Give Pathology A Try

[Guest Littlest Zooropa]

I posted this for the clinical clerks, but then realized that it might be interesting for the med students, too.

 

I'm a resident in pathology (a specialty that traditionally is invisible in medical school), and I just wanted to put in a plug real early for my specialty so that some of you keeners might give it consideration in the future.

 

Pathology is a truly great option for med students with sharp intellects and oodles of patience.

 

First off: the average salary of pathologists in Canada was between $200-250 K. Some provinces average out less, some more. The highest paid group in pathology was General Pathology. Oh yeah, let's point out that pathologists, by and large, DON'T HAVE OVERHEAD.

 

Secondly: the lifestyle cannot be beat. I did the PGY-1 thing with just about every different discipline, and pathology has got it in the bag. EVERYTHING can go into formalin. EVERYONE can go into the fridge. Nothing has to be done about it at 3 am. **

 

And this teaching by intimidation thing that surgery has got going? No way, kids. Lousy people skills and crummy personalities? Ha, not on your life. Pathologists are doctor's doctors - you have to have some powers of persuasion to keep the surgeons in line! The only drawback to pathologists is that they tend to be very detail oriented (no surprise there) and because of that they can get very obsessive-compulsive about the little things. If you realize ahead of time that this departmental psychosis exists, it's easy enough to get used to.

 

You'll find yourself picking nits next.

 

So what do Pathologists do?

 

1) Autopsies on dead people (e.g. people who died in hospital, those who died under unexplained or suspicious circumstances, those for whom there is no physician to sign the death certificate and at the request of coroner if you are to labour under the coroner's system). This is called, not suprisingly, autopsy pathology. And now people out there are saying "Yuck, how gross." Not really. You get used to cutting people up in surgery, and in autopsy you can't hurt them. You don't have to worry about inadvertantly lacerating their liver or hacking through the common carotid or whatever it is that surgeons worry about. You get to poke around in their hearts and brains and you get to see what sort of life they lived (you smoked too much, Mr. Smith!) and what killed them (too much alcohol, Ms. Jones!)

 

2) Examine specimens sent in from other doctors. This is referred to as surgical pathology. For example, Dr. Dermatologist sends in a little lump or bump or spot he took off his patient's arm. He wants to know if it's skin cancer or a mole or what. The techs pop in into a cassette, embed it in paraffin wax, then cut very fine slices to mount on glass slices. After the slide has been stained, the pathologist looks at them under a microscope, and is able to tell if the bump was a mole, or melanoma (skin cancer). In addition, the pathologist will tell the surgeon whether he cut all of it away, and if it's a cancer, will grade it (how bad it looks) and stage it (how far it's travelled). Or let's say Dr. Surgeon takes out someone's appendix because he thinks that they have appendicitis. The pathologist receives the slides taken from that appendix, and can tell the surgeon whether the patient DID have appendicitis. Maybe the appendix is perfectly normal, and the surgeon has to re-think what was causing the patient's pain. Or maybe the patient doesn't have appendicitis, but has a carcinoid tumor tucked down there. In a variant of surg path, surgeons can send up bits of tissue from the operating rooms for a rapid evaluation by frozen section. We prepare slides and report back what we see, ideally within fifteen minutes (Pathologists R Us - Diagnosis While U Wait!)

 

3) Fine need aspirates. Many times, particularly for lumps in breasts or lumps in the thyroid gland, the pathologist or another physician will stick a tiny needle into a lump to get some cells out. The pathologist can then look at the cells, and can determine whether the cells look like they came from a benign structure, or from a malignant growth.

 

4) Run labs. General (also called clinical) pathologists are responsible for making sure that the labs keeping running. So every time someone orders a CBC or troponins or taps CSF it passes through the lab run by a pathologist. If there is anything strange or unusual that worries the technologists, they consult with the pathologist, who is responsible for evaluating all the weird and wonderful stuff. So let's say you're in the ER sending a CBC on your febrile patient, and it gets flagged in the lab as being patently abnormal. The pathologist can sit down and take a look at the peripheral smear, and diagnose a previously unsuspected leukemia in your patient.

 

Even though patients (and medical students) almost never interact with pathologists, they are responsible for most of the definitive diagnoses made in hospital (note the word definitive), with radiologists providing the rest. It's a specialty that has an enormous impact on the well-being of patients, and occupies an essential position in the chain of patient care. Although pathology doesn't have the same prestige as surgery (hell, it doesn't have the same prestige as psychiatry!), what would you rather have?

1) Money and prestige, or

2) Money and the opportunity to sleep through the night

 

Residency is very pleasant. Pathologists are among the most amiable doctors in the hospital and tend to be excellent teachers. If your med school has a path residency program, go visit the residents. See how clear the eye, how rested the faces. Watch the pathologist transform people's lives for good or for ill with a few pieces of glass, light, and a cup of Starbucks at her elbow.

