Third Track Pathology

[Sunesis]

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There is an interesting editorial in the Archives of Pathology and Laboratory Medicine advocating for a necessary but optional third track in pathology training dedicated to building a new generation of genomic pathologists (see attached).
Essentially, those who are not interested can stick to the AP/CP track, but you could do AP/GP or CP/GP. You could also do AP only, CP only or GP only.
Please read the editorial on "Third Track Pathology" (plus-or-minus the Tonellato et al report of the Banbury Conference) and let's start the conversation on the crucial topic.

 

[KeratinPearls]

There is an interesting editorial in the Archives of Pathology and Laboratory Medicine advocating for a necessary but optional third track in pathology training dedicated to building a new generation of genomic pathologists (see attached).
Essentially, those who are not interested can stick to the AP/CP track, but you could do AP/GP or CP/GP. You could also do AP only, CP only or GP only.
Please read the editorial on "Third Track Pathology" (plus-or-minus the Tonellato et al report of the Banbury Conference) and let's start the conversation on the crucial topic.

I'm all for it. Pathology needs to keep up with the times or we will fall behind.

 

[Enkidu]

I'm all for it. Pathology needs to keep up with the times or we will fall behind.

I think it sounds awesome, but how can we construct a present-day curriculum for a future technology?

Edit: Also, I'm skeptical of this actually happening. What would it take for genomic pathology to become a residency on par with (at least) clinical pathology? It seems like a massive undertaking by an organization that seems to have little control over pathologist training, as evidenced by the apparent pathologist oversupply.

 

[scienceguy19]

does this mean that in addition to 2 fellowships, we will be expected to do 6 years of residency? (AP/CP/GP) 😱 good grief

 

[Ombret]

I just don't believe that "genomic pathology" is ready for prime time--ready to become its own track. Clearly it is an emerging subspecialty, but the number of faculty members qualified to train residents in this area, institutions with the infrastructure to support this kind of program, and current applications of these technologies is still very small.

My guess is that molecular pathology will just over time assume increased importance within CP training, probably at the expense of areas like coag, chemistry, and micro which currently occupy an unwarranted fraction of your CP residency.

 

[gbwillner]

I just don't believe that "genomic pathology" is ready for prime time--ready to become its own track. Clearly it is an emerging subspecialty, but the number of faculty members qualified to train residents in this area, institutions with the infrastructure to support this kind of program, and current applications of these technologies is still very small.

My guess is that molecular pathology will just over time assume increased importance within CP training, probably at the expense of areas like coag, chemistry, and micro which currently occupy an unwarranted fraction of your CP residency.

I agree except that there is definitely more room for growth in the AP realm in cancer-related genomics. That will be huge.

Untill there is reasonable reimbursement for this type of work, no one will get this training unless they are pure academics (like me). This will be an MD/PhD heavy field for years to come.

 

[Enkidu]

I agree except that there is definitely more room for growth in the AP realm in cancer-related genomics. That will be huge.

Untill there is reasonable reimbursement for this type of work, no one will get this training unless they are pure academics (like me). This will be an MD/PhD heavy field for years to come.

Doesn't the advent of genomic medicine give us a good reason to get rid of the AP/CP distinction altogether?

If most of CP is taken over by molecular pathology, which is also directly relevant to AP, why not just have one combined pathology residency program with a much abbreviated role for the CP stuff that no one seems to like.

Of course, those who are passionate about pursuing some CP subspecialty were going to do a fellowship anyway, so it's not like abbreviating their weight in residency would cause pathology as a field to lose its hold on those laboratory aspects.

 

[gbwillner]

Doesn't the advent of genomic medicine give us a good reason to get rid of the AP/CP distinction altogether?

If most of CP is taken over by molecular pathology, which is also directly relevant to AP, why not just have one combined pathology residency program with a much abbreviated role for the CP stuff that no one seems to like.

Of course, those who are passionate about pursuing some CP subspecialty were going to do a fellowship anyway, so it's not like abbreviating their weight in residency would cause pathology as a field to lose its hold on those laboratory aspects.

