Microscopes Aren’t Magic: Liver and Transplant Pathology

Session 117

Dr. Oyedele Adeyi’s journey began in his native Nigeria. He joins me with insights into the workflow, lifestyle, and training involved in Liver and Transplantion Pathology.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:19] Interest in Pathology

Dr. Adeyi got drawn into Pathology a few years after medical school. He was a family physician for a few years. But he has always loved the basic sciences as well as practicing clinical medicine. Eventually, he realized that Pathology was the best opportunity for him to combine really basic sciences and doing clinical medicine.

He attended medical school in Nigeria where he had a lot of exposure to Pathology. He barely passed the course. But when he practiced, he discovered his love of immunology and understanding the pathophysiology of diseases.

After about two years of practicing clinical medicine as a family physician, he realized that he was bored doing it. He found it predictable. But every so often, he came across interesting cases.

'Once you live in a particular area, the kind of diseases you see don't tend to change much.'Click To Tweet

Then he met a colleague going through pathology residency. He spoke to him and told him his concerns. His colleague talked more about pathology and by the time they parted ways, he knew he wanted to be a pathologist.

Looking down the microscope was the part he hated as a medical student. But he learned from his colleague how it still touches the different aspects of medicine. As a pathologist, you deal with gynecologists, surgeons, pediatricians, and everyone else. So he applied to pathology residency and since then, he never looked back.

Although a visual person, he didn’t like looking down the microscope as a medical student because he didn’t understand the different things he’d see under the microscope. He thought everything you’d see under it was the same.

“You have to have visual skills as a pathologist.”Click To Tweet

Through his third year of medical school, Dr. Adeyi wanted to be an orthopedic surgeon, pediatrician, specifically, a neonatologist.

When he came out of Nigeria after his first two years, they could go straight to practice family medicine, which he did for two years. He ultimately realized that that being ni the clinic was not his thing.

He liked the thing they do in pathology where they tie things together. They see the patients and presentation. They have the tissue in front of them to try and resolve all the questions that couldn’t have been resolved without the tissue.

He was already a board-certified pathologist back in Nigeria. When he relocated to the U.S., he did his USMLE and at that point, he had the choice of doing a different residency. At this point, he knew he has found his calling that he had to do his residency for another extra 3-4 years.

[Related episode: A Closer Look at the Pathology Residency]

[09:25] The Biggest Myths Around Pathology

One misconception around pathology is the medical school curriculum. When he was in medical school, they were taught that understanding the pathogenic basis of disease was important to what specialty you get into.

The second misconception is social media and television portrayals of pathology. Many people would think pathology as mostly forensic. It’s very exciting that’s why you see it most on TV.

But it only makes up one subspecialty in Pathology. A lot of people come to the conclusion that they don’t want to go to medical school just to be dealing with dead bodies.

'Forensics is just one subspecialty in Pathology.'Click To Tweet

As a pathologist, autopsies are part of what they do but it only represents less than 1% of their workload. 99% involves dealing with people and that changes the perception most of the time.

Lastly, pathologists are perceived to be soft and they’re not always seen by people. But this is changing now as you’re seeing more pathologists out there.

[12:22] Types of Diseases

As a specialist in Liver and Transplantation Pathology, they deal with three broad groups. They handle medical liver diseases for the most part, tumors, cancers, and transplants.

Transplant Pathology extends outside of liver into things like kidney, pancreas, small bowel transplants.

'Liver pathology includes medical diseases, tumors, cancers, and transplants.'Click To Tweet

Within the scope of Liver Pathology, he deals with hepatologists the most, and sometimes, with the hepatobiliary surgeons. An average case would involve a liver biopsy that has been performed to try to determine the kind of disease the patient has. It’s also used to grade the level and stage of the diseases, especially the chronic diseases.

From the Oncology aspect, the most common tumors in the liver are those that metastasize from monocytes. It’s not unusual for the patient to present to the ICU or it might just go to Stage 4 cancer.

The liver is the easier organs to biopsy so they would use it to determine what kind of cancer the patient has, where it’s coming from, and the kind of treatment that’s appropriate.

[15:25] Typical Day

Aside from being pathologists, they’re also educators. They have a residency training program, fellowship training programs, and they also teach at the medical school.

An average day would include sitting down with trainees to go through all these biopsies and teach them around the microscope. This constitutes about 50% of their time when they have trainees.

Some have administrative responsibilities to oversee the clinical laboratories to make sure that the quality is maintained.

They undergo clinical accreditation every so often. They also do a number of discussions with different surgeons and hepatologists to discuss the case that has just been biopsied or they’re about to biopsy.

