Career Advice - Transfusion Medicine

[futuredoc331]

I'm a CP only resident who came to pathology specifically for transfusion medicine. Coming in, I thought I would like an academic career and wanted to be involved with research. Transitioning to industry was also something that interested me. After this first year, I've realize that I may not like academics as much as I thought and I'm definitely not as comfortable with the geographical restriction that comes with the job. I also miss seeing patients. I do like transfusion medicine a great deal and areas like cellular therapy and regenerative medicine are very appealing to me.

I've been considering making a switch to a primary care specialty for the variety of work settings, ability to work anywhere, and the potentially higher earning potential. I don't know that I want to give up transfusion though. Is it possible to do both? I was thinking about going to Family Medicine, but maybe I should consider IM?

What types of other things should I be thinking about?

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[coroner]

I'm a CP only resident who came to pathology specifically for transfusion medicine. Coming in, I thought I would like an academic career and wanted to be involved with research. Transitioning to industry was also something that interested me. After this first year, I've realize that I may not like academics as much as I thought and I'm definitely not as comfortable with the geographical restriction that comes with the job. I also miss seeing patients. I do like transfusion medicine a great deal and areas like cellular therapy and regenerative medicine are very appealing to me.

I've been considering making a switch to a primary care specialty for the variety of work settings, ability to work anywhere, and the potentially higher earning potential. I don't know that I want to give up transfusion though. Is it possible to do both? I was thinking about going to Family Medicine, but maybe I should consider IM?

What types of other things should I be thinking about?

It is possible to do both primary care (as well as other specialties), plus transfusion. IM qualifies as an accepted residency to get into a fellowship in transfusion medicine; but, not FM from my understanding. Some fellowship programs simply state their criteria to be considered as an applicant include "a qualified medical specialty" e.g. Path, IM, Surgery, Anesthesiology, etc. while others are exclusive to just Path and IM. Here's a few:

Application Information | Cedars-Sinai

https://med.stanford.edu/pathology/education/clinical-fellowships/transfusion-medicine-fellowship.html

 

[futuredoc331]

It is possible to do both primary care (as well as other specialties), plus transfusion. IM qualifies as an accepted residency to get into a fellowship in transfusion medicine; but, not FM from my understanding. Some fellowship programs simply state their criteria to be considered as an applicant include "a qualified medical specialty" e.g. Path, IM, Surgery, Anesthesiology, etc. while others are exclusive to just Path and IM. Here's a few:

Application Information | Cedars-Sinai

https://med.stanford.edu/pathology/education/clinical-fellowships/transfusion-medicine-fellowship.html

Thanks so much! Any idea if people coming from non-pathology specialties end up continuing work in their original field? I think I might really like being the director of apheresis and doing primary care several days a week.

I have no idea about the logistics of this, but if I wanted to open/run my own apheresis clinic would it necessarily require board certification in TM/BB? Could I get by with 2 years of CP training that was heavily focused on apheresis plus the training I get at my next residency in FM or IM?

 

[90sportsfan]

Thanks so much! Any idea if people coming from non-pathology specialties end up continuing work in their original field? I think I might really like being the director of apheresis and doing primary care several days a week.

I have no idea about the logistics of this, but if I wanted to open/run my own apheresis clinic would it necessarily require board certification in TM/BB? Could I get by with 2 years of CP training that was heavily focused on apheresis plus the training I get at my next residency in FM or IM?

It looks like IM plus TM/BB fellowship gives you eligibility for board certification. With that, you should be able to theoretically due a hybrid primary care and apheresis practice; although it could take a wile to workout the logistics.

