The Last Respite of the Socially Inept?

Most people have heard the stereotypes about pathologists. They’re an unfriendly lot who chose their careers because they didn’t like patients – or indeed, people at all – preferring to spend their time in the company of corpses and assorted taxidermy. Pathologists don’t want to talk to anyone, lack a sense of humor, and spend their ample time off watching Quincy and Silent Witness. As pathologists, you know these stereotypes aren’t true – but do other people know that, especially young medical students who will eventually have to choose a specialty? And are stereotypes like these ones harmful to pathology as a discipline?

When trainees were asked by the Royal College of Pathologists (RCPath) about the stereotyping they had encountered, the responses were surprisingly conclusive. Almost all had heard that pathologists didn’t like people (85 percent), that they had poor communication skills (76 percent), or that they spent all day with dead bodies (83 percent). They’d also heard other comments – anything from having a morbid fascination with death to being considered a technician, rather than a “proper doctor.” And these stereotypes weren’t coming from the general public; alarmingly most of them were coming from doctors in other specialties, both consultants (63 percent) and trainees (83 percent). Other pathologists had also been involved in stereotyping the trainees (1). One head of department even claimed that “histopathology is the last respite of the socially inept.” (2)

Though this kind of labelling within the medical profession is harmful enough, the misconceptions held by members of the public are even more extreme. In a National Pathology Week survey in 2009, RCPath asked people in schools and communities a range of questions about the field. To them, pathologists are considered “creepy,” “scary,” and, in 45 percent of responses, were related specifically to corpses, dead bodies, or autopsies. Of the people surveyed, over a quarter were aware of forensic pathology as a subspecialty (28 percent), probably because of publicity from popular television; some were also aware of hematopathology (22 percent) or histopathology (9 percent), but no other subspecialties were mentioned (2).

When asked why someone might choose to become a pathologist, a number of the answers were positive – liking science or problem-solving, wanting to help others, or being interested in how the body works. Unfortunately, people also felt that pathologists might be interested in crime, fascinated with death, uninterested in patients, “weird,” or “geeky.” One respondent even stated that people might enter pathology because they “couldn’t get into medicine.” Perceived qualities needed to specialize in the field were similarly diverse, ranging from accuracy and intelligence to statements like “lack of a sense of humor” and “lack of personality.” Perhaps most telling of all, when asked what pathologists did in their spare time, only 12 percent of respondents said “normal things,” while other answers included talking about corpses, stuffing animals, going to graveyards, and collecting roadkill or pigeon claws... (2)

To anyone with an understanding of the pathologist’s role in disease diagnosis, monitoring and treatment, these stereotypes are laughable. But their effect on pathology is much less humorous. It’s already an unpopular residency choice for medical students, attracting only 1 to 3 percent of medical graduates (3) – a situation resulting in a severe and longstanding shortage of personnel to the point where it has even been referred to as a worldwide crisis (4). Of those trainees who did make it into pathology, 15 percent said that their experience of stereotypes had made them less interested in a career in the field, whereas 59 percent believe that stereotypes deter other trainees from entering the specialty. Numbers in the literature seem to support this conclusion – in one study of clinical residents who chose not to enter pathology, 17 percent said it seemed boring or repetitive, 7 percent felt it didn’t have enough contact with other people, 4 percent wanted to avoid death and autopsies, and 1 percent thought the field carried low prestige and a poor reputation (5). One resident in the study reported that pathology was “not well recognized among peers,” and they were, “not exactly sure what they do.”

Clearly, stereotypes about the nature of pathologists are costing the specialty some of its best candidates – but to understand why, it’s important to look at the worst offenders and ask how they’ve gained such a strong foothold and what can be done to counteract them.

Pathologists spend all their time with corpses

With the recent proliferation of forensic pathologists on television, it’s no surprise that they’re everyone’s idea of the essential pathologist. A list of “favorite TV pathologists” from The Guardian newspaper features 10 entries, all of whom are involved in murder investigations (6). There doesn’t seem to be much else out there – in fact, in many popular medical shows, doctors from every medical specialty can be seen either performing their own laboratory analyses or bypassing the lab altogether! “I watched a lot of X-Files as a teenager and I remember quite often FBI agent Scully would be found in a white lab coat hovering over a dead body with a scalpel in hand in a white clinical laboratory with low-level lighting”, says Hannah Jean Gregson, a histologist at the University of Manchester in the UK. With popular media portrayals linking pathology only to the examination of dead bodies, it’s easy to see where the general public might have gotten this particular misconception.

