The Lonely Life of a Clinical Pathologist: Rounding in the Lab

As I mentioned last month, a big part of my job has been to do daily rounds through the lab to seek out areas that need troubleshooting. One point I noticed was technologists don’t always see the impact of their work on patient care. I wanted to make sure they knew the importance of their work so I decided to incorporate education as a tool to highlight how their work directly affects patient care. Each section of the laboratory has their own ways of communicating so I have done something a little different in both labs.

In the microbiology section, I started a weekly “formal” microbiology rounds with the infectious disease doctors, the pharmacists, and the technologists. While I saw this rounding at both of my training institutions, there were held in different styles. In one, the infectious disease team rounded through the lab and asked the techs questions about their patients; in the other, the team discussed interesting case around a microscope.  I decided to take a combined approach:  we meet in the lab at the microscope so the techs can work if needed yet still be a part of the discussion. The techs save interesting cases that have come up over the last week or so and we show the rest of the team. It usually involves discussing organism identification methods as well as the disease process associated with the organism. This has given the techs the chance to ask the physicians and pharmacists questions about the patient isolates they have worked on directly. In addition, it has given them the opportunity to ask why physicians order certain tests. The pharmacists have added so much to these rounds and it has been nice to see a collaborative effort between multiple areas of the patient care team come together and talk about why things are done and the outcome of the patient based on laboratory results.  It demonstrates to everyone that each member of team is passionate about patient care.  In order to bring some of this knowledge to the second shift staff that performs microbiology processing, I save one or two interesting cases from rounds and present a quick rundown of what the bug is and how it is identified in the lab so they can see how their work is completed the next day.

For chemistry and immunology, the laboratory team has a monthly meeting. At each of these meetings, I run through a formal case presentation based off interesting cases the techs have come across or have had questions on specific disease processes related to the laboratory work they are performing. The topics have ranged from beer potamania (that got a lot of discussion!) to what polymerase chain reaction is. It has been another approach to show the technologists how their work directly impacts patient care and they have really enjoyed it.  The goal is to bring clinicians into these discussions, as well, but that has not been as easy for these meetings. We have been able to bring a pharmacist in to discuss vancomycin trough levels and why draw times are so specific. It really helps having other departments reach out to the laboratory staff to let them see why policies are structured the way they are.

I really enjoy being in the lab and interacting with the technologists, however, one of the principal lessons I have learned this year is how important it is to get out of the laboratory as a clinical pathologist. The next couple of months I will talk about how I have gotten involved in other areas of the hospital. But for now, let’s hear from you, do you have any formal rounding or education that you offer your techs?  What ideas have had the best responses from the technologists? I am looking forward to hearing more ideas on how to integrate education and interdisciplinary teamwork for our laboratory staff.

 

racsa_small

-Lori Racsa, DO, is the director of microbiology, immunology, and chemistry at Unity Point Health Methodist, and a Clinical Assistant Professor at the University Of Illinois College Of Medicine at Peoria. While microbiology is her passion, she has a keen interest in getting the laboratory involved as a key component of an interdisciplinary patient care team.

Microbiology Case Study: 47 Year Old Woman with History of Systemic Lupus Erythematosus

Case history

A 47-year old woman with a past medical history of Systemic Lupus Erythematosus (SLE) and liver cirrhosis of unknown etiology was admitted to the hospital for back pain and new onset neurological symptoms. She soon developed pancytopenia and study of her peripheral blood smear showed evidence of thrombotic microangiopathy. ADAMTS-13 inhibitor was negative ruling out thrombotic thrombocytopenic purpura (TTP). She then developed multiple thrombi, including a nonocclusive thrombus in the superior mesenteric vein with extension to the splenic vein as well as a femoral deep vein thrombosis. Her hospital course then became complicated by lupus cerebritis, a small ischemic focus in the left corona radiata and the left medial midbrain, and decompensated liver failure with hepatic encephalopathy. Despite intensive medical treatment, she became hypoxic and hypotensive requiring pressors, and expired in the ICU after several months of hospitalization. The autopsy was performed based on the relative’s request to better understand pathological processes that lead to patient’s demise. The flowing images were obtained from the brain at autopsy (Image 1).

toxo1
Light microscopy of H&E-stained sections of the hippocampus reveal encysted Toxoplasma bradyzoites as well as extracellular Toxoplasma tachyzoites in the CA1 region, suggestive of a subacute focal infection.

