Is Pathology its Own Worst Enemy?

“Pathology recruitment numbers are falling,” we hear – time and time again. And it’s true. Despite an 18.3 percent increase in pathology positions offered by the National Resident Matching Program in the US from 2008 to 2017, positions filled by US medical graduates over the same period declined from 77.7 percent to 50.1 percent (1).

We can see the statistics falling, but why is pathology as a profession getting lost – and, perhaps more importantly, where in the pipeline are things going wrong? Previously, we’ve considered the perception of pathology and whether or not it deters students from the profession; we’ve explored the impact of social media on residency matching programs; we’ve even highlighted tips for teaching pathology to get students interested.

But should we spend more time assessing pathology’s place in the medical school curriculum? We spoke to two professors of pathology – Gurmukh Singh and Louis Maximilian Buja – and two medical students – Amber Berumen and Lauren Miller – to gain their perspective on where pathology could do better in its recruitment efforts.

Fixing what’s not broken

Let’s start at the beginning; over the past few years, almost every medical school in the US has gone through a curriculum reform, moving from discipline-based teaching to an integrated approach. Since the Flexnerian reform of medical schools in 1910 – a complete overhaul of US medical training based on the principles set out by Abraham Flexner (2,3) – physiology and biochemistry have been foundations of students’ training and are seen as an essential part of their journey to becoming doctors.

Fast forward to the present day, however, and pathology has faded into the background – with nothing setting it apart from other specialties. “In some medical school curricula, it’s no longer an identifiable specialty unless there’s something that prompts you or you’ve had prior exposure to pathology – or if you go out of your way to get an elective in the lab,” says Gurmukh Singh, Vice Chair of Pathology at Augusta University. When he started working in the US in 1978 at the University of Pittsburgh, pathology had a year-long module within the curriculum. “It was taught in the traditional way of lectures and afternoon laboratories in which we examined the gross and microscopic features and held case discussions. People were exposed to pathology as a discipline and they had the opportunity to meet a number of pathologists.”

“Back before the reform, our pathology department had both formal lectures and a weekly laboratory session that gave students the opportunity to examine histologic slides,” says Louis Maximilian Buja, Professor of Pathology at the University of Texas. In the process of the reform, his institution lost a formal pathology course and laboratory session and now has only pathology lectures that are interdigitated throughout the first two years. “The presentation of pathology as a distinct entity – which has both a basic science and a clinical component – has been diminished by this integrated curriculum approach.”

Though Buja believes such an approach will negatively impact pathology, he’s also concerned about the broader effect. “I believe it’s diminishing the importance of basic biomedical science, because students are not getting the solid grounding they need to be astute clinicians later in their careers.”

With this lack of exposure, pathologists are already treading the line of invisibility to medical students. Amber Berumen, a final-year medical student at the time of writing, highlights that her school didn’t have a Pathology Interest Group – with faculty members advising that she shouldn’t even start one. “I was told the interest group would just fizzle out and starting it wouldn’t be worth the time,” says Berumen. “That’s not the attitude we should have. Yes, it might fizzle out, but at least it would be on the list of interest groups for medical students to see. It would put the right message out there: ‘Don’t ignore us; do consider pathology as a specialty.’”

Berumen took matters into her own hands by setting up an interest group, but the pandemic had other plans. “COVID-19 made it difficult to do many of the in-person activities we had hoped to do with the group, but luckily, a group of students have taken on leadership positions for next year, so the pathology interest group at my former medical school will continue. I’m happy about that, because I’m keenly aware of the need to be involved with medical students’ education. My goal is to make myself visible to medical students when I’m a pathology resident – showing them what I do – and that I exist!”

Shrouded in mystery

The lab is something of a mystery to students, invariably leading to common misconceptions – from both students and the wider clinical care team. “The biggest misconception I’ve heard is that the entire field is forensic pathology. When I tell people I want to specialize in pathology, they usually respond with, ‘Oh, so you like dead people?’” says Lauren Miller, a third-year medical student at the Medical College of Wisconsin.

