Surprise reactions to "you wont find a job" warning

[Cellpathology]

I am always shocked to see how few medical students respond appropriately to the warning that you will have to, literally, consider jobs all across the United States to find a job in pathology, and will struggle even if you are open to moving anywhere in the country.

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[2121115]

Everyone thinks it won't happen to them. They are a special snowflake. And their academic mentors are giving them the line "there are always jobs for good residents".

 

[turtle1966]

Everyone thinks it won't happen to them. They are a special snowflake. And their academic mentors are giving them the line "there are always jobs for good residents".

Sigh.

 

[Eostar]

They must learn the "good jobs for good residents" line in program director school. I heard those exact words on many occasions in my program.

 

[Thrombus]

That and "you need to be a team player" when they collect most of a resident's paycheck while tacking it on to their own.

 

[pongo]

Or you take don't take Internet complaining too seriously, go into pathology anyway, and watch as just about every person in your training program gets a job they are happy with.

 

[rollwithit]

I am always shocked to see how few medical students respond appropriately to the warning that you will have to, literally, consider jobs all across the United States to find a job in pathology, and will struggle even if you are open to moving anywhere in the country.

Perhaps they spoke face to face with people who have positive experiences? Or maybe they feel the good offset the bad and that overall it's still a great gig? Maybe they are easier to please than you are or have different expectations?

Or maybe this forum is so ill regarded now as a place for hyperbolic whining that any truth stated here is disregarded.

What to value more? Actual conversations with people you trust? The same half dozen posters in the forum that post nothing but complaints about the job market over and over and over?

 

[yaah]

The same half dozen posters in the forum that post nothing but complaints about the job market over and over and over?

Employed posters, by the way.

Look, this is all a complex situation. The job market is not good. But "not good" is not the same thing as "impossible." There are good residents who struggle with getting a good job, they have posted here. You can't dismiss these stories. But neither can you take them as representative of everyone's experience. A lot of people on here dismiss my opinions because they aren't strident or angry, but what can you do? It's rather like politics these days, unless you agree 100% with certain arguments you are dismissed as hopelessly out of touch, biased, or just ignorant. Everyone would do better to have a bit more respect and acknowledgement of others on here. Just because someone has an opinion that another person supports does not mean that that opinion is the most important.

Of course there are problems. Some people are doing extra fellowships instead of getting a job - this is both overblown on this forum as well as underappreciated in academic training programs. There simply are people as well who want to do extra fellowships.

Sometimes being on this forum is like arguing with a random insult generator. Any argument you make gets thrown back at you with zero acknowledgement of points of agreement and commonalities. And there is way too much scaremongering on here, that much is true. Far too little acknowledgement of the reality of medicine as a career and a business in the current age. Comparisons to things that are not valid comparisons. Wishful thinking.

I know I am not alone in this fact: I am in a great job which I love, and I am compensated reasonably well for, and do not plan on leaving. I have respectful and wonderful colleagues. I have a supportive and collegial environment with clinicians and staff. ADministrators are administrators and there are too many of them but there is mutual respect as well. The current environment in medicine is uncertain and at times frightening. Anyone who tells you this is limited to pathology is completely irrational. Anyone who tells you that other specialties are riding high while pathology is not is completely irrational. Pathology has more and different challenges than other specialties, but if you talk to any other clinician they are likely to tell you the same thing about their own specialty. Dermatology is somewhat different, but dermatology is its own world. Whether that world continues to exist in the same fashion is highly debatable however.

Would I do it again? 100% yes. I am not a pollyanna nor am I ignorant nor am I dismissive. I try to be a realist. Being a realist means acknowleging the negatives but it also means acknowledging the positives. There seems to be a near total lack of understanding of the real world at times on this forum. Claims that the government is bad and capitalism will solve things while then 5 minutes later saying the government needs to regulate more and protect us from capitalism. And always the academic programs and national organizations are completely at fault and have nothing to offer except pain and blood sucking. And all this time nothing is ever done about it except ranting anonymously. Rarely are any realistic solutions proposed.

I look forward now to someone skewing my words and saying I'm an apologist or whatever.

 

[Kilgoretrout 65]

I look forward now to someone skewing my words

Let me be the first:

There simply are people as well who want to do extra fellowships.

RRRrriggghhttttt.....

 

[gbwillner]

There are. I have known many. Sometimes it is because they feel they need it to be competitive without even trying the market, sometimes it is because it is a filler year since the fellowship they want is still a year away and they need to do something, and sometimes it is because they are indecisive about what they want to, and sometimes it is because they want to have a very specific niche and feel having two fellowships will give it to them. From what I've seen this makes up almost all people who do a second fellowship. And these have virtually nothing to do with the realities of the job market.

Of course, I come from an ivory tower where everyone gets a job, so maybe it's not reflective of everyone else's experience. In fact, I don't know anyone who couldn't get a job so they scrambled for a fellowship. None.

 

[turtle1966]

I come from an ivory tower where everyone gets a job, so maybe it's not reflective of everyone else's experience. In fact, I don't know anyone who couldn't get a job so they scrambled for a fellowship. None.

I have suspected that you were from an ivory tower, so congratulations. You guys are good. Not to be a spoiler, I have met a recent Harvard medical school residency program graduate in a commercial lab and looking for a better gig. I know it is sample of one, the guy still makes a decent income and it is statistically not significant. I just wish all residencies were as selective as you guys.

 

[turtle1966]

Sometimes it is because they feel they need it to be competitive without even trying the market,

For the select few you mention, I suspect it is "now or never" foresight and job insecurity they see.

 

[Path hall]

I asked a dozen or so private practice pathologists about the job market before I applied. Most of them told me that they have heard that the job market is in poor shape, but none of them personally knew anyone who had trouble finding a job. The other pathologists just looked at me blankly, like they had no idea what I was talking about. None of them told me not to do pathology.

 

[pathperson]

Regarding the comment about derm being its own world - I am a path resident so I have no real idea myself. However I did rotate in a fancy outpatient derm clinic in med school, and I had no interest in telling teenagers the risks of accutane, making them sign a form that said they would call a hotline if they felt suicidal, exchanging skincare tips with vain old hags, etc. There were of course aspects I enjoyed, but I wanted to do path so I did. Life's not perfect, and I do agree with a lot of the comments on here about training. BUT where I am, it is (mostly) non-malignant, and I am getting good training. I know job searching can be very tough, and I am realistic about that. What can I do? Honestly? Listen to a bunch of safely hidden naysayers on the internet and quit my program?

