Thinking about pathology...

[murdoc9]

---

Members don't see this ad.

.

 

[DIce3]

Radiology is close. In the past five years, my hospital has had five radiology groups. The hospital administration changes the radiology contract to the lowest bidder every year. Absolute nonsense. Nationwide, pathology is just in a worse place than radiology. Sure you can't stomach medicine, surgery, peds, ob, fp, or psych where there are tons of jobs?

 

[Enkidu]

Rising fourth year here, debating pathology vs. anesthesia. I like both for different reasons. After spending altogether way too much time reading sdn, i can't decide which forum is more depressing to read. Why is the situation so bad in pathology? Just low demand/increased productivity? Has there really been that much of an increase in residency class size? Forgive my ignorance, but why is the market saturation so specific to pathology?

This forum talks a lot of apocalypse, but if you actually poll the people here everyone seems to have a job, the the majority of people seem to have "great" jobs.

 

[LADoc00]

Pathology, Rads, Gas, Derm, Primary Care...anyone but niche surgeons with tons of experience are having serious problems and even the niche surgeons are starting to catch pain. There are lots of reasons for this and try to summarize would be to hand you a one line Cliff's Notes of the history of the human race but the crazy overtraining that first started in Pathology before leeching in everywhere is the main issue.

 

[deleted314957]

you have to realize that you are coming into a different world. i believe you will find work but things will not be as they were/or perhaps as you envision. the money is very different now as is the employment situation and it will not become more favorable. it is worth considering a 20 year employment with the feds( for money that is/will be comparable with outside) then get out with a %50 pension and get another practice. you cannot do what i did decades ago.

 

[B***F*****]

This forum talks a lot of apocalypse, but if you actually poll the people here everyone seems to have a job, the the majority of people seem to have "great" jobs.

I admire your optimism but I have a sneaking suspicion that what we "enjoy" now is temporary. New technologies are now emerging and our leadership does not have enough type-A personalities to defend our turf. Advances in molecular technology (one salient example is whole genome sequencing), for example, is a big threat to our field as industry represents a huge source of competition. Industry is already heavily involved in this. Furthermore, industry has the resources, manpower, political and financial power to get FDA approval for their tests and tie to FDA approved drugs. This is a threat to laboratory developed tests. The pie is getting smaller and there is more competition for pieces of the pie. Small labs are getting bought out. Big companies are getting bigger but not necessarily doing great (Caris).

I think **** will hit the fan at some point. I just hope it will not be in my lifetime...but I think this is wishful thinking. I will work hard, try my best to stay current with the times to continue to be involved in conversations, and try to save as much money as possible. Given my stresses, I find little motivation to advocate for my field...that will be a thankless endeavour. I'm going to sit back and do nothing just like everyone else as there is no incentive for me to do otherwise. What happens to pathology after I die, I do not care. As long as pathology stays alive just long enough for me to benefit. That is how I and many others think. That is the truth. Don't hate the player...hate the game.

My children will not go into pathology. This field may very well be far worse off when my child is of the age to start thinking about careers.

 

[Circumflex]

I admire your optimism but I have a sneaking suspicion that what we "enjoy" now is temporary. New technologies are now emerging and our leadership does not have enough type-A personalities to defend our turf. Advances in molecular technology (one salient example is whole genome sequencing), for example, is a big threat to our field as industry represents a huge source of competition. Industry is already heavily involved in this. Furthermore, industry has the resources, manpower, political and financial power to get FDA approval for their tests and tie to FDA approved drugs. This is a threat to laboratory developed tests. The pie is getting smaller and there is more competition for pieces of the pie. Small labs are getting bought out. Big companies are getting bigger but not necessarily doing great (Caris).

I think **** will hit the fan at some point. I just hope it will not be in my lifetime...but I think this is wishful thinking. I will work hard, try my best to stay current with the times to continue to be involved in conversations, and try to save as much money as possible. Given my stresses, I find little motivation to advocate for my field...that will be a thankless endeavour. I'm going to sit back and do nothing just like everyone else as there is no incentive for me to do otherwise. What happens to pathology after I die, I do not care. As long as pathology stays alive just long enough for me to benefit. That is how I and many others think. That is the truth. Don't hate the player...hate the game.

