Dissecting Brain from Brawn

When it comes to choosing a medical specialty, there is a distinct conflict between personal interest and societal bias. The question of specialty selection touches every part of a medical student’s life: feelings of personal accomplishment and fit; emotions like pride, guilt, and remorse; time frames for training and planning for a family; and the seldom-voiced – but palpably sensed – desire for a distinct earning potential, a specific working lifestyle, and the perception of power and influence. Medical students’ biases toward popular specialties may remain deeply rooted because popular culture tends to define physicians by these latter influences. Many students enter training with an idealized version of their future selves as mighty surgeons or distinguished clinicians, respected and praised by their patients. (They don’t realize at that point that life as a doctor is less Grey’s Anatomy and more Scrubs!) Few students, however, arrive at medical school with the distinct goal of becoming a pathologist, let alone with a full appreciation of what those within our specialty do. Even fewer come with views of pathologists as “powerful,” “influential,” or – dare we say – “sexy.”

A first-hand experience

When Austin McHenry entered medical school in the fall of 2015, he understood the uniqueness of pathology better than the rest of his class; he had already spent a gap year working for a shared research biobanking facility within a large university hospital. The facility used many of the same resources as the university’s pathology department, and the quality and number of specimens received for research depended entirely on what the pathologists could afford to part with after diagnostic requirements were met. Although pathologists performed most of the groundwork for the research, non-pathologist physicians and non-physician researchers were also heavily involved. All projects required a group discussion – in person – to decide exactly what services were being requested by the research teams. And these meetings afforded Austin the rare opportunity to gauge other professionals’ understanding of pathology. It became increasingly clear to him that most researchers did not fully understand what they were actually requesting when they asked to collect tissue in a designated orientation, isolate a specific cell type by one method and not another, or extract DNA from certain specimens and not others. Often, the meetings would consist of the pathologist explaining to the researcher a better way to obtain the data he or she sought. The combination of witnessing pathologists’ diagnostic processes under the microscope and hearing firsthand the kinds of questions they were interested in investigating sparked his own interest in the field. And although he’s still ashamed to admit it, Austin would likely never have forged this interest if not for his gap year experiences.

Pathology for the patient

The inescapable question arising from Austin’s experience is how other medical students with the same cerebral inclinations and desire for deeper understanding of disease and diagnostic approaches can possibly make an informed choice about pathology – one based not on societal biases, but on personal interests. How do we help students discover that they are interested in pathology before they commit themselves to a field less suited to their inclinations? Because ill-informed bias continues to drive talented medical students toward popular specialties, we believe we must make a greater effort to prevent individuals with a true personal interest in pathology from slipping through the preclinical years without proper exposure. Pathologists should be aggressive in their early outreach efforts. How? By combating the “no patient interaction” argument head-on instead of fleeing from it; by challenging students to think more deeply about the differing roles of surgeon and pathologist in the care of a patient; and by highlighting the uniquely cerebral and definitive aspects of pathology not found in other specialties – the diagnosis and understanding of disease.

Whether with medical school colleagues or at post-fellowship social events, when we mention our interest in pathology, we frequently hear others’ qualms about giving up patient interaction – usually garnished with a sprinkling of other gross (no pun intended) misperceptions. Although the social aspects of the patient interaction argument seem justifiable, we believe it exaggerates the profundity of most physician-patient encounters. Unfortunately, we have arrived at a time in medicine where productivity is measured in the numbers of patients seen each day. When the average acute visit is 15 minutes long, a physician’s day becomes much more about getting through each patient on time than about giving the right amount of face time to each individual. More often than not, the physician spends considerable effort steering the conversation toward only those problems they are willing to address. Physicians are notorious for interrupting patients – in one well-known study (1), patients were allowed to complete their opening statement of concerns in its entirety in only 23 percent of physician interviews. What is more, the average time to interruption was 18 seconds! There is no longer space for the kind of reflective silence that is integral to any other normal conversation. Although it is admirable to say that one should value patient interaction, it is a goal less congruent with modern medicine than with many other lines of work. Similarly, the frequent, incisive counter that pathologists – especially those in academic settings – spend their days in lonesome silence is far removed from reality.

Like any other field of medicine, pathology is a discipline that requires a large staff to move patients in and out the door. In our case, although we see but parts of the whole, our patients are no less real and important to us. To say that the experience of examining a person’s flesh under a microscope holds the same amount of meaning as examining any other inanimate object is not only wildly false, but also fails to grasp the seriousness of this responsibility. There exists a tangible sense of intimacy in holding a patient delicately between two panes of glass in your hand, knowing that your observations have consequence. Isn’t this a form of patient interaction? The experience of discovering, on histology, a cancerous finding in an otherwise unsuspecting patient harbors the same gravity as physically palpating an unsuspected mass in an exam room.

