Job Market

[LADoc00]

We do note that 34% of the reported 6129 practicing anatomic pathologists and clinical pathologists are international medical graduates, as are 43% of current trainees.(7) It is obvious that we are already not producing enough pathologists from American medical schools to meet our country's needs; closing existing training programs would only further exacerbate the shortage of pathologists from these schools.

That statement is one of the most egregious fallacies of logic I have ever seen in print. It is far from "obvious" we have arent producing enough pathologists to meet our healthcare needs, the exact opposite is true.

What it means is that as the marketplace has collapsed and AMGs burdened with high medical school borrowing are going elsewhere, academic training programs have had to find foreign labor willing to do the task.

This government subsidized foriegn labor has fattened the pockets of hospitals with ACGME training programs by allowing them to hire less PA/lab assistants and receive a nice revenue stream on top of that for the minimal effort of running a residency program in pathology.

As income/job security/opportunity collapses you will naturally see a rising number of FMGs in the field because either they are unaware of the situation or willing to grab any lifeline to remain/come to the US they can get.

And those who suffer the most from this are the FMGs, this is no different than the Chinese building the transcontinental railroad or the Eastern Europeans who were forced into California's goldmines. This is exploitation, pure and simple. AMGs with good pedrigrees as Yaah mentions WILL BE collateral damage in this. The field of pathology will suffer. And one day the Sins of the Father will come to haunt residency programs...mark my words.

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[HCE]

That statement is one of the most egregious fallacies of logic I have ever seen in print. It is far from "obvious" we have arent producing enough pathologists to meet our healthcare needs, the exact opposite is true.

What it means is that as the marketplace has collapsed and AMGs burdened with high medical school borrowing are going elsewhere, academic training programs have had to find foreign labor willing to do the task.

This government subsidized foriegn labor has fattened the pockets of hospitals with ACGME training programs by allowing them to hire less PA/lab assistants and receive a nice revenue stream on top of that for the minimal effort of running a residency program in pathology.

As income/job security/opportunity collapses you will naturally see a rising number of FMGs in the field because either they are unaware of the situation or willing to grab any lifeline to remain/come to the US they can get.

And those who suffer the most from this are the FMGs, this is no different than the Chinese building the transcontinental railroad or the Eastern Europeans who were forced into California's goldmines. This is exploitation, pure and simple. AMGs with good pedrigrees as Yaah mentions WILL BE collateral damage in this. The field of pathology will suffer. And one day the Sins of the Father will come to haunt residency programs...mark my words.

This analogy is spot on, and I think its happening in other specialties as well.

 

[yaah]

What it means is that as the marketplace has collapsed and AMGs burdened with high medical school borrowing are going elsewhere, academic training programs have had to find foreign labor willing to do the task.
.

True, except for the fact that more US grads are going into path, and this has been steadily increasing for the past 10 years. I have no doubt some AMGs are shunning pathology, but an increasing number are not. And they are not going into the field to be researchers or academic pathologists.

As far as the hiring less PAs/lab assistants, this doesn't seem to be true either. Programs I know are hiring MORE PAs, in part to take burden off of residents. This argument doesn't make sense to me. ACGME programs are not getting rich off of resident labor, at least in pathology.

And again, as I have said in other threads, I am not trying to argue and say the job market is fine and dandy. I am trying to weed through conspiracy theories, chicken littles, and disgruntled complaints.

 

[LADoc00]

True, except for the fact that more US grads are going into path, and this has been steadily increasing for the past 10 years. I have no doubt some AMGs are shunning pathology, but an increasing number are not. And they are not going into the field to be researchers or academic pathologists.

As far as the hiring less PAs/lab assistants, this doesn't seem to be true either. Programs I know are hiring MORE PAs, in part to take burden off of residents. This argument doesn't make sense to me. ACGME programs are not getting rich off of resident labor, at least in pathology.

And again, as I have said in other threads, I am not trying to argue and say the job market is fine and dandy. I am trying to weed through conspiracy theories, chicken littles, and disgruntled complaints.

Im confused, you think a program doing 50-75K surgicals employs MORE PAs because they have residents?? No, no....programs are finally getting PAs, where before they had none. The incessant whining of residents combined with the work hours limits has actually forced large academic centers to get a small handful of real PAs for the first time ever.

But it doesnt stop at grossing, residents in pathology are huge labor reducers where in many other fields like surgery, medicine etc. they arent anywhere to that degree. Residents dictate/type reports, preview and dot cases, answer phone calls even code for billing. High volume practices like Leboit at UCSF could never exist to that level without residents or at least an army of staff in their place.

Yaah, Im curious if academic programs arent making a margin on all this what is your explanation on why they are overtraining so much? Purely to torture people who will never get a job? Are they merely sadists?

 

[yaah]

Yaah, Im curious if academic programs arent making a margin on all this what is your explanation on why they are overtraining so much? Purely to torture people who will never get a job? Are they merely sadists?

I don't know the answer to that - that's why I keep asking. But I don't really believe it's due to trying to make money. If you talk to attendings at a lot of programs, residents do not save them time. They have to take extra time on cases to teach, go over things, not to mention the fact that cases get delayed so the residents can have preview time. A lot of attendings would seemingly be happier if they could just take the cases back to their office and sign them out. They like having residents for neck dissections so residents can count the nodes, fill out the templates, etc, for certain. Part of the reason I feel like they are overtraining is because ACGME keeps approving more spots, so they take them because they can.

