26
PATHOLOGY
Pathology is exciting, multidimensional, and fundamental to medicine. Its limited patient interaction makes pathology an often-misunderstood field. Until recently, popular culture has not taken to glamorizing this medical specialty, which has led to pathology’s rather low profile within society. No one writes novels about the heroic pathologist who spends hours poring over slides searching for cancer cells lurking under a lymph node capsule or searching for a compatible unit of blood for a patient with many antibodies from prior transfusions. Movies and television shows never portray the pathologist who saved a man’s life by detecting a deadly sarcoma in a seemingly routine gangrenous toe specimen, or who identified a rare form of bacteria in a sputum specimen and averted a hospital outbreak. This is, in fact, what pathology is all about.
THE STUDY OF DISEASE AND ILLNESS
The practice of pathology involves the detection, analysis, and understanding of disease processes. As the only branch of medicine considered both a basic science and a clinical specialty, pathology is somewhat unique. By studying tissues, cells, and fluid samples, pathologists unravel the mysteries of how a particular disease arises and develops. To do so, they draw on a variety of methods, ranging from microbiology to molecular biology. All diseased tissues in the body express themselves through symptoms, signs, and laboratory abnormalities. Without the information provided by pathologists, most physicians would have difficulty interpreting their patients’ clinical presentation and managing the progression of their illness.
✓ Likes precise scientific evidence.
✓ Has excellent management and organizational skills.
✓ Is an independent, studious, and inquisitive person.
✓ Likes serving as a consultant to other physicians.
✓ Enjoys the challenge of difficult cases.
The practice of pathology is divided into two primary areas—anatomic and clinical. Anatomic pathologists examine organs, tissues, and cells to diagnose or further characterize a disease process. They make exact diagnoses on specimens from sources including biopsy, fine-needle aspiration, body-fluid analysis, exfoliation, autopsy, and surgery—and the information they provide in the pathology report is used for patient prognostication and management. Anatomic pathologists typically love delving into gross and light microscopic examinations, immunohistochemistry, electron microscopy, and even molecular analyses in pursuit of the best diagnosis. Anatomic pathologists always have to be vigilant in their work. Each day, there is the possibility of discovering unexpected disease processes, and the ever-present risk of missing or misinterpreting an important abnormality.
Clinical pathologists analyze blood, body fluids, or other patient specimens. They are experts in the scientific principles and techniques of laboratory medicine as well as the administrative aspects of overseeing a laboratory. Most serve as laboratory directors at a hospital or independent laboratory, where they are also involved in issues of management and quality assurance. Clinical pathologists analyze quality control data to determine the sensitivity and specificity values of new diagnostic tests and serve as an important contact for clinicians seeking recommendations on the best test to confirm or exclude a particular diagnosis and how to interpret test results. To provide accurate and informative answers, clinical pathologists need a good understanding of how each laboratory test works and the pathophysiologic processes that can result in abnormal findings.
Pathologists, however, are more than experts on the abnormal—they also are intimately familiar with the normal state of health. Consider the following example: to detect cellular aberrations within a section of thyroid gland, pathologists mentally compare the specimen with their thorough understanding of normal thyroid morphology. Knowing healthy anatomic structure well is the most accurate way to recognize diseased states (and even yet-to-be-described pathologic conditions). Medical students interested in pathology, therefore, should focus their efforts during the biochemistry, cell biology, genetics, gross anatomy, and histology courses in order to develop a strong knowledge base in these areas, which provide the necessary framework on which pathologists expand their knowledge of human disease.
It is not always easy to achieve the noble goals of diagnosis, description, and advanced understanding of the disease. A pathologist requires an exhaustive command of the current medical literature. They have to stay on top of the latest advances and make every effort to assimilate new information. For this reason, pathology tends to attract individuals who never feel satisfied that they know (or will ever master) enough medicine. You must be committed to a lifetime of learning. Most good pathologists are copious readers because they need to know more than just the common disease entities. Their medical colleagues expect them to be ready to discern zebras—unexpected or unusual findings—and the associated clinical implications. “Pathologists have to know just about everything there is to know about disease,” commented a senior resident. This requirement makes pathology intellectually demanding, yet extremely rewarding.
