Acknowledging and Transforming Pathology Stereotypes

I find that in interactions with other specialties, even attending physicians who far surpass me in age, that many have very little idea of what pathologists do. Those who do not work closely with pathologists are the first to mention CSI, forensics, autopsies, and an office in a windowless basement morgue. In fact, I recently heard the story that when a group of attendings and residents from another specialty along with their medical students were told to meet a pathologist for a teaching session in the anatomic pathology department…that they waited outside the locked morgue door before realizing that no one was there and that the morgue was not probably not the intended meeting location.

And for those who work more closely with pathologists, there exists a spectrum of attitudes and perceptions about our profession. We have surgeons who were trained “old school” style with six months of surgical pathology during residency who will sit at the multi-headed scope during intra-operative consultations and who know more than beginning junior residents. Hematology/oncology physicians often stop by hematopathology to look over slides together or to discuss a case. And then there are those who think that pathologists exist to provide them only with diagnoses and who do not look at us as equal members of the patient care team. I’ve heard some even question a diagnosis without ever seeing the slide and others grumble or joke that pathologists take too long to render diagnoses.

I’ve more than a few times had to call attendings, residents, or fellows to recommend canceling an inappropriately ordered test or less commonly, to suggest ordering an indicated one. I found that this more often occurs when there is not a strong differential of diagnoses. Even so, I still have the person on the other end of the line bellowing at me that they just MUST have this expensive molecular test ASAP.

Recently, a medical student who is interested in pathology told me that some residents from a non-pathology rotation harassed and made fun of this student for choosing pathology as their future career. I could continue with more examples but instead I ask this question, “Why is pathology as a field not valued?” especially with respect to specialties like surgery where there is a heavy reliance on pathologists to provide them with diagnoses?

I believe part of the reason lies in lack of exposure to the practical and daily aspects of pathology as a legitimate medical field during medical school. Furthermore, those who chose pathology as a career are often not personality types who proactively engage in promoting or advocating on behalf of the profession, especially at the state and federal levels. We also subconsciously contribute to this issue. For example, we often refer to all non-pathologists as “clinicians” as if there is a difference between these types of doctors and pathologists even though we all completed four years of medical school.

So, what are other reasons do you think contribute to the undervaluing of pathology as a profession, and more importantly, what can we do to change these stereotypes and misconceptions? Let me know by leaving a comment.

-Betty Chung

9 thoughts on “Acknowledging and Transforming Pathology Stereotypes”

  1. Your commentary resonates, particularly this line:

    We also subconsciously contribute to this issue. For example, we often refer to all non-pathologists as “clinicians” as if there is a difference between these types of doctors and pathologists even though we all completed four years of medical school.

    This is why I always refer to non-pathologist doctors as “referring physicians”, not “clinicians”, for I am a consultant whose opinion is sought by those doctors who refer their patients (or their biopsies/resections) to me.

    1. True. We are all physicians, here after i am going to use “referring physician” than ‘clinician’.

  2. Great suggestion Dr. Black! Even though I’ve on occasion used the term because my attendings do, I think I’ll use “referring physicians” as well. The only way pathologists will be seen as an equally valuable member of the patient care team is if we show our worth and believe and act as if we are equal. Transformation of our field begins with US!

  3. Thoughtful post. What resonates with me is the lack of exposure for medical students Ito pathologists in the clinical realm. I think that pathology often gets left behind as part of the basic science foundation of medical understanding and while students continue their exposure in the clinical side of training the extent of pathology education continues to decrease for non pathologists. We know the value of the pathologist when we don’t have answers, when we do, we take your contributions for granted.

  4. Another problematic issue is the use of the word “test” (as in “the test for estrogen receptor is positive” when immunohistochemistry results are reported). By doing this, we degrade our role to that of a machine that simply spits out a result. Instead, we should say that we render an interpretation, which is often fairly complex. The use of the word “test” also perpetuates the false notion that our role will be easily automated and replaced by computers in the future.
    It is accurate that pathology education is under-represented in medical school. The reason is often cost but also competition for time with other contents. With the teaching tools of digital pathology, we have a chance to bring back pathology.
    I agree with the above statements about the problematic use of the term “clinicians”. A better term would perhaps be “treating physicians”.