It seems to me that programs are training so many residents simply because they can! In terms of torturing people who will never get a job, it also seems to me that many program directors honestly don't think this. To them, the residents are getting jobs. They don't really live in the real world.

In terms of the PA issue, PAs are more efficient than residents. They cost more, but the average PA does not make twice what a resident does, even though they have the time and skill to probably gross at least 3 times what a resident can gross. If you can get me an academic pathologist to back up the theory that residencies are cash cows, I will be more willing to believe this. But I don't think they are.

 

[mlw03]

But it doesnt stop at grossing, residents in pathology are huge labor reducers where in many other fields like surgery, medicine etc. they arent anywhere to that degree.

i can't believe that path residents are more labor-saving than clinical residents. medicine, pediatriac, obstetric, surgical, and psychiatric inpatient units at my school are almost entirely run by residents and interns, with faculty serving a supervisory role primarily. residents write the notes, write and carry out the orders, and do the procedures.

i make this point because it gets back to the argument that pathology residents are being added because we make money for programs. i believe that medicine and pediatric residents are profitable, probably surgical, ob-gyn, and psychiatric residents too. but i just don't think that pathology departments are making significant profit by having residents. i see this argument the way yaah does. thanks for your comments on these threads though - this is certainly an important discussion to have and revisit periodically.

 

[exPCM]

i can't believe that path residents are more labor-saving than clinical residents. medicine, pediatriac, obstetric, surgical, and psychiatric inpatient units at my school are almost entirely run by residents and interns, with faculty serving a supervisory role primarily. residents write the notes, write and carry out the orders, and do the procedures.

i make this point because it gets back to the argument that pathology residents are being added because we make money for programs. i believe that medicine and pediatric residents are profitable, probably surgical, ob-gyn, and psychiatric residents too. but i just don't think that pathology departments are making significant profit by having residents. i see this argument the way yaah does. thanks for your comments on these threads though - this is certainly an important discussion to have and revisit periodically.

Path residents are there because they make money for hospitals and save costs for path departments.
Back in the 1990's when GME funding was even lower than today they continued to churn out pathology residents despite an abysmal job market due to $$$$$$
see link:
http://members.tripod.com/~philgmh/pjm3.htm
The path job market today is also lousy. I have attached a link from a knowledgeable pathology recruiter - see below
http://www.americanlabstaffing.com/recruiting.html

Particularly enlightening are these quotes "The job market for pathologists today has improved only slightly since 1998"
"The number of pathologists looking for jobs still outpaces the number of opportunities available"
I have talked with Fred Robinson at American Lab Staffing and I find him to be a very astute and knowledgeable individual who is quite attuned to the realities of the job market.
Since his search firm is dedicated to pathology, it stands to reason his business would improve if the job market was hot.

Pathology did not make the top 20 in physician searches by MHA, which I believe is the nation's largest physician recruting firm - see link:
http://www.merritthawkins.com/pdf/2007_Review_of_Physician_and_CRNA_Recruiting_Incentives.pdf
For those who want to look at the job market through rose-colored glasses, I say do so at your own risk.

 

[yaah]

Well, you can state that the job market is not good and that doesn't mean you have to agree that programs are in it for profit and "future of the profession be damned." All of these links about the $$$ going to GME are really not incredibly informative, because they do not factor in any costs to residency programs except for the cost of actually paying residents. I've posted a bunch of this above, but when I factor in everything I am getting from the department in terms of benefits (CME, food money, book funds, health insurance, etc etc etc), it comes out to probably well over $60,000. And that's just for me. It does seem as though having residents is not a money-losing proposition for any department. But as I said above, there are better ways to increase your bottom line.

And I agree with mlw that residents in other fields are much more efficient than in pathology. We are almost like redundant components. We help gross but really, how many residents each day actually gross? In our program it's probably about 6-8 out of the approximately 30. And each grossing resident is only really grossing half a day. Is that really a money saving proposition? You're paying 30 residents to get the work of 3-4 full time PAs? Where else do residents save a significant amount of money? Dictating cases? That's minor. I can see, however, that for some smaller programs where residents are nothing more than glorified PAs that it could be a significant advantage. These are probably the programs that should not have residents - apart from those reasons, the training is also not likely to be stellar. I don't know why ACGME approves some places for training. It's not solely up to pathology programs - they have to be approved for funding, after all.

As for the job market, everything that many people post around here suggests that it is poor overall. But the problem is, not every applicant is equivalent. A poor job market for some means a better job market for others. It is not a rose-colored perspective. It's trying to be realistic. You don't have to be conspiratorial to be realistic.

 

[mlw03]

well, biersteifel, i realize my views are stained in the ignorance of (relative) youth and inexperience. i'm sure many of my opinions will also change once i get out there and see things for myself. you make some good points about PAs and about delayed gratification.

 

[LADoc00]

why is this getting rehashed?? I thought we had closure on this like a year ago?

Im not saying academic pathologists are running an Enron. Far from it, many academics are hard working self sacrificing solid human beings advancing this profession in a manner I never can. There are legendary retired professors living in small 1-bedroom apartments because they hardly made a dime during their time in academia/research. BUT there are also people stealing with both hands.

I dont care the rationalization, when someone signs out 1-2 weeks/month and is getting 7-figures while other people in the same hospital system work full time and make 80K/year, what the hell is going on...I have to call shenanigans.

Combined with the fact academic leadership at many training programs KNOW FULL WELL their graduates are being left to blow in the wind.

