Wow, it feels like a really long time since I made a blog post.
Over the past 2 weeks or so since getting back from Japan, I've been busy moving. After I moved into my new place I read the 4th edition of Orthopedic Pathology by Peter Bullough (Hosp. for Spec. Surgery in NY). A 5th ed is available, but I'm reading the late edition (since it's the only physical copy the library has). The reason I wanted to read this is because of the few times I came across bone (not in the context of bone marrow biopsy for hemepath), I felt like I had very little idea/knowledge regarding what I was looking at.
It's a really good book and I recommend it. It goes into gory detail about all things bone. Something which surprised me about this book, is it mentioned having radiologist input, which I thought would last for a few chapters or so then peter out, but it has consistent rad-path correlates pretty much the whole way through the book which I think is quite commendable. It also has really good examples of disease entities which are rare. It always amazes me how the specimens are presented in this book... very clearly, which I assume must have taken hours of careful dissection to prepare. Something which I keep wondering while reading this book, is what their gross room setup looks like. I assume it is something similar to a carpenter's shop with huge razors and the like for sawing through bones. It shows some of their gross room in the introductory section, but it would be very cool to get a tour someday.
The book would be a good read for future radiologists as well, as it goes through differential diagnoses and mimickers.
Reading this book also made me realize how much special equipment is necessary to conduct a comprehensive assessment of bone... half of the pictures in here have polarized light microscopy and a lot of special stains are used, in addition to red filter for gout and CPPD.
An interesting point that I think I got from this book is that bone pathology is very easily confused on imaging. For example, some of the benign entities discussed were removed because they were mistaken for malignant processes. This happens in other areas of pathology as well, but I suppose in bone it is more high-stakes. In other instances, a malignant lesion can be confused for a benign process... This is one area in which I wonder if molecular genetics could be very helpful in pinning down a diagnosis.
What resources do you recommend for learning bone pathology?
Wednesday, June 5, 2019
Friday, March 29, 2019
Forensic Pathology
So I am currently 1/3 of the way through the ob/gyn rotation, and unfortunately (due to very stupid reasons) I'm not enjoying it as much as I had hoped. 40 days until Japan...
In other news, I just finished reading this book called "Unnatural Causes" by Dr. Richard Shepherd.
The author writes about his career as a forensic pathologist in Britain/the UK. He writes very honestly, and I was hooked on this book from the very beginning when I first read the introduction online later reading the physical copy in very short drips and drabs at night before bed.
As of now I'm not sure what kind of career in pathology I want to pursue.
I find that I enjoy looking at slides, but I have also become interested in topics in forensic pathology.
We had one lecture (and only one) given to us by a practicing forensic pathologist and this was outside the curriculum of medical school -- in fact, it was through the activities of the pathology interest group that I first became aware that this was even a career option. Later I had the opportunity to observe a few forensic post-mortems, but I am not completely sure it's what I want to do because I'm between that and being a hospital/clinical pathologist.
One book which I think is a good starting resource would be the textbook Forensic Pathology by David Dolinak who is both a neuropathologist and a forensic pathologist. I read the entire book over a few months time. It was a very fascinating book, though I was unable to read it at length, given the material/content. I had to read it very slowly in small portions at a time. There was something fascinating about it that pushed me to read it to the end, however, similar to Dr. Shepherd's book.
Shepherd talks about his experience having PTSD which he attributes to having worked in post-disaster/massacre/terrorist situations i.e. 9/11, Hungerford massacre, Bali, Marchioness tragedy
It's strange, before this, I thought I had all but decided I wanted to look at slides all day instead of doing autopsies. I'm not sure if I'm being influenced by the unsavory interactions I'm having with the clinicians that I'm working with right now. Is it a reaction that I'm having by wanting to distance myself entirely from the microcosm of the hospital, the egos and squabbles of the clinicians, and their politics (?)
The other reason why I'm considering this again (forensics) even though previously I thought I had ruled it out as a career [...thinking back, it may have been because of my role of relative non-involvement as a student who was there on a very limited basis, essentially observing and not having a very active role in the autopsies I observed] have to do with my own curiosity and interest and I suppose a natural affinity for the job I suppose. Being able to determine why a person died is not as simple as it appears...
Either way, I guess because of this book and for my own reasons, I'm thinking about this career path again.
Two additional resources I would recommend for people interested in forensic pathology specifically would be Knight's forensic pathology (found easily online), and Simpson's Forensic Medicine (I was able to find the 11th edition in the library and flipped through it, but I would like to check out the most recent edition which I'm sure has a lot more updates).
One thing that does bother me would be the occupational hazards inherent to the job in terms of infectious disease. I have heard here and there about pathologists contracting various diseases on the job. Perhaps, given the infectious risk, there needs to be more formalized protocols when carrying out an autopsy, similar to how surgery in the past used to be much less regulated in terms of protocol leading to mistakes and surgical site infections.
What are some ways you all think infection risk could be reduced when carrying out an autopsy?
In other news, I just finished reading this book called "Unnatural Causes" by Dr. Richard Shepherd.
The author writes about his career as a forensic pathologist in Britain/the UK. He writes very honestly, and I was hooked on this book from the very beginning when I first read the introduction online later reading the physical copy in very short drips and drabs at night before bed.
As of now I'm not sure what kind of career in pathology I want to pursue.
I find that I enjoy looking at slides, but I have also become interested in topics in forensic pathology.
We had one lecture (and only one) given to us by a practicing forensic pathologist and this was outside the curriculum of medical school -- in fact, it was through the activities of the pathology interest group that I first became aware that this was even a career option. Later I had the opportunity to observe a few forensic post-mortems, but I am not completely sure it's what I want to do because I'm between that and being a hospital/clinical pathologist.
One book which I think is a good starting resource would be the textbook Forensic Pathology by David Dolinak who is both a neuropathologist and a forensic pathologist. I read the entire book over a few months time. It was a very fascinating book, though I was unable to read it at length, given the material/content. I had to read it very slowly in small portions at a time. There was something fascinating about it that pushed me to read it to the end, however, similar to Dr. Shepherd's book.
