What subspecality is best overall.

[Denmark]

What gives most plessure and Best work life balance.
I Think breast or derm

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[deleted314957]

What gives most plessure and Best work life balance.
I Think breast or derm

Breast general surgery?? Not my idea of a low key/stress
field.
I think general AP with no administrative responsibility/call/autopsy/nephro(EM/immunoflourescense)/neuromuscular would be ideal.

 

[Guest8]

What gives most plessure and Best work life balance.
I Think breast or derm

The breast cases at my practice do not seem to give much pleasure or work/life balance. The breast surgeons and oncologists are extremely anal retentive and nag about everything and anything. Derm is better, although most jobs out there these days are fairly corporate, so likely much more glass pushing to make the same pay as years ago. I don't think any one specialty is all that much better than another. Like Mike said above, it's often the other parts of the job that affect work/life balance like call, admin work, etc. If you like the specialty you focus on then you'll like doing the work in that specialty.

 

[bingbongbink]

I’m patiently waiting for a happy doc to comment

 

[deleted941485]

I’m patiently waiting for a happy doc to comment

I’d get dinner and finish up your day first. Gonna be some time

 

[Lagunamonster]

I still think it is still derm, GI or GU because so many of the specimens are small and even with all the changes in reimbursment you can still make money hand over fist with those specimens compared to gyn or breast or MSK.

Hemepath is another good one because of the way it integrates FISH, IHC, Morphology and molecular into their diagnostic entities. So it is fun work from an intellectual standpoint.

 

[deleted314957]

I’m patiently waiting for a happy doc to comment

I was an extremely happy path/doc. As LADoc has said,my situation was analogous to living in the Four Seasons while the field was like Berlin in April 1945. I have had a huge smile on my face for years. I don’t know why things worked out so well.

 

[shikimate]

I'd say academic neuropath.

 

[gbwillner]

I've been very happy in molecular.

I will say that "work life balance " is very personal and will mean different things to different people.

Does it mean money/time off? Does it mean work hours/ time with family? Does it mean stress / comfort?

I think in general academia is great for work/life balance, regarding time and stress, but that is also reflected in your pay.

That said, I don't particularly have a good work/life balance but that is not a consequence of my specialty (it is my inability to say "no" to things).

 

[LADoc00]

Im sure someone will pull out a PRE-COVID post by yours truly about how I thought Mol Path was a waste of time...

but I have come full circle, there is NOTHING in all of medicine frankly as good as Mol Path especially when you have ownership share in the windfall.

Its insane frankly. And the demand is almost unlimited. I talk to physicians every single week including very high end subspecialty surgeons who either want me to franchise my operation or throw money at me (or equity in companies) to consult so they can replicate what Im doing.

 

[dacrocytestorm]

The molecular director at my institution raves about how cush it is. It sure seems that way. He is almost never there in the lab unless in the rare case a PCR machine breaks, etc. Hell, even the fellow doesn't seem to do any work at all, and she seems to be using her time on her own "research" projects and has almost no "service" responsibilities.

 

[dacrocytestorm]

Transfusion is supposed to have very easy service responsibilities as an attending because your residents and fellows do all the work. You just have to round on patients every once in a while, which is about 8-10 weeks of the year at my institution and rounding usually only takes 20-30 minutes in the morning and afternoon (typical day it is about 15-20 outpatient apheresis patients, and maybe 10-15 inpatients).

 

[TrojanRaggy]

Dermpath is the best! Small biopsies, not much area to cover on the slides, no endless sections of fat, no arguments about grossing with the PA/resident over the phone, people thinking you are smart when all you are doing is describing what you see like a medical student, and a slightly higher pay-scale compared to other subspecialties.

 

[WEBB PINKERTON]

Dermpath ain't what it used to be. No way would I rate that the best. You better enjoy working at some VC slide mill.

 

[path vs rads]

Dermpath ain't what it used to be. No way would I rate that the best. You better enjoy working at some VC slide mill.

What would you say is the best?

 

[deleted314957]

Dermpath is the best! Small biopsies, not much area to cover on the slides, no endless sections of fat, no arguments about grossing with the PA/resident over the phone, people thinking you are smart when all you are doing is describing what you see like a medical student, and a slightly higher pay-scale compared to other subspecialties.

