Substance

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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.

Making a call on a tumor is a big deal. If its the wrong call, then all sorts of crap goes wrong down the line. Don't you think patients deserve to have the best guys doing that job?

Why does path accept low-quality applicants who got poor USMLE scores and evaluations? Why does path accept so many FMGs who can barely even communicate in English, when communication is VITAL?

What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs. If a program doesn't fill, tough. The field needs more hardcore people in it.

This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
 

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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.

Making a call on a tumor is a big deal. If its the wrong call, then all sorts of crap goes wrong down the line. Don't you think patients deserve to have the best guys doing that job?

Why does path accept low-quality applicants who got poor USMLE scores and evaluations? Why does path accept so many FMGs who can barely even communicate in English, when communication is VITAL?

What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs. If a program doesn't fill, tough. The field needs more hardcore people in it.

This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
I think you are either misinformed or are looking at a couple of programs that are not that great. Pathology (this year especially) has gotten much more competitive and biased on the people that I have talked to most pathology programs preferentially take US grads over FMGs. Most of the people that have told me this are current residents that I have talked to on the interview trail this past year. Again I think that is because of the increase in competitiveness over the last couple of years.
 

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What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs.
Nice approach. In my program the board passing rate among FMGs has been 100% (AP and CP) for the past five years at least, whie being somewhat lower for AMGs. As an FMG with 240/99 on both Step 1 and 2 I guess I should be over the moon because of the fact that I made it.
This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
What a loss for the field.
 

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1. I'm pretty sure this discussion has occurred on this message board before - about how it's ridiculous that standards aren't higher, etc etc.

2. Please don't assume all people who enter or choose pathology are underachievers or FMGs who have poor communication skills. That's just like saying all surgeons are a-holes, all orthos are neanderthals, all derms are blonde bombshells who sell wrinkle cream, etc. Perhaps perpetuating such stereotypes is one of the factors that dissuades strong students from looking more closely at pathology as a career. I'm sorry your experience with pathologists/path residents to this point has led you to these conclusions.

3. I think it is a huge disservice to strong FMGs to say they ought to be eliminated. On the interview trail I met several FMGs who were absolute rockstars - even correcting AMG senior residents during unknown conferences (that's not a dig on the seniors, that's just how good these other guys were).

4. As individuals we can only speak to our own experiences, but as for me, I was in the top quarter of my class, AMG American citizen, board scores which probably would have made me competitive for nearly any field save derm, ortho, plastics. I'm not at the Brig or Mass Gen or Stanford, so I can only imagine the stats of the awesome folks on this board who ended up there. I'm no genius, but I'm no slouch either. And I met several people on the trail who were just like me or better.

Again, I'm sorry your experiences have been so negative, and I hope in the future (with a lot of hard work) that I can be one of the people who changes perspectives like the one you have.
 
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OK the original post was rather pointless...programs can't just say "Oh we're gonna accept only the rockstar med students and have spots unfilled anyway" It'll be a bigger burden on everyone if there is not enough people doing the jobs. The field has got more competitive as more people take lifestyle into consideration. Same thing happened to Anesthesiology, which supposedly used to be the field that people at the bottom of the class go to.

And FMG's at good residency programs are knowledgeable and communicate well. True, some of them have accents, but not to the point that that interfere with communication, or else they wouldn't have passed the interview stage anyway. Nevertheless, FMG has become such a unfair stigma to applicants.
 

rollwithit

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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.

Making a call on a tumor is a big deal. If its the wrong call, then all sorts of crap goes wrong down the line. Don't you think patients deserve to have the best guys doing that job?

Why does path accept low-quality applicants who got poor USMLE scores and evaluations? Why does path accept so many FMGs who can barely even communicate in English, when communication is VITAL?

What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs. If a program doesn't fill, tough. The field needs more hardcore people in it.

This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
So much awesomeness here.

- You've acknowledged the importance of path and it's influence on patient care. Great. We are on the same page.

- You suggest path go the derm route and beef up the the "competitiveness". You do realize this is a supply/demand principle? You acknowledged that path is vital to patient care, but at the same time you think they should train less people so the field becomes more competitive. I can't speak for everyone, but path is certainly a field where I wouldn't never want an undersupply of physicians. It's a fine line to balance, but you can't just make path like derm and create a huge shortage of pathologists. Acne can wait. Tumors can't.

- You believe patients deserve the best care but you are too good to slum it in path? You sound like a really great person. Path is likely better without you. You can stroke your ego is some other speciality.

- LOL at your handle.
 

2121115

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Well, at least you understand what pathologists do. That is more than I can say for 90% of your clinician friends.
 

medicomel

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I'm very very happy where I ended up but really humbled by this process. Even the non-PhD people I met along the way are academic rockstars. It makes me proud to be in company with a burgeoning specialty.

Congrats to all that matched. Let's work together to get the respect we deserve.
 
