Poll: What's currently the hottest fellowship in pathology?
Hottest fellowship in pathology
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Do you even have to ask? We all know.
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while i agree that with the overall sentiments of this informal poll that GI is "hot"...practically speaking (having already been and thankfully finished with the job interview trail recently), i'd have say that heme fellowship training needs further discussion.
While it may not be "hot" like derm or GI, in my opinion nowadays heme cases have become so difficult and rather obscure, requiring oddball molecular tests and immuno's that most private practice folks can't even pronounce, often (but not always) necessitating the case either be sent off for consultation or reviewed by a heme-trained person from a solid, bigname institution in-house. (no, i'm not heme trained, but man oh man did i see on the job trail how many, but not all obviously, places desperately needed a heme go-to person).
crudely speaking, to me, it sorta seems like GI and derm are like the spanking hot chick you'd wanna maybe hookup with up once or twice, but not nec. marry. Heme (right now at least) is the cute, fairly attractive but uber sweet and reliable girl you end up marrying.
While it may not be "hot" like derm or GI, in my opinion nowadays heme cases have become so difficult and rather obscure, requiring oddball molecular tests and immuno's that most private practice folks can't even pronounce, often (but not always) necessitating the case either be sent off for consultation or reviewed by a heme-trained person from a solid, bigname institution in-house. (no, i'm not heme trained, but man oh man did i see on the job trail how many, but not all obviously, places desperately needed a heme go-to person).
crudely speaking, to me, it sorta seems like GI and derm are like the spanking hot chick you'd wanna maybe hookup with up once or twice, but not nec. marry. Heme (right now at least) is the cute, fairly attractive but uber sweet and reliable girl you end up marrying.
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Dermpath is still BY FAR the most in demand subspec skillset.
I have mentioned GI/GU in the past but I still dont consider those in the same ballpark as derm. Derm is just too flipping versatile. There has been of late a huge interest in part time dermpath people as well, likely due to some company putting mini-pathlabs within larger derm practices.
Hemepath is fail tbh. When they knee-capped flow reimbursements it basically gutted the field. And honestly, hemepath training is really all about marrows and smears not IHC work ups on nodes. I really cant recommend hemepath anymore.
Definitely cytology is super fail. Only marginally better than a just doing a surg path type year.
Other non-starters for me are breast path, lung path and renal. Just isnt enough volume typically to support those.
To retort to SLU, hemepath consults are really a dying breed. Hemepath has been HUGELY overtrained and there are plenty in private groups that can handle WHO classification easily enough, plus with services like Clarient/USLABS/Genzyme where you do virtual flow and IF you have issues can punt it to their experts, I think big academic consult services will die off within 5 or so years.
I have mentioned GI/GU in the past but I still dont consider those in the same ballpark as derm. Derm is just too flipping versatile. There has been of late a huge interest in part time dermpath people as well, likely due to some company putting mini-pathlabs within larger derm practices.
Hemepath is fail tbh. When they knee-capped flow reimbursements it basically gutted the field. And honestly, hemepath training is really all about marrows and smears not IHC work ups on nodes. I really cant recommend hemepath anymore.
Definitely cytology is super fail. Only marginally better than a just doing a surg path type year.
Other non-starters for me are breast path, lung path and renal. Just isnt enough volume typically to support those.
To retort to SLU, hemepath consults are really a dying breed. Hemepath has been HUGELY overtrained and there are plenty in private groups that can handle WHO classification easily enough, plus with services like Clarient/USLABS/Genzyme where you do virtual flow and IF you have issues can punt it to their experts, I think big academic consult services will die off within 5 or so years.
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I still vote GI just because to me it seems like there are fewer fellowships than derm and almost as many people who want to do it. However, there are lots of GI fellowships that aren't really advertised so they are probably more common than I think.
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GI probably has longer legs than DP simply due to far far less fellowship trained people. And a good chunk of the so-called GI people are really liver/liver transplant focused trainees, which has limited value outside big referral centers.
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considering an 88305 is being slashed 85% in Houston let's see how long DP and GIP are kings.
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So is the poll asking what respondents think is the hottest fellowship, or what respondents are actually doing for fellowship(s)?
The poll is asking what the respondents think is the hottest fellowship, not what they are planning to do/did themselves.
