"Should Pathologists be Physicians?"

Napoleon1801 said:

I couldn't believe this when I read it:

http://www.bioethics.net/2013/01/should-pathologists-be-physicians/

Where is this field going...?

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So...the author is saying med school is just to teach physicians how to interact with "sick" people, and since pathologists don't interact with "sick" people we shouldn't be physicians. Despite his 25 years of interacting with pathologists, I don't think he understands what pathologists do, and how relevant clinical training is.

The article was written by an internist who states he has spent years "interacting" with pathologists. I can only guess what that means.

Okay, the guy is a boob, but he illustrates an interesting point--why certain people, by reason of their "professional" credentials, feel empowered to spout off on topics they know nothing about.

That same reasoning applies to radiology too.

Interesting article. I wonder what kind of medical curriculum this author is teaching in. At my school, and probably at most schools, the first two years are predominantly about pathology with an almost token clinical component (granted, not pathology as practiced, but pathology nonetheless). Not counting elective time in 3rd and 4th year, which might be spent in a clinical or non-clinical field according to a student's interests, I think required clinical rotations amount to 1 year and 3 months.

So... our medical school requires more basic science and pathology than it has required clinical rotations.

Maybe instead of inventing a new curriculum for pathologists, a new curriculum should be invented to prepare clinicians who have little interest in pathology or basic science. Perhaps something more similar to nurse practitioner school?

Don't be offended.

I have seen so many posts by people going into pathology celebrating their last clinical rotation or flat out admitting how much they hate their 3rd and 4th year rotations. This guy totally has your backs.

The proper follow up would be, "Should primary care clinicians be physicians?" There is actually more of a question there - lots more research too.

pathstudent said:

Don't be offended.

I have seen so many posts by people going into pathology celebrating their last clinical rotation or flat out admitting how much they hate their 3rd and 4th year rotations. This guy totally has your backs.

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I guess, I am one of those people. I am a "clinician" (Family Medicine) by necessity, and not by choice. I guess I was not good enough to get into Pathology. I like the field of Medicine (in general), but I do not necessarily like the clinical part of medicine. By the "clinical part" of medicine, I mean the continuous, non-stop, on-going, patient follow-up and interaction (and all the paper work and social-work that goes with it). I like to help patients with their medical problems, but I am not necessarily enthusiastic about getting involved in patient's life (which is what "clinicians" do).

yaah said:

The proper follow up would be, "Should primary care clinicians be physicians?" There is actually more of a question there - lots more research too.

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Yes, primary care clinicians should be the best-of-the-best physicians. Unfortunately this in not currently the case. The medical system has it ass-backwards. The way it is now (IN GENERAL)....people in the top 10% of their medical school class go into things like Dermatology, Neurosurgery, Radiology, ENT, Orthopaedics...., while people in the bottom 10% of their medical school class (and IMGs) go into Family Medicine, IM, Peds....

No offence intended to Derm, Ortho, or Rads...but, I think the "medical educational system" should encourage "smart" medical students to go into Primary Care specialties because I think this is where their true worth can be utilized. FM, IM, and Peds docs are in the "front-lines", and need to be sharp and clever diagnosticians. Just like the good old day docs, who were able to reach a diagnosis most of the time by simply going a well performed History and Physical. Placing "smart" medical students in Primary Care specialties can help save the patient (and society) lots of money, time, and unnecessary diagnostic tests.

Leukocyte said:

No offence intended to Derm, Ortho, or Rads...but, I think the "medical educational system" should encourage "smart" medical students to go into Primary Care specialties because I think this is where their true worth can be utilized. FM, IM, and Peds docs are in the "front-lines", and need to be sharp and clever diagnosticians.

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really you put peds in that basket? Things must be different in the US because in canada, peds is one of the most competitive specialties

thebouque said:

really you put peds in that basket? Things must be different in the US because in canada, peds is one of the most competitive specialties

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Yup its definitely different. All you need to look at is where the money is at, those will be the most competitive specialties. Since peds is one of the lowest paying, it is one of the least competitive. I agree with leukocyte, it shouldn't be that way.

yaah said:

The proper follow up would be, "Should primary care clinicians be physicians?" There is actually more of a question there - lots more research too.

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Lol - word. Bring this up and watch policy wonks and pcp's heads spin like something from the Exorcist.

It's kinda already the case -- how many family practice or pediatric offices *don't* have an NP or PA?

