master's or something that doesnt require full medical training.

This whole thing is insane. The fact that people go to undergrad, medical school, full path residency, get boarded AND then do a Forensic fellowship only to be paid crap wages under a local sheriff is absurd.

Anyone pay me 5k a case, and I'll do all the autopsies you got. 200x5000 sounds about right

 

[dr4n6]

Forenics needs to separate out from Path and become its own field away from Medicine, like a Master's or something that doesnt require full medical training.

This whole thing is insane. The fact that people go to undergrad, medical school, full path residency, get boarded AND then do a Forensic fellowship only to be paid crap wages under a local sheriff is absurd.

Agreed, doing a full AP residency followed by a FP fellowship and then getting specialty boards to potentially work for an elected official that may have never even attended college is a travesty. However, the above comment about forensics not requiring full medical training is one of the most idiotic comments I have read in quite some time. Let me guess, you think that a non-forensically trained pathologist, or as you suggest someone with a masters degree, is able to sort out complex head trauma issues in a potential case of an abusive childhood injury in the background of multiple caretakers all telling a different story with extensive finger pointing. Most neuropathologists don't even want to get involved in such a case. Not too many second chances in forensics and not too many injustices greater than someone wrongfully convicted of a crime they did not commit due to an poorly performed autopsy.

 

[LADoc00]

Agreed, doing a full AP residency followed by a FP fellowship and then getting specialty boards to potentially work for an elected official that may have never even attended college is a travesty. However, the above comment about forensics not requiring full medical training is one of the most idiotic comments I have read in quite some time. Let me guess, you think that a non-forensically trained pathologist, or as you suggest someone with a masters degree, is able to sort out complex head trauma issues in a potential case of an abusive childhood injury in the background of multiple caretakers all telling a different story with extensive finger pointing. Most neuropathologists don't even want to get involved in such a case. Not too many second chances in forensics and not too many injustices greater than someone wrongfully convicted of a crime they did not commit due to an poorly performed autopsy.

Hold it. You could have a consultant Pathologist or better yet a Trauma physician to provide insight on specific items while still having a more reasonable path to getting deaths investigated than currently exists.

I have been an expert witness in accident cases before and was shocked at the level of sophistication of the field of people who professionally do accident reconstruction/AR stuff. I had to read up on the crazy physics etc they were discussing while they seemed to easily have a handle on my medical knowledge of soft tissue injuries etc.

I sat back more than a few times wondering what I was contributing other than an 'M.D' to the circus show. Trust me, a year long fellowship in Forensics at some inner city coroner office would NOT have me allowed to do this much better (and I did 2 months in residency at a very busy coroner service in large city). I think those that do NP and then Forensics are even more crazy. You dont sit around on academic NP service looking at the gross anatomical effects of contrecoupe injury...you look at TUMORS and inflammatory ailments. Im mean COME ON, what the hell are we doing?? Everyone in the expert witness world look at Pathologists, who often get 40-50% of what say a Urologist gets to testify, and wonder why the training regime is so ridiculously long!!

 

[Substance]

Hold it. You could have a consultant Pathologist or better yet a Trauma physician to provide insight on specific items while still having a more reasonable path to getting deaths investigated than currently exists.

I have been an expert witness in accident cases before and was shocked at the level of sophistication of the field of people who professionally do accident reconstruction/AR stuff. I had to read up on the crazy physics etc they were discussing while they seemed to easily have a handle on my medical knowledge of soft tissue injuries etc.

I sat back more than a few times wondering what I was contributing other than an 'M.D' to the circus show. Trust me, a year long fellowship in Forensics at some inner city coroner office would NOT have me allowed to do this much better (and I did 2 months in residency at a very busy coroner service in large city). I think those that do NP and then Forensics are even more crazy. You dont sit around on academic NP service looking at the gross anatomical effects of contrecoupe injury...you look at TUMORS and inflammatory ailments. Im mean COME ON, what the hell are we doing?? Everyone in the expert witness world look at Pathologists, who often get 40-50% of what say a Urologist gets to testify, and wonder why the training regime is so ridiculously long!!

I actually disagree with you here on this one.

Up here in Canada, pathology liked to recruit semi-*****s that caused a lot of problems. For instance. look up Charles Smith. His botched forensic examinations sent a lot of innocent people to jail.

So, forensics is very important. Sure, a PhD could do it, but the thing that is necessary is personal accountability, and the MD provides that assurance.

What the ideal situation would be is a dedicated five-year forensics residency that has very few spots per year. Nobody other than people who have completed this training should be allowed to do any forensic work. This would have the effect of increasing forensic quality, and boosting demand due to rarity, making it better paying and therefore more attractive to high-quality candidates. In Canada forensic paths get paid 350k or so, which is a recent increase in pay largely due to worries that the pittance they were making 10 years ago was scaring away competent people, leaving the trash. In the USA they are so underpaid it is frankly insulting and I can't imagine why anyone would do it other than some sort of perverse fascination with murder or CSI or something.