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Substance

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It's a shame that a lot of you are reflexively insulting me for pointing out some grievances I have with the field of pathology.

I'm not insinuating that pathology fills up with only drivel. A lot of good people, even more this year, are going into it. But the fact of the matter is that there are a disproportionate amount of non-English-fluent FMGs and low-caliber applicants in this field as compared to other more competitive fields. I find this unfortunate because its probably one of the most important fields in medicine, and it should be attracting the caliber of applicant that goes for radiology.

I also find that FMGs, even the good ones, are less likely to try to innovate and push the envelope, because of the stigma that they have to deal with. I can't blame them: getting into an American residency is hard enough - staying under the radar = less chance of being ousted. But this puts a damper on the field overall. This is one reason why pathology is being used as a money-making tool by POD labs and endoscopists, and why path is still using 100 year old tech rather than cutting edge stuff. AMGs with a healthy sense of Western entitlement would not let this happen.

With the current glut of pathologists, you could close down all residency positions for a few years and still be oversupplied. Radiology doesn't seem to have a problem with taking too long to find that tumor or that ICH and there are far less of them. Path as a field needs to cut about half of the current residency openings. Whether the workload would increase for people already in the program is irrelevant - to make an omelet you need to break a few eggs. There'd still be enough pathologists to weather the case load over the long term, and the remaining pathologists would have higher salaries due to there being less of them. This would attract more applicants to the field who have better stats and more innovative drive. It would make the field improve many times over, and patient care would improve as a result.

I know the above has been said before, but I haven't seen it mentioned from the perspective of a clinical physician such as myself. And its not that I'm too good to slum it in path. It's that the field isn't being what it could be, and by all accounts won't in the future. Not acknowledging the shortcomings of your field and instead attacking me doesn't really do much except to boost your ego.
 

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In the end it doesn't matter who is innovative or what the supply-demand ratio of a specialty is because $$$ reimbursement is about to plummet regardless. The pharmacists at my medical center get paid more than the junior pathology attendings, but hey that is about to happen to most every other specialty as well. They couldn't find a way to get the SGR fix into the reform bill being voted on tomorrow. What makes you think they will fix it after the fact with a $200 billion price tag? The year to year fix is over and medicare cuts are coming big time (radiology is going to get hit the hardest of all specialties probably). Private insurers will follow suit soon enough. Since everyone is required to hold insurance and they reimburse based on medicare plus a %, private insurance companies are about to make $$$ hand over fist.

So, the bottom line is "who cares". We are all just trying to get our student loans paid off ASAP so we aren't saddled with the equivalent of another mortgage payment when our income gets cut in half. The same goes for clinicians too. It is going to get ugly as every specialty tries to fight over the RVU scraps that fall from the table while health care costs keep going up. Good thing they are screwing physicians, whose reimbursement accounts for less than 10% of healthcare spending, rather than insurance companies.
 

yaah

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I also find that FMGs, even the good ones, are less likely to try to innovate and push the envelope, because of the stigma that they have to deal with. I can't blame them: getting into an American residency is hard enough - staying under the radar = less chance of being ousted. But this puts a damper on the field overall. This is one reason why pathology is being used as a money-making tool by POD labs and endoscopists, and why path is still using 100 year old tech rather than cutting edge stuff. AMGs with a healthy sense of Western entitlement would not let this happen.
That is absolute hogwash. A great amount of innovation in path comes from FMGs, just as a great amount comes from AMGs. The "healthy sense of western entitlement" as you put it, often results in much of the innovation and research coming from FMGs instead of AMGs, because some AMGs (some, not all!) want to do as little work as possible but get paid as much as possible. To be sure, there are probably too many path training programs and many of the lesser ones do the field a disservice by their poor quality of training. A lot of people who probably shouldn't be pathologists end up getting trained and certified this way. To your other point, pathology uses a lot of cutting edge technology - this argument you made is so weak. The reason a 100 year old technology (the H&E) is still used is because it remains an effective way (as well as a cost-effective and quick way) to practice. Why don't radiologists give up chest xrays? Why don't cardiologists give up the stethoscope? This is not a "reflexive insult" but a refutation of ignorant statements. Many of your other statements are pertinent, but the ones I quoted are pure bunk mixed with xenophobia. I agree with you that path needs to do a better job of attracting better applicants. Lots of great people go into it, but lots who would be suited for it don't for various reasons.
 

Substance

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In the end it doesn't matter who is innovative or what the supply-demand ratio of a specialty is because $$$ reimbursement is about to plummet regardless. The pharmacists at my medical center get paid more than the junior pathology attendings, but hey that is about to happen to most every other specialty as well. They couldn't find a way to get the SGR fix into the reform bill being voted on tomorrow. What makes you think they will fix it after the fact with a $200 billion price tag? The year to year fix is over and medicare cuts are coming big time (radiology is going to get hit the hardest of all specialties probably). Private insurers will follow suit soon enough. Since everyone is required to hold insurance and they reimburse based on medicare plus a %, private insurance companies are about to make $$$ hand over fist.

