Interested in pathology but worried about autopsies

[pathomed]

Hi everyone

 

I am a first year med student and have recently fallen in love with the idea of pursuing pathology as a career; however I am worried about the autopsy bit. I know that people say that that should not hold someone back and that you don't have to do them as an attending if you do not want to. I am all about the diagnostics/histology/looking at slides all day, so that is what I hope I would get to focus on as an attending. I also realize I have limited exposure to this, so I'm going to work on getting over my fear of the unknown by going to watch some autopsies. I am wondering however, how many autopsies you have to do as a resident? Is it a daily or a weekly thing? Do you just assist as a resident or are you doing them on your own/with other residents?

 

I would really appreciate any answers! Thank you!

[Lactic Folly]

It's my understanding that the volume of autopsies has really dropped over the years. Although you would need to learn how to do them (and be able to handle pediatric autopsies), I doubt you would be doing them on anything close to a daily basis, but one of the path residents can better speak to that. Remember there are also subspecialties such as hemepath that wouldn't necessarily be involved. I'm sure they would welcome having you come observe in the pathology department and have all your questions answered

[thebouque]

Path resident here.

 

To sit the american board you have to perform yourself 50 autopsies during residency. You actually do the autopsies with the help of a technician, you dont observe. However, its not a requirement for the royal college and many residency programs struggle to reach that number. Therefore, performing autopsies isnt a daily and not even a weekly activity for a path resident. Some schools however have a dedicated autopsy rotation (usually 3 months in pgy2 and then once in a while). Dont forget that each autopsy has a histo component.

 

I think fetal autopsies count towards the 50 required for the ABP. Note that theres also a compulsory 2 month forensics rotation and you might only be an observer during those autopsies depending on the province,therefore they might not count towards the 50.

 

Path is a great field and honestly, you can definitely enjoy it even if autopsies are not your cup of tea but as you said, its a great idea to go and see one as a medical student (I think it should be compulsory but thats another story).

 

Peace

[dazzle]

I've looked into both rads and path, and would recommend choosing rads over path. Both are diagnostic fields, but rads is better.

 

One of the reasons that path can't get anyone into it is, and why rads as an edge over path, as the op has noted, is autopsies. I've seen a few, and they're pretty unpleasant, and from what I gather, not very useful outside of coroners autopsies. Luckily they seem to be dying off, pun intended, so if you enjoy microscopes and cells more than computer screens, anatomy, and autonomy, path can provide that without needing you to do autopsies in your career.

 

 

 

post goes well with the sig

[pathomed]

Thank you so much for the responses everyone! Glad to hear autopsies are not a huge component during residency. I guess one can learn to get through them after you've gotten over the shock of the initial few. But yes absolutely I'll be going to the pathology department and hopefully will get some good exposure.

 

brooksbane: I have been a rads gunner until this point (have multiple research projects going on, shown tons of interest and have had lots of encouragement from radiologists, professors etc to go for it) - but lately I have realized there is no spark there. When I crack open a rads textbook, I don't get excited and don't want to tear through it and read it cover to cover. The images frustrate me because they're not clear enough for me. Maybe it sounds extremely stupid, but I just find looking at clear rows of cells, being able to see the nuclei in malignant cells so much more satisfying to my eyes/brain/soul than looking at X-rays, CTs, MRIs, no matter how awesome the quality. Don't even get me started on ultrasounds. And it's not that I'm just dismissing it without giving it a try and letting it "grow" on me.....I've tried and there is nothing there.

 

Maybe if I kept at it, I could eventually learn to like those images because I'd have mastered them. But then there is the aspect of what they actually accomplish. My impression about rads vs. path is like this: in rads I'd probably be looking at tons of normal x-rays all day because so many primary care physicians will refer people who will have normal studies. Yes I'll get some cases where something stands out, but I'd be bored to tears just dictating reports that say "Normal chest X-ray". The money I'd get from dictating that wouldn't mean much to me because I'd be dying inside a little each time.

