Pathology Job Search 2011-2012

[sirenomelia]

It is astounding how little people training in pathology know about the nuts and bolts about medicine as a business. Private practice does not receive greater reimbursement. Medicare pays the same for a given cpt code to a university as it does to a small private practice group.

People, academic salaries are not lower because of how revenue is generated. In fact academic pathology departments certainly generate far greater revenue per a similar case as a small private group because academic/training pathologists tend to order far more tests on a given case. For example we ordered cytogentics on every single soft tissue tumor even if it was obviously a lipoma. Out of the 100 or so cases I saw I can ony remember onE timewhere the pathologist said, "let's wait until the cytogentics comes back before signing this out." and for that case I think we ordered the specific fish probe for the translocation anyway. So with the other 99 cases the cytogenetic work-up didn't do anything except generate revenue for the department.

Obamacare will crush or not crush private practice revenue no more or no less than academic revenue

Thats ridiculous and abusive. Its frank asshatness of this sort that is such an underestimated anchor thats tanking our healthcare system economically.

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[rollwithit]

Yep. No better than your mechanic taking your for a ride by replacing parts that don't need replacing. It's simply taking advantage of people's ignorance of a subject matter for easy profit.

 

[Path or bust]

Thats ridiculous and abusive. Its frank asshatness of this sort that is such an underestimated anchor thats tanking our healthcare system economically.

Depends on the site, if its retroperitoneum we could be talking about liposarcoma, lipoma like subtype.

But I do agree with you, there is alot of abuse. I saw 30 immunos on a case the other day, they had no idea what they were doing. They basically ordered every immuno in the book.

 

[pathstudent]

Yep. No better than your mechanic taking your for a ride by replacing parts that don't need replacing. It's simply taking advantage of people's ignorance of a subject matter for easy profit.

I disagree. A lot of residents prepared USCAP posters based on the results of the cytogenetics eventhough they did not add an iota to the patient's diagnosis, prognosis or therapy.

My only issue is that it seemed like it was on the slippery slope of having insurance pay for research rather than patient care. But it is a drop in the bucket compared to overall healthcare spending.

 

[KCShaw]

Well, it's a bunch of drops in the bucket which ultimately overflows it, then the hose gets turned down about 25% or taken out of our hands and given to someone else. IMO it's that kind of thing which has healthcare in such a financial rot; my over-ordering is just an unnoticed drop in the bucket, and besides I'm just covering my butt.

But I mean, really.. USCAP posters? That's not a "slippery slope", that's frank abuse of the system -- if the only reason that data exists is for some academic project, has no role in the care of that patient, and insurance/medicare is paying (ostensibly solely for that patient's care). Not saying that's an unusual problem in academics, or that most departments don't have an excuse ready at hand, but I don't think we should get caught up in minimizing it by calling it a grey area or a slippery slope.

 

[sirenomelia]

I disagree. A lot of residents prepared USCAP posters based on the results of the cytogenetics eventhough they did not add an iota to the patient's diagnosis, prognosis or therapy.

My only issue is that it seemed like it was on the slippery slope of having insurance pay for research rather than patient care. But it is a drop in the bucket compared to overall healthcare spending.

Its not cost effective or beneficial to patient care to blanket triage all cases the same. If you cant recognize 99% of lipomas at the gross bench than just quit. If there is a suspicious history or some compelling gross features than you can direct a specimen accordingly. Ive never used CG to dx/work-up a liposarc anyway. If you're FISHing obvious lipomas for the purpose of academic alchemy (turning useless crap information into plane tickets for a trip/poster/pub with clinically uesless data to clutter the literature to artifactually pad your CV) than don't bilk patients/ insurers for it. Its bad enough I regularly get heparin tubes of peripheral bloood to run flow on perfectly healthy people to rule out lymphoma because their white count is 10.6 with a normal diff. Pathologist are the ones who know and understand the tests and work the equipment and we most of all should be trusted with excercising judgement and restraint to use ancillary diagnostics responsibly.

 

[BrainPathology]

I disagree. A lot of residents prepared USCAP posters based on the results of the cytogenetics eventhough they did not add an iota to the patient's diagnosis, prognosis or therapy.

My only issue is that it seemed like it was on the slippery slope of having insurance pay for research rather than patient care. But it is a drop in the bucket compared to overall healthcare spending.

Maybe someone should use the data to make a poster with the title "X millions of dollars wasted with 0 diagnostic utility at our institution from 200x-200x: a report of cytogenetic abuses" or some such. Then the data would actually be used for what it's most useful for.

 

[Tissue issue]

It's been a while since anyone has posted about their job search results so I thought I would bring the topics back up. Please share your experiences and the experiences of those you know who are looking for employment for July 2012. Below is a template of information that you may consider sharing...

Estimated CV sent out:
Total interviews completed:
Remaining interviews scheduled:
Number of job offers:
Practice setting offered:
Partnership track:
Reason for job opening:
Location:
Residency Training:
Fellowship:
Board certification:
State medical license:

Thanks

Pathguy11

Pathguy 11- Just trying to get this thread back on topic. You seem to be making a genuine effort to gather some useful information.

 

[LaBelleVN]

My husband & I won't be done with our fellowship training until June 2013, but since we are geographically-restricting ourselves to be closer to family, we sent out our CVs earlier rather than later. This region of interest, however, is not where we trained. I received a few emails expressing interest in the both of us (we are not the same specialty) & we will be visiting these centers in a month. Only one of the five pathology centers is actively recruiting a pathologist. The others were not advertising, but were interested in meeting me anyway. I'm guessing they wish to expand their services.

