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Outside the Lab Training and education, Profession

You Can DO It

I am often asked about my journey as a DO in pathology. I want to illustrate this topic with my personal experiences – and without overemphasizing the stereotypes that are prevalent in social media, comedy, and medicine itself. There are numerous Doctors of Osteopathic Medicine (DOs) who are excellent pathologists and hold leadership positions, such as residency program directors and laboratory directors. DOs are not excluded from any position or specialty in medicine. We DO it all!

Many DO students are interested in primary care, so the DO curriculum is structured for physicians pursuing this branch of medicine. But I am not here to discuss how DOs are the functional equivalent to MDs – nor to explain the intricacies of the DO experience. Instead, I am going to share my story and the lessons I have learned along the way. As I graduate from residency, I reflect on my journey to becoming a pathologist with a DO degree and hope that my experience helps other aspiring pathologists understand the DO pathway to the lab.

The journey begins
 

I was determined to fulfill my dream of becoming a physician and being a part of people’s healthcare journeys, so I applied to both MD and DO schools. My sister was in DO school at the time, so I knew what a DO was and understood that there was extra training in osteopathic manipulative medicine and techniques that could be used to help patients heal. Though the extra training meant more work on top of medical school’s already overwhelming demands, I felt I could help patients better with more skills in my toolbox. Additionally, focusing on the body as a whole rather than on independent systems was a personal belief that aligned with DO training.

Nonetheless, there were still doubts at the back of my mind that made me reflect on my decision. I recall some of my college friends talking about MDs versus DOs, saying that:

  • DOs had lower MCAT scores and GPAs
  • DOs were less likely to pursue competitive specialties
  • DOs were not as respected or represented within the field

The stereotypes are endless – but I did some research and found that DOs were in every specialty and often held leadership positions. However, up until the 1940s, DOs were not allowed to serve as physicians in the military – a systemic exclusion of DOs that only perpetuated the stereotypes. Today, DOs want to protect their professional identities. It was true at the time of my research that DO applicants had lower average GPA and MCAT scores than MD applicants, but not by much. MD and DO matriculants both had above-average grades and lengthy résumés and both were intelligent, hardworking, dedicated students who cared about helping patients.

Many students who apply to medical school attach their personal value to their grades, titles, and the way others perceive them, but we would all do well to remember that GPA and MCAT scores are an indicator of someone’s ability to answer test questions, not a reflection on their ability to practice medicine, be a good team player, or communicate with patients – all skills that are needed to be a great physician. Each individual has value that only they can define; fortunately, it has become increasingly rare for institutions to exclude or devalue DOs and their qualifications.

In the spring of my senior year in college, I received a big envelope in the mail and knew it was an acceptance letter. I tore it open and read the first line congratulating me on my acceptance. I accepted the offer and put down the deposit to reserve my spot as a student in the class of 2018! DO schools tend to be strict about their short timeframes for decisions. Usually, you are expected to accept or decline within a couple of weeks (and pay a significant deposit if you accept).

Medical school: the preclinical years
 

In the US, the first two years of medical school are mostly didactics, with a sprinkling of patient interactions. I was introduced to pathology at the end of my first year; at the time, it was just another class like biochemistry or genetics, but I found myself enjoying it and studying it more. The concepts were logical – pathology focused on disease processes, rather than rote memorization (which was the bulk of medical knowledge). I did well on the pathology portions of the exams and, as I learned more about the field, I considered it as a potential career subspecialty.

After the preclinical years, medical students must pass the first in a series of licensing exams. For DO students, it’s the Comprehensive Osteopathic Medical Licensing Examination (COMLEX); for MDs, it’s the United States Medical Licensing Exam (USMLE). Though both are for licensing, the scores are also used to gauge an applicant’s competitiveness for certain specialties. DO students are required to pass the COMLEX exam, but not USMLE, as part of their licensing; however, I – like most students – took both exams to allow residency programs to easily compare students’ scores with our own. This was prior to the merging of osteopathic and allopathic residencies and prior to both exams’ transition to a pass/fail format.

Medical school: the clinical years
 

During the clinical years, I rotated between the major fields of medicine just like any other medical student. When I had downtime on surgery and OB/GYN, I went down to the pathology lab, introduced myself, and asked if I could sit with the pathologists during sign-out. I was pleasantly surprised at how welcoming and happy they were to meet an extrovert interested in pathology.

While signing out, I often lost track of time because I was so engaged with the cases. I recall learning about colon histology as “test tubes in a rack” and about how structure and function were intertwined – a fundamental scientific principle. We also covered reactive processes and how specific tissues can react differently to damage. Learning about these processes and seeing fundamental scientific principles in daily practice drew me to apply to pathology residency.

