Which specialty to choose for community practice?

[Pathogator]

I want to create this thread to generate some discussion on some of the pros and cons of various subspecialties, specifically in the context of making oneself marketable for community practice. I am not certain on community practice, but it's a strong possibility for me, and I just have no idea what to choose.

One reason I'm confused is I was recently told by a community pathologist that they do have certain pathologists that did "fellowships" in various areas, yet when a really difficult case comes, they end up sending it out anyways because it's just safer to do that than have the "subspecialized" community guy work it up with questionable accuracy after being 20 years out of fellowship.

I have seriously considered most everything except cytology and derm, cytology due to less interest and derm because I don't know if I could get in. Everything else is a possibility.

All things being equal (i.e. program reputation), which subspecialties automatically make oneself extremely marketable in the city of one's choice. Which subspecialties might you advise steering away from (i.e. soft tissue/neuro?) ?

I should have strong general skills, but what specialty would add that extra spice to make me a killer prospect for a good job? Or, does it just "not matter" in the long term scope of community practice?

Thanks!

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[KeratinPearls]

I want to create this thread to generate some discussion on some of the pros and cons of various subspecialties, specifically in the context of making oneself marketable for community practice. I am not certain on community practice, but it's a strong possibility for me, and I just have no idea what to choose.

One reason I'm confused is I was recently told by a community pathologist that they do have certain pathologists that did "fellowships" in various areas, yet when a really difficult case comes, they end up sending it out anyways because it's just safer to do that than have the "subspecialized" community guy work it up with questionable accuracy after being 20 years out of fellowship.

I have seriously considered most everything except cytology and derm, cytology due to less interest and derm because I don't know if I could get in. Everything else is a possibility.

All things being equal (i.e. program reputation), which subspecialties automatically make oneself extremely marketable in the city of one's choice. Which subspecialties might you advise steering away from (i.e. soft tissue/neuro?) ?

I should have strong general skills, but what specialty would add that extra spice to make me a killer prospect for a good job? Or, does it just "not matter" in the long term scope of community practice?

Thanks!

Do a search. You are asking a question that has been asked and discussed many times over.

Derm, GI or GU.

 

[pathstudent]

Do a search. You are asking a question that has been asked and discussed many times over.

Derm, GI or GU.

Yeah GU is great if you want to go work for a urology pod lab.

 

[Unty]

Yeah GU is great if you want to go work for a urology pod lab.

Anyone know how much these clinicians pay pathologists? Do you get chained and whipped? Are you only fed bread and water?

I know of one guy (general pathologist with 20+ years experience who is working at a pod lab but dont know how much he gets paid). From what I hear he supervises the lab and can come and go as he pleases.

 

[Entgegen]

Anyone know how much these clinicians pay pathologists?

From what I've read, it depends on if the pod lab bills global or if they just bill the TC and the pathologist bills PC. If the pod lab bills global, then they may pay the pathologist <100k. If the pathologist maintains the PC, then he/she gets whatever the PC will get him/her.

 

[raider]

Interestingly, the most errors I see are in gynecologic pathology signouts from smaller community hospitals e.g. serous borderline tumor micropapillary variant called some absurd nonsense like intermediate grade papillary serous carcinoma or a smooth muscle tumor of uncertain malignant potential called a leiomyosarcoma or a serous intraepithelial carcinoma missed entirely etc. Also gynecologic pathology constitues a major share of any community practice. I am still not sure why gynecologic pathology is not considered in the same league (as regards desirability) as genitourinary pathology, gastrointestinal pathology and dermatopathology. The volume of gynecologic pathology cases is certainly substantial in most decent community practices.

Hematopathology is ofcourse very useful for any pathology practice.

 

[KCShaw]

Not sure when "pod lab pathologist" became the same thing as "community pathologist." Actually, I'm not real sure when "community pathologist" became well defined in terms of what kinds of cases and of what volume they always get.

Just like with any practice, the cases and volume, as well as the expertise of existing pathologists in the group, dictates what would make an applicant desirable. Generally, I agree one would probably expect volume primarily from common readily available biopsy sources, such as skin, GI, breast, and GU, with specimens to include cytology, particularly GYN, and excision specimens to be largely general-surgeon accessible, or common subspecialty, but not necessarily difficult from a surg path point of view because you've likely seen many many before (colons, prostates, +/-breast, etc.). Keeping in mind these are gross generalizations, I'd start with general surg path, then, if you're looking at a very specific city you want to be in, look at what the local practices actually get and tailor yourself to your target job/location.

I think heme is hit or miss, as my impression is that most heme clinicians find a pathologist or group very early and tend to stick with them, and the volume isn't as guaranteed as some other subspecialties. Plus it's useful to do your own flow, which a community lab may not already have, and all but necessary to have numerous reliable immunos with quick turnaround, not all of which may be in use or used enough to justify in the local histo lab unless that's already being farmed out. Might have to develop a reputation before expecting a lot of marrows, unless your practice already gets them; on the other hand, nodes may be relatively common. Maybe I'm off base on that.

Overall.. as with most questions about "..what X is best for Y..", I think it depends.