So, the bottom line is "who cares". We are all just trying to get our student loans paid off ASAP so we aren't saddled with the equivalent of another mortgage payment when our income gets cut in half. The same goes for clinicians too. It is going to get ugly as every specialty tries to fight over the RVU scraps that fall from the table while health care costs keep going up. Good thing they are screwing physicians, whose reimbursement accounts for less than 10% of healthcare spending, rather than insurance companies.
What physicians should have done is banded together to prevent this from happening. The problem with physicians is that they are selfish greedy bastards who only look out for number one. That attitude has landed them in this mess.

If they had worked together and lobbied extensively, physicians would be far better off and would not even be having this discussion. I bet the public doesn't even know how much money the insurance companies make. Compared to them, doctors make peanuts. Yet the political push has been to cut physician income, because the public's perception is that we are paid so much.

We needed to work the lobbying angle as a collective group, but we didn't and we epic failed. The public is like a child: tell it something often enough and it believes you. We didn't tell it often enough that physicians, if anything, are underpaid and the flack should go towards the middlemen insurers.

As a result, physicians should now vote with their wallets. If they're going to get screwed by insurance, they should be cash-only from now on. All primary care should be boutique. All payments should be out of pocket. If the government fails physicians, we should go back to free-market principles. Wild West medicine.

That is absolute hogwash. A great amount of innovation in path comes from FMGs, just as a great amount comes from AMGs. To be sure, there are probably too many path training programs and many of the lesser ones do the field a disservice by their poor quality of training. A lot of people who probably shouldn't be pathologists end up getting trained and certified this way. To your other point, pathology uses a lot of cutting edge technology - this argument you made is so weak. The reason a 100 year old technology (the H&E) is still used is because it remains an effective way (as well as a cost-effective and quick way) to practice. Why don't radiologists give up chest xrays? Why don't cardiologists give up the stethoscope? This is not a "reflexive insult" but a refutation of ignorant statements. Many of your other statements are pertinent, but the ones I quoted are pure bunk mixed with xenophobia. I agree with you that path needs to do a better job of attracting better applicants. Lots of great people go into it, but lots who would be suited for it don't for various reasons.
I would bet that far less innovation in path comes from FMGs than AMGs. I would go as far as saying that the more FMGs in the field, the less push there will be towards innovation. I'm not saying this because I think FMGs are incapable. I'm saying it because to innovate requires that one challenge the status quo, and FMGs are more cautious about doing this due to stigma and prejudice. It's a shame that this part of the world still has that kind of mindset, but it does. I'm not xenophobic. I'm commenting on the culture of xenophobia present in American medicine preventing FMGs from taking a stand towards innovating fields and challenging the status quo.

I'm not bashing the H&E. I'm bashing the microscope. It's day should be numbered, the same way films have been numbered in radiology. Digital is just better. Storage is easier and cheaper. Quality control is better. As a teaching tool it is better. Digital algorithms can be utilized to assist in diagnosis. It's more portable. It's faster. But there's been very little enthusiasm for it even though I cannot find any cogent arguments that support the superiority of the microscope. All I've encountered is "it's what we have been using for years" and "The resolution is better"(which is false with modern technology) and "It's cheaper"(in the short term yes. Long term it isn't. Digital storage space is far cheaper than physical, and computers are cheaper than microscopes) As for other components of pathological diagnosis such as molecular and genetic, the general docility of practitioners of the field is allowing other fields to be first in line to make inroads regarding the use of such modalities. Path should not allow that kind of encroachment to happen.

For your other points about cardiology: Nobody will support the diagnosis of a definitive valvular abnormality without an Echo, so in a way the stethoscope has been relegated to very coarse cardiovascular assessment and use by medical students and residents as a rudimentary screening tool. It's been shown that inter-rater reliability of auscultation of everything but the most obvious of murmurs is poor. As for the X-ray, it like the stethoscope is useful for some specific abnormalities in certain clinical situations. In a lot of other cases, any true definitive answers regarding anatomy are better found using CT, such as tumor masses, interstitial lung diseases, etc. But I've never heard any radiologists, save for some mammographers, comment that plain films are just better than digital and therefore digital should not be used.
 
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path24

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Substance...I agree with a lot of what you are saying, not all, but most. The fact that most disagree with you pretty much sums up why pathology is where it is today.
 

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Being a good pathologist (generalist or specialist) is not easy and those that can do it well have opportunities. This selection by ability happens at the end of residency rather than after medical school (though a good match is a step in the right direction). Those that are highly skilled take stable partnership track jobs or elite academic positions. Corporate pathology or other ventures less interested in quality (e.g. insourced pathology) are there to pick up most of the rest, if they stay in the country (I have heard that some of these megalabs even employ english speaking staff to edit their predominantly IMG pathologists' poorly written reports).