After those rotations, I made it a habit to go down to the pathology laboratory and ask if they would let me sit in during sign-out. The hospitals I rotated at were small community hospitals that did not have pathology residencies; however, the pathologists were kind enough to introduce me to pathologists’ assistants and laboratory technicians to help me get a better understanding of how specimens were processed. They also allowed me to attend tumor boards to observe multidisciplinary collaboration in patient care and, though these were informal experiences, I did get a sense of the workflow and general atmosphere of the laboratory.

Big decisions
 

If you’re unsure about pathology, perhaps the reasons that solidified my decision to pursue life in the lab may help you with yours.

  1. I was interested in the material I learned about in medical school – the subject matter (which involved everything from histopathology and pathophysiology to clinical chemistry) would put me in a state of “flow,” in which I was so enmeshed that I frequently lost track of time. This made me realize that pursuing a specialty for which I had a natural tendency would be the best decision for me.
  2. I appreciated how having a deeper understanding of disease processes could affect – and deliver better – patient care.
  3. I had an interest in quality assurance and improvement, which is essential to the daily practice of pathology.
  4. I felt that I could thrive and best serve my patients as a pathologist; I was my best self while deep in thought at the microscope.
  5. My personality, interests, and career goals aligned with the practice of pathology.
  6. There is an abstract component of pathology that is nearly impossible to describe that appealed to me on a deeper level.

I asked the pathologists I knew about the application process for residency, but they told me that informally rotating through community hospitals was not enough experience to prove my interest to program directors – I needed multiple formal pathology rotations and letters of recommendation from pathologists, ideally in an academic setting and in my fourth year. Given that my school had no affiliated lab, few pathology faculty, only one dermatopathology elective, and limited rotation scheduling slots, this was particularly challenging.

The solution was clear – I had to look outside my school system to schedule rotations. This proved difficult because my school only allowed rotations that fit within the blocked scheduled system, which significantly narrowed my opportunities and made it difficult to arrange rotations. In the end, I was only able to rotate at one hospital with a residency program; my other experiences came from a private lab and a dermatopathology lab – and my letters of recommendation came from one faculty member at my school and the private laboratory pathologists.

While scheduling my rotations, I emailed a residency program about doing a rotation at their institution, but they replied saying they did not accept DO students because there were “too many applications.” I was heartbroken; I felt that they were discriminating against DOs. I recalled the stereotypes I had heard in college. I had hoped that the discrimination wasn’t true – but it was. I had to face the fact that I couldn’t rotate at that institution, despite the slot’s perfect fit in my schedule. I felt angry at having been excluded from the opportunity because of my title, but also dejected because my chances of success in the field had narrowed once again.

Advice for incoming hopefuls
 

My current residency program director is a DO and understands the challenge of pursuing pathology as a DO. Make sure to apply to places and surround yourself with people who respect you and your degree. Seek out those who understand your value and appreciate the uniqueness you can bring.

If you are considering a career in pathology, it’s extremely helpful to be at a medical school affiliated with a hospital that has a pathology residency (or at least a strong relationship with the pathology department). This will make it easier to schedule rotations, find mentors, and seek letters of recommendation – which are a must. If you don’t have the opportunity to get one from your medical school, make sure you can get one from someone with whom you did a rotation. Additionally, network with other pathologists at academic institutions; they might have ongoing projects you can work and publish on, which can make you a more competitive applicant.  Personally, because of the difficulties I encountered with scheduling, doing any research at that time was an unrealistic goal. This also leads to my next piece of advice: schedule elective pathology rotations early!

Finally, don’t be afraid to use your soft skills. Excellent communication skills, friendliness, and a strong work ethic are great ways to show your potential to become a successful pathologist.

Finding opportunities

I didn’t have the luxury of more formal pathology guidance from my school – a problem seen in many schools because so few students choose it as a specialty. Today, it has become commonplace to post elective openings, unexpected fellowships, and even job opportunities on Twitter, so I highly recommend following the pathology community there and getting involved via #PathTwitter. Additionally, attending in-person events such as conferences and society meetings is helpful for networking.

Networking early on can yield advantages throughout the residency application process. Some institutions offer a post-sophomore year, which is an excellent opportunity to network. I didn’t hear of this until I was already a resident, so keep in mind that certain opportunities that can increase your application’s competitiveness may not be well-known. It never hurts to ask; for example, some medical schools offer flexibility in scheduling, so you could ask if there is any leniency with rotations and whether you can schedule more pathology electives in lieu of others.