Yeah, the system could probably eventually save money in the long run by redirecting funds and resources into family practice, peds, etc., encouraging more quality applicants to the field, and developing fewer folks who bill a visit just to send everyone off to specialists for more or less everything, then bill another visit to go over the specialist's recommendations, and so on. That's just not something that can be readily fixed, certainly not in 1 or 2 fiscal years or even 1 or 2 election cycles, which is about the extent to which any substantial and potentially intelligent change could survive. Carrots can be dangled in front of medical students all day to do this or that, but that doesn't make them stupid -- they know that many carrots are minimal temporary treats, and they know what the culture has bred -- it hasn't really worked since before I applied to med school.

Instead the mid-levels will continue to take over family practice, pediatrics, and a large portion of ER work, and eventually replace the existing medical system. This is all but inevitable if the cost of medical education continues upward, litigation and insurance company effects on medicine are not curbed, the government/voting taxpayers refuse to pay, and existing practitioners don't find their own ways to decrease unnecessary spending -- which many probably see on a daily basis but probably do nothing substantial about.

Is this guy for real or is he trying to pull a "Miley Cyrus". I didn't know internal med guys need publicity too.

"My view is that the 4 years of medical school education for them is largely a waste. The training for pathology should start out in the details of pathology as needed for the career itself and the degree of doctorate would most appropriately be a PhD . In these days where the cost of medical education continues to rise both for the student and the medical school and the societal need, particularly now in the United States, for more trained physicians to attend to the increasing numbers of patients, particularly for general care, there should be changes in medical education programs to make the programs fit the goals of the students and eliminate unnecessary education."

"For them"? Granted we're an odd bunch but didn't we all get into med school under the same requirements? But I do agree four years of med school is a bit unnecessary, for EVERYONE. A solid three years, 3.5 max, seems to be enough. Let's be honest, the second half of 4th year was pretty much vacation (I spent it BBQing on my balcony with my classmates almost everyday, probably could've earned a masters degree in BBQology). I also agree that maybe we should change medical education like this wise internal med guy suggests, but for all specialties. So while we focus on the "details of pathology", the internal med students' classes should be comprised of learning a list of medical subspecialties followed by fill-in-the-blank exercises, as in "Consult _____".

And don't get me started on how much these "real physicians" rely on us for diagnosis in order to treat...

I think he'd have a different tune if he were a surgeon and actually had some clue about a pathologist's role in patient care.
His only interaction with pathology is probably calling the micro lab pissed because he wants to know what the cultures grew yesterday.

He also has no idea what a PhD is if he thinks that is the most appropriate degree to give someone who is trained to do perform a clinical service like pathology.

How sad that this attitude seems to cross disciplines. I'm a veterinary pathologist and I often encounter the same thing. I've actually had to explain to people that yes, I AM a veterinarian. I have a DVM. I did a residency. Sheesh.

At least it seems to vary by who you're interacting with. The surgeons and food animal people all greatly respect what we do because we interact with them the most for individual patients and herd health, respectively. As far as the average internal medicine vet goes, they pretty much consider us a black box that they dump a biopsy or a body in and magically get a report back.

DVM pathologists may not interact directly with the live patient or the herd, but we are a huge part of the decision-making process in terms of treatment/management (as I am undoubtedly sure you all are as well, likely even more so).

A PhD may be enough to cover the morphology side of path, but there is no way it could be comprehensive enough to also include all of the clinical correlations, treatments, complex interpretations, etc. That's what medical school (and in my case, veterinary school) is for.

I think a better article would have been "Should Clinicians do Rotations in Anatomic Pathology as Part of their Formal Medical Training?" This author doesn't seem to picture a pathologist incorporating information from clinical reports, radiology, and laboratory tests in establishing a differential diagnosis aided by histomorphology and ancillary testing.... and subsequently falling back on clinical acumen and when appropriate, discussion with the referring clinician to arrive at the best possible diagnosis. In his mind, pathology is an image with a correct answer... a "pathognomonic feature" that makes each case, as with those images that appeared on med school midterm exams. He equates pathology with basic science and our skillset with that which is necessary to earn a PhD. I'm sure that rubs both scientists who have earned PhDs and pathologists who have not the wrong way.

The tone of the article is respectful, but I don't think the problem with our profession is too much exposure to clinical medicine. I think we suffer from too little exposure, or at least that is what other clinicians and some senior pathologists seem to believe. I also think that a great portion of our time wasting occurs in the training we receive after medical school. Some of you know what I am talking about.