AUTOPSY AND MICROSCOPY: TO SEE FOR ONESELF
In pathology, understanding is power. If you are the type of person who always asks “why,” then you should definitely consider a career in pathology. Pathologists do not only rely on textbooks, journal articles, or dictated reports. Instead, they want to see for themselves exactly what is going on inside the body—deep in the tissues, within individual cells, in DNA, RNA, and proteins. This curiosity explains the emphasis on gross dissection (autopsy) and microscopic examination (histology). Using these skills, pathologists investigate a patient’s disease process or the events leading to his or her death. They work methodically and diligently until a puzzle is solved and then move on to the next clinical enigma with great energy.
To appreciate disease for themselves, pathologists engage in a lot of hands-on analytical work. They handle diseased body parts, specimens, and pieces of tissue. They dissect bodies, carefully section and examine organs, and select the best sections to be processed and made into slides for histologic evaluation. In fact, you may be surprised to discover that pathologists function just like all other physicians. They obtain patient histories (by reviewing medical records, police reports, and communications from other colleagues), perform internal and external physical examinations (on bodies and specimens), and order additional tests (including radiologic, genetic, toxicologic, and laboratory studies). These investigations yield multiple pieces of information that are integrated into the final diagnosis.
Pathologists like to solve problems by analyzing increasingly detailed levels of information. In an autopsy, the pathologist reviews the clinical history and then performs the postmortem gross examination. There are many reasons why pathologists study patients after their deaths. Many people die without a known reason; others have a primary diagnosis but the exact cause of death remains a mystery. In a study of autopsy data, it was found that 48.8% of deceased patients were clinically misdiagnosed.1 Over half (58%) of these clinical errors were major diagnoses that had been missed—if detected before death, a change in treatment may have led to cure or prolonged survival. As the “ultimate measure of quality control in medical practice,”2 the autopsy is essential for determining the extent of disease and the effectiveness of treatment. Autopsies enable physicians to evaluate diagnostic and therapeutic procedures so that they can prevent similar deaths and improve clinical outcomes. Of course, forensic autopsies also provide valuable information used to pursue justice. Medical examiners interpret the physical evidence to determine criminal causes of death (accidents vs. homicides or suicides).
It is fascinating and humbling to see a human body inside and out. But this specialty has a greater scope than dissecting bodies in the morgue. Most of the anatomic pathology completed today, in fact, deals with tissues and specimens from people who are alive. Thanks to modern laboratory tests and imaging studies, many illness can be diagnosed clinically (i.e., for diseases such as congestive heart failure). But many diseases do require a tissue diagnosis. This is why pathologists are also experts at microscopic analysis of specimens. For instance, they closely examine tissues sent directly from the operating room (frozen sections) to determine the presence of malignancy. When looking at cells under the microscope, one resident commented that “the best part about pathology is the minute in which you go from staring blankly at a field of pink and blue to suddenly ‘reading’ what is going on in the specimen and, therefore, in the patient’s body.” Combined with the autopsy, these techniques yield amazing insight into human anatomy, microscopic structure, biochemistry, and physiology.
MAKING CONFIDENT DECISIONS THAT CHANGE LIVES
Every day in hospitals across the country, pathologists make critical decisions that impact patient care. Their reports dictate the direction of a patient’s treatment plan and, thereby, his or her life. The assessments are often difficult because pathologists grapple with a multitude of tough questions: Could the histologic pattern represent a follicular lymphoma or just a reactive lymph node? Does this child’s bone marrow show evidence of acute leukemia, or are the cells simply immature lymphocytes (hematogones) normally present in a young patient? Are those malignant tumor cells sitting in a lymphatic channel or within an artifactual space? Is this electrolyte measurement “real,” or does it represent a specimen handling error? How does one know if this result is correct?
Thoroughness, accuracy, and painstaking attention to detail are all essential to the practice of pathology. Keep in mind that the final pathology reports have huge consequences for the patient. Their conclusions determine, for instance, whether a teenager undergoes a risky bone marrow transplant or whether a middle-aged man loses his prostate gland. After consulting with the pathologist, an oncologist may decide to initiate chemotherapy, a neurosurgeon may stop operating on a brain tumor, and a general surgeon may completely remove a patient’s colon. Misdiagnoses lead to unnecessary disability, increased morbidity, and sometimes even death.
