There is a perception that US medical school graduates' (USMGs) interest in pathology is waning. This concern, in an era of projected physician and pathologist shortages,1,2 has implications for the delivery of quality patient care to an aging population. Given this, can we increase interest in our field?
Data from the National Residency Match Program reveal a steady decline in the percentage of first-year pathology positions filled by graduating medical students from allopathic schools since 1978.3 During that same time span, the percentage of total graduating US allopathic seniors selecting pathology as their specialty fluctuated cyclically. In 1979, 2.16% (282 of 13 036) of students selected pathology, whereas 0.88% (128 of 14 610) did so in 1998. By 2005, 2.21% (326 of 14 719) selected pathology, with the percentage falling to 1.17% (220 of 18 818) by 2018. Although the percentage of total positions filled by USMGs has decreased since 1978, the actual ratio of USMGs choosing pathology compared with the total number graduating has only mildly fluctuated. Therefore, the outlook may not be as bleak as once suspected; however, the drive for increased interest in our field should remain a goal.
To increase interest in pathology, we must focus on visibility within both medicine and popular culture. Medical students think of pathology as a clinically invisible specialty and are unaware of it, forget about it, or ignore it as a career path.4,5 Therefore, students are not rejecting pathology; it simply is not included in their slate of career options. Pathology is not a required clerkship in most American medical schools, which limits students' exposure to the role that pathologists play in patient care. If students complete elective pathology clerkships, they typically do so during the fourth year of medical school, when career path changes seldom occur. Recent changes in undergraduate medical education could also be leading to a poor understanding of the clinical practice of pathology. After the release of the Carnegie Report in 2010, many medical schools changed curriculum delivery from a traditional subject-based approach with multiweek pathology courses to a systems-based approach with integration of subjects.6 This more fragmented view of pathology may lack sufficient exposure and leads students to believe pathologists are basic scientists with limited career options.4,7,8 Moreover, when students are aware of pathologists their perceptions are limited to unflattering stereotypes perpetuated in medicine and the media.
Stereotypically, the depiction of pathologists on television has usually been restricted to autopsy and forensic pathology. Furthermore, it is unclear that those characters are physicians or they are forced to do autopsies because they are incompetent physicians. Negative portrayals of pathologists are difficult to counter in the media. Good role models in pathology, such as Bennet Omalu, MD, and his work with concussions and chronic traumatic encephalopathy, need highlighting to balance the more negative stereotypes and expose the public to the clinical practice of pathology.
Where to go from here? When looking at the data from low power, there may be less of an issue in the number of US students applying for pathology than perceived; however, the issue of visibility remains an opportunity. A better understanding of the central role pathology has in health care will lead to improvements in interdepartmental working relationships, proper use of laboratory services, and the delivery of patient care. Adding “what is the practice of pathology” lectures into the core curriculum of medical schools or giving tours of the clinical laboratory as done at the University of California, Los Angeles (UCLA)9 can give medical students early exposure to the clinical practice of pathology. Student observation of multidisciplinary conferences and tumor boards can demonstrate the role pathologists play in the overall patient care system. Providing more opportunities for pathology electives in the third year of medical school can assist recruitment efforts while also teaching proper use of pathology services for those choosing other specialties. Many schools have established pathology student interest groups to increase interaction with pathology attendings and residents. Hands-on teaching activities, such as a fine-needle aspiration workshop with phantoms or a brain cutting demonstration, can leave lasting impressions with students. Furthermore, the pathology pipeline need not begin in medical school. Shadowing opportunities for high school and premedical undergraduate students can showcase a “day in the life” of a pathologist.
Although traditionally a pathologist's patients are in the forms of microscopic slides and tubes of blood, many pathologists have patient-facing practices as well. Apheresis, fine-needle aspiration, and coagulation clinics are common ways that pathologists interact directly with patients. Increasing the visibility of pathologists beyond these roles has been a growing movement. Adam Booth, MD, Lija Joseph, MD, and colleagues have shown that patients have a desire to meet directly with their pathologist face-to-face and discuss their diagnosis to help them “see the dragon they are slaying.”10 Gibson et al11 have discussed the establishment of Pathology Explanation Clinics to address this same need. Uthman12 has written about the benefit of pathologists getting out from behind the “paraffin curtain,” interacting with other clinicians and becoming a visible part of the hospital system. This side of pathology should be visible to both our students and our colleagues to highlight pathologists as both the “doctor's doctor” and the “patient's doctor.”
Pathologists are also interacting with patients and learners through social media, such as Twitter (San Francisco, California) and Facebook (Menlo Park, California). To dispel any concerns about Health Insurance Portability and Accountability Act of 1996 (HIPAA) violations, the posting of deidentified pathology photos to social media has been shown to be both legal and ethical,13 and academic pathology departments, state pathology societies, national pathology societies, pathology journals, and individual pathologists have become increasingly present on social media. Jerad Gardner, MD, an early adopter, has demonstrated the power of social media and how his interactions with the angiosarcoma patient support group on Facebook positively impacted both the patients and himself.14 Dr Gardner also has had great success in discussing interesting cases through Twitter and other social media platforms. In addition to increasing pathologists' visibility, social media can be harnessed to engage high school students, such as the Twitter account @pathoutprogram that “empowers and engages high school students to learn about pathology.”
Pathology is a wonderful field with innumerable opportunities. The more we as a pathology community make ourselves visible to medical students, patients, and society, the better the outlook for our field and patient care into the future.
The authors have no relevant financial interest in the products or companies described in this article.