Surgical Pathology Fellowships: MSKCC vs MD Anderson

[futureresident]

Hello everyone,

I am a resident in the middle of applying and inteviewing for fellowships. I wanted to start a discussion with regards to which Surgical Pathology Fellowships are considered to be extremely strong; fellowships that would likely "open doors" irrespective of whether you wanted to go into academic or private practice.

I have read on an earlier post by LADoc that a Surgical Pathology Fellowhsip at Memorial Sloan Kettering Cancer Center is likely to open doors no matter where you go, whereas MD Anderson would only help you if you wanted to stay in Texas. I don't know if I fully agree with this. Although, MSKCC has some really big names and is always been considered the premiere place to do a surgical pathology fellowship, MD Anderson, also has quite the name for itself. Moreover, over the past few years, MD Anderson consistently has beaten out MSKCC as the number one Cancer center according to US News and World Report (of course which must be taken with a grain of salt). Any comments?

Does anybody have comments/information on any of the big name surgical pathology fellowships? Mayo, Stanford, UCSF, Wash U, MGH, Hopkin, Penn, or others? thanks

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[RyMcQ]

MD Anderson has a great reputation everywhere, as far as I can tell. The idea that someone would disrespect you for doing a fellowship there seems ludicrous.

 

[yaah]

Rankings like this are kind of silly because they don't mean anything. MD Anderson is well known though, if that is what you are going for. You certainly won't be limited to a job in texas because of it.

The only one above I really know anything about is Mayo, from doing a month there. The surg path fellows get a lot of responsibility, but they also take a lot of call (all frozen section calls). The Mayo way of doing things is quite different though, and needs a close look before you decide it is for you.

 

[PathOne]

According to John Mendelsohn, the pres. of MD Anderson, the main reason that they beat MSKCC on the US News ranking is that they have more national patients, while MSKCC patients are mainly from the NYC area - so MDA thus is wider known among referees in the USN survey.
That being said, there's no doubt that BOTH programs are clearly top tier, and overall better than any other program in the world. I would say that they'd also both be a top choice for surg path, although there are other options in some of the subspecs. Personally, I would still rank MSKCC over MDA, but rank MDA over most others, including Harvard, Duke, USCF, WashU etc. for surg path.
Also, for some reason MDA is virtually unknown outside the US - which is obviously a shame, but still a fact. If you'd ever go anywhere outside the US, for work, lectures, whatever, MSKCC would clearly have the name-recognition advantage.

 

[LADoc00]

Both places require INSANE amounts of scut work at the fellowship level.

 

[Ale]

Both places require INSANE amounts of scut work at the fellowship level.

Sorry my friend but you are completely wrong on this one.

 

[Ale]

Also, for some reason MDA is virtually unknown outside the US - which is obviously a shame, but still a fact. If you'd ever go anywhere outside the US, for work, lectures, whatever, MSKCC would clearly have the name-recognition advantage.

Not true either.

 

[caffeinegirl]

Surg path fellowship at MGH is one of the few fellowships out there with sign out responsibility. You can choose 2-3 subspecialties to sign out, and have about half the year clinical duties and half of the year academic time. You're cosigned with an attending the first two weeks you're on service (ie, first two weeks of each subspecialty), and then after that you decide what to show whom at your discretion. The staff are very open to help, and we have weekly consensus conferences for each subspecialty as well. It's a great "transition" year prior to getting out into the real world. You finalize the report...you're the bottom line. There are also few clinical conferences that you present.

As for call, we're back-up for the senior residents who do frozens after hours, and we're on for a week at a time...and we rarely get called in. We also do a few days of signing out frozens during the day.

As for scut...that's what your resident is for!

 

[deschutes]

I suspect you'll also come to find that your decision is also influenced by factors apart from "prestige", e.g. who do you want to work with, is a spot even available at the places with only a handful of positions a year (internal candidates get first dibs).

MSKCC/MDACC/Mayo are "safe" places to apply, because of the sheer number of positions and because they are all well connected in the community - both PP and academia.

