COMMENTARY

The Path to Pathology

Mark R. Wick, MD

Disclosures

September 05, 2012

With the current restructuring of medical school curricula, many students nowadays have little idea about who pathologists really are and what they do. At some point in the first couple of years of classes, people bearing that professional label show up and push formalin-fixed specimens around for students to examine. Pathologists may also participate in group teaching sessions with professors from other specialties. However, these these are typically the only times that students will interact with pathologists during medical school. Patients' specimens are sent off for analysis and answers come back, but the whys and hows of the process are largely invisible.

It's not surprising, then, that pathology is not even remotely on most medical students' radars when thinking about a specialty choice. That is very unfortunate.

Pathology and laboratory medicine (PLM) is one of the most scholastic areas of medical practice, representing the prototypical bridge between the basic sciences and the clinical disciplines.

Physicians in PLM are responsible for the ongoing translation of developmental technology in the hospital laboratory, to improve diagnosis and patient care. They also serve important roles as consultants for other doctors, quality assurance officers in the hospital, and resource scientists for other specialties.

How I Came to Be a Pathologist

When I was a third-year medical student 35 years ago, I knew that I principally enjoyed the challenge of diagnosis but felt that I was destined to be an internist. I had taken the then-standard 2 years of "systems" pathology courses and enjoyed them greatly, but I did not know what a pathologist did on a daily basis.

Fortunately for me, one of my faculty mentors saw me constantly reading about the pathophysiologic mechanisms of the diseases that my patients had and the morphologic changes that those conditions produced. He arranged for me to spend my Christmas break from school that year with an experienced community pathologist friend of his, and that experience changed my life.

"Dr. K." was not a boring, bookish, specimen-pusher. He was an excellent clinician who also happened to be a superb pathologist.

Surgeons, internists, pediatricians, and gynecologists continually stopped by the laboratory to speak with him about their difficult cases and ask for his input on further workup and prognosis. He was as comfortable interacting with them in that context as he was in diagnosing surgical pathology specimens from the operating room or interpreting panels of biochemical tests in the clinical laboratory.

And, if you asked him, he could tell you why a particular drug was used for a chosen disease and how it interfered with the pathophysiology of that disorder. Nonchalantly but clearly, Dr. K. made it known to his colleagues that the reason he could do all of this was that he had read the medical literature widely and he continued to do so; in other words, he was a kind of living encyclopedia.

I decided that I wanted to try to be one too -- not to show off or be admired by my physician-peers, but simply to help them and, by doing so, help their patients. That is what a good pathologist does.

Training and Typical Days

Now we come to the specifics. After obtaining an MD or DO degree, a pathologist serves a minimum of 4 years in general PLM residency training.

Most people also pursue further subspecialty work (1 or 2 years) in 1 or more of the many compartments of PLM. These include surgical pathology, forensic pathology, cytopathology, neuropathology, pediatric pathology, dermatopathology, chemical pathology, molecular-genetic pathology, laboratory microbiology, hematopathology, transfusion medicine, laboratory informatics, and immunopathology.

Board certification is obtained in PLM through the American Board of Pathology, a member of the American Board of Medical Specialties.

A day in the life of a practicing pathologist can be extremely variable in nature, depending on the subspecialty focus, if any. Patient contact is usually limited, except in the areas of cytopathology and forensic pathology.

In cytopathology, pathologists perform a procedure called fine-needle aspiration, in which a small-bore needle is inserted into mass lesions and cells are withdrawn from them for examination under a microscope. The pathologist typically explains the technique to the patient and, together with the attending physician, may also discuss the results of the analysis. Because evaluations of neoplasms figure strongly into the work of pathologists, the news given to patients is not always good, but it is always better to deal with facts than with fears.

Forensic pathologists principally perform autopsies, usually as formal medical examiners. Their interactions with surviving family members are important to help them understand how and why their loved ones died. Again, this task is not pleasant, but it is necessary and, when done properly, can be an important part of the healing process.

Pros and Cons of Pathology

Job opportunities in PLM are excellent, and the future looks bright. This is partly because our specialty has not been very visible compared with others and is not saturated.

In addition, compensation is very good, hours are flexible, and most pathology practices comprise groups of individuals with complementary and reinforcing skills.

Why might you choose pathology as a specialty?

  • You are a person who wants to use most of the scientific information you learned in college and medical school.

  • You want to help and educate your professional colleagues and their patients.

  • You wish to have a detailed understanding of how and why diseases evolve the way they do.

  • You have a desire to translate new technologies into practical medical procedures and tests.

Of course, pathology is not for everyone. People who absolutely thrive on the person-to-person contact of patient care, the satisfaction of performing intricate therapeutic procedures well, and the social recognition that goes along with being a high-profile and successful clinician are not well suited to PLM. We are the low-key folks.

More Information

To learn more about PLM, visit the Websites of the American Society for Clinical Pathology, the College of American Pathologists, the United States & Canadian Academy of Pathology, and the American Society for Investigative Pathology.

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