 

No doubt, I might find something crazy every now and then....or find something as an incidental - but my impression is that for the most part, you look at a lot of screening type tests/normal studies, which aren't that exciting. It comes down to a personality thing; I feel like a hypocrite doing something I find no inner satisfaction in doing. Yes, I may end up at an academic center where I'd get crazy study after crazy study, but lets be honest, getting those jobs is tough and isn't all about how good you are, it's about who you know, that's when the politics come in. So if I'm out in the community, I do think I'll end up seeing many normal cases and although I'd be paid well, I'd wonder everyday why my life matters. Of course I could be totally wrong about this and would love to be told so.

 

Pathology on the other hand: other than pap smears, if you have that slide in your hand, you know this person has most likely already had a battery of tests....they've likely had labs run on them, imaging done that found something, and someone has bothered to do a biopsy on them, so most likely there is something going on, it's just that the puzzle needs to be solved. You're not treating the healthy, well patient at this point. You need to figure out *exactly* what it is that they have, and it's likely something serious that could change the course of their life. Yes radiologists also in some ways figure out what it is that the person has. If it's cancer they see, they'll tell you that. However cancer isn't just a lump, you still need to know what kind of cancer it is, what sort of metastatic potential it has, heterogeneity, the grade, which dictates what treatment they will get, and nothing does that except pathology. Rads will tell you if something is there or not and *sometimes* be able to tell you exactly what, but pathology will tell you what that something is, which is the final word. That's cool stuff. You're answering different types of questions with each specialty and the types of questions in pathology appeal more to me. To me it's not enough to know if there is a cancer or not.....I need to know if it's there, what type it is, what the prognosis is, and a billion other things. Other ascpects that are awesome: cancer diagnosis is your bread and butter which to me is really meaningful. I love histology.....a lot. And I can read about pathology 10 hours a day and not get tired.

 

So from that angle, I know pathology is something I love. I have spent hours and hours reading about rads vs. path. You are right.....rads is more appealing if you look at it from a financial standpoint, the autonomy you get from being able to bill FFS and not be "owned" by a hospital. If I was in Quebec, I would not think twice about going into pathology because the renumeration and overall value of pathologists there seems a lot better than Ontario.

 

I'll be perfectly honest - reading about how pathologists are salaried and how they have very little autonomy is very hard for someone who has a genuine interest in the field. I might still do it because I love it, but it's frustrating to me, because I don't find the work of a pathologist to be any less stressful/important than the work of a radiologist. You need to be just as much of a nerd and a hard worker to go into either one. Yet in one you are making huge amounts of money and seems so flashy and the other seems like a specialty that's been bullied into being salaried and loses all the good applicants because it's at the bottom of every match list.

 

I am quite a strong student, am very hard working, and would hopefully not have issues matching to even the super competitive specialties (this is not my personal ego speaking, my professors/tutors/residents have said things like this to me). So when I read that pathology is a specialty where all the desperate people go, that to me is sad because although it won't stop me from doing it anyway if it's what I love (because I'm secure enough to know my own potential and don't care what others think/say, my work will speak for itself) it does make me wonder what my peers will be like and if that will become a source of frustration for me. I need to be around hard working people who are extremely worried about patients and who are obsessing over their work, not sitting in a laid back atmosphere.

 

My impression before reading things like this was that pathology has all the super smart people and that since it's not as lucrative, maybe that weeds out all the money-hungry superficial people which could be a good thing. More and more so however, it sounds like pathology just has people who couldn't go into anything else due to personality/competence issues and that's a sad thing I really hope these are rumours spread by people who just look down on path in general and that the truth is far from this. I really need to go down to the path department and hang out there to know for sure.

 

So I guess I'm really confused - I know I love pathology, but the salary part, the autopsy bit, and above all, the lack of acknowledgment for the insanely hard work and knowledge required are all downsides. It's like a slap in the face of every pathologist that other specialists are off making so much more than them when they could have destroyed those very people in terms of knowledge at any point in time in med school. I don't know how pathologists deal with that, because no matter how secure you are, it does have to rub you the wrong way at some point. I was actually shocked regarding all these aspects of pathology when I learnt more about it, because I had expected them to be super respected and well paid just like radiologists. But reality seems to be that not only do you not get appreciation/acknowledgement from your patients (which you don't get in rads either unless you do interventional stuff), you also get none from the people paying you, and you also get very little from other specialists at times. So it sounds to me like pathology must have the most humble, kind-hearted and giving people in all of medicine to work so hard despite getting such little in return.

