rural path vs. city path?

In a teaching hospital, you work with residents and the residents manage the cases for you and you teach them at the scope. At teaching hospitals/major academic centers, the specimens are more complex and you get tougher cases (due to patients that are referred to specialty clinicians). In rural community hospitals, you do all the work. Cases are probably not as complex and diagnoses may not be as challenging. Before you get all uppity and snippy, this judgment is a relative comparison and I'm not saying that rural pathologists spend all day signing out gall bladders, appendices, and hernia sacs.

As an illustration, let's take neuro specimens. I think the majority of brain tumor cases will go to the academic centers because those cases aren't emergent cases. Those patients can go to places where neurosurgeons dedicated to doing those kind of cases can treat them. The rural places still have to deal with emergent cases so you'll get blood clots from subdural hematoma decompression cases...in which case you're not making diagnoses such as pilocytic astrocytoma, oligodendroglioma, or GBM but instead are signing out "blood clots".

 

Dammit, that's what I'm counting on!

 

The pathologist that I am spending some time with in "the sticks" frequently encounters cases which she ends up sending out for consults (and she has been practicing for probably close to 30 years), usually some IPOX that aren't done in her lab or some rare tumors, etc. She did make the comment that she does see more weird cases where she's working than one would expect, though.

 

I think brain tumors are not that uncommon in community hospitals. Moreover, those three entities you listed are all pretty easy diagnoses for any pathologist to make. Neurosurgeons that treat brain tumors are found in all kinds of settings (the best doctors don't all go into academics). Secondly, University pathology could arguably be easier as most referred patients already come with diagnoses. So you do see rare things with greater frequency, but it typically has already been completely or significantly worked up by a community pathologist. When people in the community get something rare or difficult, they are starting off from scratch. Lastly, bread and butter is bread and butter everywhere.

 

That's why I made it a point to say that my comparison was relative.

Point taken...I guess I was desperate for an example and used a not-so-great one...my rebuttal would only be that I've seen consults where these "basic" cases were misdiagnosed quite egregiously. But then, just because some neuropathologist is in an academic center doesn't mean that he/she is right all the time either, right?

You know, I've sometimes wondered about this actually. The question that pops in my mind is "At what stage does the patient actually get referred?" Does the referral to the academic center usually happen before or after a pathologist has laid his hands on the case? I've seen, in my limited experience, about half and half. For instance, patients with a soft tissue neoplasm or pulmonary neoplasm have had prior biopsies worked up (sometimes completely or incompletely)...of course, we'll request the block and work it up (or re-work it up) with our own panel of immunostains if need be.

Also, I do agree that being at an academic center is a little easier. You have more people to show cases to at academic centers. And from what I've seen from local consults, the # of immunostains at community centers are relatively more limited and sometimes of poor quality. So the community pathologists really don't have as much to work with sometimes and things can be difficult for them. I guess they deserve the big bucks then!

 

the biggest difference, far and away from rural areas/semi-rural and large urban centers: more money. The complexity of cases, acuity level and types of cases you see aside from neoplastic orthopedics is virtually identical. In essence if you can stand to live in a small town <100K people, then your wallet and spouse will thank you.

 

What exactly determines how much a private practice pathologist earns? Volume? Reimbursement rates? Contract bidding with hospitals/clinics?

 

none of the above.
The biggest determinant is whether you are the CEO/group head/equity partner or whether you are an employee.