That's what I thought before starting residency. In reality, there is very little in common between AP and CP. AP is more a technical skill you need to develop (with lots of work) and CP is mostly managing a laboratory (or transfusion medicine)... There is just very little that holds those two worlds together, except for maybe the $$ the department gets for running the lab services. Yeah, genomics could bridge the gap some more, but I don't know if I see any real advantage to dissolving all barriers between departments.

 

[KCShaw]

Until people show more interest in molecular as a fellowship and jobs open up looking for molecular training, I don't see how a version of it can gain traction as an alternative to CP, which almost everyone does not because they have a particular interest in it but because they think it will make them more employable. Adding a 3rd track doesn't change the perception that one "needs" to do CP. Given that there appear to be few jobs searching specifically for molecular training, even if a so-called GP track existed...why would a resident choose it over CP which already includes "some", if minimal, such training and why would a program push it over CP when they probably need residents to take some CP (at least transfusion) call?

Personally I would be more likely to support good old fashioned "pathology" training -- no AP, CP, whateverP, except what boarded subspecialty fellowship training adds. I don't like the concept of splitting CP into something non-pathology; CP encompasses the most widely used diagnostic testing and I think there's great folly in making it the -sole- province of PhD's. The day after that happens will be when PhD's start eliminating AP jobs too, IMO. They already do most of "our" teaching of medical students, and the risk is already there regardless of what happens with CP.

 

[Enkidu]

Personally I would be more likely to support good old fashioned "pathology" training -- no AP, CP, whateverP, except what boarded subspecialty fellowship training adds. I don't like the concept of splitting CP into something non-pathology; CP encompasses the most widely used diagnostic testing and I think there's great folly in making it the -sole- province of PhD's. The day after that happens will be when PhD's start eliminating AP jobs too, IMO. They already do most of "our" teaching of medical students, and the risk is already there regardless of what happens with CP.

Would it make sense to shift a lot of the CP material like chemistry and microbiology to fellowships in those areas? It seems like they may be a bit more low yield than other parts of CP like transfusion and possibly molecular pathology.

Also, would anyone support adding some time in pathology residency for mandatory research? It seems like surgery programs do this, and pathology is plausibly more research-oriented than surgery. It may also decrease the glut of pathologists entering the market.

 

[KCShaw]

That might be a consideration if pathologists showed more interest in them as a fellowship or at least medical students had practical education regarding them from a pathology point of view. In terms of what an AP/CP trained pathologist handling only a little CP call coverage the rest of their career most needs to know.. yeah, it could be argued that transfusion/coag is probably the highest yield middle-of-the-night stuff-you-need-to-know. My ignorant ideal, however, would be that the other parts of the CP lab be directed by CP pathologists, not PhD's, who could cross-cover call rather than pulling in an AP/CP person who really has no interest in it and doesn't keep up with it until they have to for recertification.

As for requiring research time, while I get the idea of keeping a larger percentage of pathologists "in training", I'm already unclear where the money is coming from to keep residents in other programs doing it and what excuses they're using to get it paid for. I don't think "keeping the numbers at bay" is likely to be a great selling point, at any rate. The flip side is that residents are already underpaid while in ballooning debt.

 

[scienceguy19]

How about just having AP only or CP only training, and eliminating AP/CP? Molecular could be a component of both. AP/CP training was a horrible model from the start. How can you be an expert at both? Do you see faculty at medical school being experts at both AP and CP? No. Therefore newly practicing pathologists shouldn't be expected to master both AP and CP.

Many other countries have the model which separates them completely and their hospitals function fine. Why can't the United States do the same? Now if only medicare and insurances companies would reimburse CP appropriately, then more people could do CP only. It annoys me how CP got screwed over reimbursement wise.

That might be a consideration if pathologists showed more interest in them as a fellowship or at least medical students had practical education regarding them from a pathology point of view. In terms of what an AP/CP trained pathologist handling only a little CP call coverage the rest of their career most needs to know.. yeah, it could be argued that transfusion/coag is probably the highest yield middle-of-the-night stuff-you-need-to-know. My ignorant ideal, however, would be that the other parts of the CP lab be directed by CP pathologists, not PhD's, who could cross-cover call rather than pulling in an AP/CP person who really has no interest in it and doesn't keep up with it until they have to for recertification.

