Questions regarding Pathology: considering spec. change

[Cica]

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Hello

I am considering make a switch in career from Internal medicine to Pathology. The other fields that I am interested in are : Opthalmology and ENT. I currently work in Norway.

I had some important questions or concerns that are making me wonder if I should switch to Pathology. Was hoping some of you with experience can share your opinion.

- I was wondering if one gets really tired or bored eventually of looking at slides every day? And if so what do you do ?

- Here in Norway, you have to do gross dissection (makro- dissection: its called here). Does the disgust you or you just get over it. What about inhaling all those fumes from the samples?

- I really liked Pathology in med school and as well as in my internship (when I make voluntary visits to the patho. dept.): But am wondering if I will be able to tolerate autopsies after so many years or if it is something that you just get used to. I do not have the possibility of visitng a Patho. dept. right now, cos I cannot travel to a bigger hosp. with a patho dept. right now. So I guess what I am basically asking is , I guess, do you get used to the autopsies, does it eek one out, how does it affect you how you feel after work and just before lunch? And what about all those odours?

- DOes anyone regret changing from a clinical field to pathology after a while and if so why? (I guess I am wondering if I would regret leaving this place for another place - have a g reat learning opportunity here in internal medicine).

Well i guess hthese are my questions for now, hope that some of you can share your experiences or advice. Thank you in advance.

🙂

 

[pathstudent]

- Here in Norway, you have to do gross dissection (makro- dissection: its called here). Does the disgust you or you just get over it. What about inhaling all those fumes from the samples?

I love the smell of formalin in the morning. You know, one time I had grossed for 12 hours. When it was all over, I walked up. I didn't find one of 'em, not one stinkin' specimen. The smell, you know that formalin smell, the whole gross room, smelled like victory. Someday this war's gonna end...

 

[Pathologee]

I agree. Whats not fun about grossing? You actually get to do something with a blade, knife, saw, camera, hammer, radioactive seeds, paint and/or a myriad of dangerous chemicals. It is like kindergarten, only you get a digital camera instead of film.

To me, it is less disgusting than unwrapping a diabetic foot or debriding a sacral wound. Fixed specimens dont say ouch or try to get you to sign their form so they can get a handicapped parking tag. Fresh ones do sometimes, but you just pummel it until it stops bleating.

Formalin is great. The fumes you inhale prevent you from getting pneumonia or sinusitis. The only drawback to grossing is that formalin destroys the y chromosome in your sperm so you can only have girls.

Grossing is the fun part of pathology and you can make the diagnosis 95% of the time. Embrace it!

I love the smell of formalin in the morning. You know, one time I had grossed for 12 hours. When it was all over, I walked up. I didn't find one of 'em, not one stinkin' specimen. The smell, you know that formalin smell, the whole gross room, smelled like victory. Someday this war's gonna end...

 

[Cica]

Hey

Ya the thing with fumes is that I have asthma. So am a bit concered about it. Also, I am thinking if I get pregnant in the future, how that would work out in relation to work and such.

 

[smallcat]

Re: Fumes- any good, law-abiding pathology dept will have well-ventilated laboratories with hoods so that you aren't in any kind of danger from fumes. Levels are definitely low enough that it's not an issue wrt pregnancy. Of course, my kids are a little weird.

Re: autopsies- I don't know how it is in Norway, but most surgical pathologists don't spend much time doing autopsies. They are the exception rather than the rule when it comes to daily work.

In my opinion, grossing a hysterectomy is way way way less gross than cervical mucus in vivo.

Re: Boredom- yeah, it gets boring once in a while. But my IM friends tell me that managing patients with diabetes and trying to convince patients they don't need abx for their viral illnesses gets kind of boring, too. The good thing about path is that you can almost always take a break, take a walk, do something else for a few minutes, then come back. No patients on a schedule waiting for you.

The only people I've known who regret switching from clinical medicine to path are those who did so for the wrong reasons- not because they liked path, but because they hated general surg/IM/peds/whatever and were looking to get out into an "easier" field.

 

[KCShaw]

Pretty much agree with previous posters.

Most of your questions are ones that could probably be addressed with a rotation in a working pathology department. I realize that may be difficult now, but it's still the best thing I can recommend.

Slides -- staring at slides much of the day isn't for everyone. It was my biggest concern when I started, but I knew I enjoyed visual diagnosis (autopsy, gross/macro), and was fortunate that using a microscope as part of that grew on me well enough. The more you know what you're looking at, I think, the easier it is to look at microscopic slides for extended periods -- you eventually stop staring blankly hoping for something to make sense. And, of course, you can break up any "monotony" pretty easily, as people have said.

