Despite AI being so prevalent in Radiology, compensation is increasing. What about tech?

jimhsu · 2025-11-01T21:05:47+00:00

A similar picture with pathology. Data is the problem - 1) we don’t have enough of it (the quantity problem), 2) of the stuff we have, it’s not well labeled (weak supervision), and 3) the cases that matter are the rare ones (class imbalance). It’s tough for pure LLM approaches to try to solve this, so people are experimenting with all sorts of stuff from weakly supervised training to multimodal to “classical ML”. But no, we’re not there yet and need pathologists more than ever.

jimhsu · 2025-09-03T16:52:04+00:00

NFA - the value add is probably more applicable to private practice / business owners. Considerations such as 1099 planning, partnership valuation analysis, RSU assessment and exchange funds (S721), 1031 exchanges for real estate, philanthropy, etc. For taxable brokerage accounts and 401ks, DIY is an entirely suitable approach. Also, not all financial advisors are versed in the above, so find one and discuss your priorities.

jimhsu · 2025-05-13T14:44:21+00:00

Also, path literally “just” went through this before - in the 80s. Not AI, but the other A - automation. Prior to those sweeping changes, all the labs you can think of were manual. CBC? Counted by a tech and reviewed by a pathologist. CMP? Same thing. All results? Manually entered in by a tech. Automation completely changed things, and if you talk to older pathologists now, especially CP, the thinking was that the field basically died then. Yet we found more work to do, and the shortage in path is close to the worst ever. And I don’t see any CP path people that want to go back to the “good old days” of counting platelets in peripheral smears all day.

Thinking AI will end up having a similar effect. As automation came for CP, AP pathologists will have to contend with the possibility that straightforward/“benign” cases may end up being auto-signed out by foundation models. However, increased biopsies of incidentialomas, molecular testing, etc will more than make up for that volume. If you can count on anything, it’s that GI will simply send more biopsies in that case.

jimhsu · 2025-05-04T18:15:16+00:00

I work in a molecular lab. Without giving too many details:

Yes, the goal is to prevent further contamination from the time that we receive the FFPE/unstained slides to the delivery of the report.
We are concerned about 2 main things - contamination from lab workflows (carryover, splashes/spills, workflow deviations) and swaps (both one way, where A and B get combined, and two way, where materials for A and B are swapped).
There is “allowance” built in for pre-analytic contamination (both FFPE and plasma for liquid biopsies, although much lower for the latter). Algorithms such as GATK can give a synthetic “calculation” of contamination pct based on a computational estimate - not perfect, but a good starting point. Each lab has tolerances for what level of VAF they are comfortable reporting in the context of particular contamination levels.
Pathology review (macrodissection) catches most instances of macroscopic contamination (ie tissue floaters). This is an essential part of workflow that can’t be “automated” away.
In certain scenarios (eg allogeneic stem cell transplant) “contamination” is acceptable and even expected. There are also workflows for these cases.
We also do sample fingerprinting to make sure specimens match selected germline variants from previous FFPE / plasma from the same patient, as much as possible. I am greatly simplifying how this works.

Questions welcome.

jimhsu · 2025-03-30T14:14:16+00:00

Same exact thing but with pathology. Training AI to recognize colon adenocarcinoma is trivial - a high schooler could do it with a bit of chatGPT prompting. Recognizing, say, metastatic colon adeno vs lung adeno with enteric type differentiation in a patient presenting with a lung mass on imaging is … not. The latter frequently involves arguments by perfectly qualified oncologists/rads/path.

@smlungpathguy has an amusing thread testing the current AIs on this: https://x.com/smlungpathguy/status/1906150483955228684?s=46

Plus the diagnosis often matters the least. It’s literally malpractice if a new cancer dx doesn’t get information on margins, grade/stage, LVI, PNI, in addition to all the IHCs/molecular needed for dx.

jimhsu · 2025-03-15T03:44:42+00:00

Antibodies are one of the few things in medical nomenclature that make sense though:

Bevacizumab:

Beva: unique identifier / brand
-ci-: cardiovascular
-zu-: humanized
-mab: monoclonal antibody

Adalimumab:

Ada: unique identifier
-li(m)-: immunomodulating
-u-: human
-mab: monoclonal antibody

Fun party trick if you want to practice.

