Following the lead of BCBS ANTHEM and UNITED HEALTH
No chairman or department head would take department money and hand it over to residents unless it was just crushing it fiscally. This isn’t about educational altruism.... not in this market. It’s all about being at least somewhat profitable. Everyone who can will get subsidized money provided by CMS or the VA which is From CMS anyway. The hospital might pay but it has to make sense fiscally. There is no way a department or a medical center would lose money every single year just to keep an over supply of residents that are not actually working. There has to be free money in there somewhere that’s being hidden or some incentive. The reason resident labor worked in the past because you worked so hard for your pay that it made sense. Now you get paid to predominantly hang out. This is unsustainable. Eventually there has to be a reset. Less residents doing much more actual work and/or closing spots etc. Or residents paying to get trained .....The Old school Ackerman derm model. Hmmmmmmm pay to play.
Cyto could have been the savior of pathology if the leaders weren’t so short sided. There was a great push for pathologists to see the patients and control the tissue flow with US-guided FNA and even performing core biopsies. A combination of crappy leadership, short sightedness by departments destroyed this possibility. As usual the CAP and USCAP train people to do these procedures but never pushed through the infrastructure to make it a tenable and profitable modality. It is heart breaking. But life goes on... eventually there will be the liquid biopsy and NGS with some magic pseudo-AI algorithm out of Palo Alto to contend with. It will be BS but will be shoved down everyone throats by slick smooth talking sales people.
Exactly. Unfortunately the main issue is that the field of diagnostics is too broad. Pulmonary, GI, and radiology went interventional and are paid handsomely. The best interventional pathologists are amazing brilliant people but the support infrastructure and short sighted leadership made it impossible to activate in any reasonable way. Too bad some billionaire does not see the obvious benefits of this and sets it up in the private sector. Path should have had interventional centers and had all interventionalists working for us. We are the ones that should have always controlled the tissue and qualified/quantified it for optimal downstream testing and reporting. Patient is sent to the interventional center run by pathologists in which all other interventional docs procure tissue. Especially if there is NGS etc etc. the upfront investment is huge but the potential for banking tissue properly and having the highest quality standards would be natural. But as the man said “how about fantasy land”
I get the non ACGME fellow sign out thing and the programs where residents gross thing so you need less PAs but what percentage of programs actually run this way? It seems that this has become less common. Not at the fellowship level but at the residency spots being offered level. If programs were not supported by CMS and other funds for resident salary as much as they are wouldn’t there be a reassessment of number needed to perform necessary labor. Pathology may be a bottom rung, but it generates significant revenue for departments that are run well. Whenever entities get guaranteed federal funding it is difficult to figure out what Is truly required.
www.nature.com
bigthink.com
Does this mean you treat every clonal hematopoiesis of indeterminate potential patient for a heme malignancy based off of a couple of actionable mutations found in a blood sample? I understand the desire to find actionable mutations to give a patient a drug, but obviously only for patients with an actual malignancy.The future of tissue-agnostic drugs
Some people with cancer are already benefiting from drugs that target genetic features regardless of the tissue involved. But these early successes could be the exceptions.
Tissue agnostic therapeutics will likely drive the whole liquid biopsy paradigm. I foresee a push toward using liquid biopsies to stratify “incipient” malignancies and to come up with recommended treatments even if a definitive tumor is not detected. This will be dangerous and without definitive value. Also data from liquid biopsy results will be banked and connected to individuals forever. This will be a huge problem if testing becomes population based screening using liquid biopsy. It will be driven by informatics and “AI” based stratification that is foundationally flawed. They are pushing this liquid biopsy thing hardcore and it is a serious Pandora’s box.
The large tumor burden use is reasonable but it seems that there is a push to use this technology for screening of “incipient” cancer. Or first time diagnosis.
Exactly. When you test for something it is extremely important to first fully flesh out what you intend to do with the result. The field is expanding faster than thought leaders really understanding what the data means and could mean. We are getting better and better at detecting signals in smaller and smaller partitions but have not worked out what the signals truly represent. It has to be scrutinized before Palo Alto “VC”runs with it.
btw...best.movie.ever.
Tissue agnostic therapy is trying to become a thing. I hope tissue agnostic diagnosis does not become a thing.
Yes, it is definitely a thing.
humgenomics.biomedcentral.com
That’s the goal supposedly but the devils in the details.
I thought the unholy trinity was Roche, Genentech, and Ventana as the example you stated but I 100% agree with you. I am more concerned with the data that is generated from these tests and how it may impact what may part of the medical record of future generations. I just don’t want population based screening analogous to 23 and me. Starting out as a slickly marketed test for fringe primary care practitioners as a blood test to just see “what could be a potential problem.” I mean just doing NGS on a blood sample during a routine physical when it becomes cheap enough and finding **** that has not been vetted in any meaningful way.
. I guess that’s kinda personalized.
nypost.com
Lemme tell ya, it’s pretty personalized in uro oncology for prostate ca.
They ask you if you want a 3 month or 6 month course of chemical castration after your radiation therapy for a “biochemical recurrence” ( PSA 0.2 x2 post radical prostatectomy.). I guess that’s kinda personalized.
If it was not treated i would be dead. Thankfully, all the plumbing works fine.
CAP president worried about the cuts. Hope there is enough room under the bridge for all you guys.
From the President’s Desk: Painful cuts ahead - CAP TODAY
September 2020—Pathologists have been feeling the pain for months. The COVID-19 pandemic triggered furloughs and layoffs even as we ran a grueling race to implement and scale high-quality testing. And now looming cuts to pathologist physician payments threaten to make our situation even worse.www.captodayonline.com
It seems you are doing liquid biopsy NGS on a patient with solid tumor since there is a comparison(tumor to biopsy).
The former I understand.... this makes perfect sense and has been demonstrated in other modalities. I am suspicious of the latter (future use cases that are being developed, like cancer screening) but let’s see how things progress.
As stated, these future use cases are in development. It is only right to be both hopeful and critical about their success. The only way to convert a "future" use case to a "present" use case is "evidence". When talking about cancer screening, that means demonstrating the validity of detecting cancer signatures in advance of actual development of cancer. That means screening a lot of people, and then waiting for some of them to get cancer, and identifying the predictive sensitivity and specificity of your signal. This is a normal part of developing any new test.
I get it. Let’s see how this goes with lots and lots and lots of data. Let’s not rush into things with “Champaign wishes and caviar dreams”
