Careers in pathologyBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7474.s187-a (Published 06 November 2004) Cite this as: BMJ 2004;329:s187
- Adrian Newland, vice-president Royal College of Pathologists
The pathologist's role may have been misunderstood in the past, but with government backing things are changing. Ben Swift, Simon Stanworth, and Adrian Newland offer an up to date round up of the five main pathology specialties
Pathology—the scientific study and diagnosis of diseases—is the fundamental basis of medicine and surgery. Although it is the foundation of diagnosis and therapeutic intervention, fewer medical students are now considering a career pathway in the pathology specialties.1 This is partly due to the recent General Medical Council (GMC) recommended changes in medical school curriculums which have resulted in a reduction in didactic teaching from most areas of undergraduate education, with less exposure to the clinical value of pathology2 and to the consultant pathologist as a role model. But pathology has plenty to offer as a career; this article is an updated round up of pathology specialties, some of which have been covered individually in previous Career Focus articles (see web extra).
Politics and pathology
There have been huge changes in the political vision for the NHS in England over the past 10 years and there is now a greater emphasis on screening, prevention, and public health. Patient choice is becoming increasingly important and the pathologists' central role in diagnosis puts them in an ideal position through clinical audit to maintain quality and to support evidence based practice. Quality in diagnoses and results has been ensured through the use of internal and external quality assurance programmes, benchmarking and accreditation through Clinical Pathology Accreditation (UK) Ltd; few other branches of medicine can boast such extensive means of ensuring high standards of practice.
The government has clearly appreciated the central role of pathology in the new vision for the NHS; the Department of Health launched its consultation on “Pathology—the essential service” in 2002 and published Modernising Pathology Services in 2004, with its emphasis on increased funding and the development of managed pathology networks, to support the drive to provide evidence based treatment and care for patients and users.3 The basic aim is to create sufficient critical mass and expertise to support new developments and the use of new technology. In some areas there will be a reconfiguration of services, with greater standardisation of laboratory practice. These initiatives raise the profile of pathology, which has been buffeted recently by the adverse publicity arising from organ retention cases.
An essential service
In the modern NHS clinical pathology provides essential diagnostic information for the detection and monitoring of disease in patients; pathologists are involved in about 70% of all diagnoses (see fig 1). In addition, the role that many pathologists play in direct clinical care is often underestimated; many spend significant parts of the working day with patients or advising on their clinical care. The long held distinction between the laboratory-based specialist and the clinician is artificial. The pathology disciplines have also been at the forefront in the introduction of molecular diagnostics and many pathologists are at the “cutting edge” of medical science.
The pathology disciplines
A career in pathology would take you into any of five main disciplines (see fig 2).
Haematology (including blood transfusion)
Medical microbiology (including virology)
Each of these encompasses a number of specialties, for example, histocompatibility and immunogenetics within immunology, parasitology and mycology within microbiology, cytopathology, neuropathology, and forensic pathology within histopathology. There are also a number of smaller disciplines including genetics and toxicology (fig 2).
Clinical biochemistry (also known as chemical pathology) studies the biochemical basis of health and disease and the use of biochemical tests for diagnosis and treatment. Duties for medically trained laboratory staff involve interpretation of biochemical test results and clinical liaison with requesting physicians (including general practitioners) on patient follow up and management. There is also some involvement in the day to day management of the laboratory service. Direct involvement in laboratory benchwork is less common now, unless it is part of a research project. As with other specialties the pathologist has a role in the teaching of their discipline to medical and non-medical trainees. The consultant's role in direct patient management is becoming more and more important.
The specialty has moved away from the purely laboratory based career, and this sea change has now become formally recognised with the introduction of the subspecialty of metabolic medicine. This evolutionary offshoot is a joint initiative of the Royal College of Pathologists and the Royal College of Physicians, and accredits clinical biochemists for training in disciplines such as obesity, nutrition, metabolic bone disease, lipidology, diabetes, and the management of inborn errors of metabolism. Potential employing trusts will soon begin to favour this dual accreditation for many consultants' posts, and this reflects the significant clinical role of the clinical biochemist.
Accreditation and training
Accreditation in clinical biochemistry will take you at least four and a half years. You will need to become a member of the Royal College of Pathologists (MRCPath) before you receive your Certificate of Completion of Specialist Training (CCST). Dual accreditation in clinical biochemistry and metabolic medicine requires an additional year of training and possession of membership of the Royal College of Physicians (MRCP), obtained during the period of general professional training after qualifying from medical school. At the moment these would give you a good chance of gaining a consultant's post (see fig 3).
