What is anatomical pathology?

Pathology is a medical specialty that determines the cause and nature of diseases by examining and testing human biological samples such as tissue, fluid and blood. Anatomical Pathology is a subspecialty area of Pathology focusing on human tissue and cells. A Pathologist is a medical doctor who has completed at least 11 years of training, including two years as an undifferentiated hospital doctor post-medical school plus five years of training and successful completion of exams.

Pathology is often considered as a bit of a black box, however, so much work and attention to detail goes on behind the scenes from when a specimen is ‘sent to pathology’ to the generation of the final report. As a medical student, my exposure to Pathology was a didactic two-hour weekly lecture at Uni, supplemented with a rare bottle tutorial in the dusty Anatomy museum. The only contact we had as junior doctors was writing request forms and calling the lab for urgent results. Occasionally at multidisciplinary meetings, Pathologists would appear, flashing their mysterious pink and purple works of art before revealing the diagnosis like a magician. Pathology certainly wasn’t sold as a career choice at any time.

Choosing a career in anatomical pathology

As a junior doctor working in a busy tertiary hospital, I was enjoying my life on the wards and practicing clinical medicine. During my intern and resident years, I considered a number of disciplines including Obstetrics and Gynaecology, Emergency Medicine and General Practice, but still wasn’t completely sure which direction to go. I thumbed my way through the medical career guidebook multiple times and dog eared a number of pages, but kept coming back to Pathology.

I can’t say I was completely naive to it as a specialty. I had obtained my undergraduate degree in Medical Science majoring in, among other things, histology. I had also completed an Honours year in molecular techniques in a major teaching hospital laboratory plus time working briefly as a scientist. I eventually applied for and was accepted into Anatomical Pathology training, commencing at Royal Prince Alfred in 2018. Having a few extra years of clinical experience has been incredibly beneficial in my training, as it has given me a broader appreciation for the impact of a diagnosis on the patient in a bio-psycho-social sense plus an understanding of medicine over a broad range of disciplines.

Typical week

As an Anatomical Pathology registrar, part of our service work is the macroscopic examination and dissection of the specimen, or being ‘on cut’. On other days we may be on the fresh/frozen phone dealing with incoming queries or frozen sections generated as part of an inter-operative consultation.

A frozen section may be required to answer specific questions such as margin status or diagnosis while the patient is still on the operating table. Tissue is snap frozen, processed rapidly and assessed within a short amount of time, and the result is then used to guide the next stage of the operation. This may mean that the surgery is continued to completion or abandoned, or further tissue obtained for diagnostic material.

On cut

On our cut days in the laboratory, we deal with an incredibly diverse array of tissue, ranging from a tiny 1mm gut biopsy to whole limb amputations. Pretty much anything you can cut out, we can cut up. A standard day on cut would see me assessing a couple of hemicolectomies, a uterus, lung resection, prostate, 20 or so skin excisions, and any number of placentas. More difficult specimens would include total laryngectomies, Whipple’s, and complex pelvic exenterations. Dealing with these specimens requires extensive knowledge of anatomy and pathology, as well as an understanding of prognostic features in order to ensure that sampled tissue is taken to demonstrate this.

After cutting up the specimen, the sampled tissue passes through a series of time and labour intensive steps requiring input from technicians and scientists. Tissue is processed, then embedded in wax before generating stained slides. Once the slides are produced, the clinical work commences. As a registrar, we are in training to learn how to report cases. This involves looking at thousands of slides, developing an eye for patterns, and interpreting cytological clues. We work closely with our Consultants, and all of the cases we look at are reviewed before generating the final validated report.

A lot of time is spent going through cases on a one-to-one basis with our supervisors or in regular teaching sessions. Sometimes a case can be diagnosed on routine stained slides, however, others may be more undifferentiated and require investigations of the antigenic properties with immunohistochemical stains or molecular profiling. Cases can be very difficult and require review by multiple consultants, both in house and externally, and then discussion at a multidisciplinary meeting with input from Radiologists, Surgeons, and Oncologists.

Why it appeals to me

The lifestyle is incredibly attractive. There are no ward rounds, a very civilised 8am start for the most part, and generally home on time at the end of your shift. There is rarely the need for overtime, and night shifts are a thing of the past. I work with a wonderfully supportive team of medical colleagues, laboratory technicians and scientists and this makes for a great work environment.

Training is fairly flexible and allows you to incorporate areas of interest into your work life. Research is actively encouraged, and my Consultants generate and foster opportunities by highlighting interesting cases. Additionally, there is a generous study leave allocation that enables you to attend and present at local, national, and international conferences. An area of special interest for me is in teaching and education and I am able to initiate and develop courses and information sessions for medical students, junior doctors, and registrars.

Pathology is intellectually stimulating and calls on a comprehensive understanding of anatomy, physiology and biochemistry. It attracts people with scientific minds who are lateral thinkers and are curious about how and why things happen on a cellular and molecular basis. The medical landscape is shifting at a rapid rate due, in part, to new molecular discoveries that change the way we think about diseases and diagnostic classifications. It is exciting to be at the forefront of discoveries leading to improving prognostication, treatment modalities, and better patient care.

The most satisfying thing about pathology is you get to make a difference in patients’ lives every single day. Even though I would rarely see a patient face-to-face, pathology contributes vital information that directs clinical care and provides much-needed answers for patients and their families.