The practice of pathology involves the application of modern technology to the scientific study of disease in the living patient. Pathologists interact with all other medical specialties, providing them with information vital to the formulation of accurate clinical diagnoses and treatment strategies. Pathologists are at the forefront of medical research. They are educators as well as coordinators of many other medical specialties.
Generally speaking, there are two broad categories within pathology: Anatomical Pathology and Clinical Pathology. Anatomical Pathology involves areas such as surgical pathology, cytopathology, and autopsy pathology. Clinical Pathology involves blood banking, microbiology, clinical chemistry, hematopathology, molecular diagnostics, and immunopathology. When applying to pathology residency, you can choose to apply to a combined AP/CP program (most common), or to a single track (AP only or CP only). There are also other options at large programs such as AP/NP (combined anatomic pathology and neuropathology) or research tracks.
- Surgical Pathology:This field involves studying specimens resected during surgeries, biopsies, or other procedures. The pathologist’s diagnosis plays a critical role in guiding future therapy for patients. (e.g. staging of cancer). The resident will spend time examining the gross specimens and sectioning them; this is known as "grossing". The resident will then get the slides from the sections they cut and preview the slides on their own. After that, they will sit down with the attending, review the slides, and make the final diagnosis (known as "signing out"). The exact surgical pathology cycle varies by program. For example, in some programs residents will do all three activities (sign out, gross, and preview) every day, while in other programs each task will be delegated to a different day. You will not be expected to be proficient right away, but will learn on the job. As you progress through residency there is a push toward graduated responsibility in many programs. At times surgeons request an immediate diagnosis while they are still in the OR, and the surgical pathologist performs a frozen section to help guide the surgery. (Is the mass benign or malignant? Are the surgical margins free of tumor or do they need to resect more?) The sign out structure of surgical pathology is also variable among programs. Some programs have general sign out in which you will be working on a variety of specimen types at any given time. Other programs are sub-specialized with dedicated rotations for the various organ systems. Subspecialty areas within surgical pathology include neuropathology, dermatopathology, pediatric pathology, GI pathology, Gyn pathology, Breast pathology, Head and Neck pathology, Bone and Soft Tissue pathology and many more. All of these have fellowships if you want to become more specialized in a specific organ system.
- Cytology: This field involves making diagnoses from individual cells. Samples include body fluids, fine needle aspirations, and Pap smears. In some institutions the pathologist performs FNAs and biopsies in the clinic and is able to make an on-the-spot diagnosis for the clinician. It is therefore an area of pathology with some patient contact. The amount of FNAs performed by pathologists is variable among programs, with some programs having a dedicated FNA clinic run by the pathology department.
- Autopsy: This is what most people think pathologists do for a living, though only around 5% of pathologists continue to perform autopsies after residency. You are required to do 50 autopsies during residency, usually some combination of hospital-based autopsies and a rotation at the medical examiner’s office. If you are really interested in autopsy, Forensic Pathology is an option. Forensic Pathologists are the Medical Examiners and deal with the investigation of deaths that occur outside of the hospital setting. If you are interested in forensics, you need to do a one-year fellowship after your pathology residency.
- Clinical Pathology: This is a wide-reaching field which includes blood banking, microbiology, clinical chemistry, hematopathology, molecular diagnostics, and immunopathology.
- Blood Banking/Transfusion Medicine: Here, the pathologist controls the dispersal of blood and blood products (platelets, cryoprecipitate) in the hospital. If there is a request for blood products, the pathologist will review the request, approve or deny it, or make a more appropriate suggestion. They also work up transfusion reactions, coagulation disorders, and can participate in apheresis. In some hospitals apheresis is under control of pathology and you would get direct patient exposure in this area. In other hospitals, apheresis is controlled by nephrology or another department and you would have less exposure.
- Hematopathology: The pathologist is involved in diagnosing hematologic disorders and malignancies. This subspecialty involves looking at blood smears, bone marrow aspirates, and bone marrow biopsies as well as interpreting results from flow cytometry, immunohistochemistry and molecular studies in order to arrive at a diagnosis. You therefore work closely with hematologists, oncologists, and their patients. This area of pathology is on the border between AP and CP, and is considered part of one or the other depending on the program.
