The future of molecular pathology.

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pathresident2

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I am going to do a fellowship in Hematopathology. In thinking of the second fellowship to pursue, molecular seems very closely related. Do you guys think it is worthwhile to do a fellowship in molecular?
 
I am going to do a fellowship in Hematopathology. In thinking of the second fellowship to pursue, molecular seems very closely related. Do you guys think it is worthwhile to do a fellowship in molecular?

Absolutely.

IMO, the 200 year-old H&E slide will soon die off and diseases will be classified/treated/prognosticated solely by molecular methods including neoplastic/infectious/autoimmune.
 
Absolutely.

IMO, the 200 year-old H&E slide will soon die off and diseases will be classified/treated/prognosticated solely by molecular methods including neoplastic/infectious/autoimmune.

Really? You think that molecular testing will be so accurate that it won't be necessary to even look at the tissue? This seems unlikely to me. Isn't it like saying that clinicians will diagnose their patients without even doing an exam? I have a feeling that looking at the patient/tissue will never go away as a means to get at least an initial impression to make a differential diagnosis.
 
Really? You think that molecular testing will be so accurate that it won't be necessary to even look at the tissue? This seems unlikely to me. Isn't it like saying that clinicians will diagnose their patients without even doing an exam? I have a feeling that looking at the patient/tissue will never go away as a means to get at least an initial impression to make a differential diagnosis.

I agree with Enkidu. The H&E is such a cost effective means of getting a work-up started. I think the future will involve using the H&E to make diagnoses that are straightforward and sufficient by histopath alone (e.g. colonic adenoma) as well as making diagnoses that will be definitively classified after a reflexive panel of markers/molecular tests is performed (e.g. colonic adenocarcinoma, PCR mutation analysis pending). The latter situation will probably expand to encompass more and more of the diagnoses we make as more targeted therapies become available. One of the keys for us is to make sure we (pathologists) are in charge of these reflexive panels and can thus bill for them. We cannot have surgeons/clinicians ordering and interpreting these tests after we've made an H&E "preliminary" diagnosis and thus signified the appropriate panel to order.

Also, there are some things we do on H&E that a molecular analysis will either never do or be completely overkill for, e.g. margin assessment of resections, focus score in a Sjogren biopsy, assessment of hormonal status on endometrial biopsy, etc.

All of this is not to say that molecular is not important. We absolutely should make sure that as a field we embrace and utilize molecular tests in areas where they are well validated. Again, we don't want the surgeons/clinicans keeping tissue for these type of tests without ever involving us.
 
In the future that pathresident describes, there is no role for most of the pathologists that exist today. Even in the scenario where pathologists are interpreting these molecular tests and whatnot there is no way we will need even half of the pathologists that we produce today, which is even now an oversupplied market. A good pathologist may still be important, we just won't need nearly as many. Medstudents, take note.
 
In the future that pathresident describes, there is no role for most of the pathologists that exist today. Even in the scenario where pathologists are interpreting these molecular tests and whatnot there is no way we will need even half of the pathologists that we produce today, which is even now an oversupplied market. A good pathologist may still be important, we just won't need nearly as many. Medstudents, take note.

But isn't this whole discussion about the future of pathology a little alarmist? It's just like saying that robotic surgeries will cut the need for surgeons in half, or that computerized radiology reads will cut the need for actual radiologists in half. There is a conceivable futuristic scenario in which every medical specialty is in danger of severely contracting, is pathology more susceptible than other specialties to this?

Also, isn't there an issue of pretest probability when you do a molecular test on a tissue without looking at it? It may be positive for whatever molecular marker, but isn't the predictive value of those tests based on the fact that the morphology of the tissue was also positive?
 
People used to think that we needed a lot of pathologists to "interpret" CP tests back in the 80's or whatever (chem10's, thyroid functions, etc) and the pathologists would write up a little blurb with every panel that got reported. But these were all templated and it was really easy. Eventually payers just quit paying for it and hence the demise of Clinical Pathology for all intents and purposes. These things are now an after thought as they are automated and interpretation is straight forward and done by the clinician (for the most part). If it wasn't for the AP slide, pathologists would have disappeared. If AP slides get turned into CP tests, what do you think will happen?
 
Given the reliance on published literature, which overlies that long history of the H&E, properly researching and publishing methods that are "better" than H&E..for each and every previously documented entity..will take a very, very long time, even if a "better" method exists or were to be developed.

Autopsy is still around, despite having not changed much at its core in oodles of generations, though we've added newfangled H&E to that process as well as a number of other tests and better documentation of what certain things do and don't mean. It's just extremely difficult to justify elimination of looking at a thing when there is no method which is better in -every- aspect. I bring up imaging a lot because I think it's a good example -- CT, MRI, x-ray, etc. are all very good at certain things, even better than a "standard" autopsy at some, but not at others, and even in combination are simply still not as effective as autopsy for many things. Of course, numbers of autopsies have dropped sharply so perhaps that isn't the best example..

IMO slides aren't going away, at least not soon, and if they do it will be preceded by numerous comparative studies addressing not just identification but also staging, prognosis, etc. -- literally, the writing will be on the wall. Not that it hasn't started to some extent, of course.

None of that is to say that one shouldn't do a molecular fellowship; I think it's a good one to keep alive and keep putting pathologists into, because there's a certain blind faith that seems to surround it among those who don't think, just as there is a lot of current and potential future expansion of its use among those who do.

(There's alarmist and there's "I told you so". I figure one of these days pathstudent is going to come back here and dig up proof of being the first to see "it" coming and slather it in everyone's face, heh, even if other things never end up quite as dramatic as proposed.)
 
Well, I guess at this point in the thread it would be appropriate for me to ask: What exactly do you learn in a molecular pathology fellowship?
 
Sorry for the thread hijack-I will be applying for a molecular fellowship and haven't been able to find any reviews online for different programs. Any current fellows willing to chime in on their experience with programs? I heard that university fellowships are considered more educational than, say, large cancer centers, because you get to see benign and malignant cases. Is there any truth in that?
 
In the future that pathresident describes, there is no role for most of the pathologists that exist today. Even in the scenario where pathologists are interpreting these molecular tests and whatnot there is no way we will need even half of the pathologists that we produce today, which is even now an oversupplied market. A good pathologist may still be important, we just won't need nearly as many. Medstudents, take note.

If you extrapolate out every possibility of technological advancement, there will be no need for any doctors. Just technicians who take samples and put them into machines, and other machines which coordinate it all. Won't even need surgeons.
 
If you extrapolate out every possibility of technological advancement, there will be no need for any doctors. Just technicians who take samples and put them into machines, and other machines which coordinate it all. Won't even need surgeons.

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I don't really know how to privately respond to your message, but having done a fellowship, I certainly have some advice. Can you post your e-mail address or tell me how to respond privately?
 
You could always respond here for the benefit of everyone...
 
You could always respond here for the benefit of everyone...

Would be very nice.

Alternatively, can send a private message to someone on here by clicking on their name and selecting "send a private message".
 
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