Histopathology is the diagnosis and study of disease by medical interpretation of cells and tissue; this is done in the laboratory, in partnership with laboratory scientists, as well as with doctors in other clinical specialties. Histopathologists have training and skills that provide them with expert knowledge and understanding of both the pathological and the clinical aspects of disease. Histopathologists are full members of the multidisciplinary team and also have key responsibilities for cancer screening—currently for breast and cervical cancer.⇓
Training schools to meet the shortage
The NHS does not currently have sufficient trained histopathologists to support the NHS Cancer Plan targets or to provide national service requirements in paediatric pathology, ophthalmic pathology, or neuropathology. Recent initiatives have secured funding for 12 training schools nationally that will begin feeding into the profession at the rate of 100 per year from 2005. The lead-in training time is a minimum of five years in the training models currently being developed.
Several strategies will ensure the future of histopathology and its subspecialties. These include some reduction in the length of training time, introducing autopsy-free training options, the development of run-through training schools and fast track arrangements for doctors trained in histopathology to enter subspecialty pathology training.
The main subspecialties within histopathology are
Paediatric pathology, which covers three main areas—fetal and perinatal pathology, paediatric surgical pathology, and medicolegal autopsy work—and requires a teamwork approach. Pathologists in this subspecialty work closely with obstetricians, paediatricians, radiologists, and clinical geneticists
Neuropathology, the study of disease within the peripheral and central nervous system
Cytopathology, the study of cells for diagnosis or screening, such as in the breast and cervical cancer screening programmes and for fetal abnormalities.
Forensic pathologists specialise in medicolegal autopsies to find out the cause of death and to ascribe possible mechanisms for certain injury patterns or trauma discovered at postmortem examination.
For a career in histopathology you'll need to have medical, anatomical and legal experience to practise effectively within the hospital and courtroom environments.
Immunology is a small, but growing, specialty involving clinical and laboratory work. The management of patients with immune deficiencies constitutes a major part of outpatient clinical work, mainly on an outpatient basis. Most immunologists also review patients with autoimmune diseases and vasculitides, and are involved in the care of patients with allergies. On the laboratory side, liaison with clinicians is the major responsibility. Most laboratories will be responsible for autoantibody, immunoglobulin, allergy testing, and the diagnosis of immune deficiencies.
Training and exams
Most applicants for the specialty will have a general training in medicine and an MRCP, and most have some experience in immunology, such as a BSc, or previous clinical experience. The training is five years; the first two years give a basic grounding in immunology in preparation for the MRCPath part 1 examination and the next three years are spent gaining further experience and developing interests. Specialist registrars (SpRs) have to complete the MRCPath part 2 before they can be awarded a CCST. There are many opportunities for research and most SpRs will have been involved in this prior to their appointment as a consultant.
Haematology is a large and multifaceted discipline, with recognised subspecialties including haematological oncology, haemostasis and thrombosis, haemoglobinopathy, transfusion medicine, paediatric haematology, and laboratory haematology. Many consultant haematologists will work in district hospitals where the provision of specialist care requires close links with the local tertiary centres.
Direct patient care has assumed much more of the daily focus for haematologists than laboratory practice, although many trainees are initially attracted by the chance to mix clinical management with laboratory investigation. In addition to care of their own patients, haematologists have a significant general medical aspect to their work in supporting other departments. The reconfiguration of services that will follow Modernising Pathology Services,3Improving Outcomes in Haematological Cancers,4 and the European working time directive, will see more networking between neighbouring hospitals and will allow a better balance between clinical and laboratory supervision and management. The opportunity for those who want a predominant clinical commitment remains (for example haemophilia care or bone marrow transplantation).
There is also considerable scope, and need, for teamwork with other medical, surgical, and obstetric specialists to deal with haematological complications during pregnancy, neonatal haematology, or strategies for appropriate blood transfusion, and some consultants have proceeded to specialise in these areas.
The specialist training is five years, and applicants are required to have a general training in medicine and an MRCP or equivalent. The first two years are a basic grounding in haematology, prior to the MRCPath part 1 examination. The subsequent three years are spent gaining further experience and developing interests, for instance in paediatric haematology. Before a CCST can be awarded, the SpR must have successfully completed the MRCPath part 2 examination. Opportunities for research are excellent: as with other specialties the training window offers a springboard to a career in academic medicine and up to 40% of trainees will take time out to undertake research during their higher specialist training.
There are good opportunities for gaining a consultant's position on completion of training, which reflects the marked expansion of the discipline over the past five years.