Making these diagnostic decisions can be extremely difficult. Despite their poise and confidence, most pathologists humbly recognize their clinical limitations. They have to balance their own level of uncertainty with their desire to provide as much useful information as possible. Many times, they refrain from making a diagnosis (benign vs. malignant, positive vs. negative) if the specimen material is less than adequate. In these situations, under- or overdiagnosing a suspected lesion could yield catastrophic results for the patient. When additional information, such as new stains or antibody testing, becomes available, pathologists then adjust their diagnoses accordingly.
To provide the best patient care, pathologists regularly read, study, and know when to ask for help. When examining a specimen, they systematically think of every diagnosis a given abnormality could represent, from horses (common) to zebras (rare). They also have to determine whether a tissue sample is truly negative versus being nondiagnostic—two terms with distinct meanings and different consequences. Adding to this pressure, pathologists have to be certain that the patient’s clinician understands all of the implications surrounding a diagnosis. For those interested in a career in pathology, expect some sleepless nights: “Did I make the right diagnosis?” “Did I undercall (or overcall) this biopsy?” “Did I miss anything?”
The true answer to the clinical question accompanying a specimen is not always clear. Sometimes, surgeons and other clinicians identify an expected diagnosis and try to compel the pathologist to make an unwarranted conclusion. Often this type of pressure occurs even when there is no evidence supporting the preferred diagnosis. Self-confidence is highly valued by surgeons, while recognition of one’s limitations keeps patients (and pathologists) safe. Just because a clinician believes that a patient has a given disease does not mean that the pathologist has evidence to support its diagnosis. In the interest of patient care, pathologists stand firmly by their professional opinions, even in the face of disgruntled physicians and surgeons. They have to protect the patient from therapeutic interventions before firmly establishing a diagnosis (or lack thereof). In these cases, pathologists act as advocates for the patient.
On the flip side, a pathologist must be extremely careful if the clinician’s preferred diagnosis fails to correlate with laboratory data or clinical differential diagnoses. For instance, mental alarms go off when histopathology appears inconsistent with radiologic or gross impressions, or when laboratory values do not correlate with clinical signs and symptoms. In these cases, pathologists proceed with caution. In the field of bone pathology, for example, this type of clinicopathologic correlation is essential. Bone lesions have characteristic appearances on radiographic films, and many textbooks and experts therefore recommend that histologic diagnosis on bone lesions should never be rendered in isolation from the radiologic impression. During an intraoperative bone consultation, an accurate determination of benign versus malignancy could mean the difference between local resection and amputation!
PATHOLOGISTS AS CONSULTANTS
Pathologists do not spend their entire days holed up in laboratories and morgues. As experts on disease processes, they are routinely communicating with their colleagues. Whether in person, on the telephone, through a written report, or at a conference, pathologists discuss their patients with other physicians all the time. Every specimen arriving in the pathology department carries an accompanying clinical question, and a pathologist receives telephone consultations from doctors inquiring about the meaning of a laboratory value or pathologic finding. Whether the patient has an unusual neck mass or a surprising laboratory result, clinicians turn to pathologists for the answer. Sometimes the questions are not clear, and pathologists have to sort out the relevant clinical inquiry. Is it cancer? What type, grade, and stage? Are there additional features that help assess the patient’s prognosis and potential response to therapy?
The famous physician Sir William Osler once referred to the pathologist as “the doctor’s doctor.” Every aspect of their clinical care is essentially a consultative service. Because of this advice-giving role, good communication skills (both oral and written) are of utmost importance. While making the best diagnosis, pathologists often struggle to state their findings in a clear, concise manner. They formulate comments that convey the relative significance of individual findings but never under- or overstate their degree of certainty. It is a challenging art form. “Communication skills are my currency with the clinicians,” a senior faculty member in pathology remarked. “Other doctors cannot tell how good a pathologist is diagnostically. They only judge us on what they cane—on our ability to communicate with them.”