This may not be Mich or BWH or Stanford, but there are tons of programs with serious issues in placing graduates yet they continue down this path of destruction. Removing the credentialing year only compounded the issue to...

I spent quite a bit of time due to personal issues with surgical subspecialities in medical school (although I fully planned to go path). I couldnt believe the care and diligence a subspec like ENT or Ortho takes to prevent over saturating the market with their trainees, there is NOTHING like that in path. And that is why top medical students gravitate towards programs like ENT, they want to feel special and are special while in path you are one of the 500+ morass, a totally replaceable cog even if you do have top notch credentials. Im not joking when I can say I can pick up the phone and get 5+ pathologists to come to work for me in single afternoon without so much as leaving my office...think about, that is CRAZY poor job satisfaction out there.

 

[LAZYGUY]

So the golden question is.......

what if anything can we do to change the situation other than complain on these boards? Is there some political figure or agency that will address this issue? How about a journal we can write to?

Many of the programs I have interviewed at share the general ideas above but it seems nobody takes any initiative to change things. I commonly hear things like, "to be marketable you will need to complete a fellowship in something". What have other specialties done and how can we eliminate the individuals who keep failing us?

 

[Ale]

I agree complaining is not going to do much. In the 90’ a disgruntled pathologist formed the Committee for Improvement in the Pathology Job Market: http://members.tripod.com/~philgmh/CIPJM.html
This single disgruntled pathologist was so successful in his endeavor that, when the numbers of US graduates fell from 229 to 141 in 1997, his “committee” was partially blamed for the even[1].

This is what I propose: postulate candidates akin to our interested to the CAP, ABP and ACGME; limit the influence of the PRODS and the APC and include more members of the private sector in these committees. I don’t know why most of the decisions are made by the supplier as opposed to the end user.

After that is accomplished, improve the training of the pathologists so 80% of us don’t have to do a surgical pathology fellowship in order to find a job. Have you ever seen a surgery resident doing a “general surgery fellowship”? They just get a job right?

1. Sobonya, R.E. and R.S. Weinstein, Pathology manpower: a few rays of sunshine. Hum Pathol, 2001. 32(7): p. 669-70.

 

[LAZYGUY]

I agree complaining is not going to do much. In the 90’ a disgruntled pathologist formed the Committee for Improvement in the Pathology Job Market: http://members.tripod.com/~philgmh/CIPJM.html
This single disgruntled pathologist was so successful in his endeavor that, when the numbers of US graduates fell from 229 to 141 in 1997, his “committee” was partially blamed for the even[1].

This is what I propose: postulate candidates akin to our interested to the CAP, ABP and ACGME; limit the influence of the PRODS and the APC and include more members of the private sector in these committees. I don’t know why most of the decisions are made by the supplier as opposed to the end user.


I agree.

Through modern times important issues have been addressed through representation by national groups that organize and represent the interests of its group. This was the purpose of our national organizations in medicine but in pathology there are so many pathology organizations because our bone head leaders are useless and don’t look out for their own as well as other medical specialties. We need to form an organization that will give us a platform in which to be heard and be taken seriously by important, influential people, something that would never be done with a few individuals or a internet group.


Our “leaders” come out with studies and statistics that completely ignore the facts and the obivious truth that everyone recognizes is a problem. Nobody contradicts them. There were previous posters that made excellent points about the job market study that I would have never figured out on my own…..we need these people and people liky yaah and Ladoc that we all look up to.


I would not underestimate the number of people that would join up with an organization like this (ex. Society of Anatomical and Clinical Pathologists?). There are literally thousands of us that are waiting for someone to do something. However, we need to organize first so that we are taken seriously. Then we can start putting out facts/figures that directly contradict the bogus reports that mislead deciding bodies like the ACGME.


It really is Economics 101, too much supply and very little demand. So overtraining is incredible and everyone just does it, because that is how it is. Other specialties have a very tight control on these numbers because they realize that controlling this is very good for their profession (derm, ortho, plastics) 3 out of 4 threads are about fellowships and dermpath, bad job market instead of what things can be done to improve our specialty. When we start looking out for pathology nationally we will begin to start seeing improvement in our individual careers. Physicians are the worst at this type of stuff historically.

What do you all think, how do we begin? Or should we just plan on doing two or three fellowships so that we are all competing like wild chickens against each other for the jobs that they will throw at us.

 

[DarksideAllstar]

Or should we just plan on doing two or three fellowships so that we are all competing like wild chickens against each other for the jobs that they will throw at us.

Dude, doing three fellowships was so yesterday.

 

[LAZYGUY]

Dude, doing three fellowships was so yesterday.

it really is quite silly if you think about it and completely unlike anything else in medicine.

 

[Potomania]

I think another, (albeit perhaps more minor) contributor to the upping of resident slots that hasn't been mentioned is that many academic centers are switching their compensation plans over from a salary-based to a volume-based model. When I was in med school, my school switched to the relative value units or whatever it is and immediately a whole new building of ORs went up. Also, many of the non-surgical "physician-scientists" in other fields dropped their labs completely and started doing exclusively procedures when this happened. So, the surgical/procedure volume is going up at places that adopt this plan and therefore the surg path specimens are increasing. The path attendings might actually have to gross or hire lots more PAs and secretaries if they don't increase the number of residents.....they live in their world not in the community and I honestly think most aren't consciously trying to hurt the job market, they just aren't even remotely aware of whats going outside of academia.

 

[DarksideAllstar]

it really is quite silly if you think about it and completely unlike anything else in medicine.

