PathologyBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7164.2 (Published 10 October 1998) Cite this as: BMJ 1998;317:S2-7164
It's not all dead bodies and microscopes. William Marshall counters popular misconceptions about the pathological specialties, maps out the routes to a consultant post, and outlines the satisfactions of practice once you're there
“Pathology? No thanks! Stuck away in a lab all day, the stink of formaldehyde, other doctors' dead patients…“ Sadly, this is a common image, even among doctors. Another popular misconception, reinforced on television, is that all pathologists are forensic pathologists, dealing with suspicious deaths. But pathology is not about crime or death; it is about understanding disease and disease processes.
Forensic pathology is a small subspecialty of histopathology. Pathology's other main disciplines are chemical pathology, microbiology, haematology, and immunology. All pathologists spend some of their time working in the lab, but they do a lot more besides. Many pathologists now have direct responsibility for the care of patients, bringing the intellectual satisfaction of investigation and diagnosis with the practical satisfaction of patient care.
Also known as clinical biochemistry, a major role of this discipline is the provision of an analytical service for measuring a wide variety of analytes&emdash;”electrolytes,” enzymes, proteins, hormones, vitamins, drugs, etc&emdash;for diagnostic and management purposes. Much of this analytical work is performed by biomedical scientists using automated analysers, but the chemical pathologist is the director of the service, responsible for ensuring its quality and appropriateness and providing guidance on the selection of investigations and interpretation of their results.
Attractions and drawbacks of pathology
Combines science and clinical practice
Rapidly advancing subspecialties
Provision of essential service
Good career prospects
Excellent training programmes
Limited on call commitments
Applications across the whole of medicine
Multidisciplinary working environment
Opportunities for pure and collaborative research
Opportunities for audit
Misunderstood by many&emdash;the “back room” image
Involvement in and responsibility for laboratory management although this is an attraction for many doctors)
Chemical pathologists may perform some of the tests themselves, particularly dynamic endocrine tests. They consult on the investigation and management of patients with metabolic disorders, and, increasingly, have direct responsibility for this. Many consultants provide outpatient services, either independently or in conjunction with physicians, for conditions such as lipid disorders, diabetes, and metabolic bone diseases. Many are involved in their hospitals' nutrition support teams and other specialised areas.
Training in chemical pathology thus involves both clinical and laboratory work. In service training is often complemented by study towards an MSc. The increasing clinical role of chemical pathologists is being addressed through initiatives between the Royal College of Pathologists and Royal College of Physicians to establish joint training programmes in chemical pathology and metabolic medicine. Possession of the MRCP would be an entry criterion for such a programme, but increasing numbers of trainees already have experience in general medicine and have passed the MRCP before becoming specialist registrars in chemical pathology, and this is already a recommendation for entry. There are opportunities for subspecialisation in areas such as paediatric chemical pathology and toxicology.
Chemical pathology also offers excellent opportunities for research, and a research project is a requirement for part 2 of the MRCPath. The specialty is advancing rapidly, with molecular genetic analysis increasing in importance in the investigation of aetiology and susceptibility to disease.
Like chemical pathologists, haematologists have dual functions, responsible for the diagnostic laboratory services and blood banking, as well as having direct responsibility for the care of patients with blood disorders. The laboratory's biomedical scientists run the high volume automated tests such as full blood counts and coagulation assays, but haematologists examine abnormal films, collect and examine marrow aspirates, and have overall responsibility for the direction of the work of the laboratory.
General medical experience and possession of the MRCP are essential requirements for training in haematology as a specialist registrar. Some senior house officer rotations include haematology posts, and these can provide a valuable introduction to the specialty. All trainees are required to spend a period in blood banking, and the part 1 MRCPath examination includes a compulsory question on this topic.
Developments in the management of haematological malignancies have considerably improved the prognosis of patients with these conditions, and their management, while challenging, can be a source of great satisfaction. Patients with blood disorders span the whole age range, and haematologists may be consulted by colleagues from any medical specialty. Haematology also offers excellent opportunities for research, both exclusively in haematology and in collaboration with other specialties.
