Background:

Pathology, the study of disease, is the broadest of the medical specialties. Pathologists neither treat patients nor do surgery themselves. They act in the capacity of consultant to primary care and specialist physicians. There is no medical specialty that is not within the purview of the pathologist and there is no physician who does not in some way depend upon the pathologist for the care of his patient.

The specialty has two main subdivisions - anatomic pathology and clinical pathology. Some pathologists specialize in only one but most practice in both areas. As in all medical specialties neither board certification nor even board eligibility is required to practice. The majority of pathologists are certified by the American Board of Pathology in either anatomic pathology, clinical pathology or both areas.

Anatomic pathology entails diagnosis of disease and injury by the gross and microscopic examination of tissue specimens, biopsies, organs, pap smears, bone marrow aspirates and blood smears. The anatomic pathologist is also the one who performs autopsies. A part of anatomic pathology is surgical pathology which is concerned with the examination and diagnosis of tissue specimens removed during surgery. It is the surgical pathologist who responds to the operating room for frozen sections for rapid microscopic diagnosis to guide the continuation and completion of surgery.

Residency Training:

In training for anatomic pathology resident physicians spend the greatest segment of time learning gross and microscopic diagnosis. This involves first learning the unique gross and microscopic appearance of every organ and body tissue. Once able to recognize normal tissue the pathology resident must learn to recognize the many alterations in appearance caused by injury and disease.

Clinical pathology deals with the medical laboratory where the pathologist serves as medical director. The pathologist bears ultimate responsibility for medical laboratory test results. The modern clinical pathology laboratory offers a large repetoire of tests on a large variety of specimens. Clinical pathology residents are required to expand their knowledge of the basic sciences well beyond that learned in medical school. They must learn the fundamentals of instrumentation and statistics and master principles of quality control. Somewhere along the line the clinical pathologist must also develop skills in management, administration, medical politics and economics.

Board Certification:

Board certification in both anatomic and clinical pathology requires four years of full-time postgraduate training beyond the M.D. degree. Some pathologists elect to specialize in anatomic pathology or clinical pathology only, and for each the residency is three years. Pathologists trained in anatomic and clinical pathology who take the board examination in both fields but pass only one will not be certified in either, reflecting a both-or-none policy. Even for an issue confined to anatomic pathology alone it is generally held that the pathologist with dual certification may be preferred because of their broader understanding of medicine.

Pathology Subspecialties:

Some board certified pathologists opt for a fifth year of formal training which can lead to added certification in a recognized subspecialty such as neuropathology, pediatric pathology, immunopathology, microbiologic pathology, cytopathology, hematopathology or forensic pathology.

Forensic Pathology:

This subspecialty deals largely with death cases. Some forensic pathologists are anatomic pathologists only, whereas others hold dual anatomic and clinical pathology certificates. By tradition forensic pathologists distinguish themselves from non-subspecialty pathologists by referring to the latter as hospital pathologists, especially in the context of autopsies. Forensic pathologists perform hosptial autopsies but hospital pathologists do not perform forensic autopsies.

Forensic pathologists receive special training in the recognition and interpretation of wounds. They become familiar with, but are not themselves expert in, ancillary fields of death investigation such as criminalistics and forensic toxicology. When doing a medicolegal autopsy the forensic pathologist is aware that, no matter how mundane a case may seem, there may be future questions requiring answers that were obtainable only at the time of autopsy. Thus they have a tendency to be thorough on every case, documenting what is there and what is not.

One goal of the forensic pathologist is to determine the cause and circumstances of death. The breadth of the word "circumstances" quite well reflects the multitude of areas with which the forensic pathologist must concern himself.

For purpose of assisting attorneys the ideal forensic pathologist is also a hospital pathologist. A forensic pathologist who practices anatomic and clinical pathology in the hospital setting has a broad and up-to-date understanding of medical issues. This may not be the case for someone who works full-time at a medical examiner/coroner's office.

The forensic pathologist wishes not only to serve as the protector of the rights of the deceased and of society but also to assist in the prevention of disease and injury. In this sense the dead can truly help the living. First and foremost the forensic pathologist seeks the truth.

Credibility:

The pathologist should be trained and experienced in the area of pathology at issue and currently in active practice. It makes no sense for example to expect a university professor who sits as administrator and chairman of a large and busy department to address the issue of missed cancer on a prostate needle biopsy.

Superspecialists/Professors:

No individual could master the entire specialty yet the vast majority of cases can be handled by one pathologist. A few cases require the expertise of a subspecialist or a superspecialist/professor. The best superspecialist expert witness is one who is actively practicing within a hospital. Most pathologists have at least a few publications and superspecialists usually have many. Superspecialist/professors should have a bibliography that verifies their area(s) of expertise.

The Ideal Pathologist Expert Witness:

The ideal pathologist as expert witness is board certified in anatomic and clinical pathology. The expert should be actively practicing in a hospital, serves on hospital committees, is a member of the county medical society, serves on committees at the county medical society level, is active in teaching physicians, nurses and laboratory staff, is a fellow of the College of American Pathologists and the American Society of Clinical Pathologists, is a member of the state pathology society, directs a clinical pathology laboratory that is certified by the College of American Pathologists, has no recent or frequent job changes and is known and respected in the community. Credible witnesses should be able to accurately and clearly summarize complex medical issues.

Case Types Requiring a Pathologist:

Common anatomic pathology issues include missed cancer diagnosis, false cancer diagnosis, pap smear misinterpretation and errors of frozen section interpretation. Examples of purely clinical pathology cases are specimen handling/processing errors, incorrect laboratory results, inappropriate response to laboratory result, untimely reporting of critical laboratory results and transfusion reactions. Case examples that require combined anatomic and clinical pathology skills are surgery accidents and deaths, anesthesia accidents and deaths and blood transfusion catastrophes. Purely forensic pathology issues involve unnatural death, i.e. accident, homicide, suicide or unknown, toxicology problems, accident reconstruction, crime reconstruction, time of death, funeral director error, exhumation, paternity dispute, food poisoning and an extremely varied array of other situations and events that end up in litigation.

Armed with knowledge of the medical specialty of pathology the legal professional can find the right pathologist for the case at hand.