Choosing Pathology: A Qualitative Analysis of the Changing Factors Affecting Medical Career Choice

INTRODUCTION

Impetus for this study, a manpower shortage in pathology
Pathologists provide a valuable although usually unseen medical service. In the popular media, pathologists are usually seen as performing forensic autopsies and helping solve crimes. Contrary to these portrayals, the overwhelming majority of pathologists spend their time diagnosing diseases and providing information regarding prognosis and effects of treatment to living patients. As both laboratory scientists and physicians, pathologists are at the forefront of the molecular revolution in clinical medicine. The importation of new information and techniques in molecular biology into clinical medicine is often first encountered in the laboratory specialties, and as a consequence the complexity of pathology is rapidly increasing. In Canada there is evidence of a manpower shortage in pathology. The number of practicing pathologists has decreased by approximately ten per cent in the ten-year period from 1993 to 2002. In addition, 25 per cent of pathologists are anticipated to retire in the next ten years. The age distribution of Canadian pathologists is also worrying. Only ten per cent are between 30 to 39, while 35 per cent are between 50 and 59.¹

How many students are choosing pathology in order to fill these positions? The most recent and accurate Canadian data are available from the agency CARMS, (the Canadian residency matching service) that is responsible for the Canadian “match” – the process by which Canadian medical students are matched to universities and specialties for postgraduate training. The CARMS web site shows that in 2004, 24 of 1,285 Canadian medical students ranked pathology or laboratory medicine as their first choice.² This compares with 70 for anesthesia and 66 for diagnostic radiology. These are specialties often considered comparable to pathology in that they are all hospital-based, with controllable lifestyles and little direct patient care in the usual sense. The number of applicants choosing radiology or anesthesia as their first choice equaled or exceeded the number of places of offered. In pathology, by contrast, there were fewer applicants choosing pathology first than places offered. In the U.S, 37.9 per cent of the positions offered in 2000 were taken by American seniors. By 2004, this number had risen to 61.2 per cent of positions offered. Although this trend is encouraging, by comparison, radiology positions are almost all taken by U.S. seniors (91.2 per cent in 2000, 96 per cent in 2004).³

Table 1. Summary of the six themes regarding factors affecting pathology as a career choice.

Theme 1 – Medical students’ perceptions (accurate and inaccurate) regarding the role of pathologists in medical care

Theme 2 – The role of the course in pathology in career choice
Course was most important in medical student and pathologist group. Non-content related factors such as teaching style or personality more important than content for medical students.

Theme 3 – Lifestyle as a major factor in career choice among students, residents and pathologists.
Most prominent factor in the resident group

Theme 4 – The influence of rumor on career choice among medical students
Students expressed that many of career decisions were based on class rumors

Theme 5 – The influences of clinical experience and role models in choosing pathology
All groups agreed that these were important influences on career choice, both in discovering or confirming pathology as a career as well as excluding other specialty choices.

Theme 6 – Overcoming the negative stereotype of the pathologist in making career choices
Negative stereotype known to even junior medical students. Dealing with stereotype necessary in order to select pathology as a career choice.

Why does pathology lag behind comparable specialties in terms of recruiting? This is the major question that motivated this research. Although the situation may be similar in other countries, this article used a Canadian study population and further comments will concern the Canadian situation. Better understanding of the situation in the Canadian context may be relevant to experiences in other countries, because of similar experiences in pathology recruitment.

Exposure to pathology in the undergraduate curriculum as an influence on career choice.
Traditionally, pathology is taught in the first and second years of the medical curriculum. Pathology is taught at the University of Toronto in a 420-hour second-year course, combining both large and small group teaching. This course, the Pathobiology of Disease (PBD), introduces students to the basic mechanisms underlying human disease, followed by a survey of systemic diseases. It was introduced in 1993. PBD also contains some information that would usually be outside of what is classically thought of as pathology, for example, genetics. After the completion of this course, most medical students have no further exposure to pathology in their careers. This is unlike all other medical specialties where exposure essentially begins in the third and fourth clinical years of medical school and extends into postgraduate training. The two research questions arising in this background are:
1. What role does the introductory pathology course play in forming students’ impressions of pathology as a career, and are those impressions positive or negative?
2. What role do these impressions play among the wider range of motivations influencing those who have already chosen pathology as a career?

Review of relevant literature
The review of the literature in this area is of necessity selective, as previous studies on career choice are both numerous and diverse. ERIC, PsycInfo, and Medline databases were searched using headings such as “occupational choice” and “medical residency”. In addition, a second search was performed on Medline in these areas, looking for “pathology” as a key word.

A study published in 2001 by Murdoch, et al., reviewed publications from the past two decades concerning factors affecting career choice in medicine.⁴ This review yielded seven areas of content domain that were said to consistently correlate with medical students’ career choices: biosocial orientation, bioscientific orientation, academic interest, prestige, income, desire to avoid role strain, and role support.

