New workforce article

[jp123ok]

10-20 years... huh. How long is your working career again? And what exactly would you have the generation of docs currently bitching about job prospects do while they bide their time?

The working life of a newly minted pathologist is 30-35 years approx. The job market will probably pick up in 10-20 years. In the mean time people can find work in academics earning $150k/yr (+ benefits) or in POD labs earning $200k/yr+ or if they are willing to network during residency/fellowship they can still get the good private practice jobs. Most of the people on this forum are not unemployed. They are complaining because they have a sense of entitlement. A lot of their complaints are along the lines of "why should I have to work for another physician in a POD lab. The job market sucks". Physicians in other specialties work for others in hospitals and medical centers all the time. Why should pathologists be any different?

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[2121115]

Physicians in other specialties work for others in hospitals and medical centers all the time.

Show me an example of another physician specialty that gets their professional fees taken by other physicians and they don't complain about it.

 

[jp123ok]

Show me an example of another physician specialty that gets their professional fees taken by other physicians and they don't complain about it.

Physicians from every discipline work for a flat salary. eg managed care, VA, etc etc. Most of them are not complaining that the organization they work for is profiting from their labor.

When you talk about pathologists losing a portion of their professional fees then this is an emotive topic which conjures up images of severe exploitation. I would suggest it is simply the capitalist system at work. There is nothing to stop pathologists hiring a bunch of GI docs and entering into the same type of arrangement. The real question is what the pathologists entering into this arrangement are earning. If it's $200k+ then they are doing alright IMO and should just suck it up.

 

[2121115]

Physicians from every discipline work for a flat salary. eg managed care, VA, etc etc. Most of them are not complaining that the organization they work for is profiting from their labor.

Very different working for a corporation versus working for someone who used to be your medical school buddy - calling him boss, asking him when you can take vacation, etc. When you get out in the real world you'll understand the difference. And most clinicians actually get a better deal by being employed (versus working for themselves), not a drastic pay cut. They wouldn't do it otherwise.

There is nothing to stop pathologists hiring a bunch of GI docs and entering into the same type of arrangement.

Yes, there is something stopping that. I don't think you are listening to the conversation going on here.

 

[MOHS_01]

From a patient care perspective, pathology probably should reduce its residency training program number, if only to ensure that the brightest people are selected. The job market thing is an unfortunate consequence to the current setup. What's more concerning is the danger posed to the public.

As it stands, the government basically pays programs to take on residents who act as grossing scut monkeys, without any care as to their competence. Unlike clinical medicine, where incompetence could result in malpractice, gross tech work is silent and fairly insulated from this. This is why you have so many programs full of really questionable IMGs. I would hate to have my mom's biopsy read by someone who had substandard medical school and residency training. I wish there was an easy way for me to make sure this did not happen.

Unfortunately, to say as much would be for the pathology community as a whole to admit it has been making huge workforce mistakes for decades, and it just won't do that.

The CAP should be advocating for cutting resident positions. If not, then a bunch of you should get together and, independent of the CAP, provide good think-tank data to the government in support of cutting path residency spots from a fiscal perspective; if there's one thing the government likes doing, its saving money. At 160k/resident, cutting 50% of the spots would be a TON of money saved.

Haven't they cut that to about $90k / gme slot these days?

 

[MOHS_01]

The working life of a newly minted pathologist is 30-35 years approx. The job market will probably pick up in 10-20 years. In the mean time people can find work in academics earning $150k/yr (+ benefits) or in POD labs earning $200k/yr+ or if they are willing to network during residency/fellowship they can still get the good private practice jobs. Most of the people on this forum are not unemployed. They are complaining because they have a sense of entitlement. A lot of their complaints are along the lines of "why should I have to work for another physician in a POD lab. The job market sucks". Physicians in other specialties work for others in hospitals and medical centers all the time. Why should pathologists be any different?

*facepalm*

I'm with the poster above - I do not believe that you are following along very well. It is time to kick your normalcy bias and consider what is being explained to you by any number of peeps on this forum - you (pathology) have a different set of rules by which you have to play. You're not like other fields that allow you to pivot with changes - you have one skill and are wholly reliant upon other docs.

I sincerely hope your above market job holds for you... for life is not so grand for a great number of good docs.

