I know many of the senior students have gone through at least some of their interviews, and I am curious as to which programs are standing out. Any surprises? Any "sleeper" programs? Any programs with a good "reputation", but on closer inspection are less that you would hope? What do you look for in a program?
What's in a name?
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When I was looking at programs, I had a few things that I was looking for:
1) Am I going to be a pathology resident or a PA at half salary? A lot of programs work their residents hard in the gross room with too little scope time. I know faculty read this forum as well as residents, but I will adamantly argue that the AP board exam is a "microscopic" one, not a practicum on grossing. The educational value of grossing your 5th malignant colon is quite menial if at all. Yes, it is important to know how to gross and what sections you should take, but if more than 1/2 of your time is going to be spent grossing rather than at the scope you should be a little weary.
2) What breadth of cases am I going to see? If the program you're looking at only sees small bowel obstruction resections, appendices, and gallbladders, it's not going to be a very fruitful experience. On the other hand, you don't want it to be so busy that you're too occupied just moving along the cases that you can't study what is coming across your desk.
3) Sign out culture and graduated responsibility. If sign out consists of you just sitting at the scope as a dictation machine with cases you haven't seen because you're too busy to preview, it's probably not going to be the best experience. And if the faculty don't let you begin to handle the cases by yourself short of complete sign out including first draft of the report, also probably not the best experience.
These are some of the big things I was looking for and only a few programs can match these criteria. Not to say that you won't get what you need from programs that don't fit the bill for me, but it probably is going to be more annoying and much harder than it really should be.
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Great answer by Alteran. Agree with all of it. Especially #1 - I got a lot of crap from the PAs at my residency program because I couldn't gross as fast or well as them, but guess what - they do it 40 hours a week, and my job was to pass the board exam, not be able to gross a whipple in 75 minutes (which probably can be done, but not by me). I think the three things here are some of the most important for the AP side, with #2 and #3 applying to cyto as well. Any place that doesn't have seniors on AP writing a first draft of a report would be a red flag.
I'll add that you should also look for quality teaching faculty. I have no clue how you do this on the interview trail, but you really want at least a few really strong diagnosticians at your program to teach you how to think like a diagnostic pathologist. Again, very important for passing boards and eventual practice. Would also add that you don't want to go somewhere with all junior faculty because from what I saw, age was inversely related to reliance on immunos. And again, the AP board exam is 80%: here's an H&E, what's the diagnosis? If you learn to only diagnose with immunos, you're in trouble, so you want faculty that instead teach you to make a tentative diagnosis on your H&E alone, then use immunos to confirm primarily. This is in contrast to the "kitchen sink" or "shotgun" approach i saw some of the younger faculty use when they have no idea what the f they were looking at.
I'll add that you should also look for quality teaching faculty. I have no clue how you do this on the interview trail, but you really want at least a few really strong diagnosticians at your program to teach you how to think like a diagnostic pathologist. Again, very important for passing boards and eventual practice. Would also add that you don't want to go somewhere with all junior faculty because from what I saw, age was inversely related to reliance on immunos. And again, the AP board exam is 80%: here's an H&E, what's the diagnosis? If you learn to only diagnose with immunos, you're in trouble, so you want faculty that instead teach you to make a tentative diagnosis on your H&E alone, then use immunos to confirm primarily. This is in contrast to the "kitchen sink" or "shotgun" approach i saw some of the younger faculty use when they have no idea what the f they were looking at.
Ask about faculty turnover. Also inquire if there is a change in leadership (especially at the chairman position). Often these two things are interrelated (for instance: a new chairman takes over, faculty are unhappy and there is a mass exodus) and can potentially result in program instability. Red flag.
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Good point about the chairperson, but doubt most programs would be honest about this question. Very good point about faculty turnover. Some is normal, but a lot is a red flag.
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👍👍👍👍👍👍
This description by Alteran of what to look for in a pathology residency is the best summary I have ever seen. For those of you crazy enough to be going into pathology, commit this to memory- it's that good.
Yes, this. But, the way most residents interpret the "1/2" varies. Yes, the AP boards may be a little more microscopy over gross, but it's hardly the microscopic portion of the exam that gets folks. The microscopic portion are mostly aunt-minnie's, i.e. you take one look and you make the diagnosis. That's the easy part. The tougher part is all the other carp they ask you, most of which you'll have to read up on your own as it's hardly the sort of stuff you'd learn at the scope most of the time anyways. I would also argue that looking at your 5th malignant colon under the microscope is "quite menial if at all educational" and what really matters is a good gross. The same goes for your nth breast, or whipple, or whatever.