A large direct survey study was published by Krol, et al., in 1998.⁵ It surveyed almost 5,000 physicians who had trained at the Yale-New Haven Hospital from 1929 through 1994. It found that the intellectual content of the specialty, altruism, opportunity to make a difference in people’s lives, and consistency with personal identity or personal skills were stable factors in career choice over seven decades. Negative factors included high demands on time and effort, stress, and malpractice costs.

Both of these studies are useful in that they give some broad ideas about career choice in medicine, and its motivational stability over time. On the other hand, both illustrate some of the difficulties in the quantitative approach. The results are somewhat predictable and the studies are so broad that it is difficult to apply their findings to how students pick a particular specialty, especially one as small as pathology.

Davis’s review of the literature published in 1990 begins with a description of the weaknesses of the literature in career choice in medicine.⁶ These include the very broad classification of specialties that are being compared, for example, primary versus non-primary care. Davis states it is difficult to compare studies that examine the same factors but are performed at different points in a student’s professional development. It is not possible to determine in such cases whether differences between studies reflect true differences in the subject populations or are just a reflection of the changes in choice, motivation, and memory that occur over a period of years. In addition, few longitudinal studies are available. In addition this review stated that most studies take a snapshot view of motivation, or look at motivation before and after a brief educational intervention. Most studies are also conducted at a single institution, and are often retrospective. Notwithstanding these limitations, the article points out some of the more established findings in this field. Sex appears to consistently influence career choice, while standard tests of personality have not been found to be very predictive as far as career choice is concerned.⁶ The final area reviewed in the Davis article is the literature on stability of choice.⁶ The decision for primary care is usually made early, often before the entry to medical school or in the pre-clinical years, and is thus most susceptible to being changed during medical school. Conversely, hospital-based careers such as radiology and pathology are characteristically chosen later, and thus are not as subject to change before the end of medical school.

The qualitative literature in the area of specialty choice is not nearly as extensive. Burack, et al., described the process of specialty choice as a socially constructed process of “trying on possible selves” – that is, projecting oneself into a hypothetical career role.⁷ Burack criticizes the more quantitative literature, which views specialty choice as a rational process of calculated inputs and outputs, where personal aptitudes and needs are calculated against the costs and aspects of different specialties. The discussion of the paper described three aspects of “fit” that medical students used to help decide a specialty: self, others, and the content of the specialty. For a specialty like pathology, the technical and intellectual content of the specialty appeared most important. The authors also discuss three processes of career choice: confirmation, inclusion, and exclusion. In confirmation, pre-existing beliefs about a specialty choice are confirmed. The other processes are inclusion – that is, finding a specialty that includes all the aspects of medicine that one enjoys, versus exclusion – finding a specialty that excludes all the aspects one does not enjoy.

In the following paragraphs, selected articles from the literature of career choice are discussed which have special relevance for pathology or the influence of specific undergraduate experiences on career choice.

Teachers and role models are one of the most thoroughly examined factors in career choice among medical students. Studies usually concentrate on the characteristics of good role models and their influence on specific career choices.^8,9 Many specialties including pathology use elective and other experiences to encourage students to enter that specialty. Studies of these curricular efforts all have the same problem – is a student’s career choice the result of a specific intervention or experience, or a pre-existing preference?^10,11 Choosing a given specialty is of course also a process of rejecting all the others. This would appear to be especially important in a specialty like pathology, as some studies have indicated it appears to be a later decision for many students.⁶ Thus many students who choose pathology have made their choice by rejecting the other specialties they initially had in mind. A British postal questionnaire study published in 2003 by Lambert, et al., found that about one-third of physicians reject a specialty path they had considered.¹² This was done mainly for lifestyle reasons, job prospects, or because a given specialty did not appear as interesting as it initially had. The hospital specialties such as pathology were the least often rejected. A retrospective questionnaire was administered to students just prior to graduation from medical school in a 1984 study by Katz, et al.¹³ This study further describes the nature of “changing your mind” about specialty choice. Most of the change of direction took place for negative reasons, a process of “exclusion” as described above.⁷ Almost two-thirds of those choosing pathology found this choice in medical school after initially being interested in something else. This compares with only nine per cent of those choosing family medicine.¹³