I would estimate that the top 50-100 or so applicants in path are among the very best medical students and could do anything they wanted. I agree that program directors across the country could collectively limit spots to increase prestige, but this will not happen. For the op, choose pathology if you love it and make it work for you. Like any other area of medicine true respect comes from taking good care of your patients, not from telling people your USMLE scores.

So, I guess the message for clinicians is, not all board certified pathologists are the same and, since your patient's life is in our hands, choose wisely. For patients, they need education as to the role a pathologist plays in their care and should have freedom to direct their tissue to someone they trust (and they should be educated about the greed and questionable practices of many providers, GIs and uros in particular). Sophisticated patients already do this in my experience.
 

yaah

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I'm not bashing the H&E. I'm bashing the microscope. It's day should be numbered, the same way films have been numbered in radiology. Digital is just better. Storage is easier and cheaper. Quality control is better. As a teaching tool it is better. Digital algorithms can be utilized to assist in diagnosis. It's more portable. It's faster. But there's been very little enthusiasm for it even though I cannot find any cogent arguments that support the superiority of the microscope. All I've encountered is "it's what we have been using for years" and "The resolution is better"(which is false with modern technology) and "It's cheaper"(in the short term yes. Long term it isn't. Digital storage space is far cheaper than physical, and computers are cheaper than microscopes) As for other components of pathological diagnosis such as molecular and genetic, the general docility of practitioners of the field is allowing other fields to be first in line to make inroads regarding the use of such modalities. Path should not allow that kind of encroachment to happen.
Do you honestly think work is not being done on this? Digital has advanced in radiology quicker because the size of the file is many powers of ten lower than even a simple H&E with a small amount of tissue. And digital has enhanced radiology because the ways studies are performed and analyzed lends itself very well to a computer-assisted format. Again, you are taking your minimal knowledge of pathology and presuming that it is fact. Digitizing pathology is proceeding, but there are serious flaws that need to be worked out. And part of the issue with this is indeed cost-based and efficiency related. Whereas digitizing radiology makes financial and clinical sense (and can be healthy for your bottom line), digitizing pathology currently makes no financial sense and makes very little clinical sense. This will change. But just because it hasn't jumped completely doesn't mean that it won't or that it can't. Again, digitizing pathology is orders of magnitude more complicated than digitizing radiology. As an example - the process of reviewing a digital slide in pathology takes the exact same processing as the process of reviewing a slide by microscope, up to a certain point, and that point is right before you put the slide on a microscope stage. Thus, in order to digitize the slide you have to have the resources to scan in the slide (at exceedingly high quality, often up to several gigabytes of data for EACH SLIDE) as well as the resources to analyze it. Or, you can put the slide on a several thousand dollar scope. Computers may be cheaper than microscopes but the type of computer needed to digitize a typical department's files and then call them up for review is far far more expensive. Do you not get that? This will change as technology improves, but the fact that it is not happening faster has almost nothing to do with pathology, it has to do with computer science. Writing the programs that do it all has more to do with pathology, but there are limitations to this.

I agree as a teaching tool it is better. Have you seen pathology CME these days? A great deal of it is in digital format. Our exams include digital slides. I suspect the next way digitizing slides will be utilized is in the consultation process where instead of sending glass slides to other institutions a scanned-in slide can be substituted. Ultimately when technology gets better and faster it will move to most cases. But just because it hasn't happened yet doesn't mean it won't, and it doesn't mean pathologists are resistant to change or that this change is not happening. Your conclusions are oddly strong considering that you seem to be quite uninformed.

Again, none of this portrays a resistance to change or innovation. To suggest that is short sighted, I am not sure why you are so hell-bent on thinking this. But we don't jump to drastic changes in how things are done if there is no good reason to do so. There are good reasons to integrate such technologies, and that is being done. There are excellent reasons to digitize radiologic studies, hence why there have been more rapid movements to do so.

The advances in radiology have exceedingly little to do with the ethnic background of people practicing within the field. To say otherwise is a very silly and bizarre comment to make. You say it isn't xenophobic but it is! It's an ignorant comment. Individuals have a wide range of motivations and backgrounds, all of these contribute to innovation. Ethnic origin and fear of not fitting in may come into play for some FMGs, but not a significant component. A great many advances in computer-assisted technology also come out of industry. I am not an FMG, I have no axe to grind here. Your stereotypes may be perfectly valid for a subset of FMGs, but as I said stereotypes of AMGs as lazy and non-innovative, worried entirely about financial gains, are also perfectly valid for a subset.
 

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do away with the microscope? Jesus, that's ludicrous. You still need a microscope to take the pictures from a slide, am I wrong? I don't know about you, but I get a different sense when I look at a slide under a microscope vs. an LCD. Might sound crazy, but I actually feel connected to the patient using a microscope, and rather withdrawn on an LCD. In fact, I find it a huge step backwards when medical schools started to show slides through a monitor, rather than getting a real feel by using the microscope.

