Tue, 01 Dec 2015
Student, Kayla Rimando interviewed Rosemary Henderson, MD, FRCP Pathologist, Queen Elizabeth Hospital.
1. Why am I passionate about this career?
Pathology is a fascinating blend of science and medicine that is constantly changing and evolving. It allows one to understand sickness and disease on a molecular and genetic level (the scientific aspect), while still helping people in a very practical way (the medical aspect). We have traditionally been known as the "doctor's doctor" because we act mainly as consultants to physicians (the physician requests the body fluid test, takes the biopsy or resects the organ, and we do the assessment and provide the report directly to the physician), but these days patients and the public are becoming increasingly knowledgeable about the role of pathologists and the importance of the pathology assessment. There is always something new to learn about disease entities (and the normal function of the body) that we thought we knew about, and always the possibility that I'll see something under the microscope that I've never seen before.
2. What school did I attend, and would I recommend it to future pathologists?
I attended Dalhousie University, in Halifax, Nova Scotia, Canada, for both my medical degree as well as my pathology residency, and I would recommend it for both programmes. Dalhousie is a well regarded Canadian university with a solid medical school, one of the oldest in the country. The pathology residency is not only undertaken in Halifax, but also in the Dalhousie affiliated teaching hospitals in other parts of the Maritimes (Nova Scotia, New Brunswick and Prince Edward Island). This allows the resident to experience a variety of practice settings and meet different pathologists, thus assisting with the process of deciding what sort of practice to aim for (academic vs. community, small group vs. large group, general pathology vs. anatomic pathology, subspecialty vs. generalist, or perhaps whether they wish to become another type of laboratory physician such as a Medical Microbiologist, Hematopathologist or Medical Biochemist instead of a pathologist). It also develops a useful network of pathologists, should the individual continue to practice in Canada.
3. Which subject areas are most important?
It used to be that medical schools required a science background. However, since about the mid 1970's, they have de-emphasized science, realizing that individuals with a science background do not do better in medical school or make better physicians than those individuals with non-science backgrounds. There is much to be said for having a well rounded and broad education. There are probably still prerequisites such as organic chemistry, so one obviously has to research the specific medical schools that one intends to apply to and make sure that one knows what the prerequisite courses are and take them (and do well in them).
There are no specific undergraduate courses that are needed for pathology. The best way of preparing for a career in pathology is to train to be the best doctor that you can be.
4. What do I most like/dislike about my job?
I most like the fact that I am being useful to society as well as to individual patients. Although I don't interact directly with patients very often, my assessment of their tissue sample provides is the foundation of their future management (whether they need any further management - e.g. more surgery, chemotherapy, radiation therapy, or not) and their prognosis.
I wouldn't say that I dislike anything about my career. However, the one disadvantage is that it tends to be sedentary - I sit at a microscope most of the day, or I sit at the grossing bench (where we dictate the description of the specimens and select the areas to be sampled). We know that sitting for long periods isn't good for people and so pathologists should make a particular effort to counteract that tendency. These days, desks are being designed that one can sit or stand at, but they are expensive and not readily implemented in a tight fiscal environment.
5. What does a typical day look like?
The daily activities and duties vary depending on what one is assigned to do, and who or what comes through the door. In my practice, one person is assigned each day to do autopsies, frozen sections, to gross (if the pathology assistant is away) and do quality assurance reviews. Others are assigned to sign out surgical specimens and cytology. I'll explain what those duties are.
Autopsies are self explanatory. We do hospital autopsies (the individual dies in the hospital and not in one of the various circumstances that would require an autopsy as authorized under the Coroner's Act) as well as medico-legal autopsies authorized by the Coroner under the Coroner's Act. We no longer do forensic autopsies in which homicide is suspected, as they are performed by specialized forensic pathologists in Nova Scotia.
Frozen sections - the patient is under anaesthesia on the operating table. The surgeon requires a rapid assessment of the tissue to determine immediate operative management (for example, to take a wider cuff of normal tissue around a malignancy). The tissue is rapidly frozen, sectioned, stained and examined, all in a matter of minutes, compared with the usual processing which takes closer to 24 - 48 hours.