What does a first look entail? How likely (hard to say) do first looks develop into second looks & contract signing? I would hope that by inviting me for a first look that these places will have potential openings for my desired time frame. If I find a job that is seemingly perfect, is it wise to sign a contract even before starting my 2nd fellowship?

Estimated CV sent out: 25
Total interviews scheduled: 5 first looks
Practice setting offered: 4 private, 1 academic
Location: Northeast
Residency Training: AP/CP at a university hospital
Fellowships: Surgical pathology (2010-2011), Dermatopathology (2012-2013)
Board certification: AP/CP
State medical license: PA

 

[KeratinPearls]

My husband & I won't be done with our fellowship training until June 2013, but since we are geographically-restricting ourselves to be closer to family, we sent out our CVs earlier rather than later. This region of interest, however, is not where we trained. I received a few emails expressing interest in the both of us (we are not the same specialty) & we will be visiting these centers in a month. Only one of the five pathology centers is actively recruiting a pathologist. The others were not advertising, but were interested in meeting me anyway. I'm guessing they wish to expand their services.

What does a first look entail? How likely (hard to say) do first looks develop into second looks & contract signing? I would hope that by inviting me for a first look that these places will have potential openings for my desired time frame. If I find a job that is seemingly perfect, is it wise to sign a contract even before starting my 2nd fellowship?

Estimated CV sent out: 25
Total interviews scheduled: 5 first looks
Practice setting offered: 4 private, 1 academic
Location: Northeast
Residency Training: AP/CP at a university hospital
Fellowships: Surgical pathology (2010-2011), Dermatopathology (2012-2013)
Board certification: AP/CP
State medical license: PA

I know I am not answering your question, but I was curious as to how the dermpath market is not. I heard it is getting tight?

 

[LaBelleVN]

I know I am not answering your question, but I was curious as to how the dermpath market is not. I heard it is getting tight?

A couple of the current dermpath fellows at my future fellowship institution are expressing difficulty in getting a job. However, they are also geographically restricting themselves. There was a recent post on here by a dermpath stating how terrible the market is right now. I do see ads on pathologyoutlines for dermpaths, but whether or not these are true openings...who knows. I can say that my dermpath training was a big factor in what got me these first looks.

 

[mlw03]

wow - you're starting about as early as I did, and I wasn't restricting myself.

I can't comment on what your look will entail or what it may lead to, since i'm in forensic, and our world is quite different, as is our job market. i strongly agree that your doing dermpath is a huge part of what got you those invites. that said, if your husband can also secure a job in the area you want, i see no harm in signging a contract uber-early, especially if you really are geographically restricted.

My husband & I won't be done with our fellowship training until June 2013, but since we are geographically-restricting ourselves to be closer to family, we sent out our CVs earlier rather than later. This region of interest, however, is not where we trained. I received a few emails expressing interest in the both of us (we are not the same specialty) & we will be visiting these centers in a month. Only one of the five pathology centers is actively recruiting a pathologist. The others were not advertising, but were interested in meeting me anyway. I'm guessing they wish to expand their services.

What does a first look entail? How likely (hard to say) do first looks develop into second looks & contract signing? I would hope that by inviting me for a first look that these places will have potential openings for my desired time frame. If I find a job that is seemingly perfect, is it wise to sign a contract even before starting my 2nd fellowship?

Estimated CV sent out: 25
Total interviews scheduled: 5 first looks
Practice setting offered: 4 private, 1 academic
Location: Northeast
Residency Training: AP/CP at a university hospital
Fellowships: Surgical pathology (2010-2011), Dermatopathology (2012-2013)
Board certification: AP/CP
State medical license: PA

 

[Pathguy11]

Just a quick job search summary for several of the Pathology fellows in my geographic location. Out of 11 fellows (in various specialties) that I know, 7 (including myself) have either received job offers and/or signed contracts with groups (mostly private practices and few academics). We still have a few months left before July for the rest to find jobs. Recently I heard about a new opening in my area for example so jobs can definitely still pop up. There are other fellows in my region of the state that I know are also looking for jobs but I am unaware of their current status. I will update with more details when I have them and try to get at least a few of them to share their experiences if possible.

Anyway, I would encourage the rest of the followers of this forum and thread to do the same. Find out what the fellows around you are doing and please post the information!

Pathguy11

 

[2121115]

Just a quick job search summary for several of the Pathology fellows in my geographic location. Out of 11 fellows (in various specialties) that I know, 7 (including myself) have either received job offers and/or signed contracts with groups (mostly private practices and few academics). We still have a few months left before July for the rest to find jobs. Recently I heard about a new opening in my area for example so jobs can definitely still pop up. There are other fellows in my region of the state that I know are also looking for jobs but I am unaware of their current status. I will update with more details when I have them and try to get at least a few of them to share their experiences if possible.

Anyway, I would encourage the rest of the followers of this forum and thread to do the same. Find out what the fellows around you are doing and please post the information!

Pathguy11

7 of 11? Wow, that is dismal.

Now, I'm sure someone will post saying that the other four were obviously "not good candidates" because we all know that "there are always jobs for good candidates" as we have been told over and over again.

 

[Pathguy11]

7 of 11? Wow, that is dismal.

Now, I'm sure someone will post saying that the other four were obviously "not good candidates" because we all know that "there are always jobs for good candidates" as we have been told over and over again.

I don't think dismal is the right word to use just yet. Wait a couple more months and see what the results are. Just because I provided statistics from a very small sample size, doesn't tell you anything about the 4 individuals who have not found jobs. For example, I know one who has probably made the least effort the be proactive out of the group. Two of the others have geographic restrictions and have received interviews...perhaps in another month they will have their spots secured. The last of the four I am not sure why he/she has not found anything yet.