I guess part of the issue is that in other clinical fields, fellowships are generally 2-3 years of additional training (at least half of which is research, which, admittedly, is of questionable utility to those who want to go into the community anyway). Whereas in Path (and I think Radiology, with the possible exception of an IR fellowship) fellowships can be completed in a year. Also take into consideration that once you do a clinical fellowship (ie Gastro or Cards after medicine) you can build a practice that will encompass that subspecialty almost entirely. Aside from maybe dermpath and some GI pod labs, not sure that you could build nor sustain a practice based on a single subspecialty (ie s/o only heme) like our clinical compatriots. But yeah, overall it is quite ridiculous.

 

[deschutes]

This is what I propose: postulate candidates akin to our interested to the CAP, ABP and ACGME; limit the influence of the PRODS and the APC and include more members of the private sector in these committees. I don't know why most of the decisions are made by the supplier as opposed to the end user.

When a similar question about the influence of community pathologists was asked of ABP's Betsy Bennett, she said that there were community pathologists on the review panel for board exam questions. 5-6 people are on the review board, serving 5-year terms. Most are academics; community pathologists are highly sought after, but not many volunteer.

When we start looking out for pathology nationally we will begin to start seeing improvement in our individual careers.

What do you all think, how do we begin? Or should we just plan on doing two or three fellowships so that we are all competing like wild chickens against each other for the jobs that they will throw at us.

As an FMG who won't be staying in the country too much longer, this is what I'm seeing:

Too many residents competing against each other for too few fellowships to make them "marketable",
Too many fellows still competing against each other and against attendings who have been out in the field for years for jobs,
Community practices worried about being bought over and/or losing marketshare in the "businessization".

Why are pathologists competing against pathologists to the detriment of themselves and the field as a whole? Not to sound trite, but it seems collaboration and cooperation were left behind somewhere along the way.

I found this Canadian news report dated May 2007 an interesting read:

Pathologists' raises not competitive enough, NDP claims
Snippet:

Dr. Kara Laing, an oncologist practising in St. John's, said it is impossible to overstate the importance of pathology to her job.

Laing said she relies on pathologists to interpret test results and to determine what treatment is best for her patients. Laing said a chronic shortage of pathologists and a high turnover rate kept errors with the hormone receptor tests from being detected earlier.

"That's something that really needs to be brought out," said Laing, adding that the Newfoundland and Labrador Medical Association has been lobbying for a better compensation package for pathologists.

...the maximum salary for a pathologist at Eastern Health will be $241,000. However, the starting salary for a pathologist in Ontario is about $330,000.

If you didn't already know, the Canadian dollar is currently at parity.
I'm not saying it's sunshine and lollipops on either side of the border, but I think it's significant that a Canadian oncologist is lobbying for a pathologist in her province to be paid more.

By the way I completely agree that if training was adequate in the first place, then fellowships like "general surgical pathology" should not have to be pursued.

why is this getting rehashed?? I thought we had closure on this like a year ago?

The rehash is probably a reflection on the continued poor health of the job market.

A few words about organizing (so much easier said than done, but still vitally important nonetheless):
I have found that there are many who would rather (whether actively or passively) wait around for someone else to speak up for them, or simply fail to recognize a time for change (whether major or minor). This "upward delegation" happens around the world, so I wouldn't jump to the conclusion that it is a pathology-specific occurrence

For those who want to do something about it, the CAP Residents' Forum may be a good starting point for organizing a concerted message and solution(s). I have only been there once so far, but they are very community-practice-oriented in a way that I found quite refreshing. I definitely found their CAP RF meeting much more useful than the USCAP Housestaff meeting.

I'd love to help with the organizing, but unfortunately I am only a lowly J-1 with dogs snapping at my heels!

 

[Ale]

When a similar question about the influence of community pathologists was asked of ABP's Betsy Bennett, she said that there were community pathologists on the review panel for board exam questions. 5-6 people are on the review board, serving 5-year terms. Most are academics; community pathologists are highly sought after, but not many volunteer.

That’s exactly what I am saying; we need MORE involvement of community pathologist and less from academia.

 

[b&ierstiefel]

When a similar question about the influence of community pathologists was asked of ABP's Betsy Bennett, she said that there were community pathologists on the review panel for board exam questions. 5-6 people are on the review board, serving 5-year terms. Most are academics; community pathologists are highly sought after, but not many volunteer.

That's exactly what I am saying; we need MORE involvement of community pathologist and less from academia.

People raise good points here...I am certainly guilty of bitching and moaning about this but what have I done to fix things? Nothing.

There is a problem and hopefully things can be done to fix things for us who are entering the workforce after residency/fellowship. My only worry is that what is the motivation for an established community pathologist to fix things?

I liked LADoc00's suggestion to severely cut the # of training spots. What could complicate things is this...the dynamics between pathologists and PAs. I hear that PAs have tried to lobby or are lobbying for increased pay...mainly on a per specimen basis. I don't have much understanding of this management/business sense but I believe that PAs are simply salaried employees whereas pathologist can get paid on a per specimen/case basis. If we were to hire more PAs and have an increasing proportion of the clinical load done by PAs, could that somehow threaten the livelihood of pathologists? I think this is an issue that may contribute to the overabundance of resident trainees. The man wants to fight off the surge from the PAs by continuing to have a lot of the work done by people with MDs.