Because of this consultative role, pathology is a perfect specialty for medical students who appreciate precision in written and spoken language. Pathologists have to produce the most accurate and clearly written reports. They have to dictate each observation succinctly and in the proper format. For cases in which a diagnosis cannot be made, they must enumerate the relevant findings and the significance of each. If a possible diagnosis exists, the pathologist has to be cautious, never overstating their conviction. Like all fields of medicine, pathology is fraught with gray areas. Thus, in some cases, pathologists walk a fine line between under- and overinterpreting the findings. It is quite a challenge to submit final reports that are clinically useful yet do not overimply diagnostic certainty. Word selection and order become critical factors. As such, pathologists tend to be good writers, striving to develop precise and accurate reports.
THE DOCTOR–PATIENT RELATIONSHIP
Like other hospital-based physicians, such as those in radiology and anesthesiology, pathologists are anonymous, behind-the-scenes doctors. After all, most pathologists do not meet, talk with, or examine their patients in vivo. It is an unsuitable specialty for medical students wishing to meet patients, perform thorough history and physicals on their patients, and have intimate doctor–patient relationships. Although there are rare exceptions—bone marrow biopsy, fine-needle aspiration, and plasmapheresis—in general, pathologists have little to no patient contact. Instead, pathology is perfect for those immensely satisfied by providing other physicians with the best thing possible—the most carefully considered, sweat-over, thoroughly analyzed, complete and accurate diagnosis.
Despite this lack of patient contact, pathologists are real doctors who always care about people. Indeed, many pathologists relate their personal need for distance from the patient as a reason for choosing pathology—because they are at risk of becoming too emotionally involved. Although seemingly invisible to their patients, their unique role allows them to make a big difference in patients’ lives. One residency program director reiterated why pathologists are some of the most caring doctors around:
When I was in medical school, one of my patients died during a surgical procedure that I, pressured by my attendings and residents, advised the patient to have. After that point, I decided that never again would a person die because of something I said.
Although she wanted to avoid making life-or-death decisions in medicine, she ironically chose a specialty—breast pathology—where she makes these decisions every day. She pores over cases late into the night and through weekends, searching for foci of tumor invasion and double- and triple-checking resection margins to verify if the surgeon completely removed the tumor. A diagnosis of invasive malignancy sentences a patient to a dangerous and traumatic course of surgery, chemotherapy, and radiation. In fact, this pathologist cares about patients so much that she turned to a specialty in which she would not have to go through the emotional pain of directly interacting with patients, their fatal diseases, and their families. Many pathologists relate similar experiences and claim they chose pathology because they care “too much.” They are so pained by the suffering of their patients that they cannot practice effectively. For many, pathology provides much-needed distance from the emotional demands of patient interactions.
QUESTING FOR KNOWLEDGE: PATHOLOGY RESEARCH
In all fields of medicine (and especially pathology), the current textbooks are slightly behind and medical literature barely keeps up with the growing amount of clinical and basic science information. There is always much more to discover and learn. And the pathologist holds an ideal position to ask and answer probing questions about disease processes. Every day, pathologists are examining gross, histologic, cytologic, chemical, and molecular alterations. They have daily access to clinical material and are in regular direct communication with clinicians. Because of the integration of basic science and clinical consulting, pathologists have a distinct advantage in the area of translational research. As physician–researchers, pathologists maintain a special ability to identify the tissue, diagnosis, and cells in question. Today, with an ever-increasing number of molecular tests and techniques, researchers can detect subtle changes in human tissues and cells with ever-increasing levels of sensitivity and precision.
Pathologists advance our understanding of disease by studying tissues, cells, receptors, proteins, and genes, and their roles in disease. They analyze unusual findings, recognize patterns of disease, and make new connections between abnormal observations. They take new developments from laboratory bench research and test them for bedside utility. They develop new diagnostic tests and procedures, identify gene mutations and new disease entities, and study the pathogenesis of disease. In doing so, many pathologists either conduct their own research or collaborate with other researchers (MDs or PhDs). Through articles in scientific journals, together they bring the latest techniques to the forefront of clinical use. For these reasons and more, pathologists hold an optimal position to pursue descriptive and experimental research.