During a recent conversation with 2 derm residents, they said in no uncertain terms that derm is suffering. They said dermpath as a derm is impossible to find a job with ANY dermpath. They had complaints about derm I hadn't even thought of, such as needing to carefully and with a VERY high-resolution camera photograph their patients' faces before injecting any fillers, because these vain old tramps scrutinize their every wrinkle afterwards, and screech at them for creating "new" wrinkles. So they are constantly being yelled at and criticized for their every move, by patients. One of them told me a patient actually thanked her for something, and hugged her, and she almost cried. I told them we in path think everything is so horrible for us, and they strongly stated that things are bad for them too, and that they do not look down on us whatsoever. That they feel very very looked down upon, by patients. Plus they just got slammed in the NYT a few weeks ago for overuse of Mohs. (If you haven't read that article, search for it. There's an interesting discussion in the derm forum here about it.) So no thanks to derm.

I am in a very large hospital system with a high specimen volume and a small residency program. Overall I think my program is pretty good. AP/CP is balanced, general surg path signout, lots of call bc we are a small number of residents. Our hospital system is fully integrated and closed system, so there is no opportunity for surgeons or derm to send their specimens anywhere else. We are sort of mixed private/academic, and affiliated with a medical school. Our dermpath is SQUARELY within our path department. Our chairman is a badass who has been quietly playing the game for many decades, and when that came up for discussion he rose to battle and won.

There is one guy in our place who has said we will find a job if we are good. He says it all the time. If you are excellent, everyone will want you. In his case, he is truly a genius, so it is probably true.

Here's what I have learned from years of lurking here:

1) Pathology is horrible, no one respects you, you will never find a job, you will be poor, you will live in a tent, in a rural area, most likely under a bridge, if your area is even urban enough to build bridges. Otherwise, your tent will be located in a field. The brightest part of your existence will be your opportunities to hunt for "organic" meat right outside your tent.

2) I might find a job, but it will be hard because I did not go to residency on the east coast

3) Do fellowship, bc its impossible to find a job otherwise, but not too many, bc then you look stupid and desperate.

4) I am a woman, so no one will hire me anyway, because woman pathologists are lazy, "only want to sign out one tray of biopsies and then go home" as I once read here, and having babies is BAD. Intelligent people reproducing is BAD. Married couples deciding together to have a baby, which last time I checked falls to the woman, is BAD and is somehow a woman's fault, and she is to be shamed. Where do all you men think you came from? Do you think you just appeared? Hatched from the soil? Your mother gave birth to you, God help her. Maternity leave or paternity leave is BAD. (Wake up people, have you seen Google's parental leave policy?? GOOGLE IT. I know, I know, its never going to happen in medicine bc we are all too poor. But at least someone gets it.) Needing to spend 15 minutes twice a day pumping at work is BAD. (How many minutes a day do people at your hospital spend smoking per day? How many minutes per day do you spend on this forum? If you are a man, how many unreasonably long trips to the bathroom do you take per day? Why does it take you so long? Please don't answer that.)


Anyway, if I can't find a job in pathology, I will find something else to do with my life. I won't kill myself. But I think I will find a job. I think it will be tough. But I don't want to live in Cali or on the East Coast, so I think I will be fine. I wish things in path were still good. Go back and read threads on here from 10 years ago. People sure were in a better mood. Jesus. I do think there are too many residents, and I think the younger people should make cutting positions a priority.

In my opinion, what Yaah wrote on this thread is one of the most refreshing things I have read here in years. I think Yaah is correct. All areas in medicine are suffering. Its not a great time to go into medicine, period. But I did, and I won't switch into another field of medicine. Do you people honestly think that's smart? Spending another 4 plus years in training? In those 4 years, I could be making my mark in my career as a pathologist. If pathology sucks, it is our job to make it suck less. Frankly I don't have a ton of friends whose jobs I would want to have either, for a variety of reasons. You might have to live in a place that's not great, but do any of you people have any friends? Do any of them have jobs? I have friends who travel constantly for their work. That is much worse in my opinion than living in a place other than NYC or wherever. I have a friend who travels with zero notice for up to 3 weeks at a time, year round. That's not a job I would want.

What would be great is if ya'll could bill for your posts. Then maybe you would all be happier )))

 

[yaah]

I asked a dozen or so private practice pathologists about the job market before I applied. Most of them told me that they have heard that the job market is in poor shape, but none of them personally knew anyone who had trouble finding a job. The other pathologists just looked at me blankly, like they had no idea what I was talking about. None of them told me not to do pathology.

This is pretty accurate. A lot of practicing pathologist don't really think much about the job market, as you said. And interestingly, when they do start looking for a candidate there is typically no shortage of candidates but a lot of them will tell you there is often a shortage of a qualified candidate (in their view anyway). Sometimes that's because they want someone with multiple years experience + a specific skill set. And when they advertise a specific position they get applicants who really don't fit that position at all. There are some pathologists though who pay more attention who are more of the opinion that the job market is weak, especially for newer graduates.

 

[yaah]

There simply are people as well who want to do extra fellowships.

RRRrriggghhttttt.....

You obviously don't know many people. There were lots of peopel I trained with or knew through various national committees, projects,etc, who really did do multiple fellowships because they wanted. Derm + heme or GI + heme because they wanted both. Molecular + something else. Some combinations like cyto + derm or GI + GU don't really make sense. There are others for whom the second fellowship was because the second one was the one they really wanted and they didn't get it the first year (like someone I know who did surg + GU). And others who simply change their mind (if you haven't met any of these latter category individuals you are really isolated - they are often the ones in med school who come in sure they want to be a surgeon, then decide they like anesthesia, and then end up in ER). I would agree though that the fact that many residents finish training and do not feel comfortable signing out most things without doing a fellowship is somewhat of an indictment of current training practices as well as, in part, the residents themselves.