So, attending level folks don't want to gross as much and have others do the grunt work for them (residents and PAs). Hell, they deserve it! But now I can see how the issue lies at the hands of the attendings? Maybe they need to do more work done by residents and PAs...but what's their motivation? None...at the moment. They have great lifestyles...they're bugged by other things but have good hours...isn't that one significant reason why pathology is attractive these days anyways? Anyways, I need to ponder more about this...but there's some food for thought.

 

[yaah]

Yeah, I agree that "What is the motivation" for established community pathologists is a big question. To me, cutting the # of training spots seems to be valid for multiple reasons. 1) Too many trainees for not enough jobs, 2) Many smaller programs just don't have enough volume or expertise or teaching to adequately train good residents. As one of our eminent attendings says in regards to community practice, "It's scary out there."

One would like to think that the market would sort itself out. As in, subpar residency graduates who are less qualified would have a harder time finding jobs than people who trained at better programs. But does it work that way? Seems to me like there are lots of employers out there who are looking for not much more than a warm body with eyes. The problem is that people with any clout to change things benefit from status quo. Change is bad for those in power. Just look at politicians for a real world example.

 

[Ale]

I hear that PAs have tried to lobby or are lobbying for increased pay...mainly on a per specimen basis. ... If we were to hire more PAs and have an increasing proportion of the clinical load done by PAs, could that somehow threaten the livelihood of pathologists?

I have heard similar things in the past too. What I heard was that they wanted to sign-out the “easy cases” just like cytotechs do. Meaning the 88300, 88302 and 88304. These are the main specimens in a lot of community hospitals. I don’t know if this is true or just an urban legend. But what we don’t want to happen is what is happening now in big cities where a physician assistant gets roughly the same salary as an internal medicine doctor. Forget GP, they can’t find a job!

Depending on the hospital, the PA may be paid by the –TC or -26 components. If they get paid by the –TC component it means that they have to split their pay with the histotechs. I don’t now if they are going to be able to pull that one off. Last time I saw histotechs wanting to get paid by specimen/block they all got the “your services are not longer required” letter. But again, maybe some places do.

If they get paid by the -26 component, I can see them asking for it. But why would any pathologist go for it. Then they would cost as much as a pathologist and the savings provided when hiring them vanish.

Do we really hate grossing so much?

This is a good abstract on the salary subject. If I find any references to any of the previously mentioned claims I will post them.

http://gateway.nlm.nih.gov/MeetingAbstracts/102272204.html

The other thing is PAs are in demand now. When the market equalizes it won’t be such a “buyers market anymore”

I liked LADoc00's suggestion to severely cut the # of training spots.

I believe that the easiest way of reducing the number of trainees would be establishing a quota of resident per year per program instead of per program only. Meaning that if your program sucks or one of your residents does not like pathology, they cannot replace those 2nd or 3rd or 4th lost with more 1st years.

You see this every year. Some programs vary from 1 open spot to 6 and they only have 15 positions in total. In some programs this would reduce the number of residents by 25% instantly without affecting their “total spots”. It would benefit all by graduating a maximum of residents per year but no known minimun and it will definitively level off the market a little bit.

This would mean more work for you during residency but will guarantee a better job for the next 30 years of your life.

 

[Ale]

Does anyone know how I can stop the program from double posting?

 

[devildoc2]

Am I missing something here? I thought the 1997 balanced budget amendment specifically blocked money for new residency programs?

How is it that pathology has been able to add all these new residency spots over the years? Where are they getting the money for these programs? As far as I know, CME has decided they wont pay for any new residency slots.

 

[yaah]

Does anyone know how I can stop the program from double posting?

Can't help you there - doesn't seem to be happening to anyone else. There is a site support section http://forums.studentdoctor.net/forumdisplay.php?f=160 perhaps you can post there and see if this has been reported before. Maybe it's your browser?

 

[Ale]

Am I missing something here? I thought the 1997 balanced budget amendment specifically blocked money for new residency programs?

How is it that pathology has been able to add all these new residency spots over the years? Where are they getting the money for these programs? As far as I know, CME has decided they wont pay for any new residency slots.

You are completely right. The balanced budget act does control the total spots per residency training program. If your program has sixteen spots they can't get a seventeenth unless they pay it out of pocket or take a spot from another residency program in their institution (maybe there are exceptions I don't know). But because they have sixteen spots (four per year) if they lose one first year, next year they will have three second years (25% decrease in residents that year). They will still get 4 new 1st year residents plus 1 to account for the loss of one. Thus, bringing their total number of residents back to 16 instead of 14; creating an imbalance between the amounts of residents that are graduated those two years and preventing a 13% decrease in total graduates.

 

[exPCM]

Am I missing something here? I thought the 1997 balanced budget amendment specifically blocked money for new residency programs?

How is it that pathology has been able to add all these new residency spots over the years? Where are they getting the money for these programs? As far as I know, CME has decided they wont pay for any new residency slots.

When AP/CP programs went from 5 yrs to 4 yrs, this alone added many residency slots on a per year basis. Instead of ~2200+ path residents spread over 5 yrs (440+/yr) you now have ~2200+ path residents spread over 4 yrs (540+/yr). This leads to a more than 20 percent increase in the number of graduating residents per year. There has been a corresponding increase in spots in the NRMP match each year for pathology as well. You can see this supply surge by looking at the rise in spots offered in pathology in the match.
http://www.nrmp.org/advancedata2007.pdf
A lot of people made a big deal out of the fact that 2006 saw 2 classes of pathology residents graduate in the same year (the final 5 year class and the first 4 year class). That was a ONE TIME LARGE BLIP on the radar. A big issue is that we have also now developed a 20+ percent increase in pathology residents finishing EVERY YEAR. This has ratcheted up the competition for fellowships (more graduates fighting for the positions) and made the oversupply of pathologists worse (more graduates per year).
A big issue underlying this is that programs who had CMS (Medicare) funding for 20 slots (4 per year x 5 years) prior to shortening the residency length now continue to fill those 20 spots (5 per year x 4 years). The programs collectively appear to not want to decrease their CMS funded spots and there appears to me to be scant attention to pathology workforce planning.