 

[pathstudent]

Surg path fellowship at MGH is one of the few fellowships out there with sign out responsibility. You can choose 2-3 subspecialties to sign out, and have about half the year clinical duties and half of the year academic time. You're cosigned with an attending the first two weeks you're on service (ie, first two weeks of each subspecialty), and then after that you decide what to show whom at your discretion. The staff are very open to help, and we have weekly consensus conferences for each subspecialty as well. It's a great "transition" year prior to getting out into the real world. You finalize the report...you're the bottom line. There are also few clinical conferences that you present.

As for call, we're back-up for the senior residents who do frozens after hours, and we're on for a week at a time...and we rarely get called in. We also do a few days of signing out frozens during the day.

As for scut...that's what your resident is for!

That MGH fellowship sounds awesome and a great way to transition into private practice or an academic subspecialized career.

They must have to hire you as an attending but with fellowship pay as medicare and insurers won't pay for work signed out by trainees.

 

[caffeinegirl]

They must have to hire you as an attending but with fellowship pay as medicare and insurers won't pay for work signed out by trainees.

We're paid by the physician's organization rather than the hospital, but at PGY pay as "Graduate Assistants"...that's how we get through the billing process...

 

[yaah]

They must have to hire you as an attending but with fellowship pay as medicare and insurers won't pay for work signed out by trainees.

Many fellows these days (particular surg path or subspecialty surg path) are considered "clinical lecturers" and thus can sign out cases and bill. I can. The difference comes if the fellowship is ACGME accredited and is thus considered as a true "fellowship" where you are a trainee. You are not paid like a clinical lecturer though.

There is accreditation at some places for general surg path fellowships now, I am not sure technically what they are called (selective pathology or something like that?).

 

[deleted57552]

Many fellows these days (particular surg path or subspecialty surg path) are considered "clinical lecturers" and thus can sign out cases and bill. I can. The difference comes if the fellowship is ACGME accredited and is thus considered as a true "fellowship" where you are a trainee. You are not paid like a clinical lecturer though.

Exactly! From comparing notes, this explains the discrepancy of how certain fellows at certain programs can sign out and bill whereas others cannot.

 

[deschutes]

For applicants who are reading this - in case there was any doubt, I wanted to point out that having billing/signout privileges does not necessarily make a fellowship superior.

It does however generally indicate a high level of trust in a fellow's performance.

Those same transition skills can be acquired in settings that don't offer their fellows the option of pushing the "sign-out" button.

Just sayin'.

 

[caffeinegirl]

Agreed!!

For applicants who are reading this - in case there was any doubt, I wanted to point out that having billing/signout privileges does not necessarily make a fellowship superior.

It does however generally indicate a high level of trust in a fellow's performance.

Those same transition skills can be acquired in settings that don't offer their fellows the option of pushing the "sign-out" button.

Just sayin'.

 

[pathstudent]

For applicants who are reading this - in case there was any doubt, I wanted to point out that having billing/signout privileges does not necessarily make a fellowship superior.

It does however generally indicate a high level of trust in a fellow's performance.

Those same transition skills can be acquired in settings that don't offer their fellows the option of pushing the "sign-out" button.

Just sayin'.

Disagree. There is a huge difference between pressing the button when you know someone is going to go over your write up/Dx versus when no one is going to review it.

That MGH surg path fellowship sounds amazing.

 

[stickyshift]

Knowing that it's your name on the bottom line and that treatment decisions will be made based on your judgment makes all the difference in the world: suddenly the diagnoses that you would scribble down with hardly a thought as a resident become heart-in-the-throat, sweaty-palmed decisions that seem to be beyond your meager abilities.
That's what being a first-year attending is like unless you spend your last year of training in a program that gives you as much autonomy and responsibility as possible.

 

[deleted57552]

Knowing that it's your name on the bottom line and that treatment decisions will be made based on your judgment makes all the difference in the world: suddenly the diagnoses that you would scribble down with hardly a thought as a resident become heart-in-the-throat, sweaty-palmed decisions that seem to be beyond your meager abilities.
That's what being a first-year attending is like unless you spend your last year of training in a program that gives you as much autonomy and responsibility as possible.

I agree wholeheartedly. I think that when you do not sign the bottom line on a report, there is always something in your subconscious that tells you that you have backup.