 

[Pathwrath]

*facepalm*

I'm with the poster above - I do not believe that you are following along very well.

Oh, I think he's following fine. It's called whistling past the graveyard. That, or the congenital contrarianism of pathologists. Like herding cats.

 

[jp123ok]

Oh, I think he's following fine. It's called whistling past the graveyard. That, or the congenital contrarianism of pathologists. Like herding cats.

Actually, you are both wrong. I am listening. I just disagree with what is being said. Perhaps it is a regional issue, but the environment for pathologists where I am is not the one that is being described on this forum. I am about to start fellowship at a program where senior residents and fellows are being actively recruited. I have accepted a job paying $300k starting salary at a practice that has more work than they know what to do with and which is constantly growing. And, I have plenty of ideas about how to help the practice grow further if only we can find the space to house the additional staff! "Whistling past the graveyard"?... I don't think so.

 

[2121115]

Actually, you are both wrong. I am listening. I just disagree with what is being said. Perhaps it is a regional issue, but the environment for pathologists where I am is not the one that is being described on this forum. I am about to start fellowship at a program where senior residents and fellows are being actively recruited. I have accepted a job paying $300k starting salary at a practice that has more work than they know what to do with and which is constantly growing. And, I have plenty of ideas about how to help the practice grow further if only we can find the space to house the additional staff! "Whistling past the graveyard"?... I don't think so.

Ppppppppppfffffffffffffffttttttttttttttttttttt!!!!!!!!!!!!!!!!!!!!!!!!!!!

 

[Pathwrath]

...the environment for pathologists where I am is not the one that is being described on this forum.

Where do you think you are going to work, Brigadoon? The forces at play patiently described here--for your edification, no less!--are not geographically restricted, although some areas are getting hit harder and faster.

The economics of my work, and that of EVERY other longtimer on this forum, I assure you, are fundamentally different now than even ten years ago. And it will be for you. Those of us with a lot of business sense and ruthlessness have survived this mess.

You will regret having spouted off about our "sense of entitlement". Listen and learn.

 

[jp123ok]

I've been a member on SDN for a long time Pathwrath, a lot longer than you. The thing that I have learned is that there is a small but vocal group of 'attendings' who enjoy scaring people regarding the pathology job-market. Why? Who knows. The field of pathology does attract some odd people, so it's no great surprise that some of them would find their way onto this forum. What I find funny about this situation though is that many of these people do not even claim to be pathologists. I wish more of the pathologists who enjoy their jobs would speak up like on this thread:
http://forums.studentdoctor.net/showthread.php?t=985736&page=2

And just for the record, less than one week into my fellowship and I've already been approached by a private practice group with a job offer. I had to tell them that I've already accepted another job... The departing dermpath fellows told me that they were constantly being approached with job offers. Maybe the answer for all the malcontents on this forum is to do a dermpath fellowship like me.

As far as the business of pathology having deteriorated in recent times, yeah maybe for some, but certainly not for all. I got to know three private practice dermpath groups quite well as a result of networking during residency and fellowship and all three are expanding at a healthy rate. Interestingly, each is using a different method to attract new business. Maybe dermpath is different to other areas in path, or maybe the vocal 'Doom and Gloom' crowd on this forum are all just a bunch of noisy losers with poor marketing skills ...

 

[WEBB PINKERTON]

I've been a member on SDN for a long time Pathwrath, a lot longer than you. The thing that I have learned is that there is a small but vocal group of 'attendings' who enjoy scaring people regarding the pathology job-market. Why? Who knows. The field of pathology does attract some odd people, so it's no great surprise that some of them would find their way onto this forum. What I find funny about this situation though is that many of these people do not even claim to be pathologists. I wish more of the pathologists who enjoy their jobs would speak up like on this thread:
http://forums.studentdoctor.net/showthread.php?t=985736&page=2

And just for the record, less than one week into my fellowship and I've already been approached by a private practice group with a job offer. I had to tell them that I've already accepted another job... The departing dermpath fellows told me that they were constantly being approached with job offers. Maybe the answer for all the malcontents on this forum is to do a dermpath fellowship like me.