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Why would you consider cytology to be "super fail"? Seems to me there is a possible boom coming with minimally invasive techniques being all the rage. Besides, with flow, molecular techniques, etc., it may not be all morphology in the future. There is no grossing. Usually only a single or at most couple of slides per case (granted they take a long time to look at). Pap smears are easy. You see jobs advertised all the time. Am I wrong?
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How is dermpath so versatile? Yes, I know about the volume and how fast these dermpaths can signout a case.
What about this post about dermpath applicants getting all teary eyed because compensation is going to be slashed (30% is the number floating around).
http://forums.studentdoctor.net/showthread.php?t=622369
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Cyto is "super fail" because that is just what it is. I've never met anyone who truly liked cyto (even fellows), only ones that think FNA skills are "marketable" or "its difficult and I need an extra year doing it". Looking at paps and exfoliative urine sucks a big one also.
From pure marketability standpoint, I am surprised that so many people think so lowly of hemepath and so highly of GI.
Let's consider GI... First, someone said there are 'few' fellowship-trained people. I doubt this claim--I've met several people who landed 'GI' fellowship that I've never even thought they exist. Second, what do you need a GI fellowship for? Where I'm from, GI is the bread and butter of surgpath. Any resident can sign out 99% of cases.
Now, onto hemepath. I think you guys underestimate its value, but maybe I'm biased by the frequent in-house consults at my department. Anything with lots of inflammation gets sent. Maybe things are different in the real world, but it seems that someone with heme background should be a tremendous asset to a private practice group.
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It's not always about difficulty of cases, in part it's about marketing to clients. If you have a "fellowship trained" GI pathologist, some people would be more likely to send you their business. Derm is similar - it doesn't take a dermpath fellowship to sign out 90-95% of dermpath.
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It is funny to me that we are view ourselves as service providers to other physicians. When a internist send his patient to a cardiologist for his help in the care, it is one physician consulting another physician for an opinion. When we get involved, we view ourselves as customer service, like we are waiters or something. That is kind of too bad.
But I agree that within the realm of one's practice that you don't need a fellowship to sign-out 99% of the cases once you get some experience under your belt. A fellowship is all just about focused training. Anyone can read the books and journals. A fellowship just ensures you are up on the latest diagnostic terminology and helps you learn some pitfalls before you are on your own. It is not like you are learning magic or some special secrets that no one else knows.
I know many academic pathologists that didn't do a fellowship in their area of expertise, and trust me, they can sign out 100% of the cases that come before them.
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Maybe I've been naively thinking that pathology market is efficient.
But think about it: anybody and their dog can sign out tubular adenomas and Barrets. But at least at most departments Ive seen, only dermpath trained people sign out SCCs/BCCs/AKs/nevis. And only hemepath people can look at a reactive lymph node and rule out lymphoma
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Trust me, this is only in academics. Every and any surgical pathologist (and their dog
) can sign out SCCs/BCCs/AKs/nevis. The same is true for TAs/HPs and Barrets. The vast majority of general surgical pathologists are comfortable signing out lymph nodes. This is the bread and butter stuff. If you can't sign out a BCC, you aren't much of a general surgical pathologist in my book. All of this is besides the point in terms of marketing yourself for a job. For most groups, even if you did a GI fellowship you will be signing out a mix of other stuff. Same goes for DP and heme trained people.
Remember, in academics many places have perinatal pathologists signing out all of the placentas and fetal autopsies, for example. This doesn't mean a community pathologist would hesitiate a second to sign out a placenta. And this doesn't make perinatal path a "hot fellowship".
This is why we say things like DP, GI, GU are hot and why lung, soft tissue, Neuro, perinatal are not.
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There are GI, GU, derm, and currently heme jobs that are the exact equivalent to a pap or urine mill.
Met a GI trained guy recently that was making an excellent salary signing out HUGE volumes of dysplasia cases at a mill type entity. He was losing the will to live even with all that cash. How is this different than a pap mill or a urine mill.
If you are doing a fellowship to signout only in one area, there is the danger of getting a job at a mill. Mills exist in derm, cyto, GU, and heme.
Good cyto fellowships are at places that use cytology as a diagnostic tool not as a bastard child screening modality for surg path.
These minimally invasive NONGYN procedures are increasing...
pancreatic EUS FNAs
billary brush/wash
Bronchial brush/wash
thyroid FNAs
LN FNAs for mets/lymphoma
Salivary
Head and neck
Soft tissue....
