Saturday, February 22, 2014

In which I write a long post to answer dumb questions about my medical subspecialty

Questions I get asked about being a pathologist (in no particular order):

“Are you even a real doctor?  You don’t see patients.”
Yes, I am a “real” doctor.  I understand how it might be confusing for a patient, because unlike primary or specialist providers, patients don’t actively choose the pathologist involved in their case.  But please rest assured, I completed the same four years of medical school that your surgeon, internist, pediatrician, or OB-GYN completed.  My title includes the letters M.D.  I also completed four years of general anatomic and clinical pathology residency to learn how to do everything that a pathologist does.  And then I added a year of subspecialty training, too.  Yes, I am a 'real' doctor.  

"So you're like a lab tech then?"
No. No, no, no…just no.  A pathologist is not a glorified lab tech.  Calling me a lab tech is sort of on the same level as assuming all women who work in healthcare must be a nurse - it just makes you look stupid.  Please note that I'm not at all dismissing what lab techs do - which is a lot of really important stuff - but their role in healthcare is different than mine.  In the same way that I am not qualified to do what a lab tech does, they cannot do what I do - we are not interchangeable entities.  {Also, on a distantly related note, when you assume I'm a lab tech and you treat me like dirt *ahem, surgeons*, it makes me angry - not because you are treating me like dirt -  but because it means you are likely treating my lab staff even worse.  I can bust you for your unprofessional behavior on the spot, MD to MD, but my staff doesn't have that luxury.  So please, for the love of all that's good, quit letting your inner jerk out to play}.

“So pathology, huh?  That’s like CSI stuff, isn’t it?”
Wrong.  Stupid wrong, on so very many levels.  I have not once analyzed a soil sample or found a killer using only a strand of blond hair.  I work in a hospital, not in a Hollywood studio.  The killers I look for are tumors of unknown origin.  And what I do to find them is wicked cooler than CSI.

“So what is it, exactly, that you do?”
I look at stuff.  Lots of stuff.  If it comes out of your body, the odds are good that a pathologist has been involved somehow.  This includes the breast (or appendix, gallbladder, uterus, lymph node, prostate, colon, etc) that your surgeon removes.  It includes the skin lesion that your family practitioner biopsies.  It includes the sputum that you cough up, the pus that grosses you out, and the urine that you pee into a cup.  It even includes poo…and semen.  It includes the fluid that your endocrinologist aspirates from the nodule in your thyroid, the lung mass that your interventional radiologist samples, and the pancreatic cyst that your endoscopist biopsies.  It includes the pterygium (or the encleated globe) from your ophthalmologist and the tooth cyst from your dentist or oral surgeon.  It includes blood from your lab draws and bone marrow from the aspirate that your oncologist performs.  It includes the placenta from your newborn baby and the small, 18-week gestation fetus that you miscarried.  It includes the bodies of both the 20-year-old woman who was texting while driving and the 56-year-old man who was found unresponsive on the floor in his home.  It even includes the tick that you picked off of your child’s small leg and the fluid from your lumbar puncture.

“Um…ok.  So you look at stuff, like, all day.  What does that even mean?”
It means that I give you (and your clinician) answers. It means that I can tell you whether or not the lump in your breast or the mass in the head of your pancreas is cancer.  I can tell you what type of cancer it is and if that small hypodense region in your liver indicates metastatic disease.  The immunohistochemistry that I perform on your tumor helps determine both your prognosis and your treatment options.  When your surgeon sends down a sample for frozen section during your surgery, I help them determine how much more of your tongue they need to remove to rid you of your oral cancer.  I diagnose familial cancer syndromes using a combination of histology and advanced molecular techniques.  It’s not just cancer that I diagnose – I diagnose everything from benign skin to colon polyps to neuroblastoma to Crohn’s disease.  Really –I do mean everything.  When I autopsy a fetus, it means that I do my best to help its parents find a cause for why they have miscarried the baby they waited so long to conceive.  And when I find the complete blockage in the left anterior descending coronary artery accompanied by areas of old myocardial scarring, my report tells a family, with reasonable certainty, why it is that their loved one is no longer with them.

It means that I can tell you what kind of bacteria is causing your pneumonia – and the kind of antibiotics to which it will (or won’t) respond.  {Ditto for any organism – fungal, viral, mycobacterial, or parasitic – that you throw my way.  I’ll even tell you what kind of tick your kid picked up during their camping trip and whether or not you should worry about something like Lyme}.  Looking at your peripheral blood, I can tell that not only are you anemic but also the probable cause of your anemia.  I diagnose leukemias and lymphomas by integrating cytogenetic analysis, flow cytometry, and histology.  I determine that the cause of your joint pain is crystalloid and not infectious in nature (this helps save you a trip to the OR, by the way) and I interpret the serologic tests that determine whether you have HIV, syphilis, hepatitis or a host of other conditions.  I oversee the clinical tests that determine how likely your fetus is to have Down syndrome, and if you should (heaven forbid) require amniocentesis or other invasive testing, I also interpret the subsequent testing that gives you a more definitive diagnosis.