But I do agree that medical autopsies are absolutely worthless. I can't believe pathologists still agree to do these, and for free! Radiologists don't, even though dead-CT-scans are better for fractures, AV malformations and vascular issues than a straight up death-carve, and they're quicker, and storable. But you can't bill for practicing medicine on the dead, so no go. Pathologists ...man, they are just fools to do these. Clinician or family curiosity are not valid indications, in my opinion.

Pathology as a field is a really strange thing. Important in theory, but treated like the dregs of medicine in practice. You guys should demand more respect and increase your standards.

 

[dr4n6]

So, forensics is very important. Sure, a PhD could do it, but the thing that is necessary is personal accountability, and the MD provides that assurance.

Frankly, I think that the misconceptions of what forensic pathologists do, and the training that we have is somewhat disconcerting. You do realize that there is more to doing an autopsy than just slicing and dicing a body. The real practice of forensics is not necessarily made at an autopsy table, but rather in a case where a gross cause of death is not obvious. Would you trust a PhD to look at a brain biopsy or a breast bx? Of course not, so why do you think that a PhD can sort out a complex cardiac system dissection or a pediatric head trauma situation? These are the not so uncommon situations where only a properly trained and board certified forensic pathologist should intervene-not a PhD, and not a hospital based pathologist that thinks they can turn out a proper autopsy because they rotated through a busy ME Office during their residency.

 

[Substance]

Frankly, I think that the misconceptions of what forensic pathologists do, and the training that we have is somewhat disconcerting. You do realize that there is more to doing an autopsy than just slicing and dicing a body. The real practice of forensics is not necessarily made at an autopsy table, but rather in a case where a gross cause of death is not obvious. Would you trust a PhD to look at a brain biopsy or a breast bx? Of course not, so why do you think that a PhD can sort out a complex cardiac system dissection or a pediatric head trauma situation? These are the not so uncommon situations where only a properly trained and board certified forensic pathologist should intervene-not a PhD, and not a hospital based pathologist that thinks they can turn out a proper autopsy because they rotated through a busy ME Office during their residency.

I think we are saying the same thing.

A PhD could practice any medicine, really. The major thing is personal accountability, which the MD guarantees.

Since forensic medicine involves still living people (suspects etc), it is medically important and can have far reaching consequences. Medical autopsies, on the other hand, seem to be nothing more than data gathering exercises which should be the sole purview of the PhD.

 

[LADoc00]

Maybe its just my experience at 3 or so urban centers that leads me to believe this but I dont think the "Forensics" fellowship is at all rigorous compared to say a hemepath or high volume dermpath fellowship. Maybe Im wrong. But I just have always had this sense the training was pretty slipshod and lacked much scientific rigor...I could be totally wrong but I had more a "LE-style" approach to FP training rather than something you might find at Brigham for example (not to be an elitist snob).

Maybe someone here can prove me wrong.

 

[mlw03]

Maybe its just my experience at 3 or so urban centers that leads me to believe this but I dont think the "Forensics" fellowship is at all rigorous compared to say a hemepath or high volume dermpath fellowship. Maybe Im wrong. But I just have always had this sense the training was pretty slipshod and lacked much scientific rigor...I could be totally wrong but I had more a "LE-style" approach to FP training rather than something you might find at Brigham for example (not to be an elitist snob).

Maybe someone here can prove me wrong.

I'm not sure anyone can "prove" you wrong. Your opinion is what it is. That said, I know my training was rigorous. The issue is that forensic path is just different than surg path, in so many ways. My training involved doing 300 or so autopsies, over half with histology and about 80 homicides, over about 10 months of service work. Now you talk about scientific rigor, and that's where we get into problems. Forensic pathology is a science, and an art. When someone had lethal blunt force head injury, it's often impossible to tell from the autopsy findings alone whether that person fell (accident) or was pushed (homicide) - if that means it's not scientific, then so be it, but good forensic pathologists admit the limitations of our field. It's the ones who do NOT that are dangerous.

As to the comments about FP as a separate field, I think there's merit to that idea and that is how it's done in parts of Europe. My proposal would be med school --> transitional year --> 4 year FP "residency" that would include the parts of AP/CP that we use, a flavor of the other stuff so we know what we need to ask for help about (ie, blistering skin diseases, which can mimic burns), and lots of autopsies. I strongly disagree with that PhD notion - FPs need to be doctors with a general medical background in order to do the job that is asked of us.

 

[malchik]

I think we are saying the same thing.

A PhD could practice any medicine, really. The major thing is personal accountability, which the MD guarantees.

Since forensic medicine involves still living people (suspects etc), it is medically important and can have far reaching consequences. Medical autopsies, on the other hand, seem to be nothing more than data gathering exercises which should be the sole purview of the PhD.

Do you have a PhD? I do and I can tell you that kind of degree is not designed to train one to think in general medical terms integrating multiple disciplines as medical training does. Even if there were such a thing as a PhD in autopsy science, it would have to look like medical school plus pathology training. Autopsies are medicine.