As for requiring research time, while I get the idea of keeping a larger percentage of pathologists "in training", I'm already unclear where the money is coming from to keep residents in other programs doing it and what excuses they're using to get it paid for. I don't think "keeping the numbers at bay" is likely to be a great selling point, at any rate. The flip side is that residents are already underpaid while in ballooning debt.

 

[KeratinPearls]

How about just having AP only or CP only training, and eliminating AP/CP? Molecular could be a component of both. AP/CP training was a horrible model from the start. How can you be an expert at both? Do you see faculty at medical school being experts at both AP and CP? No. Therefore newly practicing pathologists shouldn't be expected to master both AP and CP.

I would have to agree with the above. Throughout my residency training I've realized most general pathologists forget everything about CP, except those that have specialized in a particular subspecialty. The only CP most remember is from practical daily use. I think training is broad and I think the knowledge base tested in the AP/CP board exam has got to be one of the most complex out there. I feel like most just study CP just to pass the board exam and when they are in practice, they forget it all. However, I hear you need CP certification to be on the medical staff at comm hospitals.

Most general pathologists I've met have focused on AP and the labs are stocked with a PhD who of course knows more than the pathologist and is actually the go-to person for any questions. So why do we need to be studying all this?

 

[Enkidu]

Most general pathologists I've met have focused on AP and the labs are stocked with a PhD who of course knows more than the pathologist and is actually the go-to person for any questions. So why do we need to be studying all this?

I realize that it's in the best interest of pathology as a profession that PhDs do not take over the labs, but do CP pathologists bring something extra to the table that PhDs don't?

What is the best argument to show that Pathologists shouldn't be replaced by PhDs, even though it would save the hospital money?

I want to believe in clinical pathology, but so far I've never met any pathologists that like it, or even care about it. Combined with the fact that they don't usually even remember much about it makes it hard to argue that CP pathologists are indispensable.

Edit: I mean fields like Coag, chemistry, microbiology... not transfusion or hematopathology

 

[scienceguy19]

subspecializing chemistry, coag, or microbiology with a main focus on these seems like a waste of resources..
can you imagine writing a personal statement for medical school admissions saying that you your aspirations are to be a director of a chemistry, coag, or micro lab? they'll be laughing asking why the freak you don't just go for a phd instead of taking a spot in med school? you don't need to go to med school, do clinical rotations, learn anatomy, to do that...

I realize that it's in the best interest of pathology as a profession that PhDs do not take over the labs, but do CP pathologists bring something extra to the table that PhDs don't?

What is the best argument to show that Pathologists shouldn't be replaced by PhDs, even though it would save the hospital money?

I want to believe in clinical pathology, but so far I've never met any pathologists that like it, or even care about it. Combined with the fact that they don't usually even remember much about it makes it hard to argue that CP pathologists are indispensable.

Edit: I mean fields like Coag, chemistry, microbiology... not transfusion or hematopathology

 

[Enkidu]

subspecializing chemistry, coag, or microbiology with a main focus on these seems like a waste of resources..
can you imagine writing a personal statement for medical school admissions saying that you your aspirations are to be a director of a chemistry, coag, or micro lab? they'll be laughing asking why the freak you don't just go for a phd instead of taking a spot in med school? you don't need to go to med school, do clinical rotations, learn anatomy, to do that...

So what were of you thinking of when you suggested that we have more CP only pathologists?

 

[scienceguy19]

My main point is that AP pathologists shouldn't have to learn all of this CP and use it only occassionally.

I'm suggesting we eliminate (AP/CP) positions and moderately increase the number of CP only positions. CP pathologists may act as a clinical consultant for the lab (knowledge in between the phd and the MD clinician). Every hospital be mandated to have at least one full time clinical pathologist with PHDs underneath him/her (chemistry). My personal opinion is that MDs will not be as good PHDs for day to day specific operations of the chemistry lab. I would exclude blood banking and hematology/hemepath, as I think MDs are better off running these divisions. Of course, all this is contigent upon reimbursement changes to CP pathologists. 🙂

So what were of you thinking of when you suggested that we have more CP only pathologists?

 

[KCShaw]

My main point is that AP pathologists shouldn't have to learn all of this CP and use it only occassionally.

Well.. they -don't- have to. You can "choose" to be AP only. However, most programs make no bones about pushing residents to do AP/CP (staying around another year), and most residents agree to it, knowing also that at least some advertised jobs require it. But there is an option to do AP only, and some people choose it.

