Sunday, February 05, 2006


No, for a number of reasons. For one, there are a TON of cyto fellowship positions, probably 2x as many that are needed. And this is nowhere near as marketable as it used to be given that breast FNAs are being replaced by cores from radiology. Pap smears too hopefully will go away with universal HPV screening. So move that down the list.

Now GYN in my opinion is near worthless, gynpath is bread and butter stuff you can get in any solid surg path year. Competition for these fellowships is limited to academic geek types who fantasize about large ovarian masses and endometrial polyps...move that down.

GI is HUGE and up-n-coming. How many solid GI fellowships are there? Maybe MAYBE 6 in the whole US: Odze at Brigham being no1, MGH, BID, UCLA (but their big guy left), Cleveland, Hopkins...the list is slim. And dont bring up UCSF please, that fellowship is 80% liver. Move that one WAY up.

GU is interesting b/c out of the blue this is hugely marketable. Okay realize Im saying "marketable" NOT useful. I can dx anything that someone who spent a year with Epstein can but in terms of marketing myself to urologists I dont have the same leverage, move this way up, there are less GU fellowship slots than GI!!

Overall my list:
1.) Derm, still king
2.) GI
3.) GU
4.) Heme
5.) Cyto
6.) Forensics (can be very competitive at the best places: NM and MiamiDade)
7.) Blood bankTM
8.) BoneSoftTissues
9.) Gyn
10.) general surg path
11.) Lung
12.) Liver (near worthless)
Thanks for sharing your insights...very much appreciate it.

I remember talking to you about derm last year. I really enjoyed my derm weeks and derm is definitely on my radar now. However, I'm certainly more than aware of the competitiveness of getting a derm fellowship and honestly, this is quite unsettling.

And I second your opinion on the GI fellowship. We have a very strong GI fellowship here with Odze at the helm.
No. But I don't wanna spend the clinical part of my career (as limited and minimalized as it may be) just doing autopsies. Those kind of jobs are not very abundant. I want to be able to sign out cases in some specialty. That way I can have a more stable job and increase my salary. If this doesn't happen, I've wasted my time by going through medical school and I've wasted my time doing a residency. It's all about sound backup plans.

I will say this's gonna be "my way or the highway". If I don't get the fellowship I want for whatever reason, that's it! I'm going straight to postdoc. I'm not gonna waste a year doing some fellowship I have absolutely no interest in (like cyto) just to wait in line for the fellowship I want. For example, this is the case for Heme and Neuro at my program. Spots are booked not just for next year but for future years as well.

There's the musings of a future scientist. How you like dem apples?
Ouch, babe. The cyto slam kinda hurts. I agree to a point that there are indeed lots of cyto fellowships. However, cytology is still an integral part of pathology practice, and fellowship-trained people do it better than generalists (and thats not just my defensive cyto-trained self talking). GI path seems to be somewhat in favor, but isn't this bread and butter surgpath too? I also think heme should be higher. My list:
1) Derm
2) Heme
3) Cyto
4) GI (I'll include liver with this)
5) GU
6) TM
7) Bone/ST
8) Forensics
9) GYN
10) Gen. surgpath
11) Pulmonary
Sorry for the cyto slam, cyto is absolutely a key skill, my issue is there are just way too many cyto trained pathologists nowadays and overall the field is trending away from cyto. Differentiate a fellowship that is "useful" (which cyto would be far and away no1, you see prob. 5x more cyto than derm) from those that are "marketable."

Heme was good, circa around 1 year ago. The reimbursements for flow were so crazy at one point that even small hospitals were buying million dollar equipment packages. It had been that flow was actually reimbursed similar to immunostains, on a per antibody basis. So if you had a rule out panel with 18-20 antibodies (not totally uncommon) at $95 per, you were pulling down $1800 just for the professional component (a negative takes me aroun 20 min to read and write up, do the math on a per hour billing for that)! Then you billed another $65 for the spin adequacy. That was insane money, especially if you could get your hemeoncs to order flow on every marrow and node. People flooded into heme fellowships, got phat offers and then it all changed. Now flow is a gobal fee, so where before you got $1850, now it is $500 or even less. Huge hit. People were saying flow was now even a money LOSER to do as the fees were all capped. Crazy. Anyway, lots of places that were bringing flow on line and hiring hemepath people reversed course realizing it was far more cost effective to send to USLABS/Clarient etc.

I am a hemepath person so Im being frank, I definitely would not have done a whole year of it (I still like hemepath) if I saw the writing on the wall years ago. I think heme will undergo further mass consolidation in the near future to commercial labs like Quest due to fixed asset costs required in building a cutting edge diagnostic hemelab.

*Oh and Neuropath isnt on there, it would be dead last. In fact I highly advise people to not do neuro unless 1.) you are at a very very high volume place 2.) you also do a surg path year/cyto/heme or derm to tighten your skill set 3.) you also do CP as you can see that would be a 4yearAPCP+2NP+1fellowship=7 year plan, which is freakin absurd, hence why it is dead last.
I'd put neuropath second to last, just before opthomologic path (I actually knew an opthomologic path fellowship trained guy. Is there a less useful fellowship out there? I think not. The only thing they're good for is orienting the one globectomy specimen you get once every ten years).

I am thinking of going back and doing a GI path fellowship, but focused to the 2nd part of the jejunum. This way, I would be sub-subspecialized. If it isn't from the 2nd part of the jejunum, I don't want to even see it. I would know nothing about the duodenum, ileum, rest of the jejunum, liver, or remainder of the GI tract. But if you have a lesion from the middle of the jejunum, I'm your guy. I bet some affected university would hire me, just so they can brag that they have the (2nd part of the) jejunum expert. It would be a sweet gig, too. I wouldn't get paid crap, but I would look at about seven slides a year in consultation. Sweet.
Its ALL about marketing, why do think our large consumer corps spend billions a year on this crap? Why are there multimillion $$$ ads for flipping Viagra during the super bowl? You can argue what is more useful all day long, but at the end of the day the group with the fellowship trained GI and GU people will walk away with the contracts and you will be holding your nuts in your hand and crying for momma. This is the sad and f'd up thing about the path market today. This isnt superficial bro, this is what puts the spam n eggs on your kids plate, makes your Benz payments and pays your employees. i.e. this is the nuts n bolts of real life in pathlandia.

Until the ABP wises up and closes down 50% of the residency programs, the surplus in path will continue to increase already cut throat competition.
Truth be told, the souless moronic bean counters who make the decisions on granting contracts aren't even sure what "GI" stands for. They don't give contracts based on credentials. They give them based on cost. To them, cheaper=better. Plain and simple. If you can underbid your competitor, you win. This is how the sweatshops like Quest and Labcorp of the world get by. They are mills and they can thus get by with low contracts by producing huge volume.

btw, I agree with your point on cutting the residency spots 1000%. This would greatly increase our earning potential.


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