subspeciality vs general

[alaska82]

---

Members don't see this ad.

Hi Friends,

I am wondering which type of signout is usefull to the residents, subspeciality signout or general signout. The program in which I am doing my residency has subspeciality signout and I am curoius how the general pathology signout works?

 

[Pathologee]

General signout is pretty dope. I did residency and fellowship at a place where you get everything at any given time. The only way we separated things were into bigs and smalls. I liked general because you always got to see every type of specimen and had to read about a variety of different cases. You will get a chance to see any organ at any given time throughout your residency. I know some programs that have subspecialty signout may get bone and soft tissue right off the bat, for example, and you may not see it again except on frozens. You will get exposed to all of the clinicians in small doses over your 3-4 years and you can build a relationship with them over time.

The weakness is that you can't really dive into an organ system like you could at a subspecialty place, and you may not get to see consults if you are doing general.

I feel there are two ways to fix this though. After a few months of surg path under your belt, after you are comfortable, try to pick a few organs and really focus on learning that. For example, pick GU and learn about all of the biopsies, resection specimens, staging etc. Just kill it. Continue to read about the other stuff but really dive into the "system of the month."

Number two, which I feel is most important is you must have a good working relationship with other residents and you must share cases! When you are on a light rotation, hang out by the surg path sign out area and eavesdrop on the good cases. Be available to see these cases whenever possible. Set up a buddy system and get a few recuts for you and your buddies.

Although I trained as a generalist, I took a job that subspecializes. I am excited to see how that works out. If anyone could counter on the benefits of subspecialization training and your experience working, I would appreciate it.

 

[KCShaw]

General signout, simply put, means you get all the cases grossed the previous day (or however long your turnaround cycle is), rather than the grossed cases being split up and breast going to the breast resident/attending, GI, neuro, etc. A lot of places mix general and subspecialty signout by virtue of only having, say, a hematopathologist and neuropathologist who take those cases while another AP attending of the day covers the rest. Unless there are huge numbers of cases this is usually the most efficient way to handle the work.

I trained with -mostly- general signout. In retrospect, I think the concept of doing general signout + autopsy early, for much of 1st year AP, has an edge over 100% subspecialty signout from day 1. In my discussions with people who have trained with subspecialty signout, the only thing that has come up with some regularity is that you see one organ system for a couple of months early in 1st year when you're still trying to figure out what a microscope is then never see that organ system again until you hit an elective late when you're already trying to cram for boards. To be fair, I was not a fan of feeling like I needed to read up on primary kidney tumors, hepatic tumors, and thyroid tumors all at the same time during general signout and feel unable to give any of them the attention they deserved, so it's a double-edged sword.

The up side of specialty signout, of course, is that you get to immerse in one organ system without as many distractions -- and I think that's great...once you already have a very basic, but broad, foundation.

 

[green mantis]

I don't think subspecialty signout would've worked at my residency because we covered 3 hospitals. I don't think any of the hospitals had enough volume to support different subspecialties. We also didn't have enough grossing benches. Our specimens were divided into biopsies & surgicals.

Personally, I liked general signout. It meant that I could see a little bit of everything when I was signing out. I tend to get bored easily, so I enjoyed the variety.

Either system can produce competent pathologists, so it's not a big deal in the long run. Also, general sign out is what you'll be doing when you work at a community hospital (like me).


----- Antony

 

[TMZ2007]

How does grossing work in a subspecialized system? Do you only gross your system or do you gross everything then only signout your system?

 

[Euchromatin]

How does grossing work in a subspecialized system? Do you only gross your system or do you gross everything then only signout your system?

We have general signout at my residency, with derm, medical kidney/liver, cytology, and hemepath separated out. It was a little overwhelming at the very beginning of the year. I found Molavi's Practice of Surgical Pathology helpful for the cases that I hadn't yet had time to read in-depth about, as well as a convenient place to jot down notes from lectures and sign out (such that they were organized and I could actually find them later).