I did one fellowship, which is what I do with about 50% of my time at work now, but I cover most other stuff and run 2 offsite hospital labs without having done a fellowship and I am fine with this. Some residents don't realize that they will be fine, especially if they make excellent use of their electives and don't spend most of their electives doing whatever their fellowship is going to be. I spent most of my 4th year and fellowship elective months doing stuff like heme and cyto that I figured I was going to have to do in my future practice. I worked with a resident who used their electives to basically find something that would be 1-2 hours a day. In retrospect I wish I spent more time learning about mundane stuff like QA QC, procedure manuals, coag, but it can be really hard to learn that stuff in residency to any substantial and meaningful level.

Now, there is definitely a substantial subset who are doing multiple fellowships either because they can't find a job or because they think they can't be competitive for a job. I know a couple of these. The problem some people run into is that they get towards the end of the year and they basically panic and take the fellowship because they don't want to risk being unemployed. That's the real world - sometimes you settle and take something that isn't your first choice for fear that something better won't come along soon enough. Sometimes those fears would end up being unfounded. So, you can take this fact as clear proof that the field is failing and dying and you should never go into it, or you can take it as a fact of life and reality, and realize that career paths are not usually perfectly laid out in front of you. Lots of people have to take jobs in parts of the country, at least for awhile, that they don't want to be in. This sucks and reflects badly on the field but it is also not the end of the world. It is far better to take a job you like in an area you don't like as much than an abusive or ****ty job in an area you do like. The ****ty job will almost always be there.

 

[DermViser]

Regarding the comment about derm being its own world - I am a path resident so I have no real idea myself. However I did rotate in a fancy outpatient derm clinic in med school, and I had no interest in telling teenagers the risks of accutane, making them sign a form that said they would call a hotline if they felt suicidal, exchanging skincare tips with vain old hags, etc. There were of course aspects I enjoyed, but I wanted to do path so I did. Life's not perfect, and I do agree with a lot of the comments on here about training. BUT where I am, it is (mostly) non-malignant, and I am getting good training. I know job searching can be very tough, and I am realistic about that. What can I do? Honestly? Listen to a bunch of safely hidden naysayers on the internet and quit my program?

During a recent conversation with 2 derm residents, they said in no uncertain terms that derm is suffering. They said dermpath as a derm is impossible to find a job with ANY dermpath. They had complaints about derm I hadn't even thought of, such as needing to carefully and with a VERY high-resolution camera photograph their patients' faces before injecting any fillers, because these vain old tramps scrutinize their every wrinkle afterwards, and screech at them for creating "new" wrinkles. So they are constantly being yelled at and criticized for their every move, by patients. One of them told me a patient actually thanked her for something, and hugged her, and she almost cried. I told them we in path think everything is so horrible for us, and they strongly stated that things are bad for them too, and that they do not look down on us whatsoever. That they feel very very looked down upon, by patients. Plus they just got slammed in the NYT a few weeks ago for overuse of Mohs. (If you haven't read that article, search for it. There's an interesting discussion in the derm forum here about it.) So no thanks to derm.

I am in a very large hospital system with a high specimen volume and a small residency program. Overall I think my program is pretty good. AP/CP is balanced, general surg path signout, lots of call bc we are a small number of residents. Our hospital system is fully integrated and closed system, so there is no opportunity for surgeons or derm to send their specimens anywhere else. We are sort of mixed private/academic, and affiliated with a medical school. Our dermpath is SQUARELY within our path department. Our chairman is a badass who has been quietly playing the game for many decades, and when that came up for discussion he rose to battle and won.

There is one guy in our place who has said we will find a job if we are good. He says it all the time. If you are excellent, everyone will want you. In his case, he is truly a genius, so it is probably true.

Here's what I have learned from years of lurking here:

1) Pathology is horrible, no one respects you, you will never find a job, you will be poor, you will live in a tent, in a rural area, most likely under a bridge, if your area is even urban enough to build bridges. Otherwise, your tent will be located in a field. The brightest part of your existence will be your opportunities to hunt for "organic" meat right outside your tent.

2) I might find a job, but it will be hard because I did not go to residency on the east coast

3) Do fellowship, bc its impossible to find a job otherwise, but not too many, bc then you look stupid and desperate.

4) I am a woman, so no one will hire me anyway, because woman pathologists are lazy, "only want to sign out one tray of biopsies and then go home" as I once read here, and having babies is BAD. Intelligent people reproducing is BAD. Married couples deciding together to have a baby, which last time I checked falls to the woman, is BAD and is somehow a woman's fault, and she is to be shamed. Where do all you men think you came from? Do you think you just appeared? Hatched from the soil? Your mother gave birth to you, God help her. Maternity leave or paternity leave is BAD. (Wake up people, have you seen Google's parental leave policy?? GOOGLE IT. I know, I know, its never going to happen in medicine bc we are all too poor. But at least someone gets it.) Needing to spend 15 minutes twice a day pumping at work is BAD. (How many minutes a day do people at your hospital spend smoking per day? How many minutes per day do you spend on this forum? If you are a man, how many unreasonably long trips to the bathroom do you take per day? Why does it take you so long? Please don't answer that.)


Anyway, if I can't find a job in pathology, I will find something else to do with my life. I won't kill myself. But I think I will find a job. I think it will be tough. But I don't want to live in Cali or on the East Coast, so I think I will be fine. I wish things in path were still good. Go back and read threads on here from 10 years ago. People sure were in a better mood. Jesus. I do think there are too many residents, and I think the younger people should make cutting positions a priority.

In my opinion, what Yaah wrote on this thread is one of the most refreshing things I have read here in years. I think Yaah is correct. All areas in medicine are suffering. Its not a great time to go into medicine, period. But I did, and I won't switch into another field of medicine. Do you people honestly think that's smart? Spending another 4 plus years in training? In those 4 years, I could be making my mark in my career as a pathologist. If pathology sucks, it is our job to make it suck less. Frankly I don't have a ton of friends whose jobs I would want to have either, for a variety of reasons. You might have to live in a place that's not great, but do any of you people have any friends? Do any of them have jobs? I have friends who travel constantly for their work. That is much worse in my opinion than living in a place other than NYC or wherever. I have a friend who travels with zero notice for up to 3 weeks at a time, year round. That's not a job I would want.

What would be great is if ya'll could bill for your posts. Then maybe you would all be happier )))

To be fair: Dermatology's numbers are low. The demand >>>> supply (LA and NYC are exceptions). No specialty has the characteristics of derm, and none of them will.