[17:22] Taking Calls and Work/Life Balance

Most of their calls are around transplants. They evaluate the quality of a disease tumor organ about to be transplanted. Sometimes, the surgeon is not sure if the quality of the graft is good to be transplanted to someone else so they do rush biopsy.

He takes calls one day every other week. Weekend calls may also be common. They also share calls with their trainees. Usually, they’re not on call as frequently as most of the specialties. And when they’re not on call, they’re not working.

'When I leave work, I tend to leave everything behind.'Click To Tweet

Pathology gives you more flexibility to manage your time and how they balance work and family.

[19:35] Training Path

After medical school. there are two pathways to being a Liver and Transplant Pathologist. You could go in straight for Anatomic Pathology for three years. In other countries, it probably ranges from 3 to 5 years.

In the U.S., you could combine anatomic and clinical pathology for four years. At the end of that, you have to go for subspecialization training which is a fellowship training. That also ranges from one year to three years.

Dr. Adeyi did two fellowships. He did Renal Pathology as a research scholar in Nigeria. His Transplant Fellowship was Liver and Transplantation combined which he took one year. He had the option of a second research in the U.S.

'Most of the fellowship trainings are quite flexible around the trainee.'Click To Tweet

He recommends students determine the kind of career they’re looking at. Fellowship training programs prepare you for whatever it is you see yourself doing. Following this, he took his first faculty position in Toronto as a Liver and Transplantation pathologist.

[21:21] Academic vs. Community

In Nigeria, once you’re a pathologist, you work in a university. He doesn’t recall having any community pathology. It was more likely expected that once you go into pathology, you are choosing an academic career. So this wasn’t a choice he needed to make.

When he came to the U.S., he realized that his love for immunology was going to be fulfilled in Liver and Transplantation pathology. At that point, too, there were not many Transplant programs outside of the university. He doesn’t think there was a particular time that he sat down to determine if he wanted to go into the community or not.

'My career path was pretty much determined for me... my choices pretty much had the implication that I was going to be in academia.'Click To Tweet

[22:55] What He Wished Other Specialties Knew About Pathology

'The tissue that they look at under the microscope doesn't come with any magic information that is going to tell us what is going on.'Click To Tweet

Pathologists put things together. If you don’t interact with your pathologist to provide them more clinical information as possible, you’re probably not going to get much out of that.

Dr. Adeyi reminds their GI and Pathology fellows that he can describe everything that’s on the tissue but it’s going to be meaningless to anyone and less efficient. The only time it becomes useful is when he can look at what is on the tissue and use it to explain the clinical profile and the phenotype. Then they can put things together.

What you get out of Pathology is as good as what you put into it. Take time to ask questions and provide information to your pathologists. Then your pathologists will always be able to put things together in a nice package and everyone will be happy.

Most tissues have very few ways of reacting to different kinds of injury. He could be looking at the end results of an injury that resulted from any number of injuries.

Working at the university, this won’t be much of a problem because most of the colleagues they deal with in clinical practice understand these things. So they get a lot of interactions together.

[26:33] Most and Least Liked Things and Major Future Changes

What he likes the most about being a pathologist is the ability to solve problems. It’s like detective work. Knowing what goes on in a patient is very gratifying and satisfying, especially that the results you’re releasing is going to make a big difference.

What he likes the least is not having enough clinical information. He also doesn’t like having so many cases at times that you wish you had more time to spend on each one, Unfortunately, you don’t.

Dr. Adeyi really wishes that the clinical workload be reduced. But he doesn’t think this would happen anytime soon considering the economic environment we’re in.

That being said, Google is becoming invested in machine learning for pathology. AI is going to make things easier. Digital pathology is going to change the way pathology is practiced. In fact, it’s already changing.

'AI is not going to replace pathology but in the next few years, the AI is going to be a component of everyday practice that is going to make things better.'Click To Tweet

[31:32] Final Words of Wisdom

If this is something you’re probably interested in, Dr. Adeyi recommends that you Interact more in Pathology during your medical school years. There are opportunities for electives. They have people coming in for one week of elective, others for one month. So take advantage of this. He adds that they haven’t encountered students who have been there for electives that were not glad that they did.

They also have a post-sophomore fellowship in the second year of medical school where students get to spend one year in pathology. They function more as a junior resident. Many of those end up going into pathology.

Even if you’re not interested in getting into Pathology, just feel free to walk into a pathologist’s office. Ask questions, chat, and interact with them. The more every physician knows about pathology, the better they can make use of the services of the pathologists one day.

And to residents who are already in other specialties, some residents can also go in and do electives in Pathology. Interact with pathologists. Ask questions and just be curious about what they do