A young woman receives a call from her physician: her Pap smear is normal. She sighs with relief and goes about her day. She may never know that the reassuring words came only after a pathologist reviewed her cells under a microscope. Across town, an older gentleman in the emergency department learns that his chest pain is not due to a heart attack after his troponin level returns negative. Again, a pathologist’s laboratory guided the diagnosis, unseen yet indispensable. Every day, in every hospital and clinic, patients rely on the quiet certainty of pathology. This is the paradox: while patients and even many physicians think of pathologists as specialists, our work is woven into the most primary and universal layers of care.
In truth, pathology is the most primary of primary care disciplines. Nearly 70 to 80 percent of clinical decisions depend on laboratory and pathology input, touching virtually every patient who enters the health system. Pap smears and HPV testing have reduced cervical cancer incidence in high-resource countries by more than 70 percent. During the COVID-19 pandemic, billions of PCR tests performed by pathology and laboratory medicine sustained global public health responses. Yet, paradoxically, pathologists represent less than 2 percent of US physicians, their essential role often hidden from view. To understand pathology only as a subspecialty or as “behind the scenes” science is to overlook its foundational role in public health, in clinical medicine, and in the everyday care of people around the world.
After chatting with a medical student who wanted to go into primary care, I got to wondering: if we define primary care as the place where medicine begins, then pathology is its most faithful steward. Every new patient encounter starts with data that flow from the laboratory: blood counts, metabolic panels, microbiology cultures, and Pap smears. These are the entry points to diagnosis, prevention, and reassurance. They do not discriminate between age, race, or geography.
In this sense, pathology is “medicine of the people,” foundational to every clinical decision, whether in a family practice in Detroit or a rural health outpost in Kenya. Like family medicine, pathology is comprehensive and universal; unlike family medicine, its ubiquity is largely invisible.
In my own practice, I have often reflected on the strange intimacy of pathology. I may never meet the patient whose biopsy sits under my microscope, yet the decisions I render ripple outward into their life story. The public health dimension makes this even clearer. The global scale of Pap smear and HPV testing has altered the trajectory of cervical cancer. The newborn screening panel, another pathology-driven public health intervention, detects dozens of metabolic and genetic conditions before symptoms arise, saving lives and averting costly morbidity. Pathology provides these population-level touchpoints with the same reliability and accessibility that primary care physicians bring to their patients’ annual visits.
To call pathology only primary care, however, would be incomplete. The field also operates with the depth and specificity of subspecialty consultation. Hematopathologists refine leukemia classifications that determine chemotherapy regimens. Neuropathologists identify rare neurodegenerative disorders that guide counseling and prognosis. Molecular pathologists decode the mutational profile of cancers, enabling targeted therapies that have transformed survival for diseases once uniformly fatal.
The paradox is that pathology functions as both generalist and specialist at once. On one hand, it anchors the broad base of medicine’s pyramid, providing the first layer of diagnostic certainty. On the other, it provides expertise at the most rarefied levels of clinical decision-making. No other specialty spans that breadth so completely.
Pathology is also medicine’s translator. It takes the raw material of discovery, such as new viral genomes, novel cancer biomarkers, or machine learning classifiers, and renders them clinically useful. Every genomic sequencing panel ordered for a patient with lung cancer, every liquid biopsy that detects minimal residual disease in leukemia, passes through the interpretive lens of pathology. In this way, the discipline continually dissolves the boundary between bench and bedside.
This dual role is not accidental. Pathology’s history has always been entwined with basic science. Virchow’s cellular pathology, the advent of microbiology, the birth of immunohistochemistry, and the rise of flow cytometry each expanded the reach of medicine. But the field’s true power lies in its ability to embed these discoveries into the clinical narrative of an individual patient, turning molecules and stains into actionable care.
Public health would falter without pathology. During the COVID-19 pandemic, public confidence and government policy hinged on the output of diagnostic laboratories. Cancer registries, which depend on pathology reports, shape population-level screening and funding decisions. Blood banks, managed by pathologists, ensure the safety of transfusions across the globe. In each of these functions, pathology operates with the same ethos as primary care: to keep populations healthy, to prevent disease, to provide reassurance.
Globally, the absence of pathology is often the limiting step in delivering modern healthcare. In sub-Saharan Africa, up to 80 percent of the population lacks timely access to pathology services, leading to missed or delayed diagnoses of treatable cancers and infections. As the World Health Organization has noted, laboratory capacity is the cornerstone of effective cancer control programs. No matter how advanced the therapy, without diagnosis, treatment cannot begin. To build equitable health systems worldwide, pathology must be recognized as both a clinical and public health necessity.
Why, then, does pathology remain misunderstood? Partly because it is often hidden from view. Patients rarely meet their pathologists, and medical students may spend only fleeting weeks in pathology rotations. This invisibility has consequences: it perpetuates the notion that pathology is a supportive service rather than the primary bedrock of medical decision-making.
Correcting this misperception requires deliberate cultural change. It requires integrating pathology visibly into the education of future physicians and highlighting its role not only in rare diagnoses but in everyday wellness. Just as family medicine and pediatrics are understood as community-facing specialties, pathology must be reframed as the unseen but universal primary care of disease.
Every patient carries pathology within them, through their blood counts, their biopsies, and their screening tests, long before they ever meet a surgeon, oncologist, or primary care physician. Pathology is both the first and last chapter of medicine: it begins the clinical story with diagnosis and, at times, closes it with autopsy. It is the quiet backbone of healthcare, at once local and global, primary and consultative, basic and clinical.
To view pathology only as a specialty is to miss its most profound truth. It is medicine’s universal primary care, anchoring the health of individuals and societies. Whether in the whisper of normalcy from a Pap smear, the urgency of a leukemia diagnosis, or the billions of PCR tests that sustained global public health, pathology is always present, even when unseen. If medicine is the house we all inhabit, then pathology is its foundation: steady, indispensable, and woven into the lives of every patient, everywhere.
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