A recurrent theme in the literature is that the lifestyle specialties, meaning those that entail responsibilities which can be most easily meshed with a doctor’s personal life, are growing in popularity. Schwartz, et al., tracked career choice among students in the top 15 per cent of the class at three medical schools over a period of six to ten years.¹⁴ Over this period, the percentage of these students choosing lifestyle specialties increased significantly while those choosing surgical specialties remained the same. All other choices (including internal medicine, family medicine and pediatrics) decreased significantly. In a second study, published in 2003 by Dorsey, et al., there was evidence not only of an increase in students choosing a lifestyle specialty, but also that it was the lifestyle, and not other factors, that was motivating students to choose these careers.15 There is also evidence that the shift to controlled lifestyle professions is not evenly spread among all demographic groups in medicine, and is particularly pronounced among women and older graduates. 16 There is little information regarding the importance of lifestyle factors pertaining directly to a career in pathology. One longitudinal questionnaire-based study that addressed this to a degree was published by Firth-Cozens, et al., in 1999.¹⁷ The main problem with the study for the purposes of the current project was the low number of lab physicians involved – eight. The main reasons for choosing a lab specialty were less patient contact and perceived lower stress levels in this career. These are exclusionary reasons: students are trying to avoid aspects they do not enjoy. Considering this, it is ironic that lab physicians were found to have higher levels of stress by standard measures, both as students and as practitioners.¹⁷ The authors proposed that pathologists’ stress levels were more a personality trait that influenced their choice of profession than a result of this choice.

In a book published in 1971, Snyder used the phrase “hidden curriculum” to describe the covert context of learning at a university. This includes the values of the faculty and the expectations of the students, as well as the social context in which the curriculum occurs.¹⁸ A small group of articles has also documented related findings in medical schools.^19,20 Hunt, et al., administered a questionnaire in 1996 to examine the effect of what he termed “badmouthing” on career choice.¹⁹ Badmouthing was heard regarding all specialties beginning early in medical education. The most common career choice to be affected by badmouthing was surgery – pathology was not even ranked in the paper. The phenomenon of badmouthing appears to take root in an environment with little explicit discussion regarding careers, and flourishes in an atmosphere where students feel uninformed regarding choices they have to make. An article describing these difficulties experienced by medical students in choosing a career was published in 1986 by Savickas, et al.²¹ In this mail survey, sent to all four years of medical students at a single university, three of the six top problems involved lack of information or knowledge regarding specialties.

We undertook this study to examine the impression that students formed regarding pathology from their PBD course and how this compares to the motivations for choosing pathology articulated by those who have already made that choice. In the interpretation of our data we compared our findings to the general literature in career choice and the small amount that exists for pathology specifically.

MATERIALS AND METHODS

Rationale for a Qualitative Approach
Davis, in his review of the literature, notes the difficulties in a statistical approach to a problem with so many variables that cannot be controlled or isolated.⁶ A quote from Crimlisk and McManus reflects some of the overall difficulties with a quantitative approach to this problem.²²

Career preference may perhaps best be construed as a mass of idiosyncratic factors, each of great importance in a small number of students, but of little importance in the aggregate, and thereby defying conventional statistical analysis which assumes homogeneity of response in populations. (p. 467)

Qualitative research, with its strengths in revealing depth or richness of data as well as probing complex and multilayered topics such as human motivation, appeared to provide a more fruitful and revealing method to explore career choice, and was chosen to address the research questions of this study.

Rationale for focus group methodology
The focus group methodology is a form of group interview that uses group interaction to amplify and diversify group opinions beyond those that would be obtained from other methods such as direct personal interviews.²³ This method explores not only the experiences and knowledge of participants, but also why and how they think the way they do.²³ These strengths make it appear a particularly appropriate method for the research questions in this study. In addition, the group dynamic can empower participants to express views they might feel intimidated to express in a traditional one-on-one interview.²³ This aspect appeared particularly important in the focus groups with medical students and residents when the interviewer was a faculty member. Finally, from a practical point of view, the interviews at the Canadian Association of Pathology meeting (see below) had to be conducted over a period of two days. Scheduling numerous individual interviews in a narrow time frame, when the participants had conflicting priorities, was not practical.

Study Populations
This study was carried out on three study populations: medical students, residents and practicing pathologists. Focus group sessions with the medical students were carried out at the University of Toronto. Subjects for the study were second-year medical students who had just completed their PBD course. Focus group sessions for residents and practicing pathologists were held at the annual meeting of the Canadian Association of Pathologists in Charlottetown, Prince Edward Island, in the summer of 2003.

Ethics approval
Ethics approval was obtained from the Research Ethics Boards of the University of Toronto and of Sunnybrook and Women’s College Health Sciences Centre. Consent was obtained as part of this process from the relevant course directors, residency program directors, and departmental chairs. Consent and co-operation were also obtained from the president of the Canadian Association of Pathologists. Informed signed consents were obtained from all participants.

SUBJECTS
Number of focus groups and participants
Four focus group sessions were used to collect data for this study. The medical students were expected to have more heterogeneous opinions than the residents or pathologists, and thus a larger number of participants was considered more desirable. The number of attendees at a Canadian national meeting of pathologists is in the hundreds, rather than the thousands found at U.S. or international meetings. In addition, schedules at the meeting varied among participants, with pathologists and residents generally not as easily available as the medical students. For these reasons, two focus group sessions were carried out for the medical students while one focus group session each was planned and held for the resident and pathologist groups. There were five participants in each of the two student focus groups and in the pathologist focus group. Eight participants took part in the resident focus group, for a study total of 23 subjects.

