Jumping Into the World of Cytopathology and Hematopathology

Session 175

Dr. Siba El Hussein is an academic-based cytopathologist and hematopathologist. She busts some pathology myths and talks about how COVID-19 has changed pathology.

If this is something you’re interested in, check out some resources from the American Society of Cytopathology and the Society for Hematopathology.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

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

[01:08] Interest in Cytopathology and Hematopathology

'To be a good cytopathologist or hematopathologist, or even like a general pathologist, you need to be curious about diseases all over the body.'Click To Tweet

A lot of people are more interested in the brain or in the GI tract. But for a pathologist, you really need to be curious about everything.

People don’t really understand what cytopathologists and hematopathologists do in general because it’s such a small niche or a small community of people. People just restrict themselves to forensics, or what they see on TV, and it’s actually way more than this.

For cytopathology, for example, the whole thing is about doing fine needle aspiration of masses that people can develop, whether these are superficial masses or deep tissue masses. On the other hand, hematopathology is more about studying tissues, lymph nodes, and bone marrow. So they’re basically dealing with people with lymphomas and leukemias.

At the end of the day, you have to be very curious about DNA, genetics, and molecular and try to put everything together to give the most accurate assessment possible.

[04:10] Traits to Becoming a Good Cytopathologist and Hematopathologist

Curiosity is one of the most important things to be a good cytopathologist and hematopathologist.

They get a very small fraction of tissues, and they call out the diagnosis based on the various scanned material. So you’re basically solving a puzzle. You have to put everything together and read the clinician’s notes. You have to look at the X-rays or MRIs or CT scans and try to put everything together, including what you have, what you sent for genetics or flow cytometry.

'It's really like a big puzzle that you have to solve within a couple of hours you're dealing with people who are very sick.'Click To Tweet

They get a lot of frozen sections so they deal with surgeons all the time. And, somehow, they know how to speak their language. And this is part of their job where they have to talk in a language that is very understandable to clinicians and to surgeons to give the most accurate diagnosis possible.

[07:06] Typical Day

In terms of cytopathology, there are two parts to it. You’re either reading slides or you’re doing assessments.

When reading slides, she has a tray at the beginning of the day. She goes over multiple patients up to 80 slides. Then she puts everything together and gives a diagnosis. So she’s basically sending out reports on that day.

When on rapid onset assessment, she does Fine Needle Aspirations (FNA’s) which have two types: ultrasound-guided and on-site assessment. She looks at the tissue that she just aspirated under the microscope and finds out what’s happening and anything else needed.

“If you are missing the part of medicine where you're dealing with patients and seeing them, Cytopathology is one of the subspecialties where you actually have to deal with patients.”Click To Tweet

Cytopathologists are seeing patients just like any other clinician. So if you’re missing that, this is one of the things that you can go to. Some people are comfortable not seeing a lot of patients. This is one of the factors that drive people to go into this specialty. But there are also a lot of people that, once they’re in residency, start missing those patient encounters.

Siba says that to be a good cytopathologist, you have to be a good general pathologist. Because what you’re looking at instead of pathology is, you know, just small cells, instead of looking at the whole tissue as you would in pathology. So you’re looking at single cells here and there. But the differential is still the same.

And for hematopathology, it’s more about everything that there is in the world of leukemias and lymphomas. There are new techniques, next-generation sequencing kinds of things, mutations here and there. It’s constantly changing. And Siba felt that residency was not enough to sign up lymph nodes. Once you graduate, it’s a different world. So you need to dedicate a whole year to it if you’re interested in it.

[13:29] Taking Calls

There isn’t a call for hematopathology. The only emergency they get is someone who comes in with an ACL, which is acute promyelocytic leukemia, and this is a medical emergency. So this is probably the only emergency they have in the leukemia/lymphoma world.