Discussion

Toxoplasmosis is considered to be a leading cause of death attributed to foodborne illness in the United States. More than 60 million men, women, and children in the U.S. carry the Toxoplasma parasite, but very few have symptoms because the immune system usually keeps the parasite from causing illness.

People typically become infected with Toxoplasma by contaminated food or animal-to human routes of transmission. Toxoplasmosis is not passed from person-to-person, except in instances of mother-to-child (congenital) transmission and blood transfusion or organ transplantation.

Persons with compromised immune systems may experience severe symptoms if they are infected with Toxoplasma while immune suppressed. Persons who acquire HIV infection and were not infected previously with Toxoplasma are more likely to develop a severe primary infection. The diagnosis of toxoplasmosis is typically made by serologic testing. A test that measures immunoglobulin G (IgG) is used to determine if a person has been infected. If it is necessary to try to estimate the time of infection, which is of particular importance for pregnant women, a test which measures immunoglobulin M (IgM) is also used along with other tests such as an avidity test. Due to the high rate of falsely positive Toxoplasma IgM testing, the FDA advises physicians testing pregnant women not to rely on the results of any one positive IgM test as the sole determinant for diagnosis of acute Toxoplasma infection.

Diagnosis can be made by direct observation of the parasite in stained tissue sections, cerebrospinal fluid (CSF), or other biopsy material. These techniques are used less frequently because of the difficulty of obtaining these specimens. Molecular techniques that can detect the parasite’s DNA in the amniotic fluid can be useful in cases of possible congenital transmission.

Clinical correlation

The case patient was at risk for developing toxoplasmosis due to SLE disease, and chronic immunosuppressive therapy that she was receiving for the aggressive course of her illness. However, most likely Toxoplasma gondii organisms seen in the brain parenchyma were in a dormant state due to lack of associated inflammation or architectural distortion. Her neurological decline is most likely related to thrombotic microangiopathy. Opportunistic infection is common in patients with SLE. In some patients, it is difficult to distinguish between the effect of infection and exacerbation of SLE because both can produce similar symptoms. There have been many reports of toxoplasmosis in SLE patients, with conditions such as cerebritis and pericarditis mimicking SLE manifestations.

References
1) http://www.cdc.gov/parasites/toxoplasmosis/

2) Seta N, Shimizu T, Nawata M et al. A possible novel mechanism of opportunistic infection in systemic lupus erythematosus, based on a case of toxoplasmic encephalopathy. Rheumatology (Oxford). 2002;41(9):1072-3.

3) Zamir D, Amar M et al. Toxoplasma infection in systemic lupus erythematosus mimicking lupus cerebritis. Mayo Clin Proc. 1999; 74(6):575-8.

 

Contributors

Written by Anastasia Drobysheva, MD, 2nd year Anatomic and Clinical Pathology resident, UT Southwestern Medical Center

Image provided by Bret Evers, MD, PhD, Neuropathology fellow, UT Southwestern Medical Center

 

-Erin McElvania TeKippe, Ph.D., D(ABMM), is the Director of Clinical Microbiology at Children’s Medical Center in Dallas Texas and an Assistant Professor of Pathology and Pediatrics at University of Texas Southwestern Medical Center.

Show Us Some Skin

Which epidermal layer is indicated by the arrow?

  • A. Stratum corneum
  • B. Stratum germinativum
  • C. Stratum granulosum
  • D. Stratum lucidum
  • E. Stratum spinosum

Skin1

 

The answer is E, stratum spinosum. The stratum spinosum, also known as the prickle cell layer of the skin, is often several cell layers deep, and is located immediately above the stratum germinativum. Cells in this layer are polygonal, and are connected to each other by numerous desmosomes. During fixation, the cell membrane retracts around desmosomal contact points, giving the cells a prickly appearance. The cells contain many bundles of intermediate filaments as well as keratinosomes, which are membrane-bound granules thought to deposit a “toughening” layer on the surface of the cell membrane.

Skin2

 

The stratum germinativum (also known as the basal layer) is composed of a single layer of cells adjacent of the basal lamina. The cells are tall cuboidal or columnar, and are connected to the basement membrane by hemidesmosomes, and to other cells by desmosomes. Cells in the basal layer are mitotically active, and contain numerous polyribosomes and intermediate filaments.

