I thought pathologists only did autopsies and worked with dead people?
We do! But in contrast to the popular image of the television show Quincy, we usually do not run around the city, solving murder mysteries, although it would be interesting! Most pathologists work in hospital laboratories or in outpatient reference laboratories. In private practice pathology, the pathologist spends most of his time directing the operation of the laboratory and diagnosing the biopsies from surgical procedures from the day before. This is the art of surgical pathology, the pathology of the living patient!
Are there specialists and specialties within pathology?
Absolutely! For every specialty in medicine and surgery, there is a corresponding specialty in pathology. This may come as a surprise to many of you. Probably, you have heard of forensic medicine, pathologists who are coroners. But the specialty is as rich and diverse as any field in medicine. Pathology is divided into two major specialties, anatomic and clinical pathology. Anatomic pathology deals with the tissue diagnosis. Clinical pathology deals with the laboratory test diagnosis. Most private practice pathologists are board certified in both specialties (double board certification).
Additional board certified subspecialties include dermatopathology (skin pathology), hematopathology (bone marrows and clotting disorders), transfusion medicine (blood banking and donation of blood products), forensic pathology (coroners and medical examiners of the Quincy type), and cytopathology (Pap smears and fine needle aspirations).
In addition, there is corresponding expertise in every area of medicine and surgery. For example, some pathologists choose to develop expertise in a very narrow field such as bone pathology or kidney pathology. These pathologists usually practice in academic or university settings.
What kind of training is involved in becoming a pathologist?
The pathologist is an M.D. or D.O. Thus in addition to the usual 4 years of college, there is an additional 4 years of medical school. Pathology is a recognized medical subspecialty with board certification. It is one of the longest postgraduate training programs, encompassing 4-5 years. In comparison, internal medicine and pediatrics are only 3 years. After board certification, there are several subspecialties which the pathologist can pursue to gain additional expertise. Depending upon the subspecialty, this can range range from 1 to 3 additional years of training.
Can you describe an average day for a pathologist?
This depends upon the type of practice setting but in general, the pathologist's schedule closely follows the surgical operating room schedule. During the day, the pathologist is often called upon to immediately examine surgical specimens in the operating room. This may range from opening a uterus to identify the disease process, to opening a segment of intestine to ensure that the surgeon has taken adequate margins. Depending upon the case, a frozen section may be performed. This is a rapid diagnosis where a small sample of the specimen is chosen and rapidly frozen. This frozen tissue is then cut into very thin sections (thinner than the width of this line "I"), placed upon a microscope slide, and stained with specialized solutions. The slide is then reviewed under the microscope and a diagnosis is rendered. The entire process takes about 10 minutes but can change the course of the surgery. What was thought to be an infectious process by the surgeon, may now turn out to be a highly malignant tumor. For a personal account of an average day, please follow this link.
Diagnosing cases under the microscope is surgical pathology, the pathology of the living. This is where your breast biopsies, your skin biopsies...all biopsies, are diagnosed.
Why are pathologists so under recognized?
That is a good question! Part of the problem is the media and its portrayal of the laboratory and the pathologists who work in it as a "black box". How often have you heard the phrase, "We are waiting for the results"? What you are really waiting for is the pathologist to make the diagnosis. Yet, whenever a public figure undergoes a biopsy or has a laboratory test, there is never any mention of the pathologists' work behind the scenes. Instead, there is often an incorrect conclusion that the surgeon or internist makes the diagnosis. While these physicians may strongly suspect the diagnosis based upon their experience and expertise, the definitive and final diagnosis always rests with the pathologist.
Where does the pathologist work?
The laboratory is often the largest and most complex department of any hospital. This is where your blood samples, cultures, Pap smears, and biopsies are sent. It is also where the phlebotomists, the people who draw your blood samples, work.
Many pathologists also work in outpatient, freestanding laboratories. These laboratories service physicians who do not work in the hospital.
Who works with the Pathologist?
Assisting the pathologist are numerous highly skilled individuals. The clinical laboratory scientist (medical technologist) is to the pathologist what the nurse is to the physician on the hospital floor. In the laboratory, they are the ones who manage the complicated and sophisticated instruments that measure and produce your blood sugar, cholesterol, and white blood cell count. They work with the microbiology culture plates. They ensure the blood products you receive have been properly tested for blood borne diseases such as AIDS.
The phlebotomist takes your blood sample. The cytotechnologist screens or reviews your Pap smear. The histotechnologist prepares your biopsy specimen on a microscope slide. And ensuring that all the diagnoses are conveyed to your physician, transcriptionists put the pathologists' dictated diagnoses to print.
In all, a 200-300 bed hospital often employs about 50-70 personnel in the laboratory.
Does the pathologist have direct patient contact?
Surprisingly yes! Pathologists perform the bone marrow biopsies to evaluate blood and bleeding disorders.
We are called upon to perform fine needle aspirations. This is a technique where a superficial lump or mass is entered by a small needle and a small sample is retrieved by suction (aspiration). This sample is smeared on a slide, stained, and immediately reviewed by the pathologist. In many instances, an immediate diagnosis can be rendered, saving the patient a costly and time consuming surgical biopsy.
In transfusion medicine, the administration of blood products is a complicated and highly regulated area of medicine, especially with the ever increasing concern of the safety of the blood supply and diseases such as AIDS which can be transmitted through blood product transfusions. Since the administration of blood products is actually a treatment, the pathologist must often manage the patient receiving these products, necessitating bedside monitoring.
Finally, whenever there is a discrepency between the diagnosis on the microscope slide or with a laboratory test, the pathologist may need to examine the patient and review the patient's records to resolve the issue. Remember, the pathologist is first a physician.
It is ironic that the physician making your diagnosis, the pathologist, very rarely has communicated with the patient...until now. The Doctor's Doctor is ready to be your physician.
Do pathologists made a difference with patient care?
There are many examples of pathologists making a difference with direct patient care. In fact, without pathologists directing the laboratory, modern medicine would be paralyzed. Please visit with some pathologists who have made a difference.
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