American Board of Pathology

 

[Med Director New England]

Sounds like your best path is IM followed by transfusion medicine…I’ve seen apheresis services run by the dept of pathology and by IM.
I believe it is much better for patient care to have a background in IM for apheresis patients — who are often complicated and occasionally have chest pain, seizure activity or even code….

most apheresis occurs in academic setting

 

[futuredoc331]

Sounds like your best path is IM followed by transfusion medicine…I’ve seen apheresis services run by the dept of pathology and by IM.
I believe it is much better for patient care to have a background in IM for apheresis patients — who are often complicated and occasionally have chest pain, seizure activity or even code….

most apheresis occurs in academic setting

I think a more important issue for me is that I'm already a second year CP resident. If I apply through the match to start IM or FM next July, I'll be making the switch with only one more year required in CP. Would sticking around for that additional year to get boarded in CP be all that beneficial? I don't see myself becoming a full time medical director for any of the other areas in CP (chem, micro, molecular, etc). I may be interested in doing something part time at some point, but my understanding is that almost any MD can do that and I will have all of my required CP rotations already done.

 

[futuredoc331]

Can a CP + FM or IM trained physician oversee and charge for apheresis procedures without a transfusion medicine fellowship?

 

[gbwillner]

I think a more important issue for me is that I'm already a second year CP resident. If I apply through the match to start IM or FM next July, I'll be making the switch with only one more year required in CP. Would sticking around for that additional year to get boarded in CP be all that beneficial? I don't see myself becoming a full time medical director for any of the other areas in CP (chem, micro, molecular, etc). I may be interested in doing something part time at some point, but my understanding is that almost any MD can do that and I will have all of my required CP rotations already done.

My advice is that if you still want to do transfusion medicine and apheresis, to stick with your current training and go to a top-notch TM fellowship program. UPenn and WashU come to mind for this. You will be in practice in 2 years. If you stop now and do IM:

1. you will absolutely NOT make any more money with this approach;
2. you will delay entry to the marketplace by at least 3-4 years

I also agree with others that apheresis is mostly academic, so if you don't want to stay in academia, you should reconsider your motivations.

Your real question is if you want to actually do TM. If you do, I would stick with the current plan. If you don't, apply to IM residency programs.

 

[gbwillner]

Can a CP + FM or IM trained physician oversee and charge for apheresis procedures without a transfusion medicine fellowship?

What do you mean by "can"? You are a licensed physician and "can" practice medicine, including all aspects of it. The question isn't if you "can", it's if you should. Also if anyone will pay you to do it.

 

[futuredoc331]

My advice is that if you still want to do transfusion medicine and apheresis, to stick with your current training and go to a top-notch TM fellowship program. UPenn and WashU come to mind for this. You will be in practice in 2 years. If you stop now and do IM:

1. you will absolutely NOT make any more money with this approach;
2. you will delay entry to the marketplace by at least 3-4 years

I also agree with others that apheresis is mostly academic, so if you don't want to stay in academia, you should reconsider your motivations.

Your real question is if you want to actually do TM. If you do, I would stick with the current plan. If you don't, apply to IM residency programs.

What do you mean by "can"? You are a licensed physician and "can" practice medicine, including all aspects of it. The question isn't if you "can", it's if you should. Also if anyone will pay you to do it.

By "can" I mean will I be able to get paid by any type of insurance company.

A better explanation of my ideal practice would probably help here. It's not something that is currently being done in many places, but I think there may be a future in it.

There have been several studies now, and more on the way, regarding therapeutic plasma exchange slowing or halting the progression of Alzheimer's disease. In mouse models, they've even shown that it could help rejuvenate muscle and organ function. I think my ideal practice setting would be a clinic (possibly my own) where I offer TPE for these indications. I think practicing some general medicine as well would be a great addition to this practice, but that would obviously require an additional residency.

 

[gbwillner]

By "can" I mean will I be able to get paid by any type of insurance company.

A better explanation of my ideal practice would probably help here. It's not something that is currently being done in many places, but I think there may be a future in it.

There have been several studies now, and more on the way, regarding therapeutic plasma exchange slowing or halting the progression of Alzheimer's disease. In mouse models, they've even shown that it could help rejuvenate muscle and organ function. I think my ideal practice setting would be a clinic (possibly my own) where I offer TPE for these indications. I think practicing some general medicine as well would be a great addition to this practice, but that would obviously require an additional residency.

Let me get this straight....

1. you want to run a clinic for TPE for alzheimers patients- an approach that is at best investigational; and

2. you want to also practice general geriatrics or family medicine or... something?

