The Secret Life of Junior Pathologists: Challenges and Future Directions

Junior pathologists were defined as pathologists who had been practicing independently for up to 5 years after completion of postgraduate education including residency and fellowship. An online survey was distributed on October 13, 2022, to those who met the definition of junior pathologist at the time of survey distribution. The participants were graduates of The University of Texas MD Anderson Cancer Center fellowship programs (Houston, Texas) and MedStar Georgetown University Hospital residency program (Washington, District of Columbia) from 2017 to 2022.

An institutional review board–approved survey in Qualtrics was created in collaboration with the MD Anderson Office of Institutional Research. The survey included 16 questions. The full survey is provided in the supplemental digital content at https://meridian.allenpress.com/aplm in the July 2024 table of contents. The survey included questions about participants’ demographics, challenges faced during the transition period, wellness, and clinical and nonclinical areas in which participants wished the training program had provided more training and guidance. Participants received the survey via provided emails, and 2 reminder emails were sent after the initial notification. The survey was open from October 13, 2022, through January 31, 2023. Participants were instructed to answer the questions based on their overall experience from both residency and fellowship programs. The survey questions were in either multiple-choice or free-text formats. All multiple-choice questions included an “other” free-text answer option.

The question about challenges faced was a free-text question in which participants described challenges in their own words. These responses were evaluated by contributing authors (D.K., M.T., P.P.A.) to identify frequently occurring same keywords (ie, independent sign-out or clinical significance) or phrases denoting similar concepts (ie, “efficiency,” “slow,” “time”). These keywords and phrases were grouped into broad categories as best as possible by equally contributing authors (D.K. and M.T.) independently at first, and then comparison was made. Any conflicts or concerns were adjudicated by the senior author (P.P.A.). Some categories (2, 3, 6) contain multiple challenges, which were thought to be interdependent and have direct or indirect correlation. If multiple themes were identified in 1 free-text answer, the result was grouped into 1 best representative category for analysis. The following categories were created for analysis and discussion: Category 1: No challenge; Category 2: Challenge with pathology reporting and communication; Category 3: Challenge with efficiency, case complexity, and workload; Category 4: Challenge with administration; Category 5: Challenge with independence; Category 6: Challenge with mentorship and work-life balance; Category 7: Challenge with professional identity formation.

Regarding the response to the free-text questions about strategies to decrease burnout, qualitative analysis was performed in a similar manner as described above. The following categories were established: Category 1: Social and wellness activities; Category 2: Positive working environment centered around trainee advocacy; Category 3: Faculty interaction and offloading of cases; Category 4: Not applicable or no burnout.

Associations between each survey question and groups of interest defined by work setting (academic or nonacademic), gender (male or female), age (<40 years or ≥40 years), and country of medical school (United States or non–United States) were evaluated by using the Fisher exact test or its generalization. All statistical analyses were performed with SAS 9.4 for Windows (SAS Institute Inc, Cary, North Carolina). All statistical tests used a significance level of 5%. No adjustments for multiple testing were made.

The online survey was distributed to 118 recent graduates, and 39 (33%) responded, all of whom met the definition of junior pathologist. The mean (SD) age of participants was 39.3 (4.8) years (range, 32–52 years). Of the 35 participants who chose to answer the gender question, 15 participants (43%) were female, 18 (51%) were male, 2 (6%) preferred not to disclose their gender, and none of the participants (0%) selected the nonbinary option. Of the 37 participants who indicated the country of their medical school, 9 (24%) graduated from a medical school in the United States, and 28 (76%) were foreign medical graduates. The number of years in an independent practice was less than 1 year for 13 participants (33%), 1 to less than 2 years for 10 participants (26%), and 2 years to less than 5 years for 16 participants (41%). None of the participants selected more than 5 years (0%); thus, all the participants met the criteria of a junior pathologist. Twenty-three participants (59%) worked in an academic institution, 14 (36%) worked in a community hospital, and 2 participants (5%) chose “other” as their work setting, which was not further described. None of the participants chose the provided work-setting options of “industry” or “government.”

Twenty-six participants replied to the free-text question about challenges faced during their transition from a trainee to a junior pathologist. Their responses and the categorizations of the responses are presented in Table 1. The distribution of challenge categories is represented in the Figure.

The types of challenges faced did not differ significantly by work setting (Table 2). However, only participants in academic settings indicated having challenges with independence, mentorship and work-life balance, and professional identity formation. Participants in nonacademic settings indicated that their challenges were pathology reporting and communication; efficiency, case complexity, and workload; and administration.

