Under the Microscope With a Community GI/Surgical Pathologist

Session 144

What’s life like under the microscope? Dr. Rashna Meunier shares her experiences as a GI and surgical pathologist in a community setting. She has been out of training now for three years and so today, she talks about her path to Path!

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[01:30] Interest in Pathology

Rashna basically went through medical school, not knowing what she wanted to do. She went through all the rotations and didn’t fall in love with any of them.

She didn’t see herself doing everything on the floor system that she loved. She realized she’s a really visual person. After she did a two-week rotation in pathology, she knew it was it.

So she applied to multiple residency programs and did a residency. Rashna knew that she wanted to be in private practice.

“A big part of each pathology case is a little puzzle. And you're trying to solve it with only having a certain number of clues or hints.”Click To Tweet

What she likes specifically about path is that you’re puzzle-solving on your own time where you can get to think about it on your own time. Read about it on your own time.

[04:40] Overcoming the Stereotype of Pathology

Rashna was initially worried about it because she thought she’s a people person. She likes interacting with people all day so she was worried that she was not going to have that patient experience.

But she realized that she really didn’t miss it. And the interactions that you have with other people are not necessarily patients. Although she may not be seeing a patient every day, she is talking to clinicians multiple times a day on the phone or talking to someone in radiology.

They present on the tubor board to different physicians like a radiologist, oncologist, etc, to discuss a patient’s case. She still feels like she’s part of a team and interacting with other physicians. Even though she doesn’t have that direct patient contact personally, she thinks the benefits of the job outweigh that one downside.

[05:44] Traits that Lead to Becoming a Good Pathologist

“If you have an interest in continuous learning, that's very helpful in choosing a pathology career, because nomenclature is constantly changing.”Click To Tweet

You need to stay up to date and keep reading and talking with your peers and reading the most recent journal articles to stay up to date. So if you’re somebody that likes to just learn about it in medical school, close the book and call it a day and continue to practice, it might not be the best specialty choice for you. But if you are interested in that continuous learning process, it might be something to consider.

[06:47] Types of Cases

In GI, there’s a broad range, with the most basic like a biopsy, a colonoscopy or endoscopy. So if the gastroenterologist does either those and finally some polyps, they’ll take out those polyps and you’ll look at them to make sure they don’t have pre malignant or malignant features.

For surgical pathology, it’s really almost any piece of the body that a clinician, whether it’s a surgeon or somebody in the office removes from the body. It’s really almost all sites for surgical pathology.

[07:59] Typical Day

If she hasn’t finished things from the day before, she’ll start working on those. Rashna’s schedule is pretty flexible in that it’s a job where you work until the case is done. Then you can manage how you want to organize those things.

So if anything is leftover from the day before that was waiting for immuno stains or other tests that couldn’t be finished the prior day, she’ll work on those.

And throughout the day, she’ll just continuously receive slides and look at them under the microscope, and find out cases.

They have a couple clinical pathology responsibilities as well. If there are issues overnight that happened in the blood bank or hematology or chemistry, they’re often brought both types of questions.

Some days of the week, she’ll present on the tumor board. Along with other specialties, she’s helping manage a patient’s cancer care where they all get together and discuss certain patients. And then she’ll basically just continue to sign out slides until she goes home.

[09:25] Life Outside the Hospital

Rashna says she has life outside of the hospital. She has pretty good hours, usually coming in if she wants it as late as 8:30 or 9. And on a good day, she’ll be done by 5 and the later day might be 6:30. But it’s nice and flexible. So if she needs to leave early one day, then she can just come in early the next day.

She does have a lot of time outside of work to pursue extracurricular activities. But it really depends where you are.

“It depends on the workload and the number of pathologists to divide that workload.”Click To Tweet

[10:22] Community vs. Academics

When you’re in your residency and fellowship, traditionally, they are usually in large academic centers. So you’ll get a lot of exposure to that and not so much probably to the community practice.

“If you are a pathology resident, and you're considering a community practice, consider taking some outside rotation that’s affiliated with your residency program.”Click To Tweet

Rashna felt the community was a better fit for her. Dealing with a broad variety of cases is more likely to happen in community practice. In academia, the trend is to become sub specialized. Pathologists in an academic center usually will do mostly cases in their specialty that they’ve done a fellowship.

