Choosing Pathology
by Benjamin R. Coleman, M.D.


Friday, February 14, 2003

Choosing Pathology
Benjamin R. Coleman, M.D.

In a medical career, there will be many difficult decisions to make. Perhaps the most challenging will be the choice of specialty. Many medical students spend long hours struggling to decide among a variety of medical fields. Others simply know their chosen specialty after a certain point. Regardless of the method of arriving at a specialty choice, one thing medical students desire is testimony from those who have gone through such decisions. Hearing the reasons why a particular physician chose his or her field can shed light on different aspects of the decision as well as validate the thoughts of the medical student on the specialty in question. With this in mind, I offer some information about pathology followed by my testimony as to why I chose pathology with the hopes that it will help medical students considering pathology in their decisions.

What Is Pathology?

Many medical students know pathology as a difficult second year course that is a vital part of Step 1 of the medical boards. Also, most students know it is a medical specialty but aren’t quite sure what goes on in those laboratories in the bowels of the hospital. Pathology is defined as the study of disease. The role of the pathologist, however, is much broader than this definition indicates. The main part of a pathologist’s job is diagnosing disease by examining surgically procured (meaning biopsies, resections, excisions, etc) specimens. This aspect of the pathologist’s job falls under the general designation of surgical pathology. By rendering his or her diagnosis on the surgically obtained tissue, the pathologist conveys important information to the clinicians caring for the patient. This information will guide the treatment of the patient in a variety of ways, perhaps leading to further resections, radiation therapy, chemotherapy, watchful monitoring or joyous news of a benign condition.

While surgical pathology is a large part of the pathologist’s job (and generates the largest amount of revenue), pathologists are involved in many other areas. Many pathologists will have roles in managing a laboratory. Pathologists also read chemistry studies (such as hemoglobin electrophoresis, LDH studies, protein electrophoresis, etc), perform autopsies, manage the blood bank, manage microbiology labs and participate in research. Thus, the role of the pathologist is multifaceted; for those medical students who are under the impression that all pathology is surgical pathology, it may be refreshing to note that a large variety of subspecialties and practice situations are available.

Speaking of subspecialties, there are a multitude of subspecialty fellowships that are available to the pathologist after completion of the 4 year residency. Most fellowships are 1 year; some are 2 years. Areas of specialty include hematopathology, cytopathology, neuropathology, soft tissue, dermatopathology, blood bank, pediatric pathology, microbiology, forensic pathology and further training in surgical pathology (note that this list is not complete). Each of these fields offers unique challenges thus allowing the pathologist to have a wide choice of different practice settings.

A little more information before I get to my thoughts on choosing pathology. The residency for pathology is 4 years. During those 4 years, the resident will be trained in areas of clinical pathology (chemistry, blood bank, microbiology, etc) and anatomic pathology (surgical pathology, autopsy, cytopathology, dermatopathology, hematopathology, neuropathology, etc). No clinical year is required prior to starting pathology residency (i.e.- no transitional year).

What’s Residency Like?

I can only relate to you the experiences I’ve had at my program. Keep in mind that most programs vary somewhat in the way they run things. Generally, a resident does 2 years of clinical pathology (CP) and 2 years of anatomic pathology (AP). Some programs do these separately; my program integrates CP and AP throughout the 4 years. We do rotations that are 1 month long; we switch rotations when the calendar month switches. We rotate between 5 different hospitals: a community hospital, a children’s hospital, a VA hospital, a university hospital and a county hospital. This gives exposure to a wide variety of patients and specimens.

The typical day begins around 7:30 or 8:00 A.M., usually with a conference. We have conference 4-5 days of the week. Monday is required CP and AP conference, Tuesdays are gross pathology conferences, Wednesdays are autopsy and neuropathology conferences (alternating weeks), Thursday are dermatopathology conferences and Fridays are cytopathology conferences. Each conference lasts one hour with the Monday conferences being the only required conferences of the week. There is also a 4:00 conference at the university hospital where cases are shown for quality control. The day usually ends around 5:00 or 5:30 P.M.

After morning conference, the duties of the rotation are assumed for that day. I don’t have the time to discuss every detail of each rotation so I’ll give a few brief comments. On surgical pathology rotations, the schedule varies. Some weeks, we sign out in the morning and gross in the afternoon. Other weeks will consist strictly of grossing and covering frozen sections or signing out and covering frozen sections. Each hospital has it’s own way of doing things. On autopsy, a resident spends the day doing any cases that come in and then working on paper work and signing out the autopsies with staff.

On the CP months, the schedule varies greatly depending on the rotation. Blood bank involves seeing patients for apheresis procedures during the day as well as working up antibody reactions and transfusion reactions. Chemistry involves signing out protein and hemoglobin electrophoreses for a few hours a day. Microbiology and CP rotations at different hospitals have varying schedules.

Call is taken one week at a time and taken from home. On call, the resident is responsible for covering frozen sections, covering blood bank issues and procedures, answering any questions from clinicians, dealing with mislabeled specimens and performing immunosuppresion protocols (a staining procedure done on various specimens for rapid diagnosis of the presence or absence of microbiotic pathogens). These services are covered after 5:00 P.M. on the weekdays and 24 hours on the weekends by the call resident. Generally, a first year resident takes call 7 weeks out of the year. This number decreases as the resident progresses.

Why Did I Choose Pathology?