 

[LADoc00]

People raise good points here...I am certainly guilty of bitching and moaning about this but what have I done to fix things? Nothing.

There is a problem and hopefully things can be done to fix things for us who are entering the workforce after residency/fellowship. My only worry is that what is the motivation for an established community pathologist to fix things?

I liked LADoc00's suggestion to severely cut the # of training spots. What could complicate things is this...the dynamics between pathologists and PAs. I hear that PAs have tried to lobby or are lobbying for increased pay...mainly on a per specimen basis. I don't have much understanding of this management/business sense but I believe that PAs are simply salaried employees whereas pathologist can get paid on a per specimen/case basis. If we were to hire more PAs and have an increasing proportion of the clinical load done by PAs, could that somehow threaten the livelihood of pathologists? I think this is an issue that may contribute to the overabundance of resident trainees. The man wants to fight off the surge from the PAs by continuing to have a lot of the work done by people with MDs.

So, attending level folks don't want to gross as much and have others do the grunt work for them (residents and PAs). Hell, they deserve it! But now I can see how the issue lies at the hands of the attendings? Maybe they need to do more work done by residents and PAs...but what's their motivation? None...at the moment. They have great lifestyles...they're bugged by other things but have good hours...isn't that one significant reason why pathology is attractive these days anyways? Anyways, I need to ponder more about this...but there's some food for thought.

PAs asking for pay on a per specimen basis is ludicrous...if they received that then so should histotechs and cytotechs. They would also lose their benefits. It would be a serious lose situation for them if they successfully argued that.

There is NO shortage of PAs in my opinion IF you are willing to take non-certified people. Why should I pay someone 50+ bucks an hour when I can take a college graduate, pay them 20 bucks/hr and train them to gross??

You are an idiot if you are falling into the trap that somehow PAs need special certification...they dont. That is a fabrication of PA schools and lobbying.

I can hire well experienced PAs at 20-35 bucks/hr depending on experience and never run out of potential candidates.

 

[b&ierstiefel]

PAs asking for pay on a per specimen basis is ludicrous...if they received that then so should histotechs and cytotechs. They would also lose their benefits. It would be a serious lose situation for them if they successfully argued that.

There is NO shortage of PAs in my opinion IF you are willing to take non-certified people. Why should I pay someone 50+ bucks an hour when I can take a college graduate, pay them 20 bucks/hr and train them to gross??

You are an idiot if you are falling into the trap that somehow PAs need special certification...they dont. That is a fabrication of PA schools and lobbying.

I can hire well experienced PAs at 20-35 bucks/hr depending on experience and never run out of potential candidates.

It is bloody ludicrous! That's why it's so infuriating when I hear stuff like this. They don't have doctoral degrees!

Oh? So you're implying that there is a shortage of "certified" PAs. There is an increase of folks deciding to go into PA schools. And do other people in your position share your view?

Sure, you can fight things by enslaving college students but I'm worried that there could be a critical mass of certified PAs who have lobbying power, whether we like it or not!

I don't care about the fabrication of PA schools and lobbying. How does that change things?

 

[b&ierstiefel]

I have heard similar things in the past too. What I heard was that they wanted to sign-out the "easy cases" just like cytotechs do. Meaning the 88300, 88302 and 88304. These are the main specimens in a lot of community hospitals. I don't know if this is true or just an urban legend.

Yeah, especially gross only specimens or obviously benign gall bladders and appendices (although that could be quite dangerous).

But what we don't want to happen is what is happening now in big cities where a physician assistant gets roughly the same salary as an internal medicine doctor. Forget GP, they can't find a job!

Well, the job of a physician is now considered an "overrated" job. More people are going into physician assistant track careers. This affects medicine in general and isn't pathology specific.

Depending on the hospital, the PA may be paid by the –TC or -26 components. If they get paid by the –TC component it means that they have to split their pay with the histotechs. I don't now if they are going to be able to pull that one off. Last time I saw histotechs wanting to get paid by specimen/block they all got the "your services are not longer required" letter. But again, maybe some places do.If they get paid by the -26 component, I can see them asking for it. But why would any pathologist go for it. Then they would cost as much as a pathologist and the savings provided when hiring them vanish.

And that's the way it should be! There was some thread regarding a story of a lawsuit involving a pathologist and a cytotech. The pathologist got sued when the cytotech certainly deserved a significant part of the blame for the screwup. OK, so the PAs want more money and privileges but when the hammer comes down, they can get off the hook like that? WTF? They better not be able to pull that off but I wouldn't be surprised if they sure as are trying! And this adds strain to the whole notion of cutting back the # of resident spots.

Do we really hate grossing so much?

I don't think it's a matter of that but if pathologists themselves had to physically gross in all those small biopsies, that would certainly impinge on their nice lifestyle, wouldn't it?