- Microbiology and Clinical Chemistry: In each of these areas, the pathologist is in charge of running the laboratories. In microbiology, you work closely with Infectious Disease and are responsible for making sure the lab makes quick but accurate diagnoses. In Clinical Chemistry, you are in charge of making sure the lab runs efficiently, and equipment is up to date and accurate. Quality control issues and lab management skills are important in these areas.
- Molecular Diagnostics: This emerging and increasingly important field involves identifying changes in genes and gene expression to guide treatment of disease. Larger academic centers will have a more in-depth Molecular Department.
- Research/Teaching: All pathologists are involved in teaching, whether teaching medical students in an academic institution, or teaching residents and faculty about the various aspects of disease. They frequently hold conferences for other specialties such as dermatology, surgery, and infectious disease. Many programs have residents give talks for the department as well. Most pathologists are also involved in research. Some make it their whole career, with little time spent on diagnostics. Others publish a case here and there that they find interesting. Different programs will place different emphasis on research and teaching requirements in addition to clinical diagnosis as part of residency. If there is anything you take home from this it’s that Pathology is VERY flexible and you can focus your interests in a variety of different areas. Pathologists don’t just do autopsies!
- What to look for in a Residency Program: It is important to consider the type of career you want: academic vs. community practice. Academic programs offer research opportunities whereas community programs are more focused on laboratory management and pathology training. You also need to consider whether you want a combined Anatomical and Clinical Pathology (AP/CP) training or just Anatomical or just Clinical Pathology (AP only, CP only). If you plan on pursuing community practice, you need the combined AP/CP training. Most community practices expect you to be proficient in not only diagnostics but also how to run a lab and the blood bank. If you are 100% certain that you want to go into research/academic practice, either AP or CP training may suffice. However, most people advise getting both AP/CP training even if you are going into academic practice, because it is good to be well-rounded in the various areas of pathology and because you may change your mind later on and want to go into a community practice. Most programs let you switch from AP/CP to a single track in your first year if you change your mind. AP/CP programs are four years long, while single track programs are three years long.
- Size of Program: Mid-size programs take 3-6 residents per year with 12-20 total residents at any one time. Big programs take up to 8 or 9 per year and have up to 30 total residents. Small programs take 1-3 residents per year and have 12 or less total residents. Programs that have less than 10 residents may not have enough volume to get the most well-rounded training. Plenty of small programs are going to give great training, but make sure you ask a lot of questions about diversity of specimens and work load when you interview. The bigger programs will have more fellowships offered and it is usually easy to stay at the same place for fellowship.
- Pathology Assistants: You also want to ask about how many Pathology Assistants the program has. These people help with grossing, autopsy, and frozen sections. Maryland has a training program for PAs (they were in anatomy lab with you). If a program has a lot of PAs, it may give you more flexibility to gross the larger, more educational specimens. This lets you focus more on your learning since grossing small biopsies has little educational value after the first or second time you do it. Small programs may not have many PAs (or any) and the residents may be required to do all the grossing.
- Reputation of Program: A prestigious sounding program may not always give you the best education depending on your career goals and learning style. If you want to go into academics and be heavy in research, then the prestigious places may be the best option. But if you want to work in community pathology there are also many other programs that will provide a strong education. It is important to find a good fit for you, so on interviews make sure to spend as much time talking and interacting with the residents as you can. Ask about recent graduates fellowship and job placement. Make sure to ask about their Pathology board pass rate. If their alumni are getting good fellowships and good jobs, and if they are passing their boards with higher than a 95% rate, then the program is likely to provide you with good training.