Keep pushing forward

I didn’t think I was a particularly glamorous applicant. My résumé didn’t expand much during medical school because of the intense demand; getting involved in anything outside school was unsustainable. Though I did have some experience in college, I didn’t do research during medical school, but I tried my best to get involved in extracurricular activities I enjoyed. I was a normal medical student with an average application – and, despite what self-doubt or impostor syndrome might whisper to you, most medical students in the US are actually average!

At times, I doubted my ability to get into a suitable residency. Pathology attracted international graduates with prior training, applicants with years of research experience, applicants with a year of pathology internship, students with multiple work experiences at academic institutions, and applicants with publications in top-tier journals. I had to quiet the voice of judgment in the back of my mind about my limited opportunities and “lackluster” résumé and just keep pushing.

Know your value

On paper, I seemed like an average applicant, but in person I was much more lively, curious, confident, and caring. I brought my “A-game energy” to the interviews. Coming from a liberal arts undergraduate college, I had had countless opportunities to enhance my soft skills in communication, critical thinking, positivity, and dedication. I wanted to convey my interest and passion for pathology and bring a positive attitude to my match, hoping to be an excellent co-resident.

Shut off the imposter syndrome

Residency applications and medical school are tough – but, if you are in medical school, you belong in residency! At its baseline, medical school is all-consuming and exhausting; being an average applicant already exceeds most people’s capacity. Being an overachiever is doable if you take time off and set up your resources and connections beforehand or take an elective if you have time. Academia is filled with highly accomplished people but, though they get a lot of visibility on social media and in publications, they are not representative of the majority. Most pathologists are happy to work in industry, community hospitals, or private practice and do not share their daily accomplishments on social media.

There are factors that some residency programs won’t take into account when ranking applicants, but others will, such as failing a licensing exam or taking a gap year. I found that pathology had many people who had started their medical education journey with intentions to become an internist or a surgeon but had since switched to pursue a life in the lab. Program directors understand that the natural course of life changes, so it’s important to use setbacks as a way to highlight growth and resilience in your application.

A note on social media

Social media is a great way to share accomplishments and cases and connect with others – but don’t fall into the trap of comparing yourself to others. I fell numerous times when I felt I wasn’t doing enough – from publications and posters to presentations and projects. Social media is a highlight reel, making people appear highly accomplished (although certainly deserving of celebration) and causing the “average” applicant to feel inferior. I would see the work of others and immediately doubt my efforts, feeling that I needed to work harder despite a demanding residency load.

Residency is all-consuming; if you can learn the pathology (and learn it well) while fulfilling your resident duties, that is an enormous accomplishment! To the so-called “average” resident: you are enough. You have your own story to tell and your own experiences. Social media is not representative of the majority and should be approached with caution. Those who are highly accomplished should be celebrated and we should all continue to share interesting cases, but make sure to use them as an opportunity to learn and not as a form of self-deprecation.

At last, success!
 

I applied to about 30 pathology residency programs and received approximately 15 interviews, of which I was only able to attend 10 due to travel costs. One interview was for an out-of-match position that only hired DOs and international medical graduates. I was not aware of this until the day of the interview, because the program’s website did not share that information. However, most pathology programs participate in the residency match; those that don’t tend to only accept graduates from DO programs and international applicants. It was unclear to me at the time, but programs that don’t participate in the match are a good option for students who feel they aren’t competitive enough for a traditional within-match residency.

Despite the setbacks I encountered, I matched into a pathology residency! I did my first year at the hospital where I matched, then transferred to another program when a second-year position opened up. I graduated from that program and will continue on as a surgical pathology fellow once I finish residency.

Residency so far
 

Once I started residency, did I feel there was a difference between how my MD colleagues and I were treated? Not at all. As residents, we were treated with equal expectations, compassion, and respect. My title was never an issue, nor a subject for conversation. It was a “non-subject” – something that was not relevant to discussion. No co-resident or attending made me feel that my degree was inferior to others. The reality is, in practice, no one makes it an issue if you have an MD, DO, or MBBS degree; you are a physician and aspiring pathologist. Period.

The pathology community does not make an issue of the title either. No one points it out when you network with others in the field – a pathologist is a pathologist. Early in my journey I had to overcome many obstacles to pursue pathology; however, DOs can overcome these challenges and achieve the same things as their colleagues with other medical titles. In fact, I invite my colleagues with unique experiences, such as international medical graduates, non-traditional applicants, and minorities to share them. Pathology is full of people who took different paths to get here and we are a better field for it.

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About the Author
Alae Kawam

Surgical Pathology Fellow, Northwell Health, Greenvale, New York, USA

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