Shepherd talks about his experience having PTSD which he attributes to having worked in post-disaster/massacre/terrorist situations i.e. 9/11, Hungerford massacre, Bali, Marchioness tragedy
It's strange, before this, I thought I had all but decided I wanted to look at slides all day instead of doing autopsies. I'm not sure if I'm being influenced by the unsavory interactions I'm having with the clinicians that I'm working with right now. Is it a reaction that I'm having by wanting to distance myself entirely from the microcosm of the hospital, the egos and squabbles of the clinicians, and their politics (?)
The other reason why I'm considering this again (forensics) even though previously I thought I had ruled it out as a career [...thinking back, it may have been because of my role of relative non-involvement as a student who was there on a very limited basis, essentially observing and not having a very active role in the autopsies I observed] have to do with my own curiosity and interest and I suppose a natural affinity for the job I suppose. Being able to determine why a person died is not as simple as it appears...
Either way, I guess because of this book and for my own reasons, I'm thinking about this career path again.
Two additional resources I would recommend for people interested in forensic pathology specifically would be Knight's forensic pathology (found easily online), and Simpson's Forensic Medicine (I was able to find the 11th edition in the library and flipped through it, but I would like to check out the most recent edition which I'm sure has a lot more updates).
One thing that does bother me would be the occupational hazards inherent to the job in terms of infectious disease. I have heard here and there about pathologists contracting various diseases on the job. Perhaps, given the infectious risk, there needs to be more formalized protocols when carrying out an autopsy, similar to how surgery in the past used to be much less regulated in terms of protocol leading to mistakes and surgical site infections.
What are some ways you all think infection risk could be reduced when carrying out an autopsy?
Monday, March 18, 2019
The Match and Ob/Gyn
Hey everyone, this past week was quite momentous as (medical readers likely know) it was Match Day just last Friday (in addition to it being St. Patrick's Day Sunday).
Match Day is the day where all the fourth year medical students in the country find out the location of the residency program where they will be working in residency (a.k.a. first real job out of medical school). It marks the transition from being a 'medical student' to being a resident 'doctor' although still a trainee. For my close friends, some of them matched to their top choice program, while for others they matched further down the list (i.e. in more competitive specialties, for example).
The rules are that the applicant creates a 'rank list' which lists the programs where the person would like to go to, and the program creates their own list of applicants. A computer program takes this massive amount of data, crunches it, and matches person to program.
On the actual Match day ceremony (typically a Friday), students, their friends and family receive and open the letters containing information about the hospital and the location where they will be working for the next several years. It is similar to other ceremonies (weddings, funerals) that commemorate and mark an important transition in one's life.
Even so, there are imperfections.
The difficulty of the match system is that one has very little control over where one actually ends up, given that it is determined by a computer algorithm.
It is especially difficult when couples are separated by this system. Even the 'couples match' (two applicants declare themselves 'a couple' and tries match them to programs within the same general region) can result in applicants being separated by hours. So what is the solution to this problem?
From what I understand ... one has to have two things - faith, persistence, and strategy. Expressing interest in a certain program in a desired geographic region can raise an applicant's rank on a program's list. Applying to many programs in the region of interest also increase one's chances of matching in a geographic area. And finally, doing an away rotation at an institution one would like to be at. Other than the things applicants typically do which consists of doing well on exams and making a good impression on an interview. The converse of which is what people applying have told me is referred to as 'avoiding red flags' (i.e. failing an exam, making a bad impression on an interview).
On a completely unrelated note, I finished my surgery rotation last week.
Today I just had my first day of conferences for my Ob/Gyn rotation. I realized that it is a completely different language! Obstetrician-gynecologists communicate using unique terminology which you do not hear in any other field of medicine! It was kind of a shocker how much I realized I didn't know about the female body and pregnancy. I have a lot to learn the next 6 weeks.
An interesting conversation between two ob/gyn's which I overheard today was regarding the sufficiency of cytology specimens. One remarked that sometimes his samples resulted as insufficient for evaluation, and a few tricks/tips to avoid this. A suggestion was : because blood cells an obscure a sample, do not over-instrumentate while taking a sample. The other talked about how she improved by avoiding getting lubricant in the sample by ensuring that it was on the outer blades of the speculum (while doing a pelvic exam). It got me thinking about how to improve the yield of cytology specimens. She did discuss some laboratory factors such as compatibility of the media with machines used to process specimens etc. Due to variability in these factors, I would assume the yield varies between laboratories and it is interesting to think about how to potentially increase yield and specimen quality given the quantity given. This is a frustrating point for obstetrician-gynecologists because it means that the patient must come back for another visit, taking a chunk out of her day, and ultimately leading to decreased rapport and patient satisfaction, due to factors out of their control.
Hearing the clinician perspective about this made me realize how important it is for laboratory professionals to handle specimens with care, but also troubleshoot and make improvements in our own processes so that patients do not undergo extra procedures unnecessarily.
As much as people might say (as one surgery resident did to me just the other day in the OR), in pathology, "all your patients are dead", this illustration begs to differ. The information we relay to clinicians has an enormous impact on medical decision making, and we should consider carefully the message and potential impact/consequences. A very important way of framing this, I think, is by considering the range of actions a clinician might make based on the information contained in the report, as a thought exercise. For example, I was told by a surgery resident that even though a diagnosis may not be certain, a surgeon may choose to bring a patient to the OR simply based on a 'highly suspicious' diagnosis, in some cases. Of course this is on a case-by-case basis and clinical judgement, but it is always important to consider.
This brings up a few questions, such as: What happens when an interpretation gets out of hand? For example, a pathologist has made an equivocal diagnosis favoring two possibilities and it is interpreted as being 'entity X' (error of omission) in the patient's medical chart/clinician's notes. Is the role of the pathologist to point out this discrepancy and effectively impose oneself by correcting the people involved in the patient's medical care? This is an interesting ethical dilemma for pathologists as some might argue it is overstepping our bounds. Another sticky situation involves a pathologic diagnosis that is failed to be followed up on, effectively being missed by clinicians in review of the patient's charts. Should a pathologist be more proactive in alerting busy clinicians of the findings? Which would be the best way to do this (by letter, phone call)? Should we as pathologists take a more proactive role in improving our communication to the healthcare providers ultimately responsible for keeping track of the patient's medical course (?)
