Molecular pathology fellowship

[Lemuel]

Hellow everyone. Can somebody comment on how competitive is to match into a molecular pathology fellowship and what are the jobs available for a molecular pathologists. Im assuming it is more confined to big university programs/academic settings. Thank you for your time and input.

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[gbwillner]

Hellow everyone. Can somebody comment on how competitive is to match into a molecular pathology fellowship and what are the jobs available for a molecular pathologists. Im assuming it is more confined to big university programs/academic settings. Thank you for your time and input.

There are only a handful of accredited programs out there, so competitiveness varies year-to-year although I would not call it "competitive". Jobs range from running a meolecular diagnostics lab full-time at a large academic institution, to runing a small set of test part-time at a small academic institution, to signing out molecular tests/interpretations in provate practice. Also a few of us will do primarily research, but this is not the intent of the fellowship.

 

[KCShaw]

Unfortunately ABPath has apparently seen fit to remove all their newsletters from prior to 2009 and I can't find an archived copy anywhere. However, based on the recent newsletters 49 took the exam in 2009, compared to only 10 in 2007. According to an excel file I have (unfortunately I can't remember the source...it's possible I've posted it somewhere here before, back when I remembered..) in 2006-2007 there were 18 mol/gen programs with 18 of 28 positions filled -- prior to that the numbers were smaller, in terms of programs and percent of positions filled. I don't have anything more recent than that.

As far as jobs, while on the one hand everyone seems to agree molecular pathology is a good thing and is growing, on the other hand many tests are handled like many CP lab results and therefore those who are fellowship trained are probably best suited for running a molecular lab. And as labs tend to go, only one director is typically needed and PhD's are typically cheaper and may come with their own grant money. That doesn't mean one couldn't get a job as an AP +/- CP pathologist who also helps with molecular interpretation (if out-of-house testing is done), but I think it's likely that to do molecular & only molecular one would need to find a large enough institution to be doing those things in-house AND be able to compete with PhD's for the relevant job. What that really pans out to in the job market, I don't know.

 

[quant]

Hi There,
Here is a link to a comprehensive listing of Molecular Pathology Programs in the country

http://www.amp.org/committees/training_educ/molecular_pathology_training_programs.cfm

I believe the future for Molecular Pathology is indeed very bright. While it might have been the case that one would have wanted candidates to signout Something+Molecular a few years ago, it is not the case anymore. There are programs out there which want sole Molecular Signout, though they are far and few. There are quite a few private enterprises out there which need trained pathologists to do "Molecular Signout" which probably means a lot of Administrative aspects of Molecular. While it is certainly true that a lot of tests are the cookie cutter variety similar to CP, that probably will not be the case in the future. Many of the tests are fast becoming complex requiring expert interpretative opinion. Whether these tests get a CPT code for the interpretative component or not is still up in the air, though many agencies are trying to fight for one.

I personally think the future is bright, but hinges on a lot of other factors. You would be well advised to specialize in Molecular with ONE other speciality as your core areas of expertise.

My 2 cents.

 

[KluverB]

Not that long ago, there used to be fellowships in Immunohistochemistry when that "technology" was novel and such. Molecular will go the way of push-button automation the way most of CP-type testing is done now.

 

[zao275]

The Pathology Wiki also has a fellowship directory for molecular.

http://pathinfo.wikia.com/wiki/Molecular_Genetics_Pathology_Fellowship_Directory

 

[DDolderer]

Any new opinions on this? Best places to train?

 

[gbwillner]

Any new opinions on this? Best places to train?

Best places to train from what I've seen:
MSK, WashU, UPMC, BWH, maybe a handful of others.

 

[Torsed]

I know a pathologist that did molecular at a large fellowship, his words from personal correspondence:

"Most of these fellows go on to run molecular labs or do heme or something. This molecular fellowship is not all I intended. I do learn a lot and everyone is nice but this stuff is freaking tough and I don't know if I want to sign this crap out every day. Plus, half of the medical directors here are PhDs and they take a much lower salary than the MD molecular guys. Makes me wonder if MDs have a future in molecular. I know we should embrace it, but with PhDs willing to do it for half the price, I'm just not sure how MDs will fit into the business model and demand a good salary. So doing a molecular only job requires I work at a big corporate lab, reference lab or academic center. I'm guessing, private practices won't care that much when they can just send out their molecular tests. To be honest, I don't like the big "corporate" environment that you find at reference labs. I much prefer smaller setups. I definitely do not want to work at a large place like where I'm at now. Nobody really gives a **** about me at this job. They only care about themselves."

Be warned.

 

[JeSuisPathology]

...with PhDs willing to do it for half the price, I'm just not sure how MDs will fit into the business model and demand a good salary.

This.

Has anyone else heard of non-MD healthcare executives supposedly being in the process of making a very big push at federal/state regulatory levels to at least begin questioning the need to pay MDs for certain services- such as molecular interpretation?

Hate to say it, but I imagine that from an executive's point of view, it would save a heck of a lot of money for hospitals.

 

[coroner]

Seems like LA's thoughts on the field still ring true a decade later...

