The Path To GI and Liver Pathology

Session 222

Dr. Wenqing Cao is a physician who specializes in the pathology of the GI and Liver. She is a program and fellowship director at NYU and has been out of training now for 11 years. Today, she talks about her journey and her specialty, and the type of person this specialty is a fit for!

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[01:13] Interest in Pathology, GI, and Liver Pathology

Wenqing was an international medical graduate from China. She initially didn’t want to be a pathologist so she chose to be a clinician working with patients. She chose dermatology and became a dermatologist in China where she worked for two years.

Then she got the opportunity to come to the United States to work in a research lab. She was working on learning about liver tumors or carcinogenesis, working with animal models and human tissue. She was interested in histology pathology where the animal had a genetic mutation, and then after a while, they developed tumors.

Seeing those molecular changes driving the carcinogenesis drew her attention, which led her to go down the pathology residency path. She wanted to know every aspect of pathology before eventually deciding on what subspecialty she wanted to get into.

Inspired by her mentors. She eventually decided to become a GI pathologist in an academic setting, which she has been doing for 12 years now.

[05:57] Traits That Lead to Becoming a Good Liver Pathologist

Pathologists, in general, need to be attentive to details. You need to find the subtle changes that can tell you it’s normal or abnormal.

For GI pathology, particularly, Wenqing says you have to be an organized person because you have to sign up cases and you have to work with residents, and attend meetings. And so, there are a lot of things going on on a certain day. Finally, you have to keep up with new knowledge or new technology in the field.

[07:18] Types of Disease Processes

GI and Liver Pathology deals with everything in your GI tract from the esophagus to the anus. They deal with diseases like neoplastic cancers, inflammatory disease, neoplastic and non-neoplastic liver disease, and transplantation of the liver.

They deal with conditions affecting the pancreas, biliary tree, all the bile duct lesions, gallbladder stones, gallbladder cancer, pancreatic cancer, and the non-neoplastic process. All of these are included in this sub-specialty.

'We are dealing with a variety of diseases from a benign normal all the way to cancer.'Click To Tweet

[08:42] Percentage of Patient Interaction

'It's a misconception in pathology that we would never work with patients. It is true, we don't directly talk with patients. But our diagnosis is really important for patient care.'Click To Tweet

Wenqing explains they work very closely with gastroenterologist surgeons who rely on pathology diagnosis to treat the patients. As part of the team that does patient care, they discuss challenging cases extensively with clinicians. They exchange information and how the radiology looks like, the potential diagnosis, how they get the pathology tissue, the markers they’re working with.

And so, although she clarifies that although they are not talking with patients directly, they are extensively involved in every aspect of patient care from diagnosis to treatment.

[09:45] Typical Day

Wenqing works at an academic center that has a big group of people. They have 15 pathologists working on GI, Liver, and Pancreas.

Depending on the service, your day may be a little bit different. They may have a liver-only service, where you are responsible for all the liver biopsies resections. You’re on call for transplantation. And sometimes you can get calls in the middle of the night for a rash case.

Most of the time, they are signing out cases and they are at conferences teaching. Her day usually starts with a morning conference at 8-9 AM. There’s a multidisciplinary clinical conference involving all the subspecialties. And they discuss the patient and present their pathology, radiology, and individualized treatment plans for patients.

Then she will begin to review her cases. If she has a resident with her, they will review and sit together to look at the case together. They would discuss the pathology in each case and what’s the diagnosis differential.

They also have a consensus conference at two o’clock. Every GI pathologist will sit together to show challenging cases so they reach a consensus diagnosis. Then they continue with signing out until they finish their cases.

In terms of remote work, Wenqing thinks scanning slides and working remotely is coming. It’s not FDA approved so it’s not in their daily practice. But digital pathology or AI telepath pathology is all coming. And it’s going to change in a couple of years and they have to adapt to those kinds of changes.

[13:34] Taking Calls

Their calls are 24/7 if they are on Liver. This is alternated by five people so they may have to do two-week calls, every five weeks or so. They also have a general surgical pathology call where the whole team of surgical pathologists would have to share the calls.

'Pathology in general, we don't have to stay in the hospital long. Hours are relatively flexible.'Click To Tweet

Wenqing also clarifies that they don’t do procedures. When talking about pathology working with patients, they are mostly cytopathologists. But for most surgical pathologists, including GI and liver pathologists, they don’t have that direct patient interaction.

