Should there be a match for pathology fellowships?

[yaah]

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As I am discovering, the process of getting pathology fellowships does not have any kind of match, it's more like a job search. You apply to individual places and they decide on their own timeline when they will interview you (if they do), and then after that they decide on their own timeline if they will offer you a position, and then it is their timeline as to how long you have to accept it or lose it. And these timelines vary incredibly, from those who fill fellowships over two years in advance to those who want to fill them about a year or so ahead of time (if not less).

Personally, I find this system to be an abomination. Obviously it works well for some people, but in my view it certainly doesn't optimize things for better candidates. Some programs favor internal candidates to the exclusion of others. Other programs ignore internal candidates or marginalize them. The good candidate is often faced with the proposition of having to decide on a fellowship before they even interview at programs they might be interested in, or risk losing out totally. And since the system is generally frontloaded, you have to apply or start applying 2 years in advance, which is also too much. An AP only candidate will only have had one year of training before they have to apply. Terrible.

Other fields (like IM) have a match-like system. I much prefer this.

I know there are some who will defend the current system, and they will argue that it favors stronger candidates, it's much easier to navigate, etc. Bull****. If they truly were rolling admissions I would somewhat understand. But they are not. If they were all on similar timelines, I would somewhat understand. But they are not. And the programs often publish application timelines on their websites which are not accurate. Generally, people who defend the current system are those who lucked out.

Anyone want to defend the current system? It may work out in my favor (probably will, actually), so that isn't the point.

 

[mlw03]

This comes as a surprise to me - even though I'm 5 years from having to go through this, I just sorta assumed there was a match-type system in place.

I obviously haven't gone through it, but based on what I know of the residency match versus general med school admissions, I think I favor a more formal process whenever possible. Such a system levels the playing field by forcing programs to utilize standardized dates and not make side offers to candidates. The current system described above by yaah sounds to me a lot like things were before the match was instituted way back when. A fellowship match could still allow programs to pick whomever they wanted, but it would provide a level of equality that seems to be absent from the current system.

 

[mcfaddens]

Ill give this one a shot. Keep in mind I’m only dropping a few points to consider. Path is a much smaller community than IM, fellowships are at most 2yrs, where as some IM fellowships can be 3 or 4 yrs. Some path programs scrap the match for general AP/CP residency already for a couple of positions. And if you know someone who can get you in somewhere your in (match or not, internal or external candidate). The major problem I have with a match for fellowship is the added cost. I’m paying off loans right now for the expense I incurred for residency match, why should I have to pay again when the selection system is unlikely to change in the first place for a fellowship match.
I do agree with a reasonable timeline or something like that. What would be even better is if you could call a program and ask if the spot is open and get a direct answer. This would be the only real way to maximize you efforts for fellowships and not waste time.

 

[yaah]

It doesn't help you with cost though - unless, as you say, you are one who "knows somene who can get you in somewhere." Is this supposed to be a guarantee? As I said, this works well if you are lucky. I find the current system to have equal potential for excessive expenses.

As I said, the possibility of a match is not as desirable as even just a more specific timeline. I mean, you can theoretically call programs now and ask if a spot is open, but the answer you will most likely get is that "we are still accepting applications." As of now, for competitive fellowships they are only going to interview a few candidates for the one spot anyway (often only 2-3). So you aren't going to be going on more interviews necessarily.

I don't think it should depending on having to know the right people. As I said, many people will be having to do this after only one year (or less) of training. Are they reasonably going to know anyone, or are we going to start favoring candidates who started greasing the wheels when they were in college? I think this is objectionable - it disrespects the process and selects for candidates who make a decision early, whether or not that decision is even appropriate for them or they are even qualified.

 

[CameronFrye]

It doesn't help you with cost though - unless, as you say, you are one who "knows somene who can get you in somewhere." Is this supposed to be a guarantee? As I said, this works well if you are lucky. I find the current system to have equal potential for excessive expenses.

As I said, the possibility of a match is not as desirable as even just a more specific timeline. I mean, you can theoretically call programs now and ask if a spot is open, but the answer you will most likely get is that "we are still accepting applications." As of now, for competitive fellowships they are only going to interview a few candidates for the one spot anyway (often only 2-3). So you aren't going to be going on more interviews necessarily.

I don't think it should depending on having to know the right people. As I said, many people will be having to do this after only one year (or less) of training. Are they reasonably going to know anyone, or are we going to start favoring candidates who started greasing the wheels when they were in college? I think this is objectionable - it disrespects the process and selects for candidates who make a decision early, whether or not that decision is even appropriate for them or they are even qualified.

Yeah, I agree with you yaah. We have some upper-levels currently applying for outside fellowships and they've definitely ran into programs that are full two years in advance. For the places that aren't full, you have to decide if you're going to jump at a possible offer and cancel your other interviews, or turn down the offer and check out other places (and hope for more offers). Of course, the upper levels who have already secured in-house fellowships probably prefer the current system.

 

[mcfaddens]

I was just bringing up some points to consider. I do agree that the current system sucks and alot of people end up getting screwed. Im just not sure if a formal match system is the answer. I dont know personally how all of the programs around the country conduct business, but I wonder if such a system is in place would anyone really use it, programs in pathology have been known to be stubborn to change. I feel that its a good idea in theory but would it be functional in our specific setting?

 

[b&ierstiefel]

I think having a match for fellowships would add an element of fairness to the system...although it would also add an element of chaos to the system. This is complicated by the fact that many fellowships are for one year only and the pathology residency community is much smaller than other fields where the match is utilized for filling fellowship positions (which are longer in duration).

I also think it's convenient to have fellowships positions fill internally. This is of benefit for programs as they know the strengths of the internal candidates the best whereas outside applicants are not known as well. This is of benefit for the resident as he/she doesn't have to move to a different state, sell his/her property, find a new place to live for just one year, for fellowship. Of course, this totally sucks for those who are not happy where they are or those who are at programs that don't offer strong fellowships in their fields of interest. They're kinda stuck...and screwed in a way.

I don't know what the right answer is. I certainly have my biases as I'm fortunate enough to be at a place where most of the fellowships are quite strong. I'd hate to have to go through some long-winded application process all over again. It's not that I feel entitled to these spots but I like where I am and am appreciative of the fact that I was able to secure fellowship positions for my PGY-3 and PGY-4 years.

Now that I think more about it, I'm more hesitant to support the notion of a match process for fellowship spots. The job market, in the real world, doesn't utilize a match. People apply to jobs, a subset are interviewed, and offers are made. Those who don't get the job try to negotiate getting a different job. And so on and so on. This applies especially to board-certified fellowships...and dermpath readily comes to mind as an example. I think the system is just fine the way it is (albeit not perfect). For instance, the Harvard dermpath program interviewed 10 people and accepted 3. Whatever...the current system works fine in this example...I don't really see a need for the match.

I will end with this...some people join residency programs because they know what field they're interested in for fellowship. I think they would only be comforted to know that they can secure a in-house fellowship spot without having to compete against outsiders. It gets quite dicey enough when several people in a given class are interested in the same fellowship spot. In summary, I don't think the current system is necessarily "broken"...and why should one try to fix something that isn't necessarily broken? I see little reason to institute a match for fellowships.

 

[b&ierstiefel]

As I said, many people will be having to do this after only one year (or less) of training. Are they reasonably going to know anyone, or are we going to start favoring candidates who started greasing the wheels when they were in college? I think this is objectionable - it disrespects the process and selects for candidates who make a decision early, whether or not that decision is even appropriate for them or they are even qualified.

This is an intriguing point and a good one...you got me thinking now, man...(and it's getting too late for this ) Let's consider a slightly different scenario...

Candidate #1 (outsider) is in his 3rd yr in a 4 yr AP/CP program when applying to a fellowship spot...has had at least 2 years to prove his worth in a residency program...

