How to work in Pathology
Dr Izak Loftus, forensic pathologist and anatomical pathologist at Pathcare, sheds some light on pursuing a career in pathology
The word “pathology” refers to the study of disease (“pathos” = disease; “logos” = study). It plays a very important role, not only in the diagnosis of diseases, but also in the management of chronic illnesses. The Royal College of Pathologists of Australasia estimates that 70% of the diagnosis of diseases relies on pathology findings.
Who works in a pathology laboratory?
Pathologists are usually the smallest group of professionals employed by a pathology laboratory. In addition to the reception staff and nursing sisters or phlebotomists, who are often the only contact point with the patient in the “front” office, the “back” office consists of technicians, technologists and medical scientists. They perform the analytical component of the laboratory tests, whilst the pathologist interprets more complex or complicated cases, and discusses these findings with the clinicians. It is therefore important that a pathologist must be a team player by the nature of the close working relationship with the other members of the diagnostic and clinical teams.
Diagnostic services in the private sector, like pathology and radiology, differ from clinical disciplines as they only employ already qualified pathologists. In academic medicine some pathology disciplines, like forensic pathology, may employ medical officers. This unfortunately limits the opportunity for interested individuals to get some exposure to the specialty before embarking on a career as a registrar and ultimately a pathologist.
An average day
This depends to a large extent on the type of pathologist. Some, like a chemical pathologist, will spend most of the time in the laboratory interpreting results and consulting with clinicians by telephone. The same applies to a haematologist, although the need to perform bone marrow biopsies requires travelling to the surrounding hospitals and direct patient interaction. Haematology pathologists also often run anticoagulation clinics. The increasing need for interaction between microbiologists, clinicians and intensive care staff has resulted in more and more clinical-microbiological ward rounds next to the patient’s bedside, ensuring that the appropriate antibiotic is prescribed.
Duties are usually distributed amongst the different pathologists in each discipline according to the roster. Although the bulk of the workload will be done during working hours, a pathologist will always remain on call in each discipline to consult on difficult cases.
The day of a forensic pathologist usually begins in the mortuary, or medicolegal laboratory, conducting autopsies. The afternoon is typically spent finalising postmortem reports, performing the histopathology examination of tissue specimens or other specialised tests like neuropathology examinations. In addition, forensic pathologists will assist the judicial systems by compiling a medicolegal report or assist as an expert witness or assessor at an inquest.
Although the working hours may appear very structured from 8am to 5pm, forensic pathologists may sometimes be called out to visit a crime scene or even to inspect an aircraft accident site in the mountains. Most forensic pathologists are employed by the state, and specifically the Department of Health and Forensic Pathology Services.
Although histopathologists also have structured working hours during the week, most histopathology laboratories will have a pathologist on duty on Saturdays to report cases. This individual will also examine and report any urgent histology or cytology cases, or perform frozen sections after hours. The normal working day of a histopathologist usually starts by examining slides and reporting on them. A frozen section may require him to go to a hospital theatre or to do the “cut-up” or dissection of the specimens as they arrive in the laboratory.
As clinicopathological correlations form an integral part in the management of patients, some days may start or end with a multidisciplinary meeting attended by pathologists, radiologists and clinicians. In smaller laboratories the histopathologist may have to work on his or her own, while larger laboratories may have a number of histopathologists at the same site. All laboratories have an internal referral system to allow even the most remote histopathologist access to review and gain input from other colleagues when dealing with a difficult case. The larger laboratories will also be the reference centres for the performance of special techniques like immunohistochemistry or molecular studies.
The professional responsibilities of a pathologist are the same in private practice and the public sector, although the latter may also have academic responsibilities, including teaching, if attached to a medical school. In South Africa, all public sector pathologists are employed by the National Health Laboratory Services (NHLS).
Pathology training is a combination of theory, supervised practical training (including the use of multi-header microscopes), and hard work. There are usually very limited opportunities for a medical doctor to be able to acquaint themselves with pathology by first working as a medical officer in a pathology department. Medical officer posts do exist in forensic pathology, and the candidate will usually enrol for a diploma with the Colleges of Medicine. There is both a pathology and clinical forensic medicine diploma.
In the other disciplines, entry to a department is usually by being appointed as a registrar in a training position. The period to qualify as a pathologist varies between four to five years. A dissertation, portfolio form and log book may form part of this process. Although a MMed degree or fellowship of the Colleges of Medicine is required for qualification and registration as a specialist pathologist, most South African medical schools now only offer a fellowship.
Job prospects and remuneration
There is a shortage of pathologists throughout South Africa. This may be due to the perception that pathology is less glamorous than “life-saving” disciplines, such as surgery. It may also be due to a lack of exposure to the science of pathology amongst undergraduate medical students. Remuneration in the public sector is according to the published salary scales. Although the reward in the private sector may be greater, the competitive nature of this sector is more demanding.
I would like to thank my colleagues Johan Dempers, Younus Essack, Illse Louw and Elizabeth Wasserman for their discipline-specific comments.