1) You don't have to do any cosmetics if you don't desire. Are cosmetic patients very high maintenance? Yes. However, this is expected bc they are paying cash.

2) Dermatopathology fellowship for a derm is a good option bc it's an ancillary part of your practice. Many dermatologists who see patients are inquisitive people by nature. We characterize the morphologic nature of the skin disease on a macro level, so naturally we would want to be able to do the same on the micro level. It's wonderful to be able to correlate and put together the two, which sears it into your brain. I've even known people who do Derm, Dermpath, and MOHS as they all fit together like a puzzle.

That being said a Dermatologist-trained Dermatopath has the option of still practicing in seeing patients, if there aren't jobs for Dermpath only.

Pathology-trained Dermatopathologists don't have this option. In fact, there are Dermatopathologists who end up applying into Derm and match bc they really are able to contribute a lot to the residency program.

 

[turtle1966]

To be fair: Dermatology's numbers are low. The demand >>>> supply (LA and NYC are exceptions). No specialty has the characteristics of derm, and none of them will.

1) You don't have to do any cosmetics if you don't desire. Are cosmetic patients very high maintenance? Yes. However, this is expected bc they are paying cash.

2) Dermatopathology fellowship for a derm is a good option bc it's an ancillary part of your practice. Many dermatologists who see patients are inquisitive people by nature. We characterize the morphologic nature of the skin disease on a macro level, so naturally we would want to be able to do the same on the micro level. It's wonderful to be able to correlate and put together the two, which sears it into your brain. I've even known people who do Derm, Dermpath, and MOHS as they all fit together like a puzzle.

That being said a Dermatologist-trained Dermatopath has the option of still practicing in seeing patients, if there aren't jobs for Dermpath only.

Pathology-trained Dermatopathologists don't have this option. In fact, there are Dermatopathologists who end up applying into Derm and match bc they really are able to contribute a lot to the residency program.

I absolutely confirm ALL of the above.

Yes, derm-DP can no longer expect to do exclusively DP, however, there are many who prefer the luxury of working part time and doing clinic only sporadically. Even with all the cuts, PC portion of skin biopsies alone is very profitable when done in a POL setting; 100% captive market + leisurely turn around time + 100% of fee is yours + no marketing cost + minimum or paper work + perfunctory description + no extra billing cost + ability to select cases you want to biopsy +ability to decide to how many lesions to biopsy (according to insurance) + specials stains at will + ability to send out for outside consults at will + markup for TC when allowed + 1000-3000 biopsies per MD + 500-1500 biopsies per PA, etc. Plus small excisions that they turn into Mohs.

Acne counseling is done mostly by PAs.

Back in the late 1970 and 1980's, at residencies, the talk was that dermatology would dwindle because PC would act as gate-keepers and do most of bread and butter dermatology. It did not happen, and one big factor was controlled supply of trainees. I am very puzzled why the same idea has such a hostile reception on this Board.

 

[DermViser]

I absolutely confirm ALL of the above.

Yes, derm-DP can no longer expect to do exclusively DP, however, there are many who prefer the luxury of working part time and doing clinic only sporadically. Even with all the cuts, PC portion of skin biopsies alone is very profitable when done in a POL setting; 100% captive market + leisurely turn around time + 100% of fee is yours + no marketing cost + minimum or paper work + perfunctory description + no extra billing cost + ability to select cases you want to biopsy +ability to decide to how many lesions to biopsy (according to insurance) + specials stains at will + ability to send out for outside consults at will + markup for TC when allowed + 1000-3000 biopsies per MD + 500-1500 biopsies per PA, etc. Plus small excisions that they turn into Mohs.

Acne counseling is done mostly by PAs.

Back in the late 1970 and 1980's, at residencies, the talk was that dermatology would dwindle because PC would act as gate-keepers and do most of bread and butter dermatology. It did not happen, and one big factor was controlled supply of trainees. I am very puzzled why the same idea has such a hostile reception on this Board.

Honestly, most Dermatologists don't want to have "bread-and-butter" Dermatology patients all the time. Why? It's a waste of our time. That's why dermatology does courses for PCPs, "Dermatology for the Primary Care Physician" etc. It would drive me nuts to have most Seborrheic Keratoses patients. The problem is that when given the responsibility of being gatekeepers, they don't do it.
When was the last time you saw a Family Medicine doc do a skin biopsy? Maybe in an academic residency, but not after that (or maybe in a rural area).

The one problem that Dermatologists have brought on themselves, is that instead of being satisfied, they hire NPs and PAs, when there are more than enough medical students who would kill to be dermatologists. Many of these students are bright and wish to contribute in a meaningful way to a highly academic and intellectual field.

I believe in that sense Dermatology and Pathology are similar - both are very highly academic and intellectual fields. Medical students who are naturally prone to wanting to learn about medicine are initially attracted to these specialties. The problem is that your Pathology ACGME RRC has allowed Pathology residencies to pop up in the most utter-****hole places: https://services.aamc.org/eras/erasstats/par/display8.cfm?NAV_ROW=PAR&SPEC_CD=300 (and I'm not even talking about location).

It's my belief also that Pathology should be AP/CP training only, none of this AP only and CP only crap.

 

[Substance]

There are. I have known many. Sometimes it is because they feel they need it to be competitive without even trying the market, sometimes it is because it is a filler year since the fellowship they want is still a year away and they need to do something, and sometimes it is because they are indecisive about what they want to, and sometimes it is because they want to have a very specific niche and feel having two fellowships will give it to them. From what I've seen this makes up almost all people who do a second fellowship. And these have virtually nothing to do with the realities of the job market.

Of course, I come from an ivory tower where everyone gets a job, so maybe it's not reflective of everyone else's experience. In fact, I don't know anyone who couldn't get a job so they scrambled for a fellowship. None.

In other fields, doing a second fellowship generally means that the applicant's desirable job could not be found with just one fellowship, thus the applicant bides time by doing a second one. I am unsure how it works in pathology given there are two very different views on the topic and I do not know which to believe.

Pathology does have a significant number of programs that should be closed down. Such programs do not have the standards of the elite programs, or even the middle-of-the-road ones, and exist solely to recruit residents as PAs. Most of the New York programs tend to have this kind of arrangement.

It's my belief also that Pathology should be AP/CP training only, none of this AP only and CP only crap.