My children will not go into pathology. This field may very well be far worse off when my child is of the age to start thinking about careers.

Yeah, there are definitely a lot of challenges for diagnostic pathologists. I'm so glad that I am in forensics. The salaries keep going up each year and there is a huge demand that cannot be met by the current FPs in practice. Sure, there are challenges working for local or state governments, but it is a good gig.

 

[Enkidu]

Pathology, Rads, Gas, Derm, Primary Care...anyone but niche surgeons with tons of experience are having serious problems and even the niche surgeons are starting to catch pain. There are lots of reasons for this and try to summarize would be to hand you a one line Cliff's Notes of the history of the human race but the crazy overtraining that first started in Pathology before leeching in everywhere is the main issue.

Well, Rad Onc also seems to be quite tight

http://forums.studentdoctor.net/showthread.php?t=981281

Edit: And here's a dark thread from anesthesiology

http://forums.studentdoctor.net/showthread.php?t=993497

 

[Enkidu]

Actually - every field of medicine seems not to be doing too well. Pathology, Radiology, Rad-onc, anesthesiology all have declining job markets. Primary care specialties are boring as hell and pay poorly. And surgery is brutal and uninteresting.

 

[lipomas]

Rising fourth year here, debating pathology vs. anesthesia. I like both for different reasons. After spending altogether way too much time reading sdn, i can't decide which forum is more depressing to read. Why is the situation so bad in pathology? Just low demand/increased productivity? Has there really been that much of an increase in residency class size? Forgive my ignorance, but why is the market saturation so specific to pathology?

SDN =/= real world.

There are true things said here of course, but many many exaggerations and misinterpretations. Kind of like real life.

 

[mlw03]

SDN =/= real world.

There are true things said here of course, but many many exaggerations and misinterpretations. Kind of like real life.

Concur with my colleague. SDN is a decent resource and mildly amusing at times, but should not be taken as the holy gospel. Anesthesia and path are quite different. You should take the next few months trying to figure out which type of medicine you'd like to practice. If you're not a putz and you're willing to move, you will likely find a job upon completing your training in either of those specialties.

 

[murdoc9]

.

 

[Path_to_Endo]

There are routine parts of all fields. I dislike grossing specimens, that gets especially tedious even with different pathologies. Moreover pathology is poorly understood by our clinical colleagues and it gets tiresome having to explain the basics over and over again. Think about pathology twice, I certainly wish I had.

 

[Silent Cool]

There are routine parts of all fields. I dislike grossing specimens, that gets especially tedious even with different pathologies. Moreover pathology is poorly understood by our clinical colleagues and it gets tiresome having to explain the basics over and over again. Think about pathology twice, I certainly wish I had.

MOG,

What field do you wish you had pursued instead?

thanx

 

[Silent Cool]

There are routine parts of all fields. I dislike grossing specimens, that gets especially tedious even with different pathologies. Moreover pathology is poorly understood by our clinical colleagues and it gets tiresome having to explain the basics over and over again. Think about pathology twice, I certainly wish I had.

.

 

[Path_to_Endo]

Honestly I feel the 'training' offered at this point is geared so much towards grossing you feel like a PA or a tech. On biopsy services you feel like a secretary/pack mule carrying boxes of slides to sign out with various attendings . You really can't make independent diagnoses/decisions until done with residency (not even easy ones) so you don't feel much like a doc at all. So, in short, something where you actually feel like a physician at least some of the time.

 

[ermonty]

Honestly I feel the 'training' offered at this point is geared so much towards grossing you feel like a PA or a tech. On biopsy services you feel like a secretary/pack mule carrying boxes of slides to sign out with various attendings . You really can't make independent diagnoses/decisions until done with residency (not even easy ones) so you don't feel much like a doc at all. So, in short, something where you actually feel like a physician at least some of the time.

This is 1000% how I feel. You are not a doctor or treated like a physician by most attendings. This leads to not being viewed or treated like a doctor by lab techs, secretaries, etc. And this latter group have no context of what you have been through or what you could have done in a differect specialty. I never ask anyone to address me as doctor and have no ego whatsoever. But the problem is when these laboratory employees dont see you as a doctor, they ignore basic requests you ask of them (things that are within the spectrum of their duties to do). I'm sure Medicine or Peds residents probably have similar frustrations with RNs and techs on the wards, but at least they can complain and claim that this lack of respect is compromising their ability to care for their patients. I will at least say that fellowship has been MUCH MUCH better...at least you are treated like an attending, just without the power to signout independently...

