So you want to be a pathologist. You detest the idea of being around other human beings and find solace in staring down a microscope. Let’s debunk the public perception myths and give it to you straight. This is the reality of pathology.
What is Pathology?
Pathology is the field of medicine concerned with the study of body tissues and body fluids. It is considered a “support specialty”, similar to radiology, in that it is ancillary to the clinical staff. Pathologists examine specimens to give tissue diagnoses as well as manage all of the clinical labs ordered by other physicians – from microbiology, to hematology, to chemistry, and everything between.
The field of pathology is heavily intertwined with other fields of medicine. Many of the treatment decisions that other physicians make have in some way been influenced by the pathologist. Whether it be the interpretation of a tissue sample or the results of a blood test, pathologists heavily impact many clinical decisions.
Anatomical vs Clinical Pathology
There are two main divisions within pathology: anatomic pathology and clinical pathology. The easiest way to differentiate between the two is by the type of sample they work with.
Anatomic pathologists focus primarily on histopathology – the diagnosis and study of disease by examining tissues and cells under a microscope. These tissue samples may come from more routine procedures such as Pap smears and fine needle aspirations, or more invasive surgical procedures such as tumor resections and hysterectomies. Examining samples underneath a microscope and determining a histologic diagnosis is the foundation of anatomic pathology.
Clinical pathologists, on the other hand, focus primarily on laboratory medicine and test blood and other bodily fluids. This includes routine tests such as complete blood counts, or CBCs, and comprehensive metabolic panels, or CMPs, as well as more complex tests such as molecular testing for cancer markers and genome sequencing. As experts in laboratory medicine, they spend most of their time analyzing and interpreting these tests; however, they also often take on more director-type roles within the lab and ensure quality control and proper proficiency testing.
Academic vs Community vs Private Practice
Another important way of differentiating a pathologist’s practice is academic versus community versus private practice.
Academic pathologists work at universities and research institutions and will further split their time between teaching and research responsibilities. They often see more complex cases than their community or private practice colleagues and tend to work more hours on average. The additional hours worked each week are not necessarily a consequence of having a greater number of cases, but can instead be attributed to the complexity of the specimens they are evaluating. Due to this complexity, pathologists in academia tend to be very subspecialized and often only practice within that subspecialty.
In community or private practice settings, there is often little to no teaching or research involved. They tend to see more of the bread and butter cases; however, depending on the skill of the pathologist, they may take on more complex cases. This will depend on the pathologist’s individual strengths and weaknesses and what they feel comfortable with. If a pathologist ever receives a sample they are not comfortable with, it is common to collaborate with other pathologists or send the sample out for evaluation at an academic institution.
In terms of lifestyle, community and private practice pathologists tend to have more of a nine-to-five type schedule and don’t generally work weekends or take call. In the academic setting, however, this will vary greatly depending on where you work and what your caseload is.
In terms of compensation, private practice pathologists tend to make the most, followed by community pathologists, and lastly academic pathologists. The differences can be quite significant in some cases, with private practice physicians sometimes taking home over $100,000 more per year than their academic colleagues.
Misconceptions About Pathology
Let’s clear up some of the misconceptions about pathology.
The first is that pathologists aren’t “real doctors” because they don’t see patients. Although it is true that most pathologists spend the majority of their time in the lab and rarely see patients directly, they are all still physicians. They went to medical school, completed residency, and passed their boards just like any other board-certified physician.
Another common misconception is that all pathologists are geeky and have poor communication skills. Contrary to popular belief, pathologists don’t spend all day sitting alone in a room looking at slides – nor do they do everything themselves. Pathologists often manage a team of pathology assistants and techs who do much of the grossing, slide preparation, and actual running of the tests. The pathologist’s primary job is to direct the team and focus on the diagnosis of disease.
Pathologists also regularly communicate with various physicians, surgeons, and other members of the healthcare team to ensure patients receive accurate diagnoses and treatments. For instance, a pathologist working in academics can expect to spend 1-4 hours per day teaching residents in addition to hosting weekly tumor boards.
Many people also believe that pathology is a dying field that will soon be replaced by artificial intelligence and machine-learning; however, based on current technology this is unlikely to happen in the foreseeable future. Although there have been many promising studies where AI algorithms have been able to accurately diagnose disease, you will ultimately need to have someone knowledgeable to interpret the results and determine whether or not they are accurate.