Would your clinic that you own and operate only be open 1 day a week, so that you can practice your general medicine specialty the other 4 days a week? Would you have a general practice clinic, build up a patient book of business, and then also just have a wing of dedicated apheresis nurses and equipment that only functions to handle a few patients that may need these services?

This is not a good plan. I haven't yet seen the details of what you propose to do, but I can already tell you this.

 

[futuredoc331]

Let me get this straight....

1. you want to run a clinic for TPE for alzheimers patients- an approach that is at best investigational; and

2. you want to also practice general geriatrics or family medicine or... something?

Would your clinic that you own and operate only be open 1 day a week, so that you can practice your general medicine specialty the other 4 days a week? Would you have a general practice clinic, build up a patient book of business, and then also just have a wing of dedicated apheresis nurses and equipment that only functions to handle a few patients that may need these services?

This is not a good plan. I haven't yet seen the details of what you propose to do, but I can already tell you this.

It's a bit unconventional, for sure, but it is being done. There's a guy by the name of Dobri Kiprov, who from what I can tell is a pretty big name in apheresis, who is running a clinic in San Francisco. I'm not sure the structure or hours of it. He's also the medical director for Fresenius' apheresis unit so idk how his time is split.

There's also at least one family medicine clinic (The Maxwell Clinic) that's doing exactly the same thing. They delve into some "functional medicine" things that I would probably steer clear of, but overall I think it's pretty close to what I'm thinking about.

I'm answering my own question about whether this can be done. The question I have remaining is if/when TPE becomes an approved treatment for Alzheimer's will I be able to bill for it. Might be a simple question, but I have zero experience in billing.

 

[SunBakedTrash]

It's a bit unconventional, for sure, but it is being done. There's a guy by the name of Dobri Kiprov, who from what I can tell is a pretty big name in apheresis, who is running a clinic in San Francisco. I'm not sure the structure or hours of it. He's also the medical director for Fresenius' apheresis unit so idk how his time is split.

There's also at least one family medicine clinic (The Maxwell Clinic) that's doing exactly the same thing. They delve into some "functional medicine" things that I would probably steer clear of, but overall I think it's pretty close to what I'm thinking about.

I'm answering my own question about whether this can be done. The question I have remaining is if/when TPE becomes an approved treatment for Alzheimer's will I be able to bill for it. Might be a simple question, but I have zero experience in billing.

There is no evidence to support these kind of things currently. The procedure and potential donor exposures are not without risk and without a solid evidence based foundation, you are pretty much fleecing patients and their insurance (which won’t be paying for this anyway) with pseudo-science BS and false cures for untreatable diseases.

 

[futuredoc331]

There is no evidence to support these kind of things currently. The procedure and potential donor exposures are not without risk and without a solid evidence based foundation, you are pretty much fleecing patients and their insurance (which won’t be paying for this anyway) with pseudo-science BS and false cures for untreatable diseases.

The replacement fluid for these procedures is albumin. Some groups are trying to use albumin with additional vitamins and such, but I think that probably is just a bogus attempt to come up with a proprietary product.

Are you aware of the AMBAR Trial? Do you think that the authors are full of crap?

A randomized, controlled clinical trial of plasma exchange with albumin replacement for Alzheimer's disease: Primary results of the AMBAR Study - PubMed

This trial suggests that PE with albumin replacement could slow cognitive and functional decline in AD, although further studies are warranted.

pubmed.ncbi.nlm.nih.gov

 

[futuredoc331]

I can see how academia would be the better place to try to study this.

 

[SunBakedTrash]

The replacement fluid for these procedures is albumin. Some groups are trying to use albumin with additional vitamins and such, but I think that probably is just a bogus attempt to come up with a proprietary product.

A randomized, controlled clinical trial of plasma exchange with albumin replacement for Alzheimer's disease: Primary results of the AMBAR Study - PubMed

This trial suggests that PE with albumin replacement could slow cognitive and functional decline in AD, although further studies are warranted.

pubmed.ncbi.nlm.nih.gov

Even if there turns out to be substantial evidence to support this (which I doubt) it would be unethical to offer this “treatment” to patients let alone run a clinic offering these kind of services anytime in the near future.