Again, I am not trying to paint a positive or negative picture of how things are but I want it to be objective. I think we can all agree the market is not great like in some other specialties in which doctors are being recruited out of residency. At the same time, we all know the job market is "tight". The real question for me is how tight is it? Is it to the point that newly trained Pathologists can absolutely not find obs or is it that their are/will be jobs out there, though some are more desirable than others? Based on the young Pathologists I have known over the past few years (who are ALL employed by the way) the truth is closer to latter of the scenerios I mentioned.

Pathguy11

 

[cjw0918]

Out of the seven leaving us this year, three have secured jobs. Two of these three are finishing a second fellowship. One is going out of state to a desirable location for her. The remaining two with jobs found local jobs. One was at a place he has been moonlighting at for years.

All four of the remaining fellows would prefer not to move I think, but they are not beholden to staying here is my impression. One for sure is still interviewing and trying hard. Not sure how proactive the others are. For the record, they are all good candidates with pleasant personalities and no red flags. It's just rough out there.

 

[Substance]

Your job market seems pretty bad. Its probably because there are too many training programs.

I suppose someone could start a list of crappy places to train that exist as nothing more than gross tech training programs for MDs; that's like saying there are internal medicine residencies where the residents do all the nursing work. Maybe then even the FMGs will avoid them because they'll reason that the the job market and the training at these reachable programs is terrible. Maybe then, with the FMGs gone to FP or IM, they'll have to close? Who knows?

 

[KCShaw]

My suspicion is that there are enough people out there who struggle to get a residency position -anywhere- that they already gravitate to the less competitive programs in the less competitive specialties. People with no real alternatives I think will love to have a position in Hell itself if it's the only way to get board certification -> job -> adequate money/stay in U.S./whatever-end-goal. Accredited training positions just won't go totally unfilled, year in and year out, so long as there are more graduating-USMLE-passing students than residency positions -- if they did, of course, those places would stop putting in the effort for accreditation.

 

[Substance]

My suspicion is that there are enough people out there who struggle to get a residency position -anywhere- that they already gravitate to the less competitive programs in the less competitive specialties. People with no real alternatives I think will love to have a position in Hell itself if it's the only way to get board certification -> job -> adequate money/stay in U.S./whatever-end-goal. Accredited training positions just won't go totally unfilled, year in and year out, so long as there are more graduating-USMLE-passing students than residency positions -- if they did, of course, those places would stop putting in the effort for accreditation.

It's true. I guess its kind of scabby, but from the perspective of a desperate FMG I suppose getting something, no matter how garbage it is, is better than getting nothing.

Nonetheless, if there is a huge glut of pathologists as you all say, employers and groups can be a lot more critical of where people trained. Perhaps if the pathology community made a fairly well-understood list of places where the residents don't actually learn pathology, but instead learn to be gross techs, the graduates of these programs would be unable to find work, which would dissuade anyone from going to those programs in the future.

 

[gbwillner]

I guess I will chime in for my group of fellows:
Overall, everyone who looked for a job got one. Many fellows were completing the first of multiple fellowships, so I can't count that against them.

surgpath fellows: 1- hemepath fellowship, 1-GI fellowship, 1- molecular fellowship, 1- Academics, 2- private practice

Hemepath fellows: 1- Molecular fellowship, 1- dermpath fellowship

Molecular fellows: 1- private practice, 1- academics

dermpath: private practice

1 cyto fellow: private practice

There are a few others I don't know where they are going...

 

[Substance]

What's the deal with a "surg path" fellowship? It just sounds like an extra year of residency to me..not very valuable. Am I right?

 

[KluverB]

What's the deal with a "surg path" fellowship? It just sounds like an extra year of residency to me..not very valuable. Am I right?

Perhaps it is just like an extra year of residency. However, if you're going into a general practice setting, it's perfect. Got me my ideal position. That isn't to say I wouldn't have gotten here some other way, perhaps. But, at least this way, I was ready to sign out everything that came my way on day one, and didn't have to pull stuff out of my *ss having been 1-2 years out of gen surg path, like some of my colleagues, which I'm sure was taken into consideration when I was being hired. Besides, I have my sub-speciality interests, which I cultivated during the fellowship, and continue to now; and despite being fresh out of fellowship, other pathologists (including senior paths) consult me on their cases in these areas, not to mention clinicians to whom I present some of these cases at tumor boards.

YMMV. Overall, I'm glad I didn't waste my time doing any other fellowships (did AP/CP + surg path fellowship only). For example, I had strongly considered doing derm or heme, for all the reasons that most people do derm or heme. In the end, I didn't. Maybe half of the cases I sign out on a daily basis are derms. No special training required for the vast majority of these. I get the odd hematolymphoid case, which I work up just fine myself, before sending it off for confirmation to our heme folks, who spend another 1-2 wks mulling over the case before agreeing with my diagnosis. Granted, the latter cases have been rather straight forward, for the most part, so far. So, how do you put a value on that?

 

[BU Pathology]

I guess I will chime in for my group of fellows:
Overall, everyone who looked for a job got one. Many fellows were completing the first of multiple fellowships, so I can't count that against them.

surgpath fellows: 1- hemepath fellowship, 1-GI fellowship, 1- molecular fellowship, 1- Academics, 2- private practice

Hemepath fellows: 1- Molecular fellowship, 1- dermpath fellowship

Molecular fellows: 1- private practice, 1- academics

dermpath: private practice

1 cyto fellow: private practice

There are a few others I don't know where they are going...

