The Role Of A Pathologist
Pathologists are at the interface of science and medicine and prevent, diagnose and treat disease by examining body fluids and tissue samples. This identification of the disease process informs all patient care. There are five specialty jobs within pathology.
These are chemical pathology, haematology, histopathology, medical microbiology and medical virology. Pathologists employ a multidisciplinary model; work is conducted in teams comprising, for example, biomedical scientists, GPs and other doctors, including doctors of the other pathology specialties.
Extensive medical knowledge is requisite and favourable key skills are an analytical mindset, effective communication and dexterity. In 2017, 54% of pathologists were women1.
Chemical pathologists analyse body fluids, for example blood and urine, to detect chemical changes2. They care for patients, primarily adults, with metabolic disorders in wards or outpatient clinics. Examples of outpatient clinics led by clinical pathologists are lipid clinics and metabolic bone clinics.
Chemical pathologists also have leadership roles in biochemistry laboratories. Chemical pathology is a very small specialty; chemical pathologists may be solitary members of this specialty within a hospital.
Haematologists diagnose and treat disorders of the blood and bone marrow in persons of all ages.3 Examples of conditions managed by haematologists are anaemia, leukaemia and haemophilia.
Histopathologists diagnose disease by microscopic examination of biopsies. They have a central role in cancer screening and diagnosis. The work area is extensive and, consequently, histopathologists generally focus on specific parts of the body.(4)
They also perform autopsies. Histopathologists have infrequent patient contact and work in laboratories and mortuaries. Presently, traditional microscopy is employed but novel modalities which allow samples to be shared digitally may result in more remote or centralised working instead of histopathology departments in smaller hospitals(4).
Medical microbiologists lead the prevention, diagnosis and management of diseases that are caused by microorganisms. They combine work in laboratories, hospital wards and outpatient clinics to advise on the most appropriate samples to collect to diagnose an infection and utilise microscopic examination and biochemical and molecular tests to identify infectious agents(5).
They advise on treatment and monitor patients following its implementation. Additionally, medical microbiologists have public health roles. They promote antibiotic stewardship and measures to limit the spread of infection and monitor patterns of infectious disease incidence.
Medical virologists lead the prevention, diagnosis and management of viral infections. They work in laboratories, outpatient clinics, hospital wards and the community to manage, for example, HIV/AIDS and hepatitis B. Medical virologists also study the pharmacology of, and the development of resistance to, antiviral agents(5). They have public health roles, for example, advising on immunisation strategies.
A Typical Week
Outpatient clinics comprise half of the activities performed by a chemical pathologist in a standard week. The residual work is conducted in laboratories and comprises advising laboratory staff on the selection of tests, reporting test results and guiding other hospital doctors and GPs on the management of persons with abnormal test results(2).
Additionally, chemical pathologists are engaged in the development and implementation of novel diagnostic tools. Other activities include meetings, teaching and research. Emergency cases are rare and on-call work may be conducted remotely.
Haematologists enjoy comprehensive involvement in patient care, from interpreting blood test results to administering treatment in wards, including high dependency and intensive care units, and outpatient clinics. Haematologists also provide a consultancy service to other hospital doctors and GPs and lead diagnostic laboratories(3).
Additional responsibilities assumed are organising blood transfusions and stem cell transplantations and genetic testing. Haematologists are at the forefront of staff training and many undertake research. Working hours are regularly antisocial as laboratory services operate at all times(3).
For histopathologists, a typical day may be commenced by performing autopsies; on average, a half day per week is occupied in the mortuary. Most of the daily workload comprises microscopic examination of tissue specimens and subsequent construction of clinical reports(4).
Other activities are multidisciplinary team meetings, teaching, audits and research, for which there are good opportunities in this specialty. There is little on- call work.
A standard day for medical microbiologists and medical virologists includes reporting, via ward visits or telephone, to clinical colleagues on cultures that have become positive and advising on the best management of these patients. They make frequent visits to intensive care units and participate in multidisciplinary team meetings of specialties that regularly treat infections, for example, haematology and paediatrics(5).
They also respond to telephone enquiries from other hospital doctors and GPs. Teaching is a key job responsibility and many medical microbiologists are involved in research. On-call duties are minimal and are often conducted remotely.
The Route To Pathology
The route to pathology commences after successful completion of a medical degree and two years of foundation training. Subsequently, general medical training is attained. This can be Internal Medicine Training (IMT) stage 1 or Acute Care Common Stem (ACCS), which are three-year programmes.
Both programmes feature several rotations across a variety of medical specialties; ACCS facilitates increased focus on acute medicine, emergency medicine, anaesthetics and critical care medicine in the initial two years.
Application to these is through a form examining entry requirements, for example, core competence, clinical reference, and details of achievement in various areas – and an interview.
Typically, training in chemical pathology has a duration of five years. Data on competition ratios is not available for this specialty. The training programme comprises four stages6. In stage A, which corresponds to the first year of training, a broad understanding of the principles and practices of chemical pathology is acquired under immediate supervision.
Progression to stage B is subsequent to passing the Royal College of Pathologists’ Chemical Pathology Year 1 Assessment. Stage B is the next two years of training and trainees are empowered to manage most of the daily workload but continue to be supported with more complex cases.