Now, backup isn't a bad thing. Let's say that you have a really difficult case. Some fellows will still consult an attending and have the attending tell him/her to go show the case. If you're the "attending" whether it be as a fellow with signout privileges vs. a junior attending, that step is bypassed because you ARE serving as the attending.

 

[deschutes]

Here's the context of my remark: if it is the trainee's mindset that needs changing, then things like having them push the signout button is are merely tools (albeit a powerful prod) to get them to change their mindset from trainee to an attending having ultimate responsibility for a case.

It doesn't matter whether you do a surg path fellowship + subspecialty at any of the top-rated institutions, or go directly into a 5-person semi-rural group doing general AP+ CP lab directorship after residency (our program yields a wide spectrum of grads), the fact is we are all going to struggle for the first few years with stuff we've never encountered. We'll all have three piles, the "I can do these" cases, the "I know what these are about, but I just have a quick question" cases, and the "NFC" cases. The trick is to be competent, and know when and how to get help.

There are still safeguards in practice e.g. frozen call-a-friend, second review, daily consensus conferences to ensure that pathologists aren't practising completely in a vacuum.

I am saying that there are excellent fellowships where for whatever reason you simply won't be able to push the signout button. That should not prevent applicants from applying. It should not prevent fellows from thinking how they want to word their frozen section diagnoses. It also should not prevent these fellows from taking charge and treating every one of their cases as if they were attendings.

Ideally this shift in mindset would occur during residency so we stop this upward delegation of counting on a fellowship to bring about the necessary skills.

 

[fna]

Previewing your cases as if you had ultimate responsibility is good practice as a resident or non-signout fellow. But in most programs, the main expectation is to get all of your cases written up for your attending in a timely manner. i.e. quantity and TAT limits the quality of your work. So if you do make a mistake, even when pretending as hard as you can that it's real, you have the excuse that "I'd wouldn't have missed that.... if I only had more time". Or if I ordered these stains. Or if it wasn't 2AM. Or, etc. Ultimate responsibility is more than getting to hit the signout button.

The closest thing I could imagine to having actual signout privileges is (if you're in a place that has no TAT or cost pressures) that they allow you to workup cases as you see fit- ordering multiple rounds of immunos, showing select slides, telling a PA to put more tissue through, talking with clinicians, etc. And only when you are 100% satisfied with your report, which with some cases may be a week later, do you give the slides to an attending. Do that for a year, and you'll be well prepared to transition to your first job.

Anything short of that is just a game. For most people for most situations, that type of training is good enough. The first few years after graduation will be intensive on the job training. But pity the graduates, and their patients, whose confidence outweigh their ability.

Analogy: just because I can intubate a plastic torso, even if I try really hard to believe it's real, does not mean I'm ready to intubate a living person.

Better analogy:
http://www.youtube.com/watch?v=wEcu7d4dvXg


Another excellent analogy I wish I had a clip of:

Ripley: How many drops is this for you, Lieutenant?

Gorman: 38. ...Simulated.

Vasquez: How many combat drops?

Gorman: Uh... 2, including this one.

Drake: Ah, ****.


Anyway, signout fellowships aren't that common so don't feel bad if you don't have that opportunity. But it's good training, if you can get it.

 

[caffeinegirl]

Just another point to clarify fellowships for those reading out there...

non-ACGME fellowships (surg path, gi, gu, breast, gyn) are funded usually by departments, and thus you can have sign out responsibilities (depending on your institution)

ACGME fellowships (hemepath, cyto, dermpath) are usually funded by the hospital (same funding as resident spots) and you cannot have sign out responsibilities.

 

[deschutes]

Anyway, signout fellowships aren't that common so don't feel bad if you don't have that opportunity. But it's good training, if you can get it.

That is exactly my point. I'm not trying to discourage readers from pursuing signout fellowships (as if I could or would!). There are a spectrum of residents at all levels who read these forums, and I am trying to prevent some from thinking it's the end of the world if they don't get a signout fellowship, or thinking that they should only apply to signout fellowships, and then end up with nothing because the signout fellowships were mostly filled by internal candidates.