Pathology Musings

[sacrament]

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I now am deep into my pathology elective, which I have looked forward to ever since my first clinical encounter with a patient. My thoughts follow in outline form.

I. No Patients
a. There really are no patients. They weren't kidding. I mean, the pathologists will refer to autopsy specimens as "patients" in a euphemistic, P.C. sort of way, but personally I think the removal of your brain precludes you from being labelled a "patient."
(i. Autopsies, btw, are the coolest f-ing thing I've been a part of since I started medical school, and if medical examiners didn't make approximately the same salary as Wal-Mart greeters, I'd have found my life's passion.)
b. The fact that there are no patients gives me a kind of joy that previously was reserved for fornication and well-prepared steaks.

II. The Phenomenon of Inexplicable Excitement
a. Pathologists get excited about things that I cannot imagine myself ever getting excited about. "HOLY MOTHERF'ER, everybody get in here! Everybody come look at this!" Twelve pathology residents sprint into the room and plaster their eyeballs against a multi-headed microscope. "OMG, do you see that? Do you see that? That's a TINKERMYER CELL. It's like a plasma cell but not quite because it's got a little orange speck in it! Holy jesus!" The first few times this happened, I thought they were joking, but they aren't.
b. Okay, so I get it, Tinkermyer Cells and Woozlebonkle Complexes and Trout Bodies are rare or something. It's also rare to see an episode of "Welcome Back Kotter" in the afternoons on TBS, but if it happens I'm not going to give a sh1t about it. Maybe I just don't know enough about pathology to realize how rare and special and amazing these slightly off-shape cells are.

III. The Myth of No Rounds
a. I have heard three pathology residents say that one reason they went into pathology was because they hated rounding.
b. I think this is absurd.
c. Because:
d. What the hell is sign-out, if not rounds? Except that you get to do it sitting down? A resident presents a case, gives some clinical history, everybody takes a look, attendings wax on philosophically about differentials with increasingly subtle findings, some pimping occurs, a tentative conclusion is arrived upon, and you move on to the next case. In what fundamental sense is this different from rounding, except that it lasts substantially longer than any rounds I've ever been a part of, except possibly neurology?

IV. Cytology Is 50% Imagination and 50% Utter Fabrication
a. I have absolutely no choice but to believe this.
b. Previously, I thought that radiologists were the masters of medical B.S. ("This lucency here, see that... squint a little, see it? That's an ectopic kidney.")
c. Radiologists have nothing on cytologists. ("See how these cells here are plump? Plump and dusky and fluffy? That's an ectopic kidney.")
d. BTW, why must everything in medicine be given utterly non-descriptive terms? Nothing in medicine ever looks, feels or sounds like it is described. The hippocampus looks like a seahorse? To who? Somebody on mescaline? "Ground-glass" patterns? "Woody" edema? "Nutmeg" liver? None of these make any sense.

V. The Myth of Cushy Hours
a. I don't think I've yet seen a resident leave that place before 6 PM.
b. WTF.

Anyway, I definitely haven't fallen in love with pathology, but I can usually muster up a mild sense of interest at least a couple of times a day, which I suppose is more than I've been able to say about most things I've done in medical school.

 

[deschutes]

Oh sacrament, you made my morning!

I think this is particularly quote-worthy:

"...Twelve pathology residents sprint into the room and plaster their eyeballs against a multi-headed microscope."

What the hell is sign-out, if not rounds? Except that you get to do it sitting down?

That is the whole point 😀 Elegant in its simplicity. And the evidence is right in front of your eyes!

My curiosity is piqued - I couldn't find your tinkermyer cell on Google. Will you let me know how it is spelt?

I just saw a f@gg0t cell (in acute promyelocytic leukemia) yesterday from teaching files... better than any image online. ("F@gg0t" being, unlike what many would think, a bunch of sticks - just as "gay" was once non-denominational, I guess. And yes I had to spell it like that, since it is one of the seven bad words on SDN.)

 

[sacrament]

My curiosity is piqued - I couldn't find your tinkermyer cell on Google. Will you let me know how it is spelt?

It's spelled "Tinkermyer" and I know this for a fact because I'm the one who made it up.

 

[deschutes]

It's spelled "Tinkermyer" and I know this for a fact because I'm the one who made it up.

I feel cheated out of a Moment of Inexplicable Excitement!

It's 6pm and I'm still in the hospital btw 😉

You gotta adjust your definition of "cushy hours" a little. Cush = evenings and weekends off.

 

[Brian Pavlovitz]

plump?[/i] Plump and dusky and fluffy? That's an ectopic kidney.")
d. BTW, why must everything in medicine be given utterly non-descriptive terms? Nothing in medicine ever looks, feels or sounds like it is described. The hippocampus looks like a seahorse? To who? Somebody on mescaline? "Ground-glass" patterns? "Woody" edema? "Nutmeg" liver? None of these make any sense.