In terms of the areas in which the participants wished the residency or fellowship program had provided more training and guidance, more participants working in academic than in nonacademic settings wished they had received additional guidance in effective time management and understanding the importance of turnaround time (P = .03), while more participants in nonacademic settings than in academic settings wished they had received additional training in Current Procedural Terminology (CPT) codes, billing, and cost-effective patient care (P = .02) (Table 2). Participants in academic and nonacademic settings were similar in their responses to the question about additional guidance they wished they had received in nonclinical areas and the question about the most important experience they gained aside from education and training.

Analysis of the survey responses by binary gender category (male versus female) revealed 1 significant difference: 79% of the female participants indicated that they wished they had received more guidance in leadership and soft skills, compared to 28% of the male participants (P = .01) (Table 3). No significant differences were observed when the survey responses were analyzed by age (Table 3).

No significant differences were observed between graduates of US medical schools and foreign medical graduates in challenges faced, areas in which they wished they had received more training and guidance, or, most importantly, experience (Table 3). Both groups indicated that they felt well prepared for tumor board presentations, histopathologic evaluation and proper interpretation of ancillary study results, and intraoperative frozen section interpretation and communication skills. Only 11% of US medical school graduates and 19% of foreign medical school graduates indicated that they wished they had received more training and guidance in manuscript-writing or research grant–writing skills (Table 3).

Twenty-six participants replied to the free-text question about strategies to decrease burnout in their respective training programs. The comments could be grouped in 4 broad categories, which were social and wellness activities, positive working environment centered around trainee advocacy, faculty interaction and offloading of cases, and not applicable or no burnout. The responses and the categorizations of the responses are presented in Table 4.

Most participants (23 of 39 [59%]) had been in practice for less than 2 years. The higher response rate from the more recent graduates may be expected as they are more likely to feel connected to and stay in contact with their respective training programs. Another possibility is a selection bias, as this group (in practice for less than 2 years) may have been experiencing transition-related challenges more than participants in the other groups, who may have already developed mitigation strategies.

Several participants in both academic and nonacademic settings commented about speed or efficiency and reporting skills. Depending on the structure of their program, trainees may only rarely see the “behind the scenes” of the faculty practice. For example, trainees may not observe how faculty engage in frequent peer-to-peer consultations, formulate pathology reports, and communicate with clinicians. In addition, the training may not emphasize the art of pathology reporting, which requires careful selection of words and crafting of sentences to deliver messages with both clinical significance and legal protection.

Once trainees have achieved diagnostic competency, the faculty should focus on refining trainees’ reporting skills. Without this type of coaching, several problems can occur in the first transition year. Specifically, junior pathologists who are bogged down by every detail of pathologic changes will invariably lag in speed and struggle to complete the workload, and their pathology reports may not offer clinically relevant information that their clinical colleagues are seeking. During training, trainees should be constantly reminded to ask “why” and “so what” questions during evaluation of pathologic specimens, for example, Why was this biopsied? and What will my reporting mean to my clinical colleagues?

Some survey participants indicated that benign entities could be more challenging to report. This may particularly be true for those who trained in institutions with cancer-heavy populations (Table 1). Reporting on nonneoplastic entities requires descriptive microscopic reporting skills and understanding of the nuances. Reporting skill is an art that needs to be taught, practiced, and mastered. Training in writing succinct pathology reports and knowing when to “let go” will increase efficiency and confidence in junior pathologists.

Several participants commented about feeling nervous or lacking confidence during the early phase of their career as junior pathologists (Table 1). All pathologists can remember the feelings that accompanied clicking the “sign-out” button in their first case. The feelings were a mixed bag of pride, excitement, fear, and concern. Every junior pathologist has a unique phase of initial nervousness when releasing reports. Some may overcome this nervousness earlier than others. This nervousness can stem from legal concerns and concerns about the clinical implications for patients. The added effect of practicing with no oversight can be shocking and surreal. Among various factors, one important psychological concept to highlight is imposter syndrome, defined as self-doubt of competency and fear of being exposed as fraud.⁹  Particularly in new environment and work settings, junior pathologists, regardless of their true skills and competency, experiencing imposter syndrome will undermine their abilities and have difficulty gaining independence.

Compared to training in other medical fields, pathology training appears to involve a higher level of supervision, with more restrictions on trainees’ activities. In the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, 3 levels of supervision are described: direct supervision, indirect supervision, and oversight. Most likely, many readers will agree that most senior trainees and even some fellows may graduate without fully reaching the oversight level, which ACGME defines as follows: “the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.”¹⁰  The transition from lack of sign-out privileges before graduation to working independently after graduation can be a shock to some newly graduated pathologists, as a survey participant commented. The challenge of graduated responsibilities is a recognized subject of ongoing discussion among directors of ACGME-accredited anatomic pathology programs and will remain unresolved because this challenge is compounded by the delicate dance between trainee autonomy and patient safety.¹¹ 

