Dr. Strangelab...

Do you remember when you first made the decision to pursue a career in pathology? More to the point, do you remember the feedback you received from your peers and supervisors? Did they “approve” of your decision – or was it a “waste of your outgoing personality?” Were you accused of lacking an interest in patient care? All of these attitudes and more combine to discourage today’s medical students from considering one of the noblest fields of medicine. And that’s why a group of medical students, residents, and attending physicians with a shared interest in pathology got together to discuss the obstacles that stood in their paths, their colleagues’ impressions of the discipline, and what can be done to encourage future students to consider pathology.

The students

Lacey Durham is a fourth-year medical student at Texas A&M University, College Station, Texas.

Christopher Felicelli is a fourth-year medical student at Loyola University, Chicago, Illinois.

Lily Mahler is a third-year medical student at the University of Alabama, Birmingham, Alabama.

Ellie Pernicone is a third-year medical student at the University of Central Florida, Orlando, Florida.

Ashley Scholl is a third-year medical student at West Virginia University, Morgantown, West Virginia.

Mel Toeller-DeSimone is a fourth-year medical student at the University of Wisconsin, Madison, Wisconsin.

The facilitators

Adam L. Booth is a fourth-year AP/CP resident at the University of Texas Medical Branch, Galveston, Texas, and a 2020–21 gastrointestinal and liver pathology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Patrick Godbey is President of the College of American Pathologists and Founder and Laboratory Director at Southeastern Pathology Associates, Brunswick, Georgia, USA.

Jennifer Laudadio is Associate Professor of Pathology and Service Line Medical Director at the University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Anne Champeaux is Professor and Chair of the Department of Pathology and Cell Biology at the University of South Florida, Tampa, Florida, USA.

Christina Wojewoda is a pathologist and Associate Professor of Pathology at the University of Vermont Medical Center, Burlington, Vermont, USA.

Scott Anderson is Professor of Pathology and Director of Cytopathology and of the Pathology Residency Program at the University of Vermont Larner College of Medicine, Burlington, Vermont, USA.

Emily Volk is President-Elect of the College of American Pathologists and Assistant Professor of Pathology at the University of Texas, San Antonio, Texas, USA.

Kamran Mirza is Assistant Professor of Pathology and Laboratory Medicine and Medical Education at Loyola University Stritch School of Medicine, Maywood, Illinois, USA.

Yonah Ziemba is a third-year AP/CP resident at Northwell Health, New Hyde Park, New York, USA.

Mariam Molani is a third-year AP/CP resident at the the University of Texas Southwestern, Dallas, Texas, USA, and the founder and CEO of LibraMed, LLC.

What piqued your interest in pathology?

Lacey Durham: Since I was 17 years old, I had planned to go into pediatrics. About six months ago, I accidentally clicked on pathology – and when I got my schedule, I thought, “What is AP/CP?” I decided to go with it and, after one day, I realized that I had had no idea how much pathologists do. I got online and started looking up pathology, but the only information I could find was for speech pathology.

I speak passionately about pathologists on Twitter because I couldn’t find much information when I looked – and what I did find was all negative; everything I read said, “Don’t go into pathology.” And if I hadn’t met pathologists and their patients in real life, I might have believed it. I think it is important that we continue to promote pathology on Twitter because I can get to know my colleagues and learn from them. All I want is more pathology online, and it’s nowhere to be found – so I’m grateful to everyone who tweets cases and posts tutorials. It’s my informal education.

Lily Mahler: During my first year of medical school, we had a “fundamentals block” of basic science classes in the first six months, which included a crash course in pathology. The lectures were interesting and full of good information, so I was intrigued – and then we had a resident-run session in the pathology lab with a bucket of specimens for us to pick up, look at, and learn about. The resident who taught it was really funny and down-to-earth and understood that this was all new to us. At that point, we had no idea what pathologists did, but I was interested enough to shadow some pathologists, talk to a lot of residents, and start considering a future in pathology.

Ashley Scholl: I knew I wanted to be a pathologist because of my interest in forensics. After my second year of medical school, I did a one-year post-sophomore fellowship in pathology and loved it.

