A Closer Look at the Pathology Residency

Session 116

Residency director and pathologist Michelle Dolan, MD joins me to talk about how to get the most out of your residency and what it means to slap glass.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:45] Interest in Medicine

Michelle initially didn’t know what to do back in medical school until during her second-year pathology course. One of their lecturers encouraged them to do a pathology rotation. So she did and she loved it.

She had to choose between Internal Medicine and Pathology. What drew her to Internal Medicine was hands-on patient care. But there were also some things that she didn’t like.

One of those five years could be a clinical intern year. So she decided to do an internship in internal medicine and she realized she really likes hospital care. This was before the advent of the hospitalist. She didn’t like the clinical aspect but she liked the slower pace of pathology.

[04:30] Traits That Lead to Being a Good Pathologist

The ability to focus is an important trait to have in order to be a good pathologist. For instance, you need to be able to sit in one place for an extended period of time at the microscope or the computer screen.

If you’re going into anatomic physiology, a good chunk of your day is going to be spent “slapping glasses” where you just sit at the microscope and look at a lot of different cases. But not every field in Pathology is like that.

One of the things that she likes about the field is how varied it is. You just have to be able to find that good fit for yourself.

Because pathology is so varied, there are people who are very visual and love learning by seeing. There are also other parts where it’s much more conceptual where you learn a lot by reading and thinking. There are other areas where you can learn by doing. To help you figure out which area to go into is to know yourself.

'Applicants should know what they like and how do they learn best and just to educate themselves about the broad variety that pathology has to offer.'Click To Tweet

[Related episode: The Pathologist as Medical Detective]

[06:45] Pathology as a Varied Field

There are not many trained pathologists that are cytogeneticists. One of the benefits of the Pathology residency is the exposure to every area within pathology. You can see what you like and you don’t like, or what’s a good fit and what isn’t. Then you can plan your career from there.

Pathology is a broad field in that they can look at a variety of patients from prenatal through geriatrics patients. They look at the entire lifespan.

'We do testing on just about any body tissue you can think of.'Click To Tweet

Moreover, pathologists get to know clinicians from a huge number of different fields. Michelle is also boarded in Molecular Pathology, which now goes hand in hand with Cytogenetics. There are so many tests now coming on board for molecular testing, most of which are housed in Pathology laboratories. Those connections among the different fields of medicine are only going to grow.

[09:50] Increasing Exposure to Pathology

All those being said, Pathology is not a required rotation in medical schools. This is a huge challenge because there’s a striking decrease in the number of U.S. medical school graduates choosing Pathology.

'Pathology is the best-kept secret primarily because it's a great lifestyle choice.'Click To Tweet

There’s so much curriculum change in medical schools now that Pathology is getting shorted on some face time so it’s difficult to engage students.

To overcome this challenge, they try to be creative in coming up with ways to engage students. One of which is through a Pathology interest group.

They also offer a Post-Sophomore Fellowship (PSF). It’s an entire year spent between the first two basic science years and years 3 and 4. It’s sort of a hiatus year where the PSF works like a Pathology resident.

While a number of people who have done their PSF program have gone on into Pathology, there’s also a good number of those who have gone into different paths. 

It’s a great year to learn your clinical medicine because Pathology requires a lot of knowledge of clinical medicine. Because they test a pretty broad patient spectrum, it’s very helpful for people going into other fields to have a firm understanding of Pathology.

[12:40] Breaking the Stigma

There could also be this ego among students where they go into medicine thinking they want to save people’s lives. So why go into something they “assume” can’t have a big impact on people’s lives.

'They think we're sociopaths who like to sit in the basement and not interact with people at all.'Click To Tweet

There is this weird stereotype around Pathology where people think they’re sociopaths. And Michelle admits to still hearing interviewees for residency being questioned by other specialties on choosing Pathology when they’re so good with people.

This is a big point of contention for a lot of them in Pathology. So much of their jobs require interaction with clinicians.

There’s a very strong drive now in Pathology to be out there more interacting with patients. 

They have initiatives like the “see, diagnose, and treat” put forth by the College of American Pathologists. Women from underserved areas would be able to come in and have a pap smear done. They’d be able to see those cells underneath the microscope. A diagnosis would be made at that time and interaction with the pathologist to be able to help them move forward with their care.