 

[GLOBALPATH]

In my opinion, FP and AP have similar form (autopsy) but the content is very different. A residency in FP with a specific syllabus seems to make sens.

 

[yaah]

Pathology as a field is a really strange thing. Important in theory, but treated like the dregs of medicine in practice. You guys should demand more respect and increase your standards.

You don't get respect in the real world by demanding it. You lose respect that way. Pathology is not treated like "the dregs" although I am sure in some places it is. It depends on the local institution and culture. At our institution pathologists are very respected and appreciated.

 

[LADoc00]

I'm not sure anyone can "prove" you wrong. Your opinion is what it is. That said, I know my training was rigorous. The issue is that forensic path is just different than surg path, in so many ways. My training involved doing 300 or so autopsies, over half with histology and about 80 homicides, over about 10 months of service work. Now you talk about scientific rigor, and that's where we get into problems. Forensic pathology is a science, and an art. When someone had lethal blunt force head injury, it's often impossible to tell from the autopsy findings alone whether that person fell (accident) or was pushed (homicide) - if that means it's not scientific, then so be it, but good forensic pathologists admit the limitations of our field. It's the ones who do NOT that are dangerous.

As to the comments about FP as a separate field, I think there's merit to that idea and that is how it's done in parts of Europe. My proposal would be med school --> transitional year --> 4 year FP "residency" that would include the parts of AP/CP that we use, a flavor of the other stuff so we know what we need to ask for help about (ie, blistering skin diseases, which can mimic burns), and lots of autopsies. I strongly disagree with that PhD notion - FPs need to be doctors with a general medical background in order to do the job that is asked of us.

4 FP residency souns INSANELY long to me. 5 years with a trans. year is overkill.

Perhaps 2 years total? Or 3?

I think we are overeducating EVERYONE in society, including physicians. We need to cut like 3-4 years or more off everyone's classroom time, from plumbers to attorneys to surgeons.

 

[Pathologee]

This will never happen. How will we possibly rack up more college and med school loans if they cut down on the amount of time we are paying tuition?

The Department of Education is a pimp.

4 FP residency souns INSANELY long to me. 5 years with a trans. year is overkill.

Perhaps 2 years total? Or 3?

I think we are overeducating EVERYONE in society, including physicians. We need to cut like 3-4 years or more off everyone's classroom time, from plumbers to attorneys to surgeons.

 

[Johnny Sunshine]

The Department of Education is a pimp.

Yup. As is every other department. If our society "trimmed the fat" and actually worked towards efficiency, the unemployment rate would skyrocket and corporate profits would plummet.

The main reason society has problems is that there's no money in solutions.

 

[member0007]

http://pathologyblawg.com/medical-n...289121fb4-RSS_EMAIL_CAMPAIGN&utm_medium=email

 

[KCShaw]

Trauma/ER docs tend to get GSW entrance/exits right about half the time, or about as good as a flipped coin. I hear from cardiologists who don't seem to grasp that longstanding hypertension is potentially lethal, since the deceased seemed to be so good at their last appointment. I find cases almost daily where physicians from many specialties fail to link a fall, with hip fracture or subdural, to death sometimes only days later because, well, they had really bad COPD anyway. And non-FP pathologists often have around the same level of experience as those clinicians with non-natural death. Remember that JFK thing? We might not be talking about it had Dr. Rose won his standoff with the Secret Service to have the autopsy done at the Dallas MEO in accordance with Texas law (or the Armed Forces ME been up and running with policy in place to do it) rather than sending him to Bethesda and calling back a hospital pathologist to do it. The focus of non-FP's is simply elsewhere, and for the most part it should be, although I'd rather more of them think back a little bit when they do a discharge summary and before they fill out the death certificate.

I don't think the current AP/CP training is optimal for someone going into FP. It's useful, but not efficient, given that so much of AP is tumor-centric. Those who aren't regularly seeing medical renal, liver, lung biopsies, etc., probably don't suddenly get comfortable with them again overnight. It would be nice if more programs had quality non-tumor services, or at least simply got (and knew what to do with) a reasonable number of non-tumor specimens, and it would be nice if one could track into FP a little more easily and efficiently. But rare are the AP/CP programs who have all of the key elements for a good, tracked FP program that doesn't completely throw out the baby with the bathwater. One -does- need a solid foundation in pathology, and although I do think there is room to maneuver it would take some convincing to see it done in 3 years. 4 is already do-able with straight AP followed by FP, and that's already throwing in some relevant CP rotations.

As for the sheriff comments previously mentioned, a few jurisdictions (including parts, if not all, of California) have a Sheriff-Coroner (where the Sheriff is also the coroner) or similar systems with the ME/coroner either directly under or partly under law enforcement or the prosecutor's office by budget or something in administration. Those kinds of systems are generally not looked on well, but there they are. The refusal of so many local jurisdictions to adopt a better system is, I think, part of why eventually the feds will impose something big and in some ways worse upon us.. but that's another story.