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.

Dr. Jubbal, MedSchoolInsiders.com

Welcome to our next installment in So You Want to Be.

In this series, we highlight a specific specialty within medicine, such as pathology, and help

you decide if it’s a good fit for you.

You can find the other specialties on our So You Want to Be playlist.

If you have a specific specialty you want covered, be sure to vote in our upcoming polls,

and to do that you’ll need to be subscribed.

If you’d like to see what being a pathologist looks like, check out my second channel, Kevin

Jubbal, M.D., where we'll be covering a day in the life of a pathologist in the future.

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 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.

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, or 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.

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 as well.

This will depend on the pathologist’s individual strengths and weaknesses and what they feel

comfortable with.

When pathologists receive difficult samples, 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 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.

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

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.

It is often said that “a pathologist’s diagnostic skills are only as good as their

ability to communicate them effectively.”

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 technologies, 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.

That being said, it is possible that AI will be used as a tool to increase pathologists’

efficiency to the point that we experience decreases in demand for pathologists; however,

only time will tell what the true impact of AI on the field of pathology will be.

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.

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 with more time to study for boards.

It should be noted, however, that some programs 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 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.

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, as we’ve discussed before on this channel, 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 and don’t mind skipping

out on patient care.

They tend to be more detail-oriented, enjoy working independently, and, unlike perhaps

most medical students, actually like histology.

Because pathology is such a broad field, most pathologists choose to subspecialize after

residency by completing fellowship training.

Subspecialties within pathology can be broken down into anatomical and clinical.

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 you

are not only competing against fellow pathologists for a spot but also dermatologists, who tend

to be very competitive applicants.

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.

Cytopathology is also one of the few pathology specialties where pathologists are trained

to perform procedures - specifically superficial FNAs.

That being said, the majority of FNAs are still performed by the radiologist.

There are a number of other anatomic pathology fellowships including pediatric, forensic,

ophthalmic, head and neck, breast, thoracic, gastrointestinal, 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.

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 a blood bank and transfusion medicine

fellowship.

Physicians who have completed residency in internal medicine, pediatrics, and anesthesia,

among others are also able to apply for these fellowships.

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.

There are also a number of other clinical pathology subspecialties including clinical

chemistry, clinical informatics, medical microbiology, molecular, immunology, and coagulation pathology.

To learn more about these different subspecialties within pathology that we couldn’t cover

in this video, be sure to check out our So You Want to Be a Pathologist blog post on

MedSchoolInsiders.com - link in the description.

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 multiple factors.

If you don’t enjoy hands-on patient care, you can also take comfort in knowing that

there are 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 and cellular 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.

While pathology is an awesome specialty, it’s not for everyone.

To start, pathology is in the middle of all specialties in terms of physician compensation.

According to the 2022 Medscape Physician Compensation Report, the average pathologist makes around

$334,000 per year.

Pathology is also often misunderstood as a specialty.

Most people – including other physicians – don’t really understand the full scope

of what a pathologist 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.