Medical School 2020: Year 4, Second Half

one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.

To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous. This chapter begins in January 2020.

Year 4, Week 25 (Pathology elective, week 1)

It's mid-January and Interview season is over.

I meet my attending at 9:00 am in an office building that is a 10-minute walk from the main hospital. The 68-year-old is a fellowship-trained gastrointestinal and dermatopathologist. He is also the main partner in the pathology associates private practice that serves the hospital. Front and center on his desk is a big microscope that can be used without bending down. With a pedal underneath the desk, he can record statements that go to a dictation service. A mirror system allows a second person on the other side of the desk to view the same slide. I can adjust the microscope to my vision, but an uncomfortable neck bend ends up being required due to the desk panel that prevents putting my legs under the desk.

We begin with his morning cases of skin biopsies, already prepared by pathology assistants and lab techs who have created physical slides. He uses the Epic Media tab to look up any photos that were taken prior to each biopsy. "I train all our dermatology residents to take images. This is from a PA, doubtful they took an image." He puts the first slide of the case onto the microscope. "This must be from acral skin [hand and toes] Thickened stratum corneum layer, prominent reedy ridges." What are reedy ridges? "Oh, they are the invaginations of the basal layer." We look at several mole biopsies. "Look at the papillary lamellar fibroplasia. This is a reaction to melanocytic dysplasia. I really do not want to call this melanoma, but I have to. Look how the melanocytes devour the epidermis. Cells should never destroy something. This is high grade dysplasia," he concludes. "That will progress to melanoma over time. No one knows how long, but it will." He orders S100 (neural crest derived cell label) and elastin stains "on the block" (processed tissue saved in the tissue bank for about a month) for nerve and venous involvement.


It is still prior to the 11:00 am stain-ordering deadline, so we rush to the next case: a polyp biopsy. After five minutes of dictation, he realizes that his statements are going to be tagged to the wrong patient ID. "Oh, boy. Look what I did.  I grabbed the wrong slide. The most common medical error is clerical."

I struggled during medical school with several of the vocabulary words used to describe colon polyps. Villous, tubular, serrated, papillary, sessile, pedunculated… During this first morning, I see great examples of each. For example, villous describes fingerlike projections into the lumen by contrast to papillary, which describes smaller indentations and projections. I also learn how to assess glandular dysplasia. For example serrated describes tubular glands, e.g., crypts that instead of forming normal circular glands have ameba-like lumen. I learn several important histologic criteria to evaluate polyps including the crypt:villus ratio.

We diagnose a 24-year-old female with celiac disease after EGD (esophagogastroduodenoscopy; a procedure in which the esophagus, stomach, and proximal small bowel are examined with a scope inserted through the mouth) biopsies show destruction of villi in the duodenum with lymphocytes and neutrophils in the lamina propria (layer under the mucosa). "If the villus is less than three times the diameter of crypts, you have villous destruction." He orders fungal and bacterial gram stains to rule out an infectious process. "This doesn't look like an infection. This is celiac but we have to be thorough."

He explains the two different routes to most cancers. There is a chromosomal damage pathway in which a select number of oncogenes or tumor suppressor genes become mutated (either sporadic or inherited) causing a proliferation phenotype. If this occurs in colonic epithelial cells, this results in the classic tubular adenoma to carcinoma pathway. The other pathway occurs from disruption in the DNA repair pathways, which leads to diffuse damage to chromosomes called microsatellite instability. This results in early dysplasia such as serrations and poor gland formation.

We do a 40-slide case of a colon resection. "Pathologists determine the surgeon's reimbursement. If we can't find at least 13 lymph nodes removed, the surgeon will get penalized." We find 14 or 15 among the 40 slides and then concentrate on the main tumor. "Look at all this fibrosis. The body doesn't have that many ways to respond to abnormal tissue. This is called a desmoplastic reaction when the tissue tries to wall off the cancer with fibrous tissue deposition. The tumor volume is almost entirely desmoplastic reaction and not actually invasive colon cells."


Statistics for the week… Study: 1 hour. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Burgers and Beers with Lanky Luke and Mischievous Mary. Mary is hitting the trail for the next month to interview in cardiothoracic surgery.

Year 4, Week 26 (Pathology, week 2)

We meet at 5:55 am on Tuesday and walk over to the adjacent building for GI tumor board. Five gastroenterologists, four oncologists, two radiation oncologists, and the chair of radiology arrive at 6:00 am sharp. The surgeons arrived at 6:10 am having been delayed on their morning rounds. A group decision will be made on how to treat every GI tumor that was diagnosed in the preceding week. There are 20 cases to discuss today and, for each one, there are choices regarding radiation, chemotherapy, and surgery. A case coordinator will then schedule the patient for the agreed plan.

