How We Can Make a Clinical Difference Despite Not Seeing Patients

People assume that I chose pathology because I didn’t like patients but this couldn’t be further from the truth. During medical school, I was a Schweitzer Fellow and volunteered at two free health clinics in the Philadelphia Asian community where I helped start hepatitis B screening and vaccination programs in populations with a high prevalence of this disease. I also served as the student director of my school’s migrant farm worker health clinic where we provided screenings and care to farm workers every summer. In fact, I often was asked to speak with patients because I could convince reluctant patients to comply with care.

But this doesn’t mean that I was the best medical student on the wards or in the clinics; in fact, far from it. Now that I look back, I was often too stressed to quickly triage what was most important to do clinically. But being a trained critical thinker, I could often reason out the answers. A couple of my residents thought that I wasn’t made for clinical medicine because I thought things out in a different way than most.

For an artistic and introspective person like me, I found my home in pathology. I need work that visually stimulates me and provides variety, challenges, and most importantly, enough time to take a breath, gather my facts, and think things through. Sometimes, even my physician friends joke that we are introverts who don’t like patients. They think that we sit at microscopes all day, can’t write prescriptions, make diagnoses in isolation, and prefer to release reports with the words “recommend clinical correlation”  so that other doctors can provide the actual care. All of these things are so untrue.

On my molecular pathology rotation, I was reminded how the pathologist and the clinical lab are integral to the complete clinical care of the patient. A transplant patient on anti-CMV prophylaxis was admitted for diarrhea. His labs were positive for both C.difficile and a very high CMV viral load. He was given antibiotics and an increased anti-CMV medication dosage before being subsequently discharged. He was again admitted a few days later with worsening diarrhea despite medication compliance. He was again C.difficile positive and his CMV load was now three times higher than his previous result. He was put on IV gancyclovir and a repeat CMV load ordered to assess therapeutic response before discharge with a prescription for the same dosage of valgancyclovir he was given on his previous recent admission.

Our techs always compare abnormal results with previous values, so my attending and I were notified of the elevated CMV viral loads. The techs in my facility cannot access patient medical records so I was responsible to work up this case. I’m often amazed at how often they pick up a serious issue even without access to clinical records– more than just looking at the number, they know that something is not quite right.

I noted that the patient had been on valgancyclovir with dosage increases for CMV prophylaxis since discharge from his transplant. His CMV load was previously undetectable prior to the recent admissions. I called the transplant surgeon and suggested CMV resistance genotyping based on the clinical history and blood was sent that day. As the experts in diagnostic medicine, we can impact clinical care even when we don’t physically examine the patient. We must serve as the bridge between the clinical lab and primary physician – both informing them of available diagnostics as well as suggesting appropriate tests – because care is more than just the numbers.

-Betty Chung

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