  5. This is one of the most important issues the specialty has to address. Not uncommonly pathologists – myself included – practice pathology after beginning a career in a different specialty and come sharing varying perspectives from that training or practice. What we can’t do is come to pathology as an escape from patient-centered care. I constantly remind myself of this as I look at cases day in and day out. We are clinicians, indeed. What our specialty needs to figure out is how to provide a more tailored, concierge-type service for all providers seeing patients, including “referring physicians”. There is a lot to be gained by providing such services to the physician assistants and nurse practitioners who are assuming a bulk of the test ordering, including complex tests like molecular panels and FISH probes.

    I think our society leadership will help get us there but this kind of change ultimately happens at the local level. My personal opinion is that simple phone calls with referring providers will not make the changes we need. Meaningful personal interactions through tumor boards, committees, and conferences will help shift the tide and get us out of the “black box”, but that’ll be just the beginning. Mayo Clinic is paving the way in many respects regarding pathologist leadership (and ownership of cases) and their use of the term “consultant” is right on. The bone marrow evaluation, for instance, should really be a pathologist consultation whereby we guide testing to gain the most meaningful diagnosis with a resource-effective strategy. We should be the ones ordering the FISH panels, the molecular assays, and genomic studies on these specimens and we need to stake a claim that we are the best stewards of this material for the patients. We need to be firm on this matter with our non-pathologist colleagues and get out there and say as much.

  6. I agree with Dr Cymet that the decreasing exposure to Pathology during medical school has a lot to do with the impression of pathology that many physicians have. In the past, students at many schools were required to do a 3rd year core rotation in pathology, clinical lab and radiology as part of the beginning exposure to a hospital rotation.. Most schools have deleted that exposure as they increase the required primary care experiences. This is the last thing they should do. The primary care physician has the most reliance on the pathologist and their expertise as they decide what consultants their patients need to be referred to for abnormal laboratory results or biopsies. One of the biggest things I am doing now in my teaching is helping the students during team based learning as they figure out the differential diagnoses of their cases. I tell the students my role is, as one of the respondents mentioned, a consultant to help them decided which results are important and in helping them choose what further procedures need to be done.
    It is disheartening to have a student who is interested in pathology come to me and complain about how others mentors tell him not to become a pathologist or that pathologists aren’t people oriented. I tell the student the pathologist can see patients in consultation with their primary provider, but we always have to be able to communicate with the physician who has sought our consultation. We are after all “the Doctor’s Doctor”.

  7. The lack of exposure to clinical and anatomical pathology leads the referring physicians to make many assumptions of things they are not aware of. In times where sub-specialization is growing, everything is more focused and less time is invested in education of other areas like ours. Where I am training, Pathology is available as an elective in medical school and in residency (I don’t know if its like this across the US). It will be difficult to acknowledge and transform pathology stereotypes if pathology is not considered as important as other core rotations of medical education, and I think this is where the problem starts and where we can to do something about it. If medical students and residents spend more time in our daily practice, it would help them understand better our job and the process each specimen (either from anatomical and/or clinical pathology) goes through and how we are involved in patient care and how can we add value to any consultation.

  8. I believe that comes from the way that the residents sell themselves out. My senior resident is from Pakistan and he sees himself below the level of whole residents from other specialties. So basically it is the self-esteem that you can reveal.

    Second is the system in general. In medical school we know that pathology is dealing with the slides which are stained and that’s all! We never know the grossing techniques and how they are time consuming and nerve racking.

    We now the microscopes and the tumor but have never been able to realize the real detail behind it.

    One of the med students who rotated with us started to see the frozen reporting and grossing so by the end of her rotation she said “I had a misconception about pathology.”

    So I believe in the medical school, med student should spend more time in whole subjects of pathology not only Surgical.

    Also conferences and meeting that organized by CAP or the ASCP there should be side meetings and lectures to the attendings, program directors and the participant residents on how not to look on themselves as inferior.

    I believe if I have faith in myself and about the importance of what I am doing in patient care I won’t let any one to see me as inferior.

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