If the art of using the stethoscope is dying, I sure don't want the art of using the microscope to follow suit.

I also find the analogy of a stethoscope/echo, and a microscope/LCD display is rather pompous.
 

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I think dermpath is a good example of what substance is getting at. Few fellowships, competitive, strong candidates, good job market, good research, good turn around time....etc. The field of dermpath isn't hurting one bit in any area (and I would argue is the strongest area of pathology). The key, run by dermatology. All of the areas of pathology could be the same, but the problem....run by pathology. Too many fellowships (something people on here seem to disagree with me on) and pathologists. The funny part is the number of pathology residents that want to do dermpath.

Pathology is going digital, how long it is going to take is hard to say.
 

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Dermpath is not run by dermatology everywhere. It's run by pathology only at many places, run by primarily dermatology at others, and run jointly at others. The american board of pathology administers the certification exam in conjunction with AB dermatology. It is not "run by dermatology." There are many many reasons why dermpath fellowships are more competitive and (currently) lead to more lucrative careers. To assume that this is always going to be true is a risky opinion to take, particularly with the current rapid proliferation of reference labs poaching away specimens and the likely pending downgrade of 88305 reimbursement. These factors make dermpath's future considerably less rosy.
 
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I think dermpath is a good example of what substance is getting at. Few fellowships, competitive, strong candidates, good job market, good research, good turn around time....etc. The field of dermpath isn't hurting one bit in any area (and I would argue is the strongest area of pathology). The key, run by dermatology. All of the areas of pathology could be the same, but the problem....run by pathology. Too many fellowships (something people on here seem to disagree with me on) and pathologists. The funny part is the number of pathology residents that want to do dermpath.

Pathology is going digital, how long it is going to take is hard to say.
Not true anymore, sadly. Check out the discussion about this problem in the dermatology forum.

There is now an oversupply of dermatopathologists. In 2001, there were only 61 spots. Now there are 91, and more are in the process of being added as we speak. There are only about 350+ dermatologists coming out of residency every year. The math is not as simple, I know, but just in general, 91 dermatopathologists for 350 dermatologists equals to roughly a 1 to 3 ratio. Three dermatologists cannot generate enough volume on a daily basis to support one dermatopathologist.

Talk to the current dermatopathology fellows and you will find out the sad reality that the job market is not as good as it used to be.

Dermatology is also potentially facing an oversupply problem.
 

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Why does path accept low-quality applicants who got poor USMLE scores and evaluations?
According to the 2009 Charting Outcomes in the Match, the mean Step 1 score for the Pathology matched US senior (227) is actually higher than the average matched US Senior (225).

Just saying...

I agree that Pathology should attract more competitive candidates. It's obviously multifactorial. But, likely factors include stigma (as evidenced by your assumptions above), lack of awareness and exposure of what pathologists do, the "prestige" factor, and of course, the fears of a tight[er] job market.
 

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A recent column highlights that the majority of the innovation in science amoung the American youth comes from the children of recent immigrants. If they over-represent innovation at a young age, this should continue into adulthood. High school students are under even greater pressure to fit in to be accepted.

http://www.nytimes.com/2010/03/21/opinion/21friedman.html?src=me&ref=general

The idea that IMGs lack innovation has no basis in fact.
 

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Yes no doubt. Many of the brightest lights in pathology graduated abroad. Heck start with Abbas, Kumar and Fausto.


A recent column highlights that the majority of the innovation in science amoung the American youth comes from the children of recent immigrants. If they over-represent innovation at a young age, this should continue into adulthood. High school students are under even greater pressure to fit in to be accepted.

http://www.nytimes.com/2010/03/21/opinion/21friedman.html?src=me&ref=general

The idea that IMGs lack innovation has no basis in fact.
 

rirriri

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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.

Making a call on a tumor is a big deal. If its the wrong call, then all sorts of crap goes wrong down the line. Don't you think patients deserve to have the best guys doing that job?

Why does path accept low-quality applicants who got poor USMLE scores and evaluations? Why does path accept so many FMGs who can barely even communicate in English, when communication is VITAL?

What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs. If a program doesn't fill, tough. The field needs more hardcore people in it.

This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
EH? your post is pretty much off the mark.....but at least you're not in our field, so YEY FOR US!
 

Parts Unknown

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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.
Tell you what: when we no longer call back a frozen section diagnosis only to be told that the patient has left the OR, we'll get right on that.
 

pathstudent

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Tell you what: when we no longer call back a frozen section diagnosis only to be told that the patient has left the OR, we'll get right on that.

You know what,

If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.

So just shut up and do your job, even if doesn't affect the surgery. You would want the same if ou were the patient of a relative.
 