Candidate #2 (in house candidate) is in his 1st yr in a 2 yr AP only program (or fine...2.5 years if the fellowship spot is a boarded specialty...which throws even more kinks in the process).

Both apply for the fellowship spot...one could argue that Candidate #1 wins if he has done very well but is known for a longer period of time, has more letters of recommendation...blah blah blah...

Now, doesn't that suck for Candidate #2?

Let's twist this a little bit more and come from a different perspective.

Candidate A matched into a prestigious residency program with kickass fellowships (yeah yeah yeah...we make our own prestige...yada yada yada...prestige is a two-way street and the program, and not just the individual, DOES matter too).

Candidate B did not match into this residency because he was significantly farther down the rank list (i.e., this residency thought Candidate A was much better).

Both candidates are applying for a fellowship spot at this prestigious residency program during the beginning of PGY-2 year first year because they want to start fellowship during PGY-3 year.

OK, so have the qualifications between Candidate A and Candidate B really changed that much? Let's say that both people took residency seriously and are well respected by their respective programs.

So now let's say Candidate A and B interview for the spot and compete for the spot in a Match. The program liked Candidate A better the first time. The program is still likely to favor Candidate A this time. Has anything really changed? No. Has the Match proven to be anything special? No. Has Candidate B wasted money? Of course. See...this is analogous to if Michigan was to have a rematch against Ohio State for the national championship game. Nobody wanted to see that (well I did...but who cares).

So yeah, rematches are boring...not favoring a match for fellowships, once again.

 

[PathOne]

I think that a formal match system would be overkill in Path. Also, it'll probably convey a feeling of fairness which, to be frank, isn't always warranted. Either PD's will choose ppl they already know, or applicants can shuttle all over the country for interviews.
You'd also be liable to see the rampant over-inflation in applications obvious in the residency system. Usually, Residents have a fairly good idea about whereabouts they'd like to do their fellowship. But if you created a match system, you'll have people applying to 15-20 fellowships all over the continent, for fear of losing out.

HOWEVER, I do agree that there should be specific and public deadlines for applications. it really makes no sense for applicants or programs, that positions should be closed out a couple of years in advance. So by all means institute a common deadline, which shouldn't be too hard to do - at least in theory - and then let people apply directly to the programs they're interested in.

 

[b&ierstiefel]

OK...I don't like to just bitch and moan about why the current system is flawed or perfect or why an alternative system would be the best solution. I actually voted for the 2nd option (and not the 1st or 3rd). So...are there modifications that can be made to the system? Can we offer suggestions too?

Now, a match process would work if there were elements of standardization similar to what we have in med school for residency applications (i.e., USMLE step 1 mainly...to a lesser extent Step 2).

So, let's institute a standardized test that everybody takes at the end of first year residency. This test will examine a certain fund of knowledge. To make it fair for everyone, it will test AP and CP. Cuz if the test only tested AP knowledge, the AP only residents would have an advantage over the AP/CP folks. That's no good, right? So now, that will force every program to have standardized AP/CP curricula during the first year. Say bye-bye to AP only residency...AP residents better be off going to lab after 2nd year and not doing any fellowships.

Aight, now that's settled. Now fellowship applicants will have a specific post-graduate standardized test score associated with their application. This will distinguish applications at the residency CV level which adds fairness to the process, right. Programs will then be able to judge applicants not on achievements during med school but specifically based on one's excellence in pathology performance.

 

[mcfaddens]

Exactly, these were alot of the points I was originally shooting at. As far as the case of standardized tests, program dynamics, over inflation of applications all aside since we are in a relatively small group I really think this is where the ROL or phone call would help, especially for the outside applicant. For example if Bierstifel and yaah were both fellowship directors. And Yaah had a decent guy interested in his fellowship at his program, gets a call or a letter from bierstifel telling him he really has an extraordinary guy at his program that wants to train under Yaah, im sure yaah would at least check biersteifel's resident out for the spot. I also like the fact that it kind of resembles the same sort of process when you will be out job hunting.

 

[yaah]

So, let's institute a standardized test that everybody takes at the end of first year residency.

You mean like the RISE? 😉 This is a reasonable proposal and perhaps the most ethical, but it would NEVER work. That's partially because fellowship directors care about things other than this more. Many want someone who will commit to research. And this also presumes that the fellowship selection process is based on fairness, which it is not. Very often, a subpar candidate will get a fellowship just because they know the right people or they did an extended rotation or they got lucky in some other sense. Is this the subpar candidate's fault? No. The program doesn't necessarily care either because they filled the spot and the person will probably do a good job.

As far as limiting fellowships to internal candidates, that's all well and good but it isn't practical either. For example, at this program we have more fellowship spots than actual graduating residents. And the same ones aren't going to fill every year. Next year, for example, there are outsiders filling the GI, dermpath, one surg path spot, one hemepath spot, and I think both cytology spots. And what happens if two good residents are interested in the same spot? Does the program then reserve a backup for the one who doesn't get it? Or are they on their own?

In terms of the process resembling a job hunt, I would agree but it's not equivalent. Fellowships are only one year positions, they are extra training. They aren't equivalent to jobs. Jobs take the best person for the job. Fellowships often do not. They are on an artifically created timeline. And the timelines, as I said, are all out of whack.

My main problem with pathology fellowships is that everything is about timing, politics, and luck, and it should be more about qualifications and skill. What if fellowships instituted some sort of exam as a qualifying step? (As in, a slide test or whatever). Would that work? Probably not. As I said, the application process is often so early that you are applying before you mature as a resident. I would have nothing against a slide test or a knowledge based test personally, but that often doesn't say much about what kind of fellow the person will be.

To be fair, for many fellowships a match-like process wouldn't be necessary. Maybe for cyto, surg path, etc. But for the really competitive fellowships like GI or derm I think that it does a disservice to both the program and the candidates to be so random and unorganized nationally. I had heard actually that hemepath programs were getting frustrated because some were starting to fill over two years in advance, so they are attempting to institute at least some sort of timeline.

Part of the reason the fellowship problem is there is because of the large difference in compensation between different subspecialty areas. Is it a coincidence that derm and GI pay the most, and are the most competitive? What's fascinating is that many people who say they are interested in research based careers somehow get drawn to these fields. Are they going to go into academics? Or are they using their research background to land a fellowship before they "change their career goals." Fellowship directors have a lot of bull**** to deal with too, and I think a timeline would help them also.

 

[mlw03]

Like telemarketers, as long as the current system works for programs they have no impetus to change. Perhaps one could argue that if they changed to a standard timeline they would get the best applicants into each spot, but I guess that's not enough of a reason for fellowship directors.

Perhaps someone can enlighten me - do programs want their fellowships to fill? what i mean is that clearly residency directors want their programs to fill - there's X amount of work that is appropriate for the training of Y residents, not Y - 1 or Y - 2. but is that the case with fellowships, where a program knows there will be a certain amount of GU path and they count of a GU fellow to take a certain chunk of that workload?

Also, someone please indulge me and answer this: do all fellowships fill every year? i can sense that some (GI, derm) are more competitive than others (forensics, general surg path), but i wonder if, like residency, some of the less desired sub-specialties in less desired programs go unfilled?

 

[yaah]

Lots go unfilled. At least, they have in the past. I think programs in general want their fellowships to fill but they aren't going to take just anyone.

I personally don't understand the fellowship director position. A lot of them I think want to fill as soon as possible so they don't have to worry about it and can interview fewer people. That's an impressive mission statement there.

 

[1Path]

Very often, a subpar candidate will get a fellowship just because they know the right people or they did an extended rotation or they got lucky in some other sense.

Just when I was starting to feel like the little eager beaver for being so involved in pathology this early in the game................................