Ellie Pernicone: After graduating from university and before starting med school, I got a job in a research laboratory at Beth Israel Deaconess Medical Center. In that job, I got to work with a lot of pathologists and I discovered that they were the best teachers. I also discovered that I really liked the process of research. Pathology is valuable because, without it, you don’t know how to treat patients – and I think that is fascinating.

Chris Felicelli: I came from a basic science research background, so it seemed a good fit to continue along with pathology. I don’t have a long story – it just happens to be super interesting to me, so I’m choosing to pursue it.

Mel Toeller-Desimone: I got interested in pathology through the Chief Medical Examiner of Milwaukee County, who inspired me to continue.

What do your medical school colleagues say when you express your interest in pathology?

Durham: They mimic the same things they read on the Student Doctor Network forums. They tell me, “Oh yeah, I thought about pathology, but the job market is so bad.”

Booth: We know, of course, that that’s not true. We have studies and data showing that, in fact, the job market is quite good – and we’re trying to make sure that accurate information is available online so that people who might be interested in pathology can inform themselves about it.

Mahler: My classmates usually start laughing and say things like, “Really? Pathology? That’s kind of weird, isn’t it?” I tell them no. The people I’ve met in pathology – all of the residents and faculty in my program – are the nicest, kindest, most laid-back people I know. I feel like I match really well with the people I’ve met. Unfortunately, I think people have this preconceived notion that we’re messing with dead bodies all day and only a weirdo would do that – but either they haven’t met anybody in the field, or the people they’ve met are older and less engaged with students.

Scholl: I think a lot of people think that pathologists spend their days sneaking around coffins. People are confused when I tell them I’m interested in pathology, because they don’t know what the profession really does.

Toeller-DeSimone: I’ve never hidden my interest in pathology. I have always been upfront about it, but I have seen people dismiss me when I say I’m interested in pathology. For instance, there was a surgical procedure during my nephrology rotation that involved a biopsy – so it was related to pathology – and they said, “You’re going into pathology, so I guess this isn’t a problem for you.” They excluded me from things in which other students were included. I had to say, “This isn’t a pathology rotation; this is a nephrology rotation and I would like to be treated like any other student in nephrology.” And it’s not just the one experience – I’ve had that multiple times in most departments, even though they rely on pathology.

Pernicone: When I tell people I’m interested in pathology, I usually get some expression of distaste. “You do know what pathologists actually do, don’t you?”

Felicelli: It seems a lot of the responses are, “Didn’t you go into med school to interact with patients and to have physician/patient relationships?” I don’t entirely understand it. The same can be said to those who go into diagnostic radiology – they have as much or as little of a physician/patient relationship as we do – but they don’t get that pushback…

Booth: And we don’t even sit in dark rooms!

What insights can the attendings share from their own experiences?

Emily Volk: What I loved about pathology was that they had all the answers. I remember Plato’s allegory of the cave; the people in the cave look at the shadows and think that’s the truth – and those outside it can turn around and see that the shadows are made by the sunlight and that they are only representations of reality. I feel like pathologists are the enlightened ones in medicine in that we have the privilege to look disease in the eye every day. Other doctors see the symptoms; we see the cancer itself – not a shadow, not a concept, but a disease that is exposed to our scrutiny.

As a Senior Vice President for a large hospital system, I can tell you that pathologists are really well-suited to taking on leadership roles in healthcare. Because we interact with so many different parts of the hospital, we understand how they all work together. Pathology has offered me a career that has been fascinating and surprising, and I’m excited to see these medical students interested in pathology.

Patrick Godbey: It took me far too long to get into pathology. I’m an obstetrician/gynecologist by training, and when I started work – at a private practice with two great partners – the senior partner said, “We just do what the pathologist tells us. If the pathologist tells us to take it out, we take it out. If the pathologist tells us to bring the patient back, we bring them back.” After a few years, I decided that I wanted to be the one telling people what to do! So I went back for an AP/CP residency, which took me four years, and then I returned to the same small town where I had practiced as an OB/GYN and became a general pathologist at the same practice.