CTC's
These biopsies (modalities) are increasingly being coupled to tests such as EGFR mutational analysis, thin prep FISH (UROVYSION), cell blocks made from washes for IHC and or fluorec. FLOW,
microRNA, methylation analysis...
Oncotherapeutic teams are increasingly relying on cytology/molecular teams to provide not only a definitive diagnosis but cytogenetic as well as mutational analysis.
Don't be misled into thinking cytology is only PAPS (by the way the most successful cancer screening test in the history of medicine) and urines.
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You are absolutely correct
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The thing about cytology is that is not a "hot" fellowship, but there are reasons for this.
1) There are loads of cytopath fellowships, so they are not very competitive to get.
2) Cytology is not reimbursed in a similar fashion to areas that can be done as described above (GI, GU, heme), so it is not seen as quite as lucrative.
3) A lot of people don't like it.
However, it is a very important fellowship to consider if you want to do private practice. You will most likely see a lot of it and groups will like it if you have expertise in it. So it is quite marketable.
1) There are loads of cytopath fellowships, so they are not very competitive to get.
2) Cytology is not reimbursed in a similar fashion to areas that can be done as described above (GI, GU, heme), so it is not seen as quite as lucrative.
3) A lot of people don't like it.
However, it is a very important fellowship to consider if you want to do private practice. You will most likely see a lot of it and groups will like it if you have expertise in it. So it is quite marketable.
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Sure they do. But the question is, would you rather work in a hemepath mill or a urine mill? No brainer there. Many of us are going to wind up working in "mills" and corporate labs because the reimbursement environment just isn't going to support the classic community group practice with partners and the like. True general pathology positions where you sign out a little of everything and have a focus in one parcticular area are already rare as hen's teeth. I'd say to pick a fellowship that you could see yourself doing exclusively, such that if you wind up in a corporate lab environment only signing out that one thing you'll make the best of it.
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Not sure if this is the correct question.
A mill is a mill. If you train in cyto to sign out urines with UROVYSION at a urine lab versus only signing out bone marrows for Genoptix you are using a minute part of your fellowship training.
My point is whether its GI dysplasia, PAPs, SK and adenomas all entities that make pathologists "cubicle ******" suck.
Cyto is vast. Don't make it urines because that was your experience. Don't make it paps becxause that was your experience.
Every single cyto trained person that I know has had multiple job offers at academic places and very good private practices. All are working signing out cyto with some other surgical specialty.
I don't know anyone that is working for a place where their entire job is signing out urines.
Also I am mostly disagreeing with your notion that cytology is hated by all including fellows. Absolutely false.
I agree 100%. Human body is mostly fluid, and you can stick a needle anywhere. Cyto is underestimated IMO.
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Sure I agree, Derm/GI/GU are regarded as hot and sexy, whatever. And picking the "hottest", whatever your definition of hot is - I'll let someone else do that. But I certainly wouldn't advocate doing one subspecialty, and one subspecialty only, especially as a first job.
A fellowship is a means to an end. If you're convinced you want to make a **** ton double-quick having decided that mills and huge corporate labs are your future and you want to join the cubefarm, then by all means pursue the single subspecialty biopsy course.
It goes against the common wisdom which is to be general and adaptive early in a career, but it could work. For a while. But I believe it creates a false sense of security. So much has changed in the last 30 years of path. Are mills and huge corporate labs dealing in small specimens going to last till the time you retire? That's the gamble you're taking. Someone's going to have to deal with the resection specimens. There's a lot of marketshare warfare going on, it remains to be seen how it's all going to shake out. (So long, residency education?) And the picture will keep changing. Seems most everyone has a card up their sleeve.
Most places I have seen, whether academic or large group, want you to be strong in at least two subspecialty areas (though heme may be an exception depending on the size of the operation). I think this is healthy - it protects the pathologist and it protects the group, whatever the group is. There are various ways to accomplish this; doing two fellowships seems to be getting pretty common. You could find a split fellowship. Or you could max out your elective time with a mini-fellowship.
I agree with coomasie blue about cytology - I also think part of the disparity in opinion has to do with the quality of a fellowship (i.e. a fellowship may exist in any field, but that doesn't mean it is any good).
