A career in pathology
BMJ 2009; 338 doi: https://doi.org/10.1136/sbmj.b629 (Published 21 March 2009) Cite this as: BMJ 2009;338:b629
- 1Faculty of Medicine, Liverpool University, Liverpool L69 3GE
- 2Department of Pathology, Royal Liverpool University Hospital, Liverpool L69 3GA
- M.W.Child{at}student.liverpool.ac.uk
Abstract
A worldwide shortage of pathologists threatens patient care. Matthew Child and Limci Gupta discuss what a career in this discipline entails
The abdominal aorta is opened and inspected for ruptures and signs of thrombosis. Sequentially the liver, kidneys, spleen, and heart are freed from the connective tissue and weighed. Incisions are made in each organ and the internal integrity inspected for signs of infarction, infection, or congenital abnormalities. Inspection of the heart shows no septal or valve defects; its vasculature is intact and embolus-free; and the myocardium shows no sign of infarction: a heart attack was not the cause of death. Then the heart is sliced longitudinally into four or five segments and the myocardial thickness measured to assess for left ventricular hypertrophy, a sign of underlying hypertension and a risk factor for sudden vascular events. At 15 mm it’s larger than average but not indicative of chronically raised blood pressure. The stomach is opened and inspection fails to find any pills; deliberate overdose requires exclusion in such cases. The lungs are clear and fail to exude pus when compressed, excluding pneumonia. A mortuary technician brings over the brain, and immediately visible on the posterior surface of the cerebellum sits a mass of dark congealed blood. Tracing the blood supply through the vertebral, basilar, and posterior arteries of the circle of Willis we reach a 5 mm perforated aneurysm in the anterior cerebral artery adjacent to the exposed optic nerve. A berry aneurysm, probably congenital, has ruptured, and the subsequent subarachnoid bleed was the cause of death.
Such detective work is the attraction of the job of pathologist. It requires correlating the history with what is found from blood tests, at autopsy, or under the microscope.
Unfortunately it seems that today’s medical students and junior doctors aren’t so enthusiastic about a career in pathology. Headlines are similar around the world, from New Zealand and Canada to the United Kingdom and Malaysia: a worldwide shortage in numbers and experience of pathology specialists, such as haematologists, microbiologists, and immunologists, threatens to result in diagnostic delays and erroneous decision making, compromising patient care.
This may be surprising given the high media profile that pathology enjoys, especially the forensic and medicolegal aspects, which combine satisfying the innate human fascination with the macabre and the popularity of the detective story. In reality, however, the forensic aspect is a small subspecialty of histopathology, which is only one of five core disciplines that make up pathology.
Pathology literally means the study of disease, and consequently its scope is vast, covering five main areas: histopathology, chemical pathology, medical microbiology, immunology, and haematology. Each of these is further divided into subspecialties (box). Thousands of clinical, genetic, and microbiological tests requested each day by the general practice or hospital will be processed through the pathology laboratories and reported on by an experienced pathologist.
Five subspecialties
Histopathologists work with tissues and provide information such as the type, stage, and grade of cancer. This is used to assess which type of hormonal, chemical, or radiotherapy treatment would be most effective. They also perform autopsies required by a coroner in cases where the cause of death is sudden or suspicious and will present their findings at an inquest hearing. However, the autopsy, synonymous with the public’s perception of the specialty, is falling out of favour. As J R G Nash, a histopathology consultant at the Royal Liverpool University Hospital confirmed, “Most of our work is with the living, we do fewer post mortems than we used to, and virtually all of them are at the request and on the authority of a coroner.” However, for those keen to teach, the autopsy as a learning tool will remain popular because it gives the student the chance to see lungs blackened by decades of smoking and cirrhotic livers ravaged by alcohol abuse.
Chemical pathologists are concerned with the analysis of bodily fluids and may advise on the meaning of the results of liver function or hormone tests and tests of electrolyte concentrations. They also help in the management of patients with metabolic disorders, such as hyperlipidaemia, diabetes, or phenylketonuria, and some run their own outpatient clinics.
Medical microbiologists diagnose, treat, and monitor infectious diseases. Their work may take them anywhere in the hospital, from the paediatric ward to the emergency department. They help to combat the spread of hospital acquired infections, such as meticillin resistant Staphylococcus aureus. Others help in the management of wound infection after operations. Virologists advise on the best combination of antiretroviral drugs for patients with HIV or supervise interferon treatment for patients with hepatitis C.
Specialists in clinical immunology deal with various autoimmune diseases, primary immunodeficiencies, and allergies. Given the increase in childhood atopy, if you are interested in allergies you might find yourself working in partnership with paediatricians.
Haematologists have direct roles in caring for patients with blood pathologies, such as clotting disorders, leukaemias, and anaemias. In the case of leukaemia they can identify the malignant cell line and supervise the best treatment for its eradication. They are also responsible for blood banking and for interpreting and advising others on the meaning of various blood tests. Vanessa Martlew, a consultant haematologist at the Liverpool hospital, confirmed the high level of patient contact, “I have over 4000 patients taking long term warfarin therapy under my care.” Dr Martlew has been a consultant for 25 years and has responsibility for undergraduate training, plays a role in running the transfusion service, and is a co-director of the local care centre for haemophilia. “Haematology is relevant across medicine, surgery, and the specialties—for example, I’ve just been advising on the care of two pregnant women with clotting disorders, I also advise on the perioperative management of surgical patients receiving long term anticoagulant therapy.”