I think the future of pathology is extremely bright. I think today’s medical students are going to have all kinds of opportunities in the field, because there’s an increasing shortage of pathologists and plenty for us to do. In fact, my daughter just finished her AP/CP residency and fellowship a year ago. If I didn’t think our specialty had a promising future, I would have discouraged her from going into pathology – but I’m not sure I could have kept her out of it. It’s such a great time to enter the field.

Anne Champeaux: When I was a kid, there was a show on TV – Quincy, M.E. He was a medical examiner with a sidekick, Sam, and I couldn’t decide at the time which one of them I wanted to be. But from a very early age, I wanted to be a “lab doctor.” I started actually working in a pathology lab when I was 14, so I never strayed from my path – I went to college, then to medical school, and shut out any negative comments. I’m definitely happy with my decisions, but I’m still not sure whether I’m Quincy or Sam!

Christina Wojewoda: My mom was a medical technologist growing up, so I became familiar with lab medicine early on and spent my summers working at the College of American Pathologists. Naturally, when I went to medical school, I wanted to pursue either infectious disease or pathology – and I quickly found out that pathologists are the ones with the answers. The lab tells infectious disease what the organism is and how to treat it, and that’s perfect for me. I like to know things first!

I think exposure is key. Unless people are shown what pathology is – whether via television or a parent or a good experience with a pathologist – then they simply won’t know. How can they consider entering a discipline they don’t understand? Of course, like everyone else, I had people tell me that I was too outgoing to be a pathologist but I just said, “No, I’m the fun one that you’re going to come to for all your answers.” I shut down the negative stereotypes, helped people in the microbiology lab focus their microscopes, and never looked back.

Scott Anderson: My mom was a med-tech and my dad was a clinical chemist, so I must have the laboratory in my genes. Even so, when I went to medical school, I was not going to be a pathologist. I wanted a family practice in a rural setting, because I grew up in Los Angeles and never wanted to go back to the big city. But, as others have said, engagement is vitally important – and my medical school had some incredibly strong pathologists and a strong pathology course with excellent instructors. Although I was still uncertain, I decided to do the pathology department’s year-long student fellowship – and it didn’t take long for me to realize that this was where I wanted to be.

Even though I had made my decision, I still did a clinical intern year as well. I found it interesting because it flipped the narrative – now, I had pathologists telling me not to waste my time with a clinical internship! That year was a valuable experience and one of the better years of my training… but, in the end, I was in love with pathology.

Kamran Mirza: Now that I’m in a role where I can guide people toward pathology, I think that this conversation is highlighting the problems we have right now. There is no exposure; there is no pathology champion; you don’t have a visual for “the pathologist.” Our course is run by a fantastic educator who did a residency in pathology and then went into internal medicine. In my eyes, that makes her the perfect person to run a combined course – but, when others see her, they see someone who gave up pathology and is now a clinician. That doesn’t do our discipline any favors.

We don’t need hundreds of students going into pathology, but I would like everyone to have it on their list. If it’s on their list and they decide not to pursue it? No problem – but that’s an informed decision. Right now, most students don’t even take pathology into consideration. I know I didn’t. I went into medical school thinking that my options were OB/GYN, psychiatry, surgery, or medicine. We need to work together to get pathology on that list, so that students have the opportunity to explore it and decide for themselves whether or not they’re interested.

Jennifer Laudadio: During my second year of medical school, we had a traditional pathology course in which we attended lectures and read Robbins, but we also had small group study in which we were literally given a pot of organs. We called them “pot cases” and they came with slides and a little case history. Two of us would work the case up and present our findings to the other team members like an autopsy conference. I loved that. I loved learning about why people got sick and what it did to their bodies. I wanted to read Robbins, not clinical diagnostic books. I wanted to be in pathology, not internal medicine.

How can we best represent our discipline?

Yonah Ziemba: I finished medical school two years ago and went through the same challenges as you. Now, two years into my residency, I think I’ve found a few areas in my little world that could help other disciplines understand our field.

One is frozen section. We get a lot of third- and fourth-year medical students who come in on frozen section. As residents, we’re under pressure to satisfy our attendings before we can focus on the medical students, but I keep reminding myself that, if I engage the medical students and show them a few interesting things – if they see that the lab is not just a “black box” – then that could make a huge difference in their perception of pathology.