I'm a little suprised to see the term sub-par when referring to residents and how exactly how would you define "subpar"?? Could it be that fellowship level training in it's current form offers an opportunity for folks who are solid future pathologists, but lack the CV "bling" of a kick a$$ step 3 score or 10 pubs, to get a shot at some high profile training opportunities?

 

[yaah]

"subpar" is a relative term. It doesn't necessarily have to do with any one area other than overall suitability for the field, a good future, and a willingness to work hard. There are a lot of residents out there who don't put in the work yet expect to be rewarded. When I say "subpar" I am merely referring to a relative means of comparison. As in, a person who treats residency like an 8-5 job and can't wait to leave every day is subpar to someone with impressive diagnostic skills early on and hard work on projects.

You'll see in residency - there are just some people who stand out - not because of publications or pedigree or anything, just because they know what they are doing. They are not always the ones who get the fellowships though. They often get passed over, sadly.

Step III score is basically worthless.

 

[CameronFrye]

So Bierstefel, what sweet fellowships have you lined up?

 

[PathOne]

My main problem with pathology fellowships is that everything is about timing, politics, and luck, and it should be more about qualifications and skill. What if fellowships instituted some sort of exam as a qualifying step? (As in, a slide test or whatever). Would that work? Probably not. As I said, the application process is often so early that you are applying before you mature as a resident. I would have nothing against a slide test or a knowledge based test personally, but that often doesn't say much about what kind of fellow the person will be.

I think it's difficult to disagree that selection for Fellowship *SHOULD* be based on qualifications and skill, or that currently, it's not.
However, it's also important to look at the downside to a more "fair" selection system.

Essentially, college, med school and residencies are today filled by a combination of objective and subjective criteria. The objective criteria are mainly standardized tests (SAT, MCAT, USMLE) and to some degree GPA, while the subjective criteria are LoR's, EC's, school background, etc etc etc.

Conversely, try to see that "end users" (employers) are looking for. They don't really care about a "level playing field", but about finding the best individual for the job. Interesting thing is, that they NEVER care about the "objective" criteria. Have you EVER heard about an employer asking about your college/med school GPA, or how well you did on your USMLE? Or your board score, for that matter? Nope. Of course, some of this data is implicit, as you probably didn't go to UCSF and got your residency at Hopkins with a MCAT of 19 and a USMLE of 190. But, actually, employers just don't care.

However, training providers DO care, as objective criteria are a great way (or at least an easy way) to compare across the board. Colleges and med schools, despite their talk about individual application review, care greatly about objective criteria. If nothing else, then because they're measured on them themselves. However, it's highly debatable, if these objective tests actually are good at predicting how well people will function in their jobs down the road. E.g. MCAT, which actually used to be a good predictor of med school success. Unfortunately, it's currently better at identifying those who shelled out big $$$ for MCAT prep courses.

Now, back to Fellowship selection. Let's assume that you create a "mini ERAS" for path fellows. This would entail, among other things:
1. Setting up a central repository and selection algoritm.
2. Providing preferably objective information about how applicants are performing as residents.
3. Common and fairly stringent rules.

Questions:
A) 1,2 and 3 all costs money. Who pays?
B) To work, programs would need additional, preferably objective, criteria about the qualifications and skills of applicants. Reusing USMLE makes no sense. Ergo, we'd need some kind of national test, perhaps by the end of the second year of Residency. This, of course, would require residency programs to streamline their curricula. No can do to intermingle AP & CP training, as it would put residents at a disadvantage. Additionally, it would to some degree require programs to structure their training not only towards passing boards, but also towards passing the "fellowship test".
C) Despite it's drawbacks, this *might* work for AP. But what about CP? If CP would be relegated to the last two years, how to you insure sufficient time for taking a test, applying, interviewing and accepting people for CP fellowships?
D) If you structure residency to comply with a Fellowship Match procedure, I'd argue that you're effectively lengthening required training before applying to become an attending. It'll be mighty difficult to explain why you didn't do Fellowship, if your residency is restructured to allow a Fellowship Match procedure.
E) Tests are time-consuming for all involved parties. Would the benefit of adding a "fellowship test" to the normal board exam outweigh the costs and complications of instituting such a test? Personally, I doubt it.

So, my conclusion to a national Fellowship match is, that the problems of creating such a system by far outweigh the benefits, and that I simply can't see how it would materially result in better medical care for patients, which, after all, ought to be the central yardstick.

 

[CameronFrye]

I admit that a match is probably overkill, but I just don't see why there can't be standardized dates. I think that would take care of most of the issues with the current system.

 

[DarksideAllstar]

Step III score is basically worthless.

I think that was the understatement of the year, particularly with regard to pathology.

 

[DarksideAllstar]

I'm a little suprised to see the term sub-par when referring to residents and how exactly how would you define "subpar"??

There are ****loads of mediocre and crappy residents and med students everywhere and in every field. Subpar could mean a couple of different things. For instance,

1. You are a *******. No amount of reading, didiactics, or hands-on training could ever make you competent, yet you somehow made it into med school because you taught arts and crafts for like 10 years, had 4.0 in your Fine Arts major, and manage to score just above average on your MCAT and happened to be applying at a time that the Admissions committee wanted "well-rounded" people. You are the reason why some people think all doctors are dumb and are skeptical of their expertise.
2. You're a lazy ****. You might have some decent skillz, but you are essentially a detriment to those around you. People hate you and would rather you not be there than have to pick up your slack while you are there. Your saving grace is that you weren't on rounds during the medicine rotation to ask multiple stupid, time consuming questions like student #1. The downside is, other students on said rotation are perpetually asked where lazy **** is and why he isn't at rounds.
3. You're a combination of the above, or what I like to call, "the bifecta." See above definitions for each category. You are essentially what AdComs strive to prevent from getting into med school, but you managed to slip through the cracks and make it in. You ask dumb questions you should know the answer to, but are too lazy to look up. There are several of these in every med school class. I suggest you seek out these students and destroy them early on before they end up biting you in the ass later in your career.

Out of curiosity, are you in med school? Methinks not...

 

[yaah]

.
2. You're a lazy ****. You might have some decent skillz, but you are essentially a detriment to those around you.

I hate those ****ers. Oftentimes, apart from being lazy, they are arrogant as hell and think the world owes them favoritism for ______ (fill in the blank, could be rough childhood, high self esteem, thinking their struggles are more significant than others, etc). I like to think that people like this get their comeuppance at some point, but oftentimes even if they do they still don't learn their lesson and just alter their behavior so that next time it will be someone else's problem.

For instance, we have people in this program who when they are on call, and at home, they will call in to every path room they can find in hopes of finding another resident who will do THEIR JOB for them. If it's a simple task, like "can you look over at the specimen bench and tell me how many specimens I have," obviously that's ok, but if it's "can you go down to the morgue and look and see if a body is there and the permit is filled out?" that's pretty weak.

Unfortunately, this type of resident often has success in landing fellowships. Why? Because they kiss the asses of those above them and have a lot of confidence, and won't shut up about their accomplishments so people think they are a lot more successful or hard working than they are. Oftentimes, this type of resident results in more work for other residents who are actually hard working and decent, but people other than residents don't often find out about it if they don't pay attention, because other people end up covering for them so that the work actually gets done. Or the PAs or techs end up doing more of their work and others don't get that same assistance. Unfortunately, what I have also seen happen is that people with power often look the other way in regards to people like this if the resident in question does other things (i.e. lots of research).