LIFESTYLE CONSIDERATIONS AND PRACTICE OPTIONS
A day in the life of a pathologist is difficult to describe, given the variation between different areas of specialty. For anatomic pathologists, a typical day includes performing gross evaluation of resection specimens, interpreting slides, writing (or dictating) and editing pathology reports, and communicating with clinicians on a formal and informal basis. For clinical pathologists, a typical day includes tasks related to overseeing clinical laboratory operations in addition to speaking with colleagues. For both types of pathologists, an academic setting also includes varying amounts of teaching and research. In general, though, the practice of pathology entails relatively controllable working hours. Compared to other specialists, pathologists have more employment opportunities that provide a good lifestyle for family and outside interests. Pathologists are rarely called into the hospital at late hours, and most practices employ a rotating “on-call” system with a designated individual carrying an institutional pager on a rotational basis with other pathologists in that hospital or practice group. The pathologist on call will provide after-hours consultation, answering questions, handling urgent laboratory issues, and reviewing specimens.
In anatomic pathology, intraoperative consultations (frozen sections) require a surgical pathologist to give an immediate tissue diagnosis. In the past that required the pathologist to go to the hospital, but an increasing number of practices are employing telepathology to allow pathologists to interpret slides off-site. Most surgeries for which an intraoperative consultation is anticipated are scheduled as elective cases during the day. Sometimes, however, a late-night, weekend, or emergency surgery requires a pathologist to interpret the frozen section. In clinical pathology, high-priority overnight calls come in the form of urgent laboratory values that must be reported to the clinician who ordered the test. At other times, pathologists may have to confirm an abnormal finding that requires prompt therapeutic intervention, such as leukemic blasts in the peripheral blood smear. Other late-night calls may involve rush advice on the best test to rule out a particular diagnosis, the best way to obtain a particular specimen, or administrative and managerial issues.
Pathology |
$363,636 |
Source: American Medical Group Association.
Pathologists can pursue a variety of practice options. Most work in private pathology practices, either at community hospitals or stand-alone laboratory centers. Clinical pathologists typically serve as laboratory directors, consulting to clinical services on challenging cases and making clinicopathologic diagnoses. Others work in regional or local independent laboratories. Some pathologists are employed directly by nonpathology group practices of physicians that perform many biopsies and have in-office laboratories (i.e., urologists, gastroenterologists, and dermatologists).3,4 A significant number, particularly those dedicated to careers in research and teaching, become faculty at medical schools and university teaching hospitals. Forensic pathologists typically work in city or county medical offices. Government, military, pharmaceutical, and biotechnology organizations make up the remaining group of employers. There are many exciting opportunities for pathologists in all avenues of practice. Some professional pathology organizations have forecast a shortage of pathologists for the future, but this view is controversial.5 Other reports suggest a decline in private practice opportunities and a commoditization of pathology services by nonpathology physicians and/or large corporate laboratories.4 This situation may have arisen due to an oversupply of pathology trainees.6 Recent reports indicate that a substantial portion of fellows have difficulty obtaining jobs near the end of their training.7 Medical students with an interest in pathology should investigate the employment landscape during their pathology rotation(s) through contact with many residents and fellows to base their impressions on primary evidence rather than biased sources or anecdotal reports.
FELLOWSHIPS AND SUBSPECIALTY TRAINING
Blood Banking and Transfusion Medicine
Blood banking specialists make sure that patients in the hospital receive safe blood products. Packed red blood cells, cryoprecipitate, and single donor platelets are some of the products under the expertise of the transfusion specialist. These pathologists oversee blood donation, pretransfusion testing of compatibility and blood-related antigens and antibodies, and selection of blood for transplant. Therapeutically, they manage transfusion reactions, plasmapheresis, exchange transfusions, and peripheral stem cell harvests. From kids with leukemia to adults with anemia, these pathologists have opportunities for patient contact and work closely with clinicians. In most hospitals, they often act as immunohematologists, procuring and processing blood products and tracing the causes of transfusion reactions.
