The Pathologist as Medical Detective

Session 109

What is pathology like? Dr. Edward Uthman debunks some myths and tells us why he needs more than just a tissue sample to arrive at the right diagnosis. Having been out of training for many years now, he also discusses the changes he has seen over the years within his field.

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[01:23] Interest in Pathology

Ed enjoyed the pathology lectures in medical school more than most of the other disciplines. He was drawn to it as part of the basic sciences. But it wasn’t until he got into clinical rotations that he got interested in it as a specialty.

He wanted to be an internist and did electives in internal medicine and in pathology. He, by far, enjoyed the pathology elective a lot more for two things.

For one, he enjoyed the diagnostic part of pathology a lot more than he did the treatment part. Secondly, he liked the pathology staff and department a lot more than he did those in the internal medicine department.

The biggest misconception about pathology is that pathologists don’t like being around people. Ed clarified that as a clinician, you obviously interact with your patients. But pathologists deal with different personalities as well. More so, it’s a misconception if somebody thinks that their lack of people skills make them well-suited in pathology.

'Pathologists have to deal with a wide variety of personalities.'Click To Tweet

[04:05] Traits that Lead to Being a Good Pathologist

Ed explains that being obsessive-compulsive is important as you’re going to be paying attention to details. You have to be constantly aware when you’re making the diagnosis that mother nature is going to throw a bunch of curveballs at you and try to force you to misdiagnose the case. You can’t afford to gloss over things.

'Pattern recognition is initially done in making diagnoses. But beyond that, there's a lot of attention to detail.'Click To Tweet

[05:00] The Training Path

The general track consists of two years of anatomical pathology and two years of clinical pathology. You then become eligible to sit for the boards in both anatomical and clinical pathology.

Forensic pathology is considered a subspecialty. It starts off with the same certifications along with a forensic pathology fellowship.

Dermatopathology is different in that you can go in via either the dermatology or pathology route. So you can do a residency in anatomic pathology followed by dermatopathology. Or you can do a residency in clinical dermatology followed by the same fellowship in dermatopathology.

[06:02] Community Setting vs. Academic Setting

Ed really enjoyed the teaching aspect of academic pathology. However, basic research was expected and he felt he didn’t have the temperament or the talent to pursue it.

He is more of a generalist in the community practice where he is the only pathologist in their 200-bed licensed hospital. He thinks it suits his personality and skill set.

Ed gets specimens from the hospital but he’s also part of the big group so he gets some specimens from a commercial lab.

[07:10] Typical Day

Ed usually gets in at around 9 am. He’s the laboratory director so he also deals with any administrative problems that have occurred overnight. He often times has some references that had cases that came in the night before and diagnose based on those reports. The slides from the hospital cases start coming in late in the morning. He looks at those and dictates the reports.

During the day, he can be interrupted by phone calls or to attend a biopsy in the radiology department. He tries to determine if the specimen they got was adequate so he can let them know right away so they can let the patient go with a minimum number of sticks.

In the afternoon, the gross specimens that had come in all day have been logged in. He then dictates the gross descriptions. He’d usually be done at 5 pm which can sometimes be extended to 7 pm.

When a physician or surgeon takes out a stomach or colon, or when a gastroenterologist sends out a biopsy, they send these bits of tissue so they can do a gross exam. They’re looking at the specimen with the naked eye and describe it. Then they submit it or portions of it for processing for the microscopic exam the next day.

If the surgeon has a case that needs intraoperative consultation, Ed has to be there and available for that. For instance, when an OB/GYN does a hysterectomy and the patient has not had any endometrial biopsy beforehand, they will do a D&C (dilation & curettage) on the table.

If the endometrium is benign on the frozen section, it may proceed with the hysterectomy. And if it’s an unusual case and it turns out to be malignant, either another operation is done or they’d have to refer the patient to a gynecologic oncologist. This type of decision has to be made while the patient is under anesthesia.

Although not true of all pathology practices, the radiologist will do a fine-needle aspiration, which is a minimally invasive type of biopsy. This involves sucking cells out of a lesion. Ed would then make a direct smear and stain it, and look at it immediately. He’s then able to tell the patient what the diagnosis is while they’re still there on the table.

[10:40] Taking Calls and Work/Life Balance

Being part of a large group, Ed would only take calls every one week out of 12, which isn’t too frequent. They do it a week at a time. They get calls in the middle of the night although not frequently. They’d also take calls for four different hospitals since they’re a big group.

That being said, they would be receiving a few phone calls and be doing occasional trips to the hospital in the middle of the night.

Slide scanning is still in its infancy so they still look directly at the glass slides.

'I would certainly not let call responsibilities dissuade me from going into pathology. That's not a huge part of it.'Click To Tweet

Ed believes he still gets to have a life outside of the hospital. It’s like owning a small business in general. There’s lots of flexibility. You’re not punching a clock and you don’t have to show up at a specific time as long as you get the work done.

Another thing that Ed likes about pathology is that the slides are going to be there whenever he comes in. Whereas if he were an internist, he’d have to meet clinic hours and be paying clinical staff to maintain the clinic during those hours. And he doesn’t have to worry about any of it.