HbyHA

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You know what,

If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.

So just shut up and do your job, even if doesn't affect the surgery. You would want the same if ou were the patient of a relative.
that's a really asinine comment. do you even have a clue about what you're talking about? i'm really starting to wonder.

one of the reasons of sending a frozen section is to assure that the surgeons have diagnostic material. this information doesn't help them if they need to get more tissue but they've already wheeled the patient out of the room.

a frozen section that doesn't change or guide the course of surgery is a waste of everyone's time and a potential waste of valuable diagnostic material.
 

rockit

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You know what,

If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.

So just shut up and do your job, even if doesn't affect the surgery. You would want the same if ou were the patient of a relative.
No I wouldn't. I would want the specimen to be properly processed and stained so that the best histology and IHC are available.

Clearly if you left the OR you didn't need to know.
 

Gene_

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You know what,
If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.
that's a really asinine comment. do you even have a clue about what you're talking about? i'm really starting to wonder.

one of the reasons of sending a frozen section is to assure that the surgeons have diagnostic material. this information doesn't help them if they need to get more tissue but they've already wheeled the patient out of the room.

a frozen section that doesn't change or guide the course of surgery is a waste of everyone's time and a potential waste of valuable diagnostic material.
:thumbup:
When doing a frozen for a neurosurgeon, one of the questions you should always ask is if he will be sending more tissue (for permanent sections). If not and there is scant material, a squash prep might be a better choice.
 

Parts Unknown

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You know what,

If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.
"Even if it was only"? Dear God. I would most certainly appreciate that, as it is a necessary part of the surgery. But that's not what I was talking about.

pathstudent said:
So just shut up and do your job, even if doesn't affect the surgery.
Sorry, it's not in my job description to appease the surgeon's curiosity. It's a waste of valuable time, labor, reagents, and (as mentioned) tissue.

pathstudent said:
You would want the same if ou were the patient of a relative.
The patient of a relative? Do you mean the relative of a patient?

In any case, I absolutely would not want a frivolous frozen section performed on myself or anyone else. It is better to wait for the final diagnosis than have to overturn a preliminary one.
 

BrainPathology

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You know what,

If yoour wife/husband/boyfriend/girlfriend had a brain tumor you would greatly appreciate the pathologist coming into to look at the frozen even if was only to confirm the neurosurgeon had diagnostic tissue.

So just shut up and do your job, even if doesn't affect the surgery. You would want the same if ou were the patient of a relative.
There is no more reprehensible use of frozen section diagnoses than what you're implying. When you give a diagnosis and the surgeon reports to the family that "it's X" and the rest of the tissue upgrades or downgrades the tumor this is unacceptable. VERY

When you're then in a tumor board being accused of "changing your mind" you want to punch the surgeon square in the face for abusing and inappropriately using the results of the frozen section.

If the frozen section doesn't guide the rest of the surgery it's a waste of your time, the patient's time under anesthesia, the cost of the OR, the cost of the frozen section itself (MONEY), and is entirely and in all other ways inappropriate.

Doing our job does not always have to involve shutting up. Sometimes (should be all the time) it means speaking up and educating our colleagues. Letting them abuse you with frivilous frozen section consults is one of these instances.
 

pathstudent

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an 88305 is the majority of cases at most pathology groups. Even a lymph node for lymphoma is an 88305'. So if an 88305 get ratcheted down. Dermpath and gi will still be the most lucrative. The time it takes to gross and read a kidney for tumor or a lumpectomy or mastectomy for cancer (all 88307) you could read fifty gi biopsies or derm biopsies. Currently an 88307 pays about twice as much as an 88305. So even if they cut an 88305 in half it will Still be the most lucrative specimen in pathology. A pure dermapod or giapod would have their salary cut in half put a general surgical pathologist would probably have their salary cut 35%. So let's not hope for a cut to an 88305 to punish dermpaths. That would be like punching your face to spite your nAsolabial fold.

Dermpath is not run by dermatology everywhere. It's run by pathology only at many places, run by primarily dermatology at others, and run jointly at others. The american board of pathology administers the certification exam in conjunction with AB dermatology. It is not "run by dermatology." There are many many reasons why dermpath fellowships are more competitive and (currently) lead to more lucrative careers. To assume that this is always going to be true is a risky opinion to take, particularly with the current rapid proliferation of reference labs poaching away specimens and the likely pending downgrade of 88305 reimbursement. These factors make dermpath's future considerably less rosy.
 

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According to the 2009 Charting Outcomes in the Match, the mean Step 1 score for the Pathology matched US senior (227) is actually higher than the average matched US Senior (225).

Just saying...

I agree that Pathology should attract more competitive candidates. It's obviously multifactorial. But, likely factors include stigma (as evidenced by your assumptions above), lack of awareness and exposure of what pathologists do, the "prestige" factor, and of course, the fears of a tight[er] job market.