I also wouldn’t consider having the plasma volume of elderly frail people repeatedly replaced through therapeutic apheresis a harmless endeavor. There are a multitude of effects that can happen and needing to switch over to FFP is not at all uncommon.

Are you aware of the AMBAR Trial? Do you think that the authors are full of crap?

A randomized, controlled clinical trial of plasma exchange with albumin replacement for Alzheimer's disease: Primary results of the AMBAR Study - PubMed

This trial suggests that PE with albumin replacement could slow cognitive and functional decline in AD, although further studies are warranted.

pubmed.ncbi.nlm.nih.gov

No. Yes.

 

[gbwillner]

I can see how academia would be the better place to try to study this.

This is a sensible statement.

Private clinics are not a place to conduct research. Payors do not pay for investigational interventions. Even your publication above states that additional studies are needed to vet the utility of this approach... as the high-level summary of the work.

Payors only pay for things that are demonstrated to have value, and then, only when no one basically disagrees that it is needed.

It seems foolish to try to bank on a career performing a task that is not established and may not be established. If you want to study something, there are lots of great opportunities to do this in academia, and very few other places.

 

[futuredoc331]

My advice is that if you still want to do transfusion medicine and apheresis, to stick with your current training and go to a top-notch TM fellowship program. UPenn and WashU come to mind for this. You will be in practice in 2 years. If you stop now and do IM:

1. you will absolutely NOT make any more money with this approach;
2. you will delay entry to the marketplace by at least 3-4 years

I also agree with others that apheresis is mostly academic, so if you don't want to stay in academia, you should reconsider your motivations.

Your real question is if you want to actually do TM. If you do, I would stick with the current plan. If you don't, apply to IM residency programs.

You don't think I'd make more in private practice as a FM/IM doc than I would in academics in transfusion?

Switching in this upcoming cycle would delay my entry into the job market by 1 year (3 years FM/IM vs. 1 year remaining in CP residency + 1 year fellowship). A big concern for me is whether or not I should finish that last year of CP. Would being boarded in CP provide any benefit at all in a career focused on being a GP? Would I be more marketable by being able to oversee certain testing or would it help with any side hustles or business opportunities that I just don't know to think of?

I was thinking it might be a benefit in terms of being able to be lab director over high complexity testing, but CAP personnel requirements show that 1 year of training in the laboratory would qualify me.

It would also allow me to come crawling back to pathology if I decided I made a horrible mistake by switching.

Thanks for the help sorting this all out.

 

[gbwillner]

Do you want to do transfusion medicine or not? Even if you go IM, you would still need to do the fellowship.

If you want to be a hospitalist, do IM.

Will you make more as a FM or IM or transfusion med? Meh, probably about the same.

Per CLIA, requirements for a lab director are pretty weak. That does not mean anyone would hire you to be a lab director without proper training and certification. I mean, you COULD go out and perform neurosurgery as a pathologist too.

 

[deleted314957]

There is no evidence to support these kind of things currently. The procedure and potential donor exposures are not without risk and without a solid evidence based foundation, you are pretty much fleecing patients and their insurance (which won’t be paying for this anyway) with pseudo-science BS and false cures for untreatable diseases.

And don’t forget the hyperbaric chamber. High PaO2’s are good for EVERYTHING ( or have been tried for everything). Maybe anti-aging?

 

[futuredoc331]

Do you want to do transfusion medicine or not? Even if you go IM, you would still need to do the fellowship.

If you want to be a hospitalist, do IM.

Will you make more as a FM or IM or transfusion med? Meh, probably about the same.

Per CLIA, requirements for a lab director are pretty weak. That does not mean anyone would hire you to be a lab director without proper training and certification. I mean, you COULD go out and perform neurosurgery as a pathologist too.

I guess I want the best of both worlds?? I do miss seeing patients and I really want to have flexibility in work setting and geography. That points to IM/FM. I also really do enjoy transfusion medicine.

Ideally, I would have gone IM followed by a transfusion fellowship. After fellowship, I could have decided whether I wanted to see patients full time or do TM full time and then see patients at the urgent care or something. Having picked CP first I eliminated that option.