I also try to be very sensitive with my terminology. My father is an experienced doctor of internal medicine, but he has no idea what I mean when I say “a cassette” or “I’m going to sign out.” When I talk to people outside the pathology department, I’m very careful about the words I use. If the word “grossing” doesn’t appear in the dictionary, then I won’t use it; I won’t say “accession number,” I’ll say “report number” or whatever it takes to communicate with them in a shared language.

Finally, when I’m on blood bank and receive a question from an intern or resident, I’m very careful to be engaging and helpful. Sometimes, interns on overnight call don’t know the guidelines for each product and it might be easier to just handle things on my own without explaining to them. But, if I explain to them why the situation calls for a particular response, I’m winning them over and proving that pathology is a helpful resource. Sure, it might be three o’clock in the morning and not the time that I would have chosen for this, but it’s worth it.

Booth: My wife is currently a gastroenterology fellow, when she was completing her internal medicine residency, colleagues would look at her in surprise and ask, “How did you know that? How did you find that out?” She says, “I just called the lab and spoke to the pathologist.” People thought she had some kind of secret insider information – but no; she just knows what pathologists do and when to ask for our help. That’s one thing anybody can do: encourage people to call the pathologist.

How can we reach more students?

Booth: We need to communicate the diversity of what we have to offer, too. If a medical student has a keen interest in computer science, for instance, informatics could be a great choice for them – and it would still allow them to be a doctor and help patients. If we can show students all of the different things the laboratory does – we’re more than just autopsies! – they can make an informed decision about pursuing pathology.

Mariam Molani: I agree that it’s helpful to show them how broad our field is. Even my best friends have no idea that I do transfusion medicine. My husband works in the ER right now and he’s ordering stuff that has been triaged through me, but his colleagues have no idea. They don’t even realize that we have patient contact. Students think, “I want to do some patient care and I can’t do that as a pathologist.” I think we could pique more interest if we advertised our discipline better.

Volk: We are clinicians and we need to use the word “clinician.” I don’t know anybody named “lab,” but I do know doctors who work in the lab. We are laboratory medicine specialists, and I think we need to communicate that.

Booth: Actually, I say I’m a physician. When they ask me what kind, I say a pathologist. That way, it reinforces that a pathologist is a doctor.

Mirza: When I started as an attending, I never felt the need to introduce myself as doctor – but I’ve since realized that, in certain settings, it’s very important for people to know that I’m a physician. Medical students, for instance, need to understand that I started out where they are now, and that they could end up in my position someday.

Godbey: I think it’s important to emphasize pathology’s lifestyle benefits, too. I wanted to be a part of my daughter’s life and I could do that a lot better as a pathologist than I could as an OB/GYN.

Booth: I love pathology and I’d be doing it no matter what, but the lifestyle is an additional benefit. I don’t want to be a 65-year-old trauma surgeon working 30+ hours in a row; I want to be a pathologist who has work/life balance. And, speaking of work/life balance, I think that’s a great note on which to end the discussion.

Godbey: It has been special to see everyone, particularly the medical students, express and share their enthusiasm for pathology. Thank you, Dr. Booth, Chair of the CAP Residents Forum, for organizing this meeting.

Booth: I think we came up with some good ideas and identified some gaps to work on, so thank you to everyone for your contributions to the conversation. I’m also very grateful to the Association of Pathology Chairs for facilitating this impromptu meeting of medical students, residents, and pathology leadership. The opportunity for these students to share and discuss their experiences directly with leaders in the field was powerful and illuminating for everyone in the room.

Student Perspectives

Michael Schubert interviews Christopher Felicelli, Mel Toeller-DeSimone, Lily Mahler, and Lacey Durham

What is your current career stage – and what are your plans?

Felicelli: I am currently a fourth-year medical student applying to pathology residency this year.

Toeller-DeSimone: I am a fourth-year medical student. I plan to study anesthesia and pursue private practice in rural areas of the Midwest.

Mahler: I am currently a third-year medical student finishing my clinical rotations. I have decided to pursue pathology as my specialty of choice and plan to have a career in surgical or forensic pathology.