Power and influence

In the same way that the outpatient argument hinges on patient interaction, so too does the inpatient defense focus on feelings of close proximity to disease itself. Many students of science are drawn to medicine because they want to be as intimately involved as possible in the ailments they study. They thrive on taking care of those who are the most sick and, as a result, may have a tendency to perceive the fields of surgery and oncology to be of greatest authority. Students should not be faulted for wanting to succeed; however, these perceptions of greatness are not always an accurate reflection of “power” or “influence.” The offices of surgeons are often brimming with “thank-you” edibles and holiday appreciation gifts. That the same cannot be said of pathologists is largely a product of how society understands medicine – after all, surely it was the clinician, or perhaps the surgeon, who diagnosed your mother’s diffuse large B cell lymphoma.

The appreciation of the more “visible” doctors is understandable, but it would be unwise to delude oneself into believing this opinion should be shared by those within the field of medicine. Anecdotally, we find that a significant number of students who switch from general surgery to pathology (yes – it does happen on occasion!) were misled into thinking that the surgeon makes the diagnosis. The pathologist in the laboratory was never a consideration. Once they enter the field and find that what they truly wanted was the cerebral stimulation of the differential and the responsibility of the final diagnosis – that’s when they realize that they need to separate brain from brawn.

Think of the mighty surgeon requesting a second opinion on an initial ovarian mass biopsy reported as a fibroma. Because this diagnosis is inconsistent with the patient’s elevated serum tumor marker (which suggests dysgerminoma, a true malignancy), the otherwise intimidating and powerful surgeon’s mind remains occupied all day by a question unanswerable in her chosen specialty.

Visualize one of the highest-paid surgeons in a medical center whose procedure is reduced to stillness as the team waits for the examination of frozen surveyed lymph nodes. It is in moments like these, when the surgeon stands motionless, hands resting on top of the patient, that notions of “power” and “influence” seem utterly reversed.

The savvy medical student will quickly learn the true value of the pathology report to the surgeon, the medical oncologist, the radiation oncologist, and – most importantly – the patients themselves. Information provided by the pathologist’s examination of a simple biopsy can mean the difference between additional surgeries and going home. It can mean the difference between years of close follow-up and no follow-up at all. Thus, one might argue to the student that it is, in fact, the pathologist who holds the “power” and “influence.” But because no sane pathologist would utter a statement so conceited, the student may never truly receive this perspective without some external suggestion early in training. Power and influence are outdated remnants that our popular culture has long projected onto medicine. They are archaic, unneeded components that future generations of doctors and patients will not recognize.

What is a pathologist?

When reviewing applications for entry into Loyola University Chicago Stritch School of Medicine’s combined anatomic pathology/clinical pathology (AP/CP) program, Kamran Mirza looks for pathology experiences. Although many medical students are beginning to recognize the positives of a pathology career (hours, lack of call, income potential, job security), far too often, they use a pathology application as a “backup” when their specialty of choice is highly competitive or their board scores are low. These applications become obvious immediately in their choice of recommendation letters, and even more so in their personal statements. In contrast, some students are true “pathophiles” with their fingers on the pulse of pathology as a life beyond Robbins, Pathoma and MS2. The pictures their words paint in their personal statements are amazing: “The pathologist is the trunk of a tree where research is the roots and clinical specialties the foliage.” How brilliant is that? “The pathologist is the conductor of an orchestra controlling and facing the musicians with their back to the audience…” And our personal favorite: “The pathologist is the director of a play; the audience sees the actors, but the director, behind the scenes, controls what they do.”

What is it that sets these medical students apart from the hundreds of others who never understood what the choice of pathology truly meant – and yet excluded it just the same? The answer: preclinical exposure to real-world pathology.

The crux of the argument for pathology must focus not on defense of its criticisms, but rather on excitement about its uncommon advantages. Pathology is a uniquely cerebral discipline within medicine. Austin had the chance to scrub in on an ambulatory surgery case to perform a wide local excision of a high-grade squamous vulvar intraepithelial neoplasia (VIN) lesion. Before the procedure, he sat with the surgical PGY2 trainee, who was frustratedly flipping through a pocket gynecology/oncology handbook to find information about VIN. Austin suggested she try looking in the cervical intraepithelial neoplasia section. She retorted that it would be fruitless because they are “completely different diseases.” She may, of course, have meant that the two lesions are treated differently – but these pre-cancers have identical pathophysiology. To state that they are different is not to understand what and where the squamous epithelium is; it is to ignore the one neoplasm for which we can identify with certainty an etiological origin. Austin realized in that moment that a surgeon does not need to understand the pathophysiology of a symptomatic mass to surgically remove it…