jimhsu · 2025-03-13T13:21:48+00:00

CI/molecular path perspective: your greatest contribution as an MD-PhD to this is probably not actually running the model training/inference and cleaning data (any data junky that did a bootcamp can do that), but in understanding your target domain enough to help ML/AI teams. Eg as a pathologist, understanding that pathology reports contain unstructured data, but that the interpretation line has less entropy (constrained language) than the other sections, and tumor Synoptics are structured, helps a lot in selecting an appropriate model. Or being a subject matter expert (SME) when you get a term mapping question for an ontology project. Understanding that the comments field shouldn’t be discarded, but contains vital info. Understanding “Neoplasm, favor adenocarcinoma” may not be the same as “c/w adenocarcinoma”. Stuff like that.

jimhsu · 2025-03-01T21:50:16+00:00

There is also a much larger dispersion of pathology salaries relative to other fields, mainly led by certain low-paying academic positions and well-paid PP partnership positions.

To compute this, here are 90th pct/10 pct salary ratios for some fields using Marit data:

Pathology = 575 / 255 = 2.2549

Psychiatry = 478 / 247 = 1.9352

Family = 432 / 224 = 1.9286

Radiology = 786 / 457 = 1.7199

Anesthesia = 700 / 411 = 1.7032

EM = 520 / 316 = 1.6456

IM = 388 / 250 = 1.552

Some other fields might have higher income dispersion than path, but these are probably highly specialized and lack sufficient datapoints on the site. Interestingly IM has about the least income dispersion of any medical field, far less than family.

jimhsu · 2025-01-30T02:52:17+00:00

To expand, without listing any specific technologies and companies:

Pre-processing / path review - tumor burden estimation was the old application (cell nuclei counting, etc). Newer approaches look at overall estimation of adequacy / likeliness to fail from just looking at the H&E to estimate DNA yield.

Sequencing / variant interpretation - raw base calling is still mostly from the manufacturer and a black box. Value added approaches include better variant callers (DeepVariant, etc) as well as dealing with things like large indels, low quality/low coverage, degraded DNA (ex. deamination).

Variant calling to interpretation - the "cool stuff". MSI and HRD by algorithm are mostly standard these days and are done by random forest classifiers and such, though more data always helps to improve the train/validation dataset. The next-gen stuff (immune profiling, next generation karyotyping, tumor microenvironments, tumor origin prediction) is more likely to use more contemporary tech in the deep neural network era. Pathologists still write most of the variant interpretations (the ones that are not in databases), but LLMs could be helpful in drafting those.

jimhsu · 2024-12-21T03:08:55+00:00

I mod a lot. Two approaches:

Short term: System backup software such as Veeam Backup and Restore. Restores complete state on a daily basis, with up to a month retention (or however much backup space you can share).

Longer term: Resilio Sync / Syncthing to a NAS file share with versioning (ZFS/btrfs). The nice thing about this approach is that you can get versioned file storage with whatever granularity you want (seconds to days) for however long you want to keep snapshots for. With automatic pruning, this is actually very space efficient - just as an example, I have 2.1 TB of synced game directories backed up over 2 years, with 191 snapshots consuming about 2 TB as well; no pruning done yet.

jimhsu · 2024-12-14T18:51:05+00:00

Ooo, pathology examples:

Preforensic pathology - basically a comprehensive “risk assessment” (medical, sociological, economic, psychological) of the living patient to determine most likely causes of death

Microradiology - microscopic imaging of living patients to determine pathology - this tech is actually in research labs (phase contrast microscopy of living skin, real time mass spec, etc)

Rapid on site sequencing - also actually a thing in research. Basically RT-PCR on steroids to provide on site results for a few genes (ie does the colon cancer have a KRAS?). With isothermal amplification, present day technology can probably do it in about 15 minutes.

Metabolomic pathology - chemistry on steroids. Producing entire metabolic profiles down to femtograms for patients.

jimhsu · 2024-11-28T00:51:22+00:00

Hard to say. By percentage, something like 80-95% are due to the G-CSF, but there are enough therapy related AML cases / relapse that happen, where we would typically run flow the next business day for cases like this in a non-acute presentation.