This weekend, I also went to donate blood again, seeing that it had been about 3 months, and I had some free time, and this very nice lady from the Red Cross phoned me and asked whether I would be available. I figured, hey, I have the weekend off after my surgery shelf exam, so why not? I had about 2 weeks to prepare in advance (whereas previously I just did it on a whim). So I went, having hydrated myself nightly the week in advance (was sipping on clears at home). To my surprise, I was able to complete the donation. Fun fact: Did you know there is about a pint or just under 500 ml (half a liter) in a pack of whole blood? I give credit to the incredible staff at the Red Cross who were able to place the needle even though I have small veins, and watched me carefully after the donation. The people who work there really do care.
The hours on this rotation are 5-6AM to 6PM, typically. With 2 weeks of L&D, Gynecologic surgery, and clinic. I think after this rotation, I will have more time to post again. =)
Match Day is the day where all the fourth year medical students in the country find out the location of the residency program where they will be working in residency (a.k.a. first real job out of medical school). It marks the transition from being a 'medical student' to being a resident 'doctor' although still a trainee. For my close friends, some of them matched to their top choice program, while for others they matched further down the list (i.e. in more competitive specialties, for example).
The rules are that the applicant creates a 'rank list' which lists the programs where the person would like to go to, and the program creates their own list of applicants. A computer program takes this massive amount of data, crunches it, and matches person to program.
On the actual Match day ceremony (typically a Friday), students, their friends and family receive and open the letters containing information about the hospital and the location where they will be working for the next several years. It is similar to other ceremonies (weddings, funerals) that commemorate and mark an important transition in one's life.
Even so, there are imperfections.
The difficulty of the match system is that one has very little control over where one actually ends up, given that it is determined by a computer algorithm.
It is especially difficult when couples are separated by this system. Even the 'couples match' (two applicants declare themselves 'a couple' and tries match them to programs within the same general region) can result in applicants being separated by hours. So what is the solution to this problem?
From what I understand ... one has to have two things - faith, persistence, and strategy. Expressing interest in a certain program in a desired geographic region can raise an applicant's rank on a program's list. Applying to many programs in the region of interest also increase one's chances of matching in a geographic area. And finally, doing an away rotation at an institution one would like to be at. Other than the things applicants typically do which consists of doing well on exams and making a good impression on an interview. The converse of which is what people applying have told me is referred to as 'avoiding red flags' (i.e. failing an exam, making a bad impression on an interview).
On a completely unrelated note, I finished my surgery rotation last week.
Today I just had my first day of conferences for my Ob/Gyn rotation. I realized that it is a completely different language! Obstetrician-gynecologists communicate using unique terminology which you do not hear in any other field of medicine! It was kind of a shocker how much I realized I didn't know about the female body and pregnancy. I have a lot to learn the next 6 weeks.
An interesting conversation between two ob/gyn's which I overheard today was regarding the sufficiency of cytology specimens. One remarked that sometimes his samples resulted as insufficient for evaluation, and a few tricks/tips to avoid this. A suggestion was : because blood cells an obscure a sample, do not over-instrumentate while taking a sample. The other talked about how she improved by avoiding getting lubricant in the sample by ensuring that it was on the outer blades of the speculum (while doing a pelvic exam). It got me thinking about how to improve the yield of cytology specimens. She did discuss some laboratory factors such as compatibility of the media with machines used to process specimens etc. Due to variability in these factors, I would assume the yield varies between laboratories and it is interesting to think about how to potentially increase yield and specimen quality given the quantity given. This is a frustrating point for obstetrician-gynecologists because it means that the patient must come back for another visit, taking a chunk out of her day, and ultimately leading to decreased rapport and patient satisfaction, due to factors out of their control.
Hearing the clinician perspective about this made me realize how important it is for laboratory professionals to handle specimens with care, but also troubleshoot and make improvements in our own processes so that patients do not undergo extra procedures unnecessarily.
As much as people might say (as one surgery resident did to me just the other day in the OR), in pathology, "all your patients are dead", this illustration begs to differ. The information we relay to clinicians has an enormous impact on medical decision making, and we should consider carefully the message and potential impact/consequences. A very important way of framing this, I think, is by considering the range of actions a clinician might make based on the information contained in the report, as a thought exercise. For example, I was told by a surgery resident that even though a diagnosis may not be certain, a surgeon may choose to bring a patient to the OR simply based on a 'highly suspicious' diagnosis, in some cases. Of course this is on a case-by-case basis and clinical judgement, but it is always important to consider.
This brings up a few questions, such as: What happens when an interpretation gets out of hand? For example, a pathologist has made an equivocal diagnosis favoring two possibilities and it is interpreted as being 'entity X' (error of omission) in the patient's medical chart/clinician's notes. Is the role of the pathologist to point out this discrepancy and effectively impose oneself by correcting the people involved in the patient's medical care? This is an interesting ethical dilemma for pathologists as some might argue it is overstepping our bounds. Another sticky situation involves a pathologic diagnosis that is failed to be followed up on, effectively being missed by clinicians in review of the patient's charts. Should a pathologist be more proactive in alerting busy clinicians of the findings? Which would be the best way to do this (by letter, phone call)? Should we as pathologists take a more proactive role in improving our communication to the healthcare providers ultimately responsible for keeping track of the patient's medical course (?)
This weekend, I also went to donate blood again, seeing that it had been about 3 months, and I had some free time, and this very nice lady from the Red Cross phoned me and asked whether I would be available. I figured, hey, I have the weekend off after my surgery shelf exam, so why not? I had about 2 weeks to prepare in advance (whereas previously I just did it on a whim). So I went, having hydrated myself nightly the week in advance (was sipping on clears at home). To my surprise, I was able to complete the donation. Fun fact: Did you know there is about a pint or just under 500 ml (half a liter) in a pack of whole blood? I give credit to the incredible staff at the Red Cross who were able to place the needle even though I have small veins, and watched me carefully after the donation. The people who work there really do care.