Yes Virginia, there really is a good use for all those grossing skills, and residency shouldn't just be about preparing you for your boards. If the latter is your attitude, that's one of the reasons why we can't have nice things in pathology. If your focus during your years of training are mostly on just passing the boards, you've lost the game. I see plenty of this. The residents who whine the most about how much grossing they have to do are the ones that, in the end, know the least, and have the toughest time passing their boards. Focus on becoming a good pathologist (gross and microscopic), and you'll pass your boards.
You don't have to be fast, though guess what, the more of something you do, the faster you become at it. I could easily fly through a whipple or cystoprostatectomy or LAR in well under 1hr, complete with lymph node dissection, and all; so could most of my peers (at least the ones that didn't always whine about all the work they had to do; we were at a somewhat gross-heavy program). Again, once you understand the purpose of the gross and you know technically what you're doing, and are not constantly having to ask your PAs or seniors for help, or having to look procedures up in a grossing manual, it becomes fast and easy.
If you don't shank your gross, the micro is easy. Not a week (sometimes even not a day) goes by that I don't see a case that's fubar'ed from the get-go, i.e. the gross. And once the gross has been fubar'ed all your fancy microscopy skills go down the tubes. Besides, once you're out of training, you become responsible for the grossing that your residents, techs, and/or PAs do. So, you better know how it's done right.
Your 3rd point is probably the most important.
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I'm not interested in a grossing debate. But I disagree with your comment that AP boards is mostly aunt minnie diagnoses. Some yes, but plenty of more challenging diagnoses requiring thought and looking around the slide. Will agree they ain't testing colonic adenocarcinoma. But for my exam at least (less than a year ago) there were not a lot of second order questions - some yes, but far less than attendings at my program implied (ie, if you don't know every sarcoma translocation you're bound to fail).
The issue about the true goals of residency is a much longer discussion. Passing boards isn't the only goal, but it's a huge one. If you don't, it makes finding a job much tougher. I agree learning good gross and microscopic pathology should be the day to day job of a path resident, but keeping in mind one of the large end goals is a good idea.
The issue about the true goals of residency is a much longer discussion. Passing boards isn't the only goal, but it's a huge one. If you don't, it makes finding a job much tougher. I agree learning good gross and microscopic pathology should be the day to day job of a path resident, but keeping in mind one of the large end goals is a good idea.
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As long as there's a reasonable balance -- time to learn and do both in the gross room and with the slides and associated reading and diagnostic workups, without perpetually having to be on site. I do think a lot of residents underestimate the value of learning to be efficient, -especially- in the gross room, as once you can do that suddenly there is a lot more time for everything else.
That said, I concur Alteran's points are pretty good ones to keep in mind.
As for turnover, if you flat out ask (I did when I was interviewing), they'll tell you. They may sugar coat it, but you'll get a sense of things if you pay attention at all. Make sure you also have time with residents on interview day, not just a small number of select attendings or only 1 or 2 out of the 15 residents.
The boards don't mean quite the same as Step I. Nobody knows whether you aced the boards or snuck in by 1 point (most probably would never know if you failed twice first, for that matter), but if you can't pass then you just wasted 8 years and howevermany hundred thousand bucks on medical education and pathology training -- good luck. Of course, like most exams, passing the boards won't make you a decent or successful pathologist, though it's a critical start -- that's where all of those other things come in, and why I think KluverB also makes some good points.
That said, I concur Alteran's points are pretty good ones to keep in mind.
As for turnover, if you flat out ask (I did when I was interviewing), they'll tell you. They may sugar coat it, but you'll get a sense of things if you pay attention at all. Make sure you also have time with residents on interview day, not just a small number of select attendings or only 1 or 2 out of the 15 residents.
The boards don't mean quite the same as Step I. Nobody knows whether you aced the boards or snuck in by 1 point (most probably would never know if you failed twice first, for that matter), but if you can't pass then you just wasted 8 years and howevermany hundred thousand bucks on medical education and pathology training -- good luck. Of course, like most exams, passing the boards won't make you a decent or successful pathologist, though it's a critical start -- that's where all of those other things come in, and why I think KluverB also makes some good points.
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I agree that a 1 hour on a whipple or a cystoprostatectomy would be a minimum speed to be functioning at as an upper level resident. Speed does matter. You will never have time to actually think about the hard/interesting cases if you cannot go fast through all the other cases.