 

If you're not 100% sure what you want to do with your life, go visit your friendly neighbourhood pathology residents and see how happy and productive residents can be.

 

Good luck!

 

** Forensic pathology may require some getting up for scene investigation. But many of the homicide cops they send to the morgue are young and cute!

[Guest me maniac]

hey, Zooropa,

 

Actually, I am very interested in Path. I was wondering what province you are doing residency in and if you like it there. I am hoping to apply to UBC in two years. I was also wondering what kind of electives you took. I would really appreciate any assistance you can provide.

 

me

[Guest shy]

I totally agree. I did my undergrad in a Pathology Deptand it is a very interesting specialty of medicine and does have a great lifestyle. One thing I would like to add...all my profs were pathologists and they were great, so remember there is lots of opportunity/time for teaching as a pathologist too, if that is something you are interested in.

 

Zooropa-what precentage of female pathologists are there? Do you have any idea how it is to balance family with a career in pathology?

 

I am getting ahead of myself because I am not in medicine yet but am hoping to be this September.

[Guest Jochi1543]

I'm very interested in anatomic/forensic pathology, but I'm torn between that and family medicine. I visited my county's medical examiner (I live in the US right now) and interviewed him about the profession, and I still can't decide. Hopefully, the clinical rotations will help me with this.

 

Is anyone here familiar with the advantages of pursuing a fellowship in forensic pathology (in the US) on top of a general path residency? Assume a future career as a coroner or medical examiner. Would that lead to a higher income or make it easier to land a job?

[Guest WhiteTiger]

Thanks for that post Littlest Zooropa,

I'm currently a microbiology and immunology undergrad and I've been wondering for some time about the challenges/pay/lifestyles of a pathologist.

 

It's nice to see someone posting from the other side of the medal (not just the "ugh, dead people" posts)...

[Guest Littlest Zooropa]

I'm in Pathology at the U of Saskatchewan. It's a young program, but, as I say, the pathologists are very amiable and the lifestyle is delightful (our department is just down the hall from the JURSI [clinical clerk] callrooms, so I know of what I speak!)

 

To me, more important than deciding on a SCHOOL at this point would be to decide on the type of pathology you want to practice. You can choose general path (a combination of anatomic pathology and clinical pathology - also called AP/CP in the states) or straight anatomic pathology. The other option is to do a sub-specialty pathology right off the bat - for example, I believe that hemepath and neuropath are both offered in Canada.

 

So what's the difference? GP (general path) do a little bit of everything, and tend to work in smaller/community hospitals. If you want to get a job at Mt. Sinai in Toronto or the Vancouver General, you need to do anatomic pathology, I would expect, and probably would need to have subspecialty training to boot (a fellowship of a year or two after you graduate from your residency). And if you are really gung-ho for hemepath (hemepath is GREAT because there are a lot of ancillary diagnostic techniques which are really cool and work pretty well - e.g. cytogenetics, some molecular, immunohistochemistry and flow cytometry) or neuropath you can enter those programs directly, as far as I am currently aware.

 

So once you've made up your mind on a type of pathology, then decide on schools. Best advice - talk to the residents. This applies to EVERY and ALL residency programs. If they all have funny white scars on their volar wrists or the haunted look of refugees, you may want to re-think that particular program. As a clinical clerk, you can [discreetly] ask them about the strengths and weaknesses of the program - mostly they will give you the straight dope. And if you have a particular passion - e.g. dermpath vs soft tissue pathology vs hemepath - check where the national gurus call home. If you want to get hard core about a particular bit of the body, there's no substitute for hanging around with the highest authority in the country.

 

In terms of electives, I did a lot of random stuff just for interest's sake - e.g. clinical genetics, neonatology, ENT surgery, and of course pathology. I'm not recommending that approach; it was just what I did. If you are interested in a particular program at a particular school, it's always beneficial to do electives there and impress the hell out of them. If you don't know what you're interested in, spend some time in anatomic pathology just to make sure it agrees with you (you may discover, for example, that you faint when confronted by corpses or are colourblind).

 

When you are in med school, check out your pathology department for educational opportunities in pathology. Many pathology departments hire summer students to do projects, and it's not a bad way to get a foot in the door and make friends (and next year's tuition). In addition, some American schools have summer programs aimed at immersing medical students into the discipline of pathology, and these are, to the best of my knowledge, open to Canadian applicants as well.

 

Have fun!

[Guest Littlest Zooropa]

Hello Everybody

 

I can't get at the stats for gender ratio amongst pathologists (I'll post it as soon as I figure out what my CAP password is), but in terms of trying to juggle work and a family, pathology is one of the very best medical specialties.

 

In med school (and I was in medical school in THIS millenium not in the 1950's), one [female] physician advised the women in the class not to become mothers, as they would have to sacrifice either their careers or children. The point is that to choose medicine is to automatically put other people before yourself.

