Cytopathology and the Diagnostic Side of Medicine


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Session 124

Pathology was not at the top of Dr. Elizabeth Morency’s list. But after being smitten by histology electives, she knew pathology was for her.

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

[01:05] Interest in Pathology

She has always been interested in medicine being exposed to her dad who’s a family medicine physician. She went into med school thinking it what she wanted to do. It wasn’t until the end of her third and fourth year that she realized she wasn’t as interested in clinical medicine as she thought she would be as a career for the rest of her professional life.

During her fourth year, she did a pathology elective having never heard about it. It was more of accidental for her. And she feels that people going into pathology usually have this path.

'It's pretty rare that somebody who's a child of a pathologist or does have knowledge of pathology before they go into medicine.'Click To Tweet

She found it fascinating to see things behind the scenes and where these diagnoses are coming from. Elizabeth describes herself as somebody who’s into puzzles, she’s analytical, and always wants to know what the final answer is.

She remembers being on the wards as part of the clinical team waiting on pathology to figure out what to do next.

Curiosity was what led her to explore that side of it. She wanted to be the one with the answers to help the team direct what the next steps are.

Elizabeth enjoyed the rotations in family medicine. But she explains that there was a huge difference between shadowing her dad or her pediatrician versus being the person who has that primary responsibility and is taking care of the patient. And she just couldn’t see herself doing it day in and day out.

'In clinical medicine, there's only so much that you can control.'Click To Tweet

A lot of it has to deal with patient compliance and make sure they follow up with the recommendations you give. And she just didn’t have the patience.

Even as a third-year medical student, just experiencing the clinical care role where patients didn’t do it the first or second time, she realized it takes a special human being.

[07:00] Traits that Lead to Becoming a Good Pathologist

A good pathologist is very curious and asks a lot of questions. They’re nosy and know exactly what’s going on.

'Especially in cytopathology, or even to a higher degree than surgical pathology, you can sometimes hang a diagnosis on a single cell.'Click To Tweet

Pathologists are very detail-oriented. A slide can have thousands of cells on it. Somebody has to be very methodical and almost “anal.”

Strong communication skills are really important. This is not commonly attributed to pathologists. At the end of the day, you need to b able to communicate well with your colleagues and do follow-ups.

An interdisciplinary team goes hand in hand with communication. You’ll be working with surgeons, nurse practitioners, medical assistants, and medical students. Be able to be comfortable in that setting. Make sure you’re getting your message across clearly.

[09:10] The Biggest Myths Around the Field of Pathology

'Many people think that pathology is mainly about being a forensic pathologist. But this is only one small part of the entire scope of anatomic pathology.'Click To Tweet

Forensic pathology is only part of the entire field of pathology. To this day, people think she hangs out with dead people and she only does autopsies all the time. This is one big part and this is what their forensic pathologists do. They get into fellowship training and are boarded.

But this is just a small part of the entire scope of the field. Pathologists work in a hospital. They work with other fields like gastroenterologists and pulmonary critical care doctors.

People think pathology is boring because they don’t get to see patients. But Elizabeth clarifies that she has always enjoyed seeing patients. You don’t only diagnose stuff, but you can take it even further with molecular diagnostics, sequencing genes, and precision medicine.

Not only are they able to tell prognostic indicators to oncologists, but they’re also saving patients wasted time and potentially adding time to their life because of what they do.

Being anti-social is also another common myth around pathologists. There are some people that are more comfortable being behind the scenes.

But speaking for her department, they’re very social and very involved with the medical school. They’re very involved with their clinical colleagues. Their department itself has a very strong social atmosphere.

[12:28] Types of Cases

General anatomic pathology tend to think about surgical pathology. They get pieces of tissue and look at the whole sections. For instance, they look at the size of the breast mass. Or they do a core biopsy and look at the architecture of the tumor. They’re able to get a two-dimensional slice of the lesion where they’re looking at.

Cytopathology deals with cells. For the same patient with a breast mass, as opposed to a core biospy, they do fine-needle aspiration (FNA).

Pap Smears

Another big part of cytopathology is looking at gyne specimens like pap smears.

'A large volume of our material are pap smears from OB/Gyne.'Click To Tweet

Fluids

For example, they do paracentesis to a patient with end-stage cirrhosis with a large volume of fluid in their abdominal cavity. They take out all the fluid. Sometimes, they do serial taps that are more therapeutic than diagnostic. They just look if there’s any infection or concern for liver cell cancer. They deal with fluids that are either from the lungs or the abdominal cavity.