 

[CameronFrye]

There are ****loads of mediocre and crappy residents and med students everywhere and in every field. Subpar could mean a couple of different things. For instance,

1. You are a *******. No amount of reading, didiactics, or hands-on training could ever make you competent, yet you somehow made it into med school because you taught arts and crafts for like 10 years, had 4.0 in your Fine Arts major, and manage to score just above average on your MCAT and happened to be applying at a time that the Admissions committee wanted "well-rounded" people. You are the reason why some people think all doctors are dumb and are skeptical of their expertise.
2. You're a lazy ****. You might have some decent skillz, but you are essentially a detriment to those around you. People hate you and would rather you not be there than have to pick up your slack while you are there. Your saving grace is that you weren't on rounds during the medicine rotation to ask multiple stupid, time consuming questions like student #1. The downside is, other students on said rotation are perpetually asked where lazy **** is and why he isn't at rounds.
3. You're a combination of the above, or what I like to call, "the bifecta." See above definitions for each category. You are essentially what AdComs strive to prevent from getting into med school, but you managed to slip through the cracks and make it in. You ask dumb questions you should know the answer to, but are too lazy to look up. There are several of these in every med school class. I suggest you seek out these students and destroy them early on before they end up biting you in the ass later in your career.

Out of curiosity, are you in med school? Methinks not...

👍 👍 👍

Yep, medicine isn't some magical fairyland where everyone is hard-working, smart, nice, have no personality disorders, etc. And in pathology, you really have to watch out for number 2, b/c there are still a lot of people who think path is going to be some cakewalk residency (which I guess it is if you compare it to a surgery or medicine intern year, but it's not a cakewalk if you compare it to some 9-5 job).

 

[PathOne]

Ah, but things get better when you become an attending, at least in some ways. Like telling big-eyed Residents that "grossing is a really good learning experience" *LOL*

 

[1Path]

You'll see in residency - there are just some people who stand out - not because of publications or pedigree or anything, just because they know what they are doing. They are not always the ones who get the fellowships though. They often get passed over, sadly..

So I spent 3 years at the NIH working in the path department and for the uninformed, that means directly with the residents. So I'll conceed a sample size of one but a situation that most of you here won't have BEFORE you choose your residencies/fellowships. Doesn't make me an expert in evaluting anything but when combined with my 15 years in academia (medical research) and 3 in industry, gives, me some REAL life experiences to compare that expereince with.

I can't recall ONE subpar resident the entire time I was there and they had a variety of backgrounds, including DO's and foreign MD's. And if I had to rank them based on intelligence observed during conferences, rumored board scores, and presentations at meetings/pubs, I'd say that the educational hierachy went a LOT like this:

1) MD/PhD's just blew the socks off everyone else
2) Foerign MD's - I'm guessing because many of them had practiced in their native countires
3) DO's - Yep, you read that right
4) MD only
Now I'm wondering how many people who agree with Yaah are AP only and/or research oriented??? Because the stuff described with fellowship selection is par for the course in academic environments.

There are ****loads of mediocre and crappy residents and med students everywhere and in every field. Subpar could mean a couple of different things...

I specified subpar but by adding crappy you've changed the entrie context of what I said. Wow, you must be a Bush republician. Perhpas there wouldn't be so many crappy and subpar to use your term, folks in medicine if so many docs weren't so unwilling to rat each other out.

@DarksideAllstar, me thinks that residency is going to be your very first REAL job.🙄

 

[yaah]

And if I had to rank them based on intelligence observed during conferences, rumored board scores, and presentations at meetings/pubs, I'd say that the educational hierachy went a LOT like this:

1) MD/PhD's just blew the socks off everyone else
2) Foerign MD's - I'm guessing because many of them had practiced in their native countires
3) DO's - Yep, you read that right
4) MD only
Now I'm wondering how many people who agree with Yaah are AP only and/or research oriented??? Because the stuff described with fellowship selection is par for the course in academic environments.

No offense, but that comment is not very knowledgable. The best pathologists are not MD/PhD. Nor are the best pathologists MDs. Nor are they researchers. They are people who simply excel in the field, you can't predict it based on background. That's prejudicial and I hope you drop these biases before you enter residency. Unfortunately, many people do not drop these biases and they go on thinking that MD/PhDs are automatically better candidates or the FMGs are automatically substandard candidates (pick your choice or add a different one). Generally, people also fail to recognize their own biases but are very quick to point out perceived bias from others. You want to be an MD/PhD, therefore you clearly have more respect for them than you do for MDs. You would never have posted such a ranking if you didn't think that.

The vast majority of people out there in pathology (both in residency and in practice) are MD only. I have met people from every category you mention and in every category there are people who are excellent pathologists and there are people who are not excellent pathologists. They may be excellent at something else, I don't know, I wasn't evaluating that. And frankly I don't think most of that is relevant to the discussion. You can be a super researcher but if you aren't a very good diagnostician why should you get a diagnostic fellowship spot? You don't need to do a fellowship to be able to do research. I am not saying there are tons of residents out there who are terrible. All I am saying is that when you start to see more and more residents, you begin to realize that there is a stratification of talent and ability. Not everyone is super. Many are average. But "average" in this case often means they are excellent and competent physicians. But there are also some who just rise above (for various reasons, be they research ability, logical thinking, superior communication skills, whatever). To say that some residents are subpar compared to others doesn't mean that they suck. But darksideallstar is right - there ARE residents who simply do suck. It's a fact of life.

To say that all the MD/PhDs you met were outstanding and blew the socks out of everything else just tells me that you haven't met that many. You may think you have, you may have just had a completely lucky time in meeting great ones. Of course most MD/PhDs are smart people, would be great pathologists, etc, but so are most MDs, DOs, FMGs, whatever. It also could imply that you are seeing them not as pathologists but as something else, in which case your evaluation scheme doesn't apply here. Are MD/PhDs and foreign grads likely to be better at bench research? In general, probably more are. But why is that? Because they DO bench research! Personally, I didn't go into medicine so that I could do bench research. Some people do, obviously. If I wanted to do bench research I probably would have gone to grad school.

Obviously, the MDs you have met haven't impressed you, but there are probably reasons for that. Ranking people or stratifying them based on background is not helpful nor is it remotely accurate.

In my "real life" consisting of med school and residency, I have met people in all the categories you mention as well. And yes, I have met people in every category who are stellar, and people in every category who I would call a *******.

Don't imply that I know nothing about fellowships, pathology, and/or research because I'm not an MD/PhD. This is the kind of academic and intellectual elitism that makes many people cringe and causes a lot of problems. It also prevents many excellent and intelligent people from going into academic medicine, because they get discouraged and do not get mentored appropriately. I have seen this too.

 

[1Path]

No offense, but that comment is not very knowledgable. The best pathologists are not MD/PhD. Nor are the best pathologists MDs. Nor are they researchers. They are people who simply excel in the field, you can't predict it based on background. That's prejudicial and I hope you drop these biases before you enter residency. Unfortunately, many people do not drop these biases and they go on thinking that MD/PhDs are automatically better candidates or the FMGs are automatically substandard candidates (pick your choice or add a different one). Generally, people also fail to recognize their own biases but are very quick to point out perceived bias from others. You want to be an MD/PhD, therefore you clearly have more respect for them than you do for MDs. You would never have posted such a ranking if you didn't think that..

I NEVER said the best pathologist were MD/PhD's, I said from what I saw at the NIH which is MY opinion and I stand behind it, think whatever you like. Hell, I just happen to know that most pathologists are NOT MD/PhD's and I didn't have to go to med shool to figure that on out either. 🙄 Your reponse is unwarrented and the tone of it clearly relates to some deeper issue you have with MD/PhD's. I NEVER said they were "better" but they are generally speaking "better" trained after medical school when it comes to performing research. That's just a fact whether or not there's an MD/PhD in my future or not. So no, it's not about having more respect for MD/PhD's, its about me not being afraid to share my opinions on a public forum despite the risk of unwarrented backlash.

To say that all the MD/PhDs you met were outstanding and blew the socks out of everything else just tells me that you haven't met that many. ..

You're right I haven't met that many pathologists, but so what? It doens't change what I thought about the ones I DID meet at the NIH, and for sure I will have met hundreds by the time I get to where you are in residency. ASIP 2007?? I'm there and if things go well, ASCAP in 2008!

