One Hundred Years of the Pathology Medical Student Fellowship: Impacts on Medical Education and Career Choices

The Institutional Review Board determined oversight was not required. We compiled a list of all known student fellows from our institutional department records, which included students graduating between 1924 and 2021 (anticipated). Of the estimated 250 PSF graduates at our institution, 145 are recorded in departmental records. With the exception of Dr Warren Hunter, who graduated in 1924, departmental records of PSF graduates were unavailable before 1968. Current medical students who had completed the PSF were included. Where applicable, we determined the specialty match, residency program, and location of each graduate, using our institution's annual match list database (available for graduates between 2001 and 2020) and departmental records. We used this database to compare with the total number of medical student graduates who matched into pathology at our institution. We then conducted an email-based survey to all former student fellows to evaluate the experience and career impact on the program. Email addresses were gathered by using our institutional alumni database, online professional profiles, and available contact information from current and former faculty members. The anonymized survey was distributed to 76 PSF graduates (52.4% of known student fellows), based on availability of contact information. Statistics were performed in GraphPad Prism 8 (La Jolla, California) using Fisher exact tests, and are summarized as median and range where appropriate.

Review of institutional data revealed that of 145 recorded student fellows who graduated between 1924 and 2020, a total of 50 (34.5%) matched into pathology. The most common nonpathology specialties were internal medicine (21 of 145, 14.5%), family medicine (12 of 145, 8.3%), emergency medicine (9 of 145, 6.2%), and surgical subspecialties (9 of 145, 6.2%), including orthopedics, otolaryngology, plastic surgery, urology, vascular surgery, neurosurgery, and ophthalmology (Table 1). Between 2001 and 2020, when overall match data for our institution is available, 36 of 2250 medical students matched into pathology (1.6% of matched students), 19 (52.8%) of whom were PSF graduates, yielding a 25.7% rate of entering pathology for student fellows in this period. PSF graduates were significantly more likely to enter pathology than non-PSF students (odds ratio, 32; 95% CI, 16–63; P < .001).

We received 42 of 76 survey responses (response rate, 55.3%), with nearly equal representation between physicians who entered pathology versus other specialties. Historical cohorts were well represented in respondents; of the 42 respondents, 12 (28.6%) graduated the PSF 4 years ago or less, 12 (28.6%) graduated 5 to 10 years ago, 11 (26.2%) graduated 11 to 20 years ago, and 7 (16.7%) graduated more than 20 years ago. Before starting the PSF, 11 (26.2%) were undecided in specialty choice; 9 (21.4%) were interested in general surgery or surgical subspecialties; 8 (19.0%) were interested in broad medical specialties, including family medicine, internal medicine, pediatrics, or emergency medicine, and 5 (11.9%) were interested in obstetrics and gynecology. Although 6 (14.3%) indicated pathology as their primary field of interest before the fellowship, 19 PSF graduates who responded to the survey (45.2%) pursued or will pursue a career in pathology.

A slight majority (23 of 42, 54.8%) of student fellows began the program after their second year of medical school; and the next largest group began after third-year clerkships (15 of 42, 35.7%). Student fellows completed a median of 8 or more months of surgical pathology (including University and Veteran's Hospitals) (range, 5 to ≥8), 3 months of autopsy (range, 2 to ≥8), and zero months of clinical pathology (range, 0–3), including blood bank/transfusion, molecular, and microbiology. A median of 2 months (range, 0–3) was spent on electives including research, hematopathology, dermatopathology, neuropathology, and renal pathology. Respondents indicated that they found surgical pathology (39 of 42, 92.2%), autopsy (26 of 42, 61.9%), and research (6 of 42, 14.3%) most clinically useful.

For PSF graduates, the distribution of academic and community practice was relatively similar regardless of whether the physician pursued a career in pathology versus other specialties. Specifically, of 19 PSF graduates who pursued pathology, 11 (57.9%) practiced in an academic setting, 6 (31.6%) were in private practice, and 2 (10.5%) were retired or did not currently practice. Of 23 PSF graduates who pursued nonpathology subspecialties, 15 (65.2%) practiced in an academic setting, 8 (34.8%) were in community-based urban or suburban programs, 5 (21.7%) were in a community-based rural setting, 3 (13.0%) were in federally qualified health centers, and 1 (4.3%) was retired or did not practice medicine.