I don't know if I agree with this last statement. At my institution all of the automated lab-work is done by PhDs and techs. There are no physicians in charge of them, and this suits the hospital just fine since the PhDs cost about 25% of what a pathologist does, and that's being generous.

I've never understood how doing maintenance and upkeep on automated machines that spit out results that are interpreted not by the doc running the machines but by the ordering physician is considered something pathologists (or any physicians for that matter) need to be involved with. It's like requiring radiologists to do all of the technical work involved with obtaining a chest film but having it interpreted by only the referring physician.

Here in Canada the vast majority of pathology training is AP only, and that makes sense to me based on the above. They're phasing out "general pathology" programs.

 

[turtle1966]

In other fields, doing a second fellowship generally means that the applicant's desirable job could not be found with just one fellowship, thus the applicant bides time by doing a second one. I am unsure how it works in pathology given there are two very different views on the topic and I do not know which to believe.

I wondered it myself. Either gbwillner and yaah are describing a small sub-set of "ivy league intellectuals" or those motivated by fear of future job insecurity or I must be out of touch.

I don't know if I agree with this last statement. At my institution all of the automated lab-work is done by PhDs and techs. There are no physicians in charge of them, and this suits the hospital just fine since the PhDs cost about 25% of what a pathologist does, and that's being generous.

I've never understood how doing maintenance and upkeep on automated machines that spit out results that are interpreted not by the doc running the machines but by the ordering physician is considered something pathologists (or any physicians for that matter) need to be involved with. It's like requiring radiologists to do all of the technical work involved with obtaining a chest film but having it interpreted by only the referring physician.

Here in Canada the vast majority of pathology training is AP only, and that makes sense to me based on the above. They're phasing out "general pathology" programs.

The existence of CP is historical. Before TEFRA (Tax Equity and Fiscal Responsibility Act of 1982 (Pub.L. 97–248)), the CP was a very significant (to some, the largest) source of revenue. My CP teacher told me that he used to arbitrarily determine (with hospital CEO) that his lab supervision was worth between 10-15% of total lab charges. So a $10.00 automated CBC would automatically generate $1.00 revenue for him, 24/7/365. A common complaint back then was that, after lunch, it was more likely to find a pathology at a golf course than in the lab. I was even told of a clinical lab owner pathologist flying around in helicopters to service different sites in the plain states because Medicare had some special reimbursement provision for remote area labs.

After Tefra, I heard of a pathologist who had retired after his small town hospital did not want to renew his flat 1 million dollar contract. One dollar then should be worth 4, 5, 6 present day dollar?

In my opinion, CPs have a far deeper clinical insight into lab results than an average PhD and far more technical expertise than clinicians with special interest in lab operation; therefore, in my opinion, CPs are very valuable. However, the question is whether the payers would think likewise in the future. There could be consolidation of labs into regional mega-labs requiring less CPs, replacement of CPs by PhDs and medical scientists (as already provisioned in CLIA), an abridgment of billable CP codes or bundling of CP codes such that clinicians may be enticed to interpret their own billable CP results. I could even speculate IBM's Watson artificial intelligence making a move into CP.

If the above scenario were to come to pass and the total CP portion of revenue were to decrease significantly, would it be worthwhile for "most" of us to spend two years in CP training or not? If the answer is a "no", then we may be joining Canada, and many other countries, in this regard.

 

[turtle1966]

That's why dermatology does courses for PCPs, "Dermatology for the Primary Care Physician" etc. It would drive me nuts to have most Seborrheic Keratoses patients. The problem is that when given the responsibility of being gatekeepers, they don't do it.

In the past, I myself prodded my PCPs to do more biopsies, unfortunately, I was only marginally successful. One of the problems is reimbursement, i.e., certain payers will not pay for certain skin treatments if you are a PCP and, in others, the patients are capitated, so there is no financial incentive.

The one problem that Dermatologists have brought on themselves, is that instead of being satisfied, they hire NPs and PAs, when there are more than enough medical students who would kill to be dermatologists.

In a good measure, that is a business savvy in my opinion. We need some of that in pathology.

The problem is that your Pathology ACGME RRC has allowed Pathology residencies to pop up in the most utter-****hole places: https://services.aamc.org/eras/erasstats/par/display8.cfm?NAV_ROW=PAR&SPEC_CD=300 (and I'm not even talking about location).

This is unfair! Why is it that a derm guy has to point this out to us? Are we incapable of seeing it ourselves?

 

[yaah]

This is unfair! Why is it that a derm guy has to point this out to us? Are we incapable of seeing it ourselves?

This has been pointed out close to a thousand times in the past 5 years on this forum. The weaknesses of these programs (without discussing specific names, because some small programs are quite good) has also been hashed over ad infinitum. I have no idea why you think this is a new opinion. I also have no idea why you think many people are seriously in favor of the program proliferation.

Derm is changing - how about the proliferation of DO residency programs? Is this a good thing? Is derm in control of this? It's changing the field.

 

[yaah]

I wondered it myself. Either gbwillner and yaah are describing a small sub-set of "ivy league intellectuals" or those motivated by fear of future job insecurity or I must be out of touch.

Why must every opinion that disagrees with your reality be either elitist, rare, or delusional? How many residents have you talked to who have done multiple fellowships? I know many. There are many for whom doing multiple was a conscious choice based on interest, and a subset of those (I don't know what %) for whom they thought it would improve their job prospects. And yes it is true that there are also many for whom doing multiple was out of lack of good opportunities either for the fellowship of their first choice or for a job they wanted. As I said before, this reflects poorly on our field but it also does not reflect reality for others. I do not know what percentage of residents actually do more than one fellowship, if I had to guess I would say 50% but that might be an overestimate. I have been very clear on this. I did not go to an ivy league school for med school or residency or fellowship. The true "ivy league intellectuals," in actuality, often do just one fellowship because they have a laser focus on one specific organ or disease entity that they want to study.

There is far too much generalization on these forums. An experience that fits our bias becomes "emblematic of a trend" whereas one that doesn't is "an outlier." An even people who try to maintain a balance are skewered because their contrary opinions tend to be ignored.