 

[gbwillner]

I will strongly disagree.

In the past, molecular genetic testing was rather simple, and the role of the attending "physician" was to ensure the quality of the test, that it meets specifications, and to provide an accurate result. No wonder PhDs took over.

With NGS testing in oncology, it has become far more complicated. There is not necessarily a simple test with a simple answer- it is a very complex test that simultaneously tests potentially millions of different variables, and the results need to be considered with the patient's germline phenotype, clinical history, histology, etc. Oncologists and physicians in general do not have the capability of understanding the complex results of these tests, thus an expert interpretation will be required. Who will given this interpretation in light of cancer biology, diagnostics, and clinical significance? Do you trust a PhD to tell you what a novel variant in KRAS can mean to treating a metastatic colon cancer patient with mucinous histology? How can they accurately assess tumor content and cellularity?

The future of NGS testing in oncology is in the hands of Anatomic Pathologists if precision medicine is to move forward. We are the best suited for such medically relevant interpretations, provided a sufficient fund of knowledge in the field (a minimum of MGP fellowship). If we do not take it, Oncologists themselves will. Not PhDs- that would ensure that NGS never moves beyond hotspot testing of well-established genetic signatures.

I think the best parallel is to Radiology. Any clinician can order an Xray and review the findings. But it is a very complex test with a lot potential variables, and an expert in such tests can render a far more valuable impression of the findings than a layperson/primary care clinician. History has shown this to be the case, otherwise radiology would not exist. And radiology has only become MORE complex, requiring additional expertise. Pathology as a field was also born of surgery in the same way. The future of this field, IMHO, is expert review and interpretation of the results. right now, most findings are delivered from a lab to a clinician, and any non-common finding (other than mutations like an EGFR 858 mutation or KRAS G12C in lung adenocarcinoma) is basically ignored. Our understanding of tumor processes and targeting of those processes will only make these analyses more complex, requiring more and more expertise. This was never true of IHC- the results were always "stain +/-" and easily absorbed into a pathologist routine.

/end rant

 

[Over9000]

I will strongly disagree.

In the past, molecular genetic testing was rather simple, and the role of the attending "physician" was to ensure the quality of the test, that it meets specifications, and to provide an accurate result. No wonder PhDs took over.

With NGS testing in oncology, it has become far more complicated. There is not necessarily a simple test with a simple answer- it is a very complex test that simultaneously tests potentially millions of different variables, and the results need to be considered with the patient's germline phenotype, clinical history, histology, etc. Oncologists and physicians in general do not have the capability of understanding the complex results of these tests, thus an expert interpretation will be required. Who will given this interpretation in light of cancer biology, diagnostics, and clinical significance? Do you trust a PhD to tell you what a novel variant in KRAS can mean to treating a metastatic colon cancer patient with mucinous histology? How can they accurately assess tumor content and cellularity?

The future of NGS testing in oncology is in the hands of Anatomic Pathologists if precision medicine is to move forward. We are the best suited for such medically relevant interpretations, provided a sufficient fund of knowledge in the field (a minimum of MGP fellowship). If we do not take it, Oncologists themselves will. Not PhDs- that would ensure that NGS never moves beyond hotspot testing of well-established genetic signatures.

I think the best parallel is to Radiology. Any clinician can order an Xray and review the findings. But it is a very complex test with a lot potential variables, and an expert in such tests can render a far more valuable impression of the findings than a layperson/primary care clinician. History has shown this to be the case, otherwise radiology would not exist. And radiology has only become MORE complex, requiring additional expertise. Pathology as a field was also born of surgery in the same way. The future of this field, IMHO, is expert review and interpretation of the results. right now, most findings are delivered from a lab to a clinician, and any non-common finding (other than mutations like an EGFR 858 mutation or KRAS G12C in lung adenocarcinoma) is basically ignored. Our understanding of tumor processes and targeting of those processes will only make these analyses more complex, requiring more and more expertise. This was never true of IHC- the results were always "stain +/-" and easily absorbed into a pathologist routine.

/end rant

That's fine and dandy but cost will be the main driver, which will put pathologists out of the loop (cheaper PhD alternatives will do it, or pathologists will have to lowball them. Either way, molecular is not attractive)

Radiology has struggled to keep hold of a lot of imaging. Yet radiology requires a more nuanced, MD-level interpretation than molecular testing, which is why they've held on to most of it. As for molecular, the clinical correlation is performed by the ordering physician. All they want to know is the "result" of the test. The molecular PhD/pathologist can't really add much except QA, running the test, and making sure the automated result is acceptably precise, which is a kind of QA thing.

The histo assessment will be done by the normal anatomical pathologist who sends the case off for molecular testing.

I echo the thoughts of LAdoc00 in that yes, molecular is important in medicine, but it is not a marketable skill set.

 

[gbwillner]

...
Radiology has struggled to keep hold of a lot of imaging. Yet radiology requires a more nuanced, MD-level interpretation than molecular testing, which is why they've held on to most of it. As for molecular, the clinical correlation is performed by the ordering physician. All they want to know is the "result" of the test. The molecular PhD/pathologist can't really add much except QA, running the test, and making sure the automated result is acceptably precise, which is a kind of QA thing....