Instead of taking pathologists’ jobs, it is much more likely that artificial intelligence will be used as a tool to make their jobs easier by doing more of the routine or mundane tasks. Due to the aging population, the number of tissue samples to be examined increases year over year. AI may be able to help pathologists meet these growing demands but not replace them.
In terms of tissue diagnosis, you will always need a pathologist to review the slides to ensure the correct diagnosis and discuss the case with the patient’s doctor or surgeon. The pathologist’s interpretation often serves as the basis for much of the patient’s treatment, so the consequences of an incorrect diagnosis are simply too high.
That being said, there is the potential for AI to make pathologists’ work significantly more efficient and decrease the demand for pathologists. A hospital that may have needed to hire additional pathologists to keep up with the growing number of samples, may instead be able to implement artificial intelligence or machine learning tools to make their current pathologists more efficient. Only time will tell, however, what the true impact of AI on the field of pathology will be.
How to Become a Pathologist
After medical school, pathology residency is 3-4 years depending on which pathway you choose. The majority of pathology residents complete combined anatomical and clinical pathology residency which is four years long; however, there are separate anatomic and clinical residency programs as well which are three-years long.
For combined anatomical and clinical pathology programs, first-year residents will often spend more of their time focused on anatomical pathology. This means lots of autopsies and surgical pathology. Years two and three are generally some combination of anatomic pathology and clinical pathology, and year four is generally more focused on clinical pathology. Since clinical pathology is generally less demanding on a resident’s time, this curriculum structure provides fourth-year residents more time to study for boards. It should be noted, however, that some schools have a more simple approach to their curriculums and do two years of anatomic pathology followed by two years of clinical pathology.
Most pathologists who complete combined AP/CP residency programs will also become board-certified in both anatomic and clinical pathology; however, they will often only practice within one.
In terms of competitiveness, pathology is at the lower end of average on the competitiveness spectrum. In 2020, the average step 1 and step 2 scores for pathology residents were 233 and 242 respectively and the match rate was 98.2%.This was the second highest match rate that year only behind radiation oncology at 99.2%.
However, competitiveness is not purely a function of step scores and match rate, but also other official data reported by the NRMP.
When accounting for these other factors, pathology ranks at 8th least competitive, ahead of neurology, emergency medicine, psychiatry, pediatrics, anesthesiology, PM&R, and family medicine. Those wishing to get into a top pathology program will still need high step scores, lots of research, and everything else that makes them a strong applicant.
Medical students best suited for pathology are science-focused who don’t mind skipping out on patient care. They tend to be detail-oriented, enjoy working independently and, unlike perhaps most medical students, actually enjoy histology.
Subspecialties within Pathology
Because pathology is such a broad field, most pathologists choose to subspecialize after residency and complete fellowship training. Subspecialties within pathology can be broken down into anatomical pathology subspecialties and clinical pathology subspecialties. They can also be further broken down into American Board of Pathology-Certified and Non-American Board of Pathology Certified.
Anatomical Pathology Subspecialties
Let’s start with anatomical pathology subspecialties.
Dermatopathology is a 1-year fellowship that provides additional training in the diagnosis of disorders of the skin. This is one of the most sought after pathology subspecialties as, like dermatology, it is known for having high compensation and a hard-to-beat lifestyle. That being said, it is also one of the most competitive fellowships to get into as there are two pathways to becoming a dermatopathologist – one involves completing pathology residency and the other dermatology residency. So not only are you competing against fellow pathologists for fellowship spots, but also dermatologists, who tend to be very competitive applicants, as well.
Cytopathology is a 1-year fellowship that provides additional training in the interpretation of fine needle aspiration biopsies, or FNAs, endoscopic ultrasound biopsies, pap smears, pleural and peritoneal fluids, and bile duct and bronchial brushings. It should be noted that this is one of the few pathology specialties where the pathologist is trained to perform procedures – specifically superficial fine needle aspirations, or FNAs. That being said, the majority of FNAs are still done by radiology.