Potential suggestions are to create an environment for trainees that simulates autonomous practice, as outlined by Allen¹²  in 2013, including having senior trainees sign out with junior residents, supervise autopsies, and review frozen section slides before the attending pathologist arrives. Even the simple act of allowing trainees to click the “sign-out” button may give them enough adrenaline to simulate the conditions of independent practice. If the laboratory information system allows a “preliminary report” option, allowing trainees to click the “sign-out” button may be explored and used to increase autonomy.¹³ 

Pathologists gain in wisdom with increasing years of work experience. Senior pathologists serve as a scaffold of the practice and an extremely important source of support for junior pathologists. Survey participants who were in an academic setting reported the benefit of having multiple subspecialized faculty who could mentor them. Also, participants chose “network with mentors” and “friendship with colleagues” as important experience gained from their training programs. This further emphasizes the importance of mentoring and support systems to junior pathologists and for the future of pathology practice.

The first few years of junior pathologists’ independent practice will shape their outlook, confidence level, and reporting skills. It is thus imperative that the pathology practice group take the transition period seriously and provide adequate mentoring. One suggestion is to implement a buddy system in which the junior pathologist is assigned a dedicated mentor for the first few months who can help with anything from diagnosis to administrative matters and using computer systems. Junior pathologists may also struggle with imposter syndrome, and in such cases, reassurance and empowerment through mentoring will be helpful in the initial phase. But mentors should also give constructive and honest feedback, even if it may mean an uncomfortable conversation for both mentees and mentors, for the betterment of junior pathologists.

For graduating trainees, perhaps assessing the “culture of the practice” to ensure that the group is nurturing and willing to mentor should be one of their priorities in selecting their first job. In general, a diverse mix of pathologists at various stages of their career may indicate a healthy and stable practice. One potential problem that junior pathologists may encounter in the real-life workforce is potential “empty promises” regarding partnership track or advancement up in the career ladder. To avoid disappointment, contract negotiation should be emphasized to graduating trainees with encouragement to have partnership agreements in writing. We of course hope that practice leaders do not make empty promises to junior pathologists. But if this should occur, a strong peer support system will help the junior pathologist make appropriate career decisions.

Work-life balance was reported as a challenge for those in academic centers (13%) only; however, this was not considered as a challenge for those in nonacademic centers (0%). This may be an indirect reflection of “hierarchy culture” in academic work settings. Expectation to cover for the senior pathologists during major conferences or holidays can be problematic and cross the fine line between expecting less experienced pathologists to be good team players and abuse of junior pathologists. Experienced senior pathologists are encouraged to be mindful of junior pathologists’ vulnerability, as they have just transitioned out of the trainee mindset. Junior pathologists should be encouraged to attend conferences to establish social networks and flourish.

Other factors that can make it difficult for junior pathologists in both academic and nonacademic settings to achieve work-life balance may include high case volume, turnaround-time pressure, lack of resources (such as immunohistochemistry stains in community practice), and increased administrative activities. Junior pathologists working in academic settings may experience disturbed work-life balance due to increased responsibilities other than case sign-out, such as participation in tumor boards, conferences, and trainee education. Junior pathologists may feel that they should take advantage of all the opportunities that come their way, and they may even be forced to take on new roles. Opportunities are an excellent way to advance one’s career; however, career advancement will not result in happiness and joy if one is constantly overwhelmed with too many projects. We encourage our junior pathologists to realistically assess their capacity for additional responsibilities and never feel coerced to take on new projects. It is OK to say no.

Survey participants indicated that their training programs attempted to decrease burnout by holding social gatherings, using humor, and fostering an environment where trainees felt safe to speak up. Several participants commented that it was helpful when faculty recognized pressure and offered to offload cases. Similar strategies can be applied to work settings to decrease burnout and increase morale. Social outings, holiday potlucks, and redistributing workload when junior pathologists feel overwhelmed, although these approaches may seem trivial, could be a great way to help junior pathologists feel included and bond with colleagues in their workplace.

As junior pathologists acclimate to their new work environment, they will start to define who they are based on interactions with 2 major groups: clinical colleagues and trainees. Pathology is a consultative medical field. This means that establishing relationships with and gaining trust from clinical colleagues is a rite of passage. With confidence and effective communication skills, junior pathologists can shine in the areas of email communication, participation in tumor boards and interdepartmental conferences, and intraoperative consultations. However, the interaction with clinical colleagues and trainees also can be a source of additional stress and nervousness. Unreasonable demands from surgeons or unreasonable expectations of turnaround time from the clinical team can be frustrating, as survey participants commented. Most of these scenarios can be handled with proper communication and display of confidence and calmness. However, on the survey, “intraoperative frozen section interpretation and communication skills” was one of the top 3 clinical areas in which participants wished their training programs had provided additional guidance. The art of communication is an important skill that is often overlooked during training programs. Training programs should make an effort to involve trainees in communicating with clinicians. Under the appropriate supervision and as appropriate for the trainees’ level of expertise, trainees could provide the preliminary diagnosis by phone call or email, report findings from an intraoperative consultation, review slides with clinical colleagues, and actively participate in tumor boards and conferences. The more exposure pathology trainees have in the clinical arena, the easier their transition to junior pathologists will be.

