Where is the Next Generation of Pathologists?

You’re a pathologist. Obviously something happened during your academic studies that made you think: I’d like to get involved in that! Now that you work in the profession, you understand the crucial role that pathology plays in supporting high standards in patient care and in the advancement of scientific research. So why aren’t more medical students choosing the profession of pathology? Certainly, numbers are dwindling, and given that a large portion of pathologists are nearing retirement age (1), it’s now more important than ever to reinvigorate interest in this field of medicine.

But that‘s easier said than done. Television programs, such as CSI and Quincy, M.E., have led to the public thinking that pathology is solely about performing complicated analyses to help cops catch criminals. For most pathologists, this couldn’t be further from the truth. This misapprehension is causing problems for the profession, and it needs to be tackled in two key ways. The first: pathology’s profile in general needs to be raised – we need to show that it goes well beyond the autopsy slab and a quizzical detective. The second: the way that pathology teaching is delivered needs to be improved in a way that reflects the true value of the field. With medical students being under increasing pressure to learn non-clinical skills, such as communication and leadership, the teaching of other disciplines is being squeezed. Pathology, sadly, is one of those.

Returning to form

“I do think there’s a lack of knowledge and understanding about the range of career options in pathology. Students don’t have the sort of exposure that they do to other specialties and therefore it means they often don’t consider it as a career choice,” admits Suzy Lishman, Royal College of Pathologists’ (RCPath) President Elect.

Reflecting on her experience in the UK, Lishman believes the move away from solid blocks of didactic pathology teaching, and towards its integration into a systems-based approach is not helping. “It’s great for putting the patient at the center of care, which is where they should be. But it’s not so good for students learning the basic science that underpins diagnosis and treatment,” she explains. “I believe we’ve possibly gone too far in the wrong direction. We need to bring it back. Students need a basic understanding of pathology, physiology, anatomy, etc., before they can understand how disease affects the patient and how they can care for them,” she says. Right now, she thinks a lot of work is needed to boost the understanding of the importance of pathology, but first and foremost, actually getting students to recognize it as an independent subject is even a challenge.

Lishman believes the demise of the hospital autopsy hasn’t helped. “The number of consented autopsies performed in the UK has plummeted in recent years. This, I believe, is a global phenomenon and means that students don’t have the opportunity to see autopsies on patients for whom they’ve cared so they don’t have the chance to see how valuable they can be,” she says.  Although she believes that medical students have a huge appetite for pathology, with other subjects competing for crucial curriculum airtime, something’s got to give.

Having spoken with many pathologists around this subject recently, it’s apparent that the issues described by Lishman extend into Europe and beyond. In fact, a Canadian research team felt compelled to look into the factors that lead to a career choice in pathology, citing manpower shortage as their reason for conducting the study (2). While they highlighted the importance of good course content and access to pathologists as key factors to attract students to the profession, also made some interesting observations around the influence of rumors and negative perception amongst students. Hearsay, perception and stereotype were actually three of the six key factors that they found influenced career choice (see “Six Factors Influencing the Career Choice of Pathology”). Raising awareness of pathology more generally, ensuring good course content, but also providing students with access to pathologists, should improve the appeal of the profession. In other words it all starts with education.

Overhaul obstacles

In the UK, the RCPath is taking an active role in tackling these issues. The first step is working towards standardizing the undergraduate medical student curriculum, to ensure that every student has a basic grounding in the science of pathology, irrespective of where they study. The second was to introduce an undergraduate membership category of the College, encouraging students to learn more about the specialty by providing careers advice, talks, bursaries, competitions and awards. Increased collaboration with other medical and pathological societies formed the third step, particularly with the introduction this year of the Pathology Summer School, attended by 80 students from around the UK. Finally, the College encourages medical students to get involved in its public engagement program – either attending an event aimed at increasing their understanding of pathology or helping to deliver events for schools or the public.

However, one potentially huge hurdle to progression is the planned overhaul to the way in which junior doctors are trained in the UK. The emphasis is being firmly placed on flexibility, with doctors becoming generalists for several years after qualification, before deciding on a specialism. The main reason? To make a much larger resource pool available to over-stretched accident & emergency departments. “It could go one way or the other; this overhaul could encourage more people to come into pathology because we have well-developed curricula and clear career paths that are attractive to trainees. Or it may put people off because they’ll think it’s too general and takes too long – if you do three or five years of general medical training, you’re probably not going to want to do another five years of pathology training. So I think the reconfiguration of training is probably going to be one of the factors that determines how pathology evolves over the next decade,” says Lishman.