Gastrointestinal pathology is a 1-year fellowship that provides additional training in diagnostic surgical pathology with an emphasis on gastrointestinal, liver, gallbladder, and pancreas pathology. It should be noted that this is also one of the most common anatomic pathology fellowships.
Forensic Pathology is a 1-year fellowship that provides additional training in determining the cause and manner of death. Forensic pathologists are specifically trained to perform autopsies, investigate information relating to manner of death, collect medical evidence, and reconstruct how a person received injuries. To do this, they are trained extensively to have working knowledge of toxicology, firearms examination, trace evidence, forensic serology, and DNA technology.
Neuropathology is a 2-year fellowship that provides additional training in the diagnosis of diseases of the nervous system including the brain, spinal cord, peripheral nervous system, and skeletal muscle. Much of a neuropathologist’s time is spent examining tissue samples to diagnose tumors, inflammatory disorders, and infections of the nervous system; however, many are heavily involved in research as well. Of note, there are a few five-year combined anatomic pathology and neuropathology residency programs that exist as well; however, they are less common.
Pediatric Pathology is a 1-year fellowship that provides additional training in all aspects of pathology relating to the fetus, infant, and child. This subspecialty requires a strong foundation in general pathology and substantial understanding of normal growth and development as well as extensive knowledge of pediatric medicine.
There are also a number of other anatomic pathology fellowships including ophthalmic, head and neck, breast, thoracic, genitourinary, gynecologic, medical renal, bone and soft tissue, and general surgical pathology. In short, if there’s a medical specialty for it, there’s probably a pathology subspecialty that focuses on it as well.
Clinical Pathology Subspecialties
Next, let’s look at clinical pathology subspecialties.
Blood Bank and Transfusion Medicine is a 1-year fellowship that provides additional training in blood donor collection, blood antibody testing, transfusion practices, and therapeutic apheresis – the removal of a blood component and replacement with a healthy substitute. Blood bank and transfusion medicine pathologists often go on to serve in medical director roles in hospitals, community blood centers, or reference labs. Of note, pathology is not the only pathway to get into blood bank and transfusion medicine fellowship. Physicians who have completed residency training in internal medicine, pediatrics, and anesthesia, among others are also able to apply for these fellowships.
Clinical Chemistry is a 1-2 year fellowship that prepares pathologists for director of clinical chemistry laboratory positions. They receive additional training in instrument and test selection, test implementation, interpretation of results, familiarization with regulations and requirements governing laboratory accreditation, cost analysis, and personnel training.
Clinical Informatics is a 2-year fellowship that trains physicians to take on leadership roles in clinical informatics. This includes leading health information technology strategy and implementation projects, advancing the field’s knowledge base, and training the next generation of physicians. They also help innovate technologies such as computerized order entry, clinical decision support, digital workflows, and electronic medication administration and reconciliation, to name a few. This fellowship can also be entered from a variety of other specialties outside of pathology.
Hematopathology is a 1-2 year fellowship that provides additional training in the clinical and laboratory evaluation of blood, bone marrow, and lymph nodes. Hematopathologists are proficient in the diagnosis and classification of cancers of the blood as well as non-cancerous disease of the bone marrow, lymphoid tissues, and peripheral blood.
Medical Microbiology is a 1-year fellowship that provides pathologists and infectious disease specialists with additional training in the selection, validation, and interpretation of microbiology tests. Many medical microbiologists go on to serve as directors of clinical microbiology labs at academic health centers or public health departments.
Molecular Pathology is a 1-year fellowship that provides pathologists with additional training in molecular diagnostics and molecular genetics. This includes the diagnosis of malignant disease, inherited genetic disorders, infectious disease, neoplasia, and identity testing through the use of a wide spectrum of molecular, cytogenetic, and biochemical tests.
There are also a couple of Non-ABP certified fellowship options for clinical pathologists including immunology and coagulation.
What You’ll Love About Pathology
There’s a lot to love about pathology.
To start, pathology has one of the best lifestyles relative to other medical specialties. According to the AAMC, the average pathologist works about 47 hours per week and has low on-call responsibilities.
Even when you are on-call, there are few pathology emergencies that would drag you out of bed to evaluate a sample – the exceptions being prolymphocytic leukemia, overnight intraoperative frozen samples, and transplant evaluations. That being said, hours worked per week and on-call responsibilities will vary depending on a multitude of factors.
