A career in neuropathologyBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5119 (Published 15 August 2012) Cite this as: BMJ 2012;345:e5119
- Nicki Cohen, consultant senior lecturer in neuropathology
Nicki Cohen outlines what it’s like to be a neuropathologist
If you’re captivated by the anatomical complexity of the brain; interested in looking at disease processes and tissue reactions rather than shadows on imaging; fascinated by biological study of familial diseases with devastating consequences in patients; and less than satisfied with juggling anti-parkinsonian medication, shunt revisions, or monotonous glass crunching; then a career in neuropathology may be for you.
Neuropathology is the pathological study of disease of the nervous system, in life and in death. The specialty has the equivalent of roughly 50 full time NHS consultants, many with combined NHS and academic roles. Currently, there are nine subspecialty neuropathology trainees in the United Kingdom. Junior doctors often spend time in neurology, neurosurgery, or other “neuro-related” junior posts before discovering neuropathology. Run-through training has been deleterious for this sort of later career choice.
What do we do?
Neurosurgical specimens, taken for therapeutic and sometimes purely diagnostic purposes, are at the forefront of our workload. Samples (usually tumour) are wax embedded, sectioned, and mounted on glass slides by specialist biomedical scientists, before microscopic analysis by a neuropathologist. We look at smear preparations or frozen sections of samples to make intraoperative diagnoses to guide the neurosurgeon during surgery. Other specimen types include cerebrospinal fluid samples and muscle and nerve biopsies from neurologists, rheumatologists, and general medics. Ophthalmic specimens may also form part of the workload.
Some neuropathologists perform muscle and peripheral nerve biopsies, which is a way of maintaining some direct contact with patients. Muscle pathology is increasingly a specialist area, with national laboratories acting as tertiary referral centres after local centres have done the initial diagnostic work-up, particularly, for example, with the dystrophies.
We work alongside neuroradiologists, neurosurgeons, neuro-oncologists, neurophysiologists, and neurosurgeons as part of multidisciplinary teams. Neuropathologists contribute to a range of regular multidisciplinary meetings to discuss the assessment and management of patients with brain and spinal tumours, muscle and nerve disease, and epilepsy.
What else do we do?
Prognostic and diagnostic information from proteomic and genetic studies is increasingly being used in neuroscience, and neuropathologists often engage in this area. Most neuropathologists do some paediatric neuropathology, and a few colleagues in hospitals with high numbers of paediatric specimens work exclusively in this subspecialist field.
Examination of postmortem specimens (whole autopsies and fixed whole brains) adds further variety. Some neuropathologists perform forensic brain examinations and act as expert witnesses in medicolegal cases. Whereas advanced autopsy training has become optional for general histopathology trainees, it remains a key component of our arsenal for diagnosis and also research. Neurodegenerative diseases already make up much of the most costly, burdensome, and intractable diseases that we face and are set to increase dramatically over the next few decades as populations age. The study of postmortem brain and spinal tissue is central to progress in diagnosing these diseases, understanding their pathogenesis, and ultimately in developing treatments for them.
Since neuropathologists work almost exclusively in teaching hospitals, teaching is an additional role that many of us undertake with enthusiasm and have sufficient flexibility in our working day to do. Consultant posts have rotas for covering neurosurgical specimens, but out of hours work is minimal or absent, and many of us work flexibly.
Training in neuropathology is evolving. Previously a subspecialty of histopathology, diagnostic neuropathology was awarded medical specialty status earlier this year by the Department of Health. With this recognition has come the opportunity to define our own specialist curriculum, training programme, recruitment criteria, and system of assessment. The curriculum has been partially approved, with a few conditions pending. Neuropathology centres are seeking training programmes approval.
National recruitment starts in 2013 alongside other national specialty training year 3 (ST3) recruitment and will take place twice yearly, with the aim of recruiting around three to four trainees each year. Successful applicants will enter diagnostic neuropathology training at ST3 level . Those from histopathology should have passed the fellowship of the Royal College of Pathologists (FRCPath) part 1 exam and those from neurology or neurosurgery the membership of the Royal College of Physicians (MRCP) or fellowship of the Royal College of Surgeons (FRCS) exams. Clinical “neuro-related” experience and knowledge have become mandatory.
Rotations in neurology and neurosurgery will be included in the ST3-4 years for trainees without previous experience. Conversely, successful applicants with relevant clinical experience but not histopathology experience will have histopathology rotations included in ST3-4, after which they will sit the FRCPath part I exam. ST5-6 training will be exclusively in neuropathology.
Many trainees do some research during their training, usually leading to a PhD or MD. Knowledge of research techniques, particularly with respect to molecular genetics, is embedded within the curriculum. Ensuring the future of academic neuropathology is an aim of the new curriculum, supported strongly by the British Neuropathological Society working alongside the neuropathology subcommittee of the Royal College of Pathologists. The close link of academic neuropathology departments with clinical neurosciences and basic research institutions opens unique opportunities to pursue fascinating and competitive basic and applied research and the potential to lead world-class research teams.
Learn more at our conference
The Royal College of Pathologists is hosting a conference in London on 20 September for doctors to learn more about neuropathology as a future career. Additional information relating to diagnostic neuropathology is on the British Neuropathological Society’s website (www.bns.org.uk), and details of the conference are at www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/D/DN_prog.pdf.
Thanks to the UK neuropathology community for their contribution to this article.
Competing interests: None declared.