Obviously, the MDs you have met haven't impressed you, but there are probably reasons for that. Ranking people or stratifying them based on background is not helpful nor is it remotely accurate. ..

And why would you assume this, based on the fact that I thought MD/PhD's and foreign med shool grads at the NIH are "smarter"? Well no wonder you don't do research!🙄 Obviously if you had read my post with even an ounce of objectivity you would realize that I DID state that ALL of the path residents I met at the NIH Pathology were solid and none "subpar". Not only that, but the sharpest pathology resident I've every met was a DO (and lucky for me a personal mentor) a FACT that I've stated many times IN this fourm in SDN. So there goes your false theory about the superior knowledge I feel MD/PhD's have🙄 Once again, your obvious sore spot about MD/PhD's precluded you from reading what was REALLY in my post.

Don't imply that I know nothing about fellowships, pathology, and/or research because I'm not an MD/PhD. This is the kind of academic and intellectual elitism that makes many people cringe and causes a lot of problems. ..

Once again I didn't imply ANYTHING directed at YOU personally, but I'm not going to waste any more time defending what I said. At this point, you can think whatever the hell you like!

And in case you're wondering, no I didn't vote in your stinkin' poll!😛

 

[Adrian Cocot]

They beat this topic into the ground every single CAP Resident forum meeting, and every single time, they come up with nothing. Which is unfortunate.

I totally agree that the current system is flawed, but the problem with having a match or set timeline is that there is no official body to enforce programs to adhere to it. Any non-boarded fellowship is run by the director, who does not have to answer to anyone. Neither the ACGME nor the ABP want to touch this with a six-foot pole. As for the boarded ones -- Derm tried to get something together a few years ago, but after a brief round of talks left the whole thing alone.

The problem has already been mentioned before -- in order to have any kind of match system, you need a board that will decide on standards and criteria, both for the fellowship and the matching process. As more than half of the current fellowships don't even have a board (especially the competitive ones like GI and GU), it becomes almost logistically impossible to make all fellowship directors adhere to a single standard.

So unfortunately, as much as we may talk about this, it's quite unlikely that anything will happen, especially as long as we're residents. Nowadays some PD's are telling residents about looking around for fellowships their first MONTH of residency. It seems ridiculous to start so early; personally, I think people shouldn't even look for a fellowship until after their second year of AP. Which is just another reason why the residency should still be five years, but that's another thread entirely.

Bottom line, your best bet is learning how to work the system instead of waiting around for someone to change it.

 

[PathOne]

True. Changing ANYTHING in medicine is a true uphill battle. I know, that in Europe they're currently having a huge fight over Dermpath, because they're trying to get a pan-European system, but in some countries tradition dictates that skin biopsies are read by paths, and in other countries it's derm territory. So obviously, the end result is that they'll have meeting after meeting (more like catfights, but that's another matter), and absolutely nothing happens.
You'd think that they could just adopt the US system of a joint subspec, but noooooo...

I could just imagine what would happen, if ABP tried to take formal control over all Fellowship training. It would be bloody, and likely end nowhere.

 

[b&ierstiefel]

You mean like the RISE? 😉 This is a reasonable proposal and perhaps the most ethical, but it would NEVER work.

Wow...quite a lot of discussion (and some confrontations!) have taken place since I last checked this thread!

Anyways, I did have the RISE in mind...and I also feel it would not work either. I guess that post I made was written in the spirit of Jonathan Swift's "A Modest Proposal"

I'm not gonna quote various posts but I do share yaah's concern about the generalizations made about MD/PhD's, MD's, etc. You can't stereotypically say who is smarter and who are better pathologists. I've seen a bit of the spectrum myself; fortunately, I can say that the MDs and MD/PhD attendings I've signed out with are quite talented diagnosticians. As for the skills amongst our residents, there's a mix of people. Some people are stellar, some people are not so great, and some are in the middle. The degrees after our names, at this stage of the game, mean little to nothing.

And yaah, I share your frustration with people who have elitist attitudes. These people expect **** to be handed to them when they do very little. Of course, the problem worsens when these people are great schmoozers...but their fellow resident peers aren't stupid and notice and don't take them that seriously. Now, I will admit that I was elitist when I started residency. As 1Path was kinda alluding to, I was very proud...I had a strong record and was applying to a essentially non-competitive residency. I wanted benefits to come to me automatically...well, those sentiments evaporated pretty quickly Residency is a different ballgame. Pathology is a different ballgame...it's a skill and you have to master it if you're gonna be good. Whether you're MD/PhD or MD don't mean jack ****. So, 1Path, please keep this in mind.

 

[b&ierstiefel]

👍 👍 👍

Yep, medicine isn't some magical fairyland where everyone is hard-working, smart, nice, have no personality disorders, etc. And in pathology, you really have to watch out for number 2, b/c there are still a lot of people who think path is going to be some cakewalk residency (which I guess it is if you compare it to a surgery or medicine intern year, but it's not a cakewalk if you compare it to some 9-5 job).

Darksideallstar and CameronFrye...

Word!

 

[CameronFrye]

I NEVER said the best pathologist were MD/PhD's, I said from what I saw at the NIH which is MY opinion and I stand behind it, think whatever you like. Hell, I just happen to know that most pathologists are NOT MD/PhD's and I didn't have to go to med shool to figure that on out either. 🙄 Your reponse is unwarrented and the tone of it clearly relates to some deeper issue you have with MD/PhD's. I NEVER said they were "better" but they are generally speaking "better" trained after medical school when it comes to performing research. That's just a fact whether or not there's an MD/PhD in my future or not. So no, it's not about having more respect for MD/PhD's, its about me not being afraid to share my opinions on a public forum despite the risk of unwarrented backlash.
You're right I haven't met that many pathologists, but so what? It doens't change what I thought about the ones I DID meet at the NIH, and for sure I will have met hundreds by the time I get to where you are in residency. ASIP 2007?? I'm there and if things go well, ASCAP in 2008!
And why would you assume this, based on the fact that I thought MD/PhD's and foreign med shool grads at the NIH are "smarter"? Well no wonder you don't do research!🙄 Obviously if you had read my post with even an ounce of objectivity you would realize that I DID state that ALL of the path residents I met at the NIH Pathology were solid and none "subpar". Not only that, but the sharpest pathology resident I've every met was a DO (and lucky for me a personal mentor) a FACT that I've stated many times IN this fourm in SDN. So there goes your false theory about the superior knowledge I feel MD/PhD's have🙄 Once again, your obvious sore spot about MD/PhD's precluded you from reading what was REALLY in my post. Once again I didn't imply ANYTHING directed at YOU personally, but I'm not going to waste any more time defending what I said. At this point, you can think whatever the hell you like!

And in case you're wondering, no I didn't vote in your stinkin' poll!😛

I can't figure out what the hell any of your posts are talking about. You ask what yaah meant by a subpar resident and then you go off on some ridiculous tangent about mudphuds, the NIH, research, yaah's hatred of mudphuds, etc. No one was talking about any of that stuff. YOU brought up mudphuds. You then say that mudphuds are the best trained for research. Who gives a ****? No one was talking about that. This thread is about filling fellowships that are supposed to be mostly focused on training diagnosticians and there are definitely subpar diagnosticians. That's just the way it is.

 

[yaah]

I NEVER said they were "better" but they are generally speaking "better" trained after medical school when it comes to performing research. That's just a fact whether or not there's an MD/PhD in my future or not.

This thread wasn't about research, it was about pathology fellowships. But whatever, this is a sidetrack and not that relevant. If you want to think I have something against MD PhDs go right ahead, it's the furthest thing ever from the truth. For what it's worth, I just encourage you not to generalize. It doesn't get anyone anywhere. And to be fair, pathology residency is not technically about research. That's what post docs are for. Residency is for training to be a pathologist. If you have time to do research during elective times, etc, that's good and should be encouraged.

