A Truck Driver, A Pathologist and A Patient Consultation

Over the Summer, before a Breast Cancer Tumor Board meeting, the oncologists, radiation oncologists, surgeons and I were discussing “What if?” “What if you weren’t a surgical pathologist or a surgeon?” the radiation oncologist asked my surgical colleague and I. The surgeon responded he couldn’t imagine doing anything else (as we all said) but if he could imagine it, he would build cars. Work on an assembly line and build minivans for young families and “soccer moms”.

Without hesitation I responded, “Truck driver – long haul driver”. This drew more of a surprise than the surgeon building soccer mom-mobiles.  It’s something I had thought of many times before. The similarities are obvious.

A truck driver operates a sophisticated engineering marvel, pathologists do the same with microscopes, stains, dyes, equipment, molecular and FISH probes and more. We both operate precise machines.

A truck driver must make second to second decisions about the road conditions, wind, weather, changing traffic patterns, weigh stations, tolls and cars entering the highway into the right lane where the trucks have to drive. Surgical pathologists make decisions on every field they look at, decide if they need to move left, right, slow down, go onto a higher power, check a margin or can move onto the next slide in the tray.

A truck driver needs to keep an eye out for those “four wheelers” that cut them off, then slam on their brakes because the “four-wheeler” is trying to beat the truck carrying his beer or food to the bar they are both trying to go to when traffic piles up. A surgical pathologist is always looking for mitoses, necrosis, signs of dedifferentiation, variability in cell size/shape/outline, etc.…, particularly if they are inconspicuous like the small “four-wheeler”.

You get the idea. There are similar skill sets.

Perhaps one of the most striking similarities is the solitary nature of both professions. Surgical pathologists spend more time with their laboratory information systems in a given day than they do their spouses. And their microscopes. I spend hours looking through a microscope and on a computer screen as opposed to a windshield. We spend a lot of time talking to ourselves as we dictate cases. Anyone who has driven 8 or 12 hours by themselves knows those conversations with themselves were  some of the best conversations they ever had.

I could imagine myself in the cab, hauling automobile parts, or automobiles from Chicago to the West coast and coming back with lettuce, Apple computers or turkeys this time of year. Perhaps I would go down to the docks and pick up a container bound for Walmart with back to school supplies or Christmas gifts if I were driving a truck this week.

Instead of being compensated in CPTs I would be compensated in miles driven x weight.

Or perhaps I would deliver the supplies that save the lives. Dialysis solutions and sterile surgical equipment and pacemakers and vascular grafts. Back up into a hospital loading dock and perhaps drop off formalin, paraffin, hematoxylin and eosin and alcohols and xylenes. And I would be on my way to O’Hare perhaps to get some cargo from overseas for a downtown hotel or suburban mall.

Much like pathology starts a process, with coordinated care of multiple professionals based on a diagnosis, those semis at the loading dock require a team of professionals to unload, stock, inventory, manage and deliver to the wards, clinics, offices, suites and operating and emergency rooms the goods.

Dropping the load off at the back door is the beginning, much like a pathology diagnosis puts into motion multiple specialists trained to care for the person based on their tumor type, location, grade and stage of disease. This is what happens in tumor boards on a regular basis and medical liver conference and interstitial lung disease conference and so forth.

We are the truck drivers of medicine. We deliver the diagnosis, someone else delivers the treatment.

An e-alert appeared about an Early Online Release entitled “Please Help Me See the Dragon I Am Slaying”. The full article available here goes onto report that during a 13-month period of time, 31 patients out of 1615 patients diagnosed with cancer (2%) at a single institution (most of the consultations involved patients having malignant diseases per the paper) participated in a pathologist-patient consultation. A survey was provided to patients with a positive response and many positive comments as the paper highlights, including one patient remarking “Please help me see the dragon that I am slaying”.

We all have our anecdotal stories about reviewing slides with a patient and/or their family members. Some of my experiences have been with physicians who were diagnosed with cancer or loved ones and the patient wanting to learn more. One was a truck driver who, like one of the patient’s in the study, was the sole living grandparent determined to see his grandkids when he wasn’t on the road.

This is an important function that pathologists can serve. It is a little outside what we normally do, speaking to other physicians and writing reports intended for oncologists, radiation oncologists and surgeons. It is something that has been paid a lot of lip service, in my opinion, to try to step out from “behind the paraffin curtain” as one pathologist has been quoted as saying.

But it is going to require an effort of many pathologists – to educate pathologists on how to do this. And think about ways, if not directly reimbursed for the consultation, as an added value with pathologists looking to add value to our services.

It will have to start in training programs and train established pathologists on managing these experiences. May also require some regulatory agencies being educated. Until recently, pathologists in New York state were prohibited from speaking to patients on a consultative basis (Pathologists Cannot Talk to Patients? Fuggedaboutit).

Many pathology department and pathology group websites encourage patients to speak with their physicians about their results. Here is one example, although not unique among pathology groups.

The truth is I learned more about Yellow Fever and Bubonic plague and anthrax (this did come in handy in 2001) than I did about doing patient consultations in my residency.

I may actually know more about driving a truck and backing up a trailer and hospital loading docks and storerooms than I do about patient-pathologist consultations.

There is extraordinary value in these face-to-face encounters, educating patients, as the paper states and we can change what I think is an unfortunate moniker, “The Doctor’s Doctor” to “A Patient’s Doctor”.

Much like the diagnoses themselves, hopefully additional institutions will commence doing regularly scheduled patient-pathologist consultations and report their feelings and those of the patients.