A fellowship is a means to an end. If you're convinced you want to make a **** ton double-quick having decided that mills and huge corporate labs are your future and you want to join the cubefarm, then by all means pursue the single subspecialty biopsy course.
It goes against the common wisdom which is to be general and adaptive early in a career, but it could work. For a while. But I believe it creates a false sense of security. So much has changed in the last 30 years of path. Are mills and huge corporate labs dealing in small specimens going to last till the time you retire? That's the gamble you're taking. Someone's going to have to deal with the resection specimens. There's a lot of marketshare warfare going on, it remains to be seen how it's all going to shake out. (So long, residency education?) And the picture will keep changing. Seems most everyone has a card up their sleeve.
Most places I have seen, whether academic or large group, want you to be strong in at least two subspecialty areas (though heme may be an exception depending on the size of the operation). I think this is healthy - it protects the pathologist and it protects the group, whatever the group is. There are various ways to accomplish this; doing two fellowships seems to be getting pretty common. You could find a split fellowship. Or you could max out your elective time with a mini-fellowship.
I agree with coomasie blue about cytology - I also think part of the disparity in opinion has to do with the quality of a fellowship (i.e. a fellowship may exist in any field, but that doesn't mean it is any good).
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Might not be "SUPERHOT" but its far from fail.
I am not sure about your assertion that "a lot of people don't like it." You may be correct from your personal experience. That may be more related to the culture of where you trained than reality. A lot of people don't like heme, skin or GU for that matter. It seems like the more vocal members of this forum bash cyto. the LA's etc. This may tilt perception
Reimbursements will inevitably equalize. Also it depends on how billing is done. cell block with IHC gets reimbursed pretty well.
Private practices and academic medical centers are constantly looking for cytopathologists with excellent diverse training from good programs. Believe me they know the difference between a crappy program and a good program.
Unfortunately there are substandard programs that have fellowships. Do your homework and avoid those. Training at programs like Hopkins, UCSF, UPENN, Memorial SK, MD Andersen, BWH, NYU, PITT, MGH, BID and the like will give you as much marketability and clout as any GI, HEME, or GU program.
Many private practices are looking for competent well trained cytopatholgists that can also signout some other routine surgical pathology specimen like GI/GU.
If you train at any decent place by the time you finish you should be able to sign out GU, GI,
Dermpath and GI are in for a HUGE surprise within two years. When reimbursement equalizes a bit....perceived hotness may change.
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I know a lot of people at many institutions - I haven't met many who truly love cytology. So my assertion is true. But just because it is true doesn't mean there aren't a lot of people who do love it. I know a lot of people who love it too. I have just found it odd over the course of my training that cytopath seems to be the only fellowship where the a great number of people do the fellowship and don't really want to focus their career on it. Don't read too much into my posts.
In regards to this comment:
I agree wholeheartedly with the first statement. But the second part is true for anything (including cytopath) with the possible exception of medical renal. Fellowship is where you learn the fine points and become the go-to person. And pathology is increasingly becoming all about the fine points for most subspecialties.
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I don't think it was ever a question that each subspecialty is valuable in its own way - yes, even apheresis I was just trying to address the premise of the poll, since the discussion seemed to rapidly be veering away from "What's currently the hottest fellowship in pathology?" ("currently" and "hottest" being what I thought were the keywords), and trying to make projections as to relative value of each subspecialty given the current scheme of reimbursement.
I was also responding to the embedded subtext of young lurkers using this information as career guidance.
To state my bias: When I speak of subspecialization, I don't mean only practising in one area, but to have strengths in a couple of areas so that you're not totally without a foot to stand on if a big change happens. That partly reflects my exposure to people I've trained with. I also don't need to make the most money in a 1000-mile radius, can't see myself only working on one organ system for the rest of my life (would've done internal medicine or surgery if I wanted to do that) and have to leave the country in a few years (or get a VA/underserved area job) due to visa issues. All that is going to colour my opinion. As usual YMMV.
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WTH...of course cytology is valuable. Thats not the question, the question is "hot fellowships". There are fewer and fewer groups looking for fellowship trained cytologists because it was the one of the first fields to be crazy overtrained when the ABP initiated it.
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You may be correct about the over training... but from my experience, there are many many jobs and job offers for cyto trained people. Both in academics and private practice. From my experience where you trained in cyto is an important part of the equation.