Just to be clear, everyone has a job or fellowship?

 

[gbwillner]

Just to be clear, everyone has a job or fellowship?

yes

 

[mlw03]

so 4 of 12 are doing additional fellowship training and how many of the other 8 were one their second or more fellowship? i'm bothered by the fact that in most specialties, if you do residency you're actually able to go out, get a job, and function in that job. but that doesn't seem to be at all the case for pathology.

if 4 years of AP/CP training is really inadequate, why not let the training requirement reflect that? and if that were to happen, i wonder if my subspecialty (forensic) would then become its own residency, since (and kc, chime in if you disagree) we'd probably be better served by a 4 year program of FP, NP, and a bit of AP, rather than 4 years of AP/CP, 95% of which has 0 relevance to the practice of forensic path day to day.

I guess I will chime in for my group of fellows:
Overall, everyone who looked for a job got one. Many fellows were completing the first of multiple fellowships, so I can't count that against them.

surgpath fellows: 1- hemepath fellowship, 1-GI fellowship, 1- molecular fellowship, 1- Academics, 2- private practice

Hemepath fellows: 1- Molecular fellowship, 1- dermpath fellowship

Molecular fellows: 1- private practice, 1- academics

dermpath: private practice

1 cyto fellow: private practice

There are a few others I don't know where they are going...

 

[Substance]

Just to be clear, everyone has a job or fellowship?

I don't see why fellowships are considered equal to jobs here. I mean, they are somwhere to go next, but they are not in my opinion a good outcome.

The only reason someone should do a fellowship after residency is because they are interested in the subject matter and want to make it their primary field of interest/research. Like if you want to do nothing but derm all day, do dermpath.

Doing a fellowship just because you didn't find a job speaks very poorly for your job market.

 

[mlw03]

I don't see why fellowships are considered equal to jobs here. I mean, they are somwhere to go next, but they are not in my opinion a good outcome.

The only reason someone should do a fellowship after residency is because they are interested in the subject matter and want to make it their primary field of interest/research. Like if you want to do nothing but derm all day, do dermpath.

Doing a fellowship just because you didn't find a job speaks very poorly for your job market.

It also speaks to the fact that general pathology training does not prepare one to be a general community pathologist. See my above post.

 

[Substance]

It also speaks to the fact that general pathology training does not prepare one to be a general community pathologist. See my above post.

You're right. This is why I think the pathology community should have a pretty long list of crap ass programs that are just awful for training. I started a thread to do just that.

 

[Thrombus]

How many medicine doctors do both GI AND Cardiology fellowships? LOL
How many are relegated to being someone's serf for a career and can't go out and make it on their own, earning the fruits of the own labor????

The market is TERRIBLE and getting worse. Each year new job-seekers compete against the increasing unemployed and underemployed. And people still try to put lipstick on the pig.



20 years of busting our behind, acrruing debt, zero savings, and years off our life, after being at the top of the class only to get paid 50K in someone's "fellowship".....FAIL!

 

[Thrombus]

It also speaks to the fact that general pathology training does not prepare one to be a general community pathologist. See my above post.

WRONG! Maybe in your program but certainly not in mine. I still had to go do a fellowship to get any kind of decent job. thumbdown

 

[mlw03]

WRONG! Maybe in your program but certainly not in mine. I still had to go do a fellowship to get any kind of decent job. thumbdown

So you did a fellowship for poops and giggles? You like working for only 50K/year when you could be making 3 times that (if you can find a job that is)?

Your statement supports my contention. If employers will not (or virtually won't) hire anyone right out of residency (regardless of where they train), then that proves the market does not believe 4 years of general pathology training is adequate to practice general pathology in the community. The fact that you feel you can do it means nothing.

 

[KCShaw]

I think the fellowship trend speaks more to the expectations of employers and the job market than it does to the ability of someone just finishing AP to handle the job, even taking into account the general failure of most residencies to push their final year residents out "on their own" better. That lack of experience may not bode well for their confidence, but on average probably doesn't affect their competence that much. Everyone -still- has to learn to sign out totally on their own that first few months or year out, even after half a dozen fellowships -- and, IMO, it's probably easier to transition into the real world if you -haven't- had someone looking over your shoulder, closely or at a short distance, for every single case for >5 years.

At the moment (subject to change, and my views have changed on this more than once, so..), my feeling is that there really should be no AP/CP distinction at the "specialty" level. Sure, rotate through both anatomic and clinical labs during training, but as the bulk of pathologists do primarily anatomic path, that would be the primary training focus of a board certified general "pathologist". This could probably be done in 3 years, or stick with 4 for more flexibility. For those who want to subspecialize, they would do CP or one of the existing subspecialties as a fellowship.

For mlw, as far as FP goes I don't see any reason it couldn't be done in a 3 or 4 year track -- 1 net of just FP, at least 1.5 of typical AP though with more of a cardiac & NP focus than traditional residencies (but at least -some- exposure to everything), and at least 0.5 of CP. While in retrospect I don't think FP's need to get CP boarded (a perspective which has also admittedly changed in the last few years), I do think some background in it is very, very important -- more than I think one gets in a typical FP fellowship.

While the FP track already exists, it's rarely advertised or utilized. But I certainly don't expect CP to vanish as a separate general certification anytime soon -- frankly, employers already have enough difficulty letting non-CP pathologists handle CP duties, even though they'll happily let non-pathologists or non-MD's do it, and that's just a difficult culture to address. And I doubt anyone with the power to change it has much interest in seriously considering doing so...probably the opposite. And really, there are probably bigger things to worry about. But, eh, it was asked, so there you have it.