Trainees are assessed by the Fellow of the Royal College of Pathologists (FRCPath) Part 1 examination in Clinical Biochemistry. Stage C, which is between month 25 and month 48 of training, comprises more specialised training and is concluded by the FRCPath Part 2 examination in Clinical Biochemistry. Finally, stage D is between month 43 and month 60 of training. It enables trainees to acquire a level of competence adequate to independent practice as a consultant.
For haematology, an alternative to IMT and ACCS is Level 1 Paediatric training6. If IMT or ACCS has been attained, trainees must pass the Member of the Royal College of Physicians of the United Kingdom (MRCP (UK)) examination.
If Level 1 Paediatric training has been completed, examinations leading to membership of the Royal College of Paediatrics and Child Health must be passed. Specialty training in haematology is five years. In 2018, the competition ratio for haematology ST3 was 1.60.7 The FRCPath Part 1 in Haematology is attempted after 18 months of training. Part 2 of this examination may be taken a year after passing Part 16.
Training in histopathology can commence directly after foundation training and typically has a duration of five and a half years8. In 2018, the competition ratio for histopathology ST1 was 1.847.
It comprises of four stages. Stage A, which corresponds to the first year of training, is a structured introduction and is concluded by the Year 1 Histopathology examination. Stage B, which is between 12 months and 18 months, aims to broaden understanding and experience and is assessed by the FRCPath Part 1 examination in Histopathology. During Stage C, the focus is on developing confidence and independence and the FRCPath Part 2 examination in Histopathology is taken. Finally, stage D, that corresponds to the final year of training, allows trainees to acquire a level of competence consistent with independent practice as a consultant and explore specialist interests.
The route to medical microbiology and medical virology also demands that trainees pass the MRCP (UK) examination. Subsequent training has a duration of four years.9 The initial two years is composed of Combined Infection Training (CIT).
In 2018, the competition ratio for CIT ST3 was 1.817. This is an integrated laboratory and clinical training programme that enables the acquisition of fundamental skills in medical microbiology, medical virology, infectious diseases and tropical medicine. CIT features six months in each of: clinical microbiology and virology training associated with a diagnostic laboratory, clinical infection control duties, a selection of infection reed clinics and clinical inpatient care of patients with infection(9).
This stage of training is assessed by the FRCPath Part 1 in Infection. The final two years are higher specialty training in either medical microbiology or virology and the FRCPath Part 2 in Medical Microbiology or the FRCPath Part 2 in Medical Virology is taken as appropriate.
Finally, trainees are awarded a certificate of completion of training (CCT) by the General Medical Council.
Medical students interested to pursue a career in pathology should become undergraduate members of the Royal College of Pathologists (RCPath). In addition, it is beneficial to attend conferences and choose relevant topics for student selected components. Foundation trainees should attempt to secure a placement in the pathology specialty of their interest. The RCPath operate taster schemes for foundation doctors and the newly introduced RCPath Foundation Fellowships. Obtaining research, publication and teaching experience is beneficial for core and specialty trainees.
There are opportunities to subspecialise in the pathology specialties, except in medical microbiology and medical virology.
The solitary subspecialty in chemical pathology is metabolic medicine2. Metabolic medicine is concerned with the treatment of adult persons with metabolic disorders, for example, disorders of nutrition, lipid metabolism or calcium metabolism.
The duration of training is five and a half years. It is completed in parallel to specialty training in chemical pathology and results in the attainment of a distinct CCT.
Many haematologists also pursue subspecialisation. Haematology subspecialties include haemato-oncology, transfusion medicine and paediatric haematology.
Increasingly, a subspecialised team model is employed in histopathology. The three subspecialties are forensic pathology, neuropathology and paediatric and perinatal pathology.
Forensic pathologists perform autopsies to identify cause of death in suspicious circumstances that are under criminal investigation. Giving evidence in criminal courts and detailing cases to relatives and juries are key roles.
Neuropathologists diagnose diseases, through biopsies and autopsies, of the central and peripheral nervous systems, and skeletal muscle. They are also part of neurological research teams.
Finally, paediatric and perinatal pathologists are engaged in the diagnosis of disorders in unborn babies to children aged 18 years. It is possible to specialise in either paediatric or perinatal pathology. Training in these specialties comprises the final three years of specialty training in histopathology4.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849.6 Salaries can be further enhanced with NHS excellence awards.
Pathology is a specialty with only limited potential for private practice. JRSM reported in 2008 that private income varied from 0.35 times their NHS income for histopathologists down to 0.15 times for medical microbiologists, with chemical pathologists (0.18), and haematologists (0.2) in between.
At the other end of the scale plastic surgeons earn 1.9 times their NHS salary from private practice.10
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
Societies for pathologists include the Pathological Society of Great Britain and Ireland, the British Infection Association, the British Society for Haematology and the European Society of Pathology (ESP). Acta Neuropathologica, Modern Pathology and Annual Review of Pathology – Mechanisms of Disease are some key journals in the discipline. Additionally, the ESP organises an annual congress.
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2. Chemical pathology [Internet]. Health Careers. [cited 6 June 2020]. Available from:
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10. Morris S, Elliott B, Ma A, McConnachie A, Rice N, Skåtun D et al. Analysis of consultants’ NHS and private incomes in England in 2003/4. Journal of the Royal Society of Medicine [Internet]. 2008 [accessed 14 June 2020];101(7):372-380. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442143/table/tbl3/