I also enjoy the fact that it is difficult to get into our profession (i.e. one must first complete an MD or an equivalent medical degree). It maintains a standard. I also find the knowledge a prerequisite for practice. Ideally the pathologist is on the same page as the physician who treats the patient. Pathology deserves the best physicians. Pathology was not my fall-back plan and I doubt that it is the fall-back plan for many people in the profession. In terms of having our time wasted, there is plenty of good old fashion time wasting across the board in medical education. Since when has anyone worried about time wasting in medicine?

That brings me to my point: many clinicians think of pathologists as black boxes. They don't get how we differentiate into various subspecialists within our profession, or that we retrace the steps of the clinician with each case we encounter more often then they would like to believe. They don't seem to get that we're answering the same questions as they answer. Many clinicians spend a few weeks rotating through one of the easier clinical pathology rotations, where they listen to big, metal machines hum and watch the house officer covering service take off with the pager at 4:30 PM. No wonder they think we're lazy lab rats who never miss a meal. Fewer clinicians, as part of their elective rotation time, gross specimens and perform frozens from morning through sunset or spend all night scouring charts for data while previewing hundreds of pieces of glass that contain every possible lesion from skin papules to pituitary tumors.

Nobody questions how diligently clinicians work, because we all assist them as medical students. We all take the shelf exams. We all ponder a career move in their direction before we ultimately decide that pathology is more fascinating or suits our personality better. But particular areas of pathology that require a ton of effort, rigorous training, and medical experience.... anatomic pathology and transfusion medicine come to mind as some of the rotations where residents have their work cut out for them.... are virtually uncharted territory for the clinicians who rely on those services without having any insight into what those services actually entail.

I don't kid anybody and pretend to be a clinician. I don't feel the need to remind people that "I'm a doctor, too." I'm not writing prescriptions on surgepath. I'm not walking around the wards, introducing myself to patients. I wouldn't even have the time to do that. I enjoy doing pathology. It's a great field that is challenging as hell, requires us to cooperate with a bazillion colleagues and lab staff and clinicians on a daily basis (note to asocial med students.... you can't hide from people in pathology.... wrong profession for you), and we make a lot of difficult calls. Who would you want reading your chart and putting a top line diagnosis to your breast biopsy? Someone who sort of liked biology as an undregrad and got emself a pathology certificate, or a physician who went on to specialize in pathology for four years with an additional year or two of fellowsihp training? I think we can at least convince patients that the medical degree is of neccesity.

Applicable said:

I think a better article would have been "Should Clinicians do Rotations in Anatomic Pathology as Part of their Formal Medical Training?"

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Well said. To the ignorant, we are either automatons or oracles. Not good for patient care.

As a clinician (FM) "by force", who is currently doing a second residency in a non-clinical field (preventive medicine), I can see how clinicians can feel arrogant and cocky when they compare themselves to non-clinicians. Heck, even I (who hates clinical medicine)sometimes have this feeling of "I am better than thou" when I talk or hear the "PhD types" arround me in my preventive medicine residency......Sometimes I look at those "non-clinicians", sitting all nice and tidy in their fancy big quite office, drinking their fancy coffee in the morning and reading the news-paper, in a relaxed attitude with no care in the world, with a big label outside their office saying "Medical Epidemiologist, M.D."....and I say to myself, "you spoiled sissy **s m***** f****! You have no idea what medicine is really is." It is a faaaaaaaar cry from the world that I know...down and dirty "in the front-lines and in the trenches" dealling with extreme stress, life-or-death acute medical conditions, foul smells, body fluids, and nasty attidudes from ungrateful patients in the E.R. (where I used to work, and currently moon-light). I sometimes feel like a "U.S. special forces marine" comparing himself to a mall security gaurd.

Do not take me wrong, feeling of arrogance is wrong, and NO ONE is better than another person. But we humans sometimes look down on others, specially if we think we went through relatively "tougher/unpleasant" experiences. So I see how an ignorant clinician can feel arrogant when comparing him/her self to an non-clinician, but it does not make it right.