 

[Thrombus]

So you did a fellowship for poops and giggles? You like working for only 50K/year when you could be making 3 times that (if you can find a job that is)?

Your statement supports my contention. If employers will not (or virtually won't) hire anyone right out of residency (regardless of where they train), then that proves the market does not believe 4 years of general pathology training is adequate to practice general pathology in the community. The fact that you feel you can do it means nothing.

No the employers are overloaded with applicants who have 1-3 fellowships. That gives them a marketing angle as they fight with other pathologists over specimens. You must not be in the workforce yet and/or sheltered in some academic ivory tower. There is no reason to hire a compentent resident. NONE. Groups needs GI this, GU that, Derm this to try to hold and acquire specimens so other labs don't get them. It is a fight to the bottom!!!!

 

[mlw03]

No the employers are overloaded with applicants who have 1-3 fellowships. That gives them a marketing angle as they fight with other pathologists over specimens. You must not be in the workforce yet and/or sheltered in some academic ivory tower. There is no reason to hire a compentent resident. NONE. Groups needs GI this, GU that, Derm this to try to hold and acquire specimens so other labs don't get them. It is a fight to the bottom!!!!

I'm in FP, and seeing these threads/discussions makes me very glad of my decision. May not make as much money as some of ya'll, but pretty good job market. You say there's no reason to hire a competent resident, but I would disagree with your assumption and say there are no residents competent enough (at least in the view of the market, which is all that matters). General pediatricians do not have issues with groups doubting their competency and saying, "we want you to do an adolescent fellowship before joining our general outpatient peds group." But pathologists do such things! So I repeat my question: why have a 4 year residency when such a residency leaves trainees unable to enter the job market?

 

[Thrombus]

I'm in FP, and seeing these threads/discussions makes me very glad of my decision. May not make as much money as some of ya'll, but pretty good job market. You say there's no reason to hire a competent resident, but I would disagree with your assumption and say there are no residents competent enough (at least in the view of the market, which is all that matters). General pediatricians do not have issues with groups doubting their competency and saying, "we want you to do an adolescent fellowship before joining our general outpatient peds group." But pathologists do such things! So I repeat my question: why have a 4 year residency when such a residency leaves trainees unable to enter the job market?

You are wrong, there are many competent residents. If you don't think it can be done, then you must be from a poor program and have limited exposure to other people and their talents. I suggest not being so presumptious. You made a good career choice if you enjoy the profession. Best of luck.

 

[Pathguy11]

I don't see why fellowships are considered equal to jobs here. I mean, they are somwhere to go next, but they are not in my opinion a good outcome.

The only reason someone should do a fellowship after residency is because they are interested in the subject matter and want to make it their primary field of interest/research. Like if you want to do nothing but derm all day, do dermpath.

Doing a fellowship just because you didn't find a job speaks very poorly for your job market.

You are making a few assumptions in your statements that are not true for the vast majority of people in fellowships, including myself. Most of us are NOT are doing fellowship because we could not find a job. In fact, I had my two fellowships lined up before my 4th year. there are a combination of reasons that people are doing fellowship and I think that the inability to find a job is still a minority. I did my two fellowship for a variety of reasons...

Surgical Pathology: I wanted more continuous scope time and more exposure to frozens sections with a more experienced Pathologist before it is my ***** on the line. I also felt that it would serve me well as a general Pathologist. for me the extra year was a good choice as it was more like a junior attending experience than extension of residency

Cytopathology: I like cyto and know others detest it. I wanted to be more competent and comfortable with making a diagnosis with less material. I chose a fellowship with strength in their volume, reputation and non-gyn cases. Again this will be useful in my future job.

So my point is you can not look at doing "another fellowship" as a direct indicator of the ability to find a job.

Pathguy11

 

[mlw03]

You are wrong, there are many competent residents. If you don't think it can be done, then you must be from a poor program and have limited exposure to other people and their talents. I suggest not being so presumptious. You made a good career choice if you enjoy the profession. Best of luck.

I know I received good residency training, as did my colleagues. But we'll have to agree to disagree because you're not convincing me or vice versa. I never said there were not competent residents. I said that employers seem unwilling to hire anyone right out of residency (a statement of fact), probably because they don't feel such employees would be competent enough to do the job (a statement of presumption). Determining whether my presumption is accurate or not would require a broad survey of potential employers of general diagnostic pathologists. Fortunately for me, this is an academic issue and I think we can agree that the real pain is felt by those who are competent after many years of good training and still cannot find a good job.

 

[Pathguy11]

so 4 of 12 are doing additional fellowship training and how many of the other 8 were one their second or more fellowship? i'm bothered by the fact that in most specialties, if you do residency you're actually able to go out, get a job, and function in that job. but that doesn't seem to be at all the case for pathology.

if 4 years of AP/CP training is really inadequate, why not let the training requirement reflect that? and if that were to happen, i wonder if my subspecialty (forensic) would then become its own residency, since (and kc, chime in if you disagree) we'd probably be better served by a 4 year program of FP, NP, and a bit of AP, rather than 4 years of AP/CP, 95% of which has 0 relevance to the practice of forensic path day to day.

Well this has been the reality since AP/CP Pathology training was decreased from 5 years to 4 years. If you think about it, this was the start of the "fellowship era", not to mention they never corrected the number for the number of training spots after this change which is another conversation all together. Anyway, employers know that the time demand during training is now divided with an even greater amount of CP "stuff" than when most practicing Pathologists trained. This CP stuff basically takes you away from the continuous focus on Anatomica Pathology which is for many/most Pathologists the most important aspect of practice. I think you need more continuous scope time to really get comfortable, not just 2 months here, 1 month there, etc.