With the rise of CSI-style shows over the past few decades, a phenomenon known as the “CSI effect” has mystified the role of the laboratory in forensic investigation – and what laboratory professionals actually do. Researchers have traced this term back to a 2002 Time magazine article that discussed how public perception of forensic science may be influenced by its portrayal in popular crime scene shows (4). Pathology seems to have fallen into this trap, too. Medical students with no previous exposure to or interest in the field may think the lab is only for medical examiners and forensic pathologists. And, with no distinct pathology course in their education, there’s little opportunity to prove otherwise.

“Most students are surprised when they take the elective and realize what we do and how we contribute to patient care – but, if they don’t come, they can’t have that revelation,” says Singh. “And that’s understandable, given that most people who go into medicine have the idea of working with and treating patients and, of course, it’s not very often that we pathologists deal directly with patients.”

This void in appreciation can lead to students’ thinking that test results come out of a black box without understanding how important pathologists and laboratory professionals are. Miller sees her peers largely overlooking the role of the lab, usually until they are exposed to it themselves. “Many students seem to have no idea that the laboratory is a busy, highly efficient department full of people running specimens and providing lab results in real time,” she says. “They are often shocked at how much work goes on behind the scenes to provide diagnostic services to patients.”

The final diagnosis

Though pathologists’ role in the patient pathway is critical – a fact well known to members of the profession – the lack of patient contact may deter medical students from choosing a life in the lab. “Pathologists are the doctor’s doctor; we provide information and the diagnosis to other physicians rather than dealing with patients directly. Clinicians, not patients, are our direct clients,” says Singh, who highlights that this can make the profession unattractive to those who thrive on patient contact.

For some students, the lack of direct patient contact may be the deciding factor in choosing pathology. Singh recalls the role his personality played in his choice of specialty. “I’m an introvert and prefer to deal with science on my own rather than deal with other people too much. Some might say, ‘Isn’t that contradictory to being a doctor? You have to be around people,’” he laughs. “I understand the paradox, but that contributed to my going into pathology.”

Singh’s story seems to resonate with Berumen’s own experience. “When I first started medical school, I was actively struggling with my social anxiety. Because of that, I initially thought I would specialize in radiology or pathology because I wouldn’t have face time with patients,” she says. “But, once I started clinical rotations and got direct exposure to patients, I found that I really loved my interactions with my patients and I cared for them deeply. The loss of direct patient care was something that actually made choosing pathology much harder.”

One could argue that pathologists do deal with patients; after all their decisions directly impact patient care. Buja became particularly fascinated with this side of the field. “To realize that the type of analysis we do with the gross and histologic examination yields information that is critically important to understanding the patient’s clinical problems – that solidified my interest in a career in pathology.”

Though his introverted personality laid the foundations for his pathway to pathology, Singh had a similar realization to Buja’s in understanding the importance of pathologists in patient care. “I read The Final Diagnosis, by Arthur Healy, and it scared the daylights out of me; a pathologist hadn’t kept up to date with developments in science – and, because of that, a baby didn’t make it.” He recalls, “It reminded me that we make the final diagnosis and provide that information to other physicians. If that work is of interest, then pathology would be attractive to you, but that doesn’t necessarily get communicated very well in medical school.”

Cited as a defining factor for some choosing to pursue pathology and laboratory medicine, personality may not even enter into others’ decisions. “Pathology and laboratory medicine was always on my radar as a potential specialty, especially because I continued to work in the lab during my first two years of medical school,” Miller says. “I still kept an open mind as I went through my training in case I fell in love with a different specialty, but nothing else came close to how much I love pathology. Choosing pathology was really inevitable for me – regardless of where I was in my training, I was always being called back to the lab.”

Who goes into pathology?

“Of course, from my attendings, I heard the stereotypical, ‘But one of your strengths is working with patients – why would you go into pathology?’” says Berumen. “Another situation was when I was asked to introduce myself and state what specialty I was going into. When I said pathology, it really threw them off. They would say things like, ‘Who goes into pathology?’”

Such responses may come from clinicians who don’t fully understand either the day-to-day work of laboratory medicine professionals or the role they play in the patient pathway. And, though medical students are the ones most affected by these misconceptions, they are not in a position to change the situation. Rather, qualified pathologists and laboratory colleagues have the power to increase their visibility to other clinicians in the curriculum. Buja, in particular, has been working on this since the start of his career.

