Choosing a Pathology Subspecialty: Quick Fellowship Descriptions

by | Jan 17, 2018 | Education, Residents | 3 comments

You don’t need to do a month rotation in every fellowship to get an idea about what each subspecialty is like.  Read through these brief descriptions to see what you’ll be getting into if you decide to pursue additional training post pathology residency.



Blood Banking and Transfusion Medicine: Arguably the most clinical subspecialty of pathology.  If your lab oversees aphaeresis then you will perform physical exams, write clinical notes, and send in prescriptions on a daily basis.  Writing up transfusion reactions and working through antibody panels are the bread and butter of the subspecialty.  And if you are at a large academic center coagulation studies can be extremely complex. Here’s what a recent graduate said about why she chose this subspecialty:

Blood banking and CP for that matter appealed to me in different ways compared to AP.  I really like the interaction with clinicians in blood banking.  I am educating someone new everyday from nurses to cardiac surgeons and I really like teaching so that appealed to me a lot.  Blood banking is so different from anything else in pathology and I really liked that it was something that not a lot of people were drawn to.  Things are very standardized in blood banking and lots of areas of CP, usually clear cut processes for doing something and for me this fits my personality the best.

Stephanie Kinney, MD; Medical Director of Transfusion Services; Division of Pathology and Laboratory Medicine; Cincinnati Children’s Hospital Medical Center

Breast Pathology: Is this DCIS? Many multi-disciplinary pathologists (i.e. private practice) struggle with this question and wish they had someone in the group with breast pathology training.  Though you would have one less certificate on your wall (no board certification), it’s a high volume subspecialty where you frequently correlate with mammography reports.

Bone and Soft Tissue Pathology:  Every case is a puzzle.  Cases are rare but every group wants someone who has some experience.  If you hear the word “spindled” and don’t immediately freak out, you might end up being the “soft tissue guy/gal” in your group whether you want to or not.

Cardiac Pathology: Cardiac pathology is even more niche that Pulmonary and a singular fellowship is something to be pursued only if you have a very specific interest and plan on staying in academics. There are a few Thoracic fellowships that combine both cardiac and pulmonary pathology.

Clinical Chemistry: Tired of looking through a microscope?  Clinical chemistry might be for you.  According to “Chemical pathologists manage the processes [of automated analyzers] and the laboratory staff. They provide guidance on the selection of appropriate tests, and assess the significance of the results. This is particularly the case with more unusual tests. They also provide quality assurance as part of their strategic leadership role.” If Quality Assurance, Levy-Jennings, Westguard, and CAP inspections makes you feel giddy, look no further than clinical chemistry. There is a subspecialty certification board. Oftentimes you will be competing with PhD’s for fellowships.

Clinical Informatics: This relatively new subspecialty just offered its first board certification in 2013 and receives fellows from every field of medicine.  A quick search through fellowship programs was pretty sparse on particulars about what your daily duties would be.  If you aspire to become Chief Medical Information Officer (CMIO) of a hospital one day, or phrases like “well on [your] way towards becoming a leader in the field” ( sound attractive, then give your local informatics guru a call.

Cytopathology: If directing a surgeon to do a Whipple based on a single, probably dehydrated, cell makes you squeamish, maybe rethink cytopathology.  If you can stomach it though, cytopathology is a highly marketable, board certified subspecialty with lots of volume.  Recent medical technology advances (primary HPV testing) have made the future uncertain for cytopathology so find a mentor who can help guide your decision.  It is a useful skill to have for both private and academic practice environments. I think this quote from a previous Chair of the CAP Residents Forum sums up cytopathology well:

Cyto is voodoo, I don’t care what anyone says.

Pathologist, Ruffolo, Hooper, and Associates / Assistant Professor, Department of Pathology, USF Health Morsani COM

Dermatopathology: Kind of an exclusive group.  Relatively easy subspecialty, until it’s not.  If you had a clique with all the gunners (future dermatologists) in medical school then you might enjoy dermatopathology.  High volume, quick turnaround time, strong clinical correlation, and a heavy dependence of a single billing code (88305) summarize this subspecialty.

Forensics:  Hardest working, least paid subspecialty.  Decomposed bodies are super stinky, but you get to see interesting cases and help the criminal justice system.

Gastrointestinal/Liver Pathology: If you love whipping through tubular adenomas and hyperplastic polyps and screening twenty biopsies from an ulcerative colitis patient GI is for you! GI is high volume subspecialty without a board (no more tests!) that is heavily sought after in both academics and private practice. Competition is usually high for fellowship spots. If liver is something you are interested in, be sure to choose your fellowship carefully as it is often not part of a GI fellowship or is its own fellowship.

Genitourinary Pathology: GU is another subspecialty of pathology without a board so you don’t have to sweat another test. Depending on your location this may be high volume, but no one would argue that prostate cores aren’t bread and butter and any institution. Like many of the AP subspecialties, this is well paired with another fellowship unless you have a particular job in mind where you can practice just GU.

Hematopathology: Highly marketable, numerous ancillary tests, and standardized (WHO) are descriptions often used to described this board certified, AP/CP hybrid subspecialty.

“Very analytical and structured.  Early players in the molecular world (think CML/Ph chromosome), so classification is based on complex studies and genetic findings and not purely on morphology.  Has some of the more acute diseases in pathology and not infrequently we’re finding the initial suspicion of acute leukemia based on a peripheral smear where it may not always be suspected (i.e. I’ll routinely call up an ER doc who ordered a CBC to tell him that the patient likely has acute leukemia rather than an oncologist telling me they’re [doing a biopsy on] this guy’s lung cancer)”

Drew Nedved, MD; MAWD Pathology Group; Kansas City, Missouri

Microbiology: If laboratory management and looking at petri dishes sounds like fun microbiology may be for you! It can be difficult finding a microbiology only job, but it’s not impossible. And if you pair it with another fellowship and aim for academics this can be a very nice practice environment.

Neuropathology: Low volume, high complexity is a good way to describe neuropathology.  It’s a board certified subspecialty after two years of fellowship.  There is and increasing use of standard criteria and molecular methods to characterize neoplasms.  Brain biopsies are performed at large hospitals and academic centers so don’t expect to find a rural or private practice job with this subspecialty.

Pulmonary Pathology: Pulmonary pathology, especially non-neoplastic is arguably a niche specialty either paired with another high-volume subspecialty to increase your marketability and/or relegated to a large academic center. That said, it’s a fascinating topic and lung cancer is currently undergoing a revolution in molecular testing that puts pulmonary path on the forefront of individualized treatments. And you will always impress if you can diagnosis interstitial lung diseases without batting an eye!

What Do You Think?

Have I mischaracterized a subspecialty that you’re interested in? Please let me know in the comments below.  Thanks!