The post-sophomore fellowship and other pieces of the pipeline

There is a huge disconnect between pathology as it is taught to medical students and the practice and art of pathology. This disconnect is what a post-sophomore fellowship addresses, for people who are desiring to understand the difference. It’s unfortunate we don’t do a better job of highlighting exactly what we do as pathologists when we practice medicine. I wish there were a better way for us to teach that.

At Duke we have a pathology student interest group, and the leader of that group tries to find opportunities for the group to see what we do in practice, but those are just glimpses. It’s not designed necessarily for the general medical student. The leader is also the course director for our Body and Disease pathology course, and she has students attend a tumor board or a conference that’s multidisciplinary and where pathologists will be presenting pathology. She has them choose a patient and then as a group they have to learn more about the patient and the patient’s disease entity. That’s one way she has figured out how to help our medical students understand pathology and get exposure to the practice of medicine from a pathologist’s perspective.

Historically at Duke the students had to observe an autopsy. And how off-putting can that be if you’re a bit squeamish or you’re grieving—anything. We had been leaving medical students with the impression that the autopsy is what we do. It’s a part of what we do; it’s not all of what we do.

Robert, does this resonate with your experience?
Dr. Hoffman (Vanderbilt): It does. Vanderbilt has a couple of different hooks we use for medical students, where we try to make sure everybody’s exposed to pathology in an important way. In each of the core rotations at Vanderbilt there is a session that is dedicated to laboratory testing and how it goes off the rails if you don’t communicate in the right way with pathology. You can apply that to every core rotation—gynecology, surgery, medicine. They hit the high points and make sure they understand what is a fair question to ask and what is not a fair question, and if you can polish a question a little rather than just check a box on a requisition, you’ll probably get a better answer. That’s important for every doctor to learn how to do.

The other thing they’ve done, which we’ve enjoyed, is you can offer an elective in surgical pathology during the surgery rotation. We have people spend a couple of weeks with us during their surgery rotation. These are people who are serious usually about surgery as a career and they come away from it with a much better idea of, How long does it take to do a frozen section? Or why can’t I ask for my routine results the same day? Things take time, and they come to understand that process. And special stains. It’s an eye-opener for a lot of them. That is a big hook.

The other thing I’m intrigued by is the accelerated program that Amyn Rojiani, MD, PhD, chair of pathology and lab medicine at Penn State, and his colleagues have put in place. Medical school applicants who apply for the pathology accelerated program and are accepted into the program will be eligible for residency after three years instead of four. They are streamlining the process (see CAP TODAY, March 2022: “At Penn State, a fast track to pathology residency”). Students who have the interest will do that, but it also creates the idea for people who may not have thought about it—Oh, that’s something I can do. I think it has an advantage for people who have even an inkling of pathology as a career interest.

Alexandra, does every medical student at Iowa at some point enter the laboratory and look at the machines, histology, and pathologists’ suites?
Dr. Isaacson (Iowa): All of the medical students who graduate from Iowa get a lab tour as part of the preclinical curriculum. They’ll get to walk through the chemistry lab and see what that looks like. In the past there was a requirement to see a frozen section or an autopsy, and that has since gone.

The exposure to the day-to-day practice of pathology seems to be what we’re missing out on for medical students. In the preclinical years, pathology is taught alongside biochemistry, anatomy, et cetera. But it’s not a subject; it’s a branch of medicine. I am interested in the ideas that Sarah and Robert brought up where pathology is being put side by side with surgery or internal medicine to show that this is what doctors do as well.

It’s to our detriment that medical students aren’t required to spend any time in pathology, besides a lab tour, before graduation. I don’t know how ubiquitous across medical schools it is to have a required pathology rotation but it does seem interesting that every other specialty has some requirement, maybe with the exception of surgical subspecialties, and that people could get through their medical school curriculum and never set foot inside a real pathology lab, aside from what they’re exposed to in lectures.

Sarah, I’m sure you would agree with that.
Dr. Bean (Duke): Yes, and there are some medical students who graduate medical school who do not understand that pathologists are medical doctors.

During the few times I’ve been allowed to be in a tumor board as an observer, it’s been impressive how everyone seems to know everything about the patient and the case and there are all kinds of opinions, and when the pathologist begins, everybody gets quiet and attentive. I would think if I could expose a medical student to that, they might say, That’s the kind of doctor I would like to be—where everybody listens and considers them to be leading the final diagnosis and planning. What do you think about that, Robert?
Dr. Hoffman (Vanderbilt): That is the ideal, and we have a lot of opportunities here for the medical students, residents, and fellows to be exposed to pathology, and the tumor boards are one. We take autopsy seriously here. I direct the autopsy service at Vanderbilt and the Nashville VA Hospital and our VA service will do a case presentation on almost every case. And they pretty much hang on every word, and they will make a teaching opportunity out of it: Here’s something we didn’t know and let’s try to pay attention to this going forward. One of the things I try to do in everything I do—I do heart pathology and autopsy pathology—is to be available to clinicians, and if they show an interest in seeing something, invite them in. Come on, let’s go over this heart; let’s go over this autopsy. And then we’ll sit down and review the slides.

