Career: Detecting disease

IT IS estimated that half of the UK population will be diagnosed with cancer in their lifetimes. This is a sobering statistic – and yet cancer survival is currently at its highest level ever. Recently Cancer Research UK commissioned some research on the implications of these trends on pathology services and found that the NHS faces some serious challenges in terms of capacity.

Staffing estimates suggest that the number of consultants in cellular pathology (encompassing histopathology and cytopathology) have increased but only by 1.2 to 3 per cent per year. In the next five to 10 years it is estimated there will be a serious shortage of consultants across all areas of pathology. The Cancer Research UK report concluded this will have the largest impact on cellular pathology as there is a shortfall of trainees compared to those leaving the profession.

No wonder the Royal College of Pathologists is keen to attract interested Foundation year doctors into training – and it is certainly worth considering whether histopathology might be the career choice for you.

Histopathology is essentially the study of changes in human tissue caused by disease. Histopathologists examine tissue sampled in clinics or removed during operations, assessing it both macroscopically and using sophisticated microscopic techniques. They work mainly in the laboratory in partnership with scientists and doctors from other clinical specialties and have an in-depth knowledge of both pathological and clinical aspects of disease.

The specialty is integral to cancer management through staging and the grading of tumours. Histopathologists also have key responsibilities in disease screening, such as for breast or cervical cancer.

Entry and training

Following successful completion of foundation training, Health Education England (HEE) states that candidates applying for ST1 training in histopathology would be expected to have or develop a range of skills including:

• extensive breadth of knowledge, not just of histopathology, but of clinical and surgical practice
• an interest in the mechanisms of disease at the macroscopic, microscopic and molecular level
• an inquisitive mind and self-motivation
• good visual pattern recognition
• manual dexterity and hand-eye co-ordination
• good diagnostic skills to determine not only the type of disease, but also its severity and extent to ensure the right treatment is given
• excellent organisational and time management skills
• good problem-solving and decision-making skills
• the ability to work well alone and also within multidisciplinary teams (MDTs).

Entry into one of the UK’s histopathology training programmes is competitive and candidates would be expected to demonstrate an interest by involvement in activities, achievements and scientific meetings relevant to pathology, attendance at pathology courses and evidence of participation in audit/research projects that are relevant to pathology. You can download a full “person specification” from HEE at tinyurl.com/h4m76sj. Training in histopathology normally takes five and a half years on the assumption that candidates will also be undertaking two optional training packages of three months each, either in cervical cytopathology, higher autopsy training or research methodology. A Certificate of Completion of Training (CCT) is awarded on the recommendation of The Royal College of Pathologists following:

• evidence of satisfactory completion of the histopathology curriculum and the minimum training period
• satisfactory outcomes in the requisite number of workplace-based assessments (including multi-source feedback)
• attainment of the College’s Year 1 Histopathology OSPE
• FRCPath by examination in histopathology
• acquisition of annual review of competence progression (ARCP) outcome 6.

Doctors applying for a Certificate of Eligibility for Specialist Registration (CESR) in histopathology must be able to demonstrate equivalence to the requirements for the award of a histopathology CCT.

The job

Much of the work of a histopathologist is laboratory-based and involves dissecting and examining histology and cytology specimens under the microscope and preparing clinical reports. These are then often presented at regular MDTs in which diagnosis and clinical management plans are discussed and formulated.

It is a rapidly changing specialty with new immunohistochemical and molecular methods coming into use on a continual basis. Biomedical scientists are increasingly undertaking more of the ‘routine’ cut-up of smaller specimens and also conducting microscopic examination and report writing. Some histopathologists have specific clinical roles, such as taking fine-needle aspiration cytology specimens in breast clinics, but patient contact tends to be limited. Others may spend time working in the hospital mortuary carrying out autopsies to help determine cause of death.

Histopathology can offer flexible working and often involves relatively little out-of-hours work, although there may be some occasional on-call. There is increasing sub-specialisation, with the traditional generalist histopathologist rapidly becoming a thing of the past. Histopathology also provides ample opportunities for further learning, research interests, audit and teaching.

Sources and further information

• Royal College of Pathologists

• Histopathology training at nhshistopathology.net

• Health Careers NHS: Histopathology

Q&A Dr Rebecca Morrison, ST1 in histopathology, Imperial College Healthcare NHS Trust

What first attracted you to histopathology?

Throughout medical school I was always most interested in the pathophysiology behind disease and I enjoyed the few pathology tutorials that I had. I didn’t realise I wanted to train in histopathology until I fully understood the role of the pathologist by spending time in the pathology department and speaking with consultant and trainee pathologists. Moreover, trainees with an interest in research, like myself, are actively supported and encouraged to get involved, and there are many opportunities available for a career in academic pathology.

What do you enjoy most about the job?

As a trainee I get one-to-one teaching with a consultant almost every day and I feel valued within the department. The job itself is interesting: trainees will see a wide variety of cases from all specialties and you are required to recall and use your medical knowledge and problem-solving skills, which I felt I had not had much opportunity to use in my foundation training. Training in histopathology is like learning a new language: when I first started I felt completely clueless, however just five months in I have already learned so much.

What do you find most challenging?

As a first year trainee everything I do is supervised so there is some loss of independence compared to my previous work, and this can make me feel more like a student than a doctor at times. You really need to have a genuine interest in histopathology because the sheer volume of information that there is to learn can be overwhelming and you are required to put in a great deal of hard work and dedication in order to progress through training.

Has anything surprised you about the specialty?

I didn’t fully appreciate just how much clinicians rely on pathologists: we really play a vital role in the diagnosis and management of patients in all specialties. This is especially true with cancer diagnosis, staging and management. A pathologist works very much behind the scenes and the importance of the job is under-recognised by clinicians and patients.

What do you consider the most important attributes of a good pathologist?

You must be able to spot subtle microscopic features to provide an accurate diagnosis and this requires excellent visual pattern recognition skills. The subsequent interpretation of microscopic findings requires problem-solving skills and ability to work under pressure, as there will always be a looming deadline and an awareness that your pathology report will determine what treatment a patient receives. We also play an important role in the MDT (multidisciplinary team) and need to have excellent verbal and written communication skills to ensure that the patient receives the correct treatment.

What advice can you give to a final year or FY trainee considering histopathology?

I think it is an excellent career choice and there are so many facets to histopathology that there is something for everyone. However, entry is competitive so you need to show that you are genuinely interested in the specialty. Go to your hospital’s pathology department and arrange a taster week in pathology. You will get a chance to see what exactly the job entails and can get involved in an audit or research project to make your application stand out.