What makes an expert in Histopathology?

The topic of the current ACP news issue is academic pathology. My training route into pathology was unusual, with a background in surgery, basic (biological) science, and a PhD investigating the molecular pathology of apoptosis in colorectal cancer. My background in a related research topic initially made me interested in academic pathology. My first trainer and inspiration for leaving surgical training in favor of pathology talked me out of pursuing an academic career. Although my nostalgia for my research days sometimes makes me wonder if I would have liked it, I think a conventional histopathology career has suited me. I have maintained my passion for science, and although I haven’t continued my PhD studies, being fully or partly employed by an academic institution or university shouldn’t prevent a pathologist from being involved in research. Case reports and series are achievable, and it is still possible to take a peripheral part in research projects as an NHS consultant, although the opportunities, funding, and time are admittedly limited these days.

Defining Expertise in Pathology

Thinking about academic pathology made me consider what constitutes an expert pathologist. Experts in science are usually considered to be those who have the greatest academic prowess, but is that the same for a pathologist? Our skills are a combination of macroscopic and microscopic pattern recognition, combined with scientific and clinical understanding of disease processes. We describe disease processes by their microscopic appearance and can potentially define new diseases or disease patterns.

Productivity and Case Numbers

In the NHS, we are judged by our managers (and certain colleagues) by the numbers of cases we report. I have heard senior consultant pathologists boasting about the numbers of cases they can report compared with their junior colleagues. Most (but not all) of the pathologists I would describe as “big hitters” in terms of numbers are more senior consultants, and some but by no means all are considered national or international experts. Reporting high numbers of cases can prevent opportunities to become known as an expert, and some would prefer to keep their head down and “push the glass” than present their work and wisdom at conferences.

Geography and Mentorship

Most experts in pathology work in big cities and well-known hospitals, with a tendency for specialist work and/or academic prowess. Although most experts have been in these roles for many years or decades, it is possible to acquire expert status quite quickly if a younger consultant is employed in an institution where an expert resides and mentors the new consultant before he or she retires. There is genuine kudos to be gained from having trained or been mentored by an international expert who receives many difficult referrals. Although there is experience and wisdom to be gained by seeing lots of easy routine cases, difficult cases with a seasoned expert certainly sharpen diagnostic and reporting skills. I would certainly recommend a young pathologist working at a smaller hospital who hopes to gain specialty expertise as a consultant to seek out a period of experience with an expert at a specialist centre.

Teaching, Lecturing, and Research

Pathology experts usually work at a large university hospital where they are involved in teaching and research. The future of pathology and ensuring medical students get exposure to the subject depends on this continuing, but I have sensed pathologists have gradually lost the time they spend teaching medical students, even in the bigger centres. There is a vicious cycle as job plans become consumed by solo DCC reporting, with a reduction in supporting professional activities and teaching. As we do less teaching to medical students and other health professionals, we are in danger of seeming less relevant as a career to scientifically minded students and junior doctors. Our specialty needs to ensure it is leading research studies in the future, rather than just being included as an afterthought by the clinical team who want to include some photomicrographs for scientific legitimacy. Recognised experts in histopathology will usually speak at national/international conferences and have publications in core specialist journals such as Histopathology and the Journal of Clinical Pathology. In the future, however, online publications, YouTube webinars, and social media presence may contribute more towards international expert status.

Peer Recognition and Expertise

Local experts may be self-nominated or decided by colleagues when there is specialist reporting and MDT leads at a workplace. With experience and exposure to increased case numbers, clinical colleagues may approach the local expert for help interpreting reports and general diagnostic advice. A large part of the skill of an expert in any subspecialty, in my opinion, is not just the pattern recognition but the subspecialty terminology, knowledge of micro-anatomy, clinical and Royal College updates. It is helpful for a pathologist to know the implications of subspecialty terminology when specific phrases may prompt a particular testing protocol, treatment option, or follow-up protocol.

External Quality Assurance (EQA)

EQA is a system for objectively checking laboratory performance using an external agency or facility. Proficiency testing is used for pre-existing and new biomarkers being used in cellular pathology laboratories but is also used to assess individual pathologists for their proficiency. With increasing specialization, more and more consultant pathologists are choosing not to take part in a general EQA as they do not feel proficient to diagnose cases outside of their specialist expertise. Multiple national specialist EQA schemes exist and are a requirement for pathologists to demonstrate evidence of continuing professional development. Private reporting companies use evidence of participation in specialist EQA as recognition of specialty expert status. It is arguable whether they realistically reflect the complexities of making a difficult diagnosis in real life closely enough to be evidence of true expert status, however.

The “Informal” Expert Review

Even experienced senior pathologists occasionally need “handholding” when encountering infrequently diagnosed pathology. Sending a case away to a remote expert using the conventional “slides and blocks in a jiffy bag” can take weeks when booking out and booking in processes are so overwhelmed in most NHS hospital labs these days. When remote experts are comfortable receiving digital referrals and replying within a day or two, it seems unethical to use the old-fashioned method. I am fortunate enough to be in frequent contact with many experts in the UK and overseas via phone, email, and digital scanning. Even without digital pathology, most experts are approachable via email for questions about the workup of a difficult case or a staging query. I have pathology “WhatsApp groups” with several national expert pathologists, and there are several social media groups brimming with experts who are always willing to answer queries. The McKee derm group on Facebook is an excellent example of the latter, with a range of diagnoses discussed from the mundane to the spectacularly rare; queries are often answered within a few hours by multiple experts. Twitter, or “X” as it is now known, is a route for anyone brave enough to share anonymized cases with the wider international pathology audience, and I now attend a twice-monthly Zoom teleconferenced GI pathology group hosted by USCAP experts. Dr. Philip McKee, who was encouraged to run his online discussion group by the notorious social media pathologist Jerad Gardner, describes these discussions as “curbside opinions” which can be extremely educational and valuable but should not be quoted in a formal report as forming the basis of the diagnosis.

Summary:  The path to becoming an expert in histopathology involves a blend of academic achievements, clinical practice, and continuous professional development. Experts are often distinguished by their superior ability to recognise macroscopic and microscopic patterns, coupled with a deep understanding of disease processes. Factors contributing to expert status include case volume, mentorship, involvement in teaching and research, participation in external quality assurance (EQA) programs, and engagement with professional communities through both traditional and digital means. While numerical productivity and working in prestigious institutions play roles, true expertise is also marked by contributions to scientific literature, leadership in professional activities, and the ability to provide nuanced diagnostic insights. .

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