The hours on this rotation are 5-6AM to 6PM, typically. With 2 weeks of L&D, Gynecologic surgery, and clinic. I think after this rotation, I will have more time to post again. =)
Friday, February 8, 2019
Surgery and Autopsy
Hi everyone,
I'm on my surgery rotation this block and it is pretty grueling.
The best part of the rotation is that I get to 'follow the specimen' to the frozen/cutting room once the operation is almost over. The worst part is the hours (sleep deprivation much?). And the residents are really snappy. This is gen surg btw. [For anyone interested: the hours are the following: Wake up at 4 am, get to hospital by 5, round at 6, get to ORs by 0730, observe operations, eat between surgeries, evening handoff at variable time from 4-6pm. Leave hospital, maybe read, eat, sleep. It's kind of crazy hours compared to most 'regular' jobs.]
Nonetheless, I am learning some cool anatomy via pimping. I kind of gradually forgot most of the spaces/recesses and artery/vein connections from way back when I was a M1, so it's a good review. It is interesting how the surgeon almost never pimps the resident. I guess we are there to help the resident learn as well (?) as it could be potentially embarrassing if they were asked something and they didn't know causing them to lose track of a vital part of the operation (because it distracted them somehow). This rotation is definitely giving me a newfound appreciation for the 'larges' (large specimens) that we receive from surgery. The other thing it made me appreciate as well is that surgery really is a team sport. Besides 'us' (pathology) surgeons also highly depend on radiologists, anesthesiologists, other OR staff and other healthcare providers to ensure that surgery goes safely. It definitely gives me a sense of the bigger picture when it comes to patient care, which is the ultimate goal of anyone in the medical field.
On a different note, I was prowling the interwebs and I found two editions of the same book, an autopsy handbook. I suggest it for anyone wanting to know more about anything autopsy. The 3rd and 4th version can be found here and here. I recommend checking out both. Although they are different versions of the same book, they actually have pretty different info/chapters.
I guess suture and knot tying is giving me some weird sort of confidence that by the end of the 3rd year of medical school, I would be able to meet the basic medical needs of a human settlement on an uninhabited land/island away from civilization if I was the only medically-trained person there.
One thing that is helping me get through this rough rotation is my 'light at the end of the tunnel' ... I'm going to Japan in 88 days with my SO, so that is definitely a factor that makes each day a little bit better than the next as it is 'another day' before I get to go back to Japan. Counting down...
I'm on my surgery rotation this block and it is pretty grueling.
The best part of the rotation is that I get to 'follow the specimen' to the frozen/cutting room once the operation is almost over. The worst part is the hours (sleep deprivation much?). And the residents are really snappy. This is gen surg btw. [For anyone interested: the hours are the following: Wake up at 4 am, get to hospital by 5, round at 6, get to ORs by 0730, observe operations, eat between surgeries, evening handoff at variable time from 4-6pm. Leave hospital, maybe read, eat, sleep. It's kind of crazy hours compared to most 'regular' jobs.]
Nonetheless, I am learning some cool anatomy via pimping. I kind of gradually forgot most of the spaces/recesses and artery/vein connections from way back when I was a M1, so it's a good review. It is interesting how the surgeon almost never pimps the resident. I guess we are there to help the resident learn as well (?) as it could be potentially embarrassing if they were asked something and they didn't know causing them to lose track of a vital part of the operation (because it distracted them somehow). This rotation is definitely giving me a newfound appreciation for the 'larges' (large specimens) that we receive from surgery. The other thing it made me appreciate as well is that surgery really is a team sport. Besides 'us' (pathology) surgeons also highly depend on radiologists, anesthesiologists, other OR staff and other healthcare providers to ensure that surgery goes safely. It definitely gives me a sense of the bigger picture when it comes to patient care, which is the ultimate goal of anyone in the medical field.
On a different note, I was prowling the interwebs and I found two editions of the same book, an autopsy handbook. I suggest it for anyone wanting to know more about anything autopsy. The 3rd and 4th version can be found here and here. I recommend checking out both. Although they are different versions of the same book, they actually have pretty different info/chapters.
I guess suture and knot tying is giving me some weird sort of confidence that by the end of the 3rd year of medical school, I would be able to meet the basic medical needs of a human settlement on an uninhabited land/island away from civilization if I was the only medically-trained person there.
One thing that is helping me get through this rough rotation is my 'light at the end of the tunnel' ... I'm going to Japan in 88 days with my SO, so that is definitely a factor that makes each day a little bit better than the next as it is 'another day' before I get to go back to Japan. Counting down...
Sunday, January 20, 2019
Optics and Tech
To follow up on my previous post, I want to try and imagine the pathology workplace of the future. When the frozen section was invented in the 1890s, doctors hardly could have imagined the workplace of today (2019) 130 years later. In the last century, many advances were made in the field of pathology, aided by the increased availability and means of communication and exchange of ideas (telephone, radio, television, and most recently, computers and the internet became widespread). A century before that, dyes originally invented for the textile industry were applied to biological specimens. About one to two centuries before that, the microscope was invented.
Now, I would like to discuss the possibilities and logistics regarding what I believe to be an eventual and inevitable transition from traditional microscope viewing of physical slides to what I shall loosely call 'digital pathology'.
While radiologists get a bad reputation for being in 'the dark room' perhaps we as pathologists have something to learn from them, as both are highly visual specialties. By reducing the amount of bright light exposure, radiologists have attempted to create a workplace in which a certain type of eyestrain is reduced (but not due to squinting), the details of the surroundings are obscured and their visual attention is focused on what is being assessed. In a similar manner, pathologists desire (or should I say, require) an immersive experience when we are looking at tissue through our microscopes. This, I believe is why pathologists tell me, books cannot compare to looking under the scope. What is seen is much larger when looking under the microscope compared to a picture in a book, moreover there are fewer distractions. A similar phenomenon is when one holds his or her cell phone close to the face, in effect 'blowing-up' the screen.