Due to modern utilization practices, hospitals no longer want to hold patients in just because they’re waiting for results. They only hold patients that are sick enough to be in the hospital.

But in uncommon cases where a decision point is necessary, they would ask that they submit the specimen so they can look at it first thing in the morning.

[13:45] Other Subspecialties in Pathology

There are some great subspecialty opportunities in pathology. If you go to a medical center or a tertiary care center, pathology departments are ultra-specialized. They have sections of gynecologic pathology, dermatopathology, and hematopathology.

'There are all sorts of both formal and informal types of training programs to subspecialize.'Click To Tweet

Dermatopathology is very popular as well as hematopathology and cytopathology. Other subspecialties include neuropathology and eye pathology.

Ed chose to remain a generalist as it fits his personality better. He likes learning new things and reading a broad base of literature. He gets angsty when he has to get too focused on something for too long a time.

[15:30] Bias Against DOs

In Houston area, Ed doesn’t see any bias against DOs. He can’t even tell who’s the DO or MDin his group. They train in the same specialty and the same residencies that the MDs trained.

'In my part of the country, they are totally equivalent degrees.'Click To Tweet

[16:22] Working with Primary Care and Other Specialties

Ed wishes primary care providers knew as to how much help they need in making their diagnosis.

'The clinical information they have helps make them make the right diagnosis and can keep them from making the wrong diagnosis.'Click To Tweet

Sometimes, pathologists may seem to present themselves as being too omniscient in that they can just take a tiny bit of tissue and make a life-changing diagnosis. In some cases, this may be true. But in plenty of cases, they need clinical information. The more information they give, the less likely they are to screw up.

Ed wishes to tell primary care physicians that skin biopsies without a really good dermatologic evaluation are of limited value. If somebody sends a punch biopsy of a rash and they don’t have it narrowed down clinically to three or four possible entities, it’s going to be garbage in and garbage out.

'To my colleagues in dermatology, I wish that the training of medical students in primary care and clinical dermatology were more robust than it is.'Click To Tweet

Other specialties they work the closest with include radiology, gastroenterology, OB/GYN, and general surgery. Any physician that has a patient and is biopsied and has blood or body fluids sent for analysis.

[18:40] Special Opportunities Outside of Clinical Medicine

Ed’s wife, for instance, started as an academic hematopathologist and is now an associate dean at a medical school, responsible for all postgraduate training programs. There can also be some role for a pathologist in regulatory functions and peer review functions.

'There's a very well-populated educational track in pathology if you go into academic practice.'Click To Tweet

There could be a potential in machine learning but it’s not something Ed has personal experience with so far.

[20:06] The Most and Least Liked Things

Ed has no complaints about his choice of specialty. What he likes most about pathology is people interaction – strangely. But this is his honest answer.

He has been practicing since 1981 and he feels he’s now in a position where he could retire. He would definitely miss the people that he works with on a daily basis when the time comes that he’d finally have to leave.

Over those years, the biggest change he had seen was the development of immunohistochemistry. It’s a specialized technique in anatomic physiology that has totally changed everything in terms of how they make diagnoses. It has started from being non-existent to completely indispensable now.

'The next generation of pathologists is going to experience that in molecular pathology. That's the next big horizon that we're heading towards.'Click To Tweet

What Ed likes the least about pathology is opening an unprepped colon. He dislikes the visceral stuff the most. But this is just a minor complaint. That being said, he enjoys coming to work everyday.

[22:43] Major Changes in the Future of Pathology

Again, Ed mentions immunohistochemistry as the game-changer, specifically in molecular pathology. The question is how will pathologists be utilized in interpreting the molecular data. And he’s optimistic that molecular pathology is going to make pathologists even busier than they are.

'I don't think we're going to be replaced by it. I think it's just going to be another tool that we use to make the diagnosis.'Click To Tweet

Many of the neoplasms and sarcomas have specific chromosomal translocations that are either define the tumor or are important diagnostic criteria. And they use molecular techniques for those which pertain to DNA, gene structure, and gene expression. Anything that has to do with DNA and RNA is going to be filed under molecular pathology.

[24:55] Going to a Top-Tier Institution

If Ed had to do it all over again, he still would have chosen the specialty. But he wished he had aimed a little higher in his choice of medical school and residency. He believes the kind of training you get at the top-tier institutions really pays off.

'If they think they can get into a really highly competitive med school or a highly competitive residency, shoot for it.'Click To Tweet

There were some areas of pathology that he was really weak on when he started practicing and he had to play catch-up ball. And he thinks this was because the place he trained at had deficiencies in attracting certain types of cases.

As they say, if you haven’t seen it, you haven’t diagnosed it. You could read the textbook from cover to cover. But a month later and you’ve forgotten most of it. But if you have the case and you really have to grind to get that case down, you’re never going to forget that,

[26:50] Final Words of Wisdom

Ed says that people who were interested in visual identification things when they were kids would make really good diagnostic pathologists. They know how to make visual distinctions and how to classify things.

If you have this kind of talent and interest, you might want to take an elective in pathology and see if this is something you want to do as a career.