We then walk 10 minutes to the hospital to start looking at "frozen sections," prepared via flash freezing. These are slides acquired during ongoing operations that need immediate analysis. Depending on what we say, the patient will be closed up or if the surgeons will keep cutting until they get negative tumor margins..

On the way we discuss why our health system has outsourced its lab, which is still physically in the hospital, to a third party. "Our health system was a large hedge fund with all its investments. During the [2008-2009] financial crisis, we sold the lab to Quest to make up for stock market losses," he explains. "This deal with the devil might have saved the hospital, but we're stuck with a long term exclusive contract. Quest's technicians are slow and don't use the latest equipment. It's the Walmartization of medicine." He is especially animated on the subject of tissue being outsourced to Quest's pathologists. "They're just machines," he says. "Our pathologists are better." One problem with the division of labor is that Quest's pathologists aren't local and therefore can't be present for discussion at the boards. As with outsourced radiology, there is no attempt to use video conferencing to bring the physicians who did the work into a real-time discussion and therefore the boards must rely on often-cryptic notes in Epic.


I ask whether working in a private practice is typical for pathologists. "We're a dying breed. I get 2-3 buyout offers per month. I could make $1.5 million and become an employee with a guaranteed higher salary for three years. But if I did that, how would the young doctors get to where I have been fortunate enough to get to? Employee-pathologists at places like Quest have no control over their work or their pay. They get paid a lot for the first three years of a guaranteed contract and then the company will cut their pay and gut their quality of life. Patient care is better when I'm my own boss and can spend extra time researching an unusual case." (I saw him spend an additional three hours doing research on an unusual lymphoma, work for which he wouldn't have been paid anything extra.)

The first frozen is for a squamous cell cancer located on the hard palate (part of a 60-year-old male smoker's mouth). We look under the microscope and can clearly see HPV-related dysplasia of the epithelial layer at the distal margin. We go over to the pathology assistant who prepared the specimen to clearly articulate which margin is positive to the surgeon. My attending calls the surgeon on his personal cell to give him the bad news. "He probably already closed." Two more frozens are both positive. "You never know if you have good margins. You think you got it all, but you just don't know until you look under the microscope."

Friday at lunch with the five pathology attendings, I give a presentation on pancreatic neoplasms, of which there has been an epidemic coinciding with the rising use of CT and MRI scans. When anomalies are seen, even ones that have only a tiny chance of progressing to malignancy, the health care system springs into action to treat these "incidentalomas". I discuss pancreatic neuroendocrine tumors (e.g., insulinomas in which pancreas tissue secretes uncontrolled insulin) and intraductal pancreatic mucinous neoplasm (IPMN, tumors of the pancreatic duct with malignant potential). I reviewed a pancreatic cancer case that I participated in, showing pictures of the specimen that I helped section and review the negative margins after resection of part of the portal vein. The partner points out that the rise in incidentalomas is not a problem for the healthcare industry: "IPMNs are going to keep pancreatic surgeons in business for the next decade."


Saturday is my attending's "pathology call day". He goes into the office for all of these and catches up on ordinary cases. On roughly half of the days he actually does get a call. Today a 64-year-old presents to the ED with abdominal pain and distention. He has a small bowel obstruction requiring operative exploration. During the operation they find a small bowel tumor as the cause. We go to the gross lab to examine the specimen and assess margins on a frozen section. "The most common reason for call is that surgeons now do elective cases on the weekends. We usually have one or two breast cases where they wait on the pathology read to determine if they need to continue with an axillary lymph node dissection."

Jane has a mundane ED shift until a six-year-old falls off his bike resulting in a 3 cm eye lid laceration. The ED nurse bubble wraps the kid, but he is still squirming. Jane, "I'm terrified. How am I going to suture this kid?" After a few attempts, the mother grabs her phone and plays Frozen. "The kid didn't move an inch with Let It Go blasting."

Statistics for the week… Study: 1 hour. Sleep: 9 hours/night; Fun: 1 night. Example fun: Jane and I go to the local pound for a puppy search and come home with an 8-week-old black lab mix. We are added to the selective Dog chat on GroupMe for meet ups. Several classmates graciously gift us their old crates and puppy accessories.