6 Reasons to be a pathologist

A med student stopped by the office today.

Asked me why I chose to be a Pathologist.

Here’s what I told him.

6 Reasons To Be A Pathologist (If You’ve Already Committed To Finishing A Residency).

#1 Protect the morning. 

First decide what type of person you are. Introvert vs extrovert. Morning person vs evening person.

When I look back on my early career frustrations with medicine, they all stemmed from losing my morning quiet time.

You take this time for granted when you are a teenager and in your early 20s.

My best days are when I have no obligations in the morning. I prefer to work at my own pace. I don’t like people breathing down my neck. I like to read and think through diagnostic problems slowly.

I like to write out my thoughts in the privacy of my dimly lit office. Its how my brain works. When my morning is filled with appointments and meetings, I feel like the best creative hours in the day have been stolen from me.

In every patient-facing specialty (which is most of medicine) you start everyday with your schedule booked. Some people love this. Not me.

You have to direct your attention outward. Its the worst. Its no surprise I faced an existential dilemma rotating through every branch of medicine.

I knew early on that the “traditional” Doctors workday was not for me.

I wanted a job where my morning was protected from distractions. Of course interruptions are inevitable when covering morning frozen, but its still much less of an intrusion than bedside medicine.

In fact, I often bring my notebook and a few articles to the frozen lab in case there will be a longer case. I usually enjoy the change of pace, talking to the Histotech and Surgeon. Knowing I can retreat back into my solitary oasis to work at my own pace is one of my highest order values in a job.

#2 No social work. 

Hospital and outpatient medicine are full of complicated family and social scenarios which contribute to disease. When you are younger, you have a higher tolerance for these scenarios. But after a few years, especially when you have a family, you realize you are essentially whoring out your empathy to drug-addicts and personality-disordered patients.

Its worse in fields like Family Medicine, Psychiatry and Pediatrics.

I know this because I was a Psychiatry resident for 6-months before I metaphorically “saw the light.” There used to be these “family meetings” on the Psych Ward where everything would be discussed with the patient and members of their family.

Treatment, medicines and therapy goals.

It was interesting at first. But after a while it became emotionally draining. You are dealing with people who have a broken life, and now it is your responsibility to fix it - because you are the licensed physician responsible. This is an unrealistic ask. The standard of care revolves around using psychiatric drugs with marked side effects. 

Even if the patient is noncompliant with the treatment or overtly hostile, you bear responsibility for the outcome. The psych ward was an extreme example of this, but comparable scenarios occur on the inpatient medicine wards.

For example: Complex transplant patients and end-of-life care. Sons and daughters will ignore their parents for decades until Dad ends up in the ICU. Now they are demanding everything be done to save a family member with multi-organ failure and a < 1% chance of surviving outside of a vegetative state.

During the early years, my compassion for these poor should outweighed my boredom of the social work procedures involved in the care of complicated patients. That window of time expired halfway through my intern year. I knew I needed to find another niche within medicine.

I was motivated by self-preservation.

#3 Diagnostic addiction. 

The practice of surgical pathology is a slow game with a variable reward schedule.

It takes a couple years to learn the language. With training, you begin to formulate differential diagnoses based upon gross, microscopic and clinical findings. When you start making accurate diagnoses, you get a buzz from it. You never know when an interesting case is going to come across your desk. 

I compare it to a night at the “Door Guy Show” on Wednesday nights at the LA Comedy Store.

90% of the comics are just shuffling through. Doing open-mic level material. Its good stuff but it ain’t great. That’s why its a free show. Then Bill Burr or Dave Chapelle drop in and blow everyone out of their seats. That’s what keeps you coming back. Its the anticipation of an uncertain reward.

Same thing with being a pathologist.

My first two weeks on the job I had an adreno-cortical carcinoma in a 20-year-old man, followed by a low-grade fibromyxoid sarcoma and then a breast abscess with cystic neutrophilic granulomatous mastitis.

You start craving these “weird” cases because of the novel intellectual stimulation they provide. Though I am not an academic, I can appreciate the appeal of academia.

#4 Side hustle. 

Pathology is flexible enough to let you have one.

Years ago, I talked to a radiation oncologist named David Grew. You should follow him. We were both “weirdos” in medicine because we were both doing stuff on the side. I was doing open-mic comedy and he was building a content platform with simplified explanations of cancer treatment.