The other possible case where their presence is immediately required is the superior vena cava syndrome. If somebody has a lymph node or mass that is compressing the superior vena cava, they want to know what’s happening with them and so they could treat them immediately.

Hence, these are the only two things that they’re being called for, which aren’t very frequent. Although they still hold their pager on Sunday and Saturday when they are on call, they don’t really get a lot of them unless somebody has a very high clinical suspicion of these two diagnoses. In such a case, you’d then have to go there and provide a rapid assessment of what you’re seeing on the microscope so people can treat them as other specialties.

[15:13] Life Outside of the Hospital

If you’re someone who wants to have a life outside medicine, and you want to dedicate time for this, then you can do this in pathology But that’s if you choose to.

However, you can also choose to be buried under the burden of academia and try to publish as much as you can. You can choose to follow the whole academia thing and be very busy.

So it’s really your call on whether you want to be someone who’s really busy or not. But the specialty itself is not super overwhelming in terms of lifestyle.

'Pathology gives you enough time to have a very balanced life if you want to.'Click To Tweet

[16:15] The Training Path

First, you have to be board-certified in anatomic and clinical pathology, which is a four-year training. During this time of training, you’ll get acquainted with surgical pathology and cytopathology and hematopathology, and everything molecular pathology.

It’s like an introduction to everything. This is the time where you make up your mind whether you want to go into this fellowship or this subspecialty, or not.

'You have rotations in every single aspect of pathology, which is like the general umbrella.'Click To Tweet

After that, you go into one year or two years of subspecialty training. Siba went for a one-year psychopathology training. And then she did a two-year hematopathology training to become a double board-certified hematopathologist and cytopathologist.

In terms of the competitiveness in matching, Siba doesn’t think her specialty is as competitive as the other specialties. There’s a lot of room to do pathology, at least in the U.S., if you want to do it. However, some programs, in particular, can be competitive. In that case, you have to have a good CV.

“In pathology, people want to see that you're enthusiastic about academic life.”Click To Tweet

To be competitive, you have to have as many publications as possible ahead of time. Usually, people who go into pathology are people who like to publish and analyze. They’re very much into publishing as much as possible. So they have that inherent in them beforehand. This is what will boost their CV in comparison to other people.

Another thing that people can do is to do electives at places they want to go to for fellowships for a month or two, and this can bring you up on the list.

[19:10] How COVID-19 Has Affected Her Practice

'Everything pathology is image-based.'Click To Tweet

Siba explains that in pathology, everything can be digitized. Even with COVID, you don’t really actually have to be physically anywhere in the hospital to work since everything can be on your screen. And this is a very big advantage to pathology.

In Europe and some cities in Europe, everything is now digitized. So you really don’t have to go physically to an office to look at the microscope. You can see everything by just using a link and software. In the U.S., we’re not there yet. But the College of American Pathologists is now working on the digital aspect of pathology.

In hematopathology, particularly in flow cytometry, they no longer have to go to the hospital. They simply open their software at home and see the reports on every single patient so they can analyze them and generate their final report.

Siba says they’re seeing a lot of lymph nodes that are excised from people who’ve had the vaccine, for example, or from people who actually contracted the virus. She further explains that people develop this lymphadenopathy and they’re worried about an underlying lymphoma. But they forget we’re living in a pandemic, and this can be just a reactive response to a virus that was not really full-blown.

People can develop this lymphadenopathy and they’re starting to see some lymph node biopsies or excisions.

They’ve also seen some people who are diagnosed with lymphomas who have contracted COVID. And now, they’re developing lymphadenopathy again so clinicians are worried about a relapse. They’re more cautious when they see this kind of lymphadenopathy. So they want to read a whole lot more because the patient has a history of that and they go back to the patient care.

[24:18] Message to Future Primary Care Doctors

For surgical pathology, for example, every tissue they receive is really dependent on the operator. What they deal with 60% of the time are corneal biopsies from all over the body, and these are taken by interventional radiologists.