Leukocyte said:

As a clinician (FM) "by force", who is currently doing a second residency in a non-clinical field (preventive medicine), I can see how clinicians can feel arrogant and cocky when they compare themselves to non-clinicians. Heck, even I (who hates clinical medicine)sometimes have this feeling of "I am better than thou" when I talk or hear the "PhD types" arround me in my preventive medicine residency......Sometimes I look at those "non-clinicians", sitting all nice and tidy in their fancy big quite office, drinking their fancy coffee in the morning and reading the news-paper, in a relaxed attitude with no care in the world, with a big label outside their office saying "Medical Epidemiologist, M.D."....and I say to myself, "you spoiled sissy **s m***** f****! You have no idea what medicine is really is." It is a faaaaaaaar cry from the world that I know...down and dirty "in the front-lines and in the trenches" dealling with extreme stress, life-or-death acute medical conditions, foul smells, body fluids, and nasty attidudes from ungrateful patients in the E.R. (where I used to work, and currently moon-light). I sometimes feel like a "U.S. special forces marine" comparing himself to a mall security gaurd.

Do not take me wrong, feeling of arrogance is wrong, and NO ONE is better than another person. But we humans sometimes look down on others, specially if we think we went through relatively "tougher/unpleasant" experiences. So I see how an ignorant clinician can feel arrogant when comparing him/her self to an non-clinician, but it does not make it right.

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I think if you look deeper, it's not neccessarily the "I'm better than you" mentality but rather an "I"m envious of you" feeling. Just like you had described someone sitting in their fancy corner office, sipping on premium roast coffee while reading a newspaper, I mean, who doesn't want that? Not to mention going home at 5 and spending weekends with the family. Maybe this IM guy was secretly thinking "why the hell didn't I go into that field?". And the answer is...ego, pride, or whatever you want to call it. I like to think that we pathologists are secure with our chosen profession and we really don't need validation from other doctors, especially ignorant ones like him. And I really, really, really, do not feel the need to get "down and dirty" as you put it, in order to feel important or look good to other doctors. I'll gonna go ahead and pass on the rectal and the disimpaction, please and thank you.

Everyone is entitled to his opinion. I'm not bothered by what clinicians may think of me, considering what I generally think of them. Fair is fair.

Demanding clinicians with a bad attitude are a different story, however. Belittling pathologists while routinely requiring their assistance just to function is poor form. It is unprofessional and smells of deep insecurity. If a clinician truly felt he was a better specimen, he would show it by a noblesse oblige attitude toward his social inferiors, not by being an as$hole.

Leukocyte said:

You have no idea what medicine is really is." It is a faaaaaaaar cry from the world that I know...down and dirty "in the front-lines and in the trenches" dealling with extreme stress, life-or-death acute medical conditions, foul smells, body fluids, and nasty attidudes from ungrateful patients in the E.R. (where I used to work, and currently moon-light).

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This is the attitude I've encountered in operative consultations and at tumor board. If these clinicians switched into pathology, they would complain how messy, physically revolting, and taxing a day in the grossroom or autopsy room could feel. They would complain how demoralizing it feels to be paged for preliminary results on a surgical case that was received fresh two hours ago while being paged for 2 frozens at opposite ends of the hospital, while being paged by the histology laboratory to put out some fire between employees, while being paged by chemistry with regards to the upcoming inspection, while being paged by and pressured by a clinician who wants you to perform additional tests he just read about to your case even though you are fully aware of how much time and money those tests will waste. They would also keep track of how frequently their clinician colleagues left work before them. They would complain about having little to no influence over the dozens if not hundreds of ancillary workers and managers incessantly demanding more and offering less in return. They would complain about the terrible treatment they received from clinical colleagues (whom they sat right next to in medical school) despite having to depend upon them for patients. They would complain about feeling the snub and often having to take a back seat in collaborative research endeavors as well. They would complain about the 6 or 7 years of training they needed in order to face the job market, which I hessitate to even mention in this discussion, when their medical school dean had told the class that pathology was a 3 year residency program without an internship. They would complain about how unprepared they felt for their training, and how it was surprisingly more stressful than they had ever imagined it would be. But mostly, they would complain about having inferior advocacy in comparison to classmates who went on to become clinicians since clinicians feel they're not really doctors, but scientists who don't encounter much stress and should therefore be compensated as some sort of technical assistant, after 9 or 10 years of training. They would complain of inferior advocacy by virtue of having many fewer members to represent their interests despite the sentiment that there are more than enough pathologists to meet the demands of the job market. They would complain about having inferior advocacy in comparison to classmates who became clinicians since patients have even less knowledge of what a pathologist does in the role of a transfusion medicine physician, laboratory director, medical examiner, surgical pathologist, or cytopathologist. They would also complain about how legally vulnerable they felt, often having to make decisions in the absence of adequate information about patients and being unable to foster any sort of an interpersonal relationship with their patients. To them, you are a right or wrong answer and the amount of subjectivity in this profession, which the clinician convert would also inevitably complain about, makes it fairly easy to have your diagnosis reversed or at least compromised depending on where your case is forwarded for review.