I may have really misunderstood, but surely you must have to bottom -line the report. A micro description ALONE does not cut it, which is what I understand your post to be saying.

I can understand that there may be frequent cases where ONE DEFINITIVE diagnosis cannot be established. That is why one would discuss a differential diagnosis in a commentary.

An ambiguous case would get a diagnosis of “large cell, fast eatin’ carcinoma” (see comment) and then that is where you would talk all about the wide wide world of large cell fast eatin’ carcinomas.

 

[caffeinegirl]

I would suggest that the OP doesn't have the right perspective here - it's not about the subspecialty but it's about the practice setting. And what gives you "plessure" depends on the individual. It could be a research setting, clin/research combo, purely clinical, academic, private hospital setting, private outpatient, etc. I would start there - and also, realize that your job isn't the entire picture either - what about where you live, your spouse's career, etc. Lots of other things to think about first - then you can decide on the subspecialty (unless you fall in love with an organ system - renal folks - I'm lookin' at you!)

 

[octopusprime]

I would suggest that the OP doesn't have the right perspective here - it's not about the subspecialty but it's about the practice setting. And what gives you "plessure" depends on the individual. It could be a research setting, clin/research combo, purely clinical, academic, private hospital setting, private outpatient, etc. I would start there - and also, realize that your job isn't the entire picture either - what about where you live, your spouse's career, etc. Lots of other things to think about first - then you can decide on the subspecialty (unless you fall in love with an organ system - renal folks - I'm lookin' at you!)

+100
There are absolutely no hard & fast rules about subspecialties being the 'best'...there are more competitive ones from the standpoint of myopic or ill informed residents, but that's about it.

 

[SunBakedTrash]

It never got old watching multiple naive PGY-1s walk in the door each July thinking they independently found a magical backdoor to dermatology with grand plans of carving out some kind of dermpath consult empire and cashing out. Turns out they missed the boat by about three decades or so. Too bad, here are some placentas to gross.

 

[stickyshift]

It never got old watching multiple naive PGY-1s walk in the door each July thinking they independently found a magical backdoor to dermatology with grand plans of carving out some kind of dermpath consult empire and cashing out. Turns out they missed the boat by about three decades or so. Too bad, here are some placentas to gross.

On the other hand, I wouldn't mind building a placenta pathology empire myself. Sweet, sweet 88307s...

 

[gbwillner]

On the other hand, I wouldn't mind building a placenta pathology empire myself. Sweet, sweet 88307s...

ewww... you can have them. How many macrophages in this one? How about this one? This one?

 

[Vicinal]

In other news

 

[deleted314957]

In other news

This is what happens when an institution ( or, individual) adopts the seemingly “state-of-the-art” attitude that is usually expressed somehow as “ oh, we send ALL our XYZ’s
for the ‘super-duper’ cancer test”. And, lo and behold, this is what happens.

 

[Vicinal]

“molecular” is having its moment. It will be cut mercilessly. Especially since sequencers the size of microwaves are now available for 30K. Anything that pays up to 4K per test and is easy to set up and run will be by definition quickly reassessed and realigned. Especially when it leads to very expensive therapeutics.

 

[Vicinal]

Keep in mind the gorilla in the room… Roche…. They own foundation, Genentech, and Ventana and they make the therapeutics. Amazing

 

[Lagunamonster]

On the other hand, I wouldn't mind building a placenta pathology empire myself. Sweet, sweet 88307s...

On the other hand, I wouldn't mind building a placenta pathology empire myself. Sweet, sweet 88307s...

Yes

And do special stains for infectious organisms, IHC for all pediatric tumors, submit some fresh for flow and Placental NGS to screen for clinically occult mutations.

And then sign it out as
Placenta, delivery
Mature placenta, 550 g
3 vessel cord and normal membranes.

Or my favorite

Placenta, delivery
Consistent with placenta.

 

[Dave CX]

Dermpath ain't what it used to be. No way would I rate that the best. You better enjoy working at some VC slide mill.