Deep Biopsy

They do superficial aspirations of palpable lesions. They may refer to an interventional radiologist. But where they did her fellowship, they did a fair number of thyroid aspirations themselves with and without ultrasound guidance.

They have a clinic at their institution where their fellows get the opportunity to do FNAs themselves. 

Generally, they do the biopsy themselves. This is something Elizabeth loves because she misses this aspect of medicine. Seeing the patients themselves and being able to tell them within a matter of minutes what their preliminary impression is. There’s no other specialty that can do that.

However, a lot of these have been taken over by an interventional radiologist. This depends on where you are. But they do those kinds of things as part of their fellowship training.

[16:45] Typical Day

If she’s teaching, Elizabeth comes and does a didactic lecture. They break it down by organ system. The residents and fellows have the opportunity to preview the cases coming up for the day.

Then she catches up on emails and other projects. They sit together with the residents and go over the cases. They’re usually done by 3-4 pm. The rest of the afternoon is involved in medical school teaching, mentoring, and preparing for meetings and lectures.

[19:20] Academics vs. Community Setting

Elizabeth was trained at highly regarded academic institutions. Some of the attendings she worked with became her mentors up to this day. She also shares her share of impostor’s syndrome, questioning herself if she knows enough to teach other people.

As a fellow, she was teaching residents so she was finally able to talk herself out of it to see what it was really like.

She came to Chicago to do her last fellowship and fell in love with the city. With only academic spots open, she decided to do it. 

There were a lot of back-and-forth consults, she applied and interviewed. She just fell in love with the department. Being on the other side, she realized it wasn’t as scary as she thought it was going to be. And that she had something to share and that she could contribute.

'Day-to-day, you have the opportunity to teach residents, fellows, and medical students.'Click To Tweet

That being said, she never wants a medical student who’s interested in pathology to not have real exposure to it until their fourth year (like she did).

Moreover, you don’t have to have a million publications or all of your electives done before you submit your residency application. But it’s still nice to know earlier on than later that this is something you would want to do.

[22:12] Life Outside of the Hospital

Pathology can be busy but Elizabeth definitely still has a life outside the hospital. This is part of the reason they decided to stay in Chicago. It’s a great town to live in. Additionally, pathology is a great lifestyle field.

'There is still plenty of time to have a life outside of the hospital and outside of your clinical and academic responsibilities.'Click To Tweet

[23:13] The Training Path

You basically do four years of general anatomic pathology (AP) and clinical pathology (CP). You can do anatomic pathology only for three years. However, this is not encouraged.

If you go into community practice or private practice, they’re going to want you to have clinical pathology training. They’re going to want you to have experience in the lab and medicine including microbiology, clinical chemistry, and blood bank.

Elizabeth doesn’t use those skills now but if she were to go out into the community, she’s glad that she had it.

The typical route is four years of AP and CP, and then one year of cytopathology. Then you sit for the boards and then practice.

Pathology is a bit easier than the standard internal medicine or surgery residency. You still have a good amount of time to sleep. For the most part, your call is at home.

'You just don't get any or very little pathology exposure or training in medical school.'Click To Tweet

Because of little to no pathology exposure in medical school, the amount of material you have to learn is just huge. It’s like you’re starting completely blind.

Most pathologists are easy-going people. There are some who are “old school” but it’s not too bad. It’s rigorous in the sense that the learning curve is very steep. You might find it more comfortable by your second year as you’ve done a couple of surgical pathology rotations.

Then you can begin to think about what subspecialty you’re interested in. Then based on that, you can work on your projects; For instance, you want to look at gynecologic pathology, so you want to look at uterine cancer or ovarian cancer.

By your third and fourth years, you get more responsibility. You’re considered a senior resident. You can onboard and orient the first-year residents. Then you begin building your CV and start interviewing for fellowship.

It’s good to know what you’re interested in by the end of your second year. At their institution, they’re already filled for the next two years.

Fourth-year is spent pretty much studying for the boards. A lot of programs are really good about making sure you have your heavier rotations earlier on so that you can do lighter rotations and have dedicated study time for the boards.

'Pathology boards is one of the most challenging of all specialties because of the breadth of information, especially if you're doing anatomic and clinical.'Click To Tweet

[27:35] Bias Towards DOs

Elizabeth hasn’t seen any bias towards DOs. In fact, one of their in-house residents is a DO student and going to be a cytopathology fellow in two years. And he’s great!

'There's definitely no negative perception of DOs, Caribbean, or whatever alternative pathways.'Click To Tweet

[28:00] Message to Primary Care Physicians

Elizabeth wishes to tell primary care physicians to have an understanding of the concept of turnaround time. It can probably take two days for a biopsy result to come out. This is because of the nature of grossing the specimen, which involves describing, embedding it in paraffin, and cutting it. 