It’s a little harder to understand why people in the medical field think the same way, though. It’s likely due at least in part to the “CSI effect,” where incoming medical students view pathology through the media’s macabre lens and therefore view pathology with active distaste from the start. One resident who chose a different specialty said, “When I think of pathologists, I think of TV shows like CSI and get an ‘eerie feeling’ and honestly feel scared!” (5) Even without this influence, though, the stereotype arises – medical students surveyed between 1967 and 1971, before even forensic pathology entered popular media, considered pathologists to be “morbid characters who enjoyed constant contact with the dead.”  The reason for these judgments, students claimed, had to do with perceptions of pathologists as “insecure, uncomfortable, and ill at ease with others, and inept in interpersonal communication, shy, introverted, aloof, and cold.” (7) When asked whether the stereotypes still apply nowadays, doctors agreed that they did – one replied, “Definitely. When I tell people I’m a pathologist, they start talking about TV programs like Silent Witness and dead bodies,” and another said, “Even people I know well presume I spend all day working with the dead.” (2) Gregson asked medical and postgraduate students in her University of Manchester research group how they thought pathologists filled their days; and she reports, “One postgraduate student gave the “model” stereotypical image that “pathologists look at dead bodies all day.” I’m not sure where she thinks all these dead bodies come from!”

That isn’t great publicity for pathology – no one wants to be greeted on the ward with, “Oh, dear, what’s the bad news?” as one pathologist reported. That desire to avoid being seen as morbid or associated with death is keeping good candidates out of the discipline; 4 percent of clinical residents who had chosen to specialize elsewhere said that it was because they “want living patients, and want to avoid death and autopsies.” Another study of medical students’ perceptions of pathology showed that well over half (56 to 63 percent) could identify autopsy as one of the duties of a pathologist, whereas the numbers for most other duties were much lower (8). It’s difficult to combat an image that most incoming medical students believe before their training has even begun, and even more difficult to do so when a lifetime of influence from popular culture only reinforces that image. But this apparent fascination with death may be the most negative – and certainly the most untrue – stereotype that pathology faces in trying to attract promising new candidates to the field.

Pathologists don’t like people

At every stage of their careers, pathologists report hearing from others that they apparently don’t like people. Pathologists are supposed to be unfriendly, uncommunicative and socially awkward, hiding away in their laboratories because they don’t want to – or are unable to – interact with patients or colleagues. Chella van der Post, a pathology trainee and doctoral student at Radboud University Medical Center in The Netherlands, says, “I often hear that I behave and communicate quite normally, so why did I have to become a pathologist?” Clinical residents in other disciplines overwhelmingly cite lack of patient contact as a reason for avoiding pathology; in one study, 75 percent of respondents raised it as a concern even if they had enjoyed their experiences in pathology during medical school (5). They accompanied their reasoning with statements like, “I thought it would be a waste of all my clinical training and development of skills in diagnosing and interacting with patients if I ended up in a job that didn’t involve patient contact,” or, “I went into medicine to work with people, not specimens.”

Many people feel that this perceived separation between pathologists, who are presumed introverts, and doctors, who want patient contact, begins as early as the medical school application process – explaining, “the way that the selection happens for medical students now, with the interview being a big portion […] it kind of almost weeds out some of the people who don’t want to be people-people.” (3) In an attempt to explain why pathology is supposedly incompatible with most aspiring doctors’ personalities, another student specified that medical school is geared toward selecting “those people that would be great extroverts and great at dealing with the population.” The perspective that doctors must be good at dealing with patients, while excluding pathologists from that definition, seems to begin early and continue largely unchecked – and, apparently, pathologists themselves often do little to ameliorate the stereotype. During their training, medical students emphasize the impressions made by teachers and mentors, focusing on enthusiasm and approachability rather than encyclopedic knowledge. Focus group discussions with graduating medical students elicited comments like, “My experience actually wasn’t so positive with my PBL tutor, who was a pathologist. He was a bit stuffy, talked over us – and that’s sort of where some of my hesitancy with pathology comes from.” Another student noted, “Something that interests me in terms of what I’m going to go into is actually the interaction that you have with colleagues, and I got the sense that there was very little of that with pathology.” (9)