I am a slide mill GI jockey. I LOVE the slide mill. The work waits for me other than the other way around. I come and go as I please. No phone calls/meetings/fires to put out/ CP/Call/ bull****/ partners/collection issues/ lab drama/tumor boards/ autopsies, just me and the scope and my $$$$. Did the busy hospital system gig for 14 yrs, way less stressed and more prosperous now.

 

[deleted314957]

“molecular” is having its moment. It will be cut mercilessly. Especially since sequencers the size of microwaves are now available for 30K. Anything that pays up to 4K per test and is easy to set up and run will be by definition quickly reassessed and realigned. Especially when it leads to very expensive therapeutics.

Oh, you hit that nail DIRECTLY on the head. I’ve spent at least 20 years looking at the annual “CMS” hit-list and it doesn’t take a rocket scientist to see what and why something gets hit.

 

[deleted314957]

I am a slide mill GI jockey. I LOVE the slide mill. The work waits for me other than the other way around. I come and go as I please. No phone calls/meetings/fires to put out/ CP/Call/ bull****/ partners/collection issues/ lab drama/tumor boards/ autopsies, just me and the scope and my $$$$. Did the busy hospital system gig for 14 yrs, way less stressed and prosperous now.

Nothing wrong at all with that gig Dave. I did a boat- load of gi and I would not have minded those circumstances at all. I REALLY enjoyed the scope. Strange, since the day I retired in 2013 I have not looked in one ( except on a rifle). But, I still have it with it’s all s-plan apo objectives. Wonder if anybody uses them anymore. At the time they were Olympus’s best.

 

[gbwillner]

This is what happens when an institution ( or, individual) adopts the seemingly “state-of-the-art” attitude that is usually expressed somehow as “ oh, we send ALL our XYZ’s
for the ‘super-duper’ cancer test”. And, lo and behold, this is what happens.

Most abuse and fraud in genetic testing is not in cancer. It's worthless germline testing in old people.

 

[WEBB PINKERTON]

I am a slide mill GI jockey. I LOVE the slide mill. The work waits for me other than the other way around. I come and go as I please. No phone calls/meetings/fires to put out/ CP/Call/ bull****/ partners/collection issues/ lab drama/tumor boards/ autopsies, just me and the scope and my $$$$. Did the busy hospital system gig for 14 yrs, way less stressed and prosperous now.

Some people don't mind being employees. I wasn't raised that way.

 

[Dave CX]

Some people don't mind being employees. I wasn't raised that way.

I'm an independent contractor. I can put 58k into retirement. We ALL work for somebody. I was way more of a bitch in hospital private practice.

 

[path vs rads]

I am a slide mill GI jockey. I LOVE the slide mill. The work waits for me other than the other way around. I come and go as I please. No phone calls/meetings/fires to put out/ CP/Call/ bull****/ partners/collection issues/ lab drama/tumor boards/ autopsies, just me and the scope and my $$$$. Did the busy hospital system gig for 14 yrs, way less stressed and more prosperous now.

Would you mind sharing how many cases on average you see on a daily basis?

 

[Dave CX]

About 130 accessions per day, 250 or so 305's

 

[cmz]

About 130 accessions per day, 250 or so 305's

So you bring in about $3M in professional billing per year. I hope you're making at least half of that...

 

[Dave CX]

Some people don't mind being employees. I wasn't raised that way.

Is it possible that in job 2 there will be some administrator with an online MBA managing your output and telling you what to do in annoying ways? Who exactly are you employed by?

Would you mind sharing how many cases on average you see on a daily basis?

So you bring in about $3M in professional billing per year. I hope you're making at least half of that...

Ha!!! That'll be the day

 

[Guest8]

So you bring in about $3M in professional billing per year. I hope you're making at least half of that...

I'd guess it would be closer to a quarter of that or so. At least based on what I know employed dermpaths at corporate labs make near me.

 

[gbwillner]

I'd guess it would be closer to a quarter of that or so. At least based on what I know employed dermpaths at corporate labs make near me.

That sounds pretty reasonable. Especially if you get partnership in their business.

 

[Dave CX]

I'd guess it would be closer to a quarter of that or so. At least based on what I know employed dermpaths at corporate labs make near me.