I have to say that I disagree with a lot of the points of the OP. But, this is a poor point. To say that the mean score is 2 points higher than the national average is really just saying...... the avg pathology applicant has the national avg scores.

I am still going back and forth about pathology, because of the intellectual aspects of the specialty (and my desire to integrate research) make it very appealing.

However, there seems to me that many people (including current residents I've spoken to and this forum), sound like a broken record: oversupply, poor job market, and lack of innovation is rampant throughout the specialty. This does not make pathology particularly appealing to students.

Until, this gets turned around, you are not going to see an average applicant to pathology with Derm, Plastic, level scores and credentials.
 
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I'm not in pathology, but i find it ******ed that the field that has the greatest ability to send patient care down the wrong track for a long period of time does not attract the best and brightest.

Making a call on a tumor is a big deal. If its the wrong call, then all sorts of crap goes wrong down the line. Don't you think patients deserve to have the best guys doing that job?

Why does path accept low-quality applicants who got poor USMLE scores and evaluations? Why does path accept so many FMGs who can barely even communicate in English, when communication is VITAL?

What path has to do is take a dermatology approach to applications: weed out anyone with less than a 240, and completely weed out FMGs. If a program doesn't fill, tough. The field needs more hardcore people in it.

This is exactly why I'm not going to switch to path. Too many concessions on the quality of applicants accepted to the field. It's a shame too, because its interesting work.
I find this amusing.

First of all, most medical schools do not place significant emphasis on pathology and some flat out insulate students from the field. It starts with how the interviews are set up. As an applicant for med school, unless you are going after an MD-PhD program, you are interviewed by clinicians who don't understand the field. Then, once you have cleared step one and are on the floor, you have residents and attendings who either don't understand what is done in the department or just hold it in contempt to some degree. I think a lot of this could be solved by having mandatory rotations through path or something combined with radiology (i.e. one month split into 2 weeks for each).

The next joke is using a USMLE cutoff for anything. It's simply not a good screening tool to find people who think. Pathology requires a much higher level of self-study to be successful. You can't recognize patterns if you don't know what they are.

Finally, my experience with FMGs in pathology is that they tend to be very good and have had better exposure to the field than most American graduates.

So, the next time you choose not to read my report on your patient's condition and proceed to make an error in their treatment because you didn't read all the words, it would be in your best interest not to call me to get you out of it. And, by the way, most of the mistakes that involve pathology somehow are clerical, not diagnostic.
 

zao275

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Many of the best and most innovative pathologists I know and work with are FMG's/IMG's. Two of them in particular have over 300 publications, have trained other pathologists who are now chairs of prestigious departments of pathology, etc.

Our program had numerous applicants this year with USMLE Step 1 scores in the 230's and 240's range. NUMEROUS. Not to mention a handful of others in the 250-260 range. One applicant had a 271. We are still talking about pathology residency applicants, in case anyone is wondering.

Just something to think about.
 

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numerous IMG interviewees at our program had triple 99's. SOme had PhD's and triple 99's. I mean even step 3...
pathology still attracts the best and the brightest.. From all countries. Its just misrepresented in most US medical school curricula. We have so many stories of 1st year American grads that have no idea what grossing is till they start surgpath in residency
 

yaah

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We have so many stories of 1st year American grads that have no idea what grossing is till they start surgpath in residency
That's pretty typical, and that is not a bad thing. The purpose of residency is to be trained, not to come in already knowing how to gross so that you can provide a service. The key is how you progress and what you are like as a pathologist when you complete residency, not how you are when you start.
 
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numerous IMG interviewees at our program had triple 99's. SOme had PhD's and triple 99's. I mean even step 3...
pathology still attracts the best and the brightest.. From all countries. Its just misrepresented in most US medical school curricula. We have so many stories of 1st year American grads that have no idea what grossing is till they start surgpath in residency
I took a surg path elective in med school to learn some of this (and determine this was what I wanted to do).
 

zao275

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I agree with Yaah that residency is for learning. But I do wish that med students were required to rotate in pathology, at least for a couple of weeks. Not so that they learn grossing or how to make a diagnosis of cancer, but just so they understand the basic idea of what happens inside the lab and that it is not just a black box. Also, it would give people exposure to our great field, so that they may decide to pursue a career in pathology. I think there are lots of surgeons, internists, pediatricians, etc out there that would have loved pathology but just didn't know what it was like until they were already in residency (or practice).
 
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I agree with Yaah that residency is for learning. But I do wish that med students were required to rotate in pathology, at least for a couple of weeks. Not so that they learn grossing or how to make a diagnosis of cancer, but just so they understand the basic idea of what happens inside the lab and that it is not just a black box. Also, it would give people exposure to our great field, so that they may decide to pursue a career in pathology. I think there are lots of surgeons, internists, pediatricians, etc out there that would have loved pathology but just didn't know what it was like until they were already in residency (or practice).
Couldn't agree with you more. As histology becomes less and less emphasized in med schools, clinicians are becoming less and less aware of what goes into making a diagnosis, which translates to suboptimal biopsies. I would argue that a short patholoy rotation (maybe as little as a few days) be required for all med students. If not that, then it should at least be required of any resident in a field that submits any kind of tissue to pathology.
 
