Choosing a Pathology Subspecialty: Forks in the Road

by | Jan 3, 2018 | Residents | 0 comments

One way to help you decide which pathology subspecialty is to break up each subspecialty into several Either/Or categories.  This will definitely help you rule out a few subspecialties and may even narrow it done to a single option to consider.  Below are a few simple categories with explanations to help you find the right subspecialty.

Originally presented at a CAP Residents Forum Breakout Session in Washington, DC, Fall 2017.

Anatomic Pathology(AP) vs Clinical Pathology(CP):

An oversimplified way to ask this question is whether you prefer to use a microscope or not. Chemistry (CC), Blood Banking/Transfusion Medicine (BBTM), and Molecular rarely ever use the microscope while the exception to this would be Microbiology (MB), which requires the use of a microscope almost daily.  AP, of course, is primarily a microscope specialty. You can also consider how much patient interaction would like to have, which I got into more detail here.

Board Certified vs Not:

The overall impression is that a board certified subspecialty will increase your marketability and/or overall reimbursement.  I have not seen data on this exact question but would generally agree with this sentiment.  Here is a list of board certified subspecialties from the American Board of Pathology website.

Patient Contact vs “Under the Door Pathologist”:

BBTM takes the cake for having the most patient interaction.  Medical school is the last time you’ll probably perform a physical exam if you choose any of the AP subspecialties.  The exception of course is if you perform a procedure that is often delegated to pathologists (see next category).

Bed-side Procedures:

Cytopathology (CTP) and Hematopathology (HP) subspecialties are more likely to perform bedside procedures such as fine needle aspirations and bone marrow biopsies respectively.  During fellowship, some dermatopathology (DP) training programs require fellows to perform shave and punch skin biopsies but once in practice, pathology trained dermatopathologists likely never perform biopsies again.  More information about patient contact in pathology can be found here.

Volume:

Do you prefer a higher number of relatively simple cases or fewer more difficult cases? One indicator of whether a subspecialty is known for high volume is to find out which medical specialties set up “pod labs” to process their own specimens.  DP, GI, and CTP come to mind.  On the opposite spectrum is neuropath with only a few cases a day (thank goodness brain tumors are not common).

Ancillary Tests:

HP stands out for using the widest spectrum of ancillary tests (i.e. flow cytometry, IHC, special stains, FISH, PCR, Nex-gen sequencing).  The down side to this is cases taken much longer to sign-out because you wait for all the different results to come back.

Clinical Correlation:

[Full Disclosure: Dermatopathology (DP) is my primary subspecialty] DP probably requires the most clinical correlation.  Thorough knowledge of the clinical appearance of a neoplasm or rash is very helpful in making the right diagnosis.  Medical liver also comes to mind as one that requires a lot of input from clinicians to make a helpful diagnosis.  Granted, Most other subspecialties require some clinical context though not as much as others.

Standardized:

Think HP and the WHO book.  Some subspecialties like HP are much more standardized than others, which makes the subspecialty as a whole more cohesive across labs.  In contrast, medical liver, breast, and genitourinary specimens, just to name a few, are fraught with subjectivity.  On the CP side, BBTM is also known for more standardized guidelines.

Taught At Your Institution?:

Sometimes the best thing to do is to rotate through a department to get a feel for what the subspecialty is like.  If you already have an idea of what fellowship you want to do but it’s not at our institution, requesting an away rotation as early as possible is a good idea for multiple reasons (experience, letters of recommendation, increase change of getting accepted at that location).

What else?

What other categories do you think help categorize pathology subspecialties?  What other factors should be considered when deciding which subspecialty to pursue?  I’d love to you hear what you think in the comment section below!