I am in an Anthem state, so I probably generate closer to 2.5 million, out of which I pull around 850k. I'm an independent contractor, so I pay my benefits out of that

 

[gbwillner]

I am in an Anthem state, so I probably generate closer to 2.5 million, out of which I pull around 850k. I'm an independent contractor, so I pay my benefits out of that

Question: when you say "generate", do you mean the global or professional only component?

 

[octopusprime]

I think my arms would fall off if i was looking at 250-300 GI biopsies/day [but i'd probably go insane before that].

 

[coroner]

Question: when you say "generate", do you mean the global or professional only component?

He's referring to professional. A pathologist doesn't generate the global unless they own the lab/equipment/reagents, etc. and he said he works for a slide mill.

The numbers add up: (250 accessions/d) (~$40/accession) = $10K/d x 5d/wk = $50K/wk x 46wks/yr (e.g. 6wks vacay/yr) =$2.3m/yr, throw in IHC, and it's around $2.5 mil/yr. From my discussions with various pathologists employed in similar settings, their cut is usually 40% of the PC. Greater than 50% is almost unheard of. So, in his case 850K/2.5m = 34%, which comes out to roughly $13.60 to sign out a tubular adenoma. To some, this may seem low, but that is the going rate for our skillset and within range of current market value. F.Y.I., there are some greedy outpatient labs where the pathologist's cut is even less, as well as some of our colleagues who will take any offer thrown at them to scrape the bottom of the barrel.

I think my arms would fall off if i was looking at 250-300 GI biopsies/day [but i'd probably go insane before that].

Hence, the term "slide mill". It's all about volume and this setting is certainly not for everybody. But if you can crank it out and it makes you happy, more power to you. I do know some of these pod labs limit the number of accessions per day a pathologist is permitted to look at before they hit their max. DermPath diagnostics is one such outfit. Can't remember what their max was, but I knew a histotech who used to work there and I believe she said it was somewhere around 150/d, not sure though. That being said, she told me most of the pathologists, if not all of them tried to hit their daily max (for more cash-o-la)...haha.

 

[HeyDalaron]

He's referring to professional. A pathologist doesn't generate the global unless they own the lab/equipment/reagents, etc. and he said he works for a slide mill.

The numbers add up: (250 accessions/d) (~$40/accession) = $10K/d x 5d/wk = $50K/wk x 46wks/yr (e.g. 6wks vacay/yr) =$2.3m/yr, throw in IHC, and it's around $2.5 mil/yr. From my discussions with various pathologists employed in similar settings, their cut is usually 40% of the PC. Greater than 50% is almost unheard of. So, in his case 850K/2.5m = 34%, which comes out to roughly $13.60 to sign out a tubular adenoma. To some, this may seem low, but that is the going rate for our skillset and within range of current market value. F.Y.I., there are some greedy outpatient labs where the pathologist's cut is even less...

Hence, the term "slide mill". It's all about volume and this setting is certainly not for everybody. But if you can crank it out and it makes you happy, more power to you. I do know some of these pod labs limit the number of accessions per day a pathologist is permitted to look at before they hit their max. DermPath diagnostics is one such outfit. Can't remember what their max was, but I knew a histotech who used to work there and I believe she said it was somewhere around 150/d, not sure though. That being said, she told me most of the pathologists, if not all of them tried to hit their daily max (for more cash-o-la)...haha.

I'm a dermpath and I am wondering what the case mix is for a place like Dermpath Diagnostics in which 150 accessions per day is the norm. What is the case complexity? Is it just an endless deluge of bcc biopsies and seb k shaves, or are there any large excisions, complex melanocytic cases, inflammatory, synoptic reports, sentinel nodes etc. I wonder because outside of those simple cases, the more complex ones generally require extra levels and stains, so a daily figure like that would turn into a huge backlog in short order.

 

[Guest8]

I'm a dermpath and I am wondering what the case mix is for a place like Dermpath Diagnostics in which 150 accessions per day is the norm. What is the case complexity? Is it just an endless deluge of bcc biopsies and seb k shaves, or are there any large excisions, complex melanocytic cases, inflammatory, synoptic reports, sentinel nodes etc. I wonder because outside of those simple cases, the more complex ones generally require extra levels and stains, so a daily figure like that would turn into a huge backlog in short order.