The fairly recent invention of VR headsets could be a game-changer in this regard. Or take augmented reality implements (such as google glass). I envision something akin to wearable sunglasses, with digital slides projected on the lens, with built in eye movement tracking in order to navigate a slide. Additionally, there will be no keyboards or controls, a pathologist will use simple hand gestures/movements which are read by sensors in the 'room' which serve as 'shortcuts' to navigate back and forth between slides (or if preferable, voice commands). Alternatively, imagine just thinking about magnifying a certain region of a slide and it happening instantaneously -- this requires nascent technology which I will elaborate on further.
Other key considerations which radiologists have heartily adopted, and pathologists should also, have to do with ergonomics and equipment. For example, on my recent visit to the radiology department, I was impressed by their adjustable table heights and comfortable chairs. An simple adjustment many pathologists can make without any fancy equipment is to obtain an adjustable microscope stand (but one might need an adjustable eyepiece as well depending). Comfort improves concentration and makes already heavy work feel lighter somehow. Importantly, they have also invested in state-of-the-art viewing equipment. Even for teleradiologists, to read at home, they must have a monitor (or monitors) which meet a certain specification in terms of quality. This is analogous to microscopes, which can be very costly, but when the inevitable transition to 'digital pathology' occurs the 'viewing station' may become very different.
Another innovation which radiology has gotten down pat, is the use of a universal file type which enables the easy sharing of information between different hospitals/medical centers. For example, one can obtain the images which were acquired in one location, and easily transfer/read the very same image in a different location because of the very fact that the filetype is the same. A simplified example of this is extensions in computer programs. For example .doc means document and can be opened by any program which can read document files. In the same manner, pathologists should decide and insist on standardization of digital slide filetype which would enable universal sharing of such information (although I wonder and hope the companies commercializing slide scanning have already decided upon this).
The final point which I would like to make is with regard to the speed of formulation of reports, and in a very real sense has to do with communication, and this is again is where the imagination part comes in. It has been shown that the human brain thinks much faster than it speaks. Additionally, I think we can all agree that one in general speaks faster than one types (hence dictation), one types faster than one writes with the hand (hence typing and writing), and that one reads, writes, speaks, and thinks faster and with more accuracy the more one uses each faculty. Regarding the conveyance of information and the formulation of reports, I wonder if in the future pathologists will be able to think up/down a report (this may require the invention of a new word).
Returning to my point of elaboration, which I referred to earlier, research is currently being done on the conscious control of objects, whether real or virtual, using brain waves. This is also called many different names, however I will use the term which I find most fitting, a mind-machine interface. It could be imagined that in the future, mind-machine interfaces will become commonplace, and eventually applied to pathology workflows.
The pathology workplace of the future may require the use of a real life, state-of-the-art 'thinking cap' which includes a built-in viewing station and neural net/hat (similar to an EEG monitor) conjoined, which would allow a pathologist of the future to complete reports much faster than before. Old pathologists will tell you, once pathology transitioned from hand-written reports to typing and eventually dictating, how turn-around times (TAT) decreased and subsequently the expectation of clinicians for same-day/the-day-after results became commonplace. If thought to text conversion is accomplished within our lifetime and applied to pathology, I believe pathologists will become ever more efficient at their jobs. Not one, but all of these in combination, and with the incorporation of yet-to-be invented technologies, all are innovations which would revolutionize pathology as we know it today.
If one makes an another analogy to radiology, one could say radiation exposure is the main limitation in conducting scans of the human body; nevertheless, advances in imaging technology (MRI, low-radiation CT) have allowed less radiating (though more costly) scans to be acquired. Radiology differs from pathology, however, in that a patient is a potentially unlimited source of scans. Moreover, the demand for scans and imaging results has on-the-whole been increasing (part of this is due to greed, and the other, negligence on the part of radiologists to serve as gatekeepers of healthcare resources). Because of these practices, modern radiology is now the practice of normology, in which one sees much more normal than 'bad' as a radiologist. The bottleneck in pathology is that it as a practice requires precious human tissue. Because I do not see resections going away anytime soon, I anticipate pathologists in the future having more time for research and academic pursuits, mentorship, safety/infection control, hobbies or perhaps even an improved lifestyle which would be pretty nice.
A very important cause which I believe all pathologists (who care) must fight for, if these changes do occur, is recognition of our speciality as being the foundation of medicine and the bridge between basic scientific research and other specialties of medicine (see the tree of medicine). And in addition, pathologists must prevent of the creation of 'mills' in which pathologists are made to work tirelessly to enrich others, from outside or within medicine itself. Technology has the power to unite people, under a common cause/interests in order to enact change.
P. S. A disturbing scenario involves the monitoring (Orwell's 1984) or de-privatization of thoughts (a.k.a. mind reading). A very dark episode (no. 1) of the anime Kino no Tabi tells the story of a town in which people automatically know each others thoughts. Would brain-computer interface technology develop to the point in which this could be enabled? Food for thought.
Now, I would like to discuss the possibilities and logistics regarding what I believe to be an eventual and inevitable transition from traditional microscope viewing of physical slides to what I shall loosely call 'digital pathology'.
First of all - I want to note that pathologists have a central role in shaping how we want the 'workplace of the future' to be.
Secondly, I believe that this is a process which must evolve organically given new developments in technology which are happening on a daily basis in our time.
Third, there are crucial mistakes to be avoided if digital pathology is to 'get off the ground' so to speak.Additionally, I do know that there are opponents (read, older pathologists) who often harbor mistrust of new technology (i.e. computers) because they are set in their ways. The pathology workplace of the future should be so foolproof (read, solid) that a late-career pathology could walk into this fictional futuristic workplace and be impressed and amazed at its capabilities, and excited about the future of pathology and the possibility of working in one of these places.