Grossing - either a pathologist or a pathology assistant (non-medical person, these days Masters degree or more traditionally a medical laboratory technologist with on the job training) documents (usually by dictation) a description of the specimen and, the case of large specimens, selects certain areas to be sampled.
Quality assurance reviews - because an accurate diagnosis is so important, cases are often reviewed by a second pathologist. This is standard practice for new cancers, for example (e.g.- a breast biopsy showing cancer) but is also undertaken in other circumstances such as a difficult case.
Surgical sign out - after the surgical specimens are grossed, the samples are processed and glass slides are produced by the technical staff. The pathologist then examines the tissue on the slides, correlates what they see with the clinical information, past history and results of other tests as applicable, and produces a report that goes to the patient's physician.
Cytology - samples of cells are mounted on slides and examined by the pathologist and a report generated. This is often to diagnose or rule out cancer, or in the case of Pap smears to identify cellular changes that if left untreated might lead to cancer.
As well as those duties, in any given day other matters may arise. In the summer, we sometimes have the police arrive with a bone or sample of tissue that a beach walker has come across and the question arises as to whether it is human or not. A physician may call or drop by to discuss a case. We may be working with the technical staff to optimize the quality of the slides or special stains produced by the lab. Some pathologists have responsibility for other areas of the laboratory such as Biochemistry, Hematology and Microbiology, or have other administrative responsibilities (I no longer do this). We sit on various committees in the hospital and attend rounds with other physicians to discuss patient management.
6. What is the most common case I see?
In my practice, it would be benign skin lesions or benign gastrointestinal biopsies. This may be different depending on what kind of practice a pathologist has (for example, a specialized urologic pathologist would see many prostate and bladder biopsies).
Many people have skin lumps and bumps that are removed but are benign. They are removed because they may be irritated and bothering the patient or to rule out cancer. This is increasingly common with our aging population. Or the patient has a rash and the physician is uncertain as to what is causing it. Cancerous skin biopsies are also very common.
Many individuals have gastrointestinal symptoms such as abdominal pain or diarrhea that bring them to endoscopic assessment (fibre optic light source is guided through the mouth to examine the esophagus, stomach and duodenum, or else guided through the anus to examine the colon, and biopsies are taken). As well, screening programmes for colon cancer generate many samples of colonic polyps, which are removed to prevent the development of cancer.
7. Do doctors rely on me frequently, and if so, how?
Doctors rely on my reports - even if it's just for reassurance that what they thought was correct (e.g. mole is benign and not malignant melanoma). They rely on my ability to accurately diagnose cancer and to tell them when a mass is not cancer. They rely on my ability to assess the parameters in a cancer resection specimen that will guide them as to whether or not to institute further therapy (e.g. excise more tissue around a breast cancer, give the patient chemotherapy (and what kind), give the patient radiation therapy).
Autopsy reports can guide doctors to assist the living. For example, severe coronary artery disease in a relatively young man may lead to screening his siblings or children for lipid disorders, sudden cardiac death in young people can lead to screening of family members for familial heart diseases, diagnosing certain infectious diseases such as tuberculosis and meningitis will lead to screening or treatment of close contacts.
8. How often do I make a diagnosis?
Many times per day. Every case I examine.
9. Do I get to interact with patients a lot?
Not directly. Patients usually discuss their reports with their physician, but periodically we will talk to a patient about a question they have, or they will call us to request assistance with obtaining a second opinion. Some pathologists have regular patient contact if they run clinics in certain areas (they may do fine needle aspiration biopsies of thyroid lumps, for example, or run coagulation clinics where blood thinning medication is adjusted based on test results). I don't do these, myself.
10. Do I feel that I make a great contribution to the health of society/society in general?
I feel that I make a useful contribution but no more or less than a competent, diligent, hard working and caring individual in any line of work. For example, I think that a competant, diligent hard working and caring housekeeper makes a tremendous contribution in a hospital - without them, we are at risk of spreading infection to hospitalized patients and possibly causing their death. I don't think my contribution is any more important than theirs - it just takes much more training, ongoing studying, and there are a whole host of professional obligations. We all have our role to play.