News of Our Patients Death Have Been Greatly Exaggerated!

| October 3, 2016

Dr. Karim Sirgi, MD, MBA, FCAP, Managing Partner and CEO, LambdaX3 International recently wrote the below post on LinkedIn. Karim has kindly agreed to allow me to repost it here to share outside LinkedIn – including our loyal patient following. I wanted to share it here because I think nearly every pathologist can empathize with the questions and cliché jokes and comments.  In truth, many of us, myself included, do very few autopsies, yet, that is a common perception among the public and the patient public.  For patient’s who have chronic medical conditions necessitating biopsies or for patients with cancer, they may know otherwise, but the stereotypes remain and I think it pathology as a specialty can’t seem to get out if this “casting” that fills up television and large screen Hollywood productions.  Even Concussion, with a lot of fanfare, and I think well done in terms of what an autopsy pathologist does, didn’t last long in theatres and was overshadowed a bit with the Oscar fallout about no African-American actors being nominated, as in this movie.

I use to have an attending in training who actually called the autopsy, the “awfultopsy”, as in “awfultopsies are not that bad if you only have to do one every other year” which I think was his goal in practice. Sometimes the autopsy pathologist would be out and others would cover if there happened to be a case so many of my attendings did not have this as part of their routine practice. And, increasingly, the number of hospital deaths and hospital autopsies has been on the decline for decades, for better or for worse. Advanced pre-mortem imaging, lack of reimbursement, and I think, lack of physicians obtaining consent for autopsies has contributed to the decline.  The point is, unless you have this skill set in a setting that provides for this service, chances are your pathologist contributes less than 5% of his/her practice to autopsies.  Yet, Quincy and CSI and Law & Order  portray an exceptional group of physicians with tremendous abilities and knowledge and skill outside this practice in a different light. 

Perhaps as we begin to further understand that diseases and tumors that affect our patients are going to be increasingly categorized by genomics and proteomics, with corresponding companion diagnostics and therapies, squarely in the pathologists’ domain, we won’t be viewed as working in dark rooms, detached from patients and their families.  

But it will be up to pathology and pathologists to make that happen and share with the patient public what our specialty does across a wide range of sub-specialties, just not the stereotypical one.  

Perhaps some day when someone asks “What do you do for a living?” I can respond with “I am a computational pathologist”. The follow up would include telling them our specialty aggregates and mines large volumes of data and images and outcomes information with elaborate information systems and images and algorithms to insure they receive the most appropriate, least toxic therapy.  

Then, maybe, there will be some other clichés about data mining and computing and direct patient care we can replace for the older clichés. 

“What do you do for a living?” people ask me. This is a simple question that merits a simple answer. Most people can summarize their trade with one word, and the inquiring party immediately understands what is meant by the answer. Nobody has doubts as to what a carpenter, ironsmith, builder, bus driver, airplane pilot, soldier, or attorney do for a living. Even cardiologist, neurologist, pediatrician, or orthopedist, to name a few of the medical specialties, are well understood by the general public.

For me, the situation is quite different: I am a pathologist, you see. I just know what goes through your mind when I announce my specialty, having experienced so many times the blank stare (sometimes, horrified look) on your face or one of many possible (not always) polite responses: The blank stare denotes of course the fact that you have absolutely no clue of what it is I do; cliché responses vary along the lines of “Oh, dead people, I understand”, or “I hope I never end up on your table”, or “you don’t have to worry about keeping your patients alive; it is already too late by the time you get them”, or “I bet you never hear complaints from your patients, winking, smiling, laughing.” During my 25 plus years of career, I think I have heard it all.

I cannot blame lay people for only being familiar with aspects of my medical specialty that represents less than 0.5% of most pathologists’ daily activities. It is, after all, how Hollywood portrays pathologists in movies and TV series: Socially awkward physicians (often poorly shaved, dirty, drunk, or a combination of all of the above) who feel more at ease working with (and talking to) cadavers. Obviously, the film industry has not bothered to meet the hundreds of forensic pathologists around the country who work with modern tools of science and technology to solve the thousands of unexplained deaths that occur in civilian, military and criminal cases. The entire justice system would crumble in our country if it were not for the unsung work of these dedicated forensic pathologists, and their teams of scientists. I have had the privilege of knowing and working with many of them, and I still have to find one even remotely suggestive of the characters portrayed by Hollywood.