Sampling – medical students Our sampling methods for students were chosen to try to interview both students interested or uninterested in pathology as a career. Students were not approached by email invitation until after the final PBD grades were submitted. Every student who indicated interest was given the specific time and date that the study would be carried out. Almost all those who indicated they could attend were part of a focus group. There was no selection made by the investigators among subjects who indicated interest and were able to attend.

Sampling – resident focus group
Invitations were sent to residents through the monthly newsletter of the Canadian Association of Pathologists as well as through email solicitation. Residents funded by foreign governments to train in Canada were not eligible to participate, as their selection process for entering pathology residency training is quite different from that of Canadian residents. In addition, they are outside the Canadian manpower pool in pathology. Residents who trained at foreign medical schools, but were now Canadian citizens or permanent residents, were able to participate. All residents who were interested and were able to come to the focus group at the specified times participated. Again, no selection process was used to narrow the focus group. As none of the eight residents in the focus groups were University of Toronto graduates an additional two pathology residents who had completed the PBD course were also interviewed separately, in order to obtain their perspective regarding the course as a motivator in career choice, and their views of the junior medical students’ comments.

Sampling – pathologist focus group
Attendees of the Canadian Association of Pathologists were invited to attend both by email and an insert in the monthly newsletter of the Canadian Association of Pathologists. Both foreign-trained and Canadian-trained pathologists were eligible. All participants who were able to attend at the specified time during the conference were able to participate. No selection process was used.

As the pathologist focus group was the smallest, the findings from the transcripts of this group were reviewed and discussed with two senior academic pathologists at the University of Toronto. These discussions, which lasted approximately one hour in total, were not transcribed, although notes were made.

Topics for discussion
A semi-structured interview format was used, with broad questions and ample opportunities for respondents to pursue issues that interested them. We began with the students discussing their ideas of how pathologists spent their time, as well as their perceived role in the medical system. We also discussed their image of pathologists. Students also were asked how the PBD course had influenced their perceptions. With the pathologist and resident groups, we discussed their motivations for entering pathology, personal characteristics, and experiences – including specifically their undergraduate course in pathology.

Conduct of discussion groups
The discussion groups lasted approximately 90 minutes. At the conclusion of each group, a small token gift was distributed. A post-focus group questionnaire was also sent to participants, and all participants but one stated that they felt able to express themselves freely. All comments in the groups were digitally recorded and then transcribed in full. All identifying comments, for example, names of faculty teaching the PBD course, were removed.

Data analysis
The analysis of data was conducted using a grounded theory approach.^24,25 This method of data analysis is particularly suited to focus group work. It allows for the management of a large amount of transcript data, by breaking comments down into categories or codes for the generation of summaries of comments, comparisons between groups, and conclusions.

The medical student focus group transcripts were examined first. These were read in an iterative fashion and a coding system was developed, an approach known as open coding. The initial coding system was structured by grouping comments made. A code was established if comments were recurrent in a discussion or if they formed a focus of discussion for a significant portion of the time. For example in the medical student group a code was created regarding the image of the pathologist. Since this code contained a large number of comments they were then sub-grouped into more manageable subcategories such as prestige or personality. A similar process was followed for the pathologist and resident focus groups. However, separate coding systems were developed independently for each of these. The transcripts analyzed were re-organized by cutting and pasting all comments regarding a single code so they were all together and could be more easily compared and summarized. The coding systems and their contained comments were then reviewed, and interpretive memos were developed that reflected the evolving themes found in the discussions. Some of these memos reflected a single coding category, while some were groupings of related codes. By comparing or combining these memos, the central themes regarding career choice in pathology emerged and related to other issues that influenced them. For example many of the comments excerpted to form the codes regarding pathologist image as noted above evolved into the memo and theme of the stigma of pathology. This entire process was performed by both authors so that codes, memos and themes developed by one author were then reviewed and commented on by the second author in a repetitive two-way process.

RESULTS

Six themes emerged from the analysis and they are described below using representative excerpts from the transcripts.

Theme One: Medical students’ perceptions regarding the role of pathologists
The level of knowledge regarding the clinical and academic responsibilities of pathologists varied among the students. Some of the students knew about the basic divisions among laboratory physicians, into those who do tissue pathology (anatomic pathologists) and those whose laboratory work is involved with non-tissue diagnoses (biochemists, microbiologists, and hematologists).
However, there was confusion and concern regarding one issue that could have a major influence in career choice: the amount of patient contact involved in pathology. One student expressed this confusion in the excerpt below: “Yeah, yeah, it was really hectic and I had this vague memory that somebody spoke to us at one point, and it gave me the impression that in pathology you can have patient contact.” The other times I got the impression that you don’t get a lot of direct patient contact, and that’s always left a bit of a question mark with me in terms of that as a career.”