 

Having said that, the disciplines most amenable to having a life are pathology, radiology and family med. Pathology and radiology are particularly good because these can (and have) been practiced from home by stay-at-home physician-mommies. In both, your physical presence isn't usually required - you can review films via your computer, or review the slides on your home microscope. Of course, one has to bear in mind that residents in both radiology and pathology could potentially be exposed to agents which would be hazardous to a pregnancy (although that probably goes for every medical specialty).

 

Anyways, in terms of family-friendliness, pathology ranks very highly because:

 

1) you can choose to work as much as you want

2) to some extent, you can choose where to work from

3) *** little to no call ***

 

Hope this helps!

[Guest Jochi1543]

I just wanted to mention in regards to the call time: in forensic pathology, you will be in call for a certain amount of time. The medical examiner I interviewed in the States was on call every 4th week of the month. He was the Chief ME and there were 3 assistant MEs in the office. I imagine in a smaller office, you could be on call for 2 weeks every month. But since forensic pathology requires visits to crime scenes which can sometimes be unearthed at 3 AM on a weekday, it's a little different.

[Guest Littlest Zooropa]

Note to those would-be Crossing Jordan types:

 

Most of Canada is under the coroner's system; the only exceptions (I believe) are Nova Scotia and Alberta, which have a medical examiner's system (feel free to correct me if necessary).

 

If you're considering Forensic Path, it's important to know the difference between these two systems (for example, under the coroner's system it is the coroner (or designate) - not the pathologist - who examines the scene and determines the manner of death*, whereas all of that falls to the medical examiner or his/her designate in provinces with a ME system). Forensic path is very cool and never dull, but I'm not aware of any forensic path fellowships in Canada (anybody out there know differently? - include a link!)

 

For those who may be interested, here are two reference sources which list most of the fellowships currently be offered around North America (the Canadian listings are not complete):

 

Pathology Outlines

Intersociety Committee on Pathology Information

 

* this is kind of sticky point, but it is my understanding that the determination of manner of death is made by the coroner's office using the information provided by the attending pathologist - which is why our reports (under the coroner's system) indicate cause of death plainly, but do not speak to manner of death

[Guest Jochi1543]

It's true, there aren't any forensic fellowships in Canada right now, everybody goes to the US to train for FP. 8o

[Guest UTMed07]

It's true, there aren't any forensic fellowships in Canada right now, everybody goes to the US to train for FP.

I just did a search in google... and found this--a list of LMP fellowships (in Toronto):

1 Advanced Electron Microscopy

2 Bone and Joint Pathology

3 Breast Pathology

4 Cardiovascular Pathology

5 Cytopathology

6 Endocrine Pathology

7 Forensic Pathology [emphasis added]

8 Gynecological Pathology

9 GI/Hepatopathology

10 Hematopathology

11 Imaging Analysis

12 Medical Biochemistry

13 Medical Microbiology

14 Molecular Diagnostics

15 Neuropathology

16 Oncologic Pathology

17 Pediatric Molecular Diagnostics

18 Pediatric Pathology

19 Sarcoma Pathology

20 Surgical Pathology

Littlest Zooropa's link (Pathology Outlines) -- shows that same link I found with google -- "Toronto, Ontario, Canada, University of Toronto-Forensic." That said, "Forensic Pathology" doesn't make it onto the currently offered page. Why it isn't offered... I suppose is for 1 of 3 reasons -- (1) it isn't offered (2) it is offered but one has to ask for it (3) it is offered but snapped up by path residents internally (and thus not listed). I'd guess it is (2); if one wants to organize a fellowship it can be done. I'm pretty sure Toronto has enough expertise to put on a program.

 

On the system (coroner's) I found this. It is a good description and also addresses the issue of additional training:

In any cases of doubt, the Coroner must request a PM. The PM will be performed by a Pathologist, a medical specialist. Hamilton, Kingston, London, Ottawa, and Toronto have Forensic Pathology Units where Coroner’s PMs are performed. In other regions of Ontario, these PMs are done by hospital Pathologists who have been approved by the Office of the Chief Coroner. Some Pathologists have passed extra examinations in Forensic Pathology, usually in the US or Britain. At this time, there is no Canadian certification in Forensic Pathology. [emphasis added]

This fits with what I know-- the murder cases are separated out and done by centrally. I imagine these people have some more training... but the above suggests it isn't formalized. Perhaps the lack of certification goes back to the fact that the Canadian pathology residency is 5 years... the American one 4 years.

 

Any case, I have the sense that a fellowship (in forensic path) isn't necessary in Canada... whereas I don't know if one could get a job (investigating murders) without one. Less than murder-- it seems a certified pathologist can do it. I shaddowed a pathologist in a community hospital (who doesn't have additional training in forensics)-- and watched a bunch of autopsies. One of the autopsies I saw was a suicide, which strictly speaking is a forensics case.

[Guest UTMed07]

One of my favourite pathology sites -- Virtual Autopsy. Try to make the Dx.

[Guest Jochi1543]

Oh, cool site, me likey.