 

Everyone please feel free to point out all the parts of my post that were wrong and totally dumb, it's the only way I'll learn the truth otherwise I'll stay in the dark

[Laika]

Pathomed, a few points regarding your well-thought out post.

 

1) Rads vs Path. I, personally, agree with your rationale for choosing path over rads. I spent a lot of time shadowing rads in med school, and it just didn't do it for me. Radiologists (often) give differentials, while pathologists (usually) give a diagnosis.

 

2) Autopsies. You'll need to do them during residency. If they're not your cup of tea, the good news is that they comprise a very small component of the workload for most practicing pathologists. And who knows? You may be surprised -- forensics is an awesome field.

 

3) Remuneration. I disagree with your statement that "other specialists are off making so much more." Subtract overhead, and divide by the number of hours a week they work. How does their hourly wage compare?

 

Granted, rads is more highly paid, but that's true when it's compared to most other specialties. And, there appears to be a trend, in Ontario at least, to decrease the discrepancy between specialty pay. For example, I believe rads billings were recently cut by 8%, and path salaries by 2%.

 

Working as a contract pathologist (so you can incorporate) is becoming more common. This will likely further change by the time you're looking for a job in ~7 years.

 

If your base salary isn't enough for you, pathologists often pick up a half day a week in a private lab. The work is boring but lucrative.

 

4) The residents. There's a wide variety of residents in path. Some are strong applicants who could've had their choice of specialty, others ended up in it because they were looking for a CO2 field. Rest assured, not all of us were desperate. Do an observership at your school and meet some of them...

 

5) Prestige in path. There is none. If this is very important to you, choose another field.

[Lactic Folly]

I don't know how pathologists deal with that, because no matter how secure you are, it does have to rub you the wrong way at some point.

 

Kudos on your well-thought-out post. With reference to the above quote, some of your reservations sound like field stereotypes (perhaps from medical school classmates or internet posts?) as they aren't along the lines of what I've heard from the pathologists and pathology residents I've talked to.

 

This is completely understandable if you've had limited exposure during your training to date, and I commend you seeking more information. Like Laika, I encourage you to spend some time in the department at your institution, and get the advice of people firsthand. I think you will find a lot of your fears eased. By and large, the people I've met in pathology departments seem very happy, well-adjusted, and satisfied with their career choice, which is in some ways a hidden gem... take care to not become bitter before your time

 

1) Salary - You can look up the Ontario public sector salary disclosures yourself, but having seen the average salaries for pathologists, I would wonder about anyone's frame of reference who would contend that they are not well remunerated. I think they come out quite well in comparison to other physicians (remember there is no overhead, and often additional benefits), especially when compared on an hourly basis. As the pathologists I worked with said, they aren't being paid for the hours they work, but for the impact of their decisions...

 

2) Respect - as I alluded to above, I wonder if you are confusing this with the lustre of prestige due to competitiveness in the minds of medical students pre-CaRMS. I remember NLengr saying that surgeons hold pathologists in even higher regard than radiologists, and certainly there are many more people who are willing to provide their own interpretation on a CT than on a histology slide. I do not doubt that the pathologist's word is much respected by those who depend on their decisions.

 

As for appreciation/acknowledgement, you need to define what you mean by that. If this is a main motivating factor, rather than the satisfaction of knowing you have set the patient's management on the right course, then arguably neither path nor rads fit the bill. However, there is satisfaction in being a valued member of the team, as well as in knowing that there is a flip side to hugs and cards from patients.

 

I have not found rads to be 'flashy' at all in the departments I've visited - both diagnostic fields tend to attract low-key personalities - when is the last time you saw an interventional radiologist on the news with a patient (compared to press conferences about surgical breakthroughs)?

 

3) Nature of the work - yes, I think that "hard working people who are extremely worried about patients and who are obsessing over their work" would be my impression of the pathologists I've met.

 

I asked Ian Wong about path vs rads previously, and he had some good insights here:

http://www.premed101.com/forums/showthread.php?t=13228

 

It's true that each study is a puzzle in itself, and plain films are the most challenging of all, if you want to grasp all the subtleties. I've been amazed by cases where a subtle shift in aortic calcification was the clue to an aortic dissection. There is so much to learn and keep up with in a constantly changing field that I do not see the practice ever becoming routine - as the saying goes, you see what you look for, and you look for what you know. Especially plain films, where it takes seeing tens of thousands of studies to become skilled.