And the comparison of pathology to other fields, again, not particularly helpful. Do gastroenterologists do multiple fellowships? Probably not but the field is also vastly different and the gastroenterology part itself is somewhat of a fellowship. Do surgeons? Usually not, but doing multiple fellowships rarely provides a viable career path. In pathology it can. You can do cyto + heme and you can have a heavy emphasis on both in your career.

 

[Kilgoretrout 65]

My sarcastic response was intended to say: wake up people! 4 yrs of residency and a fellowship and 1) you don't know what you want to do? 2) you are carving out a niche for yourself
in case the Cleveland Clinic wants to hire a hemepath+informatics trained person? 3) you don't even want to test the job market because you are insecure? 4) you are scared you will get a job and won't know how to call something ASCUS without a cyto fellowship? All this while carrying immense amount of student debt?

Doing a second or third fellowship because you don't want to leave Boston or are biding your time waiting for a spouse to finish law school is different and I understand the choices people have to make.

But 33% of current fellows doing another fellowship because the job market sucks (from the ASCP survey as I recall it) DOES mean the job market sucks.

 

[path24]

For decades (yes decades, not years) a significant number of newly trained pathologists have had trouble finding employment. This has been continuelly ignored by cap/ascp/chairs/program directors...for decades. Their answer for decades....an upcoming shortage. Has never remotely happened in all the decades its been claimed.

If you don't feel the job market is poor, please post entry level jobs in the above thread. Prove the crappy job market posters wrong and more importantly help those struggling to find work. Pathology is no different from any other job/field when it comes to hiring. If you are needed the jobs are public and widely known.

The job market is very poor and far worse than other areas of medicine. Job security and stability are big things. It is not a good career choice.

 

[turtle1966]

This has been pointed out close to a thousand times in the past 5 years on this forum.

I have been in this forum for 16 months only.

I also have no idea why you think many people are seriously in favor of the program proliferation.

I have heard of small programs that were closed, however, not commensurate with demand. What would you call the 9% increase in residency spots being advocated by CAP? Only thing I have decried was selfish passivity of those who could and should act on this matter.

Derm is changing - how about the proliferation of DO residency programs? Is this a good thing? Is derm in control of this? It's changing the field.

It would be more constructive to take care of "beam" in our own eye.

 

[turtle1966]

Why must every opinion that disagrees with your reality be either elitist, rare, or delusional?

I wondered aloud 3 possible explanations for the phenomenon and they covered all scenarios you described. To many, "ivy league" programs are those with national reputation.

I had said [I wondered it myself. Either gbwillner and yaah are describing a small sub-set of "ivy league intellectuals" or those motivated by fear of future job insecurity or I must be out of touch.]

How many residents have you talked to who have done multiple fellowships?

By tautology, no residents with fellowships. Out of old job applicants, seldom, one minimum and two or three fellowships painfully common amongst new applicants.

I hear you, but do not agree with your approach to oversupply; I am for a deep cut in residency spots.

 

[turtle1966]

For decades (yes decades, not years) a significant number of newly trained pathologists have had trouble finding employment. This has been continuelly ignored by cap/ascp/chairs/program directors...for decades. Their answer for decades....an upcoming shortage. Has never remotely happened in all the decades its been claimed.

If you don't feel the job market is poor, please post entry level jobs in the above thread. Prove the crappy job market posters wrong and more importantly help those struggling to find work. Pathology is no different from any other job/field when it comes to hiring. If you are needed the jobs are public and widely known.

The job market is very poor and far worse than other areas of medicine. Job security and stability are big things. It is not a good career choice.

Kudos for stating fearlessly the "decades old open-secret"!

 

[KluverB]

In other fields, doing a second fellowship generally means that the applicant's desirable job could not be found with just one fellowship, thus the applicant bides time by doing a second one. I am unsure how it works in pathology given there are two very different views on the topic and I do not know which to believe.

Because unlike other fields, most pathologists sign out cases in a range of sub-specialty areas. Rads might be the closest in that respect, and I certainly know rads folks who have opted to do multiple fellowships. I also know a couple plastics surgeons who have done vascular and onc fellowships. Etc. Other fields don't lend themselves as naturally to multiple fellowships... IM+GI+Urology? Interventional cards + Neuro? Obs/Gyn+Anes+Sleep med?

Pathology does have a significant number of programs that should be closed down. Such programs do not have the standards of the elite programs, or even the middle-of-the-road ones, and exist solely to recruit residents as PAs. Most of the New York programs tend to have this kind of arrangement.

And all other specialties have programs all over with the standards of elite programs? Really?

...At my institution all of the automated lab-work is done by PhDs and techs. There are no physicians in charge of them, and this suits the hospital just fine since the PhDs cost about 25% of what a pathologist does, and that's being generous.

You're in Canada, I'm sure billing/re-reimbursement rules are different. If there even is such a thing. They probably get paid in loonies.

 

[Substance]

Because unlike other fields, most pathologists sign out cases in a range of sub-specialty areas. Rads might be the closest in that respect, and I certainly know rads folks who have opted to do multiple fellowships. I also know a couple plastics surgeons who have done vascular and onc fellowships. Etc. Other fields don't lend themselves as naturally to multiple fellowships... IM+GI+Urology? Interventional cards + Neuro? Obs/Gyn+Anes+Sleep med?


And all other specialties have programs all over with the standards of elite programs? Really?


You're in Canada, I'm sure billing/re-reimbursement rules are different. If there even is such a thing. They probably get paid in loonies.

You're absolutely right. We get paid in whale blubber and loonies.

How much more ignorant can you be?

My argument was that most good programs in "good" fields don't have to dig deep to have people apply. Plastics, derm, even rads, they don't (or in the case of rads, didn't) have to recruit questionable people to secure GME funding. Now for certain fields like gen surg, FM, OB and peds you can see why a program would do this; inpatient services would collapse without residents no matter how ESL or bad. But in pathology? Not for a long shot. I mean you guys can't even independently diagnose a freakin skin tag without attendings signing off on it. Not even radiology is that paranoid.

Rads is experiencing fellowship creep because the job market is tightening, not because of "interest".

The plastics guy you speak of are probably academics, am I right?

Be honest, pathology has bad manpower standards.

 

[yaah]

I hear you, but do not agree with your approach to oversupply; I am for a deep cut in residency spots.

