How much of the patient's *case* does the pathologist see?

[Chrismander]

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Ok, kind of a dumb question, but i just started my 3rd year (took time off for research), so bear with me as i haven't done a path rotation yet.
i love the science, histology, pathophys of path, but i'm wondering how much pathologists get to see the "big picture" of the case they're working on.

I.E. I presently have a patient on the medicine service with a honkin' 5X5 cm lung mass discovered incidentally. They bronch'd her and sent a biopsy down to path. What does the path dude actually see and do? In my picture of the worse-case scenario of modern medicine, he's sitting at a microscope with an assembly line of slides going past him, just reading what he sees (like an average radiology read) and jotting it down. Is this how the majority of path is, or on tough cases do you end up reading a brief outline of the case to put it all together? Obviously on a case like this, the clinical history is probably next to useless and everything is going to come down to the histology, but on other cases I could envision someone using the clinical picture along with the pathological data to make the diagnosis.

Part of the attraction of something like Heme-Onc for me (despite the hell of 3 years of IM) is this image i have that you get to match up the clinical picture with the pathological picture, which is a lot more intellectually satisfying to me, even if it means i'd have to put up with bull**** patient care. or is that just BS, like do the heme-onc people just see patients day in day out and read the path report without ever looking at the slide or thinking much for themselves?

Basically I hate eliciting stuff from the patient (hate having to ask the same friggin question 10 times in a row to get a simple one word answer, because the patient is so spacey or talkative or equivocal) and have no problem giving up "patient contact", but I want to know if that means I'll give up some of the intellectual part of seeing the entire case--in other words, do pathologists just become technicians of sorts whose job is just to read the slide without context?

Thanks for your help!
Chris

 

[Gene_]

I.E. I presently have a patient on the medicine service with a honkin' 5X5 cm lung mass discovered incidentally.

Go find the resident who signed out the case and ask them if they would show it to you. They might tell you to get lost, but I doubt it. You'll then get to see what a pathologist does.

 

[DarksideAllstar]

I would look at it like this. We do not look at slides as if we are in a vacuum. For instance we typically correlate with radiographic findings, prior biopsies and diagnosis, as well as clinical presentation. This means that we have a fair amount of interaction with clinicians in arriving at a diagnosis. Are there cases that you can sign out without much more than your gross and micro findings? Sure. Are there cases where you need to call clinicians for more history? yes. Does it always help? No. Does it piss you off? yes.

I used to think that it drove me up the wall when I would repeatedly ask the same patient the same questions the exact same way and get different answers. Now it just happens with the clinician. Not in frequently (and particularly from a surgeon) you will get a history that is incomplete or flat out wrong. You live and learn. I would much rather deal with clinicians than directly with patients any day of the week, and I feel like I see enough of the cool stuff about a case that I dont want to run off to the oncology floor to listen for egophony due to post-obstructive pneumonia secondary to a big fuukin tumor and try and localize that ****e.

Anyway, hope this minirant was helpful.

 

[deschutes]

When looking at GI biopsies, we'd want to know what endoscopy showed.

When looking at chest wall resections, we'd definitely want to know what imaging showed.

So we use the electronic medical record for op notes, referral notes, patient's PMHx/PSurgHx and the lab record for previous encounters. As well as figuring out whether or not TB is a concern with a lung specimen, or Hep C with a liver.

As a clinician, I think most of the path you'd see would be at weekly interdepartmental conferences, the mileage of which varies depending on the institution.

I had a patient whose chest imaging was suspicious for inflammation vs infection vs lymphangitic carcinomatosis. Biopsy looked like interstitial pneumonitis, no cancer. The clinicians had been wondering if nitrofurantoin could cause something like this. Histopath wouldn't tell you what the drug was, hence the ever-present "clinical correlation is required".

 

[pathres2]

the key is that, as a pathologist, you may often interact with the clinician but almost never with the patient. even though clinicians can be annoying as hell, especially when they have no clue what you are talking about, they are definitely less annoying than trying to get meaningful histories from patients.

the way medicine is going there is increasing subspecialization and division of labor. that is, i seriously doubt that hem-onc people have the time (or the interest) to look up/know the pathology of their patients. whenever they come over to "look at an interesting case with you," most of the time it is because they think it will speed the case up and they will get their diagnosis and grade/stage information faster so they can go back and treat the patient.

the dichotomy is getting clearer as time goes by: path/rads - diagnosis, medicine/surgery - treatment, psych - i don't know let's talk about it, aneshtesia - is it time for lunch yet?

as your third year goes on see which part of the divide you prefer and take the opportunity to go over to the path department and see how they are working up the cases you come across during your rotations. you will get a feeling for pathology (without investing a whole elective yet) and you will actually score points with your clinical team as you will get more info on their patient and get back to them with differentials, etc. maybe even do a short presentation...

 

[yaah]

A clinical history is vitally important to a pathologic diagnosis. To be sure, a core biopsy of breast cancer is not usually a case in need of significant clinical history if it is a standard ductal cancer. But it could be a recurrence or the patient may have a history of another tumor, etc.

Many pathologists in private practice often have to work only with what is on the requisition form. And too often, clinicians do not take this seriously. They list the site and under diagnosis will put, "Rule out cancer," or "rule out colitis." A properly filled out requisition will include the reason for the biopsy being done. i.e. in a case of colitis, "patient has 2 months of non bloody diarrhea, serologic and microbiology studies unrevealing, colonoscopy normal." But for some reason people often have trouble with taking the time to fill it out, even though it could help their diagnosis out. And it will simply say, "Diarrhea."

Interestingly, there are some clinicians who think that if they avoid giving a good history, it will help them out, because the history won't be there to "bias" the pathologist. So if the patient has colon cancer and a new lung mass, they will leave off the history of colon cancer because they want the pathologist to make sure they consider that it might be a primary lung cancer. It's hogwash because no honest pathologist would practice like this, but it happens.

Here we are lucky too, we have an electronic medical record which is accessible, including notes and lab studies. While they don't often make the diagnosis, they very often help to confirm it or force us to rule out something. It's very uncommon that you look at biopsy, then look at the history and decide it has to be something completely different. What usually happens is that you look at the biopsy, get a general impression, and then look at the history and see what in the biopsy is consistent with what is in the history.

Cases where clinical history is vital: Derm (particularly rashes), GI colitis cases, interstitial lung disease, infections. Cancers it is usually not as vital, although for many soft tissue lesions it is important - cartilage tumors, for example, require radiology information for accuracy.