Now that I have the basics down pretty well, I really like it. I think the variety of different cases not only makes the day less boring, but it seems less tedious (and I seem to remember more) when I can read in small bites (i.e. about a specific disease entity and its differential diagnosis) based on the cases I have that day instead of trying to read based on a particular organ system. Another benefit of general signout is that we get the opportunity to work with many different attendings, so we see multiple examples of how particular types of cases are signed out (i.e. what different criteria/cutoffs different people rely on most, different ways of wording dictations, etc.).

In regard to TMZ2007's question, I would hope that residents on subspecialty signout systems are only grossing specimens they will be signing out. I believe it is against the ACGME regulations for residents to gross something without having the opportunity to preview the slides later (except when on call).

 

[pathstudent]

IMO, separating out hemepath, neuropath, cytopath, dermpath, pediatric doesn't equate to partial subspecialty training.

Subspecialty is where you have faculty that look at nothing but breast or liver or GI or Renal or Bone/ST or Lung or Cardiac or ENT or Gyn or Prostate or Bladder etc... That is true subspecialization of surgical pathology.

Only at small community practice settings do non-specialists look at Hemepath and Neuropath and derm and cytology.

Subspecilization is the wave of the present and future. It is like a snowball getting bigger and bigger. As future community practice surgeons and clinician residents train in academic centers with subspecialized pathology, they will demand subspecialty pathology when they move out into the community.

If a woman gets a breast biopsy she will demand that it be seen by a pathologists that does nothing but look at breast.

 

[KCShaw]

It's been my experience that exceedingly few pathologists, and thus exceedingly few institutions, have exclusive subspecialty sign-out at all times. Many of the big names in a given organ system still, at least occasionally, do some general sign-out. It's also been my experience that most employers (academic and private, as well as community) want someone who can reliably and confidently sign out more than 1 organ system, if only for coverage purposes. With the exception of megalabs with multiple subspecialty goons and oceans of cases, exclusive subspecialty signout just doesn't make good sense, and working like that for an extended period could make one less employable in any other setting.

It's also been my experience that even in mid-sized private and academic groups which have 1 or 2 heme, neuro, peds, GI, breast, etc., pathologists that at least at times those cases are not seen by said subspecialty trained pathologists -- it's still a matter of who's available, who's on vacation, and the confidence level of whoever's handling cases. These labs still market themselves as having subspecialists..which they do, and difficult cases would still go to them..but it's not automatically exclusive.

So while I agree that most people (clinicians & patients) would prefer their cases be seen by a pathologist with subspecialty experience/training in their particular organ system, as far as I can tell as a global effort it's impractical from a training and job-market perspective. There just aren't enough cases condensed into small enough areas in enough parts of the country/world to justify exclusive subspecialty signout. Maybe when telepathology becomes practical and widespread? And of course, many of the so-called subspecialties don't "technically" even exist as they have no accredited fellowship, though that's not really the point.

Makes me wonder if the same has been said about other specialties' subspecialists -- though for the moment we still have internists and general surgeons, and apparently an adequate market for them.

 

[pathstudent]

It's been my experience that exceedingly few pathologists, and thus exceedingly few institutions, have exclusive subspecialty sign-out at all times. Many of the big names in a given organ system still, at least occasionally, do some general sign-out. It's also been my experience that most employers (academic and private, as well as community) want someone who can reliably and confidently sign out more than 1 organ system, if only for coverage purposes. With the exception of megalabs with multiple subspecialty goons and oceans of cases, exclusive subspecialty signout just doesn't make good sense, and working like that for an extended period could make one less employable in any other setting.

It's also been my experience that even in mid-sized private and academic groups which have 1 or 2 heme, neuro, peds, GI, breast, etc., pathologists that at least at times those cases are not seen by said subspecialty trained pathologists -- it's still a matter of who's available, who's on vacation, and the confidence level of whoever's handling cases. These labs still market themselves as having subspecialists..which they do, and difficult cases would still go to them..but it's not automatically exclusive.