• Number of positions available: 601
• 232 US seniors and 614 independent applicants ranked at least one pathology program
• 90.6% of all positions were filled in the initial Match
• The successful applicants: 39.6% US seniors, 49.9% foreign-trained physicians, and 5.9% osteopathic graduates
• Mean USMLE Step I score: 233
• Unmatched rate for US seniors applying only to pathology: 5.0%
Source: National Resident Matching Program.
Clinical Chemistry
Did you particularly enjoy biochemistry class? These pathologists draw on their expertise of biochemical processes to diagnose, confirm, and monitor a patient’s disease status. They use sophisticated tests that quantify levels of many inorganic substances in body fluids—electrolytes, gases, glucose, proteins such as tumor markers and cardiac biomarkers, and hormones. Clinical chemists apply this biochemical data to understand the cause and progress of disease in the human body. Toxicology is also an important part of chemical pathology, including therapeutic drug monitoring and detection of illegal drugs or poisons. As supervisors of laboratory technicians, clinical chemists assure timely and accurate measurements through a tight system of quality control.
Cytopathology
Rather than examining whole tissue sections, cytopathologists study individual cells obtained from fluid samplings, secretions, fine-needle aspirations, scrapings, and mucosal brushings. In the pursuit of a diagnosis, these specialists draw on techniques of cytochemistry, immunocytochemistry, and molecular techniques in addition to standard light microscopy. They look closely at the nucleus, cytoplasm, cellular adhesion and architectural features, and the background material (mucin, colloid, debris, etc.). The Papanicolaou test (“Pap smear”)—the shining star of cytopathology—still remains the best cancer-screening tool ever invented. These pathologists must also stay current on molecular techniques, which are playing an increasing role in this field. Cytopathologists examine thousands of cervical screening tests and save many women’s lives.
Dermatopathology
Dermatopathologists are experts in diagnosing diseases of the skin. Certification in this subspecialty is under joint responsibility of the American Board of Pathology and the American Board of Dermatology. Dermatopathologists may undergo residency training in dermatology or in pathology, and as dermatopathology fellows they become specially trained in various forms of microscopy (light, electron, and fluorescence). Dermatopathologists work closely with their colleagues in dermatology to diagnose infectious, inflammatory, and malignant processes, and many dermatopathologists actually see patients.
Residency programs in pathology vary in length, depending on whether one chooses to complete training in anatomic pathology (3 years), clinical pathology (3 years), or both (4 years). There are currently 159 accredited programs, mainly in combined anatomic and clinical pathology. Pathology does not require a medical or transitional internship year. During residency, physicians typically do not take in-house call, but rather go home every night and return to the hospital during the night if needed. Much of the training emphasizes reading and self-study. Typical anatomic pathology rotations include surgical pathology, cytopathology, autopsy, and forensic pathology. Typical clinical pathology rotations include clinical chemistry, microbiology, transfusion medicine, hematopathology, coagulation medicine, and immunology. Fellowships in pathology last 1 to 2 additional years and many fellowship programs lead to a special qualifications certificate.
Forensic Pathology
Every day, in the hospital, at home, in the workplace, in public places, and on the streets, people die. Some deaths are expected, while others are unexplained, occur under suspicious circumstances, or may be secondary to trauma, homicide, or suicide. The role of the forensic pathologist is to properly classify deaths as natural or unnatural, and if unnatural, as accident, homicide or suicide. They establish the cause of death through gross inspection, microscopy, toxicology tests, and crime laboratory methods. In addition to performing autopsies and writing the official report, they also testify in court. In some cases, the forensic pathologist even visits the crime scene to conduct an investigation. Many forensic pathologists serve as chief or deputy medical examiners of a city or county.
Hematopathology
Hematopathologists draw on an extensive array of techniques to examine a specimen. These specialists are experts in diseases of the lymph nodes and bone marrow, such as leukemias and lymphomas. They examine bone marrow samples from patients and review abnormal blood smears for malignancy, infection, and anemia. They integrate gross and microscopic examinations with information derived from clinical hematology, flow cytometry, immunohistochemistry, cytogenetics, and molecular laboratories. Hematopathologists work closely with their colleagues in medical hematology–oncology. Together, they integrate laboratory testing and clinical data in the diagnostic workup and disease monitoring of patients with leukemias, lymphomas, and bleeding disorders.