 

[gschl1234]

Interestingly, the most errors I see are in gynecologic pathology signouts from smaller community hospitals e.g. serous borderline tumor micropapillary variant called some absurd nonsense like intermediate grade papillary serous carcinoma or a smooth muscle tumor of uncertain malignant potential called a leiomyosarcoma or a serous intraepithelial carcinoma missed entirely etc. Also gynecologic pathology constitues a major share of any community practice. I am still not sure why gynecologic pathology is not considered in the same league (as regards desirability) as genitourinary pathology, gastrointestinal pathology and dermatopathology. The volume of gynecologic pathology cases is certainly substantial in most decent community practices.

Hematopathology is ofcourse very useful for any pathology practice.

I'm betting some of the "errors" to which you refer have to do with the inherent controversy in the field of GYN. The experts don't agree on some fundamental issues. There was a platform at this year's USCAP looking at intraobserver reliability on the issue of cervical involvement by endometrial carcinoma (just glandular invasion vs. stromal) and the experts do not agree. Then there's the issue of APST/MT vs. ST/MT-LMP aka borderline ST/MT. My sense is that most everyone can agree that micropapillary carcinoma is a non-invasive carcinoma but there probably are people who disagree. But I digress. To get back to your point why GYN path isn't at the desirability level of GI/GU, one of our former attendings (general surgpath) said it's because MOST GI/GU biopsies are small (only one a few pieces of tissue), and thus can be read very rapidly. And also, (to me anyway), the "rules" of GI/GU seem a lot more defined than in GYN. On the other hand, ECC, endometrial BX/CUR's are bigger, have more pieces of tissue and thus, take a lot longer to scan to make sure you've actually looked at every piece. Even once you've identified a suspicious area, a lot of lesions are tricky, and again, the experts might not even agree on some cases because criteria aren't clearly defined or they have different belief systems. So if you have a GYN fellowship trained pathologist in your practice, they'll still disagree with "expert opinion" based on to whom you send the case.

 

[Pathogator]

Do a search. You are asking a question that has been asked and discussed many times over.

Derm, GI or GU.

I know it's cool to say "do a search" on an Internet forum, but the keywords for this subject aren't immediately obvious to me.

 

[deleted314957]

I want to create this thread to generate some discussion on some of the pros and cons of various subspecialties, specifically in the context of making oneself marketable for community practice. I am not certain on community practice, but it's a strong possibility for me, and I just have no idea what to choose.

One reason I'm confused is I was recently told by a community pathologist that they do have certain pathologists that did "fellowships" in various areas, yet when a really difficult case comes, they end up sending it out anyways because it's just safer to do that than have the "subspecialized" community guy work it up with questionable accuracy after being 20 years out of fellowship.

I have seriously considered most everything except cytology and derm, cytology due to less interest and derm because I don't know if I could get in. Everything else is a possibility.

All things being equal (i.e. program reputation), which subspecialties automatically make oneself extremely marketable in the city of one's choice. Which subspecialties might you advise steering away from (i.e. soft tissue/neuro?) ?

I should have strong general skills, but what specialty would add that extra spice to make me a killer prospect for a good job? Or, does it just "not matter" in the long term scope of community practice?

Thanks!

I have been a solo lab medical director at a 170+ bed community hospital for more than 20 years. The medical staff, esp the surgeons think i walk on water and pee ginger-ale. I have never been sued. I have a limited background in general practice prior to pathology. I have readilly available consultation in about any area as well as access to "esoteric" tests.

I know general surg path, general heme path, general cytopath and general clin path. i have forensic boards which i last used about 20 years ago and i am very good at endoscopic GI.

Most important, I believe I know WHAT I DON"T KNOW and WHEN TO ASK FOR HELP.

The above has made me respected among my medical staff and very well off.

 

[Unty]

I have been a solo lab medical director at a 170+ bed community hospital for more than 20 years. The medical staff, esp the surgeons think i walk on water and pee ginger-ale. I have never been sued. I have a limited background in general practice prior to pathology. I have readilly available consultation in about any area as well as access to "esoteric" tests.

I know general surg path, general heme path, general cytopath and general clin path. i have forensic boards which i last used about 20 years ago and i am very good at endoscopic GI.

Most important, I believe I know WHAT I DON"T KNOW and WHEN TO ASK FOR HELP.

The above has made me respected among my medical staff and very well off.

Hey Mike,

We know you are a great pathologist, all the clnicians love you, you are a multimillionaire, you are an excellent GI endoscopist....I have several questions for you...

Do you have Adonis DNA? Do you have tiger (Felidae family, most likely from Panthera tigris) in your blood? If you are taking drugs would the drug you are taking possibly be "mikesheree"?

 

[deleted314957]

Hey Mike,

We know you are a great pathologist, all the clnicians love you, you are a multimillionaire, you are an excellent GI endoscopist....I have several questions for you...

Do you have Adonis DNA? Do you have tiger (Felidae family, most likely from Panthera tigris) in your blood? If you are taking drugs would the drug you are taking possibly be "mikesheree"?

no, no and no

 

[2121115]

Hey Mike,

We know you are a great pathologist, all the clnicians love you, you are a multimillionaire, you are an excellent GI endoscopist....I have several questions for you...

Do you have Adonis DNA? Do you have tiger (Felidae family, most likely from Panthera tigris) in your blood? If you are taking drugs would the drug you are taking possibly be "mikesheree"?

OMG this is the post of the year on this site!

I just spewed scotch all over my keyboard LOLing.