If you enjoy a greater degree of certainty in your work, pathology offers more precision than the unpredictability that often surrounds bedside medicine. Most malignancies, invasive micro-organisms, and metabolic diseases can be diagnosed with a high degree of accuracy unmatched elsewhere, although sometimes diagnoses aren’t as clear cut as other clinicians or patients expect. “Pathology obviously isn’t for everyone—it’s very much the scientific end of medicine,” says Dr Nash, whose personal interest in the subject was stimulated during his early years at medical school, where an early grounding in the basic sciences led him away from clinical practice through physiology and neuroscience and into histopathology. Some people worry that the current trend away from teaching medical students subjects such as physiology, biochemistry, and histology means that many undergraduates fail to get exposure to the basic sciences that underpin modern medicine.1 The lack of exposure to these subjects with little chance to meet inspirational mentors may be one reason for the fall in the number of doctors who choose a career in pathology.
So you want to be a pathologist?
If you want to be a pathologist there is scope for professional advancement and success if you work hard and intelligently and take advantage of the opportunities that come your way. Given the reported shortages of experienced pathologists in all the subspecialties in the United Kingdom and abroad, the prospect for quick advancement is good.
Many modern undergraduate courses fail to provide students with adequate exposure to the various pathology specialties but most offer voluntary courses and student led modules, which you should take advantage of. In addition, a year doing a related intercalated degree or a rotation in the specialty in the early clinical years will show your interest to an interview panel.
In the UK after the completion of the two foundation years applicants must decide which branch of pathology they wish to specialise in. Each of the specialties differ in entry requirements and career pathways but most trainees spend their second foundation year deciding if their chosen specialty is for them. You will spend at least four years as a specialist registrar, during which you can complete a higher degree (doctor of medicine or doctor of philosophy) as well as Royal College of Pathologist exams, which provides eligibility for a consultant post. From there the opportunities expand to focus on a subspecialty, to manage departments, and to teach and train students and junior pathologists.
One drawback is limited patient contact; however, according to Dr Nash this leaves more time for other things, such as teaching and research: “Our full time NHS colleagues in other specialties may be too busy to get involved in research, whereas pathologists can devote more time to assisting with and providing expertise for research projects with the chance to get your work published as part of the research team. It’s also a specialty that fits in well with family and having a life outside the hospital.”
Pathologists must be able to communicate and liaise effectively with clinicians in all branches of medicine. They are important contributors to patient management, not only providing the optimum tissue diagnosis, but also communicating this through reports, consultations, and multidisciplinary team meetings. If you are attracted to the legal branches of the specialty, remember that the evidence you give in court is only as good as your ability to communicate it to people who may have little scientific background.
Most pathologists who opt for a more laboratory based career will find themselves working in one of the subdisciplines and must be satisfied with becoming an expert in a relatively small area. Those who reach consultant level may find themselves taking overall responsibility for managing a diagnostic service and linking the laboratory with the ward.
Trainee histopathologist’s typical week
Monday
Morning—Autopsy of a 65 year old man found dead at home; investigation shows a ruptured abdominal aortic aneurysm
Afternoon—Reporting* microscopy of various samples, including Kaposi’s sarcoma, sentinel lymph node biopsy
Tuesday
Morning—Undergraduate teaching and supervision
Afternoon—Prepare coroner’s report
Wednesday
Morning—Student demonstration of autopsy: a 53 year old woman who died suddenly; investigation shows large thrombus in cardiac vasculature
Afternoon—Reporting of samples, including oestrogen sensitive breast malignancy, small cell bronchial carcinoma
Thursday
Morning—Multidisciplinary team meeting: a chance to discuss individual cases with clinicians from other specialties, such as oncology, haematology, and palliative care
Afternoon—Reporting of samples: cervical smears, malignant melanoma
Friday
Morning—Coroner’s court: an inquest gives a chance to answer any questions that arise after submission of the earlier autopsy report
Afternoon—Continuing professional development: may include personal audit, attending lectures or conferences, or private study and research
*Under supervision during training.
Main pathology specialties and subspecialties
Histopathology
Forensic pathology
Cytology
Paediatric pathology
Neuropathology
Chemical pathology
Metabolic medicine
Endocrinology
Genetics
Microbiology
Bacteriology
Parasitology
Virology
Mycology
Immunology
Autoimmune medicine
Atopy
Histocompatibility and immunogenetics
Haematology
Transfusion medicine
Haemato-oncology
Haemostasis and thrombosis
Paediatric haematology
Many subspecialties overlap with each other and with some clinical disciplines
Find out more
Royal College of Pathologists (www.rcpath.org)
American Society for Investigative Pathology (www.asip.org)
College for American Pathologists (www.cap.org)
Royal College of Pathologists of Australasia (www.rcpa.edu.au)
Footnotes
This article was first published in studentBMJ 2009;3:100-1
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.