The only things they likely don't get are things done in hospital ORs - sentinel nodes, very large excisions, as well as biopsies on inpatients (those are usually forced to stay in-house). It's usually a high mix of basic biopsies but they will get anything a dermatologist will biopsy/excise, so tons of small biopsies but also excisions, inflammatory/rashes, etc. They will have to do synoptics on any melanoma case. They may also get slow Mohs excisions depending on their clients. I'd say outpatient GI gets less complex cases than dermpath - I fly through my GI cases and it's usually the tougher derms that bog me down - much more note writing and description involved.

 

[Med Director New England]

He's referring to professional. A pathologist doesn't generate the global unless they own the lab/equipment/reagents, etc. and he said he works for a slide mill.

The numbers add up: (250 accessions/d) (~$40/accession) = $10K/d x 5d/wk = $50K/wk x 46wks/yr (e.g. 6wks vacay/yr) =$2.3m/yr, throw in IHC, and it's around $2.5 mil/yr. From my discussions with various pathologists employed in similar settings, their cut is usually 40% of the PC. Greater than 50% is almost unheard of. So, in his case 850K/2.5m = 34%, which comes out to roughly $13.60 to sign out a tubular adenoma. To some, this may seem low, but that is the going rate for our skillset and within range of current market value. F.Y.I., there are some greedy outpatient labs where the pathologist's cut is even less, as well as some of our colleagues who will take any offer thrown at them to scrape the bottom of the barrel.

Hence, the term "slide mill". It's all about volume and this setting is certainly not for everybody. But if you can crank it out and it makes you happy, more power to you. I do know some of these pod labs limit the number of accessions per day a pathologist is permitted to look at before they hit their max. DermPath diagnostics is one such outfit. Can't remember what their max was, but I knew a histotech who used to work there and I believe she said it was somewhere around 150/d, not sure though. That being said, she told me most of the pathologists, if not all of them tried to hit their daily max (for more cash-o-la)...haha.

Some of the most heinous employers of pathologists are greedy academic chairs btw.

 

[HeyDalaron]

The only things they likely don't get are things done in hospital ORs - sentinel nodes, very large excisions, as well as biopsies on inpatients (those are usually forced to stay in-house). It's usually a high mix of basic biopsies but they will get anything a dermatologist will biopsy/excise, so tons of small biopsies but also excisions, inflammatory/rashes, etc. They will have to do synoptics on any melanoma case. They may also get slow Mohs excisions depending on their clients. I'd say outpatient GI gets less complex cases than dermpath - I fly through my GI cases and it's usually the tougher derms that bog me down - much more note writing and description involved.

I agree with that. I used to practice community AP and the derm cases were more nuanced than the GI ones, in which the variables are predominantly binary.

Of interest, are you aware of what kind of histo processing protocols these big labs employ? I can only assume they are very efficient with all that volume, so I was wondering if I could learn them and compare them to what we do at my institution.

 

[AZpath]

I think my arms would fall off if i was looking at 250-300 GI biopsies/day [but i'd probably go insane before that]

I would also be bored to death

 

[Dave CX]

Question: when you say "generate", do you mean the global or professional only component?

Professional.

 

[Dave CX]

I would also be bored to death

At least I never deal with personalities or egos. The entirety of my human interaction in the workplace involves flirting with the sexy receptionist and cute young nurses. I get excitement outside the office. No meetings, autopsies, call, tumor boards or hospital administrators. If you get off on all of that then you are a better man than me.

 

[Dave CX]

The only things they likely don't get are things done in hospital ORs - sentinel nodes, very large excisions, as well as biopsies on inpatients (those are usually forced to stay in-house). It's usually a high mix of basic biopsies but they will get anything a dermatologist will biopsy/excise, so tons of small biopsies but also excisions, inflammatory/rashes, etc. They will have to do synoptics on any melanoma case. They may also get slow Mohs excisions depending on their clients. I'd say outpatient GI gets less complex cases than dermpath - I fly through my GI cases and it's usually the tougher derms that bog me down - much more note writing and description involved.

Derm is more complex, but lots of pathologists miss GI diagnoses. Amazing how many can't diagnose autoimmune gastritis, despite a 2% prevalence.