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The “physician’s physician” slips the lab

The New Physician April 2007
The puzzle of disease, presented in dispassionate cells and tissue samples, is the trade of the pathologist. Increasingly, their stains and markers help treat that disease, taking a practice—once relegated to hospital basements and considered limited in scope—beyond its diagnostic walls.

“I think once people get to know pathologists and their departments...they’ll see we’re not really scary trolls,” says Anthony Sireci, a fourth-year at Johns Hopkins University School of Medicine. “We may be in the basement on occasion, but I think it’s a misconception that the only interested in esoteric medical minutia and [not] patient care.”

Early in medical school, Sireci held that view too. But by this past March, he was hoping to match into a pathology program. For the time being, he’s interested in pursuing an academic career in gynecological or general urinary pathology, particularly working in cervical cancer or prostate cancer.

In truth, the field is tremendously broad. The “physician’s physician”—as many call the pathologist—handles the intricate testing of samples generated by nearly every other specialty, and its numerous subspecialties run the gamut from backing up nearly every test in a rural hospital to running blood banks to tackling crime.

Anatomic pathology—examining tissue and considering anatomy in diagnosis, and clinical pathology—testing samples in a laboratory—are the two major arms of pathology training. While some residency programs allow students to stick to one arm or the other, most pathologists—around 90 percent—train in both.

Still, most pathologists follow residency with a specialized fellowship—nearly 74 percent in 2004, according to the Intersociety Council for Pathology Information. Ten percent entered academic medicine, and another 9 percent started practice. Of the 2004 crop, 51 percent were women, and 43 percent were international medical graduates (IMGs).

Most, though not all, open residency slots are filled every year, says Dr. Mark Sobel, executive officer of the American Society for Investigative Pathology, but the field is becoming more competitive. Every year, a higher percentage of slots fill, and more are occupied by U.S. medical graduates. Indeed, National Resident Matching Program data show that 91 percent of 525 slots were filled in the 2006 Match—60 percent by U.S. graduates. In 2002, by contrast, only 83 percent of 398 slots were filled, more than half by IMGs.

According to the College of American Pathologists (CAP), roughly half of pathologists work in a group setting, with the other half working solo—in an academic setting, independent laboratories or as medical examiners. Their workweek is around 49 hours, just shy of the overall physician average of 55.

But those are just averages, and with such a broad field, lifestyles can be all over the place. If you want to find a 9-to-5 pathology job, it’s out there, says Dr. Thomas Sodeman, CAP president. So is everything else, including positions requiring call.

The perception of pathology as a “lifestyle specialty” frustrates Sireci. “As a residency, it is seen as this very cushy, 9-to-5 type deal, and nothing could be further from the truth,” he says. “I’m so amazed when people say that.... You work hard, and you have to learn a lot. The learning curve is incredible.”

Sireci came into medical school thinking about primary care. Pathology first entered his mind as he did some research work after his first year. “It was something that, first of all, I was good at,” he says, “and second of all, I enjoyed doing.” After an elective in pathology during his third year, he’d made up his mind. “That’s what medicine is for me: a basic understanding of disease at the level of the organism, at the level of the cell, then going one step further and still including that knowledge of management and therapeutics.”

The sheer knowledge required for pathology also appealed to him. He is impressed by pathologists’ mastery of modern therapies, literature and ability to talk intelligently about pathophysiology—things that slip the minds of students once they’re past second or third year and getting knee deep in patient interaction.

But for some students, that interaction is what pathology is missing. “You can’t mind having to be in the background, as far as the patient is concerned,” Sireci says. “Patients are never going to go up and thank their pathologist. At least I’ve never heard of that.”

While Sireci, Sobel and Sodeman all emphasize that being a pathologist does not necessarily mean a complete divorce from patient contact—in fact, Sodeman says, direct patient interaction with pathologists is on the rise—most simply work with little pieces of patients, and Sireci says that’s something students considering pathology should think about.

“Am I going to miss that kind of intimacy? There is no level of intimacy greater than what a clinician has with his patient, I think…. It is a little addictive,” Sireci admits. “I’m planning on deriving my satisfaction in interpersonal relations from being a consultant for other clinicians…. To me, that’s just as fulfilling, being able to affect patient care by consultation.”

“Pathologists are one of the last of the general practitioners, if you really think about it,” Sodeman says. “A pathologist in the hospital receives specimens from every discipline.”

A pathologist in a small, rural hospital sees and does it all, says Sobel. Those in an urban environment would probably gravitate toward running the particular tests at which they are skilled. One might specialize in samples of the liver, another in breast tissue. But even in that setting, they would all have the expertise to cover each other’s territory.

Working with other physicians isn’t the only chance for human interaction. Forensic pathologists, beyond their deceased patients, are actively involved in community health, Sodeman explains. “Most of the seatbelt laws we see across the country are the result of the efforts of forensic pathologists in their community and nationally, because they understood the cause of death.” They know and work among police and with the legal system, not to mention relatives of crime victims.

For those who want both pathology and patient contact, there are options. Pathologists serve on tumor boards and with diagnostic units for breast cancer. Some might do fine-needle aspirations.

More such opportunities may also arise as the pace of technology and science quickens.

“The application of molecular testing is expanding and increasing and is being mainstreamed,” Sobel says, “so it is becoming more and more important for pathologists to at least understand what’s out there.” These tests form an area of specialization, but some of the more common molecular tests might be performed by general pathologists.

Increasing understanding and application of molecular markers of disease is changing the specialty, but what’s really significant, Sodeman says, are the markers that predict treatment outcomes. “All of that is opening up an incredible opportunity in this profession to really become involved in a more extensive predicting disease, and then... determining whether a patient will be responsive to therapy.”

But with growth comes pain. Like so many specialties, pathology faces a workforce crunch. Sodeman cites Association of American Medical Colleges workforce data showing that 45 percent of active pathologists are over 55 years of age, so more than 6,000 may retire over the next decade. Residency programs are only turning out 500 a year.

And there’s friction over reimbursement. Unlike physicians holding a stethoscope to a patient’s chest, when it comes to pathology, the public just doesn’t get it.

“In general, legislative bodies and regulatory agencies disregard the cost of doing a test, so third-party payers are basically squeezing the laboratories,” Sobel says. “There is a constant battle out there for getting fair compensation.” It might be a matter of public relations, but pathologists have to make clear to patients at large that the pathologist is necessary, even if invisible. “Sight unseen, you don’t understand the value of what the pathologist is doing. And the public’s lack of understanding is mirrored by their representatives and the regulatory agencies and the legislature,” Sobel notes.

But inside the hospital, there’s respect for a critical role without a lot of glory, Sireci says.

“Everyone is coming down to the pathologist, and oftentimes it comes down to ‘What’s the diagnosis?’ ‘What does the tissue say?’” Sireci says. “And the only person who can really say that is a pathologist.”
Pete Thomson is associate editor of The New Physician.