I totally agree that the current system is flawed, but the problem with having a match or set timeline is that there is no official body to enforce programs to adhere to it. Any non-boarded fellowship is run by the director, who does not have to answer to anyone. Neither the ACGME nor the ABP want to touch this with a six-foot pole. As for the boarded ones -- Derm tried to get something together a few years ago, but after a brief round of talks left the whole thing alone.

Don't boarded fellowships have some rules to adhere to in regards to their selection process? I was under the assumption that they were required to interview a certain number of people, including people from "diverse backgrounds" and other institutions, and some other things. Is this not true? I guess even if it were true the ACGME probably wouldn't remove accreditation based on these things anyway.

I was also under the impression that there is some kind of regulatory agency that potentially can be involved in so-called "selective" pathology fellowships. I think they often include surg path or perhaps research based electives. As of now, the residents in our program who are in boarded fellowships are called "House officers" just like the rest of the residents, but those in non boarded fellowships (like the surg path fellows) are considered "lecturers" and have some privileges normally accorded to staff. But I believe there is a possibility that at least some will switch back to being house staff if some regulations come into play.

But in regards to boarded fellowships being ACGME regulated, I don't understand, if this is true as I said above, how some boarded fellowships (like heme or derm) can simply select their candidates 3 years ahead of time without any significant interview process or outside candidate consideration. Can they get away with this or is it a matter of looking the other way?

It's interesting to hear that this keeps getting brought up at meetings. Obviously to me it is an issue of priorities. There really isn't any incentive for program directors to change their policies - so why should they? To me, the mission of the fellowship should be to train residents as the next generation of specialists, and it should be a resident driven and somewhat resident regulated endeavor. But what do I know.

 

[1Path]

As 1Path was kinda alluding to, I was very proud...I had a strong record and was applying to a essentially non-competitive residency. ......Whether you're MD/PhD or MD don't mean jack ****. So, 1Path, please keep this in mind.

I'm not sure what you mean by keeping things in mind. I've lived in the real world for quite some time now so if nothing else, I realize the importance of connections. But if you're telling me that 2 applicants to a fellowship program with all things being equal including a$$ kissing ability, except that one has an MD/PhD, are considered the same, I'm going to say that's a pipe dream based on my observations especially if we're talking about the "highly" regarded programs.

Now about having an MD/PhD or MD not meaning **** to you, I say live a little longer. Because given all the employment opportunities OUTSIDE of medicine available to folks with those letters behind their name, I'd say it's "hella hella" important to a LOT of other people.

 

[yaah]

1path, this thread is not about you, and it is not about whether MD/PhDs are better than MDs, or whatever. That's the most pointless argument ever and not only is there not an answer, there shouldn't even be either an answer or even an argument. Both Bierstiefel and I are talking about not having elitist attitudes, in whatever form that takes. Can we keep it on track please?

 

[1Path]

1path, this thread is not about you, and it is not about whether MD/PhDs are better than MDs, or whatever.

Pathetic!🙄

 

[DarksideAllstar]

After this post, I shall refrain from engaging in anything other than debating the merits of a fellowship match. Thank you for your cooperation.

So I spent 3 years at the NIH working in the path department and for the uninformed, that means directly with the residents. So I'll conceed a sample size of one but a situation that most of you here won't have BEFORE you choose your residencies/fellowships. Doesn't make me an expert in evaluting anything but when combined with my 15 years in academia (medical research) and 3 in industry, gives, me some REAL life experiences to compare that expereince with.

How does your "real life experience" somehow make you more apt to identify "subpar" performance. I mean, really, does it require 18 years of twiddling your thumbs trying to figure out what you are going to do with your life to realize that some people suck at what they do? And yes, I worked in path with path residents as med student, doing real anatomic pathology autonomously, so I do have some basis for my expertise in identifying a crappy/subpar resident.

I can't recall ONE subpar resident the entire time I was there and they had a variety of backgrounds, including DO's and foreign MD's.

Well, if we are going to base everything on anecdotal evidence, I'm sure I could find at least 50 people on this site, who are actually in medicine, who would agree with me that there are subpar/mediocre/crappy residents in every field. But alas, I don't have 18 years of experience working in a lab to tell me that medicine is not full of ******s. Instead all I have is 4 years of medical school and a year of an AP residency at a "prestigious" academic medical center under my belt.

I specified subpar but by adding crappy you've changed the entrie context of what I said. Wow, you must be a Bush republician. Perhpas there wouldn't be so many crappy and subpar to use your term, folks in medicine if so many docs weren't so unwilling to rat each other out.

sub·par (sŭb-pär') adj.
Not measuring up to traditional standards of performance, value, or production.
Below par in a hole, round, or game of golf.

I think identifying someone as subpar does imply crappy, particularly in the field of medicine where small things that people screw up have the potential to have disastrous outcomes. I've never heard any physician defend another from criticism if it was deserved. I have seen people not send referrals to surgeons or subspecialists if they have poor outcomes or do a **** job talking to their patients. It is unrealistic to take out a full page ad in order to "out" a ****ty doc though, and most of the ones who f up enough to cause real harm end up being out of practice anyway. BTW, nice try with the political jab (I'm guessing you ran out of other things to say that have any relevance to the conversation at hand). Oh yeah, and make sure its directed at a Republican next time.

@DarksideAllstar, me thinks that residency is going to be your very first REAL job.🙄

Well, you'd be wrong there, too. Much like dermpathlover, my days of taking anything you post seriously are over. I will only respond in the future in order to poke fun at your unfounded proclamations that you know anything at all about pathology or medicine in general. When (if) you get into med school and see a bunch of incompetent/lazy bastards in your class, you'll realize many of us were correct in our assessment (our cumulative n being much greater than 1). If you don't find anyone that meets the criteria that I so eloquently described above, I would suggest taking a hard look in the mirror-- maybe that someone is you.

EDIT: I almost forgot, the thing that solidified all of my observations of your actual knowledge of medicine or the intricacies of actually securing a residency or fellowship, was this:

but lack the CV "bling" of a kick a$$ step 3 score

 

[djmd]

sub·par (sŭb-pär') adj.
Not measuring up to traditional standards of performance, value, or production.
Below par in a hole, round, or game of golf.

I think identifying someone as subpar does imply crappy, particularly in the field of medicine where small things that people screw up have the potential to have disastrous outcomes. I've never heard any physician defend another from criticism if it was deserved.

While the use of par (by Yaah) is more even handed than saying average. Suggesting that sub-par (sub-average) anything is automatically crappy is extremely short-sighed.
Real medicine is nothing like medical school, cases don't have right answers (or not all of them), good and great pathologist can miss cases. And even two definitely qualified pathologists can disagree on a Dx.

Yes, bad residents exist. But sub-par =/= bad. A sub-par dermpath fellow candidate is not a bad path resident. It all depends on where one wants to set Par. Even worse is when people use the term average. By definition there is always below average. Sub-par is not an absolute, but depends on who and how par is set.

 

[b&ierstiefel]

Can we rename this thread, "MD/PhD vs. MD only pathway" please?
This topic is starting to devolve into something that belongs in the MSTP forum.

Anyways...I step away for a bit and there are more essay-length posts to read! 😛

This kind of topic (well the original topic at hand, I mean) came up indirectly last year amongst me and two of my classmates...both of whom were MD/PhDs btw...but that isn't important.