Pathologists are lucky; we have the freedom to allow our minds to fully develop the questions other physicians cannot. Where other fields accept poor answers, we aim for the definitive. We occupy ourselves with the goal of the truest understanding of why our bodies function the way they do, and how they can become dysregulated and disease-ridden. As a medical oncologist, one may not need to understand in intricate detail the histomorphologic, phenotypic, or molecular underpinnings of why a specific drug is approved to treat small-cell lung cancer and not adenocarcinomas to prescribe it. The oncologist’s mind may instead be appropriately occupied by clinical intricacies, such as whether or not an insurance provider will cover the cost of the drug, or whether it can be properly administered to the patient. Similarly, a clinician need not understand the function of alpha-fetoprotein (AFP) to know that its elevation is associated with yolk sac tumors. It is pathologists who allow themselves to be fascinated by the mechanism of AFP production; to wonder why it is that AFP is also associated with developmental birth defects, hepatocellular carcinomas, ataxia telangiectasia, and so on. In the same way, we afford ourselves the ability to appreciate that every cancer is different. We task ourselves with discovering what those differences are. We are at liberty to go beyond algorithms and guidelines. The individualized cellular morphology of each organ in the human body can, at times, seem to transcend our ability to comprehend it. Nonetheless, we do understand it, and we have the capacity to continue to learn more about it. To physically visualize disease at its most basic, yet simultaneously complex level, is to experience the true awe of human pathology.

Active engagement

To ensure that these arguments do not fall on deaf ears, pathologists must learn to engage with medical students. In places where such engagement already exists, it needs to improve – to start chipping away at the gross misperceptions of our careers and the personalities others assume we all have. For change to occur, we will truly need to be “out there” in as many ways as possible. Academic pathologists must be more visible – which means actively cultivating their own online presences. We are at a point when social media outreach is not only acceptable in academia and the workforce, but expected. Like it or not, Twitter and Facebook are active forums where pathologists communicate with one another. Exciting cases are discussed, educational opportunities are announced, journal articles are shared, and extracurricular pathology events are advertised. Medical students must be made aware of this community! In the same way, pathology student interest groups need robust institutional involvement and departmental support.

At Loyola University Chicago Stritch School of Medicine, we have witnessed what is possible with just limited resources. Our pathology interest group, Students Curious in Outrageous Pathology Experiences (SCOPE), had slowly dwindled out of existence over a few years’ time, eventually losing status as a student organization formally recognized by the institution. With the enthusiastic oversight and guidance of only a few individuals, we have – in just two short years – become a powerful voice for pathology among our medical students. As well as having recruited a robust group of core supporters, we have organized several events to give preclinical students exposure to the field, including laboratory tours, histology reviews, histopathology workshops, mini-symposia, autopsy observations, transplantation lectures, and even community exhibitions of pathology art. Perhaps most importantly, we organize introductory meetings called, “What is Pathology?” intended for, and led by, medical students. Our data (see Figure 1) suggest these short introductions help students form more informed opinions about the specialty. Since instituting them, applications for our pathology elective clerkship have increased over 500 percent, with month after month of at-capacity students and increasing rejections.

Because societal bias continues to drive talented students toward medicine’s most popular specialties, we must make heightened efforts to prevent individuals with a true, personal interest in pathology from slipping through the cracks. Pathologists should be aggressive in their early outreach efforts by countering the patient interaction argument, challenging students to think deeper about the differing roles of surgeons and pathologists in patient care, and highlighting the uniquely cerebral aspect of understanding and discovery not found in other specialties.

The conflict between interest and bias requires the observer to challenge their understanding of choice itself. A student may become a surgeon, her choice of career resting on the assumption that she is the conscious source of her thoughts and actions, and that her experience of wanting to do surgery is what has caused her to select surgery as a specialty. But external influence is ubiquitous in and outside of medicine. If one has never heard of the ruins of Angkor Wat, how could one possibly make a decision about traveling to Cambodia to see them? Similarly, if our student never really knew what pathologists do, how could she possibly have made the decision not to pursue pathology? In reality, we are not talking about dozens of students a year, but only a few. In each graduating medical school class, there can be no more than one or two students who pursue pathology, because – of course – residency spots are limited. More importantly, the aim should not be to increase this number; rather, we must make sure that, when ruling out pathology, all students are making an informed decision rather than acting on preconceived notions. Our wills are a combination of chance and determinism; they arrive from both coincidence and a long sequence of prior causes. It is our collective responsibility to prevent students passionate about discovery and understanding from making uninformed decisions just because they were unlucky enough not to be exposed to our amazing field. Understanding this truth matters, and it should change the way we view medical specialty choice.

Austin McHenry is a medical student and Past President of SCOPE at Loyola University Chicago Stritch School of Medicine. Follow him on Twitter @AustinMcHenry.
Kamran Mirza is Assistant Professor of Pathology and Laboratory Medicine and SCOPE faculty liaison at Loyola University Chicago Stritch School of Medicine, Maywood, USA. Follow him on Twitter @kmirza.