This is one of the best posts that I've ever read!!! As a once-upon-a-time cytotech, I can really identify with this (and for the record, I've never seen what "ground glass" is. I suppose I should go break a window and throw it into the ol' cuisinart...).

Still, the items that you mentioned are just some of the things that make Pathology such a great field.

 

[b&ierstiefel]

brilliant post, nutsac.

 

[yaah]

It's 9:15pm and I'm still here. 😳 But then again, I have enjoyed my day. I don't want to be here that much longer though.

I agree about cytology - I always find that when I see a cytology slide, once they know what it is (either by history, or from the cell block, or because the thing has already been excised and diagnosed and the cyto slide is being shown as a teaching slide) the cells suddenly take on the persona of the diagnosis.

Sign out >>> Rounds. Rounds is like pulling teeth. You actually learn things at signout.

 

[DasN]

Sacrament
If you have problems relating information that doesn’t walk or talk as not "a patient" you have some serious problems. The way you look at the process and your assessments on medicine in general is messed up. We answer the questions that you can’t figure out, and what you feel that the most important part (for you treatment and prognosis) is a lot of the time based on what we find. If we don’t view our material as patients then you are in serious trouble, because patient care is of utmost importance in pathology. We may not make small talk with them often but we provide the hard evidence that allows what the patient ultimately wants, a cure or treatment. So just because on the surface it may seem boring to you think twice before you put your foot in your mouth. Yes you may have heard of decent lifestyle ect but you would never choose a career in something that just provides the perks. I believe most pathologists have to understand their crucial role in patient care. Those who don’t will become disenchanted and leave. This is the same for all fields. You will figure it out one day. Im not saying that you should be overly enthusiastic about a particular field but not so damn negative. Hopefully you won’t be disenchanted with every field by then.

 

[sacrament]

Sacrament
If you have problems relating information that doesn’t walk or talk as not "a patient" you have some serious problems.

If I don't call a glass slide a "patient" then I have problems? Wander into your next sign-out and proclaim that you have eight trays of patients in your hands and then gauge the general response.

The way you look at the process and your assessments on medicine in general is messed up. We answer the questions that you can’t figure out, and what you feel that the most important part (for you treatment and prognosis) is a lot of the time based on what we find. If we don’t view our material as patients then you are in serious trouble, because patient care is of utmost importance in pathology. We may not make small talk with them often but we provide the hard evidence that allows what the patient ultimately wants, a cure or treatment.

OHHH, pathologists are like important or something? Uh, lemme toss a giant NO SH1T your way. A job that is important and yet doesn't involve patients... hmm, why do you think I've been interested in pathology since day... well, not day one, because I didn't see a patient on day one. But like day twelve or something. Do you think pathology is a required rotation for me, something I'm just slogging through? Do you think I'd waste a valuable elective spot (of which I'm basically getting only three during my fourth year) on something I place no value on? You've wasted your ATP on this bizarre self-righteous rant if you think if you're doing something other than preaching to the choir.

So just because on the surface it may seem boring to you think twice before you put your foot in your mouth.

At no point did I ever say that I think it's boring. I said I don't crap my pants over slightly wrinkled cells. This is clearly not going to be a great passion of mine, which sucks because it was essentially my last hope to have a truly enjoyable career in medicine. If you want to convert that in your mind to an attack on the profession, then go right ahead. Somebody in this forum has an enormous self-esteem problem, and I don't think it's me. Jesus, thank god I forgot to include one of my other observations, which is that the pathology residents all seem to have switched out of some other field. DasN the Defensive would be up my ass in a flash: "Yeah well maybe those are people who eventually came to realize the selfless toiling of the noble pathologist and his tray of patients!"

I guess what I'm trying to say is that you can eat me.

You will figure it out one day.

Gee, Dad, will I also be big like you?!

 

[Runtita]

I, too, am considering path because I am an introvert who hates dealing with stupid people aka patients.

Not that all patients are stupid, just many of them. Like the chick I saw during my preceptorship who tried to clear up her rash by taking bleach baths and scrubbing herself with rubbing alcohol. Then her skin peeled off. Duh.

Epidemiology might be nice, too.

By the way, sac, you are a very funny man.

 

[DasN]

one day maybe son

 

[Flankstripe]

This is clearly not going to be a great passion of mine, which sucks because it was essentially my last hope to have a truly enjoyable career in medicine.

I don't post often, but I've been lurking on SDN for a long time, and this is hands-down one of the funniest threads I've ever read. 🙂

I'm a PGY-2 rads resident, happily done with internship about 6 weeks ago, and while residency is showing me that the last 5 years of medical training have been absolutely useless towards my final career destination (translation: like the Path residents, I'm getting my ass handed to me on a daily basis), I can't tell you how awesome it is to get away from direct patient contact.