An anecdote:

They were AP only and one was interested in AP/Heme and the other was interested in AP/NP. But the slots for the 2007-2008 year for both were full! Basically agreements for these spots were made even before my classmates and I had even set foot into residency! As you can imagine, this caused some angst as they were faced with either applying for a fellowship elsewhere versus doing a different fellowship here versus god-forbid, doing CP. See, going somewhere else really wasn't an option since they wanted to do their postdocs HERE! I mean, hell, that's one of the biggest reasons why they came HERE to do residency instead of elsewhere. So being on the receiving end of the bitchslap stick is quite frustrating. So what do they do? They go into panic mode and look to secure a different fellowship here as early as possible. As a research-minded individual, why even do a fellowship if you're not doing the fellowship you really set your heart out to do? Well, the reasoning was, they wanted some limited subspecialty signout opportunities during their postdoc years to keep their feet wet in diagnostics (many faculty here highly encourage us research-minded folks to do a fellowship before postdoc...which makes sense).

--I'll interject here by saying that even the hard-core research-minded people, who are gonna be subspecialty diagnosticians anyway rather than general surg path diagnosticians, are doing non-boarded fellowships if they can't do boarded ones because the ABP no longer allows AP only folks to do just 2 years of AP and then postdoc. Rules have changed...we have to do 2.5 years. So why not kill 2 birds with one stone and get some subspecialty training for a year and then do a postdoc?

OK...back on track here...so imagine if this is the thought process these days? First year residents are going to enter their respective programs only to find that many fellowship spots are filled already by people much more senior to them. This problem will only perpetuate, I feel, if this trend continues.

Post-script to the anecdote: This was brought to the attention of the higher-ups. An email was then sent out to the fellowship directors advising them to try to adhere to some defined timeline. But these are not hard and fast rules because the ABP or whatever ruling body hasn't set absolute rules as to when and how early applications/considerations for any given fellowship position can open up.

Now, again, should there be a match process for any given fellowship, non-boarded and boarded? I think this would be an extreme step. Let me be a little selfish here...why do we always have to strive to level whatever playing field we're on? When it comes to my career, the microcosm I live in right now is enough for me to handle...all of rest of you don't exist...I don't have enough time to even think about how much it would suck if I had to contend with the rest of you all when it comes down to advancing my career 😛 😛 😛 😛 nanananananananana 😛 😛 😛

 

[b&ierstiefel]

1path, this thread is not about you, and it is not about whether MD/PhDs are better than MDs, or whatever. That's the most pointless argument ever and not only is there not an answer, there shouldn't even be either an answer or even an argument. Both Bierstiefel and I are talking about not having elitist attitudes, in whatever form that takes. Can we keep it on track please?

The stratification of MD/PhD vs. MD folks really dates back to undergrad years when respective folks decide what track they want to pursue. From looking at my peers, here's my synopsis (to a small extent, satiric):

MD/PhD applicants mostly did lab research during their free time. They bettered themselves and the pipets around them. For me, I must admit, the MD/PhD was the backdoor into med school based on the strengths of my premed application. It's not that I'm necessarily smarter...I'm just not very compassionate....and don't tell stories of how I made homeless Bob jump for joy when I donated my Sega to him on 27th and N. Calvert, only to go back home feeling all happy while tears of compassion and empathy rolled down my chubby little cheeks.

MD applicants did community service, bettered themselves and the people around them.

Once in med school, MD/PhD students took MS1 and MS2 years less seriously because they knew that (a) these grades don't matter; and (b) these grades really don't matter when they're like 6-8 years old! Both the MD and MD/PhD students studied for and had to take the same Step 1 exam. Both of these groups studied their balls off for a month and did well.

MD/PhD students then go to lab to spend X years away from medicine to forget it all. They come back to the wards and didn't get great clinical grades because grad school mellowed them out (so they don't suck up to attendings) and they forgot all their stuff (so they don't perform well when pimped by the attendings).

So are MD/PhDs that much brighter necessarily than MDs? In order to make any support for this argument, one must deconstruct these two populations and try to find some element of distinction at an early age...perhaps fetal week 16?

 

[Adrian Cocot]

Don't boarded fellowships have some rules to adhere to in regards to their selection process? I was under the assumption that they were required to interview a certain number of people, including people from "diverse backgrounds" and other institutions, and some other things. Is this not true? I guess even if it were true the ACGME probably wouldn't remove accreditation based on these things anyway.

I was also under the impression that there is some kind of regulatory agency that potentially can be involved in so-called "selective" pathology fellowships. I think they often include surg path or perhaps research based electives. As of now, the residents in our program who are in boarded fellowships are called "House officers" just like the rest of the residents, but those in non boarded fellowships (like the surg path fellows) are considered "lecturers" and have some privileges normally accorded to staff. But I believe there is a possibility that at least some will switch back to being house staff if some regulations come into play.

But in regards to boarded fellowships being ACGME regulated, I don't understand, if this is true as I said above, how some boarded fellowships (like heme or derm) can simply select their candidates 3 years ahead of time without any significant interview process or outside candidate consideration. Can they get away with this or is it a matter of looking the other way?

It's interesting to hear that this keeps getting brought up at meetings. Obviously to me it is an issue of priorities. There really isn't any incentive for program directors to change their policies - so why should they? To me, the mission of the fellowship should be to train residents as the next generation of specialists, and it should be a resident driven and somewhat resident regulated endeavor. But what do I know.

I don't have anything that's actually on paper, but given my personal experience (which may or may not be accurate) with the in-house fellowships here, as well as the round table discussions at the CAP-RF with folks from the ABP and ACGME, my impressions are:

- There are no regulatory agencies; the individual boards have not implemented guidelines for the application process, only for the training requirements. There are no guidelines for choosing whom to interview. Nothing is standardized, not the funding, even the applications. Thus, it's not a matter of 'looking the other way'; rather, it's a matter that there isn't anyone that's looking in the first place.

- The ACGME only accredits fellowships, and they only look at the academic aspect.

- Program directors can't do anything. They have no control over fellowships, only residency issues. Fellowship directors are rarely program directors; they may be department (or subdivision) heads. They may not be interested in training, as much as they may want a research monkey. And the money that they generate from the consult service may even be what's funding the fellowship.

Again, I agree completely with your ideas about fellowship training. But the sad truth (for now, at least) is that due to the trends and demand for subspecialty training, it's a seller's market with no system of checks and balances.

Not to attempt to derail this, but I think LADoc's idea of forcing everyone to do a combined surg path/derm fellowship is a good one. I still don't know why the fifth year was taken away, I can only guess it was because residents used the year to **** around. I would have loved to have an extra year of AP, with 6 months being heavily focused on general surg path/derm, and 6 months of elective to do whatever. It would decrease the demand for fellowships considerably, and would probably be more in line for the type of training and experience you need to easily transition into your private practice job.

Because, seriously. Who needs to train a year with Rob Petras to be able to sign out tubular adenomas in your community practice? He ain't going to teach you how to read neuro frozens.

 

[DarksideAllstar]

While the use of par (by Yaah) is more even handed than saying average. Suggesting that sub-par (sub-average) anything is automatically crappy is extremely short-sighed.
Real medicine is nothing like medical school, cases don't have right answers (or not all of them), good and great pathologist can miss cases. And even two definitely qualified pathologists can disagree on a Dx.

Yes, bad residents exist. But sub-par =/= bad. A sub-par dermpath fellow candidate is not a bad path resident. It all depends on where one wants to set Par. Even worse is when people use the term average. By definition there is always below average. Sub-par is not an absolute, but depends on who and how par is set.

You're right, I probably did over-exaggerate my equatiing subpar with crappy. I think my definition of sub-par is probably very similar to Yaah's original post, but at the same time people who are completely clueless or so lazy that they impede others from getting their stuff done could be called sub-par or crappy. Its all semantics. I have no doubts that even the "best" or most experienced pathologists or clinicians will occasionally miss something--the good ones will own up to it, and their overall diagnostic/therapeutic acumen would probably not be "sub-par". I still stand by my statement that their are **** heads everywhere and 1Path's proclamations are absurd.

BTW, I voted for option #2. I think some level of standardization is order, but I wouldn't go as far as a "match" for fellowships. Do you think that if there were a fellowship match, that they would set up loopholes so programs could offer spots "outside" the match, similar to what residency programs can currently do?