Durham: I am currently a fourth-year medical student. When I grow up, I want to be a pathologist! I am currently finishing up the interview trail and I’m looking forward to seeing where I match for residency. As far as subspecialties go, I’d say I’m still… “undifferentiated.” I know that I like pediatric pathology, neuropathology, and cytopathology, but I have not had enough exposure to other subspecialties to rule them out just yet. Lately, I’ve been thinking about bone and soft tissue pathology and forensics. But I also love the liver… And don’t get me started on microbiology…

What is your opinion of pathology?

Felicelli: Pathology is a fantastic field of medicine with a great work/life balance. It is for those who love to solve mysteries and don’t mind working behind the scenes. I did an AP/CP elective in my third year of medical school and knew it was the perfect fit for me.

Toeller-DeSimone: I love pathology; the idea of definitive diagnosis and the ability to give most patients and physicians important answers regarding their health. Pathology touches nearly every single patient, whereas most other specialties don’t have that opportunity. Although I did not choose pathology for my career, it was a very difficult decision.

Mahler: To me, pathology is one of the most interesting and dynamic fields in medicine. Pathology is critical to informing clinical guidelines, understanding mechanisms of disease, and practicing medicine. The problem-solving, detailed-oriented nature of the work appeals to me and the career options within pathology are diverse and rewarding. My opinion has been informed by the experiences of pathology attendings and residents I have met, along with my own experience in the pathology department of my program. The people I have met genuinely enjoy the work they do and are excited when students are interested in pursuing pathology, which to me speaks volumes on the merits of the field.

Durham: I think pathology is the best-kept secret in medicine! I am especially drawn to the investigative work a pathologist must perform to arrive at a final diagnosis. Making the correct diagnosis is vital to finding the appropriate treatment. I like that pathologists are the ones with the answers, often at the end of a challenging clinical workup. In pathology, there are “zebras” everywhere! The rare cases make each day challenging and exciting. As a proud millennial, I am especially intrigued by how high-tech and state-of-the-art the field is. There are so many cool machines in the lab! I also enjoy how collegial and welcoming pathologists are. Pathologists spend a lot of time reviewing challenging cases together and with other medical specialists. When physicians from different departments come to the lab with their crews of fellows and medical students, pathologists are always willing to teach and review slides with them. The wealth of teaching and learning is one of the major reasons I knew pathology was the right field for me.

Unfortunately for me, my robust opinions about pathology did not occur until my third year of medical school when I did a two-week elective in AP/CP pathology. Prior to that, I thought pathology was for doctors who did not want to interact with people. I thought a pathologist was what you became if you found no other interests in medical school. I was under the impression that all pathologists spent their days performing autopsies in the basement.

Like other medical schools, pathology was integrated into each system block during my pre-clerkship curriculum. My only exposure to pathology prior to my elective was during mandatory pathological-clinical correlate labs. During the lab sessions, my classmates and I would go over clinical vignettes with the physicians and review pathology slides together on our laptops. In other words, we would listen to the vignette, pretend to remember basic histology, and then agree with the pathologist that we were able to see whatever pink or purple dot was slightly darker or coarser or plumper than all of the others.

What do your peers think of pathology?

Felicelli: I think most people have a negative view of pathology, mainly stemming from learning about histology and pathophysiology in their second year of medical school. This is an extremely stressful year in medical school because the big USMLE Step 1 exam is looming over everyone’s head. As a result, students connect pathology with stress, leading to negative opinions.

Toeller-DeSimone: My peers think pathology is boring. They think staring down a microscope all day long is not exciting, and that you have to have a shy or bland personality to be a good pathologist. (Of course, we know that is not the case!)

In my opinion, their feelings result from a lack of exposure to pathology practice. They don’t understand the diverse areas within pathology (histology, laboratory medicine, cytology, forensics, and so on). Also, other physicians don’t help the matter by “specialty-bashing” pathologists, especially when they themselves don’t have a strong understanding of what pathologists do.

Mahler: My peers’ opinions on pathology are mixed – and most have little exposure to the discipline. Some people find it confusing and boring, whereas others enjoy pathology and like its problem-solving nature. Many don’t know what a pathologist does on day-to-day basis or are dissuaded by the mistaken belief that pathologists have little interaction with patients.

