What all medical students and DOs should know about pathology

Estimates of the current number of active U.S. pathologists vary considerably; recent estimates provided in this study range from nearly 13,000 to more than 21,000 physicians, depending on which subspecialties are included in the count. A 2019 study reported that the number of American pathologists has been decreasing in recent years.

However, DO representation in pathology residency positions increased from 6.6% to 11.4% of all pathology residency slots between the years 2011-2020, which is attributed to the growth of osteopathic medical schools and a 51% increase in osteopathic graduates in this timeframe.

Nonetheless, only 1% of graduating DOs pursue pathology each year. With the increase in the pathology job market, alongside a low percentage of medical graduates entering pathology, there is a large demand for pathologists.

Pathology is a hidden gem in medicine. While medical students may recognize pathology as a study of disease, few understand the role of pathologists as critical diagnosticians in patient care. In fact, pathology is a distinct medical specialty with over 15 areas of possible further subspecialty training.

All these subspecialties have a direct impact on patients through biopsy interpretation, cancer grading and staging, delivery of blood products and apheresis, overseeing organ transplants, performing bone marrow biopsies and fine needle aspirations on patients and so much more.

Pathologists are involved with every specimen that enters the lab to ensure accurate results and diagnoses. Even better, pathology is a growing field with plentiful job opportunities, excellent work-life balance and abundant job satisfaction. There is no doubt that there is an immense need for more medical students to enter pathology.

During medical school, I recognized that few opportunities existed for my fellow classmates to learn about what pathologists do. Thus, myself and fellow classmates established a pathology interest group to introduce students to the specialty and increase pathology visibility.

Since the establishment of our pathology interest group, enthusiastic pathologists, such as Jacqueline Macknis, MD, have stepped forward to help educate students about the role of lab medicine and pathologists. As a result of our group’s efforts, numerous students have developed a better understanding about pathology, and some have discovered their passion for pathology!

In this edited Q&A, Dr. Macknis discusses the critical role of pathologists in patient care, dispels misconceptions about pathology, and provides insight into how all medical students and DOs can better understand the role of pathologists and the laboratory.

What is pathology?

Pathology is a medical specialty focused on determining the cause and nature of disease. By analyzing tissue and body fluids, pathologists are able to render a diagnosis, which is critical in treating and managing patients.

Pathology is divided into two broad yet overlapping areas: anatomic pathology and clinical pathology. Anatomic pathology focuses primarily on the study and diagnosis of disease based on the examination of tissue, either removed surgically (such as a biopsy, needle aspiration or surgical resection) or examination of the body as a whole (autopsy). Clinical pathology focuses on the analysis of blood and body fluids (such as urine and cerebral spinal fluid) to diagnose and treat disease.

Pathologists work closely with other physicians to not only diagnose disease, but also to guide treatment in the management and care of patients.

What drew you to pathology?

During my undergraduate studies, I majored in medical laboratory science. Although this major is sought by those preparing for a career working in medical laboratories, I thought this would be an excellent premed major, providing me with a solid background of medical knowledge on which to build when I entered medical school. And it did!

I entered medical school with the intent of becoming a pediatrician, my childhood dream. But I soon realized what an impact this “laboratory intensive” major had on me. I missed the challenge, excitement and curiosity that comes with diagnosing disease, as opposed to treating it. I missed the hands-on work at the bench and microscope. I soon realized that the lab was calling me back home!

Why are pathologists important in health care? 

As an anatomic pathologist, I spend most of my time studying tissue (i.e., biopsies and surgical resection specimens) under the microscope.

As a pediatric/perinatal pathologist, I specialize in diseases/disorders of infants and children. I also perform fetal autopsies. This entails examining fetuses, including those lost early on in the pregnancy, and the accompanying placenta in an attempt to determine the exact pathology.

Such an autopsy might occur to explain an unexpected fetal demise in utero or to thoroughly document the exact pathology present, often including complex cardiac malformations in fetuses with numerous congenital anomalies and/or syndromes.

Pathology touches nearly every specialty. Being familiar with the role of pathology, and the role of the pathologist in particular, is critical to every aspect of patient care. The work of a pathologist has a tremendous impact on patient care.

Surgeons cannot perform the proper surgery if they do not know what they are removing. Oncologists cannot treat cancers that have not been properly diagnosed, staged and graded. Radiation oncologists cannot administer radiation therapy without knowledge of tumor type and margin status. Every test, from the simplest complete blood count to elaborate whole genome analysis with Next Generation Sequencing of DNA, comes through the lab and pathologists are at the center of it all.

How do you address misconceptions about pathologists?

There are many misconceptions about pathologists. Here are a few: That we are quiet, shy and socially awkward, and that we work in dark, cold rooms surrounded by dead bodies all day. Wrong, wrong and wrong! Pathologists play an integral role in the ongoing treatment of their patients.

We have a key role in presenting patient material at multidisciplinary conferences and tumor boards with our clinical colleagues on a daily basis. We have the opportunity for direct patient contact when performing fine needle aspirations, bone marrow biopsies, performing pheresis, consulting on transfusion reactions, seeing patients in donor centers, etc.

Contrary to the stereotypes, we are inquisitive, bright, challenged doctors involved in every aspect of patient care: beginning (diagnosis), middle (guiding treatment) and end (cause of death). And you will find that we are not strange, socially awkward people.

Can DOs be pathologists?

DOs can absolutely be pathologists. Both DOs and MDs are equally qualified to apply for residency positions in pathology.

Why should DO students consider exploring pathology as a career? 

All students should explore pathology as it is at the heart of patient care! Those who go into other specialties will utilize pathology services regularly, likely on a daily basis. Having background knowledge as to how the pathology department runs, the services provided, the expertise available to help in a plethora of clinical situations is extremely valuable.

Not everyone wants to be a pathologist; but everyone in medicine will use pathology services regularly.

How can students position themselves to match into pathology? 

The best way to prepare is to get exposure.

Spend time working hand-in-hand with the attending physicians who you hope to one day become. This real-life, hands-on exposure can give you a glimpse into what your daily life might look like one day. Seek out some time in the pathology department at your hospital. We would love to see you!

There are several opportunities that are free to medical students. Consider joining your school’s pathology interest group. If your institution does not have one, you can start one! You can also get involved with the virtual Pathology Student Interest Group, become a student member of the American Osteopathic College of Pathologists, the College of American Pathologists (CAP) and the American Society for Clinical Pathology (ASCP) and go to professional conferences and present a poster if you are able to do so, virtually or in person. Start connecting with pathology-interested students and pathologists through #PathTwitter. You can also apply for scholarships with the Society of ‘67 Scholars program, CAP and ASCP.

Related reading:

More to Match: Should I choose a back-up specialty?

What I wish other doctors knew about NMM/OMM