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I agree with this and your prior posts, coomasie. And there seem to be quite a few job openings for cytology trained people. In the academic sector, you can specialize heavily in this (assuming you do not go somewhere where understaffing is a major issue) whereas in the private sector, I saw more often that your employer wants [cytology + something else] most of the time, which makes sense especially for the smaller groups. Personally, from a selfish point of view, this brings a big fat smile to my face. This is where I agree with yaah that many people don't like cytology. You're right, cytology is not terribly popular. (Earlier, someone said, that many people hate cytology, including fellows...not sure if I'll bite on that one.) Anyways, the relatively decreased popularity of cytology is just fine with me because if I'm doing a job that is important but disliked by many people (including folks who simply think cytology is mainly paps and urines), then I get to have a secure hold over my job and provide for myself and my family.
yaah, where I trained, cytology is not consistently the hottest fellowship either (even though it's one of the best two here)...the popularity has waxed and waned over the years...but cytology is, by far, not the least popular fellowship either. It's in the middle of the pack. What have you seen at your institution? What proportion of your cytology fellows are from in-house vs. outside institutions? Here, most people I know seem to be keen on heme, GI, and dermpath as the fellowships of choice. But again, trends wax and wane. I wonder how the decreased reimbursements will affect these trends. Regardless, this is gonna suck for all of us.
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Why isn't FORENSICS an option? LOL I definitely think that is the coolest fellowship pathology has to offer! I am probably in the minority though!
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Does anybody else notice how often cytology is WRONG? They love to give presentations on the cases they hit out of the park, but when you're signing out surg path and looking at the prior FNA results on a resected specimen it's sobering. I can only imagine how frustrating it is for clinicians/surgeons who counted on the previous cytology result to direct surgery. Seeing fellowship trained cytopathologists with years of practice under their belt getting whalopped again and again has kept me away. Sure, it's probably a sampling issue, but if sampling issues confound the diagnosis that often there's something wrong in the premise of FNA.
I voted for GI. I think DP reimbursements are on the chopping block. It is about marketing to the crazy number of gastroenterologists running their endo-colo clinics all day.
I voted for GI. I think DP reimbursements are on the chopping block. It is about marketing to the crazy number of gastroenterologists running their endo-colo clinics all day.
Why isn't FORENSICS an option? LOL I definitely think that is the coolest fellowship pathology has to offer!
I had the same thought! but you won't find many that agree with us
Gee Britt,
We've all noticed the subjectivity of dysplasia diagnoses as well. Many GI docs get TA and HP's correct... wow a sessile serrated adenoma. Mind numbingly complex....
And how about medical liver. You might as well write a text book as note to cover your arse and not get a call back.
Any tool can sign out a hemicolectomy.
If a skilled doc hits the lesion and gets some cells an accurate diagnosis can be made. Especially with cell blocks. You don't have to open the person up.
I am more amazed that cytology can cheaply and in a minimally invasive manner give standard of care information to surgeons. Thyroids, EUS FNAS, salivary gland, lymph node with flow.
cytology is no longer a strictly morphologic descriptive field. It is used with flow, cell blocks for IHC, as well as molecular studies to drive medical care.
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although i don't think i could ever get myself to love cyto (and/or do a cyto fellowship), i kinda have to agree with cyton. Regardless of your opinion of cytologists as a group, the field is riddled with challenges. The opportunity to make a Dx on a ridiculously small tissue sample (here's where i came to realize that i don't have the balls to be a full-fledged cytologist....even the great female cyto's i know have Hugh Jass balls) if it can be done reasonably and with confidence (yes, it can often happen) is a much more practical and often safer management/alternative. The key is to know when you CAN'T confidently call something, and not be a gunslinging hotshot, freakin' GRADING lesions in addition to just outright calling them. plus, as noted, flow/molecular/IHC on a needle stick vs open bx --> + [for the patient]
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Why isn't FORENSICS an option? LOL I definitely think that is the coolest fellowship pathology has to offer!
Forensics doesn't have enough potential earning power to register with 99% of the posters on this board, that's why.
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plus, if you just use the needle (w/o the gun), you get say you "Frenched" it... ;P
{French technique}
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Haha, spot on.
The other issue is that forensics is just different - a lot of people start residency (if not med school) with a goal of doing forensics for their career. It's often a different population of residents.