I don't think I have advocated any approach to oversupply. For what it's worth, I have posted before and still agree that I don't really think the CAPs studies of future manpower and pathologist need etc are actionable data. There are way too many flaws in the assumptions (most particularly about what consitutes a true pathologist FTE now and in the future). But in a sense the claims about true numbers of pathologists are hard to argue. If you look out 2-3 years it's impossible to really predict retirement #s, but if you look out 20 years their thoughts are valid. If all else stays equal there will definitely be fewer practicing pathologists. Left unsaid is whether this is necessarily a bad thing (they say yes, I would posit no). I believe (but am not sure) that CAP has a separate publication coming out later in the year that will address this issue more specifically - the first study was mostly manpower and absolute numbers, the second study is more related to demand and is more crucial.

I have also posted before that I agree that there seems to be too many residency spots and programs currently. Cuts in residency spots would not be a bad thing, in my opinion, although I haven't studied the situation in huge detail to know the true consequences of such actions. It's easy to sit back and say "eliminate 30% of residency spots, oversupply issue solved" but that is woefully inadequate. Cutting spots is not going to have any significant impact for several years, and it's hard to know how quickly such an impact would be felt, and it what ways it would have impact. Those are the real questions that need to be studied.

 

[Substance]

I don't think I have advocated any approach to oversupply. For what it's worth, I have posted before and still agree that I don't really think the CAPs studies of future manpower and pathologist need etc are actionable data. There are way too many flaws in the assumptions (most particularly about what consitutes a true pathologist FTE now and in the future). But in a sense the claims about true numbers of pathologists are hard to argue. If you look out 2-3 years it's impossible to really predict retirement #s, but if you look out 20 years their thoughts are valid. If all else stays equal there will definitely be fewer practicing pathologists. Left unsaid is whether this is necessarily a bad thing (they say yes, I would posit no). I believe (but am not sure) that CAP has a separate publication coming out later in the year that will address this issue more specifically - the first study was mostly manpower and absolute numbers, the second study is more related to demand and is more crucial.

I have also posted before that I agree that there seems to be too many residency spots and programs currently. Cuts in residency spots would not be a bad thing, in my opinion, although I haven't studied the situation in huge detail to know the true consequences of such actions. It's easy to sit back and say "eliminate 30% of residency spots, oversupply issue solved" but that is woefully inadequate. Cutting spots is not going to have any significant impact for several years, and it's hard to know how quickly such an impact would be felt, and it what ways it would have impact. Those are the real questions that need to be studied.

The problem with the CAP's studies is that they are pushed by the CAP as exhaustive analyses, not flawed, essentially opinion piece, studies.

Maybe the job market is not as bad as is claimed by those on this forum, but I doubt the CAP's studies are accurate. When a field requires that most do two fellowships to land the entry-level position, it means that there is not enough demand for services, or that training programs are not meeting the demand due to inadequate training, or the quality of trainee is poor.

The issue with residency spots is that more than 50% of pathology residency spots are filled by FMGs. Given the above, I cannot see why programs need to, in the absence of domestic interest, recruit foreign trained physicians en masse. The CAP's stance unfortunately gives carte blanche to these bad programs to continuously recruit underqualified FMGs to be PAs at half-price.

The real remedy to everything would be for the field of pathology to increase its standards. Good scores, good schools, normal personalities, good clinical acumen, English fluent at the very least. If spots don't fill, they don't fill. Quality over quantity.

 

[turtle1966]

If you look out 2-3 years it's impossible to really predict retirement #s, but if you look out 20 years their thoughts are valid.

I have also posted before that I agree that there seems to be too many residency spots and programs currently. Cuts in residency spots would not be a bad thing, ..........

I agree with both statements above.

It's easy to sit back and say "eliminate 30% of residency spots, oversupply issue solved" but that is woefully inadequate. Cutting spots is not going to have any significant impact for several years,

In my opinion, the first half of our problem is lack of an OPEN acknowledgement of our plight. Once we overcome that inertia, events will snowball and creative solutions will be found. If we just count the mountains and barriers, we will stay put and be swept away by circumstances.

Since it appears that you have a few connections in the Establishment, I hope you will become a behind-the-scene "young blood" that will elevate our specialty and make it more responsive to our needs.

As I see it, the only lasting way to attract brightest MS is to make Pathology appealing and select.

 

[turtle1966]

When a field requires that most do two fellowships to land the entry-level position, it means that there is not enough demand for services, or that training programs are not meeting the demand due to inadequate training, or the quality of trainee is poor.

Metaphor I would use: "Ships coming to dock to a seaport that is full, therefore, are forced to cruise around."

One of the first signs of improving job market will be dwindling of 2nd and 3rd fellowship applications. If we start hearing about 4th fellowships, well then ...

I kind of like the idea of 5-6 years long residency; that way, at least, our reimbursement would go up and would alleviate the "burden of mad dash" for fellowships.

 

[Cellpathology]

The OP was meant to point out the SIGNIFICANT differences between the job search for a pathology trainee vs someone who trains in a high demand field. Compare contacting >150 potential employers prior to finding a job vs 1 (my significant other) and actually, in the latter case, the one person you contact tells you about two other possible positions, which actually call you up the next day asking you to interview...there is a huge difference in the effort required to land the job in pathology, period,....Do you understand why somebody may not want the hassle? I do not deny that most trainees find a job. There is a difference between "finding a job" and picking the city you want to live in or even the state or region of the US. That, to me, should be a big enough incentive to not go into pathology. The fact that this is not the case, is surprising.

 

[turtle1966]

The OP was meant to point out the SIGNIFICANT differences between the job search for a pathology trainee vs someone who trains in a high demand field. Compare contacting >150 potential employers prior to finding a job vs 1 (my significant other) and actually, in the latter case, the one person you contact tells you about two other possible positions, which actually call you up the next day asking you to interview...there is a huge difference in the effort required to land the job in pathology, period,....

Why I used a metaphor, not a hyperbole, of a "desert" in the midst of a "lush forest".

 

[Cellpathology]

CP.......

 

[path24]

"Compare contacting >150 potential employers prior to finding a job vs 1 (my significant other) and actually, in the latter case, the one person you contact tells you about two other possible positions, which actually call you up the next day asking you to interview"

The latter is what a real shortage looks like. There would have to be a HUGE change in pathology for that to happen. Freaking gigantic...like multiple new gi/skin/uro organ systems. Will never happen. On the verge of the shortage (supposedly starts next year) a pathology position gets 100+ applicants. The upcoming shortage is a complete lie.

