Pathology’s Crown Jewel

When someone asks me what pathologists do for a living, I tell them, “We look at biopsies, we do autopsies, and we manage clinical labs.” Many such conversations start with an explanation that pathologists are indeed doctors and do more than just autopsies. But, when I tell people about autopsies, most of them are intrigued and have a variety of questions. I was once asked if I had ever been contacted by necromancers!

I read with interest Hugh Wilson’s article on the demise of autopsy, itself inspired by an earlier article on obstacles to pathology recruitment. Wilson identified two major themes that, in his opinion, were impediments to recruiting medical students in pathology: i) a lack of understanding of what pathology is and what pathologists do, and ii) a fear of autopsies. He recounted refrains he had heard from his colleagues and classmates over the years about pathology. His solutions include a mandatory clinical internship for incoming pathology residents and removing autopsy from residency curriculum and board requirements. He extrapolated on the second point by saying that autopsy has no real place in pathology outside research or forensics. According to him, “all physicians perform a prolonged autopsy during their freshman medical school anatomy class” and that “since the advent of CT and MRI scanning” most tissues can be visualized, so we don’t require actual autopsies to confirm medical diagnoses. He also proposed a mandatory pathology rotation for medical students.

I partially agree with Wilson’s diagnosis of the obstacles in recruiting medical students – namely, that most medical students (including me at that stage) are not exposed to the practice of pathology. One way to rectify this situation is to increase pathology’s visibility and advocate for mandatory pathology rotations in medical schools. Pathology is often thought of as a “black box” system into which someone inputs an order and results come out with no human interaction or effort behind them. As a result, very few physicians and patients fully understand what we do and how vital our work is in diagnosis and treatment. Not knowing how important we are hurts pathology in terms of image, recruiting, and budget allocation.

As far as doing a clinical internship year, though, I fail to comprehend how that would benefit pathology as a specialty. With the greatest respect for the specialties, I don’t see how holding a retractor for 10 hours while on your feet or taking part in a five-hour round of the medical ward will help a prospective pathologist – or our colleagues in surgery or internal medicine. Unless a surgery resident observes what it takes to gross a complex breast case or an internal medicine resident attends a scope session to look at liver pathology cases, the black-box approach is not going to change.

I have and continue to work with medical students who are pathology-curious – and I have found autopsy to be the most effective recruiting tool. Contrary to popular opinion, not all medical students experience autopsies in medical school. I went to medical school in Pakistan and our anatomy lab was a formalin-filled hall with cadavers that were dissected by a few brave souls. The only two autopsies I saw during medical school were part of our forensics class; I was among a group of 60 medical students huddled around a body in a cramped room while a prosector performed the procedure. It was not an ideal introduction to autopsies. When I started my residency in the US, I was apprehensive about completing 50 autopsies as part of my training (the requirement has since changed). Once I got over my early jitters, I realized that my fears were unfounded. I have previously written about the importance of autopsies for patients, their families, their treatment teams, and sometimes the legal system. Hospital autopsies serve as quality control for treating physicians. Imaging tools are an important part of diagnosing diseases, but they are not always accurate or helpful. At least a quarter to half of all pre-mortem diagnoses are changed after hospital autopsies (1).

In most pathology training programs outside the US, autopsies are not a mandatory part of training. Despite that absence, there is a global shortage of pathologists and a continued decline in medical students joining pathology. Removing the autopsy requirement, in my opinion, will have a negligible difference in recruiting. Instead of removing autopsy from pathology training, I propose starting a forensics residency focused on autopsy, neuropathology, clinical chemistry, medical jurisprudence, and anthropology. This proposal would improve the supply chain problems currently facing medical examiner offices across the country. I appreciate Hugh Wilson’s concern about pathology’s pipeline problem; however, the solution is not to throw away pathology’s crown jewel.