“After I graduated from medical school, I was fortunate enough to get a position in a cardiovascular pathology lab at the National Institutes of Health (NIH), which solidified my decision to pursue pathology. However, I had to wait a year to get to the NIH. In the meantime, I undertook a clinical internship taking care of patients directly – which gave me excellent background to understand clinicians’ needs and how to help them,” says Buja. The relationship between pathologists and patient-facing clinicians can be disjointed and lack effective communication – but could the “walk in another’s shoes” approach improve this relationship (and clinicians’ perceptions of pathology) from the start?

“There are some professors who might ask their students, ‘Why do you want to do pathology?’ And that’s why it’s important for me to proactively interact with my clinical colleagues,” says Buja. “I have to make sure they have respect for me as a knowledgeable member of the clinical care team.” He hopes that building this rapport with fellow clinicians will increase their awareness of pathologists’ role in the patient care pipeline. “I’m constantly providing our cardiologists and heart surgeons with important information to help them care for their patients. Hopefully, the respect I’ve gained translates to their general impression of the field – this should be important for all professors of pathology.”

Clinicians from other specialties may not fully understand the role of the lab and its viability as a specialty for students – but Berumen says the field stands out for its collaborative opportunities and friendly nature. “I definitely see more collaboration in pathology, which is something that is really apparent once you do a pathology rotation or two. After having direct exposure with pathologists and other lab professionals,  I know that these are the kinds of people I want to work with.”

According to Berumen, while at medical school, students were invited by pathology attendings to speak up if they disagreed with the diagnosis of slides. Pathologists who invite these learning opportunities can set themselves – and the lab – apart. “Pathologists have been more open to my disagreeing with a diagnosis – and they won’t just say, ‘You’re wrong,’ because I think there’s an understanding in pathology that everything is subject to interpretation and everything needs some sort of context,” says Berumen.

Leading by example

Professors and incoming pathology residents have managed to see through the fog of misconceptions, which makes them ideal guides to show medical students the reality. For example, simply making students aware of the opportunities available behind laboratory doors may spark interest. “Students should know how diverse the field actually is. Each medical specialty has a corresponding pathology service and you can choose a unique and personalized career path,” says Miller.

Singh echoes this sentiment. “I try to emphasize to my students that pathology is vast and there’s something for everyone. All they have to do is pick an organ system of interest and there will be a multitude of clinical material to work with.” However, if medical students aren’t exposed to pathologists in the first place, this message may need to come directly from peers or residents. “You need one ambassador for pathology in each medical school to reach out to students and invite them into the lab,” Singh continues. “That representative needs to be enthusiastic and dedicated and make increasing pathology’s visibility part of their mission.”

At Augusta University’s Medical College of Georgia, where Singh teaches, a “disproportionately high number” of medical students go into pathology. He believes this is in part due to the head of the Pathology Interest Group at the institution. “They meet with the students and invite them to take electives – and that’s how we’ve maintained an interest in pathology as a discipline.”

Singh’s institution is not the only one to run such initiatives; McGovern Medical School at the University of Texas Health Science Center in Houston has trainees and pathology residents who are interested in promoting the field. They’ve also started a Pathology Interest Group for students. Like Singh, Buja believes it is a strong way to promote the profession. “From what I can tell, it’s a very positive experience for medical students to interact with people closer to their age and level.”

But don’t just take their word for it – Berumen’s first interaction with the lab is a prime example of a single moment sparking an interest that can last a lifetime. “During my internal medicine rotation, my attending sent the internal medicines and myself to the pathology lab to check on the results for a peripheral smear slide they had ordered. The pathologist showed us the slide – and I was fascinated,” she says. “One of the residents turned to me and said, ‘I haven’t seen you this excited about anything before. Why don’t you look into pathology?’ It was a weird moment where everything just clicked –  that single moment inspired me to look into the field as a potential specialty, get more involved, and seek out pathologists with whom to connect.”

Pandemic effects

We can’t talk about the role of medical school in pathology recruitment without touching upon the COVID-19 pandemic. Before March 2020, you might have been lucky to find a member of the public who knew what a polymerase chain reaction was – but, even within the clinical care pipeline, pathology’s visibility has increased.

“We pathologists, as laboratorians, have done fantastic work to develop COVID-19 testing and roll it out,” says Buja, who asserts that our understanding of the disease wouldn’t be where it is today were it not for the work of pathologists around the world. “It’s a strong indication of how important the profession actually is.”