 

Just because it was sent by primary care doesn't necessarily mean the study is normal - the patient must have had some complaint that led them to seek care. In fact, one of our previous graduates went into the community to practice for a year after graduation, and came back to deliver us a half-day of all sorts of pathologies he'd encountered during that time, basically covering the breadth of radiology. You might see more normals in the outpatient clinic setting, but in community practice, most new grads will be affiliated with a hospital, even in smaller centres. And the complex cases that are referred to academic centres are usually initially imaged and triaged in the community. Even if the study is normal, you have still done a service, by providing some peace of mind, or by guiding the referring physician down an alternate pathway.

 

Radiology does allow you to give the diagnosis and direct management in many areas of medicine outside of oncology that don't need a tissue diagnosis (see Ian's post for a better explanation)... trauma, stroke, and benign bone lesions just to name a few. Pathology may still involve differentials (histologic findings can likewise be nonspecific), but there is more expectation to come down more on one diagnosis.. I read a thread once where someone was thinking of switching from path to rads because they felt the work involved more application of findings to diagnostic criteria than they'd anticipated (versus puzzle solving) - I don't know what truth there is to this, if any (path colleagues?).

 

In any case, sounds like you are passionate about pathology, and therefore I only mean to provide a richer perspective and not to dissuade you from this career path in any way. There are smart people in all fields of medicine, so go for what suits you best.

[A-Stark]

Re: salary, the benefits of incorporation are somewhat overstated, especially for any specialty with minimal or no overhead. I was just meeting with someone from MD Management the other day, and we went through the comparative tax regimes by province. In Nova Scotia, for example, there are significant benefits to incorporation because personal income taxes are high, but this is being tightened. In Ontario the difference is only about half as much, and in Alberta you actually lose money with incorporation.

 

Either way, even if you don't clear $500,000 in billings as some radiologists do, as a pathologist you will be making a very high salary that puts you in the top 0.1%.

[Renin]

Hi everyone

 

I am a first year med student and have recently fallen in love with the idea of pursuing pathology as a career; however I am worried about the autopsy bit. I know that people say that that should not hold someone back and that you don't have to do them as an attending if you do not want to. I am all about the diagnostics/histology/looking at slides all day, so that is what I hope I would get to focus on as an attending. I also realize I have limited exposure to this, so I'm going to work on getting over my fear of the unknown by going to watch some autopsies. I am wondering however, how many autopsies you have to do as a resident? Is it a daily or a weekly thing? Do you just assist as a resident or are you doing them on your own/with other residents?

 

I would really appreciate any answers! Thank you!

 

I used to LOVE pathology - I loved autopsies, which I guess, is the opposite of you, because I hated the slide aspect.

 

I watched 3x autopsies as a pre-med student, and 2x as a med student. I'm not a pathology resident, so I don't know anything about the residency, sorry!

[ploughboy]

I am quite a strong student, am very hard working, and would hopefully not have issues matching to even the super competitive specialties (this is not my personal ego speaking, my professors/tutors/residents have said things like this to me). So when I read that pathology is a specialty where all the desperate people go, that to me is sad because although it won't stop me from doing it anyway if it's what I love (because I'm secure enough to know my own potential and don't care what others think/say, my work will speak for itself) it does make me wonder what my peers will be like and if that will become a source of frustration for me. I need to be around hard working people who are extremely worried about patients and who are obsessing over their work, not sitting in a laid back atmosphere.

 

For what it's worth the three people in my class who matched to path were all very strong students, and one of them was our gold medalist.

[Gmaarom]

Pathology apparently has a dismal job market across North America, which is going to get even worse.

 

Radiology, on the other hand, is apparently really in-demand according to Health Force Ontario (in fact one of the most in-demand specialties out there).

 

I'd pick rads for that reason alone if I was debating between the two.

[Lactic Folly]

Pathology apparently has a dismal job market across North America, which is going to get even worse.

 

Radiology, on the other hand, is apparently really in-demand according to Health Force Ontario (in fact one of the most in-demand specialties out there).

 

Can you be more specific about your source please? On HFOJobs there are 4 postings for pathology at present, 0 for radiology.

