pathology questions

[meanderson]

I've never worked in a pathology lab or with a group of pathologists. The only information I've recieved concerning path is by talking with others, reading this forum, looking at path department websites, match lists, etc. But i have a few questions that I'm sure some of the regulars on this forum who have hands on experience in pathology can provide the answer to:

1) I know that some of surgical path involves tissues being cut thin enough to put under the scope and make a diagnosis, but I'm wondering what 'grossing' actually means for most of surgical path. For example, when the surgeon removes tissue from the patient for analysis by the pathologist, what does the pathologist do in the way of grossing? Dissect it into smaller peices?

2) Are bone marrow biopsies a difficult procedure to learn? Do most residents get a lot of experience with these in every program?

3) From this path forums I've seen sarcastic comments from many people regarding the way CP training at some institutions is set up(not taken seriously, really easy hours, not all that important, etc). But if surgical path, autopsy path, cytopath, etc make up AP, isn't CP 50% of the training at most combined programs? Or do some programs focus more heavily on surgical path than CP?

4) When pathologists talk about specimen volume, on average how long does it take to do say 10 different specimens assuming that there are a few of each type(GI, derm, etc)? Including everything(grossing, dictation, etc)

5) I'm starting medical school in august and I know I would probably want to stay in the southeast. In terms of reputation and what people have heard, how are the path residency programs at Duke, UAB, Vanderbilt, and Emory? What are some university programs in the southeast that are highly regarded in path?


Thanks.

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[Weil-Felix]

I'll try to answer some of those for you...(those of you who have more experience with this stuff please feel free to add to or correct glaring errors)

1) Grossing basically consists of first eyeballing the specimen and attempting to describe as accurately as you can what you see. You describe the type of tissue, color, consistency, and the dimensions. You also describe how it was recieved (in formalin vs. fresh, in a single container vs. in multiple containters). Then, depending on the type of specimen, you will dissect it according to the protocol for your particular lab. Each tissue type is different. Tiny bits of tissue like GI biopsies may not require any dissecton. Hollow organs will be opened, and the contents and mucosa will be described. For example, a gallbladder might be opened, the color and consistency of the bile described , the presence or absence of stones noted, the texture of the mucosa described, and the wall thickness measured. A solid organ might be serially sectioned, and the tissue would be examined for defects that might not have been seen on the surface. For larger specimens, generally a few representative sections are taken and placed in cassettes. What parts of the tissue you sample depend on a lot of things, like your particular lab protocol, your own personal technique, what type of tissue you are grossing, and whether you see any defect that deserves a closer look. Then, you give the cassettes to the histotechnologists who will embed the tissues in blocks. They will then cut these into thin sections and place them on slides to be stained.

2) Bone marrow biopsies are not performed by the pathologists at many (most?) institutions. Often, the heme-onc folks do it. The place where I will be going for residency has the path residents perform all of them, but I have been told that is somewhat of a rarity. I have only watched, and it doesn't LOOK hard, but I guess I'll have to wait until I actually try one before I can really say...

3) It's true. Some residency programs really do not emphasize CP. I have heard that at some places, CP rotations consist of being given some reading material and being told to "go read".

4) How long it takes you to gross in ten specimens totally depends on your own speed, and just what type of specimen it is. I have seen residents take over an hour to gross in a single really complicated specimen. But ten straightforward specimens could take you less than fifteen or twenty minutes. Simple GI biopsies take all of about 30 seconds.

5) I know nothing about those programs, but I'd be willing to bet that there are a lot of people here who do know about them....

 

[yaah]

Some residency programs really do not emphasize CP. I have heard that at some places, CP rotations consist of being given some reading material and being told to "go read".

A private practice pathologist told me that this is a big weakness of many of the larger and more famous programs. They, in his words, do not train future community pathologists very well. Having visited many of these programs, it seems like this is partly true, although most of them seem to be doing a bit to improve their CP programs. There still are programs out there where your CP rotations consist of a couple of hours of work and lecture with most of them time spent doing whatever else you please. Some pathologists think that this is basically useless if you are ever planning on a private practice career with any significant CP involvement (and, if you are going into private practice, you pretty much have to be CP certified). A lot of CP is increasingly automated and it takes extra time and effort to teach it well, so programs have to put more work into it. When you go on interviews, ask about this, and where the graduates end up, and whether they think that the CP preparations they get are sufficient. You may not get completely honest answers to direct question (more often will get spin) but indirect questions can be illuminating.

On the grossing issue - certain specimens are notorious for simply taking a lot of time to deal with. Mostly, these are specimens that involve lymph nodes buried in fat (colons, radical necks). Bladders are a pain. Prostates take some time to learn, but once you do and get a systematic way, it gets easier. Things with bone in them are irritating because bone needs to be either sawed or decalcified prior to cutting. The longest I ever took on a specimen was probably an irradiated rectal cancer (probably 1 1/2 hours), and the reason this took so long was the attending told me I had better find at least 8 lymph nodes or I would be going back. Irradiation and chemo to lymph nodes results in severe shrinking of lymph nodes. The largest lymph node I found in that case was still less than 2 mm. And there was a lot of fat in this rectum. Times do improve with practice.