“There's initiative in our field to be more patient-centered. Our whole work is patient-centered.'Click To Tweet

Most pathologists don’t have day-to-day interaction with patients. This was even hard for Michelle initially since she liked working with patients.

That being said, there are also some downsides. You can’t romanticize the daily work involved in dealing with patients. 

[16:10] The Effect of Reimbursement Changes on Pathology

Michelle admits she’s being protected from this being in academia since they take care of billing for her.

However, insurance companies don’t reimburse well for some of the more complex testing that they want to do have. So they try to subsidize these by the bread and butter stuff so they can generate funding that will support some of the more esoteric testing.

Pathology has a very large professional footprint in the College of American Pathologists that they have a very strong advocacy role in Washington. They’ve pushed very strongly for better reimbursement for pathologists.

'There's a fair amount of disparity where the procedural based fields do not generate more income than do primary care and it's a terrible shame and inequity.'Click To Tweet

[18:50] Message to Medical Students on Rotation

A lot of their resident applicants actually found themselves being less interested in the surgery, procedure, or direct patient care than they were about seeing what happened to that specimen they took. They were curious about what those cells were in the fluid.

Typically, attendings on those other rotations are quite supportive when they realize someone has an interest in Pathology. They actually encourage them to follow it up in the Pathology lab.

Michelle recommends that third and fourth-year medical students on rotation should familiarize themselves with their hospital laboratory.

You have to understand how tests are properly validated. Know the strengths and limitations of those tests as well as the positive predictive values and negative predictive values. These things seem esoteric but they’re very important to know.

Much that goes into laboratory medicine is knowing the backstory of those results. A lot of test results are automated results. But you can’t just buy any instrument out there. There are extensive validations needed. 

You need to understand false positives, false negatives, sensitivity, specificity, etc. How low can you go to detect someone with minimal residual leukemia? How confident are you in saying that there’s no disease or there’s a little bit of disease?

These are all important things that are easy when you’re on the wards, you say all those numbers. But there’s a lot that goes into it. The more that you know about that, the better off you and your patients will be.

[22:50] A Day in the Life of a Pathologist

A typical day of a pathologist primarily depends on their type of rotations. They offer both anatomic and clinical pathology. The anatomic pathologists look at tissues coming from patient in surgery.

Clinical pathologists are involved in hematopathology. They look at bone marrow biopsies. They are the clinical chemists, cytogeneticists, molecular diagnosticians, immunologists, and blood bankers.

So it depends on what rotation the resident is on. If they’re on anatomic pathology rotation, they are looking at slides most of the day.

They may be grossing in specimens. This means they’re processing specimens so they can cut them and get them onto the slides. Then they look at them under the microscope.

They may be doing frozen sections running back and forth between the O.R. and the grossing room where they do immediate evaluations of tissues.

In cytopathology, they may be out doing a fine-needle aspiration or an adequacy assessment if someone is having a procedure done under ultrasound or interventional radiology guidance.

In a clinical pathology rotation, they’re on blood bank. They may be out doing transfusion reaction workups. They may be consulting on apheresis patients.

If they’re a hematopathologist, they may be out doing a bone marrow biopsy or evaluation bone marrows under the microscope.

'It's very clinically driven. Each of our specimens is a patient.'Click To Tweet

Michelle clarifies that although they’re not directly involved in patient care, they still want to help patients. They’re helping patients by looking at and processing all of these specimens properly.

[25:10] How to Be a Competitive Applicant

Some of their applicants will almost do a mini-residency where every one of their rotations has been skewed towards pathology.

This is not a bad thing actually. But she tells them that they have four years to become a pathologist. What she really likes them to learn well is clinical medicine. So really do good, focused clinical rotations. They will help you become a pathologist.

'Learn clinical medicine. This is your chance to get exposed to all of that wide-patient spectrum.'Click To Tweet

Of course, you should do a basic pathology rotation. This will allow you to figure out if you’re a good fit. And also, this will help you develop a good working relationship with a mentor who might be able to give you a good letter of recommendation.

It is helpful for program directors to know that the applicant actually knows what pathology is all about. So they don’t come into it thinking it’s all just forensics or autopsies. Again, know clinical medicine as best as you can.