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HAHA Yeah, I guess you really wouldn't go into forensics for the pay. But, I could go on and on about how great a field it is. It is challenging and you never know what is going to come through that door. I guess I fit into that population of starting out knowing I want forensics because it is all I have ever wanted to do since I was 14. Unfortunately, I am just starting on the road and just about to start 2nd year of med school and have a long long way to go. However, I have discovered that histology is about the coolest science I have ever been exposed to and I love being behind a microscope so I figure that is a good start to getting through a regular pathology program. I think it is also really important to be a great general pathologist first before even thinking about specializing further.
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On the forensic pathology topic:
I am currently looking over my forensic path notes one final time before boards; it just does not seem to fit well with all other aspects of pathology, even the hospital autopsy is a totally different animal. It seems to me that a forensic pathologist would be best trained in a separate forensic pathology residency, maybe combined with a JD ....
I am currently looking over my forensic path notes one final time before boards; it just does not seem to fit well with all other aspects of pathology, even the hospital autopsy is a totally different animal. It seems to me that a forensic pathologist would be best trained in a separate forensic pathology residency, maybe combined with a JD ....
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Where's LA when we need him? He has posted extensively about the ideal forensic path setup, ie, a completely separate program. I agree!
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I'm not sure I agree with the seperating it out assertion even though there are good arguments to do it. There are lots of things I've been exposed to in my residency that don't seem to relate well to the other things. Cytogenetics/karyotyping and their techniques are hard to relate to the rest of pathology for me as well, so is neuropath (which also isn't listed in this survey, even though I'm sure not one person would say it's hot), and many other things. I think knowing about them is going to be better for me than not knowing about them in the long run though. Plus a couple very talented residents ended up picking forensics out of here because they got to work ith Dr G and saw how much she loved her job; and they came to love it too. Just seems to me that exposing talent to as much options as possible is better for the overall specialty of pathology in the long run.
seeing how a vast number of cases referred to the ME's office are actually due to natural disease, i don't think you can completely separate out FP from general path. though during the last three years i have found myself wishing this were the case! a separate track, perhaps? and i'd love it if i could some how get a JD or some law classes during my training, i'm not sure if that's neccesary either. do i really need to spend time learning about real estate law as a future ME? criminal law, evidence, trial procedure, sure... but much of law school is not too applicable!
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Why isn't GU path more popular or considered "hot"? The GU pathologist that I know loves what he does, the pathology is pretty cool (at least I think so), and certainly there are plenty of prostate cores to keep one busy. Is it just too specialized of a field to be practical in private practice?
i'm wondering if most people who plan on signing out general SP feel that they NEED to do some sort of fellowship training? I haven't really paid attention to this issue since i knew i was doing FP and had to do a fellowship. For some reason, residents at my program (big name east coast) seem to feel like our SP training MUST be supplemented with a SP fellowship. They point to candidates who trained at other big name east coast programs who are doing SP or subspecialty fellowships at my program and say "oh look how well trained they are!" (this does confuse me because if they are "so great" then why are they doing the fellowship in the first place!?) some of the same people seem to feel that to get a good job, if they do a cyto fellowship they HAVE to follow that up with a SP fellowship. i just don't get it. also, this is not because they tested the job market and didn't find anything so are now doing fellowships to maintain an income/find a job.
any thoughts?
any thoughts?
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Nothing beats OTJ (on the job) learning. However, people have different levels of security when it comes to signing out after four years. If you can get a job after a GOOD cyto fellowship and had decent surg path volume and training during residency... GO TO WORK !!!!!
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Bear in mind there are some programs who treat the final year of residency as a fellowship (BWH is one such program) by bunching required rotations to early on in training.
I don't think you need to do it, a lot of it depends on comfort level and your own training. If you do a cytopath fellowship but want to market yourself as skilled in surg path, it might be harder to do but with the right references probably isn't a problem.
And yes, I agree that a lot of it is not about not finding a job. A lot of it is about job market perception - people get these fellowships assuming that they would have more trouble finding a job without it. I do know of a couple of residents who had trouble finding a job and took a fellowship when they weren't happy with the current job options, but that's less common.
Personally I don't think SP training needs to be supplemented with a SP fellowship. But for some people and some programs, it is strongly advised.