Siba hopes to tell clinicians that their diagnosis is really as good as the tissue that they receive. If they’re going to receive a very small piece of tissue, they’re not going to be able to give a lot of information. Hence, this is a message for interventional radiologists to give them more tissue when they can.

'You shouldn't really have high expectations from pathologists when you give them so little to deal with… so give as much as possible.'Click To Tweet

They’re not only using the tissue to make a diagnosis using a microscope. As time goes by, everything is really starting to be linked to molecular and genetics underlying DNA stuff.

[26:17] Targeted Medicine is the Future

“Targeted medicine is the future and every day there are new, targeted therapies that are made.”Click To Tweet

If they have enough tissue from the get-go, they’re going to have the ability to put it in the bank and save it for later. So whenever somebody discovers a new mutation or a new pathway, they’re able to go back to that tissue and give the patient a chance to be treated with this novel therapy being discovered.

Siba wasn’t initially aware of the impact of molecular and genetics on pathology in general and medicine. And that’s because it wasn’t really as evolved as it is today. We’re headed into a world where everything is getting more personalized. And everything really depends on the patient’s specific DNA or mutational profile.

Siba encourages people who are interested in pathology to immerse themselves into everything genetics, because it’s going to come in handy over time.

People are now using machine learning and deep learning. Inside of pathology, for example, AI tools are being used to triage pap smears. It’s already happening in the U.S. and it’s FDA approved.

To make the software to do this, you need an engineer who knows how to code and how to do the whole thing. But you also need somebody who has formal training and who’s a pathologist who knows how things look like. This is an opportunity for people to jump from a hospital setting into a startup or an industry of the future, which is artificial intelligence.

[34:42] Most and Least Liked Things

Siba thinks she has the best job in the world. She loves medicine in general, and she doesn’t like to be restricted to one organ at all. She finds it very gratifying to be able to know all the neoplasms of the different systems.

She knows how things work on the cellular level and molecular level, and obviously, on the genetic level as well. It’s a lot of knowledge to learn. And it’s something that keeps evolving so you have to keep up with literature every single day. It doesn’t stop at all. So this is one aspect that she loves because it keeps her on her feet.

“You should have a learning mindset. Even when you graduate and you become an attending, you never stop learning”Click To Tweet

With everything AI that’s happening now, Siba thinks this is a great time to get into pathology if this is something you’re interested in because they’re entering the renaissance of pathology.

What she likes the least on the flip side is not being able to see a lot of patients. Although she was able to work around this being a cytopathologist.

[38:37] The Future of Pathology

“There is a misconception right now that AI is gonna take over pathology and radiology and people are scared of going into these two fields.”Click To Tweet

It’s very easy to replace human beings looking at chest X-ray, and have a software trying to detect a mass. But again, it’s more way more than this. Siba says we’re just starting to scratch the surface of how we can implement AI in both pathology and radiology.

AI is a tool they’re using and it’s helping them a lot in saving time and making a more accurate diagnosis on things that the human eye can miss sometimes. So look at AI as taking care of the mundane stuff.

Siba is currently working on a project where they try to go to the next level where AI is not only making the diagnosis. But they’re also trying to make AI predict the biologic or underlying mutational profile of a certain tumor without doing any molecular testing just based on morphology.

She can envision us in 10 years from now doing everything remotely. So this is very exciting.

[42:05] Final Words of Wisdom

Have an open mind to have an open mindset when you do your rotations or electives. Do not restrict yourself to what you hear from people.

“Go and do your electives and your rotations and have an open mindset.”Click To Tweet

Even if you’ve heard misconceptions before, just go into your rotations, especially in pathology, and try to learn as much as possible. Try to ask questions as much as possible. Hang out with residents who are already in the specialty. Ask them questions about their lifestyle and all the questions that you have. Then make up your mind at the end. But don’t really be hung up on ideas that you get from here and there from other people’s experiences.