The grass is greener phenomenon affects all fields of medicine. The "Anyone can do your job but my specialty is emotionally, intellectually, and physically demanding" sentiments seem equally as ubiquitous. These are not the most helpful attitudes. It will be easier for physicians to collectively voice their concerns in this troubling time if they are less divided by specialty lines.

These are among the reasons for true broad based intern years (to include ER, IM, surg, etc.), and for reasonable length working rotations through the less common but heavily used fields such as pathology and radiology. It's not a panacea, but would lessen some of the pissy venom born largely of ignorance. Just hard to otherwise justify in the world of far too expensive medical education and lengthy poor paying (but still too much if you ask the system) residencies.

Despite there being strong practical and medical reasons why pathologists should remain physicians, there are economic/political and technological reasons why they may soon not necessarily be.

How many MDs or DOs sign out flow cytometry at your institutions? None do anymore at mine. Oh, they will sometimes look at them as part of working up a case, but they certainly don't get compensated for that, nor are they allowed the time for it.

Physicians are not getting reimbursed for molecular diagnoses either. And judging by the annual CMS updates, the areas we are "allowed" to cover are being whittled away at an accelerating pace.

People seem to enjoy talking about the brave new world of molecular/genetic pathology. Except from what I've seen thus far, pathologists are being maneuvered out of this future world before its even fully arrived. Pathologists seem impotent to do anything about it.

I blame the black box, mostly. As long as the public, politicians, and even other physicians have no clue what pathologists actually do, the problem will perpetuate. At some point, we will be reduced to morphologists. At that point, perhaps someone will claim that algorithm-driven robotic camera scopes plus a technologist review plus a simple and cheap panel of molecular tests is preferable to paying a physician to run the scope. If the cost savings and efficiency of technologic advancement are good enough, it won't matter to the suits whether an actual physician would give a better or more accurate diagnosis on a handful of difficult cases.

Until residency and fellowship programs start teaching urologists, internal medicine docs, fam medicine docs, surgeons, etc, all the pathology they need, then pathologists will still be doctors in the hospital. Technology will never be the sole decision-makers - hospital managers will always want a doctor to interpret whatever technology spits out.

I can only assume he wrote those out the very real fear HE will be replaced by NP and PhDs in Nursing, which of course he will one day.

Folks its call TRANSFERENCE and everyone is getting into the act. They see their world crumbling and their status reduced to that of a employed minion cog in a massive healthcare delivery machine and they lash out.

This is no difference than the throng of the bottom 47%'ers holding worker protests on May Day or the crazed Occupy types shaking their impotent fists at the bankers on Wall Street.

Its sad really.

I will say that Forensic Pathology needs to be a separate field though as massive chunks of your epic training really dont apply and the low pay level is dragging the rest of us down.

We have our own flow cytometry lab in house and all but one of our hematopathologists (5/6, all MDs) sign out flow cases in addition to bone marrows, lymph nodes, peripheral smears, coagulation studies, etc.. I was not aware that anyone other than an MD or DO pathologist could sign out (and bill for) flow cytometric diagnoses.

LADoc00 said:

I can only assume he wrote those out the very real fear HE will be replaced by NP and PhDs in Nursing, which of course he will one day.

Folks its call TRANSFERENCE and everyone is getting into the act. They see their world crumbling and their status reduced to that of a employed minion cog in a massive healthcare delivery machine and they lash out.

This is no difference than the throng of the bottom 47%'ers holding worker protests on May Day or the crazed Occupy types shaking their impotent fists at the bankers on Wall Street.

Its sad really.

I will say that Forensic Pathology needs to be a separate field though as massive chunks of your epic training really dont apply and the low pay level is dragging the rest of us down.

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I love reading your posts LADoc. You are always on the mark.

I just hope physicians stay non-violent as they lash out. I'd rather read that garbage article than see him go postal.