As we entered the season of interviews of candidates for pathology residency, my colleague asked me what clever question I had crafted to follow in my series of open-ended questions to gain insight into a candidate’s perspective on the field of pathology. Last year, I asked the question to all candidates expressing an interest in music, "In the symphony orchestra of medicine, what instrument does pathology play?" Those responses were the highlight of my interviews, and were summarized in a Critical Values article in April of 2021.
This year, my challenge was not only to craft a creative and memorable question, but also to find a question that was suitable for all candidates, and a question that could enable our candidates to demonstrate their understanding of essential mechanisms of pathophysiology.
Epitomizing interactive engagement
All pathology residency interviews this past year again occurred remotely via live videoconferencing applications to permit one-on-one interactions. A time limit of just 20 minutes is all that was permitted to actively engage in a meaningful conversation, with hopes of catching a glimmer of the candidate’s personality. My intent was to make the 20-minute session feel more conversational and less like a job interview. As I looked into the eyes of our candidates, I asked this question: "In the body of medicine, what hormone does pathology represent?"
The range of facial expressions always included a smile, and often included a hand to the chin, palm to the face, or scratch to the hair as candidates began to develop their response to a question that they could not have possibly anticipated. Hearing “Wow, that is such a great question,” was often followed by a period of temporary or prolonged silence, as the recollection of hormonal effector mechanisms were rushed from the cerebral depths of M2 and M3 lectures to the forebrain in an attempt to form an intelligible and impactful response. Not only is this question testing the ability to recall the role of hormones, but also to come up with one that represents the role of pathology, if pathology were a hormone. During longer periods of silence, I provided an escape, stating that this question might be better suited as a prompt for an essay, so just bring any hormone to mind, and let’s discuss the similarities of that hormone to the contributions of pathology in the care of patients.
I captured below for your enjoyment my favorite responses that demonstrate just how varied the perceptions are about the role that pathology plays in the body of medicine. The responses reproduced are all direct quotes from residency candidates, with identity withheld to preserve the anonymity of our process.
Pituitary and Hypothalamic Hormones
Thyroid-stimulating hormone (TSH) reminds me of the role of pathology. Its influence is centralized, but relays control over many other systems through the information it generates.
Adrenocorticotropic hormone (ACTH) gives a centralized support of the adrenals when we get stressed out. I think that pathology does the same to the body of medicine in providing essential support to all other fields of medicine.
The pituitary hormones come to mind first, as the pituitary is the base, the home of all effector hormones, and also needs to be open to negative feedback from the rest of the body.
I immediately thought of something ubiquitous and under appreciated, like TSH. TSH is responsible for the regulation of energy, growth, and reproduction. Without it you can’t thrive. Without pathology, the body of medicine would be without so much critical information.
Thyroid hormones effect every aspect of the body and are under the control of TSH, but I’m thinking even a higher magnitude of control when it comes to pathology. I think thyrotropin releasing hormone (TRH) from the hypothalamus is most like pathology. It’s like the seed from which all other hormones branch.
Growth hormone is needed for growth and healing. That’s exactly what pathology provides to the body of medicine.
Pathology touches everything in the body of medicine and contributes to its maturation and growth, so I’m thinking of a hormone that does the same—like growth hormone.
Oxytocin is a sensory-driven hormone that brings about stimulation that provides for the feeding of infants. I think that’s what pathology does. It starts with a feeling in the minds of physicians to order the right test to yield answers to feed newly born theories in understanding underlying symptoms.
I’m thinking of a hormone that has a multisystem effect. Thyroid hormones affect many functions of the body, from growth to metabolism. All cells have thyroid hormone receptors, and just like pathology in the body of medicine, the effects are broad ranging.
Working in the background is what pathology is known for. That’s what thyroid hormones do, work quietly in the background. But if they weren’t there, the body couldn’t function.
Thyroid hormones are generalized, but are so critical for development. You don’t see their effect until something feels wrong. That’s the way it is with pathology. You don’t think about it until you need it, and then you realize just how essential it is.
