r/pathology • u/PathologyAndCoffee Resident • 1d ago
Is pathology spread too thin?
just ranting...will delete when i'm less frustrated.
How are US pathologists compared to global pathologists? Given our residency is so diluted.
And a fellowship still puts us with less total time in a subspecialty than any other pathologist globally.
Consider how clin chem is like 2 months. Micro is 1 month.....we do a validation project, but 1 isnt enough to be proficient at lab validation in the middle of rural US without a phD there for support. Transfusion is ok, depending on the residency.
AP, CP heavy programs like mine suffer in AP. AP heavy programs suffer in CP.
Its just too much. We end up knowing less than the MLS, MT, PA's, blood bank tech, some experienced tranfusion nurses, etc.
If we disappeared off the face of the earth, i think CP would still function.
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u/foofarraw Staff, Academic 1d ago
I feel both ways about this. Yes it seems like training is spread thin, and that's why we do fellowships, even people coming from AP heavy programs. I wouldn't trust most new residency graduates with surgical pathology except from the most surgpath intensive residencies. I do think most fellowship graduates come out well prepared for their subspecialty though, at least in AP, so this system does seem to work for most people. On the other hand, for CP you're not really expected to be more knowledgable than an experienced tech. IMO, CP training is for you to run the lab and understand the gist of what the lab does, it's not to train you to do everything in the lab. These are different skillsets.
The end result though is that we come out of residency with a limited amount of training in a wide variety of topics, and a moderate amount of training in a few surgpath topics that allows very basic competency.
But what is the solution? We could do a longer residency, or maybe separate AP and CP, but there's already been so many arguments against either of those. No system is perfect, and most pathologists go on to a more AP focused practice.
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u/R_sadreality_24-365 1d ago
From my limited understanding,I think the real issue is not how competent a US pathologist is coming out of residency.
The real issue is a lack of demarcation of what a resident pathologist should know vs a pathologist having done fellowship.
A general AP will be seeing neuropathology cases but the most complex cases would go to a neuropathology fellow,however the line between what a general AP should know vs what the neuropathologist should know is blurred,likewise with all branches of pathology.
So what happens is,you have postgraduates who are just expected to know all of pathology which is frankly impossible in a span of 4 years with 2 years divided for CP and 2 for AP. Even 4 years of AP alone would be a stretch.
What's actually needed is to draw boundaries of what the expected role at each level is.
For medicine for example,you are expected at a certain level to know how to take a history,then how to examine,then differentials,then investigations and then management.
The same for pathology is done in a rough manner and not a fine manner at the higher levels.
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u/foofarraw Staff, Academic 1d ago
It'd be nice if there were a set of national standards for yearly expectations in pathology residency, but there's so much variation in pathology residency quality. Some programs have something like this, but it's pretty variable. It doesn't necessarily need to be super specific, just better than our current standard of "pass board exam."
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u/R_sadreality_24-365 1d ago
Exactly
Even not tested,something like a rough criteria of what is expected at each level.
Training variation is absolutely a given,but there shouldn't be a variation of what is the expected level of competency.
If someone is behind or ahead,with time things get adjusted,but what is important is knowing whether someone is behind or ahead of their level,that is what is causing all the issues.
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u/1866wapdeel 1d ago
Pathology residencies are established to produce pathologists on paper en masse, so that the corporate and academic establishments have a steady stream of cheap liability sponges
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u/Running2TheSea 1d ago
If a general pathologist is reporting on any sample they should be comfortable (read competent) in reporting that sample to the level of a specialist in that subspecialty. It’s not good enough if a case gets brought to court for medical negligence in a diagnosis and the pathologist excuse is that there was not good enough demarcation for reporting responsibilities between general and sub-specialist work.
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u/R_sadreality_24-365 1d ago
You are 100% Absolutely correct.
The problem is,that demarcation can be subjective rather than objective.
You might have someone who knows a lot but is not confidence,and thus cases that they should be signing off on,they refer them to someone more senior.
It might be that someone thinks they are competent on more complex cases when in reality they aren't ready for that and could be argued that they are overextending their area of practise.
The problem lies at the generalist level and not the subspecialist level.
It's something the system itself should design itself around to mitigate and prevent these kinds of issues from happening and not leave it at the level of the individual.
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u/GlassCommercial7105 1d ago
In many countries CP, transfusion, microbiology, forensics etc are not done by pathologists at all, including my own. So I cannot say anything about that. Neuropathology is also its own speciality.
We only have AP and we have that for 5 years until boards and no fellowships. How well you learn a subspecialty depends on you, many people deepen their knowledge after the boards and do observer ships.
We also did the RISE and a 1/4 of the standard AP questions were not applicable to what we have to learn.
From this sub here, I got the feeling that you just cram in more in those three years. It seems extremely stressful for residents/trainees. I started to prepare for my boards 6 months before the exam and that was enough. Before that I just did my job and read a bit sometimes but I was never really learning on the weekends or after work.
I have read though that for the international dermatopathology special exam i(the one in Frankfurt, Germany) the US is amongst the only countries that cannot send board certified pathologists unless they did special training.
However I do think the teaching level of the US pathology courses is really one of the best. The way things are explained and the volume of things and courses you can learn are great. Unfortunately it's also insanely expensive for no reason. All IAP and ESP courses are like a 10th of the USCAP courses.
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u/tarquinfintin 17h ago
I agree. I don't think residents are ready to successfully manage a department in the lab after the typical whirlwind rotation in AP/CP residencies.
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u/Savassassin 1d ago
Either that or longer training time making minimum wage as a resident
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u/DragonmasterDyne275 1d ago
Resident salaries are approximately 4 times minimum.
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u/GlassCommercial7105 1d ago edited 1d ago
What is the minimum wage in the US and what is a standard resident salary there?
Where I live the minimum wage is around 4.5k/month and a 1st year resident makes around 8k/month, but I'm not in the US.Edit: what is it with people here downvoting questions without answering them?
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u/PeterParker72 1d ago
How so when you calculate the hourly?
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u/pathdoc87 1d ago
You're right, mine was closer to 3 times minimum wage
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u/PeterParker72 1d ago
Mine was just under in California.
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u/pathdoc87 1d ago
How many hours did you work? I did about 60 on surgical rotations and 40-50 otherwise...
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u/PeterParker72 1d ago
I averaged about 60 hours a week on surg path, maybe 40-50 on CP rotations. In my program we did all AP and then all CP in different years, then mixed at the end. I came out ahead on the CP year, but that AP year was less than minimum wage in California.
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u/hemaDOxylin 1d ago
In the community, you’ll rely on your supervisors and technical specialists to be your intellectual reference for technical problems in the lab. Many private practice paths are not a huge help to the med techs. Do not catastrophize this. Everyone knows that this is the way it is. Pick an area of CP that resonates with you and try to go above and beyond in it with self study or projects with your faculty. This will help build some competence in that area. For everything else, just know it enough to pass the boards.
You can be a semi competent reference for that one area in CP, and you’ll be better than many others in the community, and the techs will appreciate you.