If you don’t enjoy hands-on patient care, you can take comfort knowing that there are very few instances where you will have to interact with patients as a pathologist. The exceptions to this are cytopathologists who perform their own FNAs and blood bank pathologists who perform apheresis procedures. Outside of these subspecialties, you will have very limited interaction with patients.
The work that pathologists do is often satisfying as well. There are few specialties where you get to give a definitive diagnosis and say for certain what a patient has. Radiologists may look at a film and say “this thing looks like this”; however, a pathologist can often look at a slide and say “this thing is this.”
If you enjoy solving puzzles and looking through all of the clues to find the culprit, pathologists do this on a tissue level day-in and day-out. Sometimes they look at a sample and recognize it immediately, other times they have to perform a variety of tests on the sample and consult with other pathologists to determine what exactly it is.
Lastly, love it or hate it, there are a lot of opportunities to perform research as a pathologist – especially at academic institutions. There are so many different subspecialties within pathology that you can carve out your own niche and focus on what truly interests you.
That being said, if you hate research, you can always go into private practice or community pathology and avoid it altogether.
What You Won’t Love About Pathology
While pathology is an awesome specialty, it’s not for everyone.
To start, pathology is at the lower end of average in terms of physician compensation. According to the 2021 Medscape Physician Compensation report, the average pathologist makes around $316,000 per year; however, this will vary depending on a multitude of factors.
For instance, starting salaries for pathologists working in academia vary from around $170,000 to $240,000; however, they will increase as you progress from assistant professor, to associate professor, and then professor.
Pathology is also often misunderstood as a specialty. Most people – including other physicians – don’t understand the full scope of what a pathologist actually does. As a result, it can often be a thankless job. If you want to go into medicine for the glory, you are probably better off looking elsewhere.
Pathology also offers little continuity of care. You diagnose the patient and move on. If you enjoy making decisions and following through with them, you will likely not enjoy being a pathologist.
With advancements in artificial intelligence and machine learning, the field of pathology also has the potential to change significantly in the coming years. Although computers and algorithms are unlikely to replace pathologists in our lifetime, it is likely that they will change the way that pathologists work – and nobody knows what the downstream effects will be. If you are not flexible and willing to adapt as new technologies become available, you may want to look elsewhere.
Lastly, some pathologists end up regretting going into pathology because they miss the patient care aspect of being a physician. If you enjoy seeing patients and want to interact with them regularly, pathology is likely not the best fit.
Should You Become a Pathologist?
How can you decide if pathology is right for you?
If you enjoy solving puzzles, pathology gives you the opportunity to be a medical detective and use a variety of tools, tests, and stains to work through complex diagnoses.
You should be the type of person who doesn’t chase glory, and instead derives their satisfaction from helping patients receive a correct and definitive diagnosis.
You should also be the type of person that is not easily grossed out as a big part of pathology residency involves processing specimens from OR, performing autopsies, and exposing yourself to the full spectrum of bodily fluids. If you have a weak stomach, you probably won’t enjoy this field.
If you have broad interests, pathology also offers a variety of different career opportunities. As a forensic pathologist, you will spend most of your time doing autopsies and death certificates. As a cytopathologist, you will be interacting with patients, doing FNAs, and examining fluid specimens. As a surgical pathologist, you will be working closely with the surgeon to ensure clear margins and help determine the appropriate treatment plan. Depending on which subspecialty you pursue, your day-to-day responsibilities can vary significantly.
And if you prioritize work-life balance, the lifestyle of a pathologist won’t make you choose between family and work.
Are you hoping to become a pathologist? To get into medical school and match into pathology, you’ll need to score well on your class tests and standardized exams. As you look at experts to work with, seek out those who are actual MD physicians. Be wary of PhDs that mislead you into thinking they went to medical school. But even then, not all MD’s are equally qualified.
Look for those who didn’t just earn their MD, but crushed their MCAT and USMLE, gained multiple top medical school acceptances, matched into competitive residencies, and even had medical schools fighting over them by throwing merit based scholarships to sway their decision. Only the top performers can best show you how to most effectively improve your own performance.
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