Informatics
Informatics is a newer specialty, with only a handful of fellowships currently available in academic pathology departments. The official recognition of the specialty, known as “Clinical Informatics,” was announced by the American Board of Medical Specialties in October, 2011. Board certification is available through the American Board of Pathology as well as the American Board of Preventive Medicine8; eligibility will eventually require accredited fellowship training, but experience-based eligibility should also be accepted for the next several years. This specialty is a natural fit for pathology, since in many hospitals, the laboratory information system (LIS) provides the bulk of the data in the patients’ electronic medical records in the hospital information system (HIS), consisting of pathology reports and laboratory test results. In the genomic era, the ability to organize, store, retrieve, and interpret vast amounts of data and apply it appropriately for clinical purposes is likely a valuable skill for pathologists to establish and maintain.
Medical Microbiology
Enjoy looking at bacteria, viruses, parasites, and fungi? Medical microbiologists strive for efficient isolation and accurate laboratory diagnosis of infectious diseases. They are trained not only in the principles used to establish diagnosis, but also in the correlation of culture results with the clinical setting. In addition to culturing and classifying organisms, microbiologists also utilize in vitro antimicrobial susceptibility testing. Also, molecular testing has increasingly become a useful tool in virology and microbiology studies. Microbiologists also participate in epidemiologic studies and hospital infection control procedures, and they may be called upon to review the significance of a particular isolate and treatment recommendations.
Molecular Genetic Pathology/Cytogenetics
If you like the latest, coolest techniques in molecular biology as they apply to human disease, this is the subspecialty for you. These pathologists apply molecular methods, such as fluorescent in situ hybridization, polymerase chain reaction, and gene sequencing, to analyze abnormal cells at the level of DNA and RNA. Tests offered by the molecular diagnostics laboratory include virus and bacterial detection and identification, mutational analysis for genetic counseling, and evaluation for clonality and translocations. Cytogeneticists study chromosomes to look for abnormal number and structure for primary diagnosis and to monitor disease status. Prenatal, constitutional, and cancer cytogenetic analysis provide information that is widely used in many fields of medicine.
Neuropathology
Neuropathologists specialize in the study of diseases of the central and peripheral nervous systems and their related tissues. They also often review muscle biopsies in the workup and diagnosis of myopathies, neuropathies, and neuromuscular disorders. Much of their work centers on gross and histologic examination of specimen material. Yet, in the complete workup of a case, neuropathologists may review MRI and CT scans and employ immunohistochemistry, molecular testing, and electron microscopy.
Pediatric Pathology
Pediatric pathologists specialize in the diagnosis and study of diseases of the developing human embryo, fetus, and child. This broad area of pathology encompasses disorders of early development (including embryology, placentology, and teratology), gestational and perinatal diseases, inherited diseases, and diseases of childhood. They often practice both surgical and autopsy pathology, reviewing surgical biopsy, prenatal, and autopsy specimens.
Surgical Pathology
Surgical pathologists make histologic diagnoses based on tissue sections from biopsy and surgical resection specimens. As a consultant to clinicians, their most acute role occurs during the urgent, intraoperative frozen section. Freezing the tissue permits thin sectioning so that microscopic analysis can be performed within minutes while the patient is in the operating room. Surgeons need these pathologists to answer a variety of questions: What is the diagnosis? Is it cancer? Should we perform a more extensive resection? Are lymph nodes involved? Is the malignancy totally excised? Have we obtained enough tissue to complete the diagnostic workup? A key skill is the pathologist’s ability to recognize or determine the key questions to be answered with every frozen diagnosis requested. Most surgical pathology work is done via “routine” (not frozen) tissue analysis. In addition to tissue diagnostics, surgical pathologists develop new classification systems, describe new disease entities, and test prognostic and diagnostic markers. Surgical pathology offers a variety of fellowship opportunities in virtually every organ system: neuropathology, dermatopathology, hematopathology/lymphoma, gastrointestinal/liver pathology, breast pathology, lung, cardiac pathology, head and neck pathology, bone and soft tissue pathology, renal pathology, genitourinary pathology, obstetric–gynecologic pathology, and endocrine pathology. Subspecialty training in an area of surgical pathology provides additional time to study, refine diagnostic skills, and pursue research.