As far as the business of pathology having deteriorated in recent times, yeah maybe for some, but certainly not for all. I got to know three private practice dermpath groups quite well as a result of networking during residency and fellowship and all three are expanding at a healthy rate. Interestingly, each is using a different method to attract new business. Maybe dermpath is different to other areas in path, or maybe the vocal 'Doom and Gloom' crowd on this forum are all just a bunch of noisy losers with poor marketing skills ...

Virtually every pathology forum is the same. Too many residents, too few jobs, lost autonomy, spiral to the bottom thanks to large corporate labs etc......Sure there are a few that actually talk about cases but when they start discussing these issues, they sound IDENTICAL. Where there is smoke, there is fire. Most pathologists spend more time trying to keep their declining business than pushing glass anymore. That seems to be true for everyone I speak to at meetings as well. Anyone thinking about pathology as a career need to go out and meet as many paths as they can. You will hear the same things offline that you read online. The field is just a few notches above pharmacist and eye doctor at this point.

 

[Pathwrath]

I've been a member on SDN for a long time Pathwrath, a lot longer than you. The thing that I have learned is that there is a small but vocal group of 'attendings' who enjoy scaring people regarding the pathology job-market. Why? Who knows.

Oh, I've been on here long enough. Certainly long enough to observe the types of commentators. Years in and out, it's always the same. There's the medical students who are primarily obsessed with whether their credentials are good enough (!) to get a pathology residency. There's the senior residents (invariably fellows and polydiplomates nowadays) worried about getting a job, many of them any job. There's the newly-minted pathologists who've landed their first great job, many of whom are obnoxiously cocky for knowing really nothing yet of practice. That's you. There's the early career pathologists, learning the ropes. There's the academic pathologists, usually joiners with CAP connections, who usually think everything is groovy. And finally there's the community pathologists with 10+ years in the trenches. The last group are the real nasty "malcontents", as you describe them.

The reasons anyone posts here are not that difficult to surmise. The medical students, residents, and fellows want reassurance that everything is going to be a-okay. At least some of the prominent academics here have an obvious self-serving agenda, although in general this site frowns on calling them on it (the malcontents, however, are fair game).

The longtimer malcontents want to complain. Oh, they are accused of deliberately sabotaging a robust field by scaring away choice residents for their own selfish gain and probably worse, but doesn't that strike you as at least a little bit too contrived? They want to complain because they have reason to complain. They are not lying about their experiences. They are not internet sockpuppets.

The thing with There's no problem for me and the people I know, so there's no problem is not the selfishness of it, but the shortsightedness. I would not write off uniformly negative comments from longterm community pathologists as some type of selection bias. The field is too small and the economics are too challenging, especially for someone planning on making serious money, as you claim to be. Listen and learn. Or not, I really don't care.

 

[Substance]

The reasons anyone posts here are not that difficult to surmise. The medical students, residents, and fellows want reassurance that everything is going to be a-okay. At least some of the prominent academics here have a obvious self-serving agenda, although in general this site frowns on calling them on it (the malcontents, however, are fair game).

I assume you're referring to Dr. Remick, who I recall was berated for his pollyannish views on the job market, only to have those who berated him chastised for doing so. I can see the reason for this: he puts his name out there and is thus accountable for his words, even if they are unreasonable. The malcontents, however, are behind internet pseudonyms. If they were to put their names out there, they might have more of a leg to stand on.

 

[Pathwrath]

I assume you're referring to Dr. Remick, who I recall was berated for his pollyannish views on the job market, only to have those who berated him chastised for doing so. I can see the reason for this: he puts his name out there and is thus accountable for his words, even if they are unreasonable. The malcontents, however, are behind internet pseudonyms. If they were to put their names out there, they might have more of a leg to stand on.

On the other hand, one could argue that advancing the standard CAP/APC party line is hardly controversial or risky, whether or not one signs one name to it.

If we are going to give special credence to certain posts because they are signed, then make it mandatory for all and be done with it. Either the opinions here are evaluated on the strength of the argument or they are not. Pick one.

 

[jp123ok]

The longtimer malcontents want to complain. Oh, they are accused of deliberately sabotaging a robust field by scaring away choice residents for their own selfish gain and probably worse, but doesn't that strike you as at least a little bit too contrived? They want to complain because they have reason to complain. They are not lying about their experiences. They are not internet sockpuppets.