Microbiology and virology
Microbiology departments are the focus for the management of infection at both the individual patient and the population level. Most expert clinical advice on management of infection originates from these departments. Medical microbiologists can combine a role with laboratory and clinical responsibilities, and health protection. Most medical microbiologists now spend an increasing amount of their time on ward rounds (for example, in intensive care or paediatrics), as up to a third of all inpatients receive antibiotics at some stage.
Microbiologists work closely with colleagues in hospital, general practice, and the consultant for communicable disease control. There are also many opportunities for career development through specialisation, and laboratory and clinical management. For example, virology is an important and exciting area with new drugs and new diseases, and is at the forefront of the molecular revolution in microbiology.
Registrars with an MRCP or relevant experience in clinical medicine, or those who have worked in research, may enter training in microbiology. The training programme lasts for five years. Candidates sit the current MRCPath part 1 examination after one year, and the second part in medical microbiology or virology, after spending four years in the specialty. It is also possible to undertake dual training in microbiology and infectious diseases.
During the training period trainees gain experience in management of acute and chronic infections, and of infections in specialist areas such as intensive care units. There's further experience in the laboratory, health protection, and in the use of antimicrobials. Attachments within communicable disease control centres are arranged to understand control of infection in the community.
There is an opportunity to do an MSc in clinical microbiology in some centres, where you can learn laboratory techniques in microbiology, parasitology, and mycology. Consultant job opportunities are favourable, with most SpRs being appointed to work in district general hospitals.
Clinical genetics is a tertiary specialty with 23 regional centres in the United Kingdom. It is a small yet rapidly expanding clinical specialty. Genetics involves the investigation and diagnosis of genetic conditions and counselling of those affected or at risk. The sort of conditions seen and discussed in a typical genetic clinic might include dysmorphology, cancer genetics, pre-symptomatic testing for adult onset conditions, discussion of rare metabolic diseases and pre-natal counselling. The specialty is largely outpatient based and apart from periods spent in research, there is little laboratory work, although a clinical geneticist does work very closely with colleagues in cytogenetics and molecular genetics. Dual accreditation with MRCPath would, however, allow a consultant to take on more responsibility for the laboratory and diagnostic service, in addition to clinical duties.⇓
A resilient specialty
Pathology has always responded effectively to outside pressures. At the moment these include the proposed Human Tissue Bill; the threats posed by infection in the community and in hospitals from MRSA (methicillin resistant Staphylococcus aureus), SARS (severe acute respiratory syndrome), Asian flu, and bioterrorism; the recent initiatives on obesity; the opportunities afforded by the National Institute for Clinical Excellence's guidance on haematological cancers4; and the English chief medical officer's initiatives on better blood transfusion.5 All of these provide challenges to which the specialties can respond and benefit.
Although academic medicine has suffered in general in the United Kingdom following the effects of the Research Assessment Exercise on universities, to which the pathologies' specialties have not been immune, pathologists are uniquely placed to exploit the opportunities provided by the recent advances in cellular and molecular biology in basic, translational, and clinical research. A significant proportion of trainees continue to take time out for research during their higher specialist training and the Royal College of Pathologists is actively pursuing initiatives to bolster academic practice across the whole of the specialty.
Bridging the gap
Pathologists can link the clinical and scientific aspects of medicine, acting as the bridge between the laboratory, the patient, and the clinician. Their role is not always understood by the undergraduate, or even the junior doctor, but the Department of Health initiative Modernising Medical Careers, which aims at major reform of postgraduate medical training, provides the opportunity to redress the balance.6 The Royal College of Pathologists has proposed that at least 10% of all second year foundation programmes should include an element of pathology; this will not only encourage trainees to consider a career in pathology but will also allow those who have career aims elsewhere to understand the importance of laboratory medicine in clinical decision making.
Despite the challenges faced recently by pathology, there is every reason to feel optimistic about it as a career option. The pathology services are key to nearly three quarters of all diagnoses, and an accurate and efficient service is fundamental to the development of many clinical treatment plans. In addition, direct clinical care of the patients has become established. The shortage in consultant numbers has been acknowledged, and over the past two years pathology has benefited from receiving many of the centrally funded training posts, particularly in the hard pressed specialties of histopathology, medical microbiology, and clinical biochemistry.
Go to webextra on bmjcareers.com/careerfocus for relevent career focus articles.
We thank the chairs of the specialist committees and the members of the Trainees' Advisory Committee, who have looked at, commented on, and contributed to this article.