[15:54] Life Outside of the Hospital

Wenqing strives to only leave her work at the office and not bring any home. But occasionally, since she is the director of the service, she has to make schedules and answer some of the phone calls.

[17:18] The Training Path

After medical school, you go to pathology residency and choose a three-year anatomic pathology program, or an AP-CP combined, which is Anatomic and Clinical Pathology. Most residents choose AP-CP because it gives them more flexibility. It allows them to work in private settings because you have to be called for the clinical side.

After three or four years of pathology residency, you can either directly go into GI and liver fellowship. Or you can do a year of general surgical pathology fellowship, and then do GI and Liver Pathology fellowship. As short as four years, you can become a GI and Liver Pathologist, or five or six years, depending on how you choose your pathway.

Wenqing says applying for a fellowship at their program could be very competitive. She would receive around 20 applicants for only one spot available so it’s relatively competitive.

[20:08] Thoughts on the Pass-Fail

Wenqing says they look at both Step 1 and Step 2 just because they want to make sure the person who goes into their program is a fast learner.

'Pathology is difficult because we have all these different specialties. You have to learn everything during the pathology residency.'Click To Tweet

[21:33] Further Opportunities to Sub Specialize

Wenqing says that things are changing and they have become more sub-specialized. Even in the GI and Liver subspecialty, there are people with a special interest in the esophagus, like Barrett’s esophagus, a precursor for adenocarcinoma. There is more focus of interest on the pancreas and liver. When you have a GI and Liver Pathology fellowship, you can sign up for every case. But in the future, you might have to choose a special interest area.

They now do conferences for specific diseases so it becomes more on a level of sub-specialized individual disease. This is harder because you don’t want to just know one thing and ignore the other things. But it has become more demanding in the clinical side that they need more people to have a special interest in a smaller area to work with the team.

[23:05] Message to Physicians Sending Slides to Them So They Can Provide Better Diagnoses

Wenqing would greatly appreciate it if they could provide her with information, clinical history, and what the patient had before or what the radiology or endoscopy finding was. They need that information to help them reach the diagnosis more quickly and more accurately.

Their target turnaround time for the biopsies is 48 hours and four days for the resections. In some cases, that could be delayed when things can get complicated and they would have to take more sections and do more studies.

[24:57] When Patients Know About Their Diagnosis Before the Doctor Does

Once they sign up a case, the patient immediately can see the report and that can cause issues. Because if the clinician didn’t see the report, and patients see it first, they could come to the physician and ask them why they didn’t tell the patients. And so, they try not to sign out a case until they talk with the clinicians.

They alert the clinicians about what’s going on so they get prepared. And then, when the case is signed out, they would know how to deal with those kinds of diagnoses.

[26:58] What She Wished She Knew Before Getting Into the Field

Wenqing reveals that at the time when she was choosing GI and the Liver, molecular pathology had just started. It’s all about hematopathology, so not much about solid tumors. Nowadays, it’s all biomarkers and molecular pathology sequencing and everything. So this is something she wished she knew before, which is to have more exposure to molecular pathology.

[27:35] The Most and Least Liked Things

As GI and Liver pathologists, they are dealing with a variety of cases. They are handling a lot of cases and helping a lot of patients with their diagnoses. And she feels it’s rewarding to be able to do that to be able to also work with different experts in their fields.

'Pathology now is part of the treating team. We are working with all the specialties to help patients, and I feel really good about it.'Click To Tweet

What she likes the least, conversely, is their case volume which can get overwhelming. And it’s going to get worse because of the new guidelines for screening colonoscopy.

With that being said, if she had to do it all over again, Wenqing says she would still be a liver and GI pathologist.

[31:08] Major Changes Coming to the Field

AI and digital pathology definitely is coming and it’s going to integrate into their daily services, Wenquing says. But she doesn’t think they’re going to replace pathology. It’s more likely a tool to help them do a better service so they can help identify the areas if something is missing.

[32:01] Final Words of Wisdom

Wenqing says that GI and Liver is a subspecialty where it’s easy to find a job. Every place needs GI and Liver pathologists. In almost all hospitals, half of the cases are going to be GI and Liver. So this is a subspecialty where you don’t have to worry about jobs.

She also advises going into rotations to see what’s going on in their daily lives. And if you have time, do some projects that can help you understand more. Do as much as you can to get involved and to see if you’re really interested in this field.