Valerie Neff Newitt
January 2022—It’s not curriculum. It’s visibility.
That’s the upshot of two companion studies on what influences U.S. medical students to choose pathology as a specialty, say Cindy B. McCloskey, MD, chair of the CAP’s Graduate Medical Education Committee, and Melissa R. George, DO, a member of the committee. Their study of allopathic medical students was published in 2020 (McCloskey CB, et al. Acad Pathol. 2020;7. doi:10.1177/2374289520951924), and their latest study, of osteopathic medical students, has been submitted for publication.
“What we suffer from is a visibility problem. I think most medical students don’t really know what a pathologist does beyond the classroom. They tend to think of pathology as a course, rather than a medical specialty,” says Dr. George, a professor in the Department of Pathology, associate program director of the pathology residency, and medical director of transfusion medicine and associate dean of continuing education, Penn State Health Milton S. Hershey Medical Center.
In a specialty focused on diagnosing disease, she says, she feels like the specialty itself has its own “disease”: a lack of visibility.
“Typically,” Dr. McCloskey says, “during the first and second years of medical school, students learn about the basic science that underpins medicine and many of those courses are taught by pathologists. The result? Many students equate pathologists with teachers. Just teachers.”
The number of U.S. medical students matching to pathology residency positions has declined, and there is worry in the specialty about the pipeline.
“A lot of pathologists thought changes in the medical student curriculum were driving decreased interest,” says Dr. McCloskey, vice chair of the CAP Pathologist Pipeline Ad Hoc Committee and associate professor, Jordan-Heartland professorship of pathology house staff education, and director of the pathology residency program, University of Oklahoma College of Medicine. But there’s no data to support that hypothesis, she says, referring not only to the two studies of students but also a third study of medical school curriculums. “We need to let it go,” she says.
“Curriculums used to be subject based—you would have a biochemistry class, an anatomy class, a histology class, a pathology class. You had discrete classes. And a lot of schools have shifted to a more systems approach,” in which the students learn, for example, “about the cardiovascular system—the anatomy, histology, and pathology of the cardiovascular system as a whole.” The thought among pathologists, she says, was that the standalone pathology course identified pathologists as a separate profession and knowledge base.
“What we found was that we didn’t see a difference in students who still had that more traditional, discrete pathology course-based curriculum versus students who had a more integrated curriculum. The truth about the effects of curriculum is among the most essential and important of our findings,” she says.
It’s likely that students identify with physicians they have seen throughout their lives, Dr. McCloskey says, perhaps a pediatrician or family medicine physician. “Chances are they haven’t had much experience with a pathologist.”
“So we need to focus less on first- and second-year curriculum course structures and shift our thinking to teaching students about our profession,” she continues. “It’s not enough to teach the pathophysiology of myocardial infarction, for example. We must also teach students what pathologists do to diagnose them.” Similarly, students need to see how pathologists diagnose cancer and what clinical pathologists do. “In both of our studies—allopathic and osteopathic students—we found students don’t necessarily know what we do.” Some students have the misperception, Dr. George says, that “all pathologists do is autopsies.”
People who work with pathologists recognize the value of their work and its impact on patients, Dr. George says, but among others there may be what she calls a “hidden curriculum.”
“When a student expresses an interest in pathology to someone, often the response will be, ‘But you’re so good with people. Why would you want to be in the basement all day looking at slides?’ No one is whispering in the student’s other ear that pathologists do much more than that and that we engage with people all day long. And many students believe pathologists have no interactions with patients or others outside of the lab.”
She says she joined a medical education listserve recently and read a post that questioned whether pathologists should even be called physicians since they don’t see patients. “I took a break, a walk, calmed down, and then wrote a thoughtful response, and a bunch of other nonpathologist physicians chimed in to say things like, ‘I’m a surgeon, and I rely on my pathologist every day. They’re every bit the physician I am.’ But there are perceptions like that. And this was a medical education listserve—a physician making that comment. That went out to thousands of people.”
With lack of visibility the diagnosis for what ails the pipeline in pathology, “it’s up to medical educators to find the cure,” Dr. George says. “Can surgeons spare students long enough to follow a specimen to the lab at least once during the rotation so they can see what it’s all about? Can students be linked more into tumor boards? Can we make sure we’re mentoring students so that they see some of the pathologists giving lectures as more than instructors?” And can students be given a glimpse into the movement toward pathologists showing patients their slides so they can understand their disease? she asks. “They need to realize that no day is the same for us. We’re faced with constant intellectual challenges. We communicate a lot and do a lot of interesting things. It’s our job to put it out there, to present ourselves in the best light, and to let students see how we impact care by applying our knowledge.”