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Sorry, we can't spend time on pathology in med school. We have to increase our time spent in small group sessions and establishing a relationship with the patient.
 

Euchromatin

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Sorry, we can't spend time on pathology in med school. We have to increase our time spent in small group sessions and establishing a relationship with the patient.
True that.

I know that I felt way too much time was wasted on touchy-feely patient communication issues (which was basically all common sense - OMG! people like it if you are polite and respectful?!?), cultural sensitivity, and disparities in health care among different populations.

I definitely think, at minimum, a few days of required time in the pathology department would be a much better use of medical students' time. Not to mention something like education in business and practice management, billing, and topics that are actually useful in the real world.
 

yaah

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It also seems to me as though a lot of med schools are decreasing actual educational time and giving students either more clinical time or giving them more "independent" time. And top students will often choose their med school because of these factors. They don't really care how much pathology they get. They want to be "in the clinic from day one." I never understood that obsession, personally. When I was in med school we had a half day a week in a primary care office, that was plenty of clinic. And we had about an hour almost every day of second year in path lab. I learned a lot, and it steered me into pathology. But in the past ten years pathology teaching has been given a few minutes incorporated into lectures of pathophysiology and students given a link to virtual slides.

Med students definitely need more education in business matters. We had a full day interclerkship on health insurance which was quite informative. But there is so much "time off" in med school that could be put to better use. I realize med students are busy and have to study, but there are opportunities.
 
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I don't understand that either. Why do med schools have to play to the med student desire to be "helping people from day one"? The first two years of med school are supposed to be about learning the fundamentals, not to spend hours every week following around someone in a white coat before you even know what the hell they are talking about. I hated my preclinical stuff because it was a waste of time. I learned some things but nothing that I would learn in far more detail in my 3rd and 4th years. I actually talk to premeds and early med students now and they tell me one of the main reasons they pick a certain school is because of "preclinical exposure to patients." What a crock of ****! Who cares?

I also took pathology before the intrusion of the virtual slide and the "virtual" pathology lab, which basically means no one goes, no one learns, and the answers to what passes for the pathology quiz are basically handed out.

I had to teach a couple of path "labs" in residency. I always tried to put in some extra information and side comments to try to get them to appreciate what they were learning more. That was a massive fail. The first question was always, "Is this going to be on the test?" And the second was, "Can I get a copy of your handout?" That is if they even show up. And if they don't show up they contact you anyway trying to get a copy.
 

zao275

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I would like to teach a pathology course (at least part time) one day. I plan to cover all of the things a pathologist does, including biopsies, frozens, blood bank, clinical path, etc, etc. And then tell them that one or two questions will come straight out of that "easy" lecture that they would normally skip. I would MUCH rather students spend time learning to understand the process than to learn what cytokine does this or that or even what tumors look like microscopically (and I love surg path, don't get me wrong!). Med students (and residents and doctors) have such a limited understanding (sometimes) of what we do and how we do it. Patient care (and our professional satisfaction) would be much improved by bettering their understanding of how we work and what it is exactly that we do. Stepping off the soapbox now...
 

mikesheree

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I would like to teach a pathology course (at least part time) one day. I plan to cover all of the things a pathologist does, including biopsies, frozens, blood bank, clinical path, etc, etc. And then tell them that one or two questions will come straight out of that "easy" lecture that they would normally skip. I would MUCH rather students spend time learning to understand the process than to learn what cytokine does this or that or even what tumors look like microscopically (and I love surg path, don't get me wrong!). Med students (and residents and doctors) have such a limited understanding (sometimes) of what we do and how we do it. Patient care (and our professional satisfaction) would be much improved by bettering their understanding of how we work and what it is exactly that we do. Stepping off the soapbox now...
"Teaching" can be a double-edge sword.
I "taught" for 2 years before I entered private practice ( basically because I had to as part of the job) and for 75% of the residents it was like teaching pigs to sing---it annoyed the pigs and it wasted my time. The other 25% were a pleasure and they still remember it more than 25 years later. The old chestnut "bitter-sweet" sure applied to my experience.
 
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zao275

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"Teaching" can be a double-edge sword.
I "taught" for 2 years before I entered private practice ( basically because I had to as part of the job) and for 75% of the residents it was like teaching pigs to sing---it annoyed the pigs and it wasted my time. The other 25% were a pleasure and they still remember it more than 25 years later. The old chestnut "bitter-sweet" sure applied to my experience.
Sad. But thanks for sharing your experience. It's good for me to know the good and the bad before deciding what to do.