The Unspoken PATH in Medicine: Reflections on Pathology by Michael Bernazzani, ’15
Michael, come over here and tell me what you see. I walked over to Dr. Ng’s microscope and looked in and said proudly, “A bunch of WBCs!” “Yes, but are they neutrophils, eosinophils, lymphocytes? My answer clearly wasn’t specific enough; as Dr. Ng continued to pepper me with further clarifications. What would it mean for our research if they stained CD8+? I had nothing else to add, to me they were just pink and purple dots, nothing more.
After a moment of silence he joked, “Well, I guess we will cross pathologist off your list of careers”. Although confused, I laughed with him and thought to myself, well yea, I’m a junior in college trying to go to medical school and become a doctor, not a pathologist.
My confusion is common among pre-meds. Many of which dream of going to medical school and becoming a doctor of some discipline. They envision a life as a surgeon, OBGYN or maybe a cardiologist, but very few come in with the notion that they will be a pathologist. Most don’t become acquainted with pathology until their second year of medical school. It is only as they embark on their preparation for STEP 1 that they begin to meet the faces of the pathology world: Dr. Goljan, Dr. Sattar and (in Loyola’s case) Dr. Mirza.
For many, it’s too late, STEP 1 gets pathology labeled as witchcraft, that has no real context to true medicine. It’s just something everyone must suffer through in their education. I should know, I was one of those students who drank the punch. It didn’t seem right though. As I pursued my studies, I continually found myself in awe of the wealth of knowledge these people contained. I needed to further understand this discipline. So, I did what any good student physician does, I jumped in to discover for myself.
After working in my pathology department at Stritch School of Medicine for the past month; I’m here to inform you that I think we are making a mistake by vilifying pathology. So, I’m going to try and dispel some myths about pathology. As a disclosure I am a 3rd year medical student speaking as a neutral 3rd party, I am not a pathologist, I’m not a resident, and truthfully I don’t even know what I want to do yet. You could say I’m undifferentiated.
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Myth Number 1: “I’m never going to need pathology in my day to day after Step 1”
This myth is partially true and I’m going to focus on future surgeons here, because you are right. You personally, correct, you don’t need to know what stains to order for your patients. You don’t need to know how to section a sample or the staining protocol. You just need to know who needs the Bx, where/why to get the Bx and how to get it without killing your patient. Which is very challenging on its own and I respect that, but how would your patient be affected if we took away the pathologist?
Imagine going to see your patients without the pathologist report, your patient probably would not be satisfied with your work. You wouldn’t be able to answer what seems like the most basic questions to the patient: what was in the sample? Did you get it all? Are there any follow up procedures needed? What are the options for targeted medication? What do you mean you don’t know?!? Despite my uninformed Pre-med statement earlier, the pathologist is the one who is truly playing doctor and coming up with these diagnoses/answers and it isn’t just magic that makes it appear.
From the moment the pathologist gets the Bx they are making critical decisions on how and where to sample the Bx, what stains to use and its these critical choices that will let you inform your patient specifically what kind of cancer they had, can it be medically targeted and if you got it all out. Just a heads up every future surgeon should spend some time in the grossing label at some point so you can learn how to best work together.
So future surgeons, I’m not saying you have to become pathologist, but don’t forget how you got your answer. Maybe every now and again offer for the pathologist to come with you and be present for the patient receiving their answers. To be fair it is the pathologist’s diagnosis, and you are part of the same team. Future you may get to relay the final diagnosis and get the credit, but most of the time you didn’t come to those conclusions on your own and that is important to remember.
Myth Number 2: “I could never not see patients as a doctor and pathology only sees dead stuff and that’s gross”
Okay, okay I know what everyone is thinking. “Mike pathology is literally the study of tissue. IT HAS TO BE DEAD! How can you refute this?” You are correct the majority of the stuff that pathologists see is dead, but before I blow your mind, I’d like to say this. Just because its dead doesn’t mean it isn’t poetically beautiful. Being a witness for the grossing of the brain as you try to discover what lead to this human’s death is one of the most beautiful things I’ve seen. Seeing the decussation of CST between the basal ganglia and getting to examine the locus coeruleus in the pons were so surreal; and when you finally make that cut and see the lacunar infarcts and have a diagnosis for a patient it’s just so satisfying. It is vitally important for a young impressionable student doctor to experience this.
To my point though, it’s not all dead. If you are at all intrigued in pathology but saying, “I just need to see real live patients Mike!”. You can actually do that if you are working in transfusion medicine. This is the branch of pathology that handles all the transfusion reactions like TACO, TRALI, febrile reactions, allergic reactions or hemolytic disease of the newborn ect. In this area you’d still get to see patients and round on them and help with determining their care. Most of the job is involved with working with the blood bank.
See not all of pathology is dead! Even more to the point the tissue they sample might be dead but the patient waiting in the OR/patient room for their diagnosis is very much alive so don’t confuse the two.
Myth Number 3: “If I’m going the diagnostic route, radiology is so much sexier, I make more and have a better lifestyle”
I just don’t really get this one. It’s tough for me to truly argue because I haven’t worked in radiology. What I can say is the following though. Pathologists and radiologist both make good money. Will you be whipping a Ferrari? Maybe not, but more likely you’ll still have a respectable status car for sure, if that’s what motivates you. You can very easily look both salaries up on the internet and come to a conclusion for yourself though.
From a lifestyle perspective pathology is really damn good. I mean during my time the attendings and residents had a lot of flexibility in their schedule. If they needed to do something for their kids, they were able to come in a little late or leave a little early without too much concern. They often joked with me about how jealous some of their non-pathologist medical doctor friends were. Heck, the resident that was overseeing me worked from home pretty much the whole 4 weeks I was there. I think I saw him in person like twice.
So, if you are looking down the line, pathology is very family and life friendly. I know right now we are all hungry 22-28yr old’s but look into your future. Some day in your 30’s you might need to attend some weddings (heck maybe even have one yourself). In your 40’s you might want to walk your kid to school in the morning. In your 50’s you might want to be able to make all their sporting events. It’s tough to look that far ahead but just keep pathology’s lifestyle in mind because it looks pretty sweet.
Plus, pathologists are very well respected as educators in medical student education. They pretty much dominate the field as second year educators. They typically are well respected by the students and at least at my school have been very open to guiding the young doctors. Plus, that’s a second income if you’re teaching. So, I’m kind of confused as to why radiology is so sexy. The only major difference is that one sits in a dark room all day looking at the computer and the other sits in well-lit room looking at a computer screen or at a microscope or in the gross lab. Both seem pretty good to me…
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Okay no more myths that’s all I have (for now), but for those of you saying, “well if you love it you do it” you’ve missed my point. My point isn’t that everyone should be a pathologist. The point is, that everyone should have a true none STEP 1 exposure to it. Pathology is so much more that what First Aid presents to you and I’m barely scratching the surface. So, if you are a young medical student or pre-med go spend some time in a pathology department you may not change your career trajectory (and that’s fine), but will you absolutely learn something relevant to the future diseases you’ll encounter, and you will never be wasting your time by exploring a different PATH.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a woods, and I—
I took the PATH less traveled,
And that has made all the difference.
-Robert Frost & Michael Bernazzani