The greatest majority of pathologists have no involvement at all with performing an autopsy, the complex and highly specialized medical act of examining the remains of a dead body, and one can wonder why the same stated perception exists in the mind and discourse of healthcare professionals intimately associated with pathologists in hospital-based and outpatient facilities. Is it ignorance, or a cowardly and cheap shot by some medical and administrative healthcare professionals at a specialty placed at a disadvantage due to its lack of direct contact with patients and their families? Most pathologists take issue with these people’s understanding of “direct patient contact”; for a pathologist, any specimen obtained from a patient at a clinic, in a hospital bed, or during surgery constitutes “direct patient contact”, and is treated with the same level of care and respect as if the patient or a family representative were present. Our specialty prides itself on doing what is right for the patient, even and especially when nobody is looking, on countless specimens obtained every day, on a multitude of very much alive patients. In addition, many of us pathologists do have “in person” contact with patients in such subspecialties of pathology as cytopathology (study of diseased cells), hematopathology (diseases of the blood), dermatopathology (diseases of the skin), and others. In addition, pathologists have become very sought after members of national patients groups, for the unique scientific and diagnostic perspective that they bring to the table. These patients to pathologists’ interactions happen on a daily basis around the country in actual meeting rooms, but also around the country and the world in virtual social networks dedicated to such specialized exchanges.

The public in general, and less excusably many healthcare professionals, do not realize that 70% of all medical decisions are based on a diagnosis that has originated in a pathology laboratory. Seventy percent! In other words, 7 out of 10 very much alive patients owe a large part of their initial and follow-up care to laboratory procedures or consultations originating from a pathology laboratory, and interpreted or overseen by pathologists. The panoply of instruments and technologies available to pathologists and their teams of scientists are bewildering, and vary from traditional microscopes to highly complex testing instrumentation capable of detecting the smallest organisms, and the most lethal cancerous cells. Personalized medicine advertised as the next step in the White House Cancer cure Moonshot, is based in large part on genetic and molecular tests and procedures developed and interpreted by pathologists. These tests are meant to personalize highly complex diagnostic and therapeutic modalities, as well as prolonging the life of patients afflicted with rare or life-threatening diseases.

A pathologist is a highly specialized physician trained in the interpretation of specialized laboratory tests and in maintaining strict standards of testing quality and safety, second to none in any other specialty of medicine. A pathologist’s dedication to quality and safe delivery of care are also reflected by the full membership of pathologists in healthcare delivery teams. Yes, medicine is nowadays a team sport, and not having a pathologist on that team would be similar to a football team deprived of key players: Patient care would irremediably suffer from such a situation! Unfortunately, if such a situation ever happened at healthcare facilities interested in cutting quality corners, the patients would probably learn about it a bit too late considering the lack of in person encounter with their pathologist. That is why an educated and engaged healthcare consumer afflicted with a serious, life-threatening, disease always needs to inquire about the healthcare team membership, and feel comfortable to directly contact various members of that team, including pathologists, as needed.

Similarly to other medical specialties, pathologists dedicate, on average, 13 years of their post-high school education to learning and perfecting the science and art of their specialty: 4 years of undergraduate education, followed by 4 years of medical school, 4 years of specialty residency training, and at least one more year of advanced fellowship training in one of the numerous sub specialties mirroring expertise in other fields of medicine and surgery.  Not only are pathologists medical doctors, they are among the most educated, specialized and sub-specialized members in the House of Medicine.

The next time your doctor comes back stating “I have your test results,” know that these results did not materialize from thin air; they were made possible because of the knowledge and dedication of pathologists and their team of laboratory scientists. Although that dedication was expressed in areas of healthcare delivery not open to the general public, you the patient were as visible to them as is your physician to you. The goal of these pathologists is very much to keep you healthy and very much alive. As your specimen was in their care, you can now leave the clinic assured that the rumor of your demise was grossly exaggerated! Even Mark Twain would agree with that.

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