So I think you are correct that 4 years is NOT enough for AP/CP Pathology training and I think the current "requirement" for residents to do at least one fellowship supports this idea. Part of it could also be the domino effect... ie you are told as a first year resident that you have to do at least one if not two fellowships to get a job. So from day one of training we are hearing this and thus starting to look for fellowship early on without real consideration for the job market fresh out of training. This also creates a problem for those who do wish to go into practice right our of training, not to say it doesn't still happen, but in general given two otherwise equal candidates for a job, the one with a fellowship is technically more experienced. So now that the freight train of fellowships has left the station, I don't see it stopping any time soon unless there is some mysterious mass extinction of Pathologist 55 yrs and old that leads to recruitment for jobs while we are still in residency. Just my opinion and partdon my grammer (no time to spell check)

Pathguy11

 

[KluverB]

...You say there's no reason to hire a competent resident, but I would disagree with your assumption and say there are no residents competent enough (at least in the view of the market, which is all that matters). General pediatricians do not have issues with groups doubting their competency and saying, "we want you to do an adolescent fellowship before joining our general outpatient peds group." But pathologists do such things! So I repeat my question: why have a 4 year residency when such a residency leaves trainees unable to enter the job market?

Well, that's the crux of it, isn't it. The fact is that a gen ped after a 3 yr residency is competent enough to handle most run of the mill cases, and anything "weird" he/she would consult out to a specialist. Guidelines and drugs change, but fairly incrementally. Lab medicine, on the other hand, with all the ancillary, molecular, IHC, etc testing has exploded tremendously over the last few decades. Pathologists are asked to give much more details in their reports, etc. I would argue that a sub-specialized pediatrician, or cardiologist, or oncologist, etc, still needs to know the basics, plus be adept at their area of expertise. An uber-specialized pathologist does not. A renal pathologist doesn't need to look at peripheral blood smears. A neuropathologist couldn't care less about skin. Etc. So, in fact, a general pathologist, ie. someone competent enough to handle all manner of frozen section and all manner of general AP, cyto, etc, that comes across their desk, needs to be competent in a lot more areas than a sub-specialist pathologist, or a generalist clinician, if we're trying to compare ourselves to other specialities.

Unfortunately, 3 years of AP only or 4 years of AP/CP, especially now with all the ACGME mandated limits on service time, etc., may not prepare one to adequately function as an independent pathologist. Maybe path residency should be extended by a year or two (it is longer in other countries). I'm sure that no one is going to propose that anytime soon, just as no one is willing to cut the number of residency spots. So, yes, we are likely at an impasse, and what's required is a crisis, perhaps in the form of mass unemployment for people to finally wake up and smell the formalin.

Again, I'll go back to an argument I've made on another thread in a time far far away... I find there are way more residents/fellows who think themselves way more competent than they actually are. There is also the converse, ie. residents who are competent but lack self-confidence; but I doubt they're the ones on here complaining about how they haven't been handed their perfect job just because they've put in their hours. I'm almost ready to side with Rush and declare that the sense of entitlement among the noobs is just staggering.

 

[Pathguy11]

I'm in FP, and seeing these threads/discussions makes me very glad of my decision. May not make as much money as some of ya'll, but pretty good job market. You say there's no reason to hire a competent resident, but I would disagree with your assumption and say there are no residents competent enough (at least in the view of the market, which is all that matters). General pediatricians do not have issues with groups doubting their competency and saying, "we want you to do an adolescent fellowship before joining our general outpatient peds group." But pathologists do such things! So I repeat my question: why have a 4 year residency when such a residency leaves trainees unable to enter the job market?

Unfortunately you are comparing apples to oranges and don't have a solid grasp of Pathology training. Most clinical training programs like family medicine or OB/GYN (which my wife is) get a TON more "real life" practice experience that any Pathology resident. Why is this? Liability!!

As a family medicine resident you are rounding on your patients, running your clinic, prescribing meds, etc. Your overseeing faculty probably take different role depending on your experience level but for the most part you are making the decions like you would in practice. Surgerical specialties take it a step further because at some point in training you are the one doing the procedure (at least as an upper level).

Pathology training is different. Because of liability reasons, most Pathology resident and even fellows will never make the actual frozen section diagnosis and call without a faculty supervision until they are actually practicing. I think effected graduated responsibility is more difficult to pull off for Pathology in these medical-legal world we live in now. My faculty frequently tell me that when they were training they were the one who would make the initial frozen section diagnosis by themselves and call the surgeon with the report. Now sure there are probably some Pathology residents of fellows who will say that in their program they are allowed to do some of this things. But I will say again that it is much harder to find quality graduated responsibility in Pathology and I have done my share of speaking to residents from across the country at meetings. I used frozen sections as just one example, but this theme is true to different degrees in other areas of our training. Just my opinion.

Pathguy11

 

[Tiki]

Pathology training is different. Because of liability reasons, most Pathology resident and even fellows will never make the actual frozen section diagnosis and call without a faculty supervision until they are actually practicing. I think effected graduated responsibility is more difficult to pull off for Pathology in these medical-legal world we live in now. My faculty frequently tell me that when they were training they were the one who would make the initial frozen section diagnosis by themselves and call the surgeon with the report. Now sure there are probably some Pathology residents of fellows who will say that in their program they are allowed to do some of this things. But I will say again that it is much harder to find quality graduated responsibility in Pathology and I have done my share of speaking to residents from across the country at meetings. I used frozen sections as just one example, but this theme is true to different degrees in other areas of our training. Just my opinion.