Miller agrees. “The pandemic has certainly demonstrated how much of a role pathology plays in disease diagnosis and the discovery of pathological processes. The laboratory has become much more visible through testing development and helping to understand how the virus affects the body on a cellular and molecular level.” She hopes the increased visibility could spark interest and potentially increase the number of applicants.

If so, we should see a new wave of medical students considering pathology as their chosen specialty; however, Singh worries that the effect may be fleeting. “We did get initial interest at the start of the pandemic because people learned that diagnostic laboratories develop and perform the tests – but it was directed more at medical technologists than at pathologists,” he says. “At our institution, one pathologist spearheaded and took control of the testing for the whole state, but that was transient – people are already over it.”

Berumen flags another effect of the pandemic that we may not even have considered: the lack of students going onto campus or into labs. “As a medical student, getting exposure to  pathology is something best experienced in person,” she says. “There are so many aspects of pathology that require you to be hands-on, such as grossing specimens and performing autopsies.”

Only time will tell whether the COVID-19 pandemic has had an effect – positive or negative – on pathology’s recruitment efforts. But one thing is for sure: it has made the discipline visible to an otherwise unknowing public – and possibly an unknowing clinical care team.

Redefining pathology’s place

It seems clear that pathology needs a much greater presence in the medical school curriculum. But how do you prove its importance in medical education? How do you present the message that pathologists are an essential and integral part of the clinical care team?

One might proactively lobby the curriculum committee for courses to include designated pathology blocks (as opposed to the fragmented approach typically seen throughout the first two years), but would that be enough? Should the curriculum give students more opportunities to spend time inside the lab – or even make it mandatory? “Lectures really didn’t cover how diagnostic tests are performed and analyzed, so students need to be taught what common tests mean, how to use them clinically, and what goes on in the ‘black box’ of the lab,” says Miller. “It would also be helpful to advertise opportunities for students to come into the clinical lab or the histology lab and see what happens – especially those who may never take a pathology rotation.”

Such opportunities would grant students the exposure to pathologists that is so desperately needed – and, if they still decide that the lab isn’t for them, at least they are making an informed decision. Berumen reminds us of her first encounter with the lab: “One slide changed everything.” How many similar revelations are lying dormant in medical students who never experience what goes on behind the doors of the lab? “We need a distinct place in the medical curriculum that shows pathology as a clinical specialty – and how pathologists practice medicine,” muses Berumen. “Or even that we do practice! There are some who don’t realize or acknowledge this latter point.”

Clearly, it’s not just pathology’s place in the curriculum that needs an overhaul. To draw in students, the field must become more attractive – and that means common misconceptions must be dispelled. As practicing pathologists, Singh and Buja can certainly attest to the lighter side of the profession. “There’s certainly a good work-life balance. The call schedule is not onerous, so you still have evenings and weekends for any activities or family interests you may have,” says Singh. “The compensation is competitive, too – pathologists are not the highest or the lowest paid, but we don't tend to complain about the pay, so that’s not putting students off.” Pathologists should showcase these benefits so that students are aware of the opportunity to balance work and personal lives without sacrificing their role in patient care or enhancing medical knowledge.

“We need to show students how fundamental pathology is to medicine and how rewarding it is as a career. Practitioners in the field have less burnout than other disciplines,” says Buja. “Pathologists are happy people and we get a lot of fulfilment from what we do. It’s a wonderful way to study the fundamentals of medicine and contribute to patient care.”

Medical schools undergoing curricular reform are standing at the edge of an opportunity to raise the profile of pathology – showcasing the value of the lab and its role in patient care and outcomes. Seize that chance and the future is bright. “It feels like there’s a new wave of pathologists who acknowledge that we need to be more visible,” Berumen says. “There’s a real movement to change how we are perceived.”

Gurmukh Singh is Vice Chair of Pathology at Augusta University, Augusta, Georgia, USA.

Louis Maximilian Buja is Professor of Pathology at the University of Texas McGovern Medical School, Houston, Texas, USA.

Amber Berumen is a first-year pathology resident at Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Lauren J. Miller is a fourth-year medical student at the Medical College of Wisconsin, Milwaukee, Wisconsin, USA.