I believe that the easiest way of reducing the number of trainees would be establishing a quota of resident per year per program instead of per program only. Meaning that if your program sucks or one of your residents does not like pathology, they cannot replace those 2nd or 3rd or 4th lost with more 1st years.

That would be a step in the right direction but I'm not sure how significantly that would impact things. As LADoc00 said, the crappy residency programs need to be closed down anyway. That would be a more significant step in the right direction. Why do we want to dilute the pathology job market with folks coming from bad training programs. It only serves to taint the respect of our profession.

 

[LADoc00]

It is bloody ludicrous! That's why it's so infuriating when I hear stuff like this. They don't have doctoral degrees!

Oh? So you're implying that there is a shortage of "certified" PAs. There is an increase of folks deciding to go into PA schools. And do other people in your position share your view?

Sure, you can fight things by enslaving college students but I'm worried that there could be a critical mass of certified PAs who have lobbying power, whether we like it or not!

I don't care about the fabrication of PA schools and lobbying. How does that change things?

yes and no. There are very few certified PAs because there are very few schools. That doesnt effect demand. Demand is measured against the fact there are tons of people who perform PA duties with no formal educational training whatsoever. I cannot possibly see legislation passing that force pathologists to use certified PAs for grossing..Im not saying PAs wont try to make this happen, but I dont see it making it thru.

Here is my own experience with PAs. I started a business and had alot of potential PAs come to me. Some with sort of outrageous claims such as they could do autopsies completely by themselves...Im sure they could, but do I care?? No.

The PAs wanted around 80K a year in salary, some more some less. For that 80K what were they going to do for me? I have around 2-3 hours of grossing per day. A vast majority of that is putting up biopsies. I hired a high school drop out at 15 bucks/hr and spent less than 5 hours training her to put up biopsies. 5 hours. TOTAL. Are PA schools gonna tell me I need to hire a person with a graduate degree to do what I could easily train my Spanish speaking housekeeper to do in a Sunday afternoon? LMAO!

So with this person my grossing was reduced to around an hour. A year passes. I hire a different person with a science background and a college degree, price: 20 bucks/hr. She can gross in almost everything after about a month of training. I usually spend around 20min in grossing room now.

On top of that, she can do all limb amputations.

IMO, certified PAs are insanely overrated. My prediction is that with declining revenue, no one should hire a highly compensated PA EVER. The numbers just dont make sense to me.

I should write a book called the PA Myth..because that is what it is, a flipping MYTH. Even in a high volume practice I could easily train enough Mexicans standing outside of Home Depot for 80 bucks in cash a day to meet demand.

 

[LADoc00]

Ale-

If there are PAs being paid on a per specimen basis and are not subcontracted out somehow, you need to back that up with some data. Im not buying, Im not saying you are lying but I find it highly improbable and it certainly isnt the norm.

By law, PAs cannot bill insurance companies UNLESS they are providing the entire TC-including supplies (formalin etc), waste disposal, histotech, grossing and transcription in which case they arent really PAs but running a real histology lab. And since histo labs make money, why would a pathologist not start his/her own? Or hospital??

 

[LAZYGUY]

Even in a high volume practice I could easily train enough Mexicans standing outside of Home Depot for 80 bucks in cash a day to meet demand.

not cool

 

[Ale]

Ale-

If there are PAs being paid on a per specimen basis and are not subcontracted out somehow, you need to back that up with some data. Im not buying, Im not saying you are lying but I find it highly improbable and it certainly isnt the norm.

By law, PAs cannot bill insurance companies UNLESS they are providing the entire TC-including supplies (formalin etc), waste disposal, histotech, grossing and transcription in which case they arent really PAs but running a real histology lab. And since histo labs make money, why would a pathologist not start his/her own? Or hospital??

Dude I never said that, I just said that there are people saying that the PAs wanted to get paid by specimen and to sign out cases. I have never seen a PA get paid by specimen or sign-out a case. I just provided a model on how that could happen.
To me that asumption is urban legend.

 

[Ale]

That would be a step in the right direction but I'm not sure how significantly that would impact things. As LADoc00 said, the crappy residency programs need to be closed down anyway. That would be a more significant step in the right direction. Why do we want to dilute the pathology job market with folks coming from bad training programs. It only serves to taint the respect of our profession.

Closing programs is not that easy. You need to give them probation; the programs can sue, etc. If you say now that you are going to close 25% of the programs, no program will go for it. If you say you are going to change the rules, it might fly without them even noticing. If you change the rules so the programs that suck can’t restock on “fresh meat” hopefully they will disappear on their own.

 

[LADoc00]

not cool

I was joking and I happened to drive by my local Home Depot where there were guessing around 200ish men standing at the curb. Its insane. If I had 200 rifles I could take over the town by simply paying and arming them....

 

[LADoc00]

Dude I never said that, I just said that there are people saying that the PAs wanted to get paid by specimen and to sign out cases. I have never seen a PA get paid by specimen or sign-out a case. I just provided a model on how that could happen.
To me that asumption is urban legend.

Good. I had an episode of reflux imagining my PAs might try to charge me per specimen....

 

[LAZYGUY]

I was joking and I happened to drive by my local Home Depot where there were guessing around 200ish men standing at the curb. Its insane. If I had 200 rifles I could take over the town by simply paying and arming them....

ok, ok....cool

 

[LAZYGUY]

What is wrong with this......

