Behind-the-scenes experts

Medicine’s detectives: Pathologists master the art of diagnosis

“Pathologists must be definitive,” says Jack S. Moskowitz, DO. “When I see cancer, I call it, but I have to be absolutely sure.”


Type A personalities who love the limelight they are not. Pathologists tend to be quiet, introspective, rather quirky individuals who enjoy solving problems, but they cannot be timid, says Jack S. Moskowitz, DO, who serves on the Board of Governors of the American Osteopathic College of Pathologists.

“Pathologists must be definitive and honest,” says Dr. Moskowitz, who practices in northern Ohio. “When I see cancer, I call it, but I have to be absolutely sure.” Pathologists sometimes press other physicians for more complete patient histories, which aren’t always available, and they may stress the need for a differential diagnosis when uncertain about results.

Because pathologists don’t share their findings directly with patients, they can leverage objectivity, Dr. Moskowitz says.

Although many would describe themselves as introverts, pathologists need to be good communicators.

“Pathology has moved away from the stereotype of loners practicing in a vacuuum,” says David Allison, DO, in his fourth year of an anatomic and clinical pathology residency at the University of Illinois at Chicago (UIC) College of Medicine. “It is definitely a team-based field.”

Pathologists serve on hospital committees on patient safety, quality assurance and laboratory utilization, Dr. Allison says. And they collaborate with oncologists, surgeons and other medical specialists in multidisciplinary cancer-case conferences (known as tumor boards).

On the front lines of diagnosing disease, pathologists need to interact effectively with other physicians and hospital administrators—in person, on the phone and through written reports.

“We seek residents who can look you in the eye and speak well, though they don’t have to be exceptionally outgoing,” says Mark T. Friedman, DO, the program director of the anatomic and clinical pathology residency at St. Luke’s-Roosevelt Hospital Center in New York City.

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Those who subspecialize in forensic pathology need especially strong communication skills because they interact with police officers and firefighters at crime scenes and testify in court, says Gregory McDonald, DO, who oversees the forensic medicine program at the Philadelphia College of Osteopathic Medicine.

Similarly, pathologists who teach need a fair amount of charisma to share their passion for the field with medical students, residents and fellows.

Though their personalities vary, pathologists tend to have one trait in common, says Candice C. Black, DO, the pathology residency program director at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. They enjoy working behind the scenes and do not crave external validation.

“If you are the type of person who needs external praise to be gratified in your work, then pathology may not be for you,” Dr. Black says.

Most pathologists have minimal contact with patients, notable exceptions being those in the subspecialties of blood banking-transfusion medicine and cytology. So individuals who relish getting to know patients and receiving thank-you’s for compassionate care should probably select another specialty.

“We do care deeply about patients, however, which is why we want to get it right,” Dr. Moskowitz says. “My osteopathic training helps me empathize with patients and holistically connect the dots to arrive at an accurate diagnosis.”

Those who become pathologists typically did not enter medical school with the notion that they would train in this specialty, unless they were specifically interested in forensic pathology, popular TV shows having glamorized the work of medical examiners.

Dr. Allison became aware of pathology as a field in his first year of medical school. “In my rotations in my third and fourth year, I realized that for me the real art of medicine is in making the diagnosis,” he says. “Pathology is one of the few fields where that is your primary job.”

One residency route—ACGME

There are no AOA-approved residencies in pathology, so individuals pursuing this specialty are limited to programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), of which there are more than 140.

The vast majority of pathology residents today are in four-year combined residencies in anatomic and clinical pathology, but some programs allow trainees to complete three-year residencies in either anatomic or clinical pathology if they plan to pursue a subspecialty in one or the other of these main pathology divisions.

In a nutshell, anatomic pathology involves diagnosing disease through the gross and microscopic examination of tissues and cells, as well as performing autopsies when indicated on entire bodies, while clinical pathology involves laboratory analysis of bodily fluids and tissues. General pathologists may do both anatomic and clinical pathology.

Medical students who want to become pathologists in the U.S. must take part in the National Resident Matching Program (NRMP). Students match from their fourth year of medical school—a transitional year is not required.

In the 2013 NRMP match, 583 pathology positions were available. With more than 100 applicants vying for each position, pathology appears to be highly competitive. But the prospects for snagging a residency spot aren’t as dire as they first seem because many of the applicants are international medical graduates, Dr. Black says.