Pathguy11

It can be done though. I am at one of the few (maybe even the only) program where fourth year residents take surg path frozen call (in the evenings and weekends) without the attending. Attendings are on call as backup, so if it is something difficult that I need help with, I could call them in, but we are the ones making the diagnosis. Just last week I had a 2 am "is it signet ring or fat necrosis" frozen that I had to make the diagnosis on with just myself and and a lower year resident. My program can do this because we don't bill for the frozens when the residents cover them. It is great experience, and I am super thankful for it.

I'm not sure why more programs don't do this, unless they don't trust their residents.

 

[KluverB]

...My program can do this because we don't bill for the frozens when the residents cover them.

^^^^
This....

... I'm not sure why more programs don't do this, unless they don't trust their residents.

^^^^
....and this

 

[Pathguy11]

It can be done though. I am at one of the few (maybe even the only) program where fourth year residents take surg path frozen call (in the evenings and weekends) without the attending. Attendings are on call as backup, so if it is something difficult that I need help with, I could call them in, but we are the ones making the diagnosis. Just last week I had a 2 am "is it signet ring or fat necrosis" frozen that I had to make the diagnosis on with just myself and and a lower year resident. My program can do this because we don't bill for the frozens when the residents cover them. It is great experience, and I am super thankful for it.

I'm not sure why more programs don't do this, unless they don't trust their residents.

Again,I hate to say it but your experience is more the exception than the rule. I even put a comment in my previous statement that I do know of a few programs who have setups similar to this because I knew one person would chime in that their program allows it. So that;s great for you and your fellow residents but it does not reflect mot programs. After 3 years involved with the residents forum, I have heard residents from around the country say the same thing about the LACK of true graduated responsibility and wishing they had more.

And to assume that other programs don't allow it because they don't trust their residents... Seriously?? Bottomline is most academic centers where we are trained would not allow this because of the liability involved. There is a real threat that clinicians will begin treatment or withhold treatment based on our "preliminary diagnosis". And when even the most competent resident is wrong in this situation there are potential legal consequences. If you are at a center where the clinicians really understand the concept of a preliminary resident provided diagnosis and you are allowed to make these calls then that's great. But bottom line for most training programs is that having a resident make a frozen section diagnosis without a faculty simply becomes a liability issue and do not happen. There are many training programs that try to maximize our experiences and simulate what it will be like when we are practicing, but realistically for many of us the first real frozen section solo diagnosis is during the first day of our jobs.

Also, though that is very progressive of your program, making a handful of frozen calls on the weekends is hardly the same as the type of "real life" experience in other medical specialty training programs.

Pathguy11

 

[yaah]

so 4 of 12 are doing additional fellowship training and how many of the other 8 were one their second or more fellowship? i'm bothered by the fact that in most specialties, if you do residency you're actually able to go out, get a job, and function in that job. but that doesn't seem to be at all the case for pathology.

if 4 years of AP/CP training is really inadequate, why not let the training requirement reflect that? and if that were to happen, i wonder if my subspecialty (forensic) would then become its own residency, since (and kc, chime in if you disagree) we'd probably be better served by a 4 year program of FP, NP, and a bit of AP, rather than 4 years of AP/CP, 95% of which has 0 relevance to the practice of forensic path day to day.

I think it's hard because there are so many different types of pathologist - I would wager these days that most pathologists coming out of training have some sort of subspecialty focus, even if they also do general stuff. And most pathologists do not do everything they cover in training. Residency training is a bit of a vestige of the past where pathologists had to be generalists. So part of the problem is the history, part is the current practice environment. For AP only or CP only people these problems are minimized. Ideally someone would go through residency and train primarily in the way they are going to practice, making sure they cover all relevant areas. But it isn't realistic because there are so many different job types. So we are stuck with the 4 years + 1-2 fellowships. Pathology is hard. There is way too much information to be competent in everything. So you have to focus somewhat.

I personally think forensics is different, it might be a good idea to have a FP-type residency where you get enough exposure to CP and AP stuff that is relevant to you, but you don't have to get all the other training that isn't necessary to you. But for other types of pathologists that is much harder. Dermpath is the closest, but many dermpaths work in AP/CP groups and cover CP and general AP.

 

[Tiki]

And to assume that other programs don't allow it because they don't trust their residents... Seriously?? Bottomline is most academic centers where we are trained would not allow this because of the liability involved. There is a real threat that clinicians will begin treatment or withhold treatment based on our "preliminary diagnosis".

Sounds like your clinicians doesn't know the meaning of a frozen section then. The only treatment we change is intraoperative management (examples: "are margins positive, do I need to take more?", "does that lymph node have lung cancer, so I don't need to do a lobectomy", "does that endometrium have invasion more than 50%, so I go back and get nodes", "is that adhesed bowel due to signet ring, should I take the bowel out?," does that liver nodule have metastatic disease, so I don't procede with a whipple") , which is what frozen sections are intended for. (I am not saying that these calls aren't a a big deal, because they obviously can have a huge impact on patient care, but we are trained well the first three years to make these calls. And when we need help, we can always call the attending in for help).

Sure, I've gotten a small round blue cell tumor in the pelvis of a 17 year old, but our clinicians are smart enough to know that isn't a diagnosis I can be definitive on frozen; that the workup is going to need IHC and that they can't start treating.

And when even the most competent resident is wrong in this situation there are potential legal consequences.

My program has been doing this for a very long time, and as far as I know, none of the residents have screwed anything up as to where lawyers would be involved.

