by Harrison Dai, MD Class of 2024, Eastern Virginia Medical School 


It is hard to say which moment which is worse, having to relive the experience of preparing for the USMLE Step 1 or acting as a human retractor during a C-section at 4:05am. If you are reading this, then that means I have passed the USMLE Step 1 and am now a newly minted third year medical student who is barely surviving his clinical rotations. As somewhat of a facetious joke, I often tell my clinical preceptors that I am a simple guy- I just want to look at cells and pretty colors for a living. Surprisingly, I’m able to get a few laughs with that particular joke.


I cannot believe it has been almost a year and a half since I wrote about my perspectives as a first-year medical student on digital pathology. I went into medical school knowing that I wanted to pursue Anatomical and Clinical Pathology. Now as a third-year medical student, I’m more than excited about that dream becoming a reality next year- assuming I don’t die of arrhythmias from too much caffeine. As much as I would like to talk about my third-year experiences so far, I would like to share a story that is somewhat more relevant. That is, how digital pathology was a godsend during my preparation for the USMLE Step 1, and is arguably one of the most underrated resources that medical students can use for board exams.


The USMLE Step 1 is the first of three board exams every allopathic medical student in the U.S. needs to take prior to starting residency. Step 1 contents tend to emphasize the basic sciences such as physiology, biochemistry, pharmacology, and, of course, pathology. Historically, the USMLE Step 1 was an incredibly high-stakes exam that often more or less determined what type of specialty and which program a medical student would be able to realistically apply to. However, around early 2020, it was announced that the USMLE Step 1 would no longer be scored numerically, but rather be changed to a pass or fail reporting system. Unsurprisingly, the decision to make USMLE Step 1 pass or fail has changed the paradigm on how residency programs are going to select applicants. Though I try not to ponder about such things, I am, for better or for worse, going to be in the first cohort of medical students applying for residency programs with no scored USMLE Step 1.


Notwithstanding the fact that the USMLE Step 1 is now pass or fail, it is remains, frankly, a very challenging exam. For most, the USMLE Step 1 covers everything taught in the pre-clinical years of medical school and very likely more material that was not covered in classes. To make matter more interesting, anywhere between 44-52% of the exam pertains to pathology including topics such as histology, pathophysiology, and oncology. Even though the exam covers a wide-breath of pathology topics, the part of the USMLE Step 1 that terrified me the most was the histology. No one was really sure about the scope of histology on the exam. Based on practice exams and board preparation materials, I’ve seen histology questions range from strictly diagnosing a histologic sample to having to make clinical correlations on what one would expect to see on histology based on clinical presentations. I sometimes even saw histology in which I had never seen before on questions and had to pick a diagnosis. Albeit missing one or two histology questions seem trivial, missing several questions do add up, especially on a relatively high-pressure exam with very little room for error.


Textbooks and USMLE Step 1 preparation materials, though incredibly useful, only covered a certain amount of high-yield histology with very little descriptions of the microscopic findings associated with certain pathologies. A lot of students, myself included, often forget that histology is a language. There are going to be situations in which histology does not match exactly what one sees in a textbook and will require an individual to consider several other factors such as cytology, cellularity, and even the stain that is being used to understand what is going on. Bluntly put, histology is often heavily reliant on pattern recognition- seeing only a single representation of a disease process is unlikely going to be useful in the long run. It was at this realization that I was able to appreciate the usefulness and instrumentality of digital pathology. Organizations, such as the Digital Pathology Association, caMicroscope, and OMERO Viewer, have whole-slide imaging repositories that contain a vast array of annotated histopathology specimens. Being able to utilize digital slides offered me ways to learn histology in ways that textbooks could not. Similar to actually having a microscope, I could look at digital slides on high power or appreciate a specimen’s margins at a lower power. Moreover, these repositories are quite extensive. If I searched for a digital slide on a neoplasm I needed to see the histology of, then odds were that I could find the slides I was looking for and then some. Needless to say, I felt a lot more reassured with approaching histology-related questions on my USMLE Step 1. In hindsight, utilizing whole slide imaging repositories for exam preparation was one of the best decisions I had made during my pre-clinical years of medical school.


I will admit that histology or looking at microscopic specimens is neither an easy feat nor is it something that many people come to appreciate. However, it is inevitable that most medical students, whether like it or not, will have to interpret or figure out what is going on with a histology sample they are looking at. Whether or not an individual chooses to pursue pathology as a specialty, I would highly recommend that medical students, who are preparing for USMLE Step 1 or any other medical school exam, to consider utilizing digital pathology/whole-slide imaging repositories as an additional study tool. I’m somewhat surprised that medical educators are not recommending whole-slide imaging and digital pathology as educational tools as these resources can be incredibly informative yet high-yield. To say the least in my opinion, digital pathology remains criminally underrated and has yet to gain the recognition it deserves.


Disclaimer: In seeking to foster discourse on a wide array of ideas, the Digital Pathology Association believes that it is important to share a range of prominent industry viewpoints. This article does not necessarily express the viewpoints of the DPA, however we view this as a valuable point with which to facilitate discussion