Unfortunately, this impression of unfriendliness often continues on into postgraduate training and beyond. Negative encounters with pathology seem to be quite frequent – one resident labeled teaching pathologists as “socially difficult to be around,” while another shared an unpleasant experience. “[We] had a very eccentric and rather negative pathologist give us our training, [who] scared me off from the field.” (5) People who managed to enter the field despite this undesirable stereotype find themselves having to defend their choice. When asked, specialists from other fields claimed that pathologists were “very isolated” and did not have enough contact with other people. One pathologist told a story of a chance encounter with someone they hadn’t seen in over 20 years. “She said that she was surprised to hear that I’d become a pathologist, as I’d always liked talking to people so much.” (2)

The good news is that the myth of the unfriendly, isolated pathologist is an easy one to counter. Medical students were surprised to discover that pathologists could be “people who were really animated, lively people” and that “if I spent all my time in the lab with these people, they’d be really friendly individuals.” (9) Among trainees who chose a career in pathology, 50 percent of those surveyed by RCPath said that they’d made their decision after a positive experience of the specialty as a student or junior doctor, and 46 percent were influenced by a role model. Nearly all (85 percent) said that positive role models were important. Of those surveyed by Jason Ford (5), 15 percent cited good pathology experiences during medical school as their reason for choosing the field, describing them as exceptionally good teachers and role models; a further 14 percent entered pathology training after admiring the personal qualities of pathologists, with one student referring to them as “one of the happiest groups of physicians that I worked with.” It’s clear that the experiences young trainees have with pathologists can reinforce the stereotype of the misanthropic pathologist – but they can just as easily debunk it.

Pathologists aren’t real doctors

The idea that pathologists are actually scientists, lab technicians, or “surgeons’ servants” is far more common than it ought to be. It’s understandable that the general public is, at best, shaky on its knowledge of pathology training and duties – surveys reveal that they think people choose careers in pathology because they “couldn’t get into medicine” (2) – but this shouldn’t be true even of medical students, let alone doctors who are past their school years. Nevertheless, the stereotype of pathologists not being “real doctors” persists.

In surveys of second-year medical students, over a quarter believed that there was no residency requirement to become a pathologist (8). Many said that, before medical school, they “didn’t even know it was a medical specialty,” and despite preclinical lectures, they remained ignorant of their teachers’ actual roles. One student said, “Here we are getting a lecture by pathologists, and we’re like, “what the heck do these guys do?” You know, like I remember seeing people and going like, “I don’t even get what you do”.” After 16 months of clinical clerkship experience, the same students gained very little understanding of the need for pathologists in clinical care – “You sent the specimen and then it’s done, and then, Oh! Miraculously, a result comes back.” The students had no clinical exposure to pathology, believed that electives were either unavailable or undesirable, and claimed they had “never seen” a pathologist in the wild. One of the students, explaining his lack of interest in pathology as a career, commented, “I don’t think you see the pathologist who examines the tumor afterwards and makes the diagnosis ultimately as being a doctor – you sort of see them as a technician who sits in the background.” (3)

Even pathologists who are well settled in their careers experience this stereotyping. They report being referred to as “just a lab rat” and being told that they’re “not a real doctor and must have a lot of free time!” (1) Trainees express concern over the lack of pathology teaching in their undergraduate medical curricula, pointing out that they were able to become qualified physicians without ever setting foot in a pathology department or being aware of meeting a pathologist. And these were the residents who were more dismissive, saying that pathology “seems more like a technician job.” (5) Alberto Berjón García, a pathology resident at La Paz University Hospital, Madrid, Spain told us, “I got very little exposure to pathology as a student. It is true that most medical students tend to prefer surgical or clinical specialties and maybe that's why it is underrepresented, but I think it is a mistake because every doctor should understand what a pathologist does.” It appears that most people outside the specialty are only peripherally conscious of its existence, aren’t aware of encountering pathologists in the course of patient care, and don’t fully understand their duties – and this combination of factors leads to the belief that pathologists are not actually doctors at all.