[13:25] Taking Calls

“Call is a combination of being on call for anatomic and clinical pathology.”Click To Tweet

An anatomic call as an example would be a frozen section during off hours.

For example, a doctor comes in the middle of the night or the surgeon is doing an appendectomy. Then he sees something that he thinks could be a tumor. He wants to know but he doesn’t know what it is because that might change his management whether he should take the whole thing now.

So if it’s going to change their management, a frozen section might be done. They quickly look at the tissue and cut it into very thin sections similar to the way they normally do. But you can just do it very rapidly in 20 minutes or less.

And so they could come in and do a frozen section for them. That’s pretty rare in their community and in their practice, but it could happen.

The clinical side of the call has to do with sometimes blood bank calls like if there’s a transfusion reaction or questions about what type of blood to give the patient.

One of the most common ones that they have is for a chemistry value that will be deemed the critical value.

For example, a potassium is very low or very high or a patient has a really low glucose or something. And the people that normally call those critical results cannot get in touch with the ordering physician or the physician taking care of the patient. So they call the pathologist to get some help and try to get somebody to “accept that value.” That way, they know another physician is aware of that value.

[15:52] Tech in Pathology

There is digital pathology where they do have the capability to scan whole slide images. You can look at that image at home on your computer. But currently, in her experience, the infrastructure to implement that doesn’t yet exist. Scanning those slides can take a little while. It may or may not be more costly than doing it the traditional way.

Another issue is that the storage space for each of those images is supposed to be large. And if your institution doesn’t have a way to save all that on the cloud or wherever, that can be tricky too.

“The technology is there and some places have implemented this… but for the average community pathologist. it's not likely to happen anytime soon given the limited resources.”Click To Tweet

[17:26] Training Path

After medical school, you would do a residency in pathology. Pathology residency has three options. It can be AP (anatomic pathology), CP (clinical pathology), or you can do what is the most common option, a PCP which is a combination of both.

A PCP residency takes four years while an AP or CP may only take 3 years, but it’s a more rare option.

After that, the typical scenario is that you would apply for a fellowship. A fellowship is not necessary in order to become a Board Certified pathologist.

“You can go straight from your residency into practice.”Click To Tweet

But these days, it’s more common to do a fellowship because you’re told that it makes you a more competitive applicant if you have specialized training in something.

The GI/surgery path combination was a rare fellowship combo although the University of Massachusetts was unique in having that one. But usually they are just one GI fellowship or a surgery pathology or just psychopathology. Those fellowships are usually one year. Some of the rare ones are two years, but for the most part, they’re one year.

“The new trend is that people are doing more than one fellowship.”Click To Tweet

It’s probably a combination of factors as to why more and more are doing more than one fellowship. You want to make yourself look as competitive as possible because a lot of jobs are asking for a specific subspecialty.

How competitive these fellowships are depends on the subspecialty. Applicants are not only coming from a pathology residency training, but they could also be coming from a dermatology training. Dermatology residents are competing with pathology residents for those same spots, so that one’s pretty competitive.

That being said, if you are willing to go to any part of the country or if you’re not too limited by where you want to do your fellowship, then it’s not too difficult to find one.

[21:36] Overcoming the Negative Bias Towards DOs

Rashna hasn’t personally perceived any negative bias against osteopathic candidates. In her world, they’re pretty much the same. She knows plenty of them and it doesn’t really ever come up although she can’t speak for their experience.

[22:20] Message for Future Primary Care Physicians

Sometimes she wishes that primary care physicians could just come and spend 30 minutes with her and see what they do in different parts of the lab. So they could understand why it takes longer for something to be done.

“There's a lot to every step. And if you haven't been in a lab, you don't know that that step actually takes a lot of manpower and a lot of time.” Click To Tweet

She also wishes to tell surgeons who still might not know it that the quality of a section is much worse on the frozen section. So she can’t see the nuclear detail as well on a frozen section as she can a permanent section.

So even though frozen is nice, because you’re going to get a result hopefully, in less than 20 minutes, it’s degrading the quality of what she can see under the slide.