'Don't start calling or emailing or scheduling your patients too prematurely.'Click To Tweet

Just educate yourself on the basics of the turnaround time. A biopsy usually takes 2-3 days. A major surgical resection specimen like a lumpectomy or mastectomy can take a week.

Have an understanding of what they mean when they say additional studies. For instance, they’re doing a breast biopsy or potential and basic cancer but it’s not obvious.

They have to do an immunostain that can show either the presence or absence of the protective lining cells. If they’re gone, they can make that call and call it minimally invasive cancer. Or if it’s still present, it takes another day to check if they’re confined.

[30:23] Message to Surgeons

For surgeons, Elizabeth wishes for them to understand how frozen section works. Frozen section or intraoperative consultation is when you’re evaluating something with the patient on the table. Usually, it’s a margin or a question of what is the tumor. How aggressive is it? How big of a margin do they have to put around it?

They can’t just lay hands on the tissue and say what it is. They need to get the tissue, process it, get a slide, and they have a 20-minute window to do this. So don’t start calling before the 20 minutes. And if you send them 5 margins at the same time, they may need more time.

'Understand that when we need more time, it's not because we're trying to hide the diagnosis or keep it away from you. Our responsibility at the end of the day is to the patient.'Click To Tweet

Just try not to put them in a position where they’re rushing. Pathology is very challenging inherently. You don’t want to put additional weight or pressure on them that could cause them to miss something or overcall something.

[32:40] Message to Older Pathologist Self

Early on in residency, Elizabeth kind of second-guessed the field. What she would have told her younger self was to believe in herself, work hard, and read more. She has always struggled with keeping up with the literature. You need to have a great clinical history and know the radiology and be really prepared.

'It's important to be prepared. Know about the case you're dealing with as far as literature.'Click To Tweet

If it’s something that’s complicated, look at the neck of where it’s coming from. Look at the radiology, the ENT note, and talk with the clinicians. Maintain great, open communication with the clinicians.

Don’t be afraid to ask questions. The more questions you ask the better. Don’t be afraid that you’re going to come off as annoying. In fact, your attendings are going to appreciate that. Even they can sometimes miss things as well.

[36:28] The Most Liked Things About Pathology

Elizabeth likes working with an interventional radiologist, which is one of her favorite things about cytopathology. They can literally give a diagnosis on anything within minutes. A lot of times, they go down to make sure the specimen is adequate.

She likes having the answers and be in the position to get things moving much quicker than having to wait for an extra processing day. 

She likes working with Gyne and doing projects with the OB/GYNEs. They’re trying to improve screening adherence and patient education as all as the synergy of high-risk HPV testing.

She likes getting to have those relationships with other fields like the ENT surgeons, the interventional radiologist, the gastroenterologist, the pulmonologist, etc.

'There's always more to learn. That goes to medicine as a whole, but in pathology, it's even more heightened and significant.'Click To Tweet

[41:35] Technological Changes in the Field

In the midst of major advancements in technology, you still needs humans and pathologists with 4-6 years of training.

It’s a helpful, diagnostic adjunct. It’s there to help you become more efficient and make sure you don’t miss the micrometastasis, for instance. At this point, Elizabeth is not worried about being replaced by the machines.

'Technology is there to make us better and more effective at what we do.'Click To Tweet

[43:43] Final Words of Wisdom

If she had to do it all over again, she would still have chosen the same field without a doubt. She didn’t plan outside of pathology as a second fellowship. Her original plan was doing a community, nonacademic practice. It was the nature of the market which wasn’t great. But she tried it and loved doing it since.

'I'm so grateful that I didn't find this perfect job at that time because I would not be here and it all worked out.'Click To Tweet

Her advice to students is to do your best in training. Do your projects. Put yourself in the best possible position you could be so that when you’re ready to start looking, you don’t have any regrets.

Don’t believe the preconceived notions that they’re scary people and that they don’t like anyone to visit them. In fact, they have a premedical intern program at their school. They have college kids interested in pathology come to them.

Lastly, don’t be afraid to ask questions. Don’t be afraid to ask attendings if you could do projects with them. Pathologists are laid back people for the most part. they’re always looking for ways to educate medical trainees as to what they do.

Do your research. Look at the different organizations like the College of American Pathology (CAP) or the American Society of Clinical Pathology (ASCP). Or just google Pathology to have an idea of what it is outside of CSI. Get involved and take initiative.

Links:

Meded Media

College of American Pathology (CAP)

American Society of Clinical Pathology (ASCP)

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