The thing with There's no problem for me and the people I know, so there's no problem is not the selfishness of it, but the shortsightedness. I would not write off uniformly negative comments from longterm community pathologists as some type of selection bias. The field is too small and the economics are too challenging, especially for someone planning on making serious money, as you claim to be. Listen and learn. Or not, I really don't care.

Thanks for your interesting analysis Pathwrath. Leaving aside the job market for a moment (this is SDN so I'm sure it will be a very brief moment), the point that several people (constantly) make is that the business of pathology is becoming more challenging. What I find really surprising though is that no one ever discusses strategies for retaining clients or securing new clients. Instead, when I try to start a discussion about this the responses are typically brief and completely negative. It seems like people are completely resigned to the fact that they will lose clients. Responses that I've received have included "it's impossible, markets are all locked up" or "starting a new private practice is about as feasible as cold-fusion", or "hiring clinicians to work in your own POD lab is impossible". I find the pervasive defeatist attitude expressed ad nauseum by several malcontents on this forum to be pathetic.

 

[porokeratosis]

I agree with jp123ok. Pleasing your clients is important in the business of pathology.

I'm Derm/Dermpath. I see and hear many of my Dermatologist colleagues (aka "clients") complain about certain Dermpaths. For example, some DP's order too many immunostains. Patients complain to their Dermatologists when they see the bill on these immunostains. Of course, immunostains are justified for malignant neoplasms. But do not order them for benign lesions. Other Derms complain that certain Dermpaths write too many descriptive path reports or their reports are too wordy. Keep the reports simple and short (aka KISS method = Keep It Simple Stupid).

So what happens when the "clients" are unhappy? They walk away with their business and find another Dermatopathologist to read their specimens.

 

[MOHS_01]

I agree with jp123ok. Pleasing your clients is important in the business of pathology.

I'm Derm/Dermpath. I see and hear many of my Dermatologist colleagues (aka "clients") complain about certain Dermpaths. For example, some DP's order too many immunostains. Patients complain to their Dermatologists when they see the bill on these immunostains. Of course, immunostains are justified for malignant neoplasms. But do not order them for benign lesions. Other Derms complain that certain Dermpaths write too many descriptive path reports or their reports are too wordy. Keep the reports simple and short (aka KISS method = Keep It Simple Stupid).

So what happens when the "clients" are unhappy? They walk away with their business and find another Dermatopathologist to read their specimens.

I agree that there are things that you can do to run off business rather easily; I just do not see that the converse is nearly as true.

As for the immunostains -- yeah, common problem. I have one person that I send some specimens to who gets them on everything. EVERYTHING. SK's, IDN's, basal cells, you name it. That's a bunch of ****, really.

...and don't comment on the margins in a biopsy. It's not uncommon (at all) to do a shave off the end of a larger lesion and have the report come back as "peripheral and deep margins free of tumor"... only to have to go back and excise the rest of the damn thing. Then, a month later when filling out some cancer policy and waiting for our $$, we have to deal with an insurance company wanting to deny payment "because the biopsy got it all".

I just do not see it being nearly as easy to crack into a pathology market by throwing up a shingle or professing great customer care. Certain specialties truly have a harder row to hoe in this regard -- pathology, anesthesiology, radiology, radiation oncology come to mind straight away, but I'm sure others fit the bill as well. If your chosen field does not enjoy direct patient care and low barriers to entry, it is not as easy to build something.

 

[yaah]

...and don't comment on the margins in a biopsy. It's not uncommon (at all) to do a shave off the end of a larger lesion and have the report come back as "peripheral and deep margins free of tumor"... only to have to go back and excise the rest of the damn thing. Then, a month later when filling out some cancer policy and waiting for our $$, we have to deal with an insurance company wanting to deny payment "because the biopsy got it all".
.

This is REALLY dermatologist dependent. Most clinicians know that negative margins do not mean cure, but for some lesions it helps them with patients I guess to have the report say that. Our dermpaths are requested to comment on the margins on everything they see, benign lesions included, by some dermatologists. The key is to know what your clients want.