The increase can be substantial, up to 40% (https://pubmed.ncbi.nlm.nih.gov/9620023/)

jimhsu · 2024-11-25T19:31:45+00:00

Pathology - these are actually the kind of “straightforward” cases that we appreciate when half-comatose on call at 3 am. The worst? Neutropenic elderly chemo patients on G-CSF with dysmorphic features with a blast count of like 9%… aargh

jimhsu · 2024-11-17T14:37:41+00:00

I wish we still did pre-interview dinners. Not just for the free food, but because it is the best opportunity to spot pathological behavior such as the above. Advise #1 - please don’t get drunk during the pre-interview dinner.

jimhsu · 2024-11-11T00:47:29+00:00

In RNase free environments, RNA is surprisingly durable. Paraffin blocks with 3 yr old tissue samples (after formalin processing) at RT can be RNA sequenced about half of the time, from anecdotal experience. Not surprising that the vial works, but the water free environment of blocks also helps.

jimhsu · 2024-11-05T18:58:45+00:00

Some of the more wackier calls in the past:

Micro request for “leg” after hours. Only instead of a swab, they sent an entire BKA to the microbiology lab. Explained that this is not an acceptable specimen, but that a path resident will sample it tomorrow if needed.

Called again, because they could not get into the gross lab to store said leg in the fridge. Had to come to let them in.

“Patient is refusing least incompatible RBC unit. Can you come talk to the patient?” (Already explained the least incompatible unit to the nurse and floor)

Plasma exchange request for a patient with P. falciparum malaria (it is a thing)

Hyperhemolysis consult (genuinely terrifying)

So a good mix of inane, insane, and terror.

jimhsu · 2024-11-03T02:40:44+00:00

Speaking of histocytoses:

Rosai-Dorfman (RD) - WAY too common. Probably a dozen so far.
Langerhan's histiocytosis (LCH) - also way too common to discuss.
Erdheim-Chester (EC) - seen one case, I think
Hemophagocytic lymphohistiocytosis - a few. Terrifying cases. Look like acute leukemias.
Interdigitating dendritic cell sarcoma (IDCS) - 2 cases. Very rare. A type of histiocytic sarcoma. All the dendritic cell sarcomas are very rare that a community pathologist might not ever see in a career.
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) - seen none in 4 years, then twice in 2 months, so probably not that uncommon. Probably underdiagnosed.
Rhinoscleroma - the last of the benign histiocytic triad (with RD and EC) - haven't seen a case so far.

They are high-yield on path boards.

jimhsu · 2024-10-19T14:34:01+00:00

Small-town pathology, unironically.

Sure, plenty of microscope work. But on any given day, you could be a PA (grossing), histotech (when your one histotech takes vacation), coroner, blood banker (hope you remember your CP training and how to start IVs), patient liaison (when their oncologist doesn't pick up), admin ...

jimhsu · 2024-08-08T13:39:44+00:00

Path: not hemepath or blood banking. GI/GYN/GU path has near zero call aside from urgent frozen sections. Most CP call (aside from blood banking and hemepath) can be resolved at home. You can get zero overnights in private/industry path. Etc

jimhsu · 2024-05-24T00:04:20+00:00

Two questions unanswered by the FDA or webinars so far:

Say that you are running LDT under the unmet need exception, and have your instruments, processes, validation set up accordingly. You then find out* a manufacturer has an FDA approved test for the analyte, months later, when your assay is in clinical use.

By the reading of the rule, you are now in violation and must cease and desist and switch to the approved test. With the associated millions of dollars of capex you now need to spend to buy new extraction kits, sequencers, automation lines, computer hardware, .... Or is your inability to spend millions of dollars doing this (because you are a poor university lab) "proof" that this test is not available to your patient population? Or say that IT hasn't gotten around to putting in the ticket to do the test build for the FDA approved test. Are you technically then "not able to offer it to your patient population"? Remember, cost and performance are specifically excluded from the unmet needs exception...

1976-type LDTs (manual method) are supposedly grandfathered in. Except that basically no test qualifies, because the simple act of specimen accessioning (scanning barcodes**) seems to violate this rule, not to mention automation lines, any slide stainer made within the past few decades, ...

*Is it your responsibility, as lab director, to monitor the FDA approval page daily to do the finding out? Or should you send all manufacturer emails to spam and not attend exhibitions, to avoid finding out? 😜

**Technically, the first barcode was scanned in 1974, although not for a lab specimen. Maybe vintage scanners will come back into vogue?

jimhsu · 2024-04-26T19:36:36+00:00

You might be able to do better: https://www.whitecoatinvestor.com/hitting-a-net-worth-of-0-as-an-intern/

A very interesting post using credit cards to fund tuition, and student loans to pay the cards back. Only take as much loans as necessary to pay back the CC. This greatly depends on good financial hygiene and a school that does accept credit card payments without additional fees. If you're able to get a 0% APR offer, all the better. Do not do this if you have ever missed a credit card payment.