 

[path24]

Honestly I feel the 'training' offered at this point is geared so much towards grossing you feel like a PA or a tech. On biopsy services you feel like a secretary/pack mule carrying boxes of slides to sign out with various attendings . You really can't make independent diagnoses/decisions until done with residency (not even easy ones) so you don't feel much like a doc at all. So, in short, something where you actually feel like a physician at least some of the time.

👍👍👍

 

[Euchromatin]

Honestly I feel the 'training' offered at this point is geared so much towards grossing you feel like a PA or a tech. On biopsy services you feel like a secretary/pack mule carrying boxes of slides to sign out with various attendings . You really can't make independent diagnoses/decisions until done with residency (not even easy ones) so you don't feel much like a doc at all. So, in short, something where you actually feel like a physician at least some of the time.

I have to disagree somewhat with MeatOnGlass here. I think that the experience you get during your residency is greatly dependent upon where you train and the way that the surgical pathology service is run.

I think that the program I am training at does an excellent job of providing a thorough, educational grossing experience without making it overly burdensome (you can search for numerous other threads discussing how grossing duties are assigned at different programs with lots of vigorous debate over just how much grossing is needed for essential training vs. scut). The fact that we have multiple full time PAs who can handle our large caseload without resident assistance is likely a big factor. Also, when we are on microscopy for the day, we preview/dictate all of the cases assigned to only one attending staff, so there is minimal "secretary/pack mule" work.

I can't argue with the fact that pathology residency has a serious lack of actual responsibility (i.e. nothing can be signed out by us) and I agree that it is a huge problem with our training. I can say that some programs do a better job than others of offering graduated responsibility. For example, senior residents (and first years once they're getting near the end of the year, depending on the person) are expected to have all cases completely dictated, including synoptic reports for malignant resection cases, to have ordered and interpreted appropriate immunos, gotten necessary audits from other attending staff, etc. so that everything, ideally, is ready for the attending staff to hit the "sign out" button. Is this the same as actually having your signature on the report? Certainly not, but (depending upon how seriously individual residents take it) I think it can be very valuable.

Maybe it is because we have had a decent number of our previous residents end up as attending staff or because the culture/atmosphere is generally fairly positive, but I have not noticed that disrespect from lab techs, clerical staff, etc. is a significant problem.

 

[gbwillner]

I have to disagree somewhat with MeatOnGlass here. I think that the experience you get during your residency is greatly dependent upon where you train and the way that the surgical pathology service is run.

...
Maybe it is because we have had a decent number of our previous residents end up as attending staff or because the culture/atmosphere is generally fairly positive, but I have not noticed that disrespect from lab techs, clerical staff, etc. is a significant problem.

I agree with this. At my program I never felt like a gross-monkey. Techs did biopsies and PAs did routines that were not interesting. Everything we grossed we signed out. We usually grossed for 2-3 hrs a day (1st year rotations it was probably more due to inexeperience). We had graduated responsibility from day 1- we were expected to make a DX and write the report BEFORE sign-out. There were times as senior residents when we could sign out frozens, as well as handle inside-outside cases.

 

[yaah]

Huh, it was my impression that programs were moving away from "traditional" skills like grossing and even cutting frozens because PAs and histotechs are more efficient. Lots of residents come out of training now without good grossing skills.

part of the problem is that lots of residents think they are getting way too much grossing when in fact they are not. They think they are proficient at grossing in a colon because they did 5. There are lots of simple things to grossing but there are lots of subtleties too that make your final diagnosis much simpler and more accurate.

And if you are going into the private world you typically need to know how to cut frozens. Not just how it works and how to interpret them - how to actually cut them, and how to troubleshoot when tissue chunks off or you get 4 specimens at once with no one to help you, or what happens when you get a fatty specimen that doesn't cut.

 

[KluverB]

huh, it was my impression that programs were moving away from "traditional" skills like grossing and even cutting frozens because pas and histotechs are more efficient. Lots of residents come out of training now without good grossing skills.

