More than any other discipline of medicine, the specialty of pathology has an image problem. This is ironic for a field whose basic premise centers around images. This is also most unfortunate for medicine at large, as pathology constitutes a highly important component of modern medical care. It is estimated that 70 percent to 80 percent of all medical decisions are based either totally or partially on pathologic and/or laboratory-produced data. Common medical quips include: “A surgeon without a pathologist is blind” and “A physician without lab data has no guide.”
In the U.S., the term pathology is often used generically to describe the work of both the anatomic pathologist (who deals mainly with studying surgical specimens and rendering a diagnosis, usually after microscopic examination, and often aided by ancillary analyses) and the clinical pathologist (who generally deals with analyzing a wide range of laboratory-based samples such as blood, bodily fluids, and bone marrow by utilizing appropriate scientific testing methods). There is significant overlap between the two, and most pathologists in the U.S. train in both pathology and laboratory medicine (P&LM) before choosing to focus on a narrower subspecialty within the field.
The practice of P&LM often taps a foundation of basic sciences to generate concrete data needed to guide medical providers. If modern clinical medicine were represented by a sprouting tree, the field of pathology and laboratory medicine would be analogous to the tree trunk that connects its basic medical science roots with the clinical branches and limbs.
The field of pathology has witnessed astonishing advancements accompanied by major changes over the last few decades. In fact, many of the recent triumphs and advances in clinical medicine are built on solid foundations of microscopic, molecular, or genetic investigations that are at the core mission of pathology.
Despite all the facts listed above, the field of pathology remains, in the eyes of many, shrouded in myths and misconceptions. Hence, it is often misunderstood, underrecognized, unappreciated, or even overlooked. This creates major challenges for the discipline itself and the field of medicine at large. To the discipline of P&LM, these challenges range from failure to fill training positions or attract the most suitable trainees to the profession creating workforce shortages or understaffing. To the field of medicine, these consequences can produce lower quality and increased cost of health care.
The myths and misconceptions about P&LM can generally be classified into three levels: the first relates to the public at large, the second is among medical students (potential future trainees), and the third is at the level of practicing medical specialists, administrators, and staff. Dispelling these misconceptions is in the interest of everyone.
The following are some of these myths and misconceptions, contrasted with realities:
Myth 1: Pathologists’ work centers around autopsies and/or diagnosing cancer.
Reality: While almost all pathologists learn to perform them, post-mortem examination (autopsy) is a small fraction of most pathologists’ responsibilities. The study and characterization of all types of disorders—cancerous and non-cancerous—constitutes a more dominant component of most pathologists’ practices.
Myth 2: Pathologists work only in the lab, and all perform similar tasks.
Reality: Pathologists carry a disproportionately higher responsibility of teaching: students, trainees, colleagues, and other staff members through various activities ranging from one-on-one, interdisciplinary conferences, and formal lectures. They are also disproportionately more involved in medical research and collaboration than any other medical specialty.
The daily practice and types of disorders a pathologist deals with are as variable as those of an internist or a surgeon. The field is broad and encompasses several subspecialties.
An anatomic pathologist may choose to train and practice one or more of several sub-subspecialties such as cytology, gastrointestinal pathology, forensic pathology, or neuropathology, among others. Clinical pathology (lab medicine) encompasses several different disciplines as well, including hematopathology, transfusion medicine, immunology, clinical chemistry, and microbiology.
Myth 3: There is no creativity in pathology. Results are obtained from instruments and data are predictable, so the room for creativity is very limited.
Reality: While the bulk of data is collected using standardized scientific methods and instrumentation, creativity and skill are needed for the interpretation and application of data to a clinical context. Clinicians often rely on pathologists to help interpret and assimilate vast amounts of generated data. Pathologists are often the behind-the-scenes champions of solving medical mysteries, even though their role is not always highlighted when clinicians celebrate successes with patients and families.
Myth 4: A pathologist’s work is boring, and they practice in lonely isolation with no personal contact.
Reality: The bulk of pathologists’ work centers around generating, sharing, and discussing results/data and solving medical puzzles. After all, solving puzzles is the most exciting and least boring part of medicine! Pathology practice is very dynamic, and most pathologists spend a significant portion of their workday consulting with other physicians, technologists, and each other. Dealing with common, uncommon, and rare diseases offers endless opportunities for self-study and continuous knowledge and skill expansion.
Myth 5: Microscopy/morphology is obsolete and much of pathologists’ work will be replaced by artificial intelligence (AI) in the future.
Reality: Pathology offers a rewarding deep understanding of the disease process in a way that no other field of medicine does, and morphology offers a unique visual perspective on context and the big picture. Microscopic examination continues to guide triage and help assess the adequacy of most specimens sent for advanced molecular and genetics studies. It continues to be highly useful in translational research as well.
Artificial intelligence will certainly have a positive impact on pathologists’ work; however, it will be used mainly as an ancillary tool that improves accuracy and enhances quality. The exaggerated fears about AI are reminiscent of expectations that swirled in the early years of immunohistochemistry (IHC), when some predicted that IHC would reduce the need for pathologists. We know now that IHC enhanced the quality of pathologists’ work and elevated diagnostic clarity, but the need for pathologists has persisted.
Myth 6: Pathologists do not bring in new customers of health care as the field follows rather than leads expansions.
Reality: No meaningful growth in clinical medicine is possible without matching expansion and excellence in P&LM. Furthermore, outreach labs that facilitate patient access to services represent an increasingly popular method of clinical labs’ independent expansion.
Myth 7: The wide use of instrumentation should make results available instantly. After all, we live in an era of instant gratification (and instant coffee!).
Reality: While some lab data can be available and reported quickly, reporting important and complex test results often requires careful review and interpretation appropriate for the clinical context.
The exaggerated expectations stem from lack of familiarity with the nature of the work and misconceptions regarding work hours and turnaround time.
Myth 8: Pathology and lab errors are common.
Reality: Health care is rarely perfect, but errors are comparatively very low in P&LM. The expectations of both perfection and instant answers are higher in pathology than any other field, perhaps because of its close relationship to the basic sciences, automation, and instrumentation. This adds disproportionate scrutiny and negative publicity at every imperfection.
Myth 9: Pathologists work from 8 a.m. to 5 p.m.
Reality: The bulk of pathologists’ work is performed during regular work hours, and the field consistently ranks highly in work-life balance. However, pathologists do take calls outside work hours as most major health care facilities have 24/7 pathology and lab medicine coverage.
Samir Kahwash is a pathologist.