So while I agree that most people (clinicians & patients) would prefer their cases be seen by a pathologist with subspecialty experience/training in their particular organ system, as far as I can tell as a global effort it's impractical from a training and job-market perspective. There just aren't enough cases condensed into small enough areas in enough parts of the country/world to justify exclusive subspecialty signout. Maybe when telepathology becomes practical and widespread? And of course, many of the so-called subspecialties don't "technically" even exist as they have no accredited fellowship, though that's not really the point.

Makes me wonder if the same has been said about other specialties' subspecialists -- though for the moment we still have internists and general surgeons, and apparently an adequate market for them.

Excuse me, there was once a day when general surgeons did hysterectomies and breast excisions and thyroidectomies and whipples, but those are now restricted to gynecologists, breast surgeons, ent-onc surgeons and hepatobiliary surgeons. General surgeons now restricted to gallbladders, appendixes and that weight reduction surgery.

Internal medicine is incredibly subspecialized to the point now where you have hospitalists and then all the subspecialties (gi, cards, ID, nephrology, pulmonary, hepatology, endocrinology).

Why should path be any different. Yes many hospitals (even some academic ones) don't have the volume to go to pure subspecilization. But it will happen in the future. Small academic centers and private practice pathologists will have to evolve and embrace subspecilization.

In Germany (a large country in terms of population but small in terms of area) has subspecilization across the board. I.e. if you have Hodgkin lymphoma there is one central place for you to go in the country. You are seen by expert oncologists in hodgkin lymphoma, your radiation is given by experts on hodgkin lymphoma, and your pathology is read by an expert in hodgkin lymphoma. That is infinitely superior to the US where your oncologist is seeing two breast patients and a lung cancer patient after you as is your radiation oncologist and your pathologist is a GU or Gi trained community pathologist trying to read your lymph node/

The fed govt needs to take over healthcare in the US and set up regions where you go for treatment and are seem by experts in your disease. It would make a huge difference.

 

[KCShaw]

Many general surgeons market themselves as also having a focus on something, such as GI, laparoscopic, breast, thyroid, trauma, etc. -- most surgical issues are not restricted to subspecialists. The same goes with the medical disciplines. Naturally, subspecialty training is a desired bonus, much as it is with pathology, but it's certainly not exclusive even these days. Now, there are -more- subspecialist surgeons & physicians who work almost solely in their subspecialty of choice than there seems to be in pathology, but many of them still cross-cover general intake to one extent or other in their hospital/institution, less so for those in a private consulting practice.

Unfortunately, exclusive subspecialization still only works when there is enough volume in a small enough area to support it. A "small" area might support a handful of surgeon &/or physician subspecialists, but only one or two general surgical pathologists. But we're talking about big numbers for it to work in pathology, or some way to funnel specimens centrally, and long transport rides are generally not cost effective to the point of supporting a bunch of exclusive subspecialty pathologists. Especially when for the average uncomplicated case a subspecialist simply isn't needed.

We -have- subspecialization, just not exclusive, and not likely to be anytime soon not because it isn't necessarily a good idea but because the logistics simply don't work.

 

[Euchromatin]

IMO, separating out hemepath, neuropath, cytopath, dermpath, pediatric doesn't equate to partial subspecialty training.

No one said that it did.

Also, I think the German model you describe (collecting subspecialists with experience in the same organ system or disease process in the same geographic location, then sending patients there) does indeed sound very good for patient care. However, as you mentioned, Germany has a fairly large population spread over a relatively small geographic area.

I just don't see a similar system being very feasible in the US. Some patients who can afford it do go to nationally-renowned hospitals far from their homes for expert consultation. But given the much lower population density in the US, I think attempting to set up a similar system would be prohibitively expensive.

Not to mention the fact that we couldn't even get a single payer system out of Congress, so a coordinated specialist system like the one in Germany is certainly a long ways off. We got stuck with the watered-down health care reform bill which gives the existing bloated, inefficient, ******* insurance companies lots of fresh meat.