To your other point, I considered the fact that I COULD see patients as a CP trained pathologist, but I really wouldn't even feel comfortable treating chronic hypertension at this point, let alone the myriad of other things that might walk through my door.

 

[futuredoc331]

And don’t forget the hyperbaric chamber. High PaO2’s are good for EVERYTHING ( or have been tried for everything). Maybe anti-aging?

There are several studies now on the possibilities of plasma exchange with albumin replacement. Most of the work has come out of one or two labs so I will maintain cautious optimism until additional trials are performed.

This is a murine study that expands a bit on previous work as well as the AMBAR trial I shared above.

Plasma dilution improves cognition and attenuates neuroinflammation in old mice - PubMed

Our recent study has established that young blood factors are not causal, nor necessary, for the systemic rejuvenation of mammalian tissues. Instead, a procedure referred to as neutral blood exchange (NBE) that resets signaling milieu to a pro-regenerative state through dilution of old plasma...

pubmed.ncbi.nlm.nih.gov

 

[SunBakedTrash]

There are several studies now on the possibilities of plasma exchange with albumin replacement. Most of the work has come out of one or two labs so I will maintain cautious optimism until additional trials are performed.

This is a murine study that expands a bit on previous work as well as the AMBAR trial I shared above.

Plasma dilution improves cognition and attenuates neuroinflammation in old mice - PubMed

Our recent study has established that young blood factors are not causal, nor necessary, for the systemic rejuvenation of mammalian tissues. Instead, a procedure referred to as neutral blood exchange (NBE) that resets signaling milieu to a pro-regenerative state through dilution of old plasma...

pubmed.ncbi.nlm.nih.gov

Better out than in: a Shakespearean approach to therapeutic apheresis.

i really don’t think you are going to enjoy sitting around and arguing about platelets with surgeons while babysitting patients getting apheresis for chronic kidney rejection. I think you should go into IM where you can specialize in any number of areas, make way more money and serve patients with more interesting and novel pathology and treatments.

The future of apheresis is not bright. Treatment will be targeted immunotherapy and other biologics. They are safer, will soon be cheaper and are way more effective than shifting entire volumes of fluid around to remove theoretical crap from the plasma.

I wouldn’t even bother finishing the CP residency if you don’t have to.

 

[futuredoc331]

Better out than in: a Shakespearean approach to therapeutic apheresis.

i really don’t think you are going to enjoy sitting around and arguing about platelets with surgeons while babysitting patients getting apheresis for chronic kidney rejection. I think you should go into IM where you can specialize in any number of areas, make way more money and serve patients with more interesting and novel pathology and treatments.

The future of apheresis is not bright. Treatment will be targeted immunotherapy and other biologics. They are safer, will soon be cheaper and are way more effective than shifting entire volumes of fluid around to remove theoretical crap from the plasma.

I wouldn’t even bother finishing the CP residency if you don’t have to.

Thank you for the straightforward and honest answer. I think you're right. I chose CP because I was all fired up about research, but I've found that interest to be at more of a theoretical level. At a practical level, I just want to be able to help people and have flexibility with where and how I work.

 

[caffeinegirl]

Thank you for the straightforward and honest answer. I think you're right. I chose CP because I was all fired up about research, but I've found that interest to be at more of a theoretical level. At a practical level, I just want to be able to help people and have flexibility with where and how I work.

If that's the case, then IM or clinical specialties are the way to go.

 

[gbwillner]

Thank you for the straightforward and honest answer. I think you're right. I chose CP because I was all fired up about research, but I've found that interest to be at more of a theoretical level. At a practical level, I just want to be able to help people and have flexibility with where and how I work.

It's a good exercise to be honest with yourself about your own motivations. If you want to see patients outside of transfusion medicine it makes little sense to be a pathologist.

One caveat I will make here is about money. I disagree with Sun about making more money in IM. There are certainly subspeciaties in IM that make bank, like Cards or Onc, but most are actually no better paying or worse than pathology. I would bet a director in Transfusion Medicine actually makes more than an internist or most IM specialties aside from oncology and cardiology. Of course, those are the very competitive ones.