When asked about the impact of the PSF on the remainder of medical school, residency training, and career (Figure 1, A through D, and Figure 2, A through C), there were no significant differences in responses between those who went into pathology and those who pursued other specialties. Respondents also reported positive impacts of the PSF on the remainder of medical school, residency training, and career in free-text format, with extracted results summarized in Table 2. Negative impacts and suggestions for improvement are summarized in Table 3.

For physicians who did not pursue pathology, we asked how frequently they used the skills gained during the student fellowship year (n = 23): 5 (21.7%) responded “daily,” 9 (39.1%) responded “weekly,” 5 (21.7%) responded “several times a month,” 3 (13.0%) responded “every few months,” and 1 (4.3%) responded “never” (Figure 2, D). When asked what skill(s) gained the physicians found most useful, 20 (87.0%) selected “interpretation of pathology results,” 20 (87.0%) selected “improved communication with multidisciplinary teams,” 17 (73.9%) selected “knowledge of pathophysiology of disease,” and 17 (73.9%) selected “improved knowledge of human anatomy” (Table 4).

In this study, we use match and survey-based data to describe the impacts of approximately 100 years of a pathology student fellowship at our institution; founded in 1919, this represents the oldest non–continuously running PSF to our knowledge. We demonstrate that PSF graduates have high rates of pursuing academic medical careers (26 of 42, 61.9%) regardless of specialty, and that a substantial minority (50 of 145, 34.5%) enter pathology. We illustrate the long-lasting impacts of the PSF for physicians across specialties.

Similar to prior studies,^1,8–10  approximately 35% of student fellows entered pathology according to institutional match lists, although this ranged by period (25.6% for 2001–2020) and how the information is obtained (45% of PSF survey respondents pursued pathology as a career choice). Previous studies have highlighted the benefit of the pathology student fellowship as a recruiting tool for a field that has otherwise become less popular.^1–4,9  In 2019 and 2020, only 33.4% and 33.8% pathology residency positions, respectively, were filled by US-MD graduates.^11,12  Our overall institutional rate of medical students matching into pathology (1.6%) is similar to national data.^11,12 Approximately half of MD graduates from our institution who entered pathology had graduated from the PSF program, despite the fact that less than 15% of student fellows were considering pathology as a career before the PSF, highlighting the pivotal role of the PSF on career choice for certain participants. Notably, half of the medical students pursuing pathology at our institution had not participated in the PSF; it may be less attractive for those who have already decided on pathology as a career, perhaps in part since no credit is given for this year by the American Board of Pathology.

In our experience, the pursuit of a more in-depth understanding of anatomy and the pathologic basis of disease are some of the most common reasons for medical students to apply for the PSF program. This priority is also reflected in how medical students valued the PSF, with the most commonly reported positive impacts being enhanced knowledge of disease pathobiology and diagnostic complexity, as well as increased confidence and autonomy. Many medical schools, including our institution, have shortened the classroom- and laboratory-based portion of the curriculum in favor of additional clinical rotation time. As a result, there is less exposure to histology, pathophysiologic mechanisms of disease, and gross anatomy for many medical students. Pathology is not a required rotation at most medical schools, and many students have no exposure to pathology in the clinical years. Whether value placed on in-depth knowledge of anatomy and pathobiology reflects a deficit in medical student education or the cohort of medical students attracted to the PSF is beyond the scope of our study.

We observed a high rate (62% versus 19.7% in published literature¹³ ) of subsequent careers in academic medicine for our PSF graduates, regardless of whether they pursued pathology or nonpathology specialties, underscoring the impact of the PSF on academic medicine in all specialties. The propensity for academic careers for former PSF graduates has previously been documented, with rates of 29.7%¹  and 43.2%⁹  in prior investigations, highlighting a consistent phenomenon across institutions and subspecialty choice. Given our survey data, this may be due to increased mentorship, teaching opportunities, exposure to research, emphasis on an inquisitive approach to cases, or other factors.

