Authors: Irene Scheimberg
Publication date: 07 Aug 2004
Coping with sudden infant deaths, postmortem examinations, and grieving parents takes a certain type of person, but it's a highly rewarding and friendly specialty, says Irene Scheimberg
If you think mentioning paediatric pathology at a dinner party is a conversation stopper which is swiftly followed by a change of subject, think again. You unexpectedly find yourself the centre of attention. Forget the suspicious stares we were getting a few years ago. We have come a long way since the days of the Bristol and Alder Hey inquiries, and most people now recognise that we do a demanding job that helps families at the most difficult time in their lives. So what exactly do we do? And is it a job for you?
The job has two major components: paediatric and perinatal pathology. Perinatal pathology is the study of the fetus and the newborn; a perinatal pathologist is concerned with normal fetal development, congenital abnormalities, and problems during pregnancy, labour, and early neonatal life. The work is predominantly necropsy related, putting together all the elements that will allow us to give the obstetricians an idea of what happened when a baby died. It's a bit like trying to do a puzzle in which some of the pieces are missing, but in the end you are able to get a good idea of the overall picture.
You need to do a lot of detective work, and sometimes that includes trying to extract relevant clinical information from your colleagues, which may be harder than you think. You also need good clinicopathological knowledge and a little imagination. So if you like detective work, don't hesitate—perinatal pathology is the job for you (box 1).
Paediatric pathology is similar to general histopathology, but slanted towards children. Remember that children are not small adults. Many of the diseases they present with are different from diseases in adults, and some of the changes can be subtle. Paediatric pathology is generally based in specialist children's hospitals which are tertiary referral centres, so the scope of diseases is large and cases can be quite challenging. Diagnostic application of molecular techniques such as fluorescence in-situ hybridisation (FISH) and polymerase chain reaction (PCR) is a routine part of most major paediatric surgical laboratories dealing with childhood cancer, and you can get as involved as you wish.
A day in the life of a paediatric pathologist
You may do paediatric or perinatal pathology, or both, depending on where you work.
Box 1: Personal characteristics
An inquiring mind
Good clinical knowledge
As a paediatric and perinatal pathologist I tend to do postmortem examinations in the morning. The range of necropsies is varied, and there is considerable interaction with my clinical colleagues, depending on the nature of the case. Typically, a postmortem examination in a termination of pregnancy for congenital malformation will entail working closely with the fetal medicine unit and the clinical geneticists, while an early neonatal death will see us working closely with obstetricians and neonatologists.
Afternoons are dedicated to looking at slides, both from surgical cases and postmortem histology. One of the things I like most about paediatric pathology is that despite the modern move towards superspecialisation and system based histopathologists, we are not limited to a single organ or system. Our limit is the age of the patient. From rare tumours (and compared with the large number of adult cancers, childhood tumours are certainly rare) to skin biopsies in obscure conditions, to more common but no less challenging intestinal biopsies, the variety will keep you interested for years to come. Also, as a paediatric pathologist you will be part of many multidisciplinary meetings including paediatric oncologists, surgeons, radiologists, gastroenterologists, and dermatologists.
Whether you do mainly paediatric or perinatal pathology, or both, you are likely to do some coroner's work. Coroner's cases are some of the most demanding because of the implications for families and clinicians. The paediatric coroner's work tends to be more intellectually challenging than that of the adult cases. In an adult coroner's postmortem examination you can usually tell the cause of death on macroscopic examination or by examining a few histological slides. The typical sudden and unexpected death in infancy requires a high degree of clinicopathological correlation, many histology slides, and numerous ancillary investigations, including microbiology, virology, metabolic studies, and genetics.
It's a small world
It is a demanding job that might require you to talk to grieving parents, so what are the rewards? The challenge of solving an incomplete puzzle, the knowledge that you are helping a family through a difficult time, and, last but not least, being a member of the smallest and friendliest group of professionals in the world. Being a paediatric pathologist is like being part of a friendly club where you know almost everybody else in Europe and elsewhere, and if you have a problem you can discuss it via email in the Paediatric Pathology List with most other paediatric pathologists across the world.
One of the things I like most about paediatric pathology is the annual international advanced course organised by the International Paediatric Pathology Association. Picture yourself for a week in a beautiful place (courses are held in places such as Lisbon, Helsinki, and Istanbul) while learning about interesting topics, doing some wonderful sightseeing, and making friends with your colleagues from Europe, North and South America, Africa, Asia, and Australia. The course lasts for five years, but then you qualify for the postgraduate courses so you can carry on learning and meeting your colleagues and friends.
So, you think this might be for you. How do you go about training? The United Kingdom has 48 paediatric pathologists, of whom eight also do adult pathology. At the moment there are 12 national training numbers for paediatric pathology.
You need to join a recognised histopathology training scheme (jobs are advertised in BMJ Careers) and make it known early on that you are interested in becoming a paediatric pathologist. Every effort will be made to find a training scheme suitable to your needs. If you have some training in paediatrics or obstetrics, this is an ideal job for someone who is fed up with being woken up at all hours of the night. Training takes five years. At least the first two years are in general histopathology, and once you've passed the first exam for membership of the Royal College of Pathologists you can start your specialised training.
If you are already an “adult” histopathologist but are discovering that “small is beautiful,” a post exam fully paid conversion scheme is available (for that you need to contact the Royal College of Pathologists). Jobs are plentiful, and a consultant post is waiting for you.
Paediatric pathology is based in regional centres so you have to be prepared to live in or near a big city. Although the need for more specialist paediatric pathologists has recently been recognised, there are still not enough of us and you might find yourself the sole paediatric (or more often perinatal) pathologist in a world of adult pathologists until enough people are recruited. It is nice to feel needed so much, but sometimes it can be a bit of a burden. Working hours are reasonable, and with proper consultant numbers it should be a nine to five job. On-call duties are non-residential and not onerous, being interesting and consisting mostly of urgent intra-operative biopsies (box 2).
Other aspects of the job
Plenty of opportunities exist for teaching—and not just undergraduates. From students to policemen, your audiences are going to be many. If you like research, and provided you allocate enough time for it in your new contract job plan, there are plenty of opportunities from cancer research to developmental studies.
You'll have the chance of rewarding direct contact with parents and families. You don't need to feel relegated to the laboratory if you like interaction with patients, unlike most other areas of histopathology. I have numerous letters and baby photos of the successful next pregnancy to attest to that, and reading them makes up for all the sadness I encounter in my work. However, forget about lots of private income, although you can do private work for the defence in court cases (if you are not already working for the police and the prosecution).
Box 2: Advantages and disadvantages
Interesting case mix
Friendly, small specialty
Civilised working hours
No private income
Irene Scheimberg consultant paediatric and perinatal pathologist
Royal London Hospital, London E1 1BB