The Top 5 Pathology Myths – Busted

Pathology is often a mystery to medical students, the average clinician, and the general public. Because of the lack of exposure to our specialty, many rumors surround our field. Here we address the top five myths about pathology that couldn’t be further from the truth. 

If you’re a medical student that has mentioned you’re interested in pathology, you’ve probably heard something to this effect. It’s totally understandable from a layman’s perspective because popular medical shows portray pathologists as being bad with patients. In the television show Scrubs, Dr. Doug Murphy fails miserably with patients (even killing one!) and gets moved into a pathology residency. In The Good Doctor, the autistic surgery resident gets moved to pathology after having difficulty working with patients. Why do clinicians keep this myth alive? The vast majority of medical graduates will never do a rotation in pathology. It’s easy for them to believe pathologists sit alone in the basement all day. 

In a standard four-year anatomic pathology /clinical pathology (AP/CP) residency, residents spend at least 18 months on clinical pathology (CP) rotations including transfusion medicine (blood banking), microbiology, and hematopathology. Each of these rotations offers numerous opportunities for patient interactions. For example, during transfusion medicine, residents interact with and treat patients during apheresis procedures. In microbiology, some institutions have pathologists rounding with infectious disease teams. In hematopathology, some pathologists perform patients’ bone marrow biopsies. On anatomic pathology rotations, residents on cytopathology routinely perform fine-needle aspirations (FNA) to determine the adequacy of a sample and provide meaningful test and therapy guidance in real-time. For instance, clinicians may suspect an enlarged lymph node is cancer, but during an FNA, the pathologist may suspect an infectious process and recommend additional tissue for microbiologic cultures.

Pathologists also frequently engage in academic education. Your medical school may have lectures taught by pathologists. In some hospitals, pathologists teach other subspecialties, particularly surgical specialties, about proper specimen handling, the appropriate use of interoperative consultations (frozen sections), and various diagnoses. Frozen sections are a critical aspect of many surgeries guiding the surgeon’s next steps, whether it is to access resection margins of cancer specimens, infectious processes, and more. Additionally, pathologists play a vital role in tumor boards by demonstrating pertinent histological findings to clinicians, answering questions about diagnoses, and translating what this information means for patients. Considering all the roles pathologists play, it is vital for them to be "good with people."

There is history related to this myth. When pathology dropped the requirement for an internship year, those residents graduating after four years found themselves competing with the same class that graduated after five years. It doubled the residents entering the job force at once. This drove many residents to pursue fellowships while waiting for the job market to stabilize. This was multiplied a few years later during the financial crisis of 2008. It is logical to assume in a specialty where it is easy to keep working a few more years, people would stay in while they waited for their retirement portfolios to recover. 

Now that we are more than a decade out from the recession, the job market has been steadily improving. In fact, recent publications have stated that over the next five years there may be a national shortage of over 5,000 pathologists. New-in-practice pathologists have described a perceived decrease in difficulty finding a position over the last five years. In fact, the majority accepted jobs in their desired practice setting and were satisfied or very satisfied with their position. It is important to note that the likelihood of taking a position did not differ according to age or gender. As you can see, the job market is very promising for the pathology profession. 

Although this myth appears on blogs, in practice, it is the opposite. Any specialty that interacts with pathologists greatly values the role pathologists play in patient care. A great example of this is the information pathologists provide to clinicians in tumor boards. Pathologists help demystify every specialty’s most complicated cases. Often, a clinicians’ most interesting case is routine for pathologists. Pathologists play a vital role in establishing a definitive diagnosis to enable a clinician to provide optimal care. This includes testing for the use of immunotherapy (ie PD-L1 testing) to equip oncologists with more treatment modalities. This is why pathologists are often known as “the doctor’s doctor” or a “medical detective.”  

This is understandable from a layman’s perspective because popular medical shows portray autopsies as the only role pathologists in healthcare, think CSI, Quincy, Bones, etc.  Also, most medical schools have extremely limited exposure to pathology as a career. It is common for “pathology” to be reduced to the courses in pre-clinical years (some without any microscopic pathology at all!). Without exposure, it is unlikely medical students opt for a pathology elective in their clinical years, given the already cramped schedule. 

The truth is autopsies are a small portion of anatomic pathology residency. Pathology residents in anatomic pathology must perform a certain number of autopsies in residency to become board certified. Some residents find this work extremely interesting and pursue further education in the field. Other residents do not enjoy autopsies and never perform an autopsy after residency. 

One of the best parts of pathology, is the field is so large you can choose how big a scope you want to have. Some people will never want to do another autopsy and will find a job that does not require this. Others will find jobs where they can occasionally do autopsies to keep their skills up. Others still will build careers around only performing autopsies. One can decide how much they like them and select their career accordingly. This is the case with other aspects of pathology—hematopathology, cytopathology, dermatopathology. It all comes down to your comfort level and interest.

Artificial intelligence will change the practice of pathology (as it will many specialties in medicine) but will not render the pathologist obsolete. This myth that artificial intelligence will take over pathology assumes that medicine is both static and completely solved, but this is very far from the truth. Pathology is extremely dynamic—as new tests become available, especially in the realm of molecular/genetics, the categorization and classification of tumors are continuously changing. 

Pathologists are at the forefront of the classification of disease and incorporating new diagnostic modalities into clinical practice. Pathologists welcome the fact that artificial intelligence will increase their productivity by screening out benign cases from malignant ones. This will allow pathologists to spend more of their time on diagnostic challenges and emerging diseases. A real-world example of machine diagnostic collaboration has already been put into practice for over a decade. In the field of cytopathology, a large portion of benign pap smears are screened without a pathologist’s intervention.