WHY CONSIDER A CAREER IN PATHOLOGY?
Consider a career in pathology because you are prepared to have patients’ diagnoses—and consequently treatment—rest in your hands. Choose pathology because you like to be precise in your words and exacting in your diagnoses. Choose pathology because you are vigilant in your work and tireless in your commitment to arriving at the best diagnosis for your patient. Choose pathology because you want to help each patient by guiding his or her care with your knowledge, experience, and wisdom. Choose pathology because you feel inspired rather than intimidated by the vast amount of knowledge you must acquire and continue to have at your fingertips throughout your career. Choose pathology because you want an intellectually rigorous specialty. Choose pathology because you want to use your knowledge to make observations, to ask questions, and, in doing so, to contribute to medical knowledge.
Pathology is a fundamental discipline of medicine, requiring a broad mastery of basic and clinical sciences. The practice of pathology requires you to retain your knowledge of pathophysiology from medical school education and build upon that knowledge to understand disease processes at ever-increasing levels of complexity. As physicians, consultants, and researchers all in one, pathologists contribute to patient care by making diagnoses and guiding therapeutic intervention. They are educators who impart their knowledge and understanding to their colleagues. Pathologists are real doctors who are simply fascinated by disease and its cellular processes.
One pathologist commented, “pathology is a versatile specialty that may not have been ‘found’ by many. Certainly those who have found it love it.”2 If you enjoy delving into scientific mystery and prefer the science of medicine over direct patient care, then consider becoming a part of the select group that have found their niche within this specialty.
ABOUT THE CONTRIBUTORS
Dr. Lisa Marie Yerian recently completed pathology residency training and fellowship in gastrointestinal and liver pathology at the University of Chicago Hospitals. She is now a gastrointestinal and liver pathologist at the Cleveland Clinic. Dr. Yerian earned her BS in Biology at the University of Notre Dame and attended medical school at the Pritzker School of Medicine, University of Chicago. In her free time, Dr. Yerian enjoys trail running and cooking (the kitchen is her second laboratory).
Dr. Edmunds Reineks earned his BS in Physics and served as an engineering division officer in the US Navy aboard the USS California (CGN-36). He then completed pre-med coursework at the University of Washington and pursued medical and graduate studies (MD and PhD) at Case Western Reserve University. He completed pathology residency training at University Hospitals of Cleveland and a fellowship in Clinical Chemistry at the Cleveland Clinic. He directs the point-of-care testing program for the Cleveland Clinic Health System, and his research interests include quality, analytics, and test development.
REFERENCES
1. Bayer-Garner IB, M Fink L, Lamps LW. Pathologists in a teaching institution assess the value of the autopsy. Arch Pathol Lab Med. 2002;126:442–447.
2. Walsh MJ. Pathology: The “unloved” specialty. Can Med Assoc J. 1993;149(8):1078–1079.
3. In Office Pathology. http://www.iopathology.com/index.html. Accessed September 28, 2017.
4. Nat Pernick, ed. Pathology Outlines. http://www.pathologyoutlines.com/management/vachette201103b.html. Published March 2011, accessed January 9, 2012.
5. College of American Pathologists. http://www.cap.org/apps/docs/pathology_residents/pdf/joint_session_presentation_slides.pdf. Published February 26, 2011, accessed September 28, 2017.
6. The Student Doctor Network. http://forums.studentdoctor.net/showthread.php?t=868089. Accessed January 9, 2012.
7. Karen F, Jay W. A report on the 2014 ASCP Fellowship & Job Market Surveys. https://www.ascp.org/content/docs/default-source/pdf/fellowship-reports/2014-job-market-surveys.pdf?sfvrsn = 2
8. American Board of Pathology. http://www.abpath.org/index.php/to-become-certified/requirements-for-certification?id=40. Accessed September 28, 2017.