I never really got grossed out by gross dissection or autopsy; yeah, there may be nasty smells on occasion (decomposition, certain necrotic infected specimens, etc.) and unpleasant histories with some of the autopsies (especially forensic, but only a very small percentage of pathologists in the U.S. are involved in that), but the purpose of and interest in what you're doing tends to override any eekiness. The only "fumes" of much concern is related to formalin, but a proper dissection table and a little training alleviate that.

For the most part, people who might not like a certain aspect of pathology tend to get used to it and tolerate it in exchange for the parts they love. I think this is pretty true for any job.

 

[Cica]

Hey
Thank you for the messages/advice so far.

The thing is that, I finished med school in 2003 and then I did a MSc. and after that I started workingin Norway. Here in the Norway the system is that one has to do something like an internship in general surgery, internal med. and family med. before starting eventual spec. So back when I was in med. school, I really enjoyed both pathology and forensic pathology and the same for ENT and ophthalmology. When I was done with med. school I really wanted to get into Opthalmology (since family didnt really support idea of patho.).

So thats why I am a bit uncertain (cos alot of time has passed since I regularly visited the patho. dept. and had to deal with gross dissection and autopsies. Also, this would be different from med. school in the sense that one has to do it for many years 🙂

Here in Norway, you just spec. in general pathology (meaning you a need a minimum of 200 autopsies amongst other requirements). Also the spec. system is not so simple as in North America (you may have to move around during you career to several hospitals in order to try and finish your spec.). And as in N. America, its not so easy to get into opthalmology and ENT. I am genuinely interested in these fields and am just having a hard time deciding. I would like to probably move before summer (into something else - am in internal now 🙂

 

[2121115]

?!??!?!?!??!

200 autopsies ?!?!?!?!?!?!?!?!?

 

[Cica]

Yes, 200 autopsies is one of the requirements in order to finish specialisation here (incl. the microscopic examination from each patient). In general here in order to specialise in most specialities, there is a list of procedures and courses that one has to fulfill in order to specialise. Course, one has to be knowledgable in certain areas too depending on the field.

 

[KCShaw]

That's a somewhat familiar system. More than Norway seem to do this -- i.e., new graduates must do a year or several of general medicine before tracking into "physician", "surgeon", "radiology", "pathology", etc. disciplines, as opposed to jumping directly into one of them straight out of medical school. This provides more junior staff for cross-coverage, but may take a little longer before you finish subspecialty training. It also means that the average physician (IM, endocrine, cardiology, etc.) has a little better grasp of surgery by having spent time covering surgical wards, and the average surgeon has a little better grasp of physician issues. For what it's worth. I don't really know how other places handle radiology or pathology specifically, but the generalist concept is familiar.

In the U.S. most pathology residents and attending pathologists complain about doing autopsies, and some suggest eliminating hospital autopsies altogether, despite numerous articles over many years indicating a significant percentage of missed or inaccurate diagnoses even in the face of improving diagnostic imaging, etc. Much of this I think has to do with reimbursement and the feeling that not getting paid for it equals a waste of time, and this disenchantment is passed on to new residents. We're now down to requiring only 50 (unless it's dropped again) autopsies over 3-4 years, many or possibly now all of which can be shared with another resident. That's one reason some people balk at the idea of having to do 200.

 

[gschl1234]

Yes, 200 autopsies is one of the requirements in order to finish specialisation here (incl. the microscopic examination from each patient). In general here in order to specialise in most specialities, there is a list of procedures and courses that one has to fulfill in order to specialise. Course, one has to be knowledgable in certain areas too depending on the field.

What % is medical vs. forensic?

 

[Cica]

Is there a spec. requirement in North America for macro-dissection (thats what its called here - guess its the same in English too)? Here there isn't any specific requirement for that. In bigger depts. its mostly the residents who take care of that while the senior doctors, do the histology and help out of with autopsies.

With regards to forensic or medical patho., its basically up to the individual what they want. There is no requirement to do forensics in order to specialise, but one can make it a part of their spec. if they like.

 

[gschl1234]

With regards to forensic or medical patho., its basically up to the individual what they want. There is no requirement to do forensics in order to specialise, but one can make it a part of their spec. if they like.