While radiologists get a bad reputation for being in 'the dark room' perhaps we as pathologists have something to learn from them, as both are highly visual specialties. By reducing the amount of bright light exposure, radiologists have attempted to create a workplace in which a certain type of eyestrain is reduced (but not due to squinting), the details of the surroundings are obscured and their visual attention is focused on what is being assessed. In a similar manner, pathologists desire (or should I say, require) an immersive experience when we are looking at tissue through our microscopes. This, I believe is why pathologists tell me, books cannot compare to looking under the scope. What is seen is much larger when looking under the microscope compared to a picture in a book, moreover there are fewer distractions. A similar phenomenon is when one holds his or her cell phone close to the face, in effect 'blowing-up' the screen.
The fairly recent invention of VR headsets could be a game-changer in this regard. Or take augmented reality implements (such as google glass). I envision something akin to wearable sunglasses, with digital slides projected on the lens, with built in eye movement tracking in order to navigate a slide. Additionally, there will be no keyboards or controls, a pathologist will use simple hand gestures/movements which are read by sensors in the 'room' which serve as 'shortcuts' to navigate back and forth between slides (or if preferable, voice commands). Alternatively, imagine just thinking about magnifying a certain region of a slide and it happening instantaneously -- this requires nascent technology which I will elaborate on further.
Other key considerations which radiologists have heartily adopted, and pathologists should also, have to do with ergonomics and equipment. For example, on my recent visit to the radiology department, I was impressed by their adjustable table heights and comfortable chairs. An simple adjustment many pathologists can make without any fancy equipment is to obtain an adjustable microscope stand (but one might need an adjustable eyepiece as well depending). Comfort improves concentration and makes already heavy work feel lighter somehow. Importantly, they have also invested in state-of-the-art viewing equipment. Even for teleradiologists, to read at home, they must have a monitor (or monitors) which meet a certain specification in terms of quality. This is analogous to microscopes, which can be very costly, but when the inevitable transition to 'digital pathology' occurs the 'viewing station' may become very different.
Another innovation which radiology has gotten down pat, is the use of a universal file type which enables the easy sharing of information between different hospitals/medical centers. For example, one can obtain the images which were acquired in one location, and easily transfer/read the very same image in a different location because of the very fact that the filetype is the same. A simplified example of this is extensions in computer programs. For example .doc means document and can be opened by any program which can read document files. In the same manner, pathologists should decide and insist on standardization of digital slide filetype which would enable universal sharing of such information (although I wonder and hope the companies commercializing slide scanning have already decided upon this).
The final point which I would like to make is with regard to the speed of formulation of reports, and in a very real sense has to do with communication, and this is again is where the imagination part comes in. It has been shown that the human brain thinks much faster than it speaks. Additionally, I think we can all agree that one in general speaks faster than one types (hence dictation), one types faster than one writes with the hand (hence typing and writing), and that one reads, writes, speaks, and thinks faster and with more accuracy the more one uses each faculty. Regarding the conveyance of information and the formulation of reports, I wonder if in the future pathologists will be able to think up/down a report (this may require the invention of a new word).
Returning to my point of elaboration, which I referred to earlier, research is currently being done on the conscious control of objects, whether real or virtual, using brain waves. This is also called many different names, however I will use the term which I find most fitting, a mind-machine interface. It could be imagined that in the future, mind-machine interfaces will become commonplace, and eventually applied to pathology workflows.
The pathology workplace of the future may require the use of a real life, state-of-the-art 'thinking cap' which includes a built-in viewing station and neural net/hat (similar to an EEG monitor) conjoined, which would allow a pathologist of the future to complete reports much faster than before. Old pathologists will tell you, once pathology transitioned from hand-written reports to typing and eventually dictating, how turn-around times (TAT) decreased and subsequently the expectation of clinicians for same-day/the-day-after results became commonplace. If thought to text conversion is accomplished within our lifetime and applied to pathology, I believe pathologists will become ever more efficient at their jobs. Not one, but all of these in combination, and with the incorporation of yet-to-be invented technologies, all are innovations which would revolutionize pathology as we know it today.
If one makes an another analogy to radiology, one could say radiation exposure is the main limitation in conducting scans of the human body; nevertheless, advances in imaging technology (MRI, low-radiation CT) have allowed less radiating (though more costly) scans to be acquired. Radiology differs from pathology, however, in that a patient is a potentially unlimited source of scans. Moreover, the demand for scans and imaging results has on-the-whole been increasing (part of this is due to greed, and the other, negligence on the part of radiologists to serve as gatekeepers of healthcare resources). Because of these practices, modern radiology is now the practice of normology, in which one sees much more normal than 'bad' as a radiologist. The bottleneck in pathology is that it as a practice requires precious human tissue. Because I do not see resections going away anytime soon, I anticipate pathologists in the future having more time for research and academic pursuits, mentorship, safety/infection control, hobbies or perhaps even an improved lifestyle which would be pretty nice.
A very important cause which I believe all pathologists (who care) must fight for, if these changes do occur, is recognition of our speciality as being the foundation of medicine and the bridge between basic scientific research and other specialties of medicine (see the tree of medicine). And in addition, pathologists must prevent of the creation of 'mills' in which pathologists are made to work tirelessly to enrich others, from outside or within medicine itself. Technology has the power to unite people, under a common cause/interests in order to enact change.
P. S. A disturbing scenario involves the monitoring (Orwell's 1984) or de-privatization of thoughts (a.k.a. mind reading). A very dark episode (no. 1) of the anime Kino no Tabi tells the story of a town in which people automatically know each others thoughts. Would brain-computer interface technology develop to the point in which this could be enabled? Food for thought.
Dermpath and AI
Hi everyone,
This weekend, I'm reading Practical Dermatopathology by Ronald P Rapini. It seems a very well organized book. There is an interesting analogy in the book. It says:
Today, I want to discuss the idea of pathology as art, within medicine, involving subjectivity. The reason for this is because of the strange idea that technology, such as high-powered computers or robots, will someday replace pathologists.
