The last generalists
Emily E. Volk, MD
June 2022—You’re probably familiar with the expression “jack of all trades, master of none.” While that sounds disparaging, it’s actually taken out of context. The original quote in its entirety is, “A jack of all trades is a master of none, but oftentimes better than a master of one.” It was intended as a compliment for someone who had good, broad knowledge.
The widespread misinterpretation of that quote supports a common idea that no individual can be really good at a lot of different things. But pathologists challenge that concept every day.
While many of us subspecialize, we are able to fall back on our broad training when circumstances require it. Such may be the case when encountering pathologic findings that indicate a disorder not commonly found in our area of expertise, or findings that indicate a systemic illness. Many of us find that we have to be experts on different things on different days and in different parts of our career.
Our abilities have been on display throughout the COVID-19 pandemic, when a lot of hospital pathologists had to get really good at understanding molecular testing. Even if they sent the tests out instead of running them in their own labs, many generalist pathologists from around the country became the local experts in microbiology. It’s something they did quite well, serving not only their hospital patients but also shoring up the local public health brain trust.
I have always appreciated the breadth and depth of our specialty. As a resident I felt particularly drawn to the clinical complexity and patient-facing nature of transfusion medicine, but I also loved the visual problem-solving and clinical correlation required of surgical pathology and cytopathology. I wound up doing a fifth year of residency with a focus on surgical pathology with an emphasis in gastrointestinal pathology, but I also managed to spend time improving my abilities in transfusion medicine. I spent mornings with a renowned group of GI pathologists and afternoons with renowned transfusion medicine experts. I rounded out my formal training with a fellowship in cytopathology, where again I worked with renowned experts.
In my career I found that these skills, as well as many I had yet to acquire, were essential to serve the daily needs of my hospital and its patients. I had to be willing and able to handle any patient issue that came my way, be that in the form of a biopsy, a Pap test, a question concerning clinical chemistry or microbiology, or an issue related to lab management. To be clear, sometimes “handling” a question meant knowing when to work with a colleague who could provide more insights to a given problem.
Indeed, there are some among us who excel in general knowledge and adaptability, who eagerly accept responsibilities outside their comfort zone and who tirelessly endeavor to remain current in broad areas of pathology. These pathologists are experts of another kind, who often go unheralded in our increasingly subspecialized profession.
Our specialty offers us the wonderful opportunity to keep learning and to keep growing as clinicians. The breadth of anatomic and clinical pathology means that we will eventually learn skills we never thought we would need. One of my first leadership roles in medicine was being the chief of the transfusion medicine service at a community hospital. It was in that role that I began to learn about the differences between management and leadership, valuable skills I have built upon throughout my career.
As pathologists, we find that both depth and breadth are necessary for providing excellent care for our patients. In medicine there is a strong tendency to subspecialize. For example, some pathologists might spend their entire careers focused on just the kidneys, or just the digestive tract. But disease doesn’t read the textbooks. It is not limited to the physiological systems we might choose to focus on. We think of leukemia as a blood disease, but because the vasculature carries the blood throughout the entire body, leukemic cells can present as a soft tissue mass, a brain mass, or a skin lesion, not just as an increased white blood cell count. If we don’t think broadly, we run the risk of missing diagnoses through the inherent anchoring bias of the subspecialty sign-out room.
Maintaining broad and deep knowledge can be aided by the numerous educational opportunities the CAP offers. Resources such as the MyCAP app, the CAP cancer protocols, the Case of the Month, and our journal, Archives of Pathology & Laboratory Medicine, covering both clinical and anatomic pathology, give CAP members a chance to keep up in our field in the broadest sense. Our national meeting and variety of CME offerings offer even more avenues to stay up to date on the full breadth of our specialty.
When I speak with pathology residents, I always offer this advice: Do your elective rotations in as many different clinical areas as possible. As a practicing pathologist, you will be expected to have a working fluency if not total mastery in the many subspecialty areas of pathology. That’s a big responsibility, but it’s also its own reward.
Dr. Volk welcomes communication from CAP members. Write to her at president@cap.org.