240K-280k
40 hours per week
12 weeks of vacation
CRNA only practice

http://www.gaswork.com/cgi-bin/ipbltview.exe?PostIDNum=73736



I know this is just supply and demand but damn that really is screwed up. I guess we know where the health care dollars are going. Don't get me wrong, I love path and would do nothing else, but this kind of crap makes you realize how crappy the system is. I just want a job when I get out, wow.

 

[LADoc00]

What is wrong with this......

240K-280k
40 hours per week
12 weeks of vacation
CRNA only practice

http://www.gaswork.com/cgi-bin/ipbltview.exe?PostIDNum=73736



I know this is just supply and demand but damn that really is screwed up. I guess we know where the health care dollars are going. Don't get me wrong, I love path and would do nothing else, but this kind of crap makes you realize how crappy the system is. I just want a job when I get out, wow.

I said years ago GAS would come back with a vengence when med school deans were claiming it was dead. This will only get worse. You can can consolidate pathology into fewer hands but you need some sort of anes. person actually there for each surgery...

12 weeks of vacation is insane.

Ive never seen that site, can that be right:1725 OPEN JOB LISTINGS??! How can that be? That is mind boggling.

If gas has that stuff going on Pathology is 100x worse off than I had imagined.

 

[LAZYGUY]

I said years ago GAS would come back with a vengence when med school deans were claiming it was dead. This will only get worse. You can can consolidate pathology into fewer hands but you need some sort of anes. person actually there for each surgery...

12 weeks of vacation is insane.

Ive never seen that site, can that be right:1725 OPEN JOB LISTINGS??! How can that be? That is mind boggling.

If gas has that stuff going on Pathology is 100x worse off than I had imagined.

and this is a starting position.....path can expect to earn this cash only after a couple of years and even then nobody guarantees you 40 hours/week and 12 weeks of vacation. Wait, why did I do medicine again? Oh yeah, I wanted to "help people".

 

[yaah]

CRNA issues got so contentious in anesthesia that it now has its own forum for angry bantering.

http://forums.studentdoctor.net/forumdisplay.php?f=281

 

[LAZYGUY]

at the end of the day all this fighting and anger, competition for this and that boils down to one thing...money. People want it and they want a lot of it, whether it's through this fellowship or the other.

 

[Ale]

What percentage of the time will the CRNA be Medically Directed by an anesthesiologist?Never

Did any of you picked-up on this? WTF

 

[docbiohazard]

I had jaw surgery. It was fairly complicated, took a long time, had an excellent oral-maxillofacial surgeon who was on faculty and did a damn fine job. He was paid about 10% of what he billed to my insurance, and the gas-passers made more than he did. Farked up.

Lazyguy is right, it is all about money. I think a great deal of the stress is generated from the piles of student loan debt we incur as well. If people want a better healthcare system, I think that's got to be looked at as well. I imagine if we all came out of residency debt free, that would alleviate some of the stress.

BH

 

[yaah]

Yeah, the piles of debt, in addition to the fact that when people seeing someone else making lots of money, they often have one of two stereotyped reactions: 1) I hate that guy, 2) I want that for myself. It fosters neverending competition and occasional backstabbing, and the backstabbing is often rewarded.

The problem with NOT focusing on money, is that if you don't, you can rest assured that someone else is, and they are happily taking advantage of your naivety and lack of concern to make more for themselves.

 

[LADoc00]

Yeah, the piles of debt, in addition to the fact that when people seeing someone else making lots of money, they often have one of two stereotyped reactions: 1) I hate that guy, 2) I want that for myself. It fosters neverending competition and occasional backstabbing, and the backstabbing is often rewarded.

The problem with NOT focusing on money, is that if you don't, you can rest assured that someone else is, and they are happily taking advantage of your naivety and lack of concern to make more for themselves.

So true. Had someone after being part of the Kaiser system explain this to me last week: the pathologists there revel in the fact they are underpaid, its so ingrained in the culture not to care about the bottom line, profit etc at the individual physician level meanwhile the Kaiser admin is laughing all the way to bank.

You need a measure of both concern about profit and the ability to shrug off not always making 7-figures.

 

[docbiohazard]

Yeah, the piles of debt, in addition to the fact that when people seeing someone else making lots of money, they often have one of two stereotyped reactions: 1) I hate that guy, 2) I want that for myself. It fosters neverending competition and occasional backstabbing, and the backstabbing is often rewarded.

I think often times it fosters both reactions - I hate that guy and I want what he has.

You're right, too, about how you can't simply not worry about money/profit because someone else will... I just think if the debt was removed from the equation people would at least be somewhat less stressed about money in general coming out of residency.

 

[LAZYGUY]

I agree. Money is important but it shouldn't be the driving force behind your decisions (residency, fellowship). Those things can easily change with one law. But don't be fooled, I too have been caught in the trap and realized that those things, in the end, would not make me as happy. Medicine gives you capital to make investments in profitable ventures. Whether be it in medicine or not, there is always the opportunity to make money without having to go about the silly business of doing 2 or more fellowships. I guess residents/fellows go about this the only way they know how...more training. I know that to some degree I do too, but I am not going to let it dictate the next 4 or 5 years. Money comes and goes.

 

[docbiohazard]

To some extent, I wonder how much the multi-fellowship game has to do with people's insecurities about their level of skill / training in surgical pathology, especially compared to their attendings... but then every year spent on a subspeciality I think you would start to feel less confident about signing out other things, leading to... more fellowships.

It seems to me that to some degree, you've got to get out and start practicing to ultimately gain that level of comfort and proficiency that you see in most attendings.

Just wonder how much that contributes to it...