Pathologists are lazy

One of the most widely perceived benefits of a career in pathology is its good lifestyle. Incoming trainees are generally of the opinion that pathology offers flexibility and a good work-life balance; in fact, 43 percent of residents in one survey listed it as a primary reason for their choice of specialty (5). But it’s possible to have too much of a good thing, and sometimes, this positive aspect of the job can be perceived as laziness or an unwillingness to work. Pathologists are thought to put in fewer hours than other specialties, leave earlier in the day, or even do less in their time at work – an impression reinforced by the fact that so many doctors in other fields don’t fully understand the duties of a pathologist.

Comments made by both medical students and pathologists were generally positive with respect to lifestyle. One student observed, “I think it’s not the actual pathology, but the lifestyle that pathology offers you is very attractive.” (9) It’s an opinion that seems to be shared not only by students, but by residents and experienced pathologists as well. In discussing the upsides of the career choice, one pathologist said, “As far as lifestyle goes, it’s fantastic… If I have to leave early or nip out for an hour or something, just the control of the hours that you have, the flexibility, is very, very good.” It’s true that pathologists as a whole tend to have fewer working hours than other medical specialties, but the difference isn’t as great as most people seem to think – in 2013, the average pathologist worked 49.2 hours per week, as opposed to about 55 hours per week in all specialties (10). The field is particularly welcoming to women; female students and qualified pathologists emphasized the appeal of control over the hours that they worked and the time they were able to take out of their careers for family.

Though it seems as if this lifestyle advantage should attract more people to pathology, it unfortunately also contributes to negative stereotypes about the profession. Pathologists report being told, “Oh, you must have a lot of free time,” or that they have easy jobs – some were even told that they must have chosen pathology as a “last resort” after failing to get into other specialties. Attitudes like this contribute to outsiders’ views of it as a choice with low prestige or a poor reputation. A concern a medical student expressed after hearing it “from a lot of people, so it kind of just keeps creeping up” is the idea that, “in terms of careers in medicine, [pathologists] are not thought as highly of as some of the others.” (9) A friendlier lifestyle than most other medical specialties offer, coupled with a lack of visibility in direct patient care and a poor understanding of a pathologist’s work, seems to result in a false view of pathology as an easy field and pathologists themselves as lazy doctors.

Pathologists are nerds

The image of the pathologist as a “weirdo in a bow tie” is probably the least damaging of the preconceptions out there. Plenty of people regard this as a negative – but there are also plenty of people who consider it a positive characteristic. When RCPath asked members of the public why people might choose to become pathologists, “weird” and “geeky” were two of the reasons offered, but many respondents also used phrases such as “like science” (16 percent), “like problem solving” (12 percent), or “interested in how the body works” (10 percent) which suggest that this particular stereotype can work in pathologists’ favor as easily as it can work against them (2).

Residents who opted not to enter pathology reported that they didn’t want to be seen as “geeky and boring” or “having Asperger’s personalities” (3), making it clear that this image is giving some medical students a reason to avoid the specialty. When discussing what she likes most about her job, Chella van der Post agreed with the stereotype of the studious thinker – “You need to like to study a lot, to go into your books and puzzle until you find the answer to the image under your microscope.” The theme of the scientifically inclined laboratory recluse seems to warn away young doctors who equate “geeky” with “boring,” or who feel that pathology appeals only to a very specific personality type – the Mister Spocks of clinical practice.