Skin3

 

The stratum granulosum is 3 to 5 cell layers thick, and is composed of flattened, polygonal cells arranged with the long axis parallel to the basement membrane. The cytoplasm of these cells contains numerous basophilic granules, called keratohyalin granules, which are thought to be keratin precursors.

The stratum lucidum is not truly a distinct layer of skin, but rather a staining artifact. It is visible in some sections of thick skin as a glassy-appearing, eosinophilic artifact at the bottom of the stratum corneum. It is not present in this particular image of epidermis.

Skin4

 

The stratum corneum is the outermost layer of skin. The thickness of this layer varies considerably from region to region in the body. The cells of this layer are dead, flattened, and fused together, with completely keratinized cytoplasm.

Skin5

 

Krafts

-Kristine Krafts, MD, is an Assistant Professor of Pathology at the University of Minnesota School of Medicine and School of Dentistry and the founder of the educational website Pathology Student.

Chief Resident Advice to Junior Residents

I haven’t been able to blog as much of late. It’s been a busy year with more than its fair share above the usual crises that a chief resident is expected to handle – an “August year” for me as my program director put it. But I’ve learned a lot and have been lucky to have the support of my attendings, program coordinator, and program director to help. Even when we’ve not always agreed on what is best for our residents, I’ve always been allowed to speak up for our residents and felt as if our concerns were heard and acknowledged even if policies didn’t go our way. I think that’s the biggest strength of a smaller program–the ability to form strong relationships with mutual respect, whether it is with one’s mentors, peers, or hopefully, both–and I know we will cheer each other on when we hear of each other’s accomplishments in the future even if we won’t see each other daily as we do now because of those bonds we built during these past couple of years. The lessons I’ve learned regarding “soft skills” have been equally as important as the knowledge I’ve gained about my favorite lymphomas or molecular mutations. And four years is really shorter than one might think to fit in all we need to as AP/CP pathology residents, so see it for the gift it is–protected time to grow into the physician you want to be. I see the fruits of these lessons more clearly now as I prepare to graduate. Much of it was obtained through mentorship, formal and informal, from those more experienced and with my best interests at heart.

So here are some pearls I’d like to hand down:

