[Columbia University Pre-Med Journal - Vol. 1, No. 1 p 6, 1961}
by Arthur Purdy Stout, M.D.
Retired Professor of Pathology
College of Physicians and Surgeons, Columbia University
Most premedical students unless their fathers are doctors probably have a very vague idea about the subjects that form the curriculum of a medical school. Although I had an uncle and a grandfather who were doctors, I knew absolutely nothing about what I would encounter when I entered the College of Physicians and Surgeons in New York. Incidentally, it was quite simple to become a medical student in those days compared with the present competitive complexities. Two days before the close of registration, without any previous correspondence I turned up at the Dean's Office, announced that I had a B.A. from Yale University and would like to enter the Medical School. Without any further palaver or questions, I was told to register and pay the fee and I was in. Today I sometimes think the prospective medical student must gain the impression that the medical schools are doing their best to discourage him from studying medicine.
Let us assume however that today's medical neophyte has succeeded in passing all the barriers, has successfully competed with his fellows and has been received into the first year of a medical school. In his first year he will learn about the gross morphological features of the human body which is anatomy, and its microscopic composition which is histology. He will study the functioning of the normal individual which is dealt with in physiology and biochemistry. Having acquired a working familiarity with the normal structure and principal functions of the body, he will pass on usually at the beginning of his second year in medicine to a study of the effects of disease, injury, malformation and all other noxious processes upon the organism. This is pathology. It is obvious that the embryo doctor must familiarize himself with pathology, for without a knowledge of the various deviations from the normal that can occur, he cannot interpret the different overt and occult manifestations to which they give rise, and without a correct interpretation of these manifestations which are called symptoms and signs, he cannot reach a diagnosis and undertake corrective, preventive or palliative treatment which is the doctor's function. This is an extreme simplification of the enormously complex science and art of medicine but it is necessary so that a prospective medical student may have some general comprehension of what lies in front of him when he begins the study of medicine.
But our chief concern at this time is with pathology. This is such a tremendous subject and so complex that it has been found impossible to deal with all of its parts simultaneously so that it has been artificially divided into pathological anatomy which deals chiefly with the gross and microscopic structural changes, and what is called clinical pathology which deals with the chemical and physiological variation and rather incongruously includes microbiology (formerly known as bacteriology and phraseology). These subdivisions are dealt with in separate courses and what is known as the course in pathology will deal chiefly with pathological anatomy while clinical pathology, microbiology, and parisitology will be taught by different specialists in those subdivision. But if you find this subdividing of a single subject extraordinary, it is simplicity itself when you come to the clinical years of your medical course and find so many subjects dealt with separately by specialists that it is very hard to realize that all these artificial divisions of the body are not separate entities living together in a kind of uneasy symbiosis.
Those of you who will encounter pathology for the first time two or three years hence will not realize it but it is a vastly different subject than when I was an undergraduate student of pathology in 1909. When one commences the study of a new subject, it is natural to concentrate one's attention upon acquiring all available knowledge concerning that subject and to take no thought of the past nor of how all these facts became known. Yet the past history of any subject is really vitally important to its proper comprehension and more important still to its future development. Some of you who happen to read this and who later study medicine are destined to make new discoveries and play an important part in its development. The well rounded medical scientist is one who learns how present knowledge has been achieved as well as a proper grasp of the facts.
I cannot undertake to recount for you the history of pathology in the past half century for I should have to describe things about which as yet you probably know nothing but I can perhaps give you some inkling by speaking of things of which you have probably heard. When I first studied pathology I was told that it was possible to have a cancer of the lung but I was never shown the lungs of a person who had died of lung cancer nor during my entire four years in the medical school did I ever have a chance to examine a patient with lung cancer. How different from today when lung cancer stands high on the list of the causes of death, particularly among war veterans, thanks largely to the enormous increase of cigarette smoking which has been so much encouraged by our "beneficent" Uncle Sam during serve in the Armed Forces. Intensive study of the pathological changes in the bronchial mucous membranes has shown what inhaled cigarette smoke does to them and prepared the way for the later development of a cancer. Fifty years ago the bacterial-induced lobar pneumonia was extremely common and an important cause of death; now thanks to antibiotics it is difficult to show classes in pathology what its effects on the lungs look like; instead there is a different kind of pneumonia caused by viruses which is much less fatal and about which next to nothing was known 50 years ago. I could multiple the differences between then and now but it would require a monograph on the history of medicine for the past 50 years to do so. All of the changes and discoveries of the past are reflected in the pathology of today; just remember when you study pathology in the next two or three years that science is not static and the medicine and pathology of 50 years hence will be equally different from what they are today or possibly more so.