In addition to the role of the pathologist, the medical students as a group had some knowledge of or experience with the intellectual attractions of the work of pathology. One student was attracted to the reasoning process involved in morphologic diagnosis: “Whereas here it’s more, you know, I’m looking for certain patterns. I’m trying to figure out what’s going on. That’s the aspect that I see different from a lot of other areas of medicine.”

Theme Two: The role of the course in pathology in career choice
This section involves the participants – most direct comments regarding the effect that the course in pathology had on their perception of pathology as a career choice.

In the medical student groups, the discussions of the course itself often focused on the organization of the course, the quality of teaching or teachers, or the distributed notes in the course. It is not fully possible for students who have not yet made their final career decision to comment on the relative importance of factors they have not yet experienced. However, given this limitation, the students did perceive the course as being important. For example, one participant described the impact of a course as follows: “And I would say that in my life, I have never even considered pathology as a career or not as a career. Like it’s something I’ve never considered I guess until the course because it was really inspiring in the way that I love the basic science of it and it was the basic science that sort of led me to think back of oh, this could be applied clinically.”

Courses can also have the opposite effect on students. As one student declared, “I think making the course as enjoyable as possible should be the number one priority, because I know, um, I’ve been turned off specialties completely by some of the weeks we’ve recently had.”

Students emphasized the importance of good teachers and role models among the pathology faculty. Relatively few of these comments concerned issues such as knowledge of the subject matter; rather, students focused on style, enthusiasm for the subject, and personal warmth of teachers in the PBD course. Students stated that the course director in particular was important in the type of impression they formed regarding pathology. One student asserted a preference for: “…people who were really animated, lively people, lots of other stuff going on, because it kind of let me know that wow, you know, if I spent all my time in the lab with these people, they’ll be really friendly individuals – which I wasn’t exactly expecting.”

The opposite was also noted. For instance, one commented: “I think the other way that we can really get to know the pathologist(s) are through PBL sessions like you mentioned – my experience actually wasn’t so positive with my PBL tutor [laughs] who was pathologist. He was a bit stuff(y), uh, talked over our – and that’s sort of a bit of where some of my, um, hesitancy with pathology comes from, is that influence from that PBL tutor.”

This student appears to be forming a “not so positive” image of pathology through a PBL (Problem Based Learning session) tutor who was “stuffy” and not interested in the same aspects of the cases as the students were.

The resident group was able to discuss the course influences on their career choice in much different terms. They were able to put the course in perspective with other influences in their completed selection of a career. For the resident group, the influence of the course was, on the whole, felt to be less than other factors. More than one resident chose pathology despite a poor experience in their course in pathology: “And so, definitely my early medical school exposure didn’t have anything to do with why I made my decision; it was more going through clinical rotations, and I’m glad that I realized that there was something called pathology that I could do, and not really try and do something else that didn’t fit.”

Some residents contrasted an enjoyment of the course in pathology with the attractions of a career in pathology: “I find that I – we always try to sort of get a gauge of how much a class might influence a career choice, but I think it’s possible to enjoy pathology sitting in a classroom and find it interesting and not necessarily like the day-to-day practice of it, and vice versa.”

The two pathology residents who were University of Toronto graduates and had completed the PBD course made comments that generally confirmed the views of the resident group. Neither had found the course the primary influence in making their career decision. One did not enjoy the course and made the decision based on an assessment of the clinical specialties, and with a personal knowledge of pathology from previous life and family experiences with laboratory medicine. The other resident had developed an active interest in pathology in high school, and had made the choice for pathology prior to entering medical school. The course reinforced a decision that had already been made.

In contrast to the residents, the pathologist group made several comments regarding the importance of the course in their eventual choice of their career. A lengthy rigorous course appeared to make an impression with these individuals, and influenced them favorably in terms of career choice.

Theme Three: Lifestyle as a major factor in career choice among students, residents, and pathologists
In the medical student, resident and pathologist groups the perceived personal advantages of pathology in terms of amount of personal time, and particularly the ability to have flexible work hours, was felt to be very important in attracting individuals to pathology as a career. One medical student put it very succinctly: “I think it’s not the actual pathology, but the lifestyle that pathology offers you is very attractive.” For some students, these lifestyle factors were influenced by gender. For example, as one woman said: “I looked at it more as, this is going to be a much more stable career, and that if it came across that you have a lot of control over the hours that you worked and for maybe probably females in the class, time in your career is – begins to become a larger issue as you think more and more about family issues and …”

The advantage of pathology in terms of a physician’s personal life was most prominent in the resident focus group. Much discussion involved comparisons of this aspect of career choice between pathology and the clinical specialties. As one resident simply stated, “Kids do not want to go into surgery. They want to go into something that will give them a good lifestyle.”