Immunos can be similar actually, some clinicians and especially patients want to see more immunos performed for some reason I guess because it means you took the case seriously or something. In residency I remember getting a very angry fax (yes, a fax) from a patient on which we diagnosed a recurrent sarcoma without any stains, and he was irate because we didn't do any special stains. We didn't spend as much time and care on his specimen as the previous pathologist, so his reasoning went. Some clinicians you can talk out of their requests for extra immunos that aren't needed, but there will always be some sticklers who will take their business elsewhere because you didn't do "extra work."

 

[2121115]

This is REALLY dermatologist dependent. Most clinicians know that negative margins do not mean cure, but for some lesions it helps them with patients I guess to have the report say that. Our dermpaths are requested to comment on the margins on everything they see, benign lesions included, by some dermatologists. The key is to know what your clients want.

Immunos can be similar actually, some clinicians and especially patients want to see more immunos performed for some reason I guess because it means you took the case seriously or something. In residency I remember getting a very angry fax (yes, a fax) from a patient on which we diagnosed a recurrent sarcoma without any stains, and he was irate because we didn't do any special stains. We didn't spend as much time and care on his specimen as the previous pathologist, so his reasoning went. Some clinicians you can talk out of their requests for extra immunos that aren't needed, but there will always be some sticklers who will take their business elsewhere because you didn't do "extra work."

We once almost lost an account because another pathology group told a clinician group that we "were not thorough enough" (IOW didn't order enough immunos).

 

[MOHS_01]

This is REALLY dermatologist dependent. Most clinicians know that negative margins do not mean cure, but for some lesions it helps them with patients I guess to have the report say that. Our dermpaths are requested to comment on the margins on everything they see, benign lesions included, by some dermatologists. The key is to know what your clients want.

Immunos can be similar actually, some clinicians and especially patients want to see more immunos performed for some reason I guess because it means you took the case seriously or something. In residency I remember getting a very angry fax (yes, a fax) from a patient on which we diagnosed a recurrent sarcoma without any stains, and he was irate because we didn't do any special stains. We didn't spend as much time and care on his specimen as the previous pathologist, so his reasoning went. Some clinicians you can talk out of their requests for extra immunos that aren't needed, but there will always be some sticklers who will take their business elsewhere because you didn't do "extra work."

We once almost lost an account because another pathology group told a clinician group that we "were not thorough enough" (IOW didn't order enough immunos).

Huh. I'm at a loss for words. That's ****ed up...

well, you know what they say -- bad medicine pays way better than good medicine. Stain away, boys...

 

[porokeratosis]

We once almost lost an account because another pathology group told a clinician group that we "were not thorough enough" (IOW didn't order enough immunos).

I do not think this statement pertains to the field of dermatology. I've worked and trained in the East coast, West coast, and the South. From my experience as a dermatologist and dermatopathologist, most derms do not want too many immunostains b/c patients see the bill and complain about the increase price hike from the immunostains. Derms dislike complaining patients. And $hi+ goes downhill from the Dermatologist client to the Dermatopathologist.

Immunos are only sometimes helpful in Derm with borderline melanocytic lesions, spindle cell tumors, soft tissue tumors (such as sarcomas), and other difficult malignant tumors. Any good dermatopathologist can diagnose the bread and butter stuff (such as BCC, SCC, AK, benign nevus, obvious melanoma, lentigo, wart, SK, neurofibroma) without immunostains.

 

[Tissue issue]

Porokeratosis- Totally off topic but I was wondering about your avatar- what is that little pink thing in front of the guy with the large mouth?

 

[jp123ok]

I do not think this statement pertains to the field of dermatology. I've worked and trained in the East coast, West coast, and the South. From my experience as a dermatologist and dermatopathologist, most derms do not want too many immunostains b/c patients see the bill and complain about the increase price hike from the immunostains. Derms dislike complaining patients. And $hi+ goes downhill from the Dermatologist client to the Dermatopathologist.

Immunos are only sometimes helpful in Derm with borderline melanocytic lesions, spindle cell tumors, soft tissue tumors (such as sarcomas), and other difficult malignant tumors. Any good dermatopathologist can diagnose the bread and butter stuff (such as BCC, SCC, AK, benign nevus, obvious melanoma, lentigo, wart, SK, neurofibroma) without immunostains.

Hi Porokeratosis, nice to see you back on SDN. You bring up an interesting point with regard to the issue of excessive immunos.