Whatever branch of medicine you may elect to pursue after you graduate you will find a basic knowledge of pathology is important. Some of you, I hope, as you pass through your four years of training in the medical school will become so fascinated by it that you will want to pursue it as a career and become a pathologist. It will be well therefore for me to tell you something about pathologist in the world of medicine. The high ideals of medicine expressed in the Hippocratic oath make it the aim of the leaders in all branches of medicine to maintain its high standards and this has led to the formation of specialty boards. The license to practice medicine is granted after examination by the various states. This however does not qualify a doctor to be a specialist. To assure that one who wishes to be a specialist is properly qualified, various boards have been formed by leaders in those specialties, that specify the amount of training that is a prerequisite and require a candidate to pass an examination before he can be considered a qualified specialist. Without board certification few hospitals will give a doctor the privilege of treating his patient in a hospital. The great majority of these boards make pathology one of the required subjects. Hospitals also are subject to the approval of a board and one of the requirements is that the hospital must have the services of a pathologist.
It is easy to understand therefore that hospitals must have pathologists and it is also easy to understand that there is a constant demand for training in pathology on the part of the majority of those seeking certification by most of the different specialty boards. This demand is very far from being filled today especially in the hospitals so that any one who has elected pathology as a career and has been certified by the American Board of Pathology will have positions in a number of hospitals available to him.
The hospital pathologist leads a busy life. He performs autopsies on those who die and for whom permission for the autopsy is obtained. He examines and reports on all tissues removed for diagnosis and treatment. He supervises all chemical, serological and other diagnostic tests and runs the blood bank. Because of his specialized knowledge he confers with the various doctors in charge of the patients and interprets his findings for them. He supervises the training of the various residents in training at his hospital and usually, if he gains a reputation for knowledge and accuracy, he will be consulted by other physicians in the community and in other neighboring communities. In the larger hospitals he will have one or more assistant pathologists working with him. The opportunities for service are unlimited and a good pathologist can raise the standards of the practice of medicine in his whole community. In addition to this activity some of the hospital pathologists have been able to make valuable contributions to knowledge. I know a great many of them in this country and other countries and I have a great respect and admiration for their accomplishments.
A small number of those who elect pathology as a career become associated with medical schools. These are the men and women who teach pathology to undergraduate students. Many of them form part of the pathology staff of the university hospital. Almost all of them are concerned with research in pathology which now covers a very wide field and uses many new disciplines that are highly specialized. The electron microscope for example has made viruses visible by making it possible for the first time to enlarge objects fifty or a hundred times or even more instead of the approximate two thousand diameters of the ordinary microscope. The study of disease changes in a single cell has now become possible and has been supplemented by the study of histochemical changes in the individual cell. Both of these techniques are further aided by tissue culture. This is not a new discipline for it was in its infancy when I was in the Medical School but in the intervening years it has grown enormously. Together with the use of rodents in animal experimentation, the modern department of pathology occupies a great deal of space and is a hive of industry with almost all of its members from professors to young residents and interns busily engaged in one or another form of research.
Even in a medical school department of pathology, in many medical schools it is not always possible to fill every position in a satisfactory fashion and any medical student with the proper mental equipment and a burning desire to pursue a career in research and university pathology should have no difficulty in gaining the opportunity to do so.
It has sometimes happened that a graduate in medicine who has decided upon pathology as a career for one reason or another may change his mind and determine that his real interest is in some other discipline. I have seen this happen a number of times. He need never regret the time spent in pathology; he becomes a better physician, surgeon or roentegenologist, because of the added training in pathology.
If some who start a career in pathology turn to other fields, it has also been the case that those who start in other fields sometimes become pathologists. You may have wondered why an emeritus professor of surgery should also be a pathologist and have been asked to be the spokesman for pathology to premedical students. While it is true that I have always been interested in pathology even before I was a second year student, when I graduated I had two years training as a surgeon and for a few years after graduate I practice both as a surgeon and a pathologist. I functioned as a surgeon in the first world war but then realized by absorbing interest was in pathology and thereafter devoted all my time to it but continued in the Department of Surgery as a surgical pathologist. Thus I was something of a hybrid and ended my active career connected both with the departments of surgery and pathology. Mine is of course an exceptional case but I use it to illustrate the fact that one can start a career in one field and transfer to pathology without detriment.
To all premedical students as well as to those who plan to become pathologists I will say there is one essential prerequisite without which your career will not b e a success. First you must be convinced that medicine is the career for you and that all other interests are ancillary to it. At some time either during your undergraduate years or after graduation will come a conviction that one or another of the many subdivisions of medicine is the one for you. If you have chosen correctly, you will pursue that branch for the rest of your active career. You will find an absorption that will make your occupation so rewarding the days will never seem long enough and you will begrudge the time you must give to any other duty. Happy is he who finds the right path and dedicates his life to its pursuit. For him the daily task is not work but a source of constant spiritual satisfaction for he is doing what interest him and what he most desires to do. Whatever one's abilities may be, choosing the right career and dedicating oneself to its pursuit will enable one to achieve the maximum of which one is capable.
I hope that some premedical students who read this will find themselves drawn to pathology at some time during their years in medical school. Whether it be as a hospital pathologist, a teacher of the subject, a research scientist or some combination of these there is a constantly growing need for reinforcements and for the dedicated individual the rewards are great. But whatever may be your choice, may I say that we welcome you at the onset of your training years--you are entering a great profession and I know I speak for all of my contemporaries who are approaching the termination of their careers in medicine when I say may you all find as much joy and satisfaction as we have in the most fascinating of professions.