Okay, now onto the good stuff. Choosing pathology was a long decision for me. I developed a small interest in pathology after my second year course but did not fully realize my interest until I was on surgery and was sent down with a specimen by an attending to observe how the pathologist handles the specimen and what it looked like microscopically. I found that I was much more interested in this aspect of the case than in the surgery itself. I did surgery early in the 3rd year and so a small seed was planted in the back of my mind at that time. Throughout my further rotations in the 3rd year, I realized that I was always very interested when microscopic slides were shown in presentations on different diseases and I knew then that I had developed a strong interest in pathology.

I also was very honest with myself concerning what I wanted in a specialty. I wanted intellectual challenge. I wanted an investigative role. And, I wanted reasonable work hours and a good life style. I was also aware that, while my grades and board scores were decent, they were not at the level required for specialties such as radiology, dermatology and orthopedic surgery.

In addition, I saw how happy pathologists were at their jobs. I never met a genuinely unhappy pathologist (however, I met a ton of unhappy obstetricians). Most said they loved their job and would not want to be doing anything else.

Other things I considered were the fact that it was not terribly difficult to match in pathology. If you are an American medical graduate, you should have no trouble matching unless you have very poor grades, scores or recommendations. Also, I liked the fact that there was no transition year.

So, all of these factors played strong roles in my decision. Additionally, I thought ahead to the future. Did I want to be 50 years old and still having to get called in the middle of the night all the time, have to work terribly long hours and never see my wife and kids? Quite simply, no. I wanted to be a father to my children and not just a source of income. I wanted to be able to spend quality time with my wife and not be stuck at the hospital or the office until 9 pm each evening. Now, don’t get me wrong, I’m not begrudging or ridiculing other fields of medicine. I admire those folks without reserve. And there are other fields besides pathology that allow a good lifestyle. I’m just giving my reasons why I chose pathology.

From what you’ve read above, it sounds like I already had it figured out that I wanted to do pathology, right? So where was the struggle? The struggle involved several issues. First, I wanted to be considered a real doctor. I thought, “Gee, no lay person has any clue what pathologists do. Do I want to constantly explain that I don’t really see patients and that I work in a laboratory?”

Second, I enjoyed pediatrics (my second choice) very much and thought I would make a good pediatrician. I had excellent people skills and I thought I’d be wasting them in pathology since I would not be seeing patients. Before I go on, let me address this point a bit. People skills are absolutely not wasted in pathology. No matter what job you do, how you interact with people is important. As pathologist, you have to explain many things to many people and you have to work in harmony with histology technicians, pathology assistants and other physicians. Social skills are vital to this. The old image of the nerdy pathologist who can’t interact with anything living is an old stereotype that needs to be laid to rest (for the record, 90% of the pathologists and pathology residents that I know are perfectly normal people…but there’s always that 10% in whatever field you choose). Pathologists play a key role in patient care and having the ability to interact well with colleagues and co-workers is an invaluable skill. I didn’t realize that during medical school but I do now.

The two reasons stated above were my big hang-ups with choosing pathology. I went back and forth for a long time. Finally, however, I did a month of surgical pathology and knew deep in my heart that I had found the right field for me. That’s a key point. Follow your heart. Yes, it sounds cheesy and very much Hollywood, but, at the same time, it is very true. Your heart will tell you if you’ve chosen the right field or not if you know how to listen to it. Honestly, some folks don’t listen to it until a year into another residency. And there’s nothing wrong with that as long as they find the right field for them in the end.

What do you lose in pathology that you might have in other fields? First and foremost, you lose the instant gratification of saving a patient’s life. Patients aren’t going to thank their pathologist because they diagnosed a difficult breast cancer case. They’re going to heap their gratitude on their primary physician who found the mass on routine breast exam. That’s simply the way it goes. So, if you are one who desires such gratification, pathology may not be the right field for you.

Gratification is present though. You can take a sense of pride when you have just diagnosed a difficult case. You can bask in the glow of amazement as you explain your astute findings to your colleagues. Okay, this is somewhat tongue-in-cheek but in all seriousness, you do get gratification knowing that you help a patient by making the correct diagnosis.

You also sometimes lose a measure of professional respect. Some (ignorant) physicians will not think pathologists, with their nice hours and lack of real patient care, deserve to breathe the same air as them. Such situations honestly don’t occur that often but realize that the good doctors respect pathologists as normal colleagues and know that a good pathologist is a valuable resource and will save their butts on more than one occasion.

Finally, you lose waiting rooms full of patients, angry parents, discharge summaries, patient’s who don’t do what you advise, in-house call, H&P’s, nursing home admissions, admissions in general, knowledge of most medications and trying to find nursing home placement for your patients. If you really like this stuff, pathology is not for you…and you might want to see a psychiatrist. Okay, okay, I’m kidding :).

I sincerely hope that my mostly serious dialogue has been somewhat helpful. I think the most critical thing to do when deciding on a medical field is to be honest with yourself, evaluate your personality (again, honestly), consider other factors (e.g.- wife, children, other family, etc) and, most importantly, follow your heart. Talk to everyone you can about your decision. Non-medical people will have great insight into some aspects of your decision. Other pathologists (or physicians in other fields you are considering) will provide you very helpful information. Non-pathologist physicians can be helpful as well as some of them may have considered pathology at one time. Don’t be afraid to ask them “Did you ever consider pathology?” Some will give you a “Yeah, right” sort of answer but others will provide invaluable information as to why they eventually decided against pathology. Again, I hope this was helpful. Best of luck in your decision.


posted by BC | 6:10 PM
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