Do the larger dermpath groups eg Dermpath Diagnostics, Miraca, etc tend to overdo immunos as a way to recoup money that they might be losing in other areas?

 

[porokeratosis]

Hi Porokeratosis, nice to see you back on SDN. You bring up an interesting point with regard to the issue of excessive immunos.

Do the larger dermpath groups eg Dermpath Diagnostics, Miraca, etc tend to overdo immunos as a way to recoup money that they might be losing in other areas?

It seems certain Derm/Dermpath Icons order less immunostains. Some of these experts work with Dermpath Diagnostics, Miraca, Quest, Labcorp, etc. I know for sure this pertains to the following: Cockerell, Rapini, Golitz, and Thomas Horn. I've also heard this is true for Elston, Farmer, Hood, and Sanchez at UTMB. I think most of them grew up in an age before immunos were big. So they trust the morphology and clinical info more than most younger people, and will orders immunos only on select cases. The person that trained me definitely thinks this way and tries his best not to order immunostains. As you may know, sometimes immunostains can actually make the case more confusing.

There is also 1 soft tissue expert that is selective on his immunos. Dr. Ayala, Professor at Methodist (and retired professor at MD Anderson).

 

[2121115]

Routine dermpath is a different animal than hospital based complex cancer cases. I doubt anyone would need immunos to do most of routine dermpath; in fact, you don't even need much dermpath training to do most of routine dermpath. Few would argue over whether or not ordering cytokeratins on a basal cell of the skin would be warranted.

The grey area comes in complex surgical pathology cancer cases and hemepath, where ordering at least some immunos is normal, and the line between what is necessary or "thorough" and what is not is less clear. I have seen good pathologists get sued for relying too much on history and not thinking there could be a second primary malignancy (when working up a metastasis) or a case that doesn't fit the mold in some other way. By contrast, there are practices who abuse the freedom to order immunos.

 

[icpshootyz]

I have personally worked with someone that made up for lost volume by adding more special stains and immunos. Kinda made me sick. However, I think most reasonable people order immunos when they need them, not when they want money. There was a private group I had some dealings with in Florida that ordered immunos on anything with melanocytes - S100, MART-1, HMB-45, MITF, and even pan-cytokeratin (for "neg control" was his argument). 5 immunos on all things melanocytic. Guy was a complete scam artist, a derm/dermpath with his own lab and several clinical offices. Makes the rest of us look terrible.

As for margins, I've seen in both ways. I have some clients that want margins on absolutely everything, benign or malignant, biopsy or excisions. I have others that only want margins on malignant, biopsy or excision. And still others that only want margins on excisions. It's a royal pain to keep track of each nitpicky client, really. Derm as a field should come up with standard recommendations.

 

[caw13]

Hi Porokeratosis, nice to see you back on SDN. You bring up an interesting point with regard to the issue of excessive immunos.

Do the larger dermpath groups eg Dermpath Diagnostics, Miraca, etc tend to overdo immunos as a way to recoup money that they might be losing in other areas?

I have practiced outpatient dermpath for 10 years, 2.5 in private practice and the rest in corporate labs, including labs you mentioned above. The only time I was encouraged to order more immunos was in the private lab setting. The owner of the group, a derm/dermpath, ordered S100 and MelanA on every dysplastic nevus. I signed out about 80% of cases between us and he ordered about 80% of the ihc. It was one of the most unethical things I have ever seen in medicine and one of the reasons I left his group.

Don't get me wrong, there is plenty wrong with the corporate labs as well, it is just encouraging extra stains to pad the bill is not one of them in my experience.

 

[Pathwrath]

Triage client demands based on return.

Prioritize all reasonable demands across the board. There is no excuse for neglecting these and you will only lose business.

As for extraordinary requests, first satisfy those clients where special service will make a difference. I'm thinking of clients who bring in a lot of revenue, may bring in a lot of revenue, or (less likely) may be made more loyal by going the extra mile. Then service the remaining clients who are are basically reasonable.

If time and workforce allows, consider the demands of the unreasonable remainder. If you have to fail to satisfy a client, always make it the one who is unprofitable and dissatisfied by nature. This sounds elementary, but you would be surprised how much time and effort is wasted on diminshing returns. Know your clients.