To be or not to be … a Pathologist

Pathology

While NEET Counselling was going on (now over?) I got a few calls from friends/acquaintances asking if Pathology is a good option for post-graduation. It’s not the first time I’ve been asked this but it always makes me smile.
Because the reason behind the query is this — Nobody remembers what Pathology was like! I mean, nobody ever asks if pediatrics or surgery or dermatology or ophthalmology etc are good options. But Pathology … hmm… what exactly did we learn in Pathology? With apologies to brainiacs who still remember the page numbers of their Robbins textbook, I would say that for the majority of students, Pathology was a rather vague and confusing subject where the pathogeneses and morphologies of all the diseases seemed to be composed of the same set of words all jumbled up and rearranged in slightly different orders. Or, for the really pathologically-challenged group, it was that subject where the slide with the broken corner was Adenocarcinoma colon, the slide with torn sticker was Amoebiasis, etc. I presume the MBBS students of today might have a far better understanding owing to their access to the internet.
But back to THE question — Is Pathology a good option for postgraduation? I usually respond with another question — Why do you think Pathology would be a good option? — and these are the oft-heard replies:

1. I don’t want my wife to be as busy as me, so I told her to take up Pathology (Number 1 answer by male doctors with doctor wives. These husbands end up with heavy regrets).
2. I don’t want a hectic subject for postgraduation, so I thought of Pathology (Major disappointment waiting around the corner).
3. I didn’t get General Medicine, so the closest option is Pathology (Huh? Really?).
4. It’s what I got and I just took it.

In all scenarios, I always give the same answer — Take Pathology ONLY if you love the subject.

Why?

1. Pathology is not easy.
The tissue on the slide is not going to wave a flag at you declaring ‘I am synovial sarcoma’ or ‘I am Marginal zone lymphoma’. You are viewing 2D sections of 3D tissues. So it takes skill and a sharp, trained eye to realize that maybe what you are viewing is not a tumorous process at all but rather a tissue section that has been cut at a wrong angle. The black and white diagnoses in the textbooks are just references to the vast ocean of grey zone diagnoses. Immense patience and tireless sifting through voluminous tomes and online literature are needed at times before a diagnosis can be arrived at.

2. You are starting from square one.
If your slate has been wiped clean after you passed 2nd-year MBBS, then you will be starting with normal histology in your 1st year of postgraduation. However, even if your slate is still intact, just remember that all the slides you ever learned to diagnose in 2nd year were just the teeny tiny tip of a ginormous iceberg.

3. It’s a long road.
Pathology has advanced drastically. Histomorphology has taken a backseat to immunohistochemistry which is on the way to taking a backseat to molecular pathology. Sub-specialties are becoming important and it won’t be long before DM courses pop up for each. So if you are starting from square 1 in normal histology, you have a long and tedious journey ahead of you.

4. A smelly, messy affair.
Yes, it is. Feces loaded colons, dermoid cysts, ulcerated squamous cell carcinomas, formalin, acetic acid, ammonia …. your nose is going to get assaulted a lot. So get used to it.
And, surprise! — Forensic Medicine is an unavoidable part of Pathology. Remember your forensics posting? Remember that smell when the abdomen is cut open? Well, you will have to perform autopsies.

5. It’s a lonely job.
Most of the time it will be just You, Yourself and the Microscope. Silence and solitude.

6. Say goodbye to the stethoscope.
The enormity of this might hit some only after venturing a little into Pathology. Your patients are going to come to you in jars — as organs pickled in formalin. Face to face interactions with patients will range from an occasional FNAC procedure to NIL. In all probability, you will never ever interact with patients again.

7. Patients do not see you as a ‘real’ doctor … and sadly, neither do several clinicians.
I’ve been asked questions like ‘What job is that?’ and ‘Did you do lab technician course?’ and ‘Oh, it is a teaching course.’ The ignorant public can be forgiven for thinking that a doctor without a stethoscope is not a doctor at all. But what of (some) colleagues in clinical specialties who share the same opinion? To them, I say please spend 2 days with me in my department before you tell me again how Pathology is an inferior form of general medicine.

8. The Limelight.
Don’t expect to be thanked for solving a diagnostic dilemma that probably saved your patient a limb or a surgery. The handshakes and tears of gratitude are reserved for the clinicians. No patient will ever come looking for the pathologist to thank her/him for deducing that his clinical diagnosis of osteosarcoma was, in fact, a myositis ossificans. Most patients don’t understand your importance, and for some, you don’t even exist.

9. Responsibility.
Just like Arthur Hailey’s famous book, the pathologist’s report is The Final Diagnosis that can make or break a clinical diagnosis. You can shout from the rooftop that it’s a germ cell tumor of the ovary, but that won’t change our diagnosis of an endometriotic ovarian cyst. We see it, you don’t.

10. Money.
The last on the list. Pathologists are one of the poorest paid doctors. I’m yet to see one who owns a Benz or Audi (unless he or she is married to a clinician).

I had to put up a bit of a fight when I opted to renounce the stethoscope for the microscope. It’s not easy to convince your relations who are just waiting to bask in the glory of having a gynecologist or cardiologist in the family. ‘Nee enthinaa malam moothram parishodikkunna doctor aavunnathu?’ (Why do you want to become the doctor that examines urine and stool).
But as one will literally be married to one’s specialization till death do you part, it was the best decision I ever made.

The summary is — Don’t be mislead by visions of a lazy job. Don’t give in to the misconceptions of an ignorant spouse.
If you are not prepared for a demanding and exhausting desk job in a silent and isolated corner of the hospital, spending lonely hours rotating between the microscope, computer and reference books, then Pathology is not for you.
I know enough people who are still living with the regret of opting for Pathology.

 

(Image credits: Unknown)

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