The RCPath’s work on postgraduate curricula is particularly important; over 50 different exams are already developed for the 19 pathology subspecialties. Depending on the outcome of planned overhauls, they may need to revise the curricula for every one of those 19; no enviable task. Lishman acknowledges that “training doctors of the future who are fit to practice and understand and value pathology is one of our biggest challenges.”

I love pathology

A second key challenge is raising awareness of the value of pathology. Not only is this important for attracting the next generation of pathologists, but it’s crucial in raising the profile of the profession more generally – the work you do affects everyone. As pathology services continue to be financially squeezed, a positive (but a realistic) public profile helps.

In the UK, the I Love Pathology brand and website, and National Pathology Week are making some real headway.

First launched by Lishman in 2008, National Pathology Week is a unique initiative that aims to build the profile of pathology amongst the public through simultaneously-run events across the UK. “The original plan for the first National Pathology Week in 2008 was for 40 events to be held around the country where pathologists would either go out into communities and hold events, or invite the public into their labs. In the end, 320 events actually took place – which is far more than we expected!” says Lishman.

National Pathology Week takes place in the first week of November and the number of events is growing year on year. The I Love Pathology website was born out of the annual initiative and is the RCPath’s year-round public engagement program. It hosts information about past events and provides educational and branded materials, the aim being to allow pathologists to select a tried and tested off-the-shelf event that they can just deliver. “One of the most heartening statistics we gained from feedback was that over half of the people who have attended National Pathology Week events had never attended any sort of science related event in the past,” remarks Lishman.

And it’s not just the public who have benefited. “The initiative has a real feel-good factor. Many event organizers have said that it has been great for teamwork in their departments. It has also allowed them to get together with different disciplines with whom they rarely speak.  Some said that it has reignited their passion for the subject because teaching it, or communicating it to members of the public, reminded them of exactly why they liked it in the first place,” she says.

According to Lishman, the “virtual autopsy” (Figure 1) is by far the most popular event amongst attendees. “It’s important to remind people that the majority of the work that pathologists do is with, or for, the living, but this event has always been the most well-received. I’ve given it many times now, to rooms of 30 to 500, aged from eight to 80 years, and at venues ranging from medical institutions and schools to music and arts festivals. I always get the same level of enthusiasm,” she says. Now pathologists up and down the country are perfecting their own virtual autopsy events. Not only have these sessions been important in raising the profile of pathology, but they’ve also educated the public on the dignified and respectful way in which autopsies are performed.

“One of the things I’ve been particularly keen to highlight is the cross over between arts and science and to work with less traditional audiences,” explains Lishman. One such event focused on the heart, where attendees were invited to view striking images of the organ and to admire its beauty and symmetry. “When you step back, you see that pathology really is beautiful,” reflects Lishman.

This year sees the very first International Pathology Day on Wednesday, November 5th. Working with more than 40 international organizations, the aim will be to raise the profile of pathology on a global scale. “We’re hoping that there will be hundreds of events happening all around the world on that day, all focusing on pathology,” says Lishman.

Communication is key

These initiatives have so far proven to be a hit in the UK; given their relative infancy, the overall impact on the future of pathology remains to be seen. It will certainly be interesting to see how the international community responds once events are rolled out globally.

Certainly, National Pathology Week has been great for encouraging pathologists to step outside of their labs and to get closer to the public that they serve. This needs to happen more often. Pathology is at the forefront of the molecular revolution that is transforming the way that diseases are diagnosed and treated; indeed there are very few news stories about innovations in medicine today that aren’t underpinned by pathology. But how many people are aware of that fact?

“It’s no good doing all the hard work and then letting somebody else make the announcement; we need to be out there communicating it to the public and to policy makers so that they value pathology,” concludes Lishman.

The exceptional achievements already made by pathologists can only be built upon if a healthy pipeline of new talent can be secured – and that means attracting government and public support for your endeavors. Admittedly, it’s not going to be easy. Hurdles will continue to present themselves, but by working together, we can make a difference. Promoting the amazing work that you do, for example, by giving talks to students at your old University department or by speaking with the press, will help make your vital field more attractive to everyone. You’re shaping the future of medicine – why not shout about it?

If you’d like to tell us about awareness-building initiatives that you’re involved in, or give us your thoughts on the issues discussed in this article, post a comment below