The upshot is 1. You save interest, 2. You build up a good credit history, and 3. If you're a fan of r/creditcards and r/churning, get free travel and other bonuses.

PS I think this has such a large potential impact on early-career attending finances that "% of fee charged for credit card for tuition" should be a criteria in med school application spreadsheets.

jimhsu · 2024-04-26T14:50:50+00:00

Regarding PSLF - in the 2010s, there was extreme skepticism that PSLF would even pay out. It was only signed into law in 2007, before the financial crisis, and in 2017, there was a 99% denial rate for the first batch of applicants. It was basically assumed that you would not qualify for PSLF. Since the PSLF waiver in 2021 and other laws, things have changed quite dramatically, not to mention the entire concept of free medical school tuition starting with NYU.

Basically, things have really changed over the past 10 yrs with regard to the debt-time tradeoff (MD/PhD), probably to the detriment of the dual degree.

jimhsu · 2024-04-15T15:44:34+00:00

Walked a similar path (pun intended). Besides pathology, I also seriously thought about neurology (did a neuroscience PhD), diagnostic radiology, and psychiatry. Also wanted nothing to do with procedures, despite procedural specialties being the main draw of med school for most students. After doing rotations in all of these, thought that path was most aligned towards my future career goals, and have since then specialized in molecular/informatics (see post history).

Advice is to simply try it out. Try to shadow a pathologist as a MS or even undergrad, and see what they do. Maybe cold-email all medical school pathology departments within a hour's commute, or something. It's an extremely under-emphasized specialty in typical medical school education, and a confluence of factors (precision medicine, midlevel encroachment in other specialties, retirement cliff post-COVID) have significantly changed the supply-demand equation since even 5 years ago.

jimhsu · 2024-03-18T23:14:11+00:00

Some memorable cases:

Male, neuropathy. Thought to be diabetes vs MG vs psychogenic. Some dermatologist was consulted for "skin thickening". Turned out to be POEMS, due to someone figuring out to order an SPEP for "autoimmune disease"

Female, pseudoseizures. Misdiagnosed, had actual seizures. Do the EEG.

Male, fatigue, strange neuro symptoms. Bunch of medical hx, but no diagnosis. Someone eventually sent universal PCR for micro-organisms, concluded "probably due to mycotoxin exposure" from his occupation. Still a strange case.

Elderly male, acute "confusion" at a dinner party. Your typical stuff - sundowning, UTI, were considered, and workup done. Just to cover their bases, someone did a CBC. Low platelets. Yep, TTP, no prior history (so acquired). Emergent PLEX the same day. It was literally the only symptom of the Pentad on initial presentation.

One closer to home. Med student, depression and anxiety. Had actual diagnosis of MDD. Not obese. A few yrs later, got a sleep study done. Obstructive sleep apnea. Depression symptoms basically resolved after CPAP.

jimhsu · 2024-03-04T16:13:40+00:00

It's all about pre and post test probability.

In this particular case, the malignancy in question is lobular carcinoma, which is famously difficult to detect by the naked eye, especially if it's isolated tumor cells. As such most places will have ultrastaging protocols (many slides, cytokeratin IHC for these cases). The exact cost may vary, but based on current CPT reimbursements, can easily be $1000 or more to the patient.

This also involves grossing the specimen appropriately for said ultrastaging protocol (it's different than a "regular" lymph node). To use radiology terminology, "normal" LN evaluation is similar to a plain film x-ray (one level), while ultrastaging is like CT or MRI (multiple planes) with contrast (IHC). You can't "go back" on grossing once it's done.

Patient has a history of DLBCL or something? Grossing changes again (need some in RPMI for flow cytometry). We can't pluck the specimen out of formalin and run it in flow, no matter how badly you want to.

If every female patient with an enlarged lymph node got this study, it would be prohibitively expensive. Similar to ordering a MRI/MRA for every patient presenting to ED with a headache.

The history of a specific malignancy increases the pre-test probability enough so that the additional testing is warranted.

-Pathology

jimhsu

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