As far as PhD's vs CP's, I'm a little surprised to hear the question -- not in general, but on here. Why a physician is generally better prepared to practice medicine than a research scientist/academic, or to consult with another physician regarding their patients, I thought would be self evident. Without having a deeper understanding of how a number or a result affects a given patient's diagnosis, prognosis, treatment, their physician(s), their family, the hospital -- what it means and what it doesn't mean -- then one is essentially a blind technician. Laboratories can't effectively influence the present or the future without pathologists involved in the hospital's day-to-day care, not to mention committees affecting every single department addressing laboratory testing. PhD's may save a little salary money or bring in a little grant money, but frankly, it could be at much greater overall cost.

 

[Enkidu]

As far as PhD's vs CP's, I'm a little surprised to hear the question -- not in general, but on here.

Ha, don't be surprised that medical students don't know what CP pathologists do... If their role is primarily managerial, as I've been led to believe, then they don't have an advantage over PhDs. If their role is primarily consulting with clinicians about their patients, then of course a PhD could never do it.

But then if their job is primarily consulting with clinicians, then there should be no competition between MDs and PhDs. One can consult with clinicians about their lab values and the other can manage day-to-day operations in the lab.

 

[KCShaw]

Maybe I'm a little spoiled by the number of path residents; didn't really look to see who was asking the quesiton. At any rate -- one thing I think may be being overlooked is that management of a pathology laboratory includes working with managers/directors of not only other labs but also other departments in the hospital. Other departments already have a tendency to think of the laboratory as a tool rather than a collegial resource, and I think replacement of physicians by PhD's generally furthers this divide.

As I've said before.. some PhD lab directors take pains to narrow this gap and take pride in learning as much as they can about the medical side of the equation, but as a system I don't think the approach is ideal. I also have doubts about the reality of salary savings of 1 different PhD for every single lab versus a few clinical pathologists each directing a couple of labs. I'm not sure the motives for replacing CP's with PhD's is purely financial.

On a related note, the technical side of laboratory management/direction is heavily dependent on medical technologists. It's reasonably accurate that a PhD generally (but not always) has more experience in the technical aspect of running some of the tests, though usually in a research lab. But one good med tech is worth most PhD's, as far as technical management alone.

 

[EvilTaz]

Wasn't there an immunohistochemistry fellowship back in the day? Imagine going to the immunohistochemistry specialist to interpret your brown stains! My point is that a new technique comes along, and people make new training tracks or fellowships or other ways to show our field is responsive to the times. But in the long run, we learn how to walk and chew gum at the same time. There are plenty of people who can look at slides and also interpret molecular studies (hemepath, soft tissue, neuropath). Saying "genomics" is what you have to do to look current, but I think it will just become another thing in the toolbox that we will have to learn.

 

[scienceguy19]

Immunohistochemistry fellowship?? you kidding me? what are you supposed to do, be an immunohistochemistry pathologist?

so the other pathologists give a preliminary on the H+E for 50 slides/cases, while you look at the 10000 corresponding immunohistochemistry slides.

It's amazing the crazy and impractical kinds of fellowships programs hospitals come up with these days to retain their cheap labor from residents.

 

[Entgegen]

Immunohistochemistry fellowship?? you kidding me? what are you supposed to do, be an immunohistochemistry pathologist?

so the other pathologists give a preliminary on the H+E for 50 slides/cases, while you look at the 10000 corresponding immunohistochemistry slides.

It's amazing the crazy and impractical kinds of fellowships programs hospitals come up with these days to retain their cheap labor from residents.

I don't believe there are any more IHC fellowships. They were more in vogue when IHC was first invented/applied to pathology. The point that the previous poster was getting at was that at the time everyone thought IHC was going to completely revolutionize pathology, and thus fellowships opened up in anticipation of that. As we all know, IHC never really turned the practice of pathology on it's head so much as it merely added another tool besides H&E to the path toolbox...which is what the poster was predicting will happen with molecular/genomic path. But who knows.