Moreover, pathology has the aura that your answer to a given specimen is the only answer. But this is not true. They consult themselves a lot. There’s not just one answer to things. There’s often not a definite answer that people are expecting.

'There are things that mimic cancer. You have to be careful not to overcall or undercall something.'Click To Tweet

[28:00] Overcoming Bias Towards DOs

Michelle says that they’ve never seen any bias towards DOs. In fact, a lot of DOs come through their program. They have a lot of applicants who are DOs. One of their strongest residents was a DO who just left for a cytopathology fellowship.

So she gives the same advice to interested DO applicants to know clinical medicine. That being said, she has never come across any bias towards DOs.

'I have not come across any bias towards DOs. They've really proven themselves to be outstanding pathologists.'Click To Tweet

[29:05] What Makes a Great Pathology Resident

No matter what field of medicine you’re in, you will get out of residency what you put into it. 

So they want to see someone who’s really interested in Pathology. One has to have the drive and they want to see things, participate, and actively do things.

'Pathology is active. Much of pathology, at least in reticular and atomic pathology is learned by seeing a lot of slides.'Click To Tweet

A resident can’t be exposed to every entity that’s in pathology textbooks. They’re going to have to do a lot of independent learning and reading. They have to look at the great images that are now available online.

They want to see some of that initiative. Get early, stay late. Participate in as many as different conferences as possible. Ask questions.

Moreover, they’ve had people who would seem they’d struggle if it were just based on paper. But they’ve overcome that. They’re stronger for it.

Michelle explains that they are liberal in the sense of not judging people on paper. They’re willing to give people a second chance. 

'There's a lot going on in people's lives in med school and sometimes, it's not just reflected well on paper.'Click To Tweet

Another misplaced emphasis is trying to do a mini-path residency as explained earlier. You have multiple areas you’ve done rotations in instead of just focusing on your clinical knowledge. 

[33:15] What She Would Have Told Her Younger Self

Michelle would probably tell her younger self that just because you’re looking for the perfect fit, don’t worry, you will find that square hole eventually.

Keep an open mind. For instance, Michelle kept her forensics rotation to the very end thinking she was going to hate it. But she loved it! Had she just had an open mind and done it a bit earlier, her whole career might be very different since she was already doing her fellowship at that point.

Be patient with yourself. They met a number of applicants every year that didn’t find anything that really clicked until they did their pathology rotation.

'Try something that you can't imagine yourself liking but it might surprise you.'Click To Tweet

[36:02] The Most and Least Like Things

Michelle loves interacting with clinicians. She finds it very rewarding as she’s able to get a sense from them as to what their struggles are. This way, they’d be able to determine what is needed for them to make a diagnosis and how to help them.

They’ve made some calls that have literally been life-saving. Those may not happen everyday, but they do happen frequently.

'Sometimes it can seem that we're just data generators. By helping clinicians work through and with our data, we see that it really does make a difference.'Click To Tweet

On the flip side, what she likes the least is the feeling that there is so much in pathology that you can’t master. There’s just so much to know. And it’s becoming more subspecialized.

They also have to realize the fact that they’re not immune to making mistakes or misses that have significant negative ramifications on patient care. It can be a difficult, almost paralyzing fear that you can develop. You just have to make the best decision and best diagnosis you can and move forward.

[37:50] Major Changes in Pathology

Michelle thinks that all of the major advances in genetics and genomics is huge. Most of these targeted drug therapies are driven by molecular diagnostics. It’s a specialty field you can do a fellowship in Pathology.

'Genetics, genomics, personalized medicine are squarely in the pathology camp. This is a huge area that's only going to grow.'Click To Tweet

Personalized medicine and informatics are two other huge areas. Particularly, computational pathology is tied into informatics.

[39:35] Final Words of Wisdom

Pathologists constantly encourage students to be interested in pathology. They’re saddened by why U.S. grads are not turning to pathology as both a great career choice and a great lifestyle choice as well.

They have many switchers to Pathology. So just try to get to know a pathologist. Call the lab director. Call the hematopathologist and ask if you can review the slides with them. There are insights that you can get that you cannot get just from reading a report. 

Understand what it is that you’re seeing so you can understand the patterns. So when you’re on a medicine rotation or a peds rotation, you can understand these things without necessarily going into Path.

'Having that background is tremendously helpful no matter what field you go into.'Click To Tweet


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