Part of the problem is that lots of residents think they are getting way too much grossing when in fact they are not. They think they are proficient at grossing in a colon because they did 5. There are lots of simple things to grossing but there are lots of subtleties too that make your final diagnosis much simpler and more accurate.

And if you are going into the private world you typically need to know how to cut frozens. Not just how it works and how to interpret them - how to actually cut them, and how to troubleshoot when tissue chunks off or you get 4 specimens at once with no one to help you, or what happens when you get a fatty specimen that doesn't cut.

^^^^
this.

 

[Path_to_Endo]

Thanks for the response. No one can argue the importance of a good gross, however when grossing takes precedence over education, there is a problem. When your residents are staying until midnight to gross, it gets to be non educational. Thanks for the input, I can only relate my experience/opinions as a junior resident at a very well-respected program.

 

[Euchromatin]

And if you are going into the private world you typically need to know how to cut frozens. Not just how it works and how to interpret them - how to actually cut them, and how to troubleshoot when tissue chunks off or you get 4 specimens at once with no one to help you, or what happens when you get a fatty specimen that doesn't cut.

I completely agree that knowing how to cut your own frozens is essential. We cut all of our own frozens all the time (not just after hours when on call) and I am regularly surprised by how many different things can go wrong that you need to be able to troubleshoot - changing nicked blades, re-positioning the chuck relative to the blade, adjusting temperature and section thickness, what to if the tissue block falls off the chuck, etc. It has also been a good experience seeing how each attending staff does their frozens, as I have seen quite a variety of methods used to embed the tissue/make the OCT block (both with and without a histobath) as well as different methods to keep track of multiple and/or multi-part cases.

And I promise that I have grossed more than 6 colons 😉

 

[LADoc00]

My big problem is essentially grossing is uncompensated work, at least in a traditional TC-PC hospital split arrangement.

Even if I global billed, I would almost always shift grossing to an extender tech than a fully boarded pathologist. Just WAY to expensive to have a physician digging through fat for 12 nodes.

I expect pathologist grossing to be gone in the next decade, which in some ways is quite sad.

 

[Path_to_Endo]

I totally agree. It doesn't really take a genius to cut a good frozen section or to troubleshoot. Plenty of our attendings can't even cut them. The value is really in making the tough diagnoses. Our rotation is essentially run by a PA, and maybe sometimes we get to see the slides we cut.

 

[yaah]

I totally agree. It doesn't really take a genius to cut a good frozen section or to troubleshoot. Plenty of our attendings can't even cut them. The value is really in making the tough diagnoses. Our rotation is essentially run by a PA, and maybe sometimes we get to see the slides we cut.

No, but it takes experience. And if things go wrong it is the attending's responsibility, not the PA's. The value is in the whole experience - you can't make a tough diagnosis without proper grossing and frozen section technique. And frozens can happen at any time, so unless you are willing to have someone on call to help you at all times (and pay them), it is (will be) on you.

 

[pathstudent]

And frozens can happen at any time, so unless you are willing to have someone on call to help you at all times (and pay them), it is (will be) on you.

Hospitals pay the histotechs salaries not me. They are on call 6p-4am for frozens. The last thing I should be doing is freezing a brain tumor and cutting a section at 2 am. Let the people that do it all day long do it. That's my recommendation.

 

[Path_to_Endo]

The troubleshooting is obviously important, but the diagnostic aspect is crucial. Again, if the technical skill is of utmost importance, why are a chunk of attendings bad at them...

 

[KluverB]

The troubleshooting is obviously important, but the diagnostic aspect is crucial. Again, if the technical skill is of utmost importance, why are a chunk of attendings bad at them...

For the younger attendings, it's because they went through residency at a program where PAs/techs cut the frozens, and/or they thought cutting 5 frozens during their treining is enough practice.

For the older attendings, I guess they may be out of practice if PAs/residents have been routinely cutting them for years and/or they're only on frozen service every so many months.

 

[malchik]

I couldn't cut a frozen to save my life.