“Most U.S. grads who want path will get it,” she says.

ACGME-accredited pathology residencies may favor graduates of U.S. medical schools for a variety of reasons, including number of years since graduation, the quality of medical education, perceived dedication to pathology, visa issues, and the less-than-fluent English language skills of some foreign applicants, according to Dr. Black.

IMGs sometimes gravitate to pathology, even if they specialized in something else in their home country, because they seek a specialty in which they don’t have to converse with patients, English not being their first language in many cases.

Nevertheless, some IMGs are desirable candidates because they have many years of prior experience in pathology, Dr. Black says. And some ACGME pathology programs will take an IMG over a DO, she cautions. Because she has heard the occasional MD program director make disparaging remarks about osteopathic medical education during pathology conferences, she believes that a smattering of ACGME pathology programs discriminate against DOs.

Dr. Black and Dr. Friedman are the only osteopathic physicians serving as pathology residency directors.

“I cannot show favoritism to a DO candidate, but I do think I am more open to reading the applications of osteopathic medical students because I am a DO,” Dr. Black says.

Through talking with residency program directors and residents and looking at resident rosters on program websites, osteopathic medical students can glean which pathology residencies welcome osteopathic physicians.

UIC’s pathology residency program, for example, is especially DO-friendly. Seven out of the program’s 20 residents are osteopathic physicians, including all three chief residents, Dr. Allison points out.

Best impressions

St. Luke’s-Roosevelt, which has 20 pathology residents, receives 500 or so applications each year for four to six openings. To come up with a short list of candidates, Dr. Friedman says he first looks at the credentials of the applicants who are U.S. citizens.

“We’ll look at the medical schools they went to and their transcripts, and we’ll look at their board scores,” Dr. Friedman says. He prefers candidates who score at least in the 80th percentile on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) or the United States Medical Licensing Examination (USMLE).

“If an applicant failed one step of the exam once but did well on the repeat, we’ll consider him or her,” Dr. Friedman says. “But if someone has more than one failure, we’ll move on to the next applicant.”

Dartmouth-Hitchcock’s pathology residency doesn’t require a minimum percentile but expects applicants to have passed all components of the USMLE or COMLEX-USA. “I will consider someone who has had maybe one failure if he or she is a really exceptional candidate in other ways,” Dr. Black says. “But if someone takes an exam again and fails it again, that’s really a red flag.”

Dr. Friedman has noticed that three-quarters of the roughly 20 DOs who apply to his program each year have taken at least Step 1 of the USMLE. In most cases, he doesn’t recommend this.

Osteopathic medical students who have strong COMLEX scores have no reason to take the USMLE because they risk getting lower scores, which will count against them, Dr. Friedman says. Pathology program directors who look favorably on DOs are familiar with COMLEX and don’t require the USMLE.

“If you do well on COMLEX, the USMLE will only hurt you,” Dr. Friedman says. “If you didn’t do well on the COMLEX, you can take USMLE Steps 1 and 2 to show that you are capable of doing well, but you had better do well. You’re not going to get in with a bad score.”

Both Dr. Friedman and Dr. Black try to filter out individuals who are simply applying to pathology as a backup if they don’t match into their first-choice specialty.

“We look for people who are committed to pathology and love the field,” Dr. Friedman says. Enthusiasm and dedication can sometimes be gauged by candidates’ personal statements and letters of recommendation.

“We want to have a sense that the candidate has a reason for choosing pathology other than ‘Nothing else seems like a good fit,’ ” Dr. Black adds.

Residency directors also weed out applicants who pursue pathology because they think they will have regular work hours and more free time than physicians in other specialties do. “If an applicant comes to us and talks about lifestyle, we’ll say, ‘So you don’t want to work hard?’ ” Dr. Friedman says.

Osteopathic medical students who are interested in pathology need to serve elective rotations in the specialty and make a great impression, residency directors say. But it isn’t necessary to do a formal rotation at every place one is applying for residency.

“If you are interested in pathology, do a few rotations and try to excel,” Dr. Allison advises. “Work hard. Be at the training site all day. Do what you’re told. And keep up with the reading. Outdo yourself and get good letters of recommendation from the supervising faculty.”