We were both channeling our frustration with organized medicine into another skill. We both felt strongly: Side hustle is a course which should be taught in medical schools. Even though we knew it will never be.

Naval Ravikant talks about how the Doctors who are able to “break-free” of the mundane corporate practice of medicine do so because of their side hustles. Some side media project they built. Some new surgical device or software application to make daily practice easier in their niche - or in someone else’s niche.

But medical school rewards obedience - not innovation. Side hustles, or anything outside of your daily duties is frowned upon by most people in the system. You’re supposed to be a good little student and do as your told. You keep paying thousand after thousand of borrowed dollars to fund your licensing examinations. Payments go to a third party agency of bureaucrats, not physicians. 

It’s a hustle. 

The problem is that you are the one being hustled.

I chose to be a pathologist because the job gives you a little bit of runway to work on something on the side. The fact I’m able to write for an hour during the middle of the day (when my mind is fresh) is an example of this. If I need to take a walk to recharge the neurotransmitters, I can do that too.

Nobody’s waiting on me. Nobody’s bleeding out.

I can stay at the office late to finish up the easy routine cases sitting on my desk. This flexibility with your daily routine is what makes Pathology attractive to someone like me.

I crave quiet and flexibility.

#5 Interesting work. 

Medicine is the application of anatomy and physiology. 

These two subjects were my favorite when I was starting out. In the field of pathology, you are applying anatomy and physiology at the microscopic level. Solving diagnostic problems for oncologists and surgeons. There’s a lot of reading involved and at times it is frustrating. 

But you learn a lot every week.

You have to learn. Otherwise your clinical colleagues won’t take you seriously. 

Quick story: I recently had an unusual tumor of the parotid gland. The patient was a 60-year-old woman. The slides came out and it looked like a well-differentiated squamous cell carcinoma. The case had irregular nests and small cells budding off the edges.

Primary squamous cell carcinoma of the parotid gland is exceedingly rare. The differential diagnosis included the remote possibility of metastasis from an unknown skin cancer. Or I was wrong and this histologic finding was all simply benign squamous metaplasia of parotid ducts, a reactive process.

So I sent the case for consultation to an internationally renown expert in Head and Neck pathology. He called a week later. I was boarding a flight to New Orleans at the time. The case had been on my mind. I was anxious I had missed a malignancy. He told me he wasn’t quite sure the name of the tumor, but favored something low-grade with features of a so-called “keratocystoma”.

A month passed and a small series was presented at a pathology conference in Tokyo. Japanese pathologists had seen several similar tumors in the parotid gland. Two of them were sequenced and resulted a RUNX2 fusion product. This is a fancy name for gene mutation. 

So I sent a few unstained slides to perform RUNX2 FISH and our case had the same fusion transcript as the group in Japan had found.

Now with a series of several cases from case records and current clinical practice, these findings will be submitted for publication.

Over time, more follow-up data will be collected to support the hypothesis that this tumor, called “keratocystoma” are indolent and can be managed conservatively. Some unsuspecting patient in the future will benefit from knowing they have an indolent tumor rather than an aggressive one.

Never did I suspect that a routine case on my desk would turn into a newly described entity with a recurring genetic aberration.

This is what happens in community practice. We see all kinds of crazy stuff.

#6 Interesting people.

Before I discovered pathology, I was wandering around as an introvert trapped in an extroverts world. 

I was always trying to fit in but never could. 

In college, I did not enjoy going out with the people in my dorm because my social battery would wear out after about 2 or 3 hours. In this profession, I’ve met ultra-runners, musicians and prolific writers. Simply being around other introverts has given me the confidence to lean into who I really am. I am still in touch with friends from residency and fellowship. 

We talk often about career and life challenges.

At national meetings, I’ve met pathologists involved in the business/managerial aspect of pathology and laboratory medicine. Some of these individuals have incredible life stories. One of my friends escaped civil war in Lebanon and trained at WashU in St. Louis. He later went on to become the president of the largest practice in the Rocky Mountains. He now runs his own consulting business, providing practice management advice to groups all over the world.

Pathologists tend to be a tight-knit professional community. It is a nurturing environment. In a way, this job chose me. 

I’m lucky.

3DEEPERCUTS