 

[KCShaw]

Continuing one of the tangents I'll just point out that a "well respected program" is often confused with a brand name program, or a diagnostically well respected pathology department, or a well known hospital, or a well known or respected medical school. I hear a lot of folks, mainly students, throw around names as if they knew what they were talking about..but clearly don't. And I hear a fair few residents from so-called top tier/brand name/respected programs describe little teaching, 80 hour weeks with oodles of after hours grossing, little preview time, angry demanding or unsupportive attendings, and a generally sour life -- but it's a great program, evidently because anyone who survived it had to learn to be strong, independent, efficient, and well read of their own accord. This does work for some people, though not for all.. which I guess is my way of agreeing that staying until midnight to gross on any kind of regular basis is not just non-educational, it's counterproductive scut. Change that from grossing to previewing and we have a different argument.

 

[Path_to_Endo]

The former description sounds much like my current existence!

 

[Kilgoretrout 65]

I totally agree. It doesn't really take a genius to cut a good frozen section or to troubleshoot. Plenty of our attendings can't even cut them. The value is really in making the tough diagnoses. Our rotation is essentially run by a PA, and maybe sometimes we get to see the slides we cut.

Residents should ALWAYS see the slides you cut on your frozen cases. If time is a factor, have the attending go over them with you after the fact. If PA's are doing your frozens, do touch preps and look at them while you are waiting. And remember to look at the frozens on a case routinely as part of the final sign out. I have had residents complain they don't see enough frozens and then I ask them where the frozen slides are for a case we are signing out and they just look at me with a puzzled expression on their face.

 

[Applicable]

Continuing one of the tangents I'll just point out that a "well respected program" is often confused with a brand name program, or a diagnostically well respected pathology department, or a well known hospital, or a well known or respected medical school. I hear a lot of folks, mainly students, throw around names as if they knew what they were talking about..but clearly don't. And I hear a fair few residents from so-called top tier/brand name/respected programs describe little teaching, 80 hour weeks with oodles of after hours grossing, little preview time, angry demanding or unsupportive attendings, and a generally sour life -- but it's a great program, evidently because anyone who survived it had to learn to be strong, independent, efficient, and well read of their own accord. This does work for some people, though not for all.. which I guess is my way of agreeing that staying until midnight to gross on any kind of regular basis is not just non-educational, it's counterproductive scut. Change that from grossing to previewing and we have a different argument.

^ T H I S ^


It's too late for the people who just matched, but those applying to residency programs next year should keep the above in mind.

If you make mistakes in your career, then it won't matter that you went to a brand name program and absorbed all sorts of punishment. There are brand name and not-so-brand name programs that treat their residents like commodities and leave many of their graduates questioning their abilities and dissatisfied with job prospects. If you're cutting frozens sections all day but not finding the chance to look at the actual slides, spending about an hour a day harvesting tissue for someone else's research, getting pulled out of your once weekly sign-out with an attending to cut more frozens, and you are grossing more than 12 hours a day an average of 4-5 days a week/weekend then you are wasting time. If the department is so disorganized that you find yourself either correcting or doing other people's work at the expense of previewing and reading up on your cases, then you are wasting time. It is important to be responsible and hardworking, and to not expect to be given more credit than you deserve as a trainee, but remember that the future of your career depends largely on your ability to think clearly and make a diagnosis whether or not your program was a 4 year hazing ritual replete with careless ancillary staff and attendings who never bothered to learn your name. It doesn't matter that you sat at the scope twice with some big shot when you subsequently need to show cases to the people in your practice that would not have flustered a mediocre fourth year resident from a mediocre program. The saddest thing about our training is that we are given relatively little responsibility over four years, while our clinical colleagues have shouldered tremendous responsibilities and are ready to start practicing if they are not already out in practice by the time we're finishing our fellowships, which we seemingly need to do these days if we want a job.