Medical microbiology concerns itself with the diagnosis, treatment, surveillance, and control of infection. Medical microbiologists have a central role in the process of advising appropriate investigation of patients with suspected infection, interpreting the results, and advising optimal treatment. They are usually based in a laboratory, over which they have managerial responsibility. They need a detailed knowledge of laboratory methods and procedures to fulfil this. They also have an important role in the prevention and control of infection at a local and wider level. In most trusts a medical microbiologist will be infection control doctor, doing varied work which relates to many professional groups within the health service.
Medical microbiologists practise in a number of areas, including NHS laboratories, the Public Health Laboratory Service, and university or teaching hospital departments. The degree of clinical involvement, public health role, management responsibility, research, and teaching commitment varies between these areas, as with any specialty.
Most trainees begin their microbiology training at specialist registrar level, although a period of exposure to patients with infection is encouraged during general professional training in, for example, an infectious diseases unit, haematology unit, or respiratory department. Some trainees enter the specialty after a period in general medicine, perhaps leading to MRCP, although this is not a requirement for entry. Trainees are exposed to laboratory aspects of medical microbiology and participate in clinical liaison and management of patients.
They are also attached to a clinical virology department and gain experience in infection control, epidemiology, food and environmental microbiology, and laboratory management and audit. A period of research is required for the MRCPath, and many trainees have the opportunity to obtain higher qualifications within the training programme (for example, MSc, DTM&H, MD, or PhD). In recognition of the increasing clinical commitment of the medical microbiologist, training programmes which would lead to dual certification in medical microbiology and infectious diseases are currently under consideration.
Immunology and allergy
As already discussed on these pages, specialists in clinical immunology and clinical allergy work with a range of illnesses, including hay fever, anaphylaxis, primary immunodeficiency and vasculitis.
In common with other pathology disciplines, there have been major advances in histopathology in recent years. Although much diagnostic work still relies on the use of well established histological methods, the newer techniques of molecular biology and immunohistochemistry are essential for the investigation of many disorders. Competence in these techniques is essential to enable histopathologists to make contributions to advances in medical knowledge. Their use has refined diagnosis and informed better management. For example, there are some 30 subtypes of lymphoma, each with different prognoses and treatments.
An increasing proportion of autopsy work is medicolegal, and histopathologists are often called to give evidence in court. Information from autopsies is important epidemiologically, and for audit.
Training programmes in histopathology enable trainees to gain experience in diagnostic skills, autopsy pathology, and research. Experience in paediatric pathology, neuropathology, cytopathology, and medicolegal work is essential for all trainees, but additional subspecialty training can be built in according to an individual's interests.
During training, clinicopathological collaboration is strongly encouraged, and many trainees will be assigned to review recent cases on which histopathology has been performed with the surgeon or physician involved. Such contact is important in developing skills in clinical liaison and provides opportunities for multidisciplinary research or audit projects.
Manpower and training
Career prospects are excellent, particularly in histopathology, where consultant expansion has exceeded the number of doctors completing their training. There has been a lesser expansion in haematology and immunology, and these specialties are presently in balance. In chemical pathology and medical micro-biology an imbalance has required a small decrease in the number of training posts. However, the increasing tendency for doctors to retire at 60 rather than 65, and the skewed age distribution of consultants, means that an increasing number of consultant posts are likely to be available in these specialties too.
Each pathology discipline has its own entry requirements and training programme, including training in subspecialties. To practise as a consultant in the NHS in any pathology discipline, a doctor must be on the specialist register of the GMC. The requirements for achieving this are satisfactory completion of a training course (lasting about five years), marked by a successful final record of in-training assessment (RITA) and obtaining membership of the Royal College of Pathologists (MRCPath) by examination. Both are required for the award of a certificate of completion of specialist training (CCST).
In summary, the laboratory disciplines are very much part of the clinical service. The diversity, diagnostic challenges and breadth of knowledge which is required to practise any of the pathology disciplines provide among the most, if not the most, intellectually rewarding consultant appointments in medicine.