I ask because in the United states it would be impossible for residents to rack up 200 (non-shared) autopsies unless a significant number were forensic. Are medical autopsies really *that* common in your country? Or do residents spend >24 months on autopsy service? Our atuopsy service is considered busy (~400 per year) covered by 1st and some 2nd year residents which works out to ~12 residents on autopsy per year (~30-35 cases each). On my Medical Examiner rotation, I met a resident from a program that has less than 10 autopsies per year. They share like crazy and fill out their required 50 with extra autopsies on their forensic rotation. Historically autopsies were much more common, though. An old attending told me that back in the day when "autopsy was king" there were over 600 per year and the first year was entirely autopsy. Yup, 12 months straight of medical autopsy (which, apparently, used to be much more *involved* than it is today where the dissection took at least 6 hours per body).

 

[KluverB]

... Are medical autopsies really *that* common in your country? ...

Although the trends are waning, mainly due to costs, in most European countries, every decedent (including all in-hospital deaths) gets an automatic autopsy, baring major objections by the family (though, I'm not entirely sure about Norway, specifically).

 

[KCShaw]

It used to be that way in the U.S., at least in that every in-hospital death was assumed to have an autopsy unless an objection was raised. Now it's assumed that no autopsy will be performed unless a request is made (usually by a physician, sometimes by family) and permission granted (by next of kin). It also used to be a requirement of hospital accreditation to autopsy a certain percentage of in-hospital deaths, which slowly tapered off over the years.

In the U.S. we generally use the term "gross dissection" or "gross exam" when we're talking about inspection, description, and cutting/dissection of a surgical specimen from the operating room with small sections then placed in a cassette for histology/microscopic slides. Gross dissection in training centers is typically handled by pathology residents on surgical pathology rotations, and the slides at least for the larger specimens reviewed by the same resident and signed out with the attending a day or two after being grossed in. We do sometimes use the term "macroscopic" / "macroscopically" simply to differentiate from microscopic examination, but for the most part instead of saying "macroscopic exam" we use "gross exam". We can basically interchange gross & macroscopic when talking among pathologists but NOT in casual conversation outside of pathology where "gross" still generally means yucky or unpleasant.

We report the number of surgical specimens we examine during residency when applying to take the board examination, but no hard-and-fast numerical requirement.

 

[pathstudent]

What needs to be addressed is that 4-6 months of AP residency training is spent on Autopsy simply to cover the service, when the truth is that most academic attendings will never perform one if not on the autopsy service and supposedly they are becoming rarer and rarer in private practice, and certainly if you go work for a pod or reference lab you will never do one. It seems like a disproportionate abount of training is spent on them.

 

[KCShaw]

I think people forget that handling autopsies as a resident isn't just about learning to do an autopsy. It's also in part about actually seeing and contributing to the clinicopathologic correlation, learning more gross pathology, and learning histology (not just tumor path, but expanding foundations in nontumor path too). But I do agree that many autopsy services are so slow that there is more dead time (ha ha, ho ho) than there should be, so disproportionate time spent is probably a fair term to apply given that one really should be able to train up then perform 50 autopsies in a couple months, 3 tops..if we're just looking at the numbers, anyway.

 

[Cica]

Hey

In Norway from my understanding, medical autopsies are not carried out automatically. One has to request it followed by an approval by the family. In my opinion they seem to be uncommon. The frequency of autopsies in Norway has fallen significantly in the recent years , making it more difficult to meet the autopsy requirement in order to specialise. I believe the autopsies during residency are some what divided amongst the residents in order to meet the requirements. Since autopsies are not that frequent, one does other things at the same time (histology, surgical speciments, etc.).

 

[Cica]

On another note, I may start Pathology after summer. I was wondering if you guys can recommend some good books for:
- Histopathology
- Gross dissection
- Pathology (either atlas or any other good book).

My books from Med. school are all the way at my parents place and I do not think I will be able to get them before summer. Hence, I thought I could buy some recommended books and start reading up (in case if I decide to make the switch).

Thank you in advance 🙂

 

[gschl1234]

On another note, I may start Pathology after summer. I was wondering if you guys can recommend some good books for:
- Histopathology
- Gross dissection
- Pathology (either atlas or any other good book).

My books from Med. school are all the way at my parents place and I do not think I will be able to get them before summer. Hence, I thought I could buy some recommended books and start reading up (in case if I decide to make the switch).

Thank you in advance 🙂

Gross dissection (of surgical specimens, not autopsy): Surgical Pathology Dissection: An Illustrated Guide (by WH Westra, RH Hruban)

Pathology (surgical pathology): an easy overview to start with is The Practice of Surgical Pathology: A Beginner's Guide to the Diagnostic Process