But there is no shortage of work to keep you busy in residency nonetheless, and you may or may not be given any sort of meaningful feedback on your diagnoses. If you have to look up the reports of your cases because your attending is too annoyed and in a hurry to discuss things with you at sign-out and or you are frequently pulled from sign-out to do the job or a PA or tech, then you might as well go to the lightest path residency program you can find, in the nicest possible location, and sit under a palm tree reading a book all day. No matter what, it seems you're destined for 1 to 3 years of fellowship. You might as well go into PRY-1, post-residency-year-one, with some book knowledge under your belt so that you can hone a practical knowledge of pathology that never quite came together at your fancy residency program. And don't get me started on the insane amount of pressure put on residents pursuing fellowship training to crank-out research, as if publications should be a priority at that stage over learning pathology. I met a PGY-7 fellow who was struggling to find a job and had gone to "great" residency and fellowship programs with many publications to boast. The fellow had never signed out a single case. Seven years! The fellow had spent one of those fellowship years doing a lot of grossing. Seven years of grossing and authoring a few case series. Frozen section diagnoses rendered: zero. Cases signed-out: zero. This person thought they'd be great for a community practice because their diploma was littered with famous names. And yet, I've met other people who have gone to "mediocre" programs where they found mentorship and some form of graduated sign-out responsibility to prepare them for the road ahead. Choose your program wisely. Path training is unlike training in other specialties. You will work hard no matter what, and you should, but set yourself up to work smart.

 

[Path_to_Endo]

^ T H I S ^


It's too late for the people who just matched, but those applying to residency programs next year should keep the above in mind.

If you make mistakes in your career, then it won't matter that you went to a brand name program and absorbed all sorts of punishment. There are brand name and not-so-brand name programs that treat their residents like commodities and leave many of their graduates questioning their abilities and dissatisfied with job prospects. If you're cutting frozens sections all day but not finding the chance to look at the actual slides, spending about an hour a day harvesting tissue for someone else's research, getting pulled out of your once weekly sign-out with an attending to cut more frozens, and you are grossing more than 12 hours a day an average of 4-5 days a week/weekend then you are wasting time. If the department is so disorganized that you find yourself either correcting or doing other people's work at the expense of previewing and reading up on your cases, then you are wasting time. It is important to be responsible and hardworking, and to not expect to be given more credit than you deserve as a trainee, but remember that the future of your career depends largely on your ability to think clearly and make a diagnosis whether or not your program was a 4 year hazing ritual replete with careless ancillary staff and attendings who never bothered to learn your name. It doesn't matter that you sat at the scope twice with some big shot when you subsequently need to show cases to the people in your practice that would not have flustered a mediocre fourth year resident from a mediocre program. The saddest thing about our training is that we are given relatively little responsibility over four years, while our clinical colleagues have shouldered tremendous responsibilities and are ready to start practicing if they are not already out in practice by the time we're finishing our fellowships, which we seemingly need to do these days if we want a job.

But there is no shortage of work to keep you busy in residency nonetheless, and you may or may not be given any sort of meaningful feedback on your diagnoses. If you have to look up the reports of your cases because your attending is too annoyed and in a hurry to discuss things with you at sign-out and or you are frequently pulled from sign-out to do the job or a PA or tech, then you might as well go to the lightest path residency program you can find, in the nicest possible location, and sit under a palm tree reading a book all day. No matter what, it seems you're destined for 1 to 3 years of fellowship. You might as well go into PRY-1, post-residency-year-one, with some book knowledge under your belt so that you can hone a practical knowledge of pathology that never quite came together at your fancy residency program. And don't get me started on the insane amount of pressure put on residents pursuing fellowship training to crank-out research, as if publications should be a priority at that stage over learning pathology. I met a PGY-7 fellow who was struggling to find a job and had gone to "great" residency and fellowship programs with many publications to boast. The fellow had never signed out a single case. Seven years! The fellow had spent one of those fellowship years doing a lot of grossing. Seven years of grossing and authoring a few case series. Frozen section diagnoses rendered: zero. Cases signed-out: zero. This person thought they'd be great for a community practice because their diploma was littered with famous names. And yet, I've met other people who have gone to "mediocre" programs where they found mentorship and some form of graduated sign-out responsibility to prepare them for the road ahead. Choose your program wisely. Path training is unlike training in other specialties. You will work hard no matter what, and you should, but set yourself up to work smart.

Well said. This reflects a poverty in training at some 'top' places. They put you through the grinder the first/second year as a grossing machine and then make you a secretary thereafter through fellowship. I think pathology rotations in medical school fail to provide an accurate picture of residency. If they did, fewer people might actually pick this field when they find out you spend most of your time alone with buckets of organs, stacks of slides, questionable teaching, and little understanding or respect from clinical colleagues.