Durham: I was quite surprised with many of my friends’ responses when I told them I was interested in pathology. I’ll never forget how a close friend of mine, concerned for my well-being, strongly advised me to consider another specialty because he believed pathology was a doomed career choice with a horrible job outlook. He mentioned that he had briefly considered going into pathology himself, but then learned online that you had to do multiple fellowships to be hirable and that digital pathology and machine learning would make pathology obsolete. I’ve had countless conversations with classmates about what pathology actually is. I think many people are as surprised as I was when I tell them that most pathologists don’t do autopsies in the basement all day. They are even more surprised when I tell them that pathology is a friendly and welcoming field. If I had to guess, I’d say their opinions of pathology are derived from the opinions of other physicians, the portrayals of pathologists on TV, and discussions of the specialty in online forums. It is a shame to me that so many medical students graduate without ever experiencing pathology’s real-life contributions to medicine.

What feedback have you received about your interest in pathology?

Felicelli: I have received mostly positive feedback. Sure, there are some individuals who think it is weird that a physician would “give up patient contact,” but radiologists do that as much as pathologists. In the current era of medicine, with overworked, stressed, and burned-out physicians, I knew I wanted a field that has a great work/life balance and is also rewarding and intellectually stimulating. With that in mind, the negative comments have never made me reconsider.

Toeller-DeSimone: When I was interested in pursuing pathology, many residents and attendings dismissed me as someone who wouldn’t be invested in a non-pathology rotation. As a result, I was sometimes denied opportunities that other students were given because they had expressed interest in other specialties. Although this was discouraging at times, it did not make me second-guess my interest in pathology. In the end, I just accidentally fell in love with something else.

Mahler: I have received mostly positive feedback about my interest in pathology. My preceptors and attendings are usually quite surprised when I mention that I plan on going into pathology and are curious as to why I chose it. I have even had a few attendings tell me that they considered going into pathology – most say that they couldn’t handle the autopsy aspect of the specialty, but enjoyed the interesting subject matter and work/life balance. I did receive one offhand comment from a resident teaching me surgical/procedural skills: “I don’t know why I’m teaching you this. You’ll never actually do it, because you’re going into pathology.” I need the same education as every other doctor!

Durham: I have received an array of feedback from physicians in other fields. I went to medical school with the sole intention of becoming a pediatrician and completed a few clerkships and electives before I found pathology. When I told my attendings I was interested in pediatrics, they spoke highly of the field, which made me happy. After I switched to pathology, I still had three core clerkships, months of clinical electives, and fourth-year requirements to complete. The first time I told an attending I was interested in pathology, the response was, “So you’re going to let all of the clinical skills you’ve learned during medical school go to waste? That’s a shame.” My jaw hit the floor.

I’ve had a handful of physicians tell me that I was too personable to go into pathology. I have explained to multiple attendings that pathologists don’t actually spend their days in the basement. I really enjoyed my surgery rotation because the surgeons I worked with were happy that I was going into pathology and mentioned more than once that they couldn’t do their jobs without pathologists. Many surgeons let me scrub out to carry specimens to the lab. One surgeon called me out in front of my classmates as the biggest nerd in the room. I was thrilled to reply, matter-of-factly, “You betcha!” The dermatologists and ophthalmologists I worked with were happy to hear that I was going into pathology, too, and tailored my rotations with them around reviewing dermatopathology and ocular pathology. Although I’ve received mixed feedback, I have never reconsidered my interest in pathology. I could not see myself doing anything else.

Did you find the discussion group helpful?

Felicelli: The discussion group was a great way to network with fellow students, residents, and attendings, and to learn their stories and passions for the field. I thought it was a great impromptu event!

Toeller-DeSimone: It was helpful to know that many other students had had similar experiences to mine. They, too, noted being dismissed by others for their interest in pathology and stereotyped as someone who lacked a vibrant personality. The solidarity was very encouraging.

Mahler: I enjoyed interacting with individuals at all levels of training. I am one of the only students in my program pursuing pathology, so it was great to connect with other students who were also interested. I enjoyed hearing some of the residents’ and attendings’ reasons for choosing pathology – some the same as my own, which was encouraging. This discussion group and the 2019 APC Annual Meeting in general helped confirm that pathology is the best fit for me.