People who say pathologists will disappear as a specialty under the threat of AI do not really understand pathology. When this topic inevitably comes up in clinic, and I try to explain why AI would not be a threat to pathologists, it seems the clinicians become disinterested in the conversation. Why this is the case, I am not really sure, since most of the time they were the ones who brought it up as a topic of discussion in the first place, in response to me telling them that I am interested in going into pathology.
Thus, I want to list my personal opinion regarding why I think AI will not threaten the livelihood of pathologists everywhere.
1) Big tumors and sampling - I watched a TEDx talk where the presenter showed machine learning in which the computer was fed images of biopsies, and was able to stratify them in terms of prognosis with some accuracy. There are many judgements which a pathologist must make regarding biopsies and large cases, which a machine is incapable of. A machine is capable of producing output based on the data given to it previously, however, would it be able to determine whether a biopsy is adequate (in other words, representative of the lesion) [absence of data], or when it comes to larger specimens, whether the tumor has been adequately sampled during grossing? For some reason, I find it hard to believe that a machine would be able to determine whether additional sections of a large tumor need to be put in. These are judgements which an experienced pathologist makes easily and instantly when assessing a case.
2) Ontology and context - a machine does not understand the true meaning of what it sees. Yes, a person (i.e. computer scientist) can assign different values to data within the program/algorithm. However, truly understanding disease processes is something I cannot see a machine doing now or in the future. For example, a pathologist notices that a prior biopsy or sample had changes similar to the one he/she is noticing today, and based on the patient's lab tests and chart, concludes that the patient has a particular disease. The pathologist is able come to this conclusion based on a compilation of disparate sources of information, observation, analysis, and medical knowledge.
This brings me to the next two points.
3) Stains and artifacts - A machine (read, computer) does not know what is plausible or implausible. Preparation artifacts occur on a daily basis. Yes, a machine could be taught to recognize these, but there may be misinterpretations because of the variable presentation of such artifacts, given that they may range to subtle to overt. This highlights the often undervalued role of the pathologist as serving in QC (quality control) of the histology lab where slides are prepared. Pathologists are the arbiter of what is allowable in the quality of histology slides that are made for diagnostic purposes, for only pathologists have the privilege of conferring diagnostic meaning to a slide. Moreover, there are many mimics in pathology. Would a machine be sophisticated enough to distinguish these. Lastly, stains which require the use of a polarized microscope/direct immunofluorescence (DIF), I see a machine struggling to interpret given that it is based on light pattern and intensity.
4) Communication - One of the jobs of a pathologist is to serve as a liaison between clinician and the laboratory given the clinical context, in instances calling the clinician to get more information or recommending the appropriate ancillary testing, or simply communicating results in tumor boards, etc. Appropriate communication is something machines still have not mastered, just note our communication frustration with Alexa, Siri, and Google Home and various other voice activated/dependent products on the market currently. Formulation of reports are also important methods of communicating to clinicians in a concise, accurate fashion our assessment of a particular case. I feel doubtful that a computer or machine would be able to fashion a report which serves to be a useful consult to a clinician.
From my experience in pathology thus far, I feel AI will be a helpful adjunct, which may increase the efficiency of existing pathologists. Where I do see AI playing a role, is in removing some of the tediousness of pathology, and introducing more standardization, for example in the interpretation of stains such as HER-2 IHC, where there is interobserver variability. Just like AI was slotted to make radiologists "extinct" years ago, when radiology was brought from the 'dark ages' of silver-stained films to digitalized imaging and reading rooms, pathology is similarly on the cusp of making the transition from physical microscopes and slides to completely digitized workstations. Just see how they do it in Belgium.
One of the revolutions in pathology which I think will happen in my lifetime is the advent of telepathology, in which pathologists are freed to live and work in whichever location that they choose while reading virtual slides for a laboratory based in another location. This may help alleviate trainees' concern in pursuing a specialization which may not be particularly in demand, or concerns about finding a suitable position in a desirable location. Overall, the advances of modern day (tech revolution) hold a lot of promise as a tool for education as well, and I am excited to see how far the next generation of pathologists take this.
This weekend, I'm reading Practical Dermatopathology by Ronald P Rapini. It seems a very well organized book. There is an interesting analogy in the book. It says:
Pathologists may be subcategorized into home-run hitters and hedgers. The home-run hitters try to "force" a diagnosis, and give only one most likely diagnosis. They are either very, very correct, and look very smart, or else they strike out and miss the diagnosis completely. This can be dangerous. For example, they might diagnose a lesion as a definite Spitz nevus, which subsequently is found to be a melanoma when it metastasizes. Most Spitz nevi can be diagnosed with relative certainly, but there are always those difficult cases for which all the experts can have their opinions, using the best of criteria, but for which there remains an element of uncertainly. Simple histology has its limits in predicting biologic behavior. Hedger pathologists, by contrast, seldom make a specific diagnosis, and instead often give a long differential diagnostic list, even to the point of listing histologic possibilities that are ridiculous from a clinical standpoint. They rarely strike out, but they are sometimes not very helpful, and are not appreciated by clinicians. Wise pathologists avoid these two extremes.This reminds me of a concept brought up by a pathology resident, the idea of spotters or 'instant diagnoses' of entities which are instantly recognizable, versus other types of cases that can be more complex. I suppose the home-run approach would work great with spotters, whereas hedging would be most applicable to more ambiguous situations. Another resident told me, 'the best pathologists consider differentials before honing in on a diagnosis'. Essentially, going from good to great requires finding a happy medium. "The art of pathology is to be dogmatic about the diagnosis as often as possible, while not being afraid to hedge and give a differential diagnosis when the diagnosis is uncertain."
Today, I want to discuss the idea of pathology as art, within medicine, involving subjectivity. The reason for this is because of the strange idea that technology, such as high-powered computers or robots, will someday replace pathologists.
People who say pathologists will disappear as a specialty under the threat of AI do not really understand pathology. When this topic inevitably comes up in clinic, and I try to explain why AI would not be a threat to pathologists, it seems the clinicians become disinterested in the conversation. Why this is the case, I am not really sure, since most of the time they were the ones who brought it up as a topic of discussion in the first place, in response to me telling them that I am interested in going into pathology.