The same ideas were reflected in the pathologist group. One pathologist commented on the flexibility of working hours in pathology: “As far as lifestyle goes, it’s fantastic…So it’s really great. If I have to leave early or nip out for an hour or something, just the control of the hours that you have, the flexibility is very very good.”

Theme Four: The influence of rumor on career choice among medical students
During the medical student focus groups, one of the unexpected findings was the influence not of knowledge about specialties, but in fact the lack of knowledge of different specialties, and the atmosphere this creates around career choice. Many of the students’ comments were prefaced with phrases referencing the source, such as: “I said that to somebody once and they said”. Such comments question the reliability of students’ sources of information. In fact, students sometimes explicitly stated that their information was not reliable in their own opinion. For example, in discussing the attractions of a specialty, one student said: “Money and lifestyle probably, or just the rumors of it. [laughs]”. The competitive situation of the CARMS match fuels the rumors and their power, as reflected in comments regarding the popularity of specialties, such as one student’s argument that “maybe that’s why there’s a cycle. Oh, that’s popular this year because everyone wants it and then the rumor is, like, oh my god, that’s so hard to get into, and everyone’s, like, forget about it.”

Theme Five: The influence of clinical experience and role models in choosing pathology
In contrast to the influence of the course, where students, residents, and faculty diverged in their opinions of the importance of this factor, the value of clinical experiences in pathology and other specialties surfaced as important in all groups.

In the medical student group, sometimes the value of even a brief elective was contrasted with the extensive course in pathology. One student stated, “Lecture based is great, but I don’t think it entices me – it doesn’t have the same power as if you spent even just a couple hours with a doctor.”

The resident group also expressed the importance of electives in making their career choices. For physicians at this stage, the elective experience was not evaluated alone, but in comparison to the alternatives in other specialties. As one resident stated: “…[I] did an elective, and out of all the rotations that I had done, that experience was probably the most – the people I met there had an approach to problems, the kind of pathology that you saw, the kind of problems that you solved were more in sync with how I thought I wanted my career to be.”

This resident appears to have chosen careers by doing a variety of electives and finally settling on pathology without any pre-existing idea that that was what he or she wanted to do.

More often, specialties were rejected after these clinical experiences showed that the specialty had an unattractive lifestyle or was not interesting to that individual. One resident described it thus: “So I looked at the kind of people that it attracted, like who my work colleagues would be, and the kind of work personality you needed to survive that residency, and I certainly didn’t have the personality to survive the surgical residency – you know, very cut-throat and very competitive. You know, if you’re not at the hospital for 48 hours straight, you’re a slacker. That’s not going to be me [laughs]”

Theme Six: Overcoming the negative stereotype of the pathologist in making career choices
The stereotypes and the stigma of pathology can be seen to be established very early in medical education. One student expressed the low prestige of pathology as follows: “It’s not really negative – but I did hear it from a lot of people so it kind of just keeps creeping up – is the fact that pathologists are not, I don’t want to say not respected – I’m sure they’re respected – but it’s just in terms of careers in medicine, they’re not thought as highly of as some of the others.”

A second medical student noted: “…something that interests me in terms of what I’m going to go into is the actually interaction that you have with colleagues, and I got a sense that there was very little of that with pathology.” This comment reflects a negative impression of pathology as a specialty isolated in the laboratory, removed from other doctors.

Another recurring story in the theme of prestige involved the opinion that a physician who chooses pathology is a “waste” of an M.D. One participant described the reaction of his colleagues to his intention to enter a pathology residency as follows: “I said that to somebody once and they said, what a waste. Like not in terms of commenting on me, but just commenting on, we’re being trained to be doctors to work with people, and to become a pathologist – just forget about all that…” The opinion expressed is that since pathologists do not deal directly with patients, they are in fact wasting their medical skills.

Finally, there was the perception that pathology lacked prestige because of low compensation. A student made the following comments in this regard: “I’ve heard students talk about the fact that, um, for example, pathologists are mostly salary-based, which I guess could be considered a drawback, since – I don’t know how you put this – earning potential is limited…”

There were many similarities between the student and resident groups concerning this theme. The predominant image of the pathologist that the residents encountered was that of an eccentric, reclusive, perhaps clever, but not very socially competent individual. For example: “I think that my experience has been sort of, our attendings are of a different – they’re a bit older, so they have different – they’re a different – they’re the classic eccentric pathologist, whereas the residents are a lot younger, and we tend to be a bit more – socially accessible, I think that’s a good word.”

This resident appears to be avoiding identification with the stereotypical image of the pathologist by attributing it to older pathologists, not the younger group he belongs to.

Similar to the medical student and pathologist groups, the residents had comments made to them by other physicians that expressed the idea that a doctor not involved with patient care was a “wasted physician”. For example, the following comment was made to one resident after they said they were going to become a pathologist: “Pathology? But you’re so good with patients!”