Medical students who want an overview of the specialty can read Robbins and Cotran Review of Pathology, which is the field’s bible, according to Dr. Allison.

To help decide whether they want to become pathologists, students can do an observership in a medical center’s pathology department. Essentially an intense shadowing experience, observerships don’t offer academic credit. But they provide an opportunity for students to not just find out about the field but also make a positive impression that could lead to an elective rotation and ultimately a residency later on.

Dr. Moskowitz recommends that individuals interested in pathology apply to many different programs. Being flexible about location helps ensure that one will land a position, he says.

But pathology candidates should carefully assess each program they are applying to, Dr. Friedman advises. The St. Luke’s-Roosevelt pathology residency, for example, is a medium-sized program for training “meat-and-potato generalists,” he says.

Individuals who know before residency what subspecialty they want to pursue should consider programs at institutions with the desired fellowship. Those planning on careers in academia should look at large programs affiliated with universities that focus more on research.

“You really have to do your homework,” Dr. Friedman says. “Talk to as many people as you can at different programs.”

Beyond residency

More than 90% of pathology residents go on to complete one of more than 20 types of subspecialty fellowships, and some do more than one, according to Dr. Black.

“Nowadays you have to do subspecialty training because no employer will take you out of a four-year program,” Dr. Friedman says. “Most of our residents are doing not just one but two fellowships.”

Anatomic pathology subspecialties include cytopathology, forensic pathology, gynecologic pathology, dermatopathology, breast pathology, and bone and soft tissue pathology, as well as pathologies of each organ system, from cardiovascular to gastrointestinal and hepatic.

The subspecialites of clinical pathology include hematopathology, cytogenetics, blood banking-transfusion medicine, molecular pathology, medical microbiology and clinical chemistry.

Almost all pathologists, DOs as well as MDs, become board-certified by the American Board of Pathology (ABP), a member of the American Board of Medical Specialties (ABMS). But DOs also have the option of being certified by the American Osteopathic Board of Pathology (AOBPa).

“A lot of DO pathologists don’t know about us,” says Dr. McDonald, DO, the AOBPa’s immediate past chairman.

Dr. Moskowitz is AOA-boarded, which allows him the same hospital privileges and ability to participate in insurance plans that being ABMS-boarded would.

Being AOA board certified, moreover, would be an advantage for pathologists who seek administrative positions at osteopathic medical schools or who want to develop and direct AOA-approved pathology residencies and fellowships in the future.

Dr. Black, however, doesn’t see the point of taking board certification examinations that are not linked to one’s pathology training. To take both the ABP and AOBPa boards would be prohibitively expensive, unnecessary and cumbersome, she says. Dually boarded osteopathic physicians must satisfy both ABMS maintenance of certification and AOA osteopathic continuous certification requirements.

Once in practice, pathologists usually are employed by hospitals or by practice groups that contract their services to hospitals, while some work for private laboratories or pharmaceutical companies. The pay for pathologists is in the mid-range for medical specialties—$221,000 a year on average, according to a 2012 Mescape survey.

Although residency directors don’t want candidates to bring up the topic of work-life balance during their interviews, pathologists do have more manageable hours than most physicians, Dr. Moskowitz says.

In addition, pathologists can have exceptionally long careers. Because pathology is not as physically demanding as most other medical specialties, pathologists can practice well into their 70s and even into their 80s.

“The career prospects for pathologists are excellent,” Dr. Black says. “We’re about to have a big shortage of practicing pathologists in the U.S. because a lot of very old pathologists are about to retire.”


  1. Emily

    It’s great to read such an article on this specialty, especially from the view of osteopathic physicians. Also – us D.O. students at PCOM are so grateful to have the autopsy shadowing program that Dr. McDonald provides to us!

    1. Pathologist

      Agreed, it’s nice for Pathology to get some recognition. Many students miss out on an otherwise great field due to lack of exposure and lack of publicity about Path.

  2. Pathologist

    “We’re about to have a big shortage of practicing pathologists in the U.S. because a lot of very old pathologists are about to retire.”

    Really now. Pathology is an excellent and exiting field, but let’s not kid ourselves about the job market. Ask any resident, fellow, new attending, or community-based pathologist for an HONEST assessment of the job market. The whole “we expect everyone to retire shortly” joke is getting old.

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