There are many training programs that try to maximize our experiences and simulate what it will be like when we are practicing, but realistically for many of us the first real frozen section solo diagnosis is during the first day of our jobs.

Also, though that is very progressive of your program, making a handful of frozen calls on the weekends is hardly the same as the type of "real life" experience in other medical specialty training programs.

I think that is sad that people don't get that experience. Both my residency and fellowship allow me to make frozen section diagnoses without the attending, and I am very thankful for it. Before I start my fellowship in July, I'll have read over 50 frozens on my own. No, it isn't as much responsibility as a third year internal medicine resident has, but at least it is something. After covering frozens on my own for four months during fellowship, I'll have a whole lot more experience before I start my first job. It will certainly make the transition a little bit less stressful.

 

[Gene_]

Of the 10 fellows looking for jobs that I know about, all but one have found jobs. The one that didn't had a reasonably good offer, but turned it down for personal reasons. I only know of one resident that found a job without doing a fellowship, and that was 6 years ago.

 

[pathstudent]

Allowing residents to read frozen sections is a terrible policy and not just because it would be illegal to bill for it, but because it is horrible pTient care. I would never allow a loved one to have surgery at a hospital if a trainee was doing
the frozen and trust me that no surgeons or pathologists at that hospital would let a resident do a frozen on one of their loves ones.

 

[Pathguy11]

Sounds like your clinicians doesn't know the meaning of a frozen section then. The only treatment we change is intraoperative management (examples: "are margins positive, do I need to take more?", "does that lymph node have lung cancer, so I don't need to do a lobectomy", "does that endometrium have invasion more than 50%, so I go back and get nodes", "is that adhesed bowel due to signet ring, should I take the bowel out?," does that liver nodule have metastatic disease, so I don't procede with a whipple") , which is what frozen sections are intended for. (I am not saying that these calls aren't a a big deal, because they obviously can have a huge impact on patient care, but we are trained well the first three years to make these calls. And when we need help, we can always call the attending in for help).

Sure, I've gotten a small round blue cell tumor in the pelvis of a 17 year old, but our clinicians are smart enough to know that isn't a diagnosis I can be definitive on frozen; that the workup is going to need IHC and that they can't start treating.



My program has been doing this for a very long time, and as far as I know, none of the residents have screwed anything up as to where lawyers would be involved.




I think that is sad that people don't get that experience. Both my residency and fellowship allow me to make frozen section diagnoses without the attending, and I am very thankful for it. Before I start my fellowship in July, I'll have read over 50 frozens on my own. No, it isn't as much responsibility as a third year internal medicine resident has, but at least it is something. After covering frozens on my own for four months during fellowship, I'll have a whole lot more experience before I start my first job. It will certainly make the transition a little bit less stressful.

Again, say what you will and I am happy to hear that your program allows this but you are still in the MINORITY compared to what most programs allow. That is all I am saying....your experience is more the exception than the rule when it comes to graduated responsibility in Pathology residency training. I agree that it is "sad" that others don't get this experience but that is the currently reality of it. And I stick to my point that you can't make a blanket statement about programs who don't allow this sort of independence at frozen section "must not trust their residents". That's sort of assumption is absurd and doesn't take into account that it is a much more complicated situation that you are making it sound like.

Pathguy11

 

[KCShaw]

Interesting. On the one hand I'm hearing that some subspecialty training is essentially necessary but that there's no practical way to track straight into it without doing the full/traditional background AP/CP (which I don't -entirely- disagree with), but on the other hand we've seen that derms have been doing exactly that, arguably rather successfully. Not saying the derm -> dermpath model is necessarily one to pursue for other subspecialties, but it's out there and hasn't exactly failed.

As for the frozen section discussion, I think allowing residents to sign out frozens (or any other cases for that matter) while having support available is no worse than, and almost certainly better than, having an attending sign them out who has never been in the position to do so and has no experienced support readily available. The problem, as everyone knows and some have mentioned, is that pathology is different from other specialties; every case is a time sensitive consultation, and providing the wrong information up front to a surgeon who is or isn't going to cut out something that may be missed, or oncologist who is or isn't going to toxify a patient, is significantly different from delaying treatment for pneumonia by a couple of hours or prescribing a single dose of unnecessary/suboptimal antibiotics until the case is discussed at lunch or morning rounds or whatever. All can lead to bad outcomes, no doubt, but in pathology those bad outcomes may more commonly be a bit more permanent. And as one of the attendings used to say, the acceptable error rate in pathology, unlike other specialties, is 0%. But that doesn't mean pathology residencies can't provide graduated responsibility/expectations, and most programs I think have room to improve in that area.

 

[gbwillner]

I don't see why fellowships are considered equal to jobs here. I mean, they are somwhere to go next, but they are not in my opinion a good outcome.

The only reason someone should do a fellowship after residency is because they are interested in the subject matter and want to make it their primary field of interest/research. Like if you want to do nothing but derm all day, do dermpath.

Doing a fellowship just because you didn't find a job speaks very poorly for your job market.

I don't think fellowship are equal to jobs, but you cannot comment on the status of the job market solely on the fact that residents and fellows choose to do more training. As far as I'm aware, NONE of the fellows choosing to do additional training did so because the failed to secure employment. I personally did not wish to do additional training and will not do so. I know many residents and fellows felt unprepared to practice without the surgpath fellowship, others felt it would just make them more competitive in the marketplace without testing it first. If I knew I only wanted to sign out general surgpath I probably would have tested the waters of academics or private practice first. But it's just not the prevailing mindset of todays trainees, whether truly based on problems with employment or not.