Surgical pathology volumes, as well as the info we have to document, have increased so much over the past few years that there just isn't time to think long and hard about the specimens. You need to have that CAP template memorized and be able to fly through a gross description and your slides quickly while getting the info you need to fill out the template and leaving the rest. The PC component of an 88309 for the whipple and an 88307 for the nodes isn't nearly enough $$ to justify a 1 hour + gross and another 45 minute micro session. As a resident/fellow you should be benchmarking yourself to get that whole thing done in 1 hour (aggregate), from looking up clinical history, to grossing, dictating the report, and proofing it to pressing the button. If you go into a traditional hospital based private practice, you will make your living and feed your family by doing large resections (since the biopsies will be contracted out to pod labs mostly) so you can't get bogged down.
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For those that are wondering the PC on an 88307 is about $75 and on an 88309 is about $130 with geographical variation.
That's right people. A breast cancer lumpectomy pays a pathologists 75. Think about how long it takes to gross, micro (with 3d margins), and make sure the report is accurate. You could sign-out 100 GI biopsies in the same amount of time.
Hell even with fee splitting the urologist makes more off the PC component of the pathology on their prostate biopsies than a hospital based pathologist makes on doing hospital based pathology.
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Dude, you better fire your billing people, you are getting SCREWED. Our 88307 is about 295 and our 88309 is 450 for PC. Geographic variation perhaps. I'm sure someone out there gets more than me.
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CMS does not reimburse that much for the PC on an 88307 unless your practice is on the moon.
That sounds more like the global for your region. TC is about 2/3 of that and PC is about 1/3. Check with your biller. Ask your biller what CMS reimburses for an 88307-26 (the code for the PC on an 88307).
Or maybe your group might charge 295 for an 88307 but CMS won't pay your charge. You'll get what the medicare fee schedule says you'll get for your region, closer to 75 bucks.
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If you are getting that for "PC" (not global) then it is not from medicare, but probably from private insurance where that wouldn't be unusual.
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That would be beyond unusual. An absurdly lucky contract with a private insurer would pay 1.8 times Medicare. No insurer would ever contract at 3.0 times Medicare not in the field of pathology.
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The biggest private insurer in my state is lucky to pay 75% of Medicare. Unfortunantly they are taking over the state and have way too much power.😡
I laugh when I hear physicians say they have to turn away Medicare patients. Heck, they are the profitable ones for us sadly. Bring on Obamacare!
I laugh when I hear physicians say they have to turn away Medicare patients. Heck, they are the profitable ones for us sadly. Bring on Obamacare!
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I've previously been relatively anonymous on the forum, but the OP wanted to know about "sleeper" programs (lesser known places with good quality training) and these descriptions provided by Alteran fit my residency, William Beaumont Hospital in Michigan, very well. So I thought I would share 🙂
I have never found preview time to be an issue and I think that we have some of the most approachable attending staff I met anywhere on the interview trail.
Another couple of programs that were high on my rank list, seemed to fit these resident-centric criteria and might not be very well known outside their geographic region were University of Vermont and University of Iowa.
We have 5 full time PAs who can generally handle the caseload on their own, so resident grossing is primarily educational and not scut. First years spend the first few weeks in an AP orientation learning to gross and perform hospital autopsies, then routine grossing days (doing biopsies, appys, gbs, placentas, etc.) gradually decreases from 1/week to 1/month. Senior residents only gross their frozen cases, which are generally the bigger, more educational specimens anyway, and Saturdays when on call.
We have one of the highest surgical volumes in the country, around 65,000-70,000 surgicals/year, with a great variety of cases including derm, soft tissue and bone, neuro, peds, hemepath, medical kidney/liver/lung. I think about the only weakness is that we don't have a particularly busy transplant department, we mostly do kidneys and only recently started livers.
Our program does this very well. Early in first year staff will cherry pick a limited number of cases for new residents so they have plenty of time to preview/read, then double-scope them all for in depth discussion. First years will start dictating later in the fall and will gradually increase the number of cases they are responsible for. Generally, by the second half of first year, residents are expected to scan the day's caseload for stuff needing stains (and have diff dx and list of stains you think are appropriate), draft complete reports for all cases (including cancer checklists, stain results, notification of clinicians, etc.), get audits from other staff when necessary, and so on and only cases that are difficult/interesting or the resident has specific questions about will be double-scoped.
I have never found preview time to be an issue and I think that we have some of the most approachable attending staff I met anywhere on the interview trail.
Another couple of programs that were high on my rank list, seemed to fit these resident-centric criteria and might not be very well known outside their geographic region were University of Vermont and University of Iowa.
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