- Format: On surgical Pathology, programs can either be sub-specialized (with residents working on one organ system at a time) or general (with residents working on whatever specimens come in that day). Another difference in structure is the “cycle” length as mentioned above. Maryland for example has a multi-day cycle: Day 1 – The residents are grossing all day. Whatever specimens from any organ system that comes in will be grossed by the resident that day. The residents will do the bigger cancer cases and the PAs will do the smaller cases. Day 2 – The resident is covering the frozen section room and signing-out small biopsy cases with the attending. Day 3 – The resident signs-out all the bigger cases that they (or the PA) grossed on Day 1 with the attending. In this system, previewing of cases generally occurs in the evenings of Days 1 and 2. Some programs have a 4 day cycle which works in a similar fashion with an extra day to preview cases. The other option is a one-day cycle. For example: Resident A is on Thoracic for 2 weeks. In the morning (s)he previews cases from the day before for 2-3 hours. (S)he then sits down with the attending (who is an expert in thoracic pathology) at noon and signs out the cases that (s)he looked at that morning for a few hours. At 2 or 3 (s)he will then go to the gross room and gross only interesting Thoracic specimens that are coming in (the PAs will do the rest). These specimens are then made into slides and ready for the resident the next day. (S)he will spend 1-3 weeks on Thoracic and then rotate to GI and then to Breast, etc. The order of events within a day may vary for a given program. Both systems have their pros and cons and you will need to talk to the residents at each program about which they prefer and why. Most community practices have general sign out, whereas many large academic centers (though not all) are moving toward subspecialty sign out. In general sign out, the attending you sign-out with may be an expert in GI but will need to look at everything, so you get to see how different people approach different cases. But that attending can’t give you all the best info about certain cases. For sub-specialty, you will always be signing out with an expert in that organ system. But you may have months or even a year between seeing a certain organ system. You may do breast early in first year, and then not rotate on it again until late 2nd year. Both types produce excellent pathologists, and you would adapt to either structure, but it is something to ask about at interviews. For reference, Maryland is general sign-out.
- Schedule: There is no intern year in pathology! The combined AP/CP residency is 4 years which is one year more than the AP only or CP only track. Some programs mix up the AP and CP rotations within each year whereas others do 1 year AP followed by 1 year CP. A resident or fellow is always on call for frozen sections 24/7, but it is rare that a surgeon will request a frozen section after 8:00 PM or on a weekend. The call schedule may be combined AP/CP call, or divided into separate call depending on which rotation you are on. AP call is mostly frozen sections and autopsy. CP call involves answering questions about the blood bank and clinical labs. These can usually be addressed from home and you usually don’t need to come to the hospital. However, programs that have the apheresis service run by pathology may require residents to come in for emergent apheresis procedures. Some programs have a resident come in on Saturday to gross specimens. This is rarely more than once a month. Most programs have 3-4 weeks of vacation per year and about $1,000 in book funds every year.
What to Do Your Third and Fourth Year
- Electives: The best way to get experience is to do some pathology rotations. A surgical pathology rotation and a clinical pathology rotation will give you a great idea as to what pathology is all about. Maryland has both of these electives plus an elective at the Medical Examiner’s Office for Forensic Pathology. One of the main things program directors look for is exposure to the field. Try to do at least 2 pathology electives by September of 4th year. Another suggestion is to do a month or more of research with an attending in the path department. Not only does this look good and may get you a publication, but it gives you an easy topic to discuss during your interviews. You can contact your PSIG officers for departmental contact information if you are interested in research within pathology. The earlier you do your electives the better; this way you can get letters of recommendation from people you worked with, as well as ensure you have a good exposure to pathology to feel confident in applying. All of the attending pathologists at Maryland are really nice and would be happy to talk with you about residency. In particular, three people who are great to talk to and get to know at the University of Maryland are Dr. William Twaddell- Residency Program Director, Dr. Olga Ioffe- Head of Anatomic Pathology and former Residency Director, and Dr. Magali Fontaine- Director of Clinical Path and Blood Banking. Schedule a meeting with Dr. Twaddell and/or Dr. Ioffe as soon as you think you are interested in the field. Once they get to know you they will work very hard to help you get into the residency spot you want, and they will be able to guide you through the process of applying.
- Away Rotations: These are useful if there is a particular program that you want to learn more about. It is especially useful for ones that have a different format than Maryland’s program. It lets you see how different styles and formats function. For example it may be useful to do an away at a place that does Subspecialty sign-out to compare to Maryland’s general sign-out. However, it is not required or even expected that you will do an away. They are mainly for your own benefit, though they may help you get an interview at a particular program.
