Saturday, November 20, 2010

Homecoming Queen

Some weeks being a pathologist is like being the coolest girl in school. All the docs, guys and girls alike, hang on your every word. They call repeatedly, stop by your office, ask your advice on how to get the most out of their specimen to get the diagnosis for the patient, and actually listen and bend over backwards to follow.

On no rotation is this more true than cytology. Interventional radiology and ancillary techniques developed in the last decade or so - all have been created to maximize knowledge yield from a minimal amount of tissue. Yep, that's my fellowship trained specialty. I'm proud.

It's also stressful, because you want your advice to work. So do they. It becomes frustrating when it doesn't.

A few months back, I was on cytology and I got a CSF (cerebrospinal fluid) specimen. The patient had a diagnosis of lymphoma, and I saw some atypical lymphoid cells on the SurePath preparation. Tried to run flow cytometry, but cell yield was QNS (quantity not sufficient) to assess the phenotype and prove clonality. I showed it around to a couple of colleagues and they laughed (in fun, of course - we all are elitist about our own areas of expertise). You see, some pathologists think cytology is like voodoo. Smoke and mirrors. "I can name that tune on three notes. I can diagnose that cancer on three cells. No you can't. Yes I can." Every couple of days I got more CSF, two to five milliliters, and every time I got the same complaint from my flow techs. "Not enough cells." Damn it. I saw the radiology. The patient had a diagnosis of lymphoma, and the meninges were lighting up like a Christmas tree, signaling CNS (central nervous system) spread. I knew it was there, I think the oncologists wanted an diagnosis so they could do intrathecal treatment (I'm a pathologist, not a clinician, so don't call me out here), but we weren't getting anywhere.

A couple of weeks later, back on the same rotation, I was saddened to learn the oncologists were still trying to get the diagnosis to no avail. I called one of them up. "Skip cytology. Skip hematology. We've seen the cells, they're scanty but weird, we know what they look like. Draw off more CSF and put it all in for flow." I was trying to get more bang for the buck.

The flow techs were by now jaded and skeptical after weeks of QNS. My hematology trained colleague was scoffing at me. So I was excited when the flow tech popped her head in my office one afternoon and handed me a blue folder. "They're positive for B-cell clonality." Me, the oncologist, hell the PATIENT got their diagnosis so they could begin treatment. I felt like dancing with my microscope.

This week was one of those weeks. I was the most popular girl in high school. My courtiers weren't jocks and stoners - but breast specialty radiologists, oncologists, neurosurgeons, thoracic surgeons, and pulmonologists. My phone never stopped ringing, and some doctors were hand delivering patient specimens to my office. Luckily this week, every effort (sometimes thrice attempted) ultimately yielded good results, and the excitement in each doctor's voice as I relayed the diagnosis gained from their efforts was palpable. They were all giddy with success, armed with knowledge to begin treating their patients. I was heady with the challenge of making tough calls, silently wishing for more straightforward cases, but thriving on each diagnostic dilemma. Poring over my books. Searching for articles on PubMed. Consulting with my colleagues. Thank goodness every week isn't as tough as this one, but I do enjoy them every once in a while.

Who says pathology is boring?? I'm finally the Homecoming Queen. Now I just need a date.


  1. Hooray! That is fantastic. What a great week. I know for patients the worse suffering comes from worry about the unknown. You give them to opportunity to recognize their challenge and sink teeth into plan for recovery.

    And I love your high school reference... I am sure you were still this cool while in high school it just took others time to "get you"!

  2. What?? Pathologists are NEVER cool! Too much protruding ear hair.

    (Just teasing :P )

  3. Pathology has totally been my favorite unit in med school so far. I could read Robbins all day.

    Unfortunately, if "lab-related occupations" are a Homecoming Dance and the Pathologist is the Homecoming Queen, I've proven myself time and time again to be the awkward frizzy girl with glasses. When I'm in a lab, no glass equipment is safe..

  4. Congratulations on a fantastic week!

    You are so right about pathology. Without your help, we can't effectively treat our patients. I think it's a fascinating field; histology was arguably my favorite class in med school.

    Doesn't it feel great to know that you are good at a difficult skill?

    (By the way, it's OK to dance with your microscope. I dance around my operating microscope in the OR occasionally.) :-)

    And, you know, we neurosurgeons claim that CSF is the champagne of body fluids. An appropriate specimen for your "crown jewel" case!

  5. Thanks JC! I was pretty stare at the floor shy in high school. Hence the last name.

    Hey Fizzy! Don't make fun of my ear hair. I still have no idea what the heck PM&R is even though you've explained it ten times (Also teasing. A little. Well, not really).

    I still love Robbins. My baby Robbins (Kumar) looked like a rainbow it was so coated with highlighters. One of the pathology students I tutored made it a fancy zebra jacket cover and it is still on my shelf. The great thing about pathology, Action Potential, is that there are so many different things you can do. You don't have to work directly with glass beakers, if you don't want to. In the lab, even the awkward girl with frizzy hair can be a queen.

    gcs15 - I love that! The champagne of body fluids. Now I'll have to start comparing all the body fluids to alcohol. You are right about dancing with the microscope - I'll have to try it. Forget the date - I've already got one in my office.

  6. I wish I could stand microscopes, otherwise I'd totally be considering pathology. It's such an interesting field, and all the pathologists I've met have been really nice. Nerds, but nice happy nerds.

  7. Rock Star MD Girl - you defined me! A nice, happy nerd. Unfortunately, you've gotta love the scope. You spend a lot of time in it. And the good ones cost as much as a car - it took me years to pay mine off and I'm finally about to buy a camera.

    Thanks, Ramona!

  8. Everyone should feel like a queen every once in a while. Good for you!

  9. Awesome!! Way to go, Gizabeth!!

  10. I think it's a fascinating field; histology was arguably my favorite class in med school.

  11. Thanks Kyla and Kelly!

    Stock trading - I loved pathology so much. Tried not to like it, because it was uncool. Practically matched in ophthalmology and backed out at the last minute. I am so happy I did - it's much nicer spending your life doing what you love and what comes naturally to you than to choose a competitive "glamour field" for the wrong reasons.


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