The residents who had chosen pathology eventually expressed a certain pride in their individuality and the choice they had made. As one declared: “I thought that I’m not a person who gets hung up a lot on what other people think, and I think you have to have that attitude to be in pathology – in order to stay in pathology.”

In the pathologist group, this negative image was also expressed, although in a slightly different way. In the particular group interviewed, only one pathologist was a graduate of a Canadian medical school. The image of the pathologist in Canada was compared to the image of the pathologist that the participants had formed while studying medicine in other countries: “But I was going to pick up on what (F1) said, and my impression was very much the same. Coming from a South African system, you know there was a professor of surgery who was right at the top of the tree and there was a professor of medicine and there was a professor of pathology and there was the three of them – certainly at our medical school – they were very highly respected and equally respected and equally regarded members of that community, and that does trickle down to students, and that’s not something that I see yet in Canada.”

Other comments were strikingly similar to those made by the residents and medical students regarding the prestige of pathology, and the perceived isolation of pathologists. One pathologist’s comments regarding the image and isolation of pathology: “I mean, there are a lot of pathologists who always talk about other pathologists being very meek and not being – not wanting to create, to stir the pot about different issues. That’s the impression that pathologists give to other pathologists, and therefore probably give to students; to some degree it’s a vicious circle, I think, that maybe pathologists or some pathologists don’t have a very high self-esteem professionally as pathologists, and that trickles down to the students.”

In addition, in the pathologist group, the comments also related to the low prestige of the profession, as related to the remuneration of pathologists.

In the return-of-findings discussion, the two faculty participants agreed that pathology suffered from a poor image. In the case of the PBD course at the University of Toronto, the participants felt that the image of the pathologist suffered, as most of the exposure to pathologists came during the PBL sessions. In these sessions, pathologists were tutors and facilitators, and were not seen as experts by the students. The participants’ own motivations for entering pathology were in part influenced by seeing pathologists as knowledgeable experts. When asked how to improve the image of pathology, the participants said most of the factors in need of improvement were outside the control of pathologists – namely remuneration and the availability of numerous desirable positions. A summary of the six themes is contained in Table 1.

DISCUSSION

There were three ideas that appeared central, unifying or novel in the results above. These are discussed below.

Changing motivations to enter pathology among the three groups. Our results suggest that the factors motivating the selection of pathology may be evolving across the generations represented in our subject populations. In the pathologist and resident study groups, an attraction to the intellectual content and thought processes underlying pathologic diagnosis were among the most prominent motivators expressed for entering into pathology. This would correspond to factors such as the “intellectual content of the specialty” in Murdoch’s review⁴ or an affinity toward the “methodology and technology” of a specialty in Jarecky.¹⁶ The prominence of this factor vis-a-vis other common factors listed in the review articles of career choice, appears to be a central characteristic of the choice of pathology as a career.^4,12 What arises across our focus groups, however, is a sense of change in how this primary determinant of career choice is reflected or expressed effectively to students in their pathology course. In the pathologist group, these attractions appear to have been reflected in the course, while in the resident group, the course appeared to be only a small factor or not a factor at all in choosing pathology as a career.

As expressed by the pathologists in the return-of-findings session, the changing nature of instruction in pathology may have a role to play in the declining importance of the course in pathology. The two pathologists in the return-of-findings group expressed the idea that in problem-based formats, much of the exposure of pathologists to medical students may not show pathologists as experts, but rather as tenuous in their knowledge and unsure of themselves in relation to clinical problem-based learning cases. They are “facilitators of learning”, rather than “teachers of knowledge”. A similar opinion was expressed in 1998, when Herdson linked the declining profile of pathologists to changes in the curriculum, including problem-based learning.²⁶ In a commentary published in 1998, even Bosman, a defender of the problem-based curriculum for pathology, stated (p. 347) that the change to this format will involve “[giving] up our old identity” and “giving up the urge to defend pathology as a separately recognizable discipline…”²⁷

For the medical student group, the course was felt to be important in career choice, but for this group, there were not many other influences to be considered. The students’ positive comments regarding the course often centered more around positive personal experiences with individual teachers or with the course director, rather than around the course content itself. If we look at some of the characteristics of good role models described in the literature on medical career choice, they include “favorable persona” and “overt satisfaction with career.”⁸ These terms are quite similar to the descriptions used by the students to describe pathologists who influenced them positively in the course, such as “enthusiastic” or “approachable”. It would appear that the characteristics of good role models found in medicine in general are also responsible for forming positive impressions in the PBD course, but are not related to the contents of the course. Thus students, similar to the residents, did not perceive the intellectual stimulation of pathology as being expressed in the course to the extent that their impressions of the course were dominated by other factors. It is noteworthy that the perceptions of the students appear to contradict those of the return-of-findings pathologists in terms of the positive perception formed regarding some pathologists in the course. However, on looking more carefully at these points of view, the pathologist return-of-findings group discussed the ability of the course to allow pathologists to make a positive impression by appearing like experts, while the medical student group seemed to express that they formed good impressions of pathologists not because of how knowledgeable they appeared in the course, but mostly for a host of other personal factors – for instance, ability and willingness to teach.

