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b&ierstiefel
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A while ago, sacrament (nickname sac, or nutsac) expressed his opinions about pathology. One point he made was that signout was not all that different from rounding. His post was genius and hilarious and we actually have his post tacked on a bulletin board (with the label, "Read...Funny." or something to that effect) for all to see.
I agree with a lot of the things he said and I wanted to make a point by point comparison between surgical pathology and clinical medicine just for fun and kicks (and maybe to rant just a tad).
I. Patient presentation:
Clinical medicine - patient comes into the ER or clinic with a complaint.
Pathology - a specimen arrives at your grossing bench.
II. Initial evaluation:
Clinical medicine - well, of course, you look up the history on the patient and then proceed to do an H&P. Your findings will guide management of the patient.
Pathology - Well, you can't really take a history since fragments of tissue or organs or tumors can't really talk back at you. So that comparison is moot. But you will look up the history to see why the specimen landed on your bench to begin with. This will guide how you examine the specimen and what details you will focus on and look for (kinda like doing a physical exam on the specimen).
III. Evaluation by attending (signout) / Rounds
Clinical medicine - OK, so your patient is admitted to the floors. You put in orders and the patient is tucked for the evening. The next morning, you pre-round and then you and the attending go over the patient presentation and physical findings.
Pathology - OK, so you describe the specimen and then you submit relevant sections for histologic evaluation. You preview the slides (kinda like prerounding) and then the next morning, you show the slides to the attending at signout with your impressions.
IV. Dispo
Clinical medicine - After rounding, you make the decision to: (1) run more tests; (2) discharge the patient; (3) consult various services (aka run around the hospital to find various attendings) to guide management. Sometimes you have to go back to the patient to get more history or try to elicit more physical findings.
Pathology - At signout, you can: (1) simply sign out the case with a diagnosis (that's the best case scenario cuz you discharge the case from your queue); (2) go back to the bucket to submit more specimen (this f*cking blows; you're not discharging the case 👎 ); (3) put in orders for some of the sections to be examined via immunohistochemistry or special stains (i.e., gram stain, AFB, fungal stain, mucicarmine, etc) or request additional levels for some sections (i.e., you're still not discharging the case 👎 ); or (4) consult various services (aka run around trying to find the attendings to show the slides; you're STILL not discharging the case and it stays in your queue 👎 ). (See Note).
Note: Now now, before all you patient care enthusiasts start getting sand in your vaginas, let me say this. Further work up is important and, in many cases, inevitable. The goal is to provide the clinicians with the best diagnosis so that they can go back to the patient and make the right management decisions. The responsibility we have as pathologists is very VERY humbling.
V. Discharge
Clinical medicine - Yeah, you better try to do this quickly because in a few days your team will be entertaining new admits to your service and you don't want your queue to get longer and longer. But in any case, when you discharge your patient, he/she is gone! Yippee!
Pathology - The bucket of the now macerated specimen is stored. The slides are filed. Your queue gets shorter. And everybody is happy. Of course, by this point, you're probably getting a new batch of specimens to keep the cycle going.
VI. So you've made it! You're the attending and you wear the daddy pants!
Clinical medicine - You don't spend all day on the floors. Why? Cuz you got residents doing all the scut for you! The residents will update you as need be.
Pathology - After signout, you're done! Why? Cuz you got residents doing all the scut for you! The residents will bring the new slides or consult info to you and all you have to do is, "OK, good job" and signout the case!
----------
Reflections, Conclusions, Perspectives:
Some of us pathologists cite not having to do an internship year as one of the many reasons to do pathology residency. Reality check - it's not all that different from clinical medicine. When you are on surgical pathology, you are still a scut bitch who runs around doing ****. You ARE an intern. Except, it's not limited to one year. You're doing this stuff whenever you're on a busy surgical pathology service. And at times, it can be good. And at other times, it can simply blow donkey balls.
Hi, my name is Andy Milonakis. I am an intern. I am everybody's bitch and I seriously need a f*cking vacation.
I agree with a lot of the things he said and I wanted to make a point by point comparison between surgical pathology and clinical medicine just for fun and kicks (and maybe to rant just a tad).
I. Patient presentation:
Clinical medicine - patient comes into the ER or clinic with a complaint.
Pathology - a specimen arrives at your grossing bench.
II. Initial evaluation:
Clinical medicine - well, of course, you look up the history on the patient and then proceed to do an H&P. Your findings will guide management of the patient.
Pathology - Well, you can't really take a history since fragments of tissue or organs or tumors can't really talk back at you. So that comparison is moot. But you will look up the history to see why the specimen landed on your bench to begin with. This will guide how you examine the specimen and what details you will focus on and look for (kinda like doing a physical exam on the specimen).
III. Evaluation by attending (signout) / Rounds
Clinical medicine - OK, so your patient is admitted to the floors. You put in orders and the patient is tucked for the evening. The next morning, you pre-round and then you and the attending go over the patient presentation and physical findings.
Pathology - OK, so you describe the specimen and then you submit relevant sections for histologic evaluation. You preview the slides (kinda like prerounding) and then the next morning, you show the slides to the attending at signout with your impressions.
IV. Dispo
Clinical medicine - After rounding, you make the decision to: (1) run more tests; (2) discharge the patient; (3) consult various services (aka run around the hospital to find various attendings) to guide management. Sometimes you have to go back to the patient to get more history or try to elicit more physical findings.
Pathology - At signout, you can: (1) simply sign out the case with a diagnosis (that's the best case scenario cuz you discharge the case from your queue); (2) go back to the bucket to submit more specimen (this f*cking blows; you're not discharging the case 👎 ); (3) put in orders for some of the sections to be examined via immunohistochemistry or special stains (i.e., gram stain, AFB, fungal stain, mucicarmine, etc) or request additional levels for some sections (i.e., you're still not discharging the case 👎 ); or (4) consult various services (aka run around trying to find the attendings to show the slides; you're STILL not discharging the case and it stays in your queue 👎 ). (See Note).
Note: Now now, before all you patient care enthusiasts start getting sand in your vaginas, let me say this. Further work up is important and, in many cases, inevitable. The goal is to provide the clinicians with the best diagnosis so that they can go back to the patient and make the right management decisions. The responsibility we have as pathologists is very VERY humbling.
V. Discharge
Clinical medicine - Yeah, you better try to do this quickly because in a few days your team will be entertaining new admits to your service and you don't want your queue to get longer and longer. But in any case, when you discharge your patient, he/she is gone! Yippee!
Pathology - The bucket of the now macerated specimen is stored. The slides are filed. Your queue gets shorter. And everybody is happy. Of course, by this point, you're probably getting a new batch of specimens to keep the cycle going.
VI. So you've made it! You're the attending and you wear the daddy pants!
Clinical medicine - You don't spend all day on the floors. Why? Cuz you got residents doing all the scut for you! The residents will update you as need be.
Pathology - After signout, you're done! Why? Cuz you got residents doing all the scut for you! The residents will bring the new slides or consult info to you and all you have to do is, "OK, good job" and signout the case!
----------
Reflections, Conclusions, Perspectives:
Some of us pathologists cite not having to do an internship year as one of the many reasons to do pathology residency. Reality check - it's not all that different from clinical medicine. When you are on surgical pathology, you are still a scut bitch who runs around doing ****. You ARE an intern. Except, it's not limited to one year. You're doing this stuff whenever you're on a busy surgical pathology service. And at times, it can be good. And at other times, it can simply blow donkey balls.
Hi, my name is Andy Milonakis. I am an intern. I am everybody's bitch and I seriously need a f*cking vacation.
Suck my balls, breast service!