Med students don't wake up until they are fellows fighting across the country for jobs while jumping from fellowship to fellowship because they can't find work. I have met to many people in pathology (yes, good bc pathologists) that had to do that, moving to the next fellowship, dragging their family and hoping it leads to employment. Yep, it happens to amg grads.[/quote]

 

[turtle1966]

Compare contacting >150 potential employers prior to finding a job vs 1 (my significant other)

Pardon me, but could tell us what specialty your significant other is on?

 

[turtle1966]

"Med students don't wake up until they are fellows fighting across the country for jobs while jumping from fellowship to fellowship because they can't find work. I have met to many people in pathology (yes, good bc pathologists) that had to do that, moving to the next fellowship, dragging their family and hoping it leads to employment. Yep, it happens to amg grads.

This is the type of experience that I am more familiar with. "Struggle to find a first job, be on the lookout for a better job, hope to hold on to the current job."

 

[Cellpathology]

Pardon me, but could tell us what specialty your significant other is on?

IM

 

[LADoc00]

I have also posted before that I agree that there seems to be too many residency spots and programs currently. Cuts in residency spots would not be a bad thing, in my opinion, although I haven't studied the situation in huge detail to know the true consequences of such actions. It's easy to sit back and say "eliminate 30% of residency spots, oversupply issue solved" but that is woefully inadequate. Cutting spots is not going to have any significant impact for several years, and it's hard to know how quickly such an impact would be felt, and it what ways it would have impact. Those are the real questions that need to be studied.

Im an intrigued by what you are implying Hauptmann Yaah.....do you mean we need to cut residency slots AND ..."dispose" of current undesirables already within in the profession?

might this involve something like Sturmabteilung...?

Im fascinated. What are you thinking here?

 

[yaah]

lol, what I meant was "woefully inadequate" is simply the underpants gnomes way of saying that eliminating spots will magically solve things.

Step 1) Eliminate 30% of residency spots
Step 2)
Step 3) Profit.

Instead of Nazi analogies, perhaps you might try a roman analogy. Perhaps to consider the origin (Roman) of the term "decimation." Crassus was rather successful with it. But I am not suggesting that, of course.

 

[turtle1966]

lol, what I meant was "woefully inadequate" is simply the underpants gnomes way of saying that eliminating spots will magically solve things.

Step 1) Eliminate 30% of residency spots
Step 2)
Step 3) Profit.​

For a contrast, decades old, time-tested CAP's solution:

Step 1) Hear nothing, see nothing, complain nothing and do nothing
Step 2) Wait for "mass retirement" next 20 years
Step 3) Then, jobs, jobs, jobs.​

I think Pathology as a respectable specialty is in the rear-mirror.

 

[LADoc00]

Instead of Nazi analogies, perhaps you might try a roman analogy. Perhaps to consider the origin (Roman) of the term "decimation." Crassus was rather successful with it. But I am not suggesting that, of course.

True Decimatio is quite rare even in over 2000 years of brutal warfare. Interestingly the only army EVER to really practice it (literally meaning "removal of the tenth" or the execution of every 10th man) on any significant scale was the Soviet defenders of Stalingrad.

Interesting it was under Nikita Khrushchev's command and supervision. I REMEMBER Krushchev, on TV, on radio. He isnt a mythical marble bust in a museum.

The Roman have been unfairly maligned by Decimation and Julius Caesar could not bring himself to ever actually do it. But Khrushchev did...shudder...

Decimatio would be the answer, but even I could not bring myself to order it.

 

[Leukocyte]

As much as I like Pathology, the possibility of not finding a job after 5+ years of training, scares me enough to re-consider my specialty. Yet, I see medical students still going to Pathology (in robust numbers). Also I do not see many Pathology residents dropping Pathology and going to another fields. Why?

I think the reason for the bad job market in Pathology is that Pathology is a comparatively "peaceful/harmonious" specialty. Yes, there is stress in Pathology...but compared to the added acute interpersonal stress that clinical specialties have to deal with on a daily basis (having to deal with tough, demanding (and sometimes crazy) patients and nurses in acute medical settings), Pathology is a chill specialty. Many docs in clinical medicine "durn-out" after a couple of years of practice, and look forward to an early retierment. In Pathology, it seems that the docs like it in there, and want to continue working as long as they can. It seems that Pathologists do not "burn-out" like their clinical couterparts...and that is the problem.

My theory: The more "chill" a specialty is, the tougher it is to get a job in that specialty.

 

[DermViser]

As much as I like Pathology, the possibility of not finding a job after 5+ years of training, scares me enough to re-consider my specialty. Yet, I see medical students still going to Pathology (in robust numbers). Also I do not see many Pathology residents dropping Pathology and going to another fields. Why?

I think the reason for the bad job market in Pathology is that Pathology is a comparatively "peaceful/harmonious" specialty. Yes, there is stress in Pathology...but compared to the added acute interpersonal stress that clinical specialties have to deal with on a daily basis (having to deal with tough, demanding (and sometimes crazy) patients and nurses in acute medical settings), Pathology is a chill specialty. Many docs in clinical medicine "durn-out" after a couple of years of practice, and look forward to an early retierment. In Pathology, it seems that the docs like it in there, and want to continue working as long as they can. It seems that Pathologists do not "burn-out" like their clinical couterparts...and that is the problem.

My theory: The more "chill" a specialty is, the tougher it is to get a job in that specialty.

Absolutely agree. I think part of what attracts people to the ROAD specialties, is the personalities those attendings in those specialties. Pathology, for all intents and purposes, is filled with nice people (outside the malignant residencies - but pathology has too many residencies to begin with IMHO). Not to mention not having to deal with clingy, dependent, and whiny patients and incompetent nurses, which you get blamed for.

 

[2121115]

Also I do not see many Pathology residents dropping Pathology and going to another fields.

Then you are not looking carefully enough. Happens all the time.

 

[icpshootyz]

Then you are not looking carefully enough. Happens all the time.

But it goes in the opposite direction as well. Plenty of people drop other fields and enter pathology residency, too. Without hard numbers showing a true gain or loss for pathology, it's not very meaningful to speculate.