Virtual connection has made that easier. I can do a microscopic session for almost anybody I can contact by email. It used to be people had to drop what they were doing and walk across campus, and that is no longer. It has given us that much more opportunity to be available. And they love it.

Alexandra, do you have a final thought or a question for your colleagues?

Dr. Isaacson (Iowa): The post-sophomore fellowships are wonderful tools, but they’re an investment for departments, if the department is doing it well, and an investment for the students who pursue them. If you were to counsel other departments, would you say that putting emphasis on or starting a post-sophomore fellowship is the best way to move forward? Or should we be putting more emphasis on third-year pathology clerkships or exposures in the preclinical years to pathologists? Where do you think the real worth is moving forward?

Dr. Bean (Duke): That is a difficult question, and the answer is going to be nuanced and contextual, depending on the institution and money available as well as the institution’s goals, visions, and initiatives. The best approach is going to be multipronged. If an institution, organization, or department has money to support a post-sophomore fellowship program, they should do that.

We also need to be doing things like what I did with the Washington Post article (“What a pathologist does in a workday,” Feb. 22, 2022). It was basic; it was easy. But it got the word out, and that was my goal—to tell people I’m a pathologist, this is what I do, and isn’t this awesome? We need to find opportunities like that in pop culture and other media outlets as much as we can. I’m active on social media, trying to get the word out about what I do, who I am, and that I’m a multifaceted person.

We need to look to preschools and elementary, middle, and high schools, and start doing road shows if we can. There are pathologists out there doing that already.

Pathology student interest groups are another way to get the word out. It’s a relatively easy thing for pathology departments to organize and shouldn’t cost much money.

Dr. Hoffman (Vanderbilt): The post-sophomore fellowships are a positive thing. I believe in them very strongly. If you give me an applicant who has a post-sophomore fellowship and one who doesn’t, all other things being equal, I will take the post-sophomore fellow hands-down. I am proud that we recruit post-sophomore fellows continually into our program.

We have a post-sophomore fellowship technically on the books here, but it has been years since anybody at Vanderbilt has wanted to do it. One thing you have at the University of Iowa, Columbia University, University of Missouri, and University of Toledo is a tradition of doing it, people know it is a good thing, and they will follow each other into it. Some things get propagated like that, and I’m glad there are places that have it.

From our end we’re trying to make the outreach more universal, trying to reach every medical student at some point in their training. I teach a pathology course for undergraduates at Vanderbilt. We do autopsy 101, and we show them hearts; it’s largely run by the biomedical engineering department. But we’ve had French majors show up and take it and get a lot out of it. I think some biomedical engineers go on to medical school, and we haven’t been doing it long enough to see how many decide to go into pathology. It is an eye-opener for them because they don’t really understand what we do.

There’s a well-founded consensus that we have a shortage of pathologists. I’m hearing that from academic programs, community programs, small groups, big groups—you name it. How do you feel the pathologist shortage is, Robert, and is there something that will help solve it?
Dr. Hoffman (Vanderbilt): I’m in a market that is growing rapidly in Nashville. We are expanding the size of our laboratories. During the next year we’re moving to a new 100,000-square-foot facility four miles from the main campus. With that, I don’t think there is any discipline in pathology that we’re not looking to fill. We need everybody.

As a program director, my phone is ringing much more frequently—Hey, I’m looking for someone, who do you have? And the anecdotal stories I’m hearing from the residents—we have second-year residents who are getting cold calls from practices in their hometowns with serious inquiries about jobs. I’ve never seen this before. There’s a real market for people coming out of training right now to go into pathology.

That’s great news if you’re looking for a job. If you’re having to fill positions, it’s not such great news, I suppose.
Dr. Isaacson (Iowa): I’ve read about this historical perception that the job market in pathology wasn’t great, and that may have turned people away. Although the shortage is a struggle for the pathologist workforce right now, there may be an opportunity here for how we present the specialty to people who might be interested, that this is a good field to go into and there’s going to be a lot of jobs in the areas you want to live.

Dr. Hoffman (Vanderbilt): Stephen Black-Schaffer, MD, and others predicted this years ago. He and his coauthors did a study that predicted a tidal wave of retirements would begin in about 2015 and peak in 2021 (Robboy SJ, et al. Arch Pathol Lab Med. 2013;137[12]:1723–1732). We’ve seen it. There used to be a lot more pathologists entering the job market from U.S. programs. There used to be a lot more U.S. programs than there are today. It has changed.

Sarah, how is the pathologist shortage affecting you at Duke?
Dr. Bean (Duke): We’re hiring multiple positions. For us, thoracic pathologists have been difficult to come by. That’s been our big challenge. Our hematopathology and gastrointestinal pathology divisions are constantly trying to find someone because our volumes are increasing and we need more people to help take care of all of our patients. So we’re feeling it too.