In contrast to prior reports, our student fellows had substantially greater time in anatomic pathology, with less dedicated research time, and little exposure to clinical pathology. Our program emphasizes surgical pathology in particular, with a median of 8 months on this service. As reported in the Pathologists Pipeline survey of program directors on PSFs,⁸  the average time spent rotating on anatomic pathology was 36.15 weeks, compared to 16.85 weeks on clinical pathology; an average of 14.65 weeks was spent on surgical pathology. Increasing time for electives and/or clinical pathology was identified as an opportunity for improvement by 6 of 30 survey respondents (20%). Other negative aspects included heavy workload described by 4 (13.3%)—for which a case cap is now in place—and issues with student loans or salary by 2 (6.7%)—for which loan counseling is now available and PSF salaries have increased over time. While general duties and activities are likely similar across programs, there is no governing body responsible for overseeing student fellowships across the nation. Consequently, the administrative structure, rotation schedule, exposure to different fields of pathology, and individual responsibilities vary, sometimes greatly, by institution.

The PSF offers the opportunity for medical students to gain experience working autonomously on clinical and nonclinical teams, develop advanced medical knowledge, and function essentially as a resident physician. The Pathologists Pipeline survey of pathology program directors noted that during surgical pathology rotations, 90% of programs stated they allow their student fellows to take ownership over the cases like a first-year resident would.⁸  The report also showed that PSF-trained residents were more likely to receive better performance ratings than non-PSF residents in the areas of patient care/procedural skills and in medical knowledge competencies.⁸  There are no objective data on PSF-graduate residency performance outside the field of pathology, representing an area that warrants further research. Though rooted in pathology, our survey demonstrates that the most common positive impacts of the PSF—advancing understanding of disease mechanisms and diagnoses, and cultivation of autonomy—are not specific to the field of pathology, and are applicable to any residency program and medical specialty. As more medical schools trend toward competency-based curricula, and national exams, including the United States Medical Licensing Exam Step 1, become pass/non-pass, there is a renewed emphasis on extracurricular activities and identification of the mature, well-rounded medical student.

The PSF is unique to the field of pathology, and no other field of medicine offers a comparable immersive experience. As such, the PSF is unfamiliar to many physicians outside the field of pathology, which may cause confusion during the residency application and interview process. Although there are only approximately 20 year-long student fellowships in the country (https://www.apcprods.org), our study shows that most student fellows pursue nonpathology residencies in nearly every specialty. Thus, program directors of all fields may be interested in the responsibilities and impacts of these programs.

We acknowledge several limitations to our study. Although the founding of the PSF is reported in our institutional archives as 1919, very limited data on the program or its participants are available before 1968. Despite using our institution's alumni database, online professional profiles, and internal contact sources, contact information could only be retrieved for approximately half of the known student fellows. This may have biased our results toward the experiences of those with more available online data—including those who practice in larger or academic settings—and may have influenced our rate of subsequent academic careers; however, the overall tendency for academic careers for former PSFs is supported by prior studies.^1,9  Although historical cohorts were well represented in respondents, our results may be influenced by survey biases due to both availability of contact information and choice to respond.

In conclusion, we provide an expanded understanding of the pathology student fellowship structure, educational benefits, graduate specialty choices, and career impacts of 100 years of the program at our institution. Skills gained from the year include enhanced knowledge of disease pathobiology, anatomy, and diagnostic complexity, as well as increased confidence and autonomy. Most PSF graduates enter academic medicine. Approximately a third of PSF graduates subsequently enter pathology, although less than half of these pathologists were considering this career choice before the PSF; other medical disciplines are well represented in subsequent career choices. Even for physicians who enter nonpathology specialties, most report using the skills they gained during the year daily or weekly, highlighting the value of PSFs for physicians across disciplines.

The authors wish to thank all the Pathology Medical Student Fellowship graduates who responded to the survey.