Thus, I want to list my personal opinion regarding why I think AI will not threaten the livelihood of pathologists everywhere.
1) Big tumors and sampling - I watched a TEDx talk where the presenter showed machine learning in which the computer was fed images of biopsies, and was able to stratify them in terms of prognosis with some accuracy. There are many judgements which a pathologist must make regarding biopsies and large cases, which a machine is incapable of. A machine is capable of producing output based on the data given to it previously, however, would it be able to determine whether a biopsy is adequate (in other words, representative of the lesion) [absence of data], or when it comes to larger specimens, whether the tumor has been adequately sampled during grossing? For some reason, I find it hard to believe that a machine would be able to determine whether additional sections of a large tumor need to be put in. These are judgements which an experienced pathologist makes easily and instantly when assessing a case.
2) Ontology and context - a machine does not understand the true meaning of what it sees. Yes, a person (i.e. computer scientist) can assign different values to data within the program/algorithm. However, truly understanding disease processes is something I cannot see a machine doing now or in the future. For example, a pathologist notices that a prior biopsy or sample had changes similar to the one he/she is noticing today, and based on the patient's lab tests and chart, concludes that the patient has a particular disease. The pathologist is able come to this conclusion based on a compilation of disparate sources of information, observation, analysis, and medical knowledge.
This brings me to the next two points.
3) Stains and artifacts - A machine (read, computer) does not know what is plausible or implausible. Preparation artifacts occur on a daily basis. Yes, a machine could be taught to recognize these, but there may be misinterpretations because of the variable presentation of such artifacts, given that they may range to subtle to overt. This highlights the often undervalued role of the pathologist as serving in QC (quality control) of the histology lab where slides are prepared. Pathologists are the arbiter of what is allowable in the quality of histology slides that are made for diagnostic purposes, for only pathologists have the privilege of conferring diagnostic meaning to a slide. Moreover, there are many mimics in pathology. Would a machine be sophisticated enough to distinguish these. Lastly, stains which require the use of a polarized microscope/direct immunofluorescence (DIF), I see a machine struggling to interpret given that it is based on light pattern and intensity.
4) Communication - One of the jobs of a pathologist is to serve as a liaison between clinician and the laboratory given the clinical context, in instances calling the clinician to get more information or recommending the appropriate ancillary testing, or simply communicating results in tumor boards, etc. Appropriate communication is something machines still have not mastered, just note our communication frustration with Alexa, Siri, and Google Home and various other voice activated/dependent products on the market currently. Formulation of reports are also important methods of communicating to clinicians in a concise, accurate fashion our assessment of a particular case. I feel doubtful that a computer or machine would be able to fashion a report which serves to be a useful consult to a clinician.
From my experience in pathology thus far, I feel AI will be a helpful adjunct, which may increase the efficiency of existing pathologists. Where I do see AI playing a role, is in removing some of the tediousness of pathology, and introducing more standardization, for example in the interpretation of stains such as HER-2 IHC, where there is interobserver variability. Just like AI was slotted to make radiologists "extinct" years ago, when radiology was brought from the 'dark ages' of silver-stained films to digitalized imaging and reading rooms, pathology is similarly on the cusp of making the transition from physical microscopes and slides to completely digitized workstations. Just see how they do it in Belgium.
One of the revolutions in pathology which I think will happen in my lifetime is the advent of telepathology, in which pathologists are freed to live and work in whichever location that they choose while reading virtual slides for a laboratory based in another location. This may help alleviate trainees' concern in pursuing a specialization which may not be particularly in demand, or concerns about finding a suitable position in a desirable location. Overall, the advances of modern day (tech revolution) hold a lot of promise as a tool for education as well, and I am excited to see how far the next generation of pathologists take this.
Saturday, January 12, 2019
Lung path
Hi guys,
Been going over lung pathology using Foundations series book and Sanjay mukhopadhyay's Youtube channel. I want to correlate with cytology, but not sure about resource to use besides DeMay. What would be really good would be an atlas with cytopath correlates.
Lung is a deceptively "simple" organ. It looks simple on H&E, but now I know there is way more than meets the eye... Autopsies, I feel, really help in understanding the lung in disease given it is pretty rare to get a full lobectomy specimen on a living patient. In that sense, it is somewhat (but not completely) like the brain. i.e. full brain, you know, person = 100% dead; Whereas, lung-wise person ≈ dead, remember you need two. But yeah... It is nice seeing coronal gross slices of lung, in an Autopsy Atlas, for example. Even better to see multiple slides (but not so nice for the patient). It is kind of unfortunate that there aren't more lung pathologists, but I understand it because of the volume.
I'm interested in how the discovery of PD-L1 will change the field of lung cancer / pathology. The lab at my home institution is trying to bring PD-L1 IHC (immunohistochemistry) in. Perhaps if there was a method that was faster (molecular anyone?) it might be worth a pretty penny. Essentially, since the technology is so new, I feel like there are many directions to take this... investigation into better IHC markers as surrogate or improved over PD-L1 perhaps, or perhaps even a new technique, or a way to standardize it, would be helpful... though I'm guessing pharma R&D are all over this right now. Just a hunch.
What are some new developments you all have noticed recently?
Side note: Was recommended this book (Diagnostic Pathology: Kidney Diseases, 2nd Edition) by Robert Colvin at MGH. Along with Silva's renal path and Heptinstall's. All seem like great books for learning renal path. It's hard to find these books, but I suggest interlibrary loan if available where you are... another resource is WorldCat, which is a worldwide catalogue for books in libraries around the world.
Side note: Was recommended this book (Diagnostic Pathology: Kidney Diseases, 2nd Edition) by Robert Colvin at MGH. Along with Silva's renal path and Heptinstall's. All seem like great books for learning renal path. It's hard to find these books, but I suggest interlibrary loan if available where you are... another resource is WorldCat, which is a worldwide catalogue for books in libraries around the world.
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