And if you don’t give her any more tissue to submit for permanent sections, then she can only have this damaged tissue to do the rest of her work on.

That’s why they tell the patient when they come out of surgery if it was benign or malignant, that it’s really not best practice to do a frozen section.

For example, if you have a metastatic tumor, and she doesn’t know that the patient has a history of a renal cell carcinoma five years ago, she may not consider that in her differential diagnosis. So it’s really important to know if the patient has a previous tumor from somewhere else in the past.

Or if you’re doing like a GI biopsy and they don’t tell you if it’s for a polyp versus a random colon biopsy, it really changes what the diagnosis will be.

[26:18] What She Wished She Knew that She Knows Now

Rashna wishes that in residency, she had paid a little more attention to knowing exactly how to sign out cases like the small details that you don’t think matter. When you’re in residency, you think about the big cancer cases and how you’re going to grow some. This means doing the physical cutting. A lot of your time is spent doing the grossing.

Then the little benign ones like a benign gallbladder, a benign appendix, a hernia sack, all these things will be called the details.

So she wishes that she had paid attention to the things that seemed like they didn’t matter. And this is something that you really should practice on in your first year.

[28:09] The Most and Least Like Things About Being a GI/Surgical Pathologist

Rashna likes her work day and the cases that she has to look at. She finds it satisfying to do little problem-solving puzzle sessions for each one. She likes learning about the cases and going through them.

On the flip side, what she likes the least is the gross thing when you’re cutting down the specimen. For example, if you have a long like a whole lobectomy that comes down, you need to cut the specimen into many slices. Then you look for what if there’s a tumor then you need to describe it.

Luckily, they have a pathology assistant who does that for them 90% of the time, but if she’s off or on vacation, then the pathologist takes turns doing that in her place.

“In residency, there's a lot of grossing and depending on where you practice in the future, there may or may not be an assistant so sometimes they'll just do all their own grossing.” Click To Tweet

So if you don’t like that aspect, make sure to ask in the job interview how much of that is involved.

[30:09] Major Changes in the Field

AI does exist. Computer learning is there. They have things that they’re working on now. She does hope that it does not completely replace the pathologist. Although she doesn’t think that it will in her lifetime and probably a lifetime of current medical students.

“You still need a pathologist to confirm the diagnosis and do other things that machine learning will take a while to learn how to do.”Click To Tweet

As pathologists, they just have to make sure that they’re at the forefront of being the ambassadors of that knowledge. So even if a machine can tell you where the cancer is and what type, maybe they should have a role in how exactly it’s used or utilized.

The other big thing to be aware of is that molecular diagnoses or molecular results are changing the landscape of pathology. Tumor types were traditionally classified based on how they look in their histology, which is what most of their job is now.

But as the molecular signatures of different tumors are discovered, the classifications can change.

Therefore, paying attention to molecular diagnostics during your medical school and residency is important. Don’t just brush off that molecular rotation. Try to keep in touch with it a little bit. Even though the scientists in the lab might be in charge of that aspect, knowing how to use that information, especially as it becomes more prevalent will be an important role for pathologists.

[32:47] Final Words of Wisdom

If she had to do it all over again, Rashna would have chosen the same specialty. Her final words to students is that if you’re in medical school, just pay attention to everything.

You may think of something as not relevant to you or you don’t see how it could help, but you really never know.

So even if you’re thinking about being in pathology, and you’re on your OB rotation, delivering a baby, and you think it’s not relevant, well, actually, you might. As a pathologist, you might get that placenta in the lab, and you’re going to have to gross it or find it out.

“Basically, everything you learn may have some role in your future.”Click To Tweet

Pay attention to things even when they don’t seem that relevant. And the same goes for when you’re in residency. There’s a lot of emphasis in residency on grossing. You’re evaluated largely in part by how well you’re doing on that grossing because you’re providing that service to the attendings.

But at the end of the day, how good at grossing you are is not necessarily going to be indicative of how good a pathologist you are.

During residency, really pay attention to how cases are signed out and learn from your mistakes. Lastly, understand that you’re going to be sitting in front of this microscope one day all by yourself so you need to pay attention.