Plummeting Profile
Soon after I arrived at the University of Minnesota Hospital, it was announced that the pathology museum would be dismantled, the space to be occupied by a clinical department. Undergraduates at my alma mater in Cape Town had used their pathology museum to examine preserved specimens of all types. Written accounts of the organs would accompany each jar. Students would migrate through the museum, motivated by the prospect of a stiff, face-to-face end-of-year oral examination. An examiner would hand over a specimen and say “talk!” When the pathology museum at the U of M was dismantled, I lost a unique vehicle through which I had been able to communicate with my students. That happened again a few years later at The George Washington University Medical Center in the nation’s capital. These days, medical students draw inspiration from two-dimensional images on computer screens.
My entire medical class in the 1970s would attend weekly autopsy sessions conducted from scratch. We would line a small amphitheater that rose steeply above the autopsy table. The prosection would be performed by either a staff pathologist or by a resident deemed good enough to hold forth in front of the students. In attendance were clinicians and a radiologist. The medical history and laboratory results would be presented, the radiologic images demonstrated, and the class would be invited to offer opinions on the physical and laboratory findings. Only then would the body be opened, the organs displayed, and the pathology revealed. During that year, we witnessed the macroscopic pathology of just about every medical condition that mattered, and acquired a three dimensional, tactile, palpable and olfactory sense of what it was all about. Seeing good pathologists in action, some of us became interested enough to enter the field.
There is a vast difference between showing a student a set of microscopic abnormalities on a screen and asking that individual to find an abnormality on a glass slide. One of the best parts of my pathology course was the microscope session, where we examined actual slides, made pencil drawings of what we saw, wrote detailed accounts of our observations, and attempted to render diagnoses. Things have changed, in that innovations in computer technology have opened up exciting means of demonstrating, transmitting, analyzing and storing microscopic images. The common microscope usually found in student laboratories simply cannot compete with the versatility of modern image manipulation, and it was therefore inevitable that the conventional microscope would yield to the computer. Some schools still seem to use microscopes, but the trend, one senses, seems to be away from these dinosaurs. I find this unfortunate, because beginners need to develop the special hand-eye coordination that connects them with what is on a slide, making them experience this activity as a keen hunt for the target. When it comes to the training of residents who intend to become pathologists, I believe that the standard microscope will remain the instrument of choice for the foreseeable future.
The profile of pathology in the medical school has, to a degree impossible for me to measure, also been suppressed because the didactic teaching of the subject has been integrated in different ways into the clinical years. The idea of teaching the pathology of, for example, the heart, in tandem with a clinical cycle devoted to cardiology, is appealing, and is an approach in which I have not personally participated. The spreading of pathology among the clinical rotations has, I gather from conversations among colleagues, subtly added to the subtraction from the curriculum of the museum, the autopsy, and the microscope. The cumulative price for these subtractions is paid at the back end, because those now leaving medical school to enter a pathology residency begin with a grasp of the subject considerably less than would have been the case a generation or more ago. This places what I regard as a significant remedial burden on stressed faculty members who must turn neophytes into surgical pathologists within two brief years at most. I recently asked a medical student from a prominent north-east coast school to tell me about her pathology program, and was astonished when she said that they didn’t have one. On further enquiry, it turned out that the program did actually exist, but had been submerged within a broader clinicopathologic unit with a modern name that I cannot quite remember.
One other loss is that residents in pathology are no longer required to have had prior clinical experience, other than the usual student clerkships and electives. This deprives them of the advantage of having had additional responsibilities (and authority) in direct patient care. There is much to be said for a rotating clinical internship for individuals heading towards pathology, just as there is much to be said for a rotating year in pathology for those intent on becoming good surgeons. This type of cross-pollination is now rare in this country, and is, to our detriment, probably extinct. (See "THE QUEST" - Fault Lines in the Ecology - Medicare Reimbursement)
For sure, there is no going back, yet unique opportunities and challenges exist for the new medical schools coming into existence to creatively adapt their curricula so that their students may once again experience the pivotal role played by pathologists, and perhaps be moved to enter the field themselves.