  1. Know thyself as early as possible: Be honest with yourself about your strengths and weaknesses so that you can build on the one while working on the other. As we have now signed on to be life-long learners, identify what works for you early or adjust those learning habits which might have worked before but are no longer working. Designate a couple of hours on a weekend day every week to do learning above and beyond what is expected for your current rotation and consistently stick to it. If you can, designating an hour everyday would be even better and it doesn’t have to be hard core studying like our med school days—you can leisurely read a review article, watch TedMed videos, casually look over boards materials or qbanks from day 1, and so forth as long as you do set aside time consistently. Take advantage of experiential opportunities to help decide early where you see yourself as a physician (academics, private practice, commercial lab, subspecialty, etc) in the future so that you can plan as early as possible your rotations, electives, opportunities, and networking with that goal in mind. But most importantly, knowing who you are, what you believe in, how you work best, and what you want and knowing early, will help you plan and see opportunities earlier. But always, be true to yourself.
  1. Time management is key: Learning to plan early and efficiently is a skill and it takes time to learn. Honestly, I’m not the best on a daily basis unless I take time ahead of time to plan my day, which I don’t always do, but plan to be better about during fellowship. But I do know how to plan effectively to juggle multiple long-term projects with deadlines at a time. You will constantly hear about time management – whether on rotation evaluations or during fellowship interviews. I find that those who are very good at time management, all have checklists and planners (whether hard copy or digital) so maybe they’re on to something there. Whatever works for you, being a deliberate planner ahead of time will serve you well.
  1. Be proactive: In some way, we’ve all be conditioned in a passive learning style where those who are more experienced hand down information to us which we are expected to regurgitate or ruminate on and respond. During residency, we don’t have the strict structure we are used to from medical school as we may be only given loose guidelines but are expected to figure out how best to manage our time on our own. We no longer have every hour planned out for us and so the quicker you learn to plan ahead and effectively use your time while at work, the more time you’ll have for personal activities. Don’t just do the minimum but use gaps in your time during the day to study, to build relationships with mentors with whom to work on book chapters, abstract submissions (for posters/platform presentations at conferences), and publications, to attend conferences/tumor boards outside your rotation even in non-pathology departments, to work with others outside of pathology on interdisciplinary projects. In some ways, these activities are networking without our even realizing it. For the rest of our lives, we will constantly be judged and compared to others by our character and work ethic and that often will include tangible items on our CV whether this is fair or not. Challenge yourself on every rotation by trying to do as much as a junior attending would within the limits of what you are allowed to do and not just the minimum.
  1. Get involved in advocacy: Participate in leadership positions at an organized level–within our professional organizations, with interdisciplinary teams within your hospital, or with volunteer organizations in your community. Bringing about change takes time but if done with a positive goal in mind, can have such a rewarding impact on those we wish to serve as well as yourself. You might discover a previously unknown passion or skill you possess that you can share. Before residency, I was heavily involved with on-the-ground, upstream-minded health equity efforts in immigrant and minority communities. And while I took a hiatus from my work due to residency training, I know that as a future public health pathologist-scientist with both public health and research training, I will return to working to change those systemic and institutionalized societal structures that maintain health inequity within those communities. So it’s now your time to find your passion and to give back. Pay it forward for every good gesture someone has shown you.
  1. Build relationships with mentors: Since I’ve been involved with organized medicine, I’ve always heard the word “networking”. Too me, it always seemed somewhat a Machiavellian “ends justify the means” insincere word but I guess that’s all up to interpretation. What I prefer to say is focus on finding colleagues with whom you share values and passions, who you respect and would like to emulate, and with whom in the future, you might want to collaborate. If your premise is sincere, opportunities always unexpectedly follow has been my experience.
  1. Step outside your comfort zone: As busy physicians-in-training who are used to structure and consistency, it’s good every once in a while to try something new. You never know what you may find–it may even turn out to be a new passion for you. Life is too short and you want to live it without regrets. You want to say when your time comes that you lived life to the fullest and maybe even tried some things that scared but surprisingly made you happy.
  1. Recharge with some “me” time: All work and no play can make any of us dull and cranky. Set aside time to spend with friends (especially non-physician friends) and family and do non-work related activities. Especially when life is getting you down, some time away from thinking about work may be the recharge you need.

 

Chung

-Betty Chung, DO, MPH, MA is a fourth year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

ASCP’s 40 Under Forty

ASCP’s 40 under Forty program recognizes forty pathologists, lab professionals, and residents under the age of 40 who are making significant contributions to the fields of Pathology and Laboratory Science. If that sounds like someone you know (or maybe it’s you!) head over the nomination page and start the process. Good luck!

The Importance of Mentors

Hello again readers. It’s been a while as I took some time off from blogging. But I hope to update you every once in a while when I can. So, I’m currently in my final year of residency and have been serving as chief since April 1st. My chief term ends before the end of the year to provide time to focus on studying for the boards (we take our boards in mid-May).

When I reminisce about residency, I can’t believe that almost four years have flown by so quickly. I remember arriving in Chicago for a 2 week boot camp we had prior to our start date on July 1st just like it was yesterday. It was nice to be back in a familiar city (The University of Chicago is my alma mater), although many things had changed in the two decades since I had last been a college student in the Windy City.

Thinking about it now, I really appreciate all the thought and hard work that my director of surgical pathology, Dr. Elizabeth Wiley, had put into organizing this boot camp to ease us into the transition to residency (and surgical pathology). We learned Rokitansky method of autopsy dissection on 3 pig blocks that she personally picked up from the butcher’s for us and later had to complete a competency exam by ourselves on a 4th pig block. We learned to cut frozen sections on various tissues from our pig blocks (and of course, had a competency exam on that as well). We learned to gross uteri and prostates on ground turkey versions (complete with chickpea leiomyomas) that she and her fellows had made for us. We had weekly online exams on histology (we had a slide scanner which I now appreciate that not everyone has one) and special didactics on surgical pathology topics we don’t see much during general sign-out (dermatopathology, neuropathology, hepatopathology, and nephropathology) in addition to the usual goings-on during a surgical pathology rotation. We eventually had online modules on surgical pathology as well. And of course, we had three months straight (I hear its five months now) of learning to gross with our awesome fellows. I now appreciate more deeply just how innovative and dedicated Dr. Wiley was to our surgical pathology education. And even though I ultimately chose to pursue fellowships in hematopathology and molecular genetic pathology, the foundation in surgical pathology that was established during that boot camp still helps and influences me now.

