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

Neophyte Pathology Resident Musings on the Impact that Staff Can Make

As a pathology resident that is just barely into the start of my second year, I’m often amazed at how my perspectives about the profession, the training, and my role within this system have changed. My program has four hospitals through which we rotate: an urban academic center, a VA hospital, and two community hospitals. During PGY-1, the six of us residents remained entirely at the academic center with one month of hematopathology at the VA. For the first three months, we were on an “intro to surgical pathology” rotation together before we were separated to various clinical or anatomic pathology rotations.

No program is perfect, but one of the assets of the surgical pathology department at our main academic center was the active hands-on effort our pathology assistants and fellows made to help us learn to gross and manage our time. Our attending physicians, if asked, also would come to the gross room to explain how and why we should gross their specimens in a specific manner. They were also very open to feedback and incorporated our comments into refining the two week orientation “boot camp” that is given every year to new PGY-1’s. Without being overbearing, they allowed us to progress at our own pace and constantly nudged us to improve in areas where we were weak, because as a PGY-2’s at the VA and community hospitals, we would be on our own. I would hear them say this over and over but didn’t really internalize the true impact of their words until the end of my first year.

During PGY-1, I was able to attend multiple conferences where I met other residents who told me about how surgical pathology was taught at their institutions. Of course, I had appreciated and recognized the extra time our PAs, fellows, and attendings had put into our learning then but now a year later, I truly understand how lucky I was to have them because not all residents were as fortunate. The interactions that staff has with residents can have a lasting impression on what type of pathologists we become, so I’d like to start my inaugural blog with a simple “thank you.”

-Betty Chung