It means that when you need a blood transfusion, I am there to help your clinicians select the safest unit for you; and when you need specialized and hard-to-find units, I am there to search the country for those products.  It means that I will beg, plead, and cajole a blood center 2,000 miles away so that you get the best product at the time when you need it most.  When you have a reaction to transfusion, I am there to diagnose what went wrong and help prevent it from happening again.  I provide product support for your ECMO, LVAD, or liver transplantation – and when you crash your car into a streetlight while texting, I’m there to monitor the massive transfusion protocol which will likely help to save your life.  I manage and interpret the coagulation testing for complex, bleeding patients and I help diagnose exactly why a 16-year-old patient with no apparent risk factors unexpectedly threw a pulmonary embolism.  Because tissue typing falls within my jurisdiction, I help patients proceed to organ transplantation.  With therapeutic apheresis, I help you keep your transplanted kidney when your body starts to reject the organ.  I reduce the risk of mortality in patients with acute TTP and help treat leukostasis in leukemic patients with hyperleukocytosis.  I restore quality of life to patients with complex neurological disorders, reduce cholesterol levels in patients intolerant of medications, and collect stem cells that will be transplanted into a leukemic patient.  I even scrub in order to harvest bone marrow from you (or your loved on) in the operating room that will be used for transplantation. 

Believe it or not, this is not even close to being an exhaustive list of all that I do for patients.  When I said that I do everything, I meant it.  You’ll likely never see me face to face, but the odds are good that I have played a role in your care, whether you are undergoing outpatient screening or inpatient intervention.

“So why did you choose pathology?“
That’s easy – I chose pathology because at the end of the day, it’s what I love.  It doesn’t get simpler than that. I didn’t choose pathology because I’m socially stunted or because I hate patients.  None of that is true.  I picked my career like I picked my spouse – for love.  I love pathology because what I do every single day makes me a part of the care team for every single patient, even though most of them will never know that I exist.  I truly believe that what I do has a profound impact on patients.  I love my job because it’s fascinating – the human body, in health and disease, fascinates me.  I love pathology because it’s incredibly beautiful – looking under the microscope at stained tissue, with all its architectural variations, is art in motion.  I love pathology because it astounds and challenges me and teaches me something new every single day.  That’s not to say that I don’t become frustrated – every job has its problems.  Being a medical provider is hard work; it can eat you alive if you let it {a blog for a different day, perhaps}.  I have moments where I forget about the awesomeness and importance of the work that I do – and I’m entitled to those moments when they happen.  But thankfully, they pass, and I am usually left with the feeling that what I do is quite possibly the coolest job on earth.

“You love your job; great.  But what do you hate about pathology?”

I hate how under-valued pathologists are.  I hate how easily we are overlooked. I hate that Hollywood cheapens what I do and turns it into a farce.  I can’t fault patients when they don’t recognize all the services that we provide for them; after all, chances are good that none of them have actually met a pathologist, let alone the pathologist that signed their biopsy report.  I do, however, fault fellow physicians when they overlook pathologists, because they ought to know better.  I can’t tell you how many times I have heard comments like, “Pathology?  Really?  But you’re so smart…,” or “people pick pathology because they can’t hack it in real medicine,” or “…just some dumb pathologist that doesn’t know the first thing about medicine.”  Yes, I am smart.  It’s why I picked a discipline that requires me to use my brain every single day – it’s why I’m considered the “doctor’s doctor.”  I’m not just some dumb pathologist; I’m a physician that knows quite a lot about medicine.  And the medicine that I practice is real medicine – it’s medicine and science in the most pure form, disease distilled down onto a glass slide.  Sure, I can put my stethoscope on a patient’s chest and pick up their soft, holosystolic murmur  (I do this in apheresis clinic, btw) - but can you take one look at a slide and know that you’re dealing with a myxopapillary ependymoma?  Or a parosteal osteosarcoma?  Can you differentiate reactive atypia from neoplasia?  My point is that one good, motivated pathologist is worth 10 mediocre internists.  So please don't make the mistake of underestimating (or under-valuing) my specialty.

Why I wrote this internet novel:
Because I'm passionate about what I do, and I want to share it with others.  And also because nobody seems to have any clue what it is that I spend my days doing - and I think that's really sad, because what I do touches on essentially every aspect of a patient's medical care.  So please, patients - get acquainted with your pathologist.  Get to know what it is we can do for you and for your loved ones. Give us a call.  Better yet, drop by to have us show you your biopsy (or your appendix, etc).  We can't give you therapeutic advice (it wouldn't be ethical), but we can absolutely introduce you to the lab and sit you down to show you exactly what your gallbladder looks like under the microscope and why we made the diagnosis that we did.  We love our job - and we'd love to share our job with you.

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