 

[pathstudent]

As I am discovering, the process of getting pathology fellowships does not have any kind of match, it's more like a job search. You apply to individual places and they decide on their own timeline when they will interview you (if they do), and then after that they decide on their own timeline if they will offer you a position, and then it is their timeline as to how long you have to accept it or lose it. And these timelines vary incredibly, from those who fill fellowships over two years in advance to those who want to fill them about a year or so ahead of time (if not less).

Personally, I find this system to be an abomination. Obviously it works well for some people, but in my view it certainly doesn't optimize things for better candidates. Some programs favor internal candidates to the exclusion of others. Other programs ignore internal candidates or marginalize them. The good candidate is often faced with the proposition of having to decide on a fellowship before they even interview at programs they might be interested in, or risk losing out totally. And since the system is generally frontloaded, you have to apply or start applying 2 years in advance, which is also too much. An AP only candidate will only have had one year of training before they have to apply. Terrible.

Other fields (like IM) have a match-like system. I much prefer this.

I know there are some who will defend the current system, and they will argue that it favors stronger candidates, it's much easier to navigate, etc. Bull****. If they truly were rolling admissions I would somewhat understand. But they are not. If they were all on similar timelines, I would somewhat understand. But they are not. And the programs often publish application timelines on their websites which are not accurate. Generally, people who defend the current system are those who lucked out.

Anyone want to defend the current system? It may work out in my favor (probably will, actually), so that isn't the point.

I don't think it is a disadvantage to the resident/applicant. They can always accept a position and then change their mind if they get a different fellowship they would rather do or a job they can't pass up.

And just because there is a match doesn't mean that programs won't favor internal candidates. It just adds more formal BS for them to go through in order to accept their internal candidates, in other words, a big huge waste of time for everybody (directors, internal and external applicants).

Lastly, how can you get all fellowship directors to agree to a similar timeline?

 

[yaah]

I don't think it is a disadvantage to the resident/applicant. They can always accept a position and then change their mind if they get a different fellowship they would rather do or a job they can't pass up.

Is this true though? I was under the impression that some fellowship contracts (not all) had some sort of language that prevented you from taking a similar fellowship at the same time (so you can't back out if you find something better). This may even extend to fellowships in other specialties, couldn't it? I have never actually seen one of these contracts but am going by what I heard. If that was allowed to happen there would be chaos. You could of course back out, as you said, if your career plans changed or you decided not to do a fellowship at all. And as I have said repeatedly above, it IS a disadvantage to the majority of applicants because you shouldn't have to decide on your career before you even experience it. Too far in advance.

As to your point about whether you could even get directors to adhere to a timeline, that's probably right. I don't know what punishment you could instill. You could take away their acgme accreditation (if it's a boarded fellowship), but that's extreme and unlikely to happen, even though it would be a reasonable step to take.

Perhaps where things are going is that when you apply to residency you will basically be applying to your fellowship at the same time. If that's true, why not build it into the match? Have one AP/DP spot, one AP/GI spot, etc? To me, that's equally bad if not worse. How many people, honestly, know for certain what they want to go into and whether they are suited for it before residency? You might have an inkling of what you want, or you might have an idea to go into a field because that was where you research was. But that means people who discover talents or interests at the APPROPRIATE time are ****ed. Do we really want that to happen? It just bothers me is all. You shouldn't have to make your career goals before you know what the hell the career is. It's almost like if you are 12 years old and they ask you what you want to be when you grow up, whatever you say you have to do. Not practical, obviously!

And if some areas (like dermpath or GI) are so obviously needed in the community and academia, then the points above are extremely prescient - people should be getting more training in these areas.

 

[PathOne]

Actually, there's nothing to prevent programs from offering joint Residency/Fellowship spots. I know MGH has (had?) a AP-only/Dermpath track. It's just not widely used.

As per the "backing out" question, you do actually sign a contract, stating that you'll begin as a Fellow on such-and-such a date. So you will in fact be braking a legally enforcable contract, if you call up and say "gee whiz, I don't think I'll be coming after all".

 

[1Path]

The stratification of MD/PhD vs. MD folks really dates back to undergrad years when respective folks decide what track they want to pursue. From looking at my peers, here's my synopsis (to a small extent, satiric):

MD/PhD applicants mostly did lab research during their free time. They bettered themselves and the pipets around them. For me, I must admit, the MD/PhD was the backdoor into med school based on the strengths of my premed application. It's not that I'm necessarily smarter...I'm just not very compassionate....and don't tell stories of how I made homeless Bob jump for joy when I donated my Sega to him on 27th and N. Calvert, only to go back home feeling all happy while tears of compassion and empathy rolled down my chubby little cheeks.

MD applicants did community service, bettered themselves and the people around them.

Once in med school, MD/PhD students took MS1 and MS2 years less seriously because they knew that (a) these grades don't matter; and (b) these grades really don't matter when they're like 6-8 years old! Both the MD and MD/PhD students studied for and had to take the same Step 1 exam. Both of these groups studied their balls off for a month and did well.

MD/PhD students then go to lab to spend X years away from medicine to forget it all. They come back to the wards and didn't get great clinical grades because grad school mellowed them out (so they don't suck up to attendings) and they forgot all their stuff (so they don't perform well when pimped by the attendings).

So are MD/PhDs that much brighter necessarily than MDs? In order to make any support for this argument, one must deconstruct these two populations and try to find some element of distinction at an early age...perhaps fetal week 16?

👍

 

[dermpathlover]

This all takes me back to a thread I posted awhile ago with advice to med schoolers.

One of the most important deciding factors on where you go to residency should be what and how many fellowships a program has, and do they play favorites with their own residents. My guess is that all programs show deference to their own residents, but I am sure someone will say their program does not. But as a general rule, you can assume it to be true. In fact you should rank programs by the following formula where we are talking about the number of spots offered.

2Xdermpath + 2XGI +GU+ Hemepath + cytopath + surgpath/2.

Whichever program has the highest score, you should strongly consider going there.

The current system is fine. It gives the advantage to the people who want the spots the most and who are willing to get off their assess the earliest. In other words, it is just like real life.

 

[yaah]

The current system is fine. It gives the advantage to the people who want the spots the most and who are willing to get off their assess the earliest. In other words, it is just like real life.

No, it doesn't and no it isn't. It may give advantage to kiss-asses but that doesn't mean they want the spots the most. It implies that they are willing to do the most to get it, even if they aren't that qualified or if it isn't that appropriate for them. Why should someone have to decide on this before they know what it's like.

In real life, you advance based on your merits and accomplishments, with some other minor factors thrown in, not on whether you were there first.

What would you say to someone who hasn't experienced a field, say hemepath, until midway through their second year of residency. Then they find out that they have a strong aptitude for it, they are fascinated by it, and they want to do it as a career. Do you tell them tough **** because they didn't start doing projects when they were still in med school, and didn't approach the hemepath faculty BEFORE THEY EVEN DID A ROTATION in it?

 

[djmd]

Do you tell them tough **** because they didn't start doing projects when they were still in med school, and didn't approach the hemepath faculty BEFORE THEY EVEN DID A ROTATION in it?

Wait are we talking about Heme or Derm....? (the worst of the worst)

I like how DLP has his spots so the system works according to DLP. The guy who has fellowships locked up 2 and 3 years out.

 

[1Path]

In other words, it is just like real life.

Word!

And not to dwell on the MD/PhD thing again 🙂p ) but I've known a few that had thier fellowships lined up after only one year in residency based I'm guessing on their talent, skill, CONNECTIONS, and publication record.

One of the most important deciding factors on where you go to residency should be what and how many fellowships a program has, and do they play favorites with their own residents

I have geographic restrictions so as premature as it was, I certainly considered this (and working around residents had some influence too) when I decided where I needed to be for the next 10 years.