 

[Enkidu]

Wasn't there an immunohistochemistry fellowship back in the day? Imagine going to the immunohistochemistry specialist to interpret your brown stains! My point is that a new technique comes along, and people make new training tracks or fellowships or other ways to show our field is responsive to the times. But in the long run, we learn how to walk and chew gum at the same time. There are plenty of people who can look at slides and also interpret molecular studies (hemepath, soft tissue, neuropath). Saying "genomics" is what you have to do to look current, but I think it will just become another thing in the toolbox that we will have to learn.

Yeah, but the current molecular tests are fairly simple. If we come to the point of signing out whole genomes to predict complex things like psychiatric risk, then it may require a further fellowship. For one, searching a genome may require significant bioinformatics knowledge just to find the genes.

Incidentally, what is pathology informatics? I guess it has nothing to do with genomics.

 

[Sunesis]

......... Saying "genomics" is what you have to do to look current, but I think it will just become another thing in the toolbox that we will have to learn.

First, the IHC saga is different from genomics, which is not a new "technique" per se. The higher throughput and the progressively decreasing cost of "next-generation" sequencing has made it more accessible and potentially more affordable, especially if we can reach hit the $1000/genome benchmark.

Second, these technologies are already being used, albeit at a low scale, by some clinicians, and some institutions already have pilot programs to test the scalability and these efforts are also considering reimbursement models that would be appropriate.

Third, many (but thankfully, not all) of the current efforts to implement genomics into "personalized medicine" are being driven by non-pathologists. Private companies are already being established to take advantage of the increasing demand for this service. We keep complaining about how other specialists are encroaching on our turf. The opportunity for diagnostic genomic pathology would seem to me an excellent example for how pathologists should not be complacent but seek to be at the vanguard of establishing this fledgling field. Otherwise the story on this forum in 10 years may be lamentations on how other people stole pathology's thunder.

Fourth, genomic sequencing is unlikely to "just become another thing in the toolbox" of pathologists. The application of genome-level information to clinical care is complex, to say the least. If pathology is to take the lead in this endeavor, it would require the training of a new cadre of genomic pathologists who will spearhead the generation, analyses, interpretation and dissemination of genome-level information. Of course, like some other areas of pathology, they will probably be medical directors who oversee technicians and computational analysts, but these pathologists have to be trained to understand and correctly interpret what they are signing out. They should also know enough to supervise assay troubleshooting, test development and analytical improvement efforts that will move the field forward.

Fifth, while a few weeks of rotations during residency may be adequate to keep this genomic pathology on the radar screen of most pathologists, the level of expertise required for everyday practice of genomic pathology will require in-depth training. I don't know if the answer is a new track or a new fellowship or a revamping of the molecular diagnostics fellowship.

Let's discuss.

 

[KCShaw]

As soon as something climbs out of a niche and becomes the norm for a broad spectrum of cases, it ceases to be as useful in subspecialty fellowship training. If many case/tumor types from many organ system origins regularly end up having molecular testing, most pathologists are going to learn enough about it to be successful. I think similar happened with IHC; it comes out as having such broad capabilities with numerous options and therefore considered too complex to "fully" learn during regular training, but eventually it became fairly standardized, widespread, and well documented such that in most cases interpretation isn't a major problem and when it is consultation with an organ system specialist tends to address it.

Molecular/genomic testing could go that route (as it already has to a large extent), or it could prove to be more obstinate and semi-esoteric, and land as a separate sort of test with separate interpretations. But as testing develops the new tests/interpretations are still niche..

 

[Ombret]

Incidentally, what is pathology informatics? I guess it has nothing to do with genomics.

Enkidu, path informatics is a subspecialty with a couple of subareas within it. At one end, there are people who are interested in the lab workflow stuff; for example, designing lab information systems, databases, ways to query them etc. It sounds deadly until you think about how many times a day you interact with computer systems as a pathologist. At the other end are the people who are interested in automated image analysis and other fancy stuff. So genomic analysis could potentially fit into the path informatics spectrum. The overall theme is that pathology generates a lot of data and that good wrangling of the data can make for better practice. There is a meeting every year (now called Pathology Informatics, formerly APIII), a Journal of Pathology Informatics, and there are a few fellowships. I myself have a passing interest, some of it is pretty interesting.

 

[Dr.Tao]

Incidentally, what is pathology informatics? I guess it has nothing to do with genomics.

http://pathologyinformatics.org/

Message from a 2 year API member.