- Post-Sophomore/Post-Junior Fellowship: This fellowship is offered at Maryland as well as at several other medical schools throughout the country. Generally, the fellowship consists of one year of paid employment with the department of pathology. At Maryland, six months consist of clinical service work with similar responsibilities as a first year resident. This includes three months of surgical pathology, one month of autopsy, and a few clinical pathology rotations. The other six months will consist of participating in research with a mentor within the department of pathology. Overall, the fellowship is very flexible and will allow you to get a great feel for what it’s actually like to be a pathology resident. Not only will you gain technical knowledge about pathology, it will also give you an incredible advantage when it comes time for residency applications. This is not required to get a good residency; most applicants haven’t done a post-sophomore/post-junior fellowship.
Applying and Interviewing
- Resources: Good resources include faculty, previous University of Maryland students who applied in pathology, and the current Maryland Pathology residents. Good ones to email and talk to (as of Spring 2019 ) are Rachel White (PGY2, Maryland Grad) and Jamie Hittman (PGY 1, Maryland Grad). A VERY helpful book that is put out each year is the Directory of Pathology Training Programs. It describes all of the programs in the country. You can find it in the Pathology Department and is available online (http://pathologytraining.org/). Also, individual program websites are very helpful in choosing where to apply and in preparing for interviews.
- Letters: Ask for letters of recommendation early (June/July) so that the faculty have time to write them. One letter from a pathologist is essential, and at least two are usually recommended. If possible, they should all be from pathologists. Don’t worry though if you can only get 1 or 2. There is no specific benefit to getting a letter from a Sub-I rotation compared to a different non-pathologist attending who knows you well. Get as many as you can from Pathologists and the rest from any attending who knows you well.
- Selection Criteria:Exposure to Pathology and clear interest in the field are very important for programs. Good LoRs (letters of recommendation) are also very useful. Step 1 scores and grades may be used as screening, but are not as heavily considered except at the most prestigious places. If your score is lower than 210, email program directors in late October if you haven’t been offered an interview. A computer filter may have stopped your application from even getting to them. No programs needed Step 2 for interview invitations, but a few require it before Match, so it’ll need to be done by February at the latest if you are applying to any of those places. Most programs don’t need it until graduation though; check individual program’s websites. Submit your application as soon as you can (ideally on September 15th).
- Interviews: Most interviews are in November and December, with some into January. You will get some invitations right after you submit ERAS in September and the rest through October and November. Email any programs you are interested in if you haven’t heard from them by the end of October. As for interviews, be prepared to answer the question, “So how did you become interested in Pathology?” and make sure you have researched the programs and have lots questions of your own to ask. Most interviewers will ask you what questions you have, and you always want to have a couple. Feel free to ask the same question to multiple interviewers to get their individual takes on it. The majority of pathology interviews are very conversational and low-stress. Having a clear understanding of the field and why you want to go into it is one of the most important factors that program directors are looking for. You don’t need to know what specific area of Pathology you want to go into (though you will be asked if you have an idea and saying that you don’t yet is completely acceptable), but you do need to have a reason why Pathology is the right fit for you. Pathology is very different from most other specialties and program directors want to make sure you know what you are getting into and that you understand different potential career trajectories. Talk to attendings and residents about the different aspects of Pathology while you are doing electives. Other questions commonly asked are “Tell me about yourself”, “What do you look for in a program?”, “Why our program?”, “Tell me about some of your research experiences”, etc. You will interview with anywhere from 2-8 faculty per interview, which can be tiresome. Some programs will have a dinner the night before and pay for a hotel. Talking to the residents at meals and the tour will probably get you the best information about whether the program is a good fit for you. Many will give you their email addresses as well. If any questions come up later that you realized you forgot to ask at an earlier place, feel free to email the residents or program director. They will be happy to talk to you. It is courteous to send a thank you to the program director, your interviewers, and the program coordinator after your interview. Email is completely acceptable, though you can hand-write a note if you desire.
Pathology is a great field with a lot of diversity. It is not one of the more competitive ones to Match into, so try not to stress too much. Apply to between 12 and 20 programs and interview at 10-15. This will give you plenty of options for the match.