This is fundamentally where I disagree. This is the bulk of what I do now and can tell you as systems become more and more complex, the physician-level nuanced interpretation will be every bit as relevant in complex genetic testing than in Radiology today.

 

[pathstudent]

I disagree that PhDs are innately cheaper than MDs. I went to a top notch state university training program and so all my attending had their salaries posted online. The PhD that ran the FISH\cytogenetic lab made 500k a year. That was more than all but 2-3 of the anatomic pathology MDs. The PhD that was medical director o immunology lab made 600k a year. That was more than all but the head dermatopathologist MD. The PhD that ran the chemistry lab made 300k a year. That was as much or more than most associate professors in surg path. These were not ancient professors who had a sweet deal set up years ago. They were mid career attendings that ran huge money making clinical labs and were compensated accordingly.

 

[bberlioz]

The histo assessment will be done by the normal anatomical pathologist who sends the case off for molecular testing.

I echo the thoughts of LAdoc00 in that yes, molecular is important in medicine, but it is not a marketable skill set.

I think molecular is not that hard to market. Here is a simplified approach:

1) Rename subspecialties in our field (ex: diagnostic breast oncology) making it self-explanatory and easy for the public to understand

2) Create easy diagrams for patients to understand, for example in breast cancer:
biopsy/surgical specimen --> pathology (diagnostic oncology) --> benign or cancer --> if cancer, localized or metastatic --> only if localized breast cancer --> eligible for molecular analysis (IHC + PAM50/Oncogenedx) to decide if need adjuvant chemo or not

3) Show that pathology starts at step 2 after biopsy to decide on treatment

4) Profit ???

I guess the argument is that unlike the other steps, gene expression analysis seems to be an automated step. So the question is whether the other clinicians should be ordering these tests.

I think as a pathologist, it just makes sense that we're ordering the molecular tests, since we are in charge of the entire "diagnostic" consultation for cancer care. To wait for the other clinicians to order the molecular tests is delaying treatment and ultimately comprising patient care.

I'm pretty sure that if we draw big bubbles and diagrams even the common public can understand.

 

[Torsed]

Pathstudent...I've never heard of any laboratorian commanding a salary like that at a University. That's all fine and dandy at BW or MGH, but those Ph.D. salaries must be outliers as I would presume investigative journalists and the state legislature would be looking real hard at that.
Those posted salaries are just that too, salaries, they don't mention income from other sources which can be deceptive how much an individual really makes. If academic pathologist XYZ is allowed to take 40 percent of consultative fees that is separate from their "salary" in most cases I've seen in academics.

 

[gbwillner]

Pathstudent...I've never heard of any laboratorian commanding a salary like that at a University. That's all fine and dandy at BW or MGH...

LOL.... Those guys probably make the least, until they move into industry or command huge consulting fees. Or develop tests that they own and patent...

 

[pathstudent]

Pathstudent...I've never heard of any laboratorian commanding a salary like that at a University. That's all fine and dandy at BW or MGH, but those Ph.D. salaries must be outliers as I would presume investigative journalists and the state legislature would be looking real hard at that.
Those posted salaries are just that too, salaries, they don't mention income from other sources which can be deceptive how much an individual really makes. If academic pathologist XYZ is allowed to take 40 percent of consultative fees that is separate from their "salary" in most cases I've seen in academics.

Again these were published on a website where you could look up what everyone makes that works for the state. They didn't have patents. They were just running huge revenue generating labs.

 

[Inez2000]

Again these were published on a website where you could look up what everyone makes that works for the state. They didn't have patents. They were just running huge revenue generating labs.

Please post the link to this website

 

[pathstudent]

Please post the link to this website

Jeez. You got no game. Just google whatever state you are interested in and "public salaries".

For instance here is Texas http://salaries.texastribune.org/

 

[Inez2000]

i am interested in seeing the specific data that you refer to. How would I know what state you are specifically referring to? I would like to see, "The PhD that was medical director o immunology lab made 600k a year."

 

[pathstudent]

i am interested in seeing the specific data that you refer to. How would I know what state you are specifically referring to? I would like to see, "The PhD that was medical director o immunology lab made 600k a year."

I'm not going to go naming names. It is out there and can be verified. And you can even check multiple past years and see the salary has remained about the same. If you don't want to believe me that is fine.

I can't guess why a PhD immunology medical director would make more than most all of the anatomic pathologists. But the in the cases of the PhDs running the hospital's chemistry (who made far more than the median AP salary) and FISH (who made more than almost all of the AP MDs) labs, they had big outreach operations generating revenue for the university which they are able to share in. It is like Leboit. He isn't making almost 1.8M a year simply by signing out the biopsies from UCSF inpatients and UCSF owned clinics. It is through outreach and referral service.

 

[Inez2000]

OK, fine. You are anonymous. Nobody will care that you are naming the state I need to google to find this information. I am not going to spend time looking at all 50 states. I looked at the Texas salary site you suggested, and there was nobody from the pathology departments making anything over an average salary except for the chair.