The second group that junior pathologists will interact with is trainees, particularly in a hospital-based practice with training programs. Junior pathologists may struggle with diagnostic uncertainty and underdeveloped mentoring or teaching skills. Organizations may be able to limit exposure of junior pathologists to trainees during junior pathologists’ initial phase of working independently. When this is not possible, our advice to junior pathologists is to be transparent by sharing their vulnerability and uncertainty with the trainees. Junior pathologists should take advantage of the opportunity to connect with the trainees, emphasize the importance of lifelong learning, and work up complex cases together. Junior pathologists can involve trainees in peer-to-peer consultations to show the real work done behind the scenes, thus being truly helpful mentors and role models for trainees. Since junior pathologists are not too far from their own graduation, they can empathize with trainees, share tips on studying for boards, and counsel trainees on career planning. Junior pathologists can also serve as wellness liaisons for trainees, encouraging them to speak up whenever they feel overwhelmed and helping them recognize symptoms of burnout. Pathology is an international medical graduate–friendly program, and many trainees are older than trainees in other programs. The mean age of the survey participants was 39 years. Those junior pathologists who are on the younger end of the age spectrum should be cognizant of cultural diversity and show respect to trainees just as the junior pathologists wish to be respected.

Participants’ responses regarding both clinical and nonclinical areas in which they wished they had received more exposure and guidance differed by work setting and gender.

First, not too surprisingly, compared with junior pathologists in academic settings, those working in nonacademic settings were more likely to wish that they had received additional training and guidance in administrative activities, namely CPT coding, billing, and cost-effective patient care. A free-text comment also included insurance and reimbursement-related knowledge on a similar theme. Although some of these skills may have to be learned on the job, training programs could help trainees develop relevant skills. For example, (1) training programs could offer a rotation at a community practice or add a management rotation to the curriculum; (2) fellowship programs or national or regional professional societies could provide a seminar series for those transitioning into the workforce during springtime; and (3) training programs could provide resources or courses on wealth management as a graduation gift.

Second, while leadership and soft skills are in high demand and all potential leaders can benefit from leadership programs, according to our survey, more female than male participants wished they had received additional training and guidance in such skills (79% of females versus 28% of males; P = .01). In recent years, females and males have been entering medical school in almost equal numbers,¹⁴  but females are still underrepresented in leadership in medicine.¹⁵  Given this disparity, increased institutional and departmental support will be needed in training programs and the workforce to excavate the unseen leadership potential in women. To encourage women in medicine to advance in their career, they will benefit from sponsorship, visibility, and transparency. Approaches to help women cultivate their leadership skills could include positively encouraging female colleagues to apply for leadership positions and providing appropriate support, introducing female trainees/colleagues at networking events or encouraging female trainees/colleagues to attend networking events for visibility, and promoting an unbiased leadership selection process for transparency (ie, removing name and gender on the curriculum vitae for review committee).

Other nonclinical skills indicated as important by participants, either in free-text responses or in responses to multiple-choice questions, included contract negotiation, recognizing pros and cons of various practice settings, and finance, tax preparation, and budgeting skills. After spending years in medical training, shifting gears to one’s finances can feel abrupt and unnatural. Training programs might be able to effectively provide trainees the information they need in this area through partnering with local and regional organizations to set up targeted seminars during the spring or summer for graduating trainees or recently graduated junior pathologists.

This study has limitations, including the relatively small number of participants from only 2 academic centers. This limitation can be overcome by increasing the number of survey participants and including multiple centers to expand the data, which is our future goal. Although we cannot generalize the participants’ statements and survey responses to be applicable to all junior pathologists, our participants are diverse and appear to be a good representative sample that can closely parallel the broad junior pathologist population. We hope that this article will start a discussion about improving training and the transition experience for junior pathologists, an important but long-neglected cohort.

Needs and challenges faced by junior pathologists are heard and described. Collective efforts from training programs, more experienced pathologists, and professional organizations can improve the transition experience.

We thank our MD Anderson Cancer Center and MedStar Georgetown University Hospital fellowship and residency graduates for participating in this survey. We thank Kareen Chin, MBA, C-TAGME, for providing the email lists of survey participants. We also thank Stephanie Deming, ELS, Research Medical Library, MD Anderson Cancer Center, for editing the manuscript.