Many trainees do acknowledge the grain of truth that gives rise to the stereotype. Some even feel that pathologists emphasize their quirky or eccentric natures, deeming them desirable rather than problematic (1). Asked about the truth of such perceptions in today’s environment, one pathologist admitted, “There are some more positive stereotypes about pathology – that you have to be clever, have a scientific approach, perhaps be a bit geeky. These ones are probably true!” Fortunately, the “nerd cred” conferred by a career in pathology doesn’t scare everyone away – one RCPath survey respondent admitted, “If pathologists have a stereotype of being a bit cerebral and wanting to understand the mechanisms of what’s gone wrong, whether or not it makes any difference, then that stereotype attracted me to the specialty.” (2)

Practicing without preconceptions

It’s plain that all of these stereotypes – the ghoul, the hermit, the technician, the late sleeper and the nerd – are damaging to the field of pathology. Not only do they cost the discipline the recognition and respect it deserves, but they discourage promising young medical trainees from choosing pathology as their specialty. The loss of incoming personnel is so great that it’s now led to an international shortage of pathologists – and so the question is: what’s the best way to combat these negative impressions?

In order to attract medical students to pathology, promotion needs to begin early. Students have expressed surprise at the lack of pathology exposure in their medical training, reporting that it was possible to make it all the way through their medical school careers without ever being aware of meeting a pathologist, much less entering a pathology department themselves. The traditional teaching block has been replaced in many universities by an integrated curriculum, which may result in students who aren’t sure which doctors are pathologists, or what they do all day. But even in schools with block courses, the current methods could use an overhaul – a study of students’ perceptions of pathology before and after their second-year course showed that their understanding of pathology increased only modestly, and their interest in it was actually decreased (8). Students need information not only on the practice of pathology, but on its place in the clinical setting. For many students another study suggests, “Pathology is a mystery: its introverted practitioners work behind the scenes, engaging in unknown activities that miraculously lead to diagnostic reports.” (3) The authors of this report suggest that, “Preclinical medical students should be explicitly taught the role that pathologists play in patient care, and senior students should be given insight into the actual daily responsibilities of pathology practice.”

“That my colleagues – old and young – from other fields/specialties do not know what a pathologist does or can do for them and the patient, is something that makes me a bit sad. But, I also see this as a challenge and a big motivation to improve the image of pathology,” says Chella van der Post, who is a member of a multi-specialty board of residents. In fact, she uses every opportunity to explain the field and how critical it is in diagnosis and disease management. “To step into the spotlight and improve our image to our colleagues and to lay people is the first step to take,” she adds.

Exposing students to pathology as an integral part of clinical care motivates them to consider further training. The positive effects of clerkships on perceptions of many disciplines are well documented – and it’s a good understanding of the pathologist’s role in diagnosis and treatment that spurs a student to consider an elective clerkship in pathology. Explaining the day-to-day work of the pathologist in as clinically-oriented a way as possible, highlighting case studies, and making pathologists visible in other disciplines by inviting their involvement in conferences, rounds and lectures; all of these are ways to make a difference to students’ opinions of pathology early in their training, which in turn encourages them to consider it when choosing a specialty. It isn’t as simple as involving pathologists in medical education, though – the doctors who participate in teaching and training are essentially the “face” of pathology, and it’s important to be selective about the tone and source of students’ early introductions to the discipline (5). Nearly one-fifth of residents who chose other specialties gave insufficient or inadequate contact with the field during medical school as a reason, and among those, many students cited encounters with teachers who were eccentric, negative, or socially awkward. In contrast, doctors who did specialize in pathology often state that their role models “definitely didn’t fit into any of the stereotypes,” describing them as “passionate about their subjects, excellent communicators” or “extroverted, funny, even a bit zany.” (2) Positive mentorship experiences like these dispel unwarranted stereotypes about pathologists and encourages a more balanced view.

As the pathologist population grows more diverse, it becomes more and more difficult to hold onto these stereotypes. Visibility to the general public, to medical students, and even to specialists in other fields, is a key part of combating preconceptions with facts. At the conclusion of one National Pathology Week event for medical students in the UK, every attendee said that they would at least consider a career in pathology, and several added that a single afternoon had taught them more about it than they had learned in their entire undergraduate careers (1).

Public engagement, medical school training, and exposure at all levels of practice are vital to clearing up misconceptions about who pathologists really are and what they do – but all of these things rely on active and positive representation, because the only people who are truly in a position to fight back against stereotypes are pathologists themselves.

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