[Gmaarom]

Can you be more specific about your source please? On HFOJobs there are 4 postings for pathology at present, 0 for radiology.

 

The poor job prospects of pathology seem to be generally accepted amongst residents I've worked with and the attendings in Path that I talked to previously. Also just visit the pathology subforum on SDN and you'll see numerous threads of path grads unable to find jobs.

 

In regards to more specific sources, the CMA profiles shed some light:

 

http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Membership/profiles/Diagnostic-Radiology_en.pdf

"Results produced from Ontario’s Population Needs-Based Physician Simulation Model indicate that there currently is and there will continue to be a significant shortage of diagnostic radiologists to meet the province’s needs. Please note that this projection is for Ontario only. Similar projections for the rest of Canada are not available."

 

http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Membership/profiles/Anatomical-Pathology_en.pdf

 

"Results produced from Ontario’s Population Needs-Based Physician Simulation Model indicate that there are enough anatomical pathologists to meet the province’s needs, now and in the future. Please note that this projection is for Ontario only. Similar projections for the rest of

Canada are not available"

 

The needs=based report can be found here: https://www.healthforceontario.ca/UserFiles/file/PolicymakersResearchers/needs-based-model-report-oct-2010-en.pdf

 

 

I'm guessing that most of the radiology jobs don't get posted on the HFO job search for some reason?

[Lactic Folly]

Well, just because there is a projected shortage does not mean groups are hiring, especially with the uncertainty of recent cutbacks in Ontario. It's counterintuitive, akin to saying that there should be a large demand for ortho since there are so many patients awaiting joint replacements.

 

I don't know what the situation in pathology is currently like; however, I suspect the situation is worse in the US than in Canada. As a medical student, I watched the pathology residents almost all find employment in the same city after graduation.

[thebouque]

The job market is dismal in the US for many reasons (way too many programs/graduates, competitive private system where pathologists get hired by clinicians who actually bill for their acts and pay them a %, pod labs, slash in their professional fees 88305 with obamacare). The truth is that the situation is very different in Canada, where most pathologists are hospital based (salaried or not, we already had this discussion many times), and the shortage is mild/non existent to very severe depending on the province. Therefore, if you want to have an idea of the canadian pathology job market, don't go on sdn (or actually go on sdn and you'll see a few threads about US pathologists who moved or who are planning to move to Canada but are afraid to pay too much tax in our ''socialist'' country ). The pathology job market is actually a lot better than most surgical specialties, and in some provinces better than radiology. You don't have to redo a 2nd residency in terms of fellowship training to land an academic position.

[vanfanal]

It's been great to hear from some actual proponents of pathology. Usually, all I read are rants telling students to avoid path at all costs.

 

I'm interested in pathology and I'll be taking an opportunity to see what it's like over the next 3 weeks.

 

The bouque, since your a path resident, I was hoping I could get your insight into the field, and others are free to reply of course.

 

 

How do you see the future of pathology? I assume you don't see it as doom and gloom as I've been reading. Just how confident are you in the job market in North America, and what type of lifestyle and salary are you expecting/do you see in the future? Also, this is probably stupid, but it's been eating away at me, is telepathology a threat?

 

Thanks for any input.

[kfcpathology]

Rumour has that conventional pathology which is based mainly on histology/immunohistochemistry will soon become obsolete and will be replaced by molecular/genetic diagnosis.

 

Of course, this is quite controversial. I wonder what current residents in pathology are thinking.

[thebouque]

Rumour has that conventional pathology which is based mainly on histology/immunohistochemistry will soon become obsolete and will be replaced by molecular/genetic diagnosis.

 

Of course, this is quite controversial. I wonder what current residents in pathology are thinking.

 

I don't think there's any controversy here. Molecular and genetic tests on tumors (which are conducted by pathologists by the way) are going to be an ancillary technique and will probably never replace H&E (standard histo) and IHC (immunohistochemistry). We thought IHC would replace H&E, but H&E remains the basis of pathological dx and is the cheapest and most efficient method. Think of it this way: would you perform an MRI without taking a good history and performing a physical exam first? Even though the MRI show herniated disks, would you send the pt for surgery even if his physical exam is normal? It's the same in path. You'll always need basic histo and you'll correlate your molecular findings with the rest.