I think pathology is most like adrenaline. It gets everything going and becomes a driving force. Adrenaline gives you an enthusiastic rush right when you need it, just like the reinforcement pathology gives in making diagnoses.
The first category of hormones that came to mind are the catecholamines, and among this category, dopamine is the hormone that is most like pathology, a hormone that gives you a supportive and rewarding feeling, but not like epinephrine that is short-lived or tied to a fight or flight reaction.
Cortisol is reliably produced to help your body prepare for the fight of every day. What could be a better analogy for pathology in the body of medicine? Isn’t that exactly what pathology does? Under periods of stress, it provides for the sustained energy needed for every battle we face in medicine.
The first hormone that came to mind is ghrelin, which initiates the action to eat. Pathology feeds the body of medicine, which needs to consume more and more knowledge so physicians can make informed decisions when treating patients.
Insulin has the role of getting energy into the cells, and that is what pathology does in the body of medicine. There’s so much information available, but pathology is needed to drive that information into the cells of patient care for so many different specialties.
Insulin is anabolic—it builds. Pathology is the foundation of medicine onto which everything builds in the care of patients.
The first hormone that came to mind is insulin because it helps to store energy the way pathology helps to store information. When energy is stored, it could be built up and used when needed, just like diagnostic information can be used as critical knowledge in making essential patient care decisions.
Insulin has so many antagonists and has to work alone to keep energy levels in balance. Without insulin, all the energy we consume has no value. Without pathology, doctors have misdirected information and cannot make informed care decisions.
Parathyroid hormones remind me of pathology. It’s a short-acting, but constant-stream of support for calcium homeostasis; support for essential cardiac health and skeletal support, just like pathology being at the heart and structure of our body of medicine.
Pathology is the brains of the medical system, so the first hormone that came to mind was NGF—nerve growth factor.
Acetylcholine is an essential neurohormone and neurotransmitter. Pathology is the source of all logic in decision making.
Insulin-like growth factor (IGF) effects growing on multiple levels. Pathology adds to the growing understanding of information needed to make informed decisions.
I’m thinking of IGF-1, a hormone that informs all other cells and helps the body of medicine grow.
You may be surprised to hear this, but renin comes to mind as being most like pathology. Even though it’s localized, it has huge effects on the body. Renin is produced on demand when the blood pressure is low, and pathology comes to the forefront when the body of medicine needs diagnostic information.
Cholesterol! I know cholesterol isn’t a hormone, but it’s the backbone and structure of every steroid hormone. That’s exactly what pathology is in the body of medicine—the backbone.
By far, the most common responses among interviewees were related to thyroid hormones because of their ability to work in the background in a generalized capacity. Perhaps this is not surprising as the perceived role of pathology among the majority of candidates looking to specialize in the field view pathology in a supportive role. Whenever I encountered a first-time or unanticipated response, I grew increasingly intrigued as to where the analogy was heading, as these unique responses serve as indicators as to how these talented candidates view the role of pathology and its contributions in the body of medicine.
As you survey these responses, what may be obvious are the hormones that are NOT represented in these analogies. We see no representation from the gonadotropins or androgens—no testosterone or estrogens—to support the aspects of fertility or outward appearance of the body. However, I would never be taken aback by any clever attempts to draw similarities between pathology and its ability to support the generation of reproducible data.
Much like my previous question that focused on the role of pathology in an orchestrated process, these responses serve as indicators as to how our candidates view the role of pathology in the medical community. We again see the association of taking comfort in being a behind-the-scenes player, while others emerge as being quite emphatic about the need to take a more visible role in recognizing that pathology provides essential energy in the form of much needed diagnostic information, the root of our effector mechanism.
I again wish to thank our candidates for their ingenuity and openness. This was not an easy question to answer, especially without providing ample time to formulate a response. The degree of creativity among my anonymous coauthors demonstrates just how deep the pool of talent has become among candidates seeking to make pathology their specialty.
As I have done in the past, if you would like to include this question in your pathology residency interview process, please do so, as I have no desire to claim copyright or otherwise obstruct your ability to actively engage in a meaningful dialogue with your candidates.
After all, of what value are hormones if they are unable to affect your receptors?