For the resident group, the impact of the course was far less than the importance lifestyle factors played in career choice. The resident focus group was dominated by women (seven of eight participants) and this may also have influenced the motivations expressed. From the literature review, it is clear that the increasing importance of lifestyle, and its special importance for women, is a finding found generally in doctors-in-training, not just pathologist trainees.^15,16

In both medical student and resident groups, the powerful positive or negative influence that short experiences and electives can have in the perception of a specialty and on career choice were repeatedly mentioned. These appeared to make a deeper impression than the lengthy, but less personal course. The power of such experiences has given rise to the studies of the literature in career choice that are the most experimentally oriented. In these studies, students are exposed to aspects of a specialty outside the mandatory curriculum. The effect of these interventions is then measured and described in these studies. The positive experiences in pathology as recounted by the participants in this study was similar to what has been described in the more experimentally oriented literature.^10,11 It would be of interest to duplicate these specialty-specific “incubators” in pathology, as some of the challenges to recruitment are shared with these specialties. For example, in psychiatry, one of the motivations for creating the special exposure to this specialty was to counter an “unfriendly medical school environment” by creating a “supportive environment for students interested in psychiatry”.¹¹ This unfriendly environment is similar to the challenges of the stigma of pathology expressed in this study.

The stigma of pathology
The second theme found in all groups was the stigma and low prestige of pathology. This was known to the medical students, even with their very limited exposure to the clinical environment. From the literature this again is not surprising, although it has not been specifically examined in pathology. The study described by Hunt regarding medical badmouthing found that this was common and influential in the pre-clinical years.¹⁹ The residents were well also aware of the stereotype of the pathologist, and in fact had confronted the stereotype in order to make the career choice they had. This stereotype is one of the difficulties in recruitment into pathology as students try to see themselves in and try on different specialties. The qualitative literature in this area emphasized the importance of role models in helping students in this task.⁷ For example, the power of electives may be due to seeing pathologists who challenge the stereotype or may exhibit parts of the stereotype, but still appear happy and enthusiastic regarding their career.

The influence of rumor in career choice in medicine
Finally, in the medical student group the influence of rumor was prominent. The system for matching to a post-graduate position determines very much the course of the rest of the individual’s life. The process is competitive, complex, and time-consuming. In this environment, rumors about specialties, or stereotypes such as those expressed concerning pathology, often take the place of information or reflection regarding specialty choice. These rumors include such aspects as the nature of the work (e.g., amount of face-to-face patient care), and the financial rewards available. The subject of these rumors may also include the availability of residency positions and the degree of competition in each specialty program. The role of rumor in how medical students get specialty information has also been noted by other authors.¹⁹

There are several limitations to this study. Although qualitative work produces information of depth, the lack of numerical data limits conclusions regarding generalizability. This was, however, a deliberate choice of the authors in order to discover information not available in many previous studies of career choice. In addition it is necessary to clarify that although we analyzed the opinions and drew our conclusions from three age groups, this is not a longitudinal study as we did not follow the evolution of motivations over a period of time. Instead we interviewed three groups at one point in time and then compared and contrasted the motivations expressed by the different “generations” of doctors, each with their own unique educational and medical experiences that influence their career decisions. In addition this is a retrospective study. Particularly for the resident and pathologist group the passage of time alters the interpretation of events and the perception of motivation. Lastly, although the conclusions may be valid for Canadian physicians, many of the factors in career choice are jurisdiction-specific. For example, the number of residency positions and the rules for licensure, both of which are factors influencing career choice, are mandated by provincial governments in Canada, and therefore different factors will be at play in other jurisdictions.

CONCLUSIONS

The research question that motivated this study was to investigate the role of the introductory course in pathology among the many factors influencing career choice. In conclusion the course plays a role subservient to many other factors. The positive impressions formed from the course seem due more to skilled teaching and other less tangible personal factors perceived in teachers and tutors, than to course content. More important than the course for many students was the role of electives or other short, but personally intense, in-hospital experiences. For the most recent generations of doctors the attractions of the lifestyle available in pathology are very prominent. In addition, the perception of the desirability of pathology is formed from many other factors outside the course. These include often negative stereotypes about the specialty obtained from classmates or other non-expert sources. The lack of explicit, reliable information perceived by students may influence career choice and points to a future direction of effort: finding ways to provide medical students with more experiences and information during their medical education regarding the process of specialty choice and the nature of different specialties. This type of information may help combat the influences of rumor and stigma that surround certain specialties, and empower students as they make this very important life decision.

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