[thebouque]

 

How do you see the future of pathology? I assume you don't see it as doom and gloom as I've been reading. Just how confident are you in the job market in North America, and what type of lifestyle and salary are you expecting/do you see in the future? Also, this is probably stupid, but it's been eating away at me, is telepathology a threat?

 

 

No one can tell what the future holds for us. Pathology is a low profile, not very well respected specialty in medicine. To counterbalance these drawbacks, it has one big advantage: it's the most fascinating of all the specialties .

 

Seriously, I don't know if path in Canada will go the American way or will remain a good and stable specialty. However, there's no intent to privatize or create big ''corporate'' labs in the near future.

 

Finally I don't think telepathology is a threat at all. It's a wonderful technology that allows pathology dx and quick access to experts opinions in underserviced areas. The standard of care is high and the quality control is very strict. Slides are reviewed by subspecialists all the time. Outsourcing is not a threat at all. Why would your hospital send slides to a lab with unknown quality control to save money, when this very hospital currently pays to have every consult slide reviewed by its own pathologists?

[vanfanal]

Thanks for the reply. I start a path rotation on Tuesday so I guess I'll see how things go. I'm hoping I finally find my fit

[thebouque]

The bad part is the whole in-vivo diagnostics thing. Why biopsy something when radiology can confidently diagnose it? Genetics is also something to be concerned about, but the sheer variety of strange cancers probably make that fear less than warranted.

 

In vivo dx isn't close to being applied clinically and I don't see how it would replace histo/IHC. Keep in mind that a path report has a lot more information than a dx (progrnostic markers, therapeutic markers such as ER/PR HER2, CKIT etc). Finally, I'm very excited by this whole molecular biology thing. It will never replace H&E/IHC, and even if it did, it wouldn't matter much to pathologists since they're the ones who sign out these tests.

 

And I agree, telepathology is awesome.

[vanfanal]

So does anyone know if there's potential to do pathology as a private business in Canada, or is it all just working for hospital labs? Also, does anyone know what kind of lifestyle Canadian pathologists have in terms of typical work days, hours, and income? Just trying to explore the other aspects of path as a career.

[thebouque]

So does anyone know if there's potential to do pathology as a private business in Canada, or is it all just working for hospital labs? Also, does anyone know what kind of lifestyle Canadian pathologists have in terms of typical work days, hours, and income? Just trying to explore the other aspects of path as a career.

 

Private practice exists but remains very limited. In terms of hours, it varies depending on your efficiency. You may work longer hours during your 1st year and make a bit less money (doesn't apply if you're salaried), but it's a 50-60 hours weeks, extremely light night/w-e call, for an income of 300-450k.

[Gmaarom]

I've been looking further into pathology as a possible specialty, but it seems like all the residents I talk to (whether in Ontario or outside Ontario) express that the job prospects are really poor for pathology. They generally suggest doing general pathology (rather than anatomic) because apparently it has better job prospects.

 

That said, you won't be working in an academic centre as a gen path, instead you'd likely be working in private labs.

 

One other thing to consider regarding pathology is the tedious scut work (aka "grossing"). If you're interested in pure diagnostics, then the large amount of grossing you'll be doing during residency will likely be an awful experience. This would be yet another advantage of rads over path.

[rask]

But I still agree with your conclusion that rads is a better choice overall. Slightly worse lifestyle in residency for what amounts to a better career afterwards; small sacrifice for large reward.

 

I think it's difficult to judge what someone else would consider a 'better career' and wouldn't be so quick to dismiss path as the inferior of the two. So called disadvantages of one specialty may be seen as a significant advantage by someone else. My SO is a path resident and loves it. He actually enjoys autopsies and even grossing. Prior to med school he did graduate work related to both rads and pathology, did electives in both and found that like the OP, there was no 'spark' when it came to rads. For him, doing something he truly loves is well worth the trade off of a potentially lower salary (which really, in the grand scheme of life is a perfectly fine salary) and honestly, he couldn't care less about the 'prestige' associated with any specialty. He's happy to go to work everyday and that is something that is invaluable.

 

He was also a strong student and chose to go into pathology, it was not a backup specialty. As Laika I believe mentioned "Rest assured, not all of us were desperate". I encourage the OP to explore electives, talk to residents and see if perhaps their passion also lies in pathology.