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DireWolf

The Pride of Cucamonga
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I was wondering what those of you interested in path feel about being the definitive authority on making the final diagnosis? Is this a big concern or something that draws you into the field? I think path is one of the coolest areas of medicine, but I don't know if I could handle the pressure of being the last line of defense so to speak. The entire course of management/treatment usually depends on the pathologist's report. Are there safety nets built into the system to help catch mistakes or are you pretty much on your own?

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it sounds like you better go into Int. Med. or something where you completely rely on others to make a definitive diagnosis. YOu know, where all you do is manage the patient and consult other services.

That will be one of the biggest satisfactions of my job is knowing that I am giving an answer to the patient's question. Typically your colleagues are your support and in rare instance you use so called "experts" at universities who are experts in that organ. However, one community path guy I know said that 99.9% of the time the experts come to the same diagnosis as they made and that they just do it for "quality control" on tough cases both for the patient and for legal reasons.
 
The gov is exactly right. You will always show your difficult cases to your colleagues to get their thoughts. Being the final authority is not as scary as it seems. The key is knowing when you need assistance with the diagnosis. I think that is part of the reason I went into path. Being able to help in the patient's care in such a definitive manner is very satisfying.
 
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Perhaps Neurology would be a good field for you also.
 
I was simply inquiring if the issue of being the final authorithy on diagnosis was considered a positive or negative for those considering pathology - or if it's even an issue at all. Almost every area of medicine carries a huge responsibility where patients' lives are at stake every day. I am not asking for input on what area of medicine I should/could pursue. I am confident that I can handle that responsibility. This post was not meant to express a lack of confidence in myself when dealing with pressure situations- rather to start a discussion of how this particular aspect of pathology is viewed by those interested in the field. The only pathologist I've spoken to at length mentioned he considered teaching rather than private practice because of a few missed diagnoses he made even with the consultation of his colleagues.
 
Originally posted by DireWolf
I was simply inquiring if the issue of being the final authorithy on diagnosis was considered a positive or negative for those considering pathology - or if it's even an issue at all. Almost every area of medicine carries a huge responsibility where patients' lives are at stake every day. I am not asking for input on what area of medicine I should/could pursue. I am confident that I can handle that responsibility. This post was not meant to express a lack of confidence in myself when dealing with pressure situations- rather to start a discussion of how this particular aspect of pathology is viewed by those interested in the field. The only pathologist I've spoken to at length mentioned he considered teaching rather than private practice because of a few missed diagnoses he made even with the consultation of his colleagues.

the pathologist you probably talked to (if it's who i think it is) isn't a very good example of a modern pathologist, IMO. don't judge the field by what he says-- he's a great teacher, but he hasn't been "out in the field" so to speak in quite awhile.

i enjoyed path-- in fact i was down to it and peds for residency. what it finally boiled down to was that I just wasn't ready to give up my stethoscope. i didn't go into medicine to look at slides, flow cytometries, run a lab, or do autopsies-- though i find each one of these things enjoyable, in the end it wasn't what i could see myself doing as a career. not to mention i found myself getting a little stir-crazy while at the scopes signing out (the path equivalent of rounds, lol). path has a lot of upside-- no gomers, good hours, good pay-- and while the sterotypical "pathologist" is still out there, for the most part my experiences with pathologists and residents has been they're pretty much like everyone else.

to address your original question-- while you are the "definitive" answer for diagnoses, you will always have colleagues to bounce things off of. in fact, anything not textbook will usually get passed around at least 2 or 3 times (it's as simple as taking the slide to Dr. XXX and saying, "hey, can you look at this?"). normally there isn't a time crunch (unless you're doind frozen sections) so you have time to look things up as well. anything really really strange you'll send off. so yes, you are it, but nothing is completely on you unless you choose it to be.

another thing that i liked about path is that unlike the medical weatherman, the radiologist, most pathologists will give you an answer instead of a possibility :)

anyway, that's just my take.
 
The pathologist I'm referring to isn't the one you're thinking of, although dr. g did mention something similar in class one time. Thanks for the response- that's exactly what I was looking for.
 
This whole "Pathologists have better working hours" argument is a bit odd, I think. The only real difference I can see is that there are fewer call hours, or at least when on call one does not have to be in house. Sure many pathologists have good working hours, but there are just as many attendings in every other field (except maybe surgery) who have a 9-5 job. Just as many pathologists as other fields work long hours, stay late, etc. In going through 3rd and 4th years of med school, I have come to the conclusion that path residency is just as time-intensive these days with the institution of the new work-hour standards. I may have come in a bit earlier when doing medicine floor or consult electives, but usually left earlier as well. I guess the impression will always be there though.

In regards to "the final word," I find that to be neither a deterrent nor a significant advantage. The more definitive diagnosis is appealing. I agree with the statement that in almost every branch of medicine, being an attending carries significant "end of the line" responsibility. Whether you are the internist who has to decide whether a test is appropriate, the surgeon who has to open someone up, the dermatologist who has to decide when a suspicious lesion needs biopsy, or the pediatrician who has to decide if a child's slow growth is concerning, all branches have their own stress-producing characteristics. For me, the responsibility (in the future) of diagnosing someone's cancer is somewhat intimidating, but I anticipate being prepared for this during residency. Similar to the intimidating nature of having to be the senior person on when someone needs a central line and others are having trouble.

There are some private practice pathologists who do work alone, without any backup for tough cases (except consulting a larger facility which may be hours away). And what happens if you are the pathologist who receives the consults? There will always be varying degrees of stress.
 
Direwolf, I am just giving you suggestions to stuff that is cool, but where you can rely on others to take care of your patients. In medicine, you can consult a millions services when things get tough and just implement their suggestions. I see it all the time even for the simplest things.


Then neruo is a fascinating field with cool physical findings, but only rarely can you really do anything for the patient.

If you are worried about calling the shots, then I would stay out of path.

yaah, I don't know of any path groups that consist of only one guy. It would have to be such a small hospital in the middle of nowhere. And people consult people from all over the country. All you have to do is mail them the slides. It doesn't matter whether they are next door or on the other coast. The only time it might matter is during frozens, then you could only use your compadres, and if you are alone, then you just play it safe and wait for the permanents cuz they can always go back to the OR, but they can't put the organ back in once it is soaking in formalin all sliced up.
 
In regards to path work hours, I think in general, they are better than most fields. True, some clinicians may have office hours from 9 to 5 but then they have to round before and/or after office. They also round on some weekends and their call is much worse than ours. In shift jobs, like ER and hospitalist services, they may have as good of hours but their work day is often much more intense. Not that path is a breeze, but there aren't going to be any codes or nursing home admissions in that pile of slides.

As for residency, the hours can vary. Generally, AP months are busy and CP months may or may not be. Interestingly, we had to submit our hours to our residency affairs department to make sure we made the 80 hour work week limit. It took most of us both weeks to get to 80 hours.

While pathology often is the final word, there are times when we can't give a definitive answer. We can only work with what we are given. For example, today we had a transplant surgeon show us a small intestine biopsy because he was concerned about GVHD. The biopsy was somewhat suspicious for it but we couldn't give him a firm yes or no. I was amazed at how much power we had, though. He basically asked us "Should I lose sleep over this patient or not?". It's at times like those that you realize pathologists are truly the doctor's doctor.
 
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