During my first year, I was also fortunate to have hematopathology at Jesse Brown VA Medical Center with Dr. John Kennedy. He is a hematopathologist who was trained as a morphologist before the heavy reliance on flow cytometry and IHC. And he taught me to love the morphology of blood cells especially with respect to lymphomas. I had enjoyed my hematology sub-I at the NIH when I was a medical student but had originally entered residency thinking that I’d pursue molecular genetic pathology and clinical microbiology. But a great mentor can really open your mind to a different path and that is what Dr. Kennedy did for me. The second time I rotated with him, he was away for much of the rotation. But I loved the opportunity that I was given to take care of the hematopathology service in his absence. I looked at all the daily cases and performed path reviews and counts on peripheral blood smears and body fluids and the surgical pathology attending at the end of the day would review and sign-out my work. This experience of graduated responsibility helped me to decide to pursue hematopathology and it was nice to have someone believe in me and my abilities. I was also fortunate that I was in a city where the Lymphoma Foundation also held quarterly inter-program Lymphoma Rounds which I was able to attend.

So my advice is to identify mentors early on in your residency. You may not be able to see the ripple effect they have on your life until later on but I promise that they will touch your lives in an indelible manner that will help shape the pathologist you will become later on in life.

This week I’m at the ASCP Annual Meeting and will write about those experiences in a future blog, but for now, I’d like to take this opportunity to personally thank my mentors. I hope that I take your lessons and make you proud as a future physician-scientist with a public health (molecular epidemiology aka biomarker discovery which was one of my areas of specialization during my MPH) focus. You have touched my life in ways that I may not always be able to articulate but do acknowledge and appreciate.

 

Chung

-Betty Chung, DO, MPH, MA is a fourth year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

The Importance of Time Management and Benefits Outside of Residency Training

So I was recently in beautiful Miami for the ASCP Leadership Forum as the resident representative on their Commission on Science, Technology, and Policy (CSTP). While I can’t talk about the specific details of our work, I’d like to take this time to elaborate on some benefits of working within organized medicine for residents and on the realizations that it has brought me concerning the importance of time management.

As residents, it’s difficult to see the “big picture” sometimes because residency training feels like a journey with multiple landmarks we must pass in order to reach a destination far into the future. But I’ve found that my work in organized medicine has always expanded my peripheral vision. In these roles, I have increased my exposure by meeting residents and attendings from other programs – I’ve been able to hear how training differs between their experiences and mine. And this provides me with a context in which to view both the strengths and weaknesses of my previous and current training. And as a chief resident, these experiences have provided me with invaluable insight that allows me to come up with creative solutions to improve both myself and my program. Of course, organized medicine also has provided me with a myriad of benefits from networking.

But participating in extracurricular activities, and in particular, organized medicine efforts as well as union efforts (as one of my hospital’s five CIR/SEIU delegates), takes a lot of time and as expected, time management. In terms of long term time management, I would say that the many leadership positions I have held have helped me to plan out tasks and to meet deadlines. And so as a first year resident, after my first three months or surgical pathology, I was surprised to see “needs to improve time management skills” on my evaluation. And even though I improved on subsequent rotations, I think it has taken me until now as a third year and as a chief to truly understand what that comment meant.

My time management is fine when planning long term goals and overseeing the tasks of those I supervise – skills I honed while participating in organized medicine for many years. But what my first evaluation as a resident was pointing out was that I had trouble initially managing my time in terms of my DAILY service duties (ie – very short term goals). Despite rotating in pathology as a medical student, as a neophyte first year, I didn’t truly understood the scope of what pathologists really did day in and day out, and more importantly, the workflow to achieve these goals. And each year, my skills have improved and shaped my outlook about what is required to be a good, patient and public health centered pathologist. But as a chief now, my view has again been further refined in this regard.

When I interviewed for fellowships, the #1 attribute that programs mentioned as important in a fellow was great time management skills. #2 was being a good team player. My yearly residency training and leadership roles in organized medicine have both hopefully nurtured those two desirable characteristics. But I guess we’ll see when I start my first fellowship in July 2016. Don’t forget to include in your planning time to relax, eat and exercise, sleep well, and set aside one day each weekend to do some casual training-related work such as reading on your current rotation topic.

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.