I've worn a white coat for a grand total of about 15 minutes since the residency started. It's still got the same pristine bleached color to it, and the original creases too. I plan on keeping the second coat they gave me at orientation in its original plastic for as long as possible. It's looking good so far. I've seen a total of about 3 patients, none for more than 10 minutes, tops. One of them I had to do a quick H&P on prior to her sedation for an MRI, which was about 12 lines long. Dig it.

I realized that it's probably not politically correct to be a physician and yet take so much glee in not seeing patients, but I'm once again having fun when I show up for work each day. My colleagues are all incredibly happy at work. I haven't seen any sign of bitterness or resentment in their career choice. I couldn't say the same thing about a large chunk of the clinical time in med school and during internship. I have basically no down-time during the day (there's ALWAYS another film to be read) compared with internship (where there's so many points during the day where you can mentally check-out for a few minutes) but I leave the hospital with way more energy compared to when I had clinical duties.

Rads and Path have it all over the other specialties for that reason alone, if you're the kind of person for whom patient care just sucks the life out of you.

sac,

I'm sure you've thought of Rads too (I think of Path and Rads to be mechanically very similar in what we do, and the role we play in patient care when the clinicians don't know what's going on and need an answer). It's a pretty clean field as well, the imaging technology is yielding better pictures with each passing year, and there's all sorts of opportunities in private imaging centers and telerads where you can stay out of the hospital (and away from patients if that's your bag) and have tons of time to devote to other interests.

I think the telerads market is here to stay (particularly for US board-certified rads), and it will continue to be hostile to those radiologists from non-US accredited programs simply because the medico-legal environment isn't going to accept reads from radiologists without ACGME-accredited training. No surgeon is going to take a patient to the OR based on what some guy trained and based in India says is a resectable tumor.

While I can't see radiology salaries going anywhere but down, I think we'll still be compensated at least average compared with other specialties. Imaging is too diversified and inextricably linked to too many other specialties for us to go down without taking everyone else along for the ride. Some of the telerad companies are offering crazy job packages. Standard packages for Nighthawk Radiology and Virtual Radiologic Consultants include 26 weeks of vacation a year. That's a lot of free time to get out and explore your other interests. I'm sure the other 26 weeks are busy and rough, but you work hard and also play hard too.

Check out this Ergopod 500 super-chair you get to use if you sign up with VRC, and do telerads out of your home. They've got another chair out there called the Perfect Chair that comes with the following:

# Easy-to-use, reliable brake control system with Mechlock™ brake for precise position control.

# Two ergonomically-shaped interchangeable pillows: a self-inflating headrest/lumbar pillow and a cervical/lumbar pillow.

# Variety of options for cup holder, upholstery as well as pressure and temperature-sensitive memory foam. Extended footrest is also available for taller frames.

Any specialty where my freakin' chair comes with a self-inflating headrest, BRAKE CONTROL, and a footrest with cupholder is the place to be. I don't think you can get any more obnoxious than that. Luckily, this stuff is situated in your home so that the clinicians won't see it when they head down to the hospital reading room...

Anyway, it's a little late to get going on a Rads application from scratch (although not impossible), but I'd encourage you to consider it hard if Path doesn't pan out like you hoped. You don't even notice the dark room thing after about 2 minutes once you start looking at the pictures...

 

[yaah]

One of the things I find rather amazing about pathology is the simplicity of it all - occasionally we will see biopsies on patients who have been worked up intensively for a vague or a chronic symptom - take, for example, a patient with CRAP (my favorite acronym - Chronic Recurrent Abdominal Pain). One we saw slides on recently had extensive history taking, labwork (to try to rule out inflammatory diseases, liver problems, pancreas, etc etc), abdominal and pelvic radiology, and endured many different treatments of varying success.

Finally, they go to endoscopy, see nothing on the scope except some erythema, but they biopsy stomach, esophagus, duodenum, and colon anyway. It takes us about 5 seconds per slide to determine "No significant abnormality" and the patient is returned to the medical community. Our consultation helps in that it is normal, no abnormality indicating disease. Yet it does not give an etiology which the treatments so far have failed at alleviating.

 

[deschutes]

Rads and Path have it all over the other specialties for that reason alone, if you're the kind of person for whom patient care just sucks the life out of you.

I appreciate your choice of words! Patients are fine, mostly. It's patient care that sucks. I would hate being the primary responsible physician/team/paperpusher, as opposed to a consultant.

On hemepath I "see" patients, and it's fine. I go in there, get the consent, chat as I get the bone marrow, get out. I like it. It's straightforward.

sacrament, now you have me all curious as to what path you will eventually choose! Maybe come back and let us know, say this time next year? 🙂