Dr. George sees her own lectures to students as a recruitment tool for her residency program. At the end of every lecture she shows students a pathology report and tells them that while they may not go into pathology, every one of them will read a pathology report at some point in their careers and have to explain it to the patient. She says, “‘I’m going to teach you the breakdown of what’s important in a report and why. If any of you are interested in pathology, I can provide more information. And if you are going into a specialty that uses pathology heavily, consider doing a pathology rotation to gain important experience.’” Every year, she says, three or four students will reach out. “If I get a couple of students going into pathology from that group, that’s exciting to me,” she says.
That there are no required pathology rotations is a problem “we run into almost uniformly,” Dr. McCloskey says. “In the third and fourth year of medical school, students rotate through clinical areas of practice—internal medicine, pediatrics, maybe surgery. They get experience in all of those disciplines. But they don’t rotate through pathology.” In some medical schools, “you can do elective time as a third year,” she says, and in most places elective time can be done as a fourth year. Applications for residency are submitted by September, so “you have only a couple of months, the very beginning of fourth year, to hope someone can elective in pathology.”
“We need to get the message out early that pathology is a fascinating specialty that covers so much more than anybody realizes. And how do we get that message out?”
In the study of fourth-year allopathic medical students, clinical rotations during medical school were the second highest rated factor impacting a student’s choice of specialty. The first was “personality fit with the specialty,” and No. 3 was opportunities for patient contact. The remaining factors, in order of importance to students, were as follows: intellectual challenge of the specialty, faculty in the chosen specialty, residents in the chosen specialty, lifestyle expectations, educational experiences prior to medical school, income expectations, “health care providers not involved in my education,” reputation/prestige of specialty, prior academic performance, basic science/didactic portion of medical school curriculum, participation in specialty interest groups, peers in medical school class, family members and expectations, and the dean of students.
[dropcap]D[/dropcap]r. George sees it as unfortunate that students are not making an informed decision when deciding against pathology, but she is optimistic because the information voids can be filled. “These are fixable problems,” she says. “If our problem is visibility, we can shed light on our field and curate the right information.” Getting a pathology rotation is “less achievable,” but other experiences are more feasible. For example, “There should be an opportunity at any hospital to embed pathology experiences in rotations like surgery or internal medicine.”
Pathology interest group sessions at medical schools, led by nearby pathologists, are another example, she says, a connection that pathology professional organizations can foster by reaching out to nearby medical schools. And schools could partner with pathology residencies, virtually or via lab tours, to give students exposure to tumor boards, for example, or subspecialties that offer more patient contact like transfusion medicine. “The virtual experiences can bridge some of the geographical gaps and constraints on time allowed for travel,” Dr. George says.
Several initiatives of the CAP Pathologist Pipeline Ad Hoc Committee to improve knowledge about pathology are underway, Dr. McCloskey says: “networking with students, pulling students into CAP activities, encouraging them to go to CAP meetings, and a fantastic medical student landing page on the CAP website.” The aim of the “pipeline champions” initiative, which had a kickoff meeting in November 2021, is to recruit pathologists and residents to interact with students to try to recruit them into pathology.
“We have participants from academic and private practice. We challenge these pipeline champions to choose one impactful intervention—something they’ve not done before—to involve and educate students,” she says. Among the suggestions for such interventions are advocating for pathology electives, directing students on surgical rotations to follow surgical specimens to surgical pathology labs, and offering medical students autopsy rotations. “We’re going to follow up to see if there are interventions that are particularly effective,” Dr. McCloskey says.
Pathologists in academic centers can aid the effort by finding out what activities their department has for students. “If your department isn’t active in trying to recruit medical students, can you change that tide?” she asks. “Become involved in a pathology interest group, volunteer to be on the school’s curriculum committee.” To those in private practice, she says: “It can be hard for osteopathic students to find experiences to rotate in pathology. Is there a need in your community for places for medical students or even residents to rotate? Can you help provide that opportunity?”
The pipeline problem is one for pathologists and professional organizations, Dr. George says, not the medical schools. “The pipeline is not their problem to fix. We own that,” she says. “We must reach out to schools and put effort into doing something about the correctable voids.” Exposure through a mentorship with a pathologist “could make all the difference to a student.”
The CAP is offering a medical student monetary award for interest in pathology, Dr. McCloskey says, and it will be extended through all osteopathic and allopathic schools in the country. “We are encouraging it to be given out when other student awards are given, to help socialize people to see pathology and the pathology community.”
Work to counter misinformation about pathology on social media is ongoing, and one of the inaccuracies that may be turning students away is “word of mouth that the job market isn’t great,” Dr. McCloskey says. The CAP Graduate Medical Education Committee has studied the job market extensively, she says, and “the reality is the majority of graduates from residency or fellowship programs are finding jobs. And the vast majority are satisfied with the jobs they are finding.” In fact, the group’s data point to it being easier to find a job in the past couple of years than it had been in prior years.
“The jobs are out there,” she says.
Valerie Neff Newitt is a writer in Audubon, Pa.