Hi everyone,
There has been a great deal of unrest the past few weeks here in the USA with rising case numbers of coronavirus in select states and protester-police clashes resulting in violence and destruction... despite all this, the summer is kicking off with blossoms and nature's bounty all around us.
I thought I'd share a few resources I've come across, and review a few books which I had time to read recently.
Resources:
MGH Learn Pathology has curated virtual slide sets
Johns Hopkins Pathology many resources here
Book reviews:
Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital by Sheri Fink
- The book chronicles the events surrounding Hurricane Katrina at Ochsner Baptist Medical Center (then known as Memorial Medical Center) in 2005. Thoughts: Similar strains to the pandemic we are experiencing now, with extreme (and I would argue unethical) "care rationing" taking place. Superb investigative journalism.
Forensic Detective: How I Cracked the World's Toughest Cases by Robert Mann
- Forensic anthropologist recalls fascinating cases which traverse time and continents from Hawaii to Vietnam and back. Advances in forensic science help identify unknown remains (mitochondrial DNA).
Currently reading:
No Stone Unturned by Steve Jackson
Details NecroSearch's attempts to find human remains and assist with cold cases.
What is on your summer reading list?
Tuesday, June 23, 2020
Monday, April 27, 2020
Covid-19 and Pathology
Hi everyone,
The coronavirus pandemic has caused many changes in the last month or so in the United States. People are advised to stay at home and maintain distance from each other, not travel, see their family and friends, in addition to wearing masks, in addition to staying away from large gatherings. Most non-essential businesses such as hair salons have closed and restaurants are either closed or only offering take-out. Elective surgery and non-emergent doctor's visits have been canceled or rescheduled.
Many people have filed for unemployment. Covid-19 has upended livelihoods and caused social changes which may last for the next 1-2 years, not to mention the massive government financing of companies and businesses here in America. Thankfully, of the people I know personally, they have kept their jobs and are working from home or going to the office very rarely.
In terms of medical training, the consensus among medical schools, in general, is that medical trainees should not be in the clinics/hospital during this time. My medical school's policy is that medical students should not physically attend rotations for the time being. The educational components are being completed from home virtually. In my masters of public health, all the classes are being taught remotely.
It has been interesting to compare the public health response of different countries and the actions they have taken against the novel coronavirus. In some countries, aggressive contact tracing and widespread testing has managed to curb or contain the spread of the virus. In the US, the government's sluggish and piecemeal response has made it difficult to effectively contain the virus. An example is the use of a smartphone app to trace the people a person could have been in close contact with, if they are found to test positive for coronavirus.
Hospitals and healthcare workers in New York, the epicenter of the pandemic in the North East US, have been overwhelmed by Covid-19 cases. In addition, the shortage of PPE (personal protective equipment) such as facemasks, gowns, and gloves in addition to other healthcare equipment has exacerbated the crisis.
Many features are being uncovered as the pandemic progresses. One example, that has come out recently is that Covid-19 can cause a coagulopathy leading to strokes or pulmonary embolism in young people. Another is that the virus may cause cardiac symptoms in individuals, causing medical examiners to erroneously attribute their deaths to cardiac cause without sufficient testing of the decreased. Without testing, there is likely an undercounting of deaths related to coronavirus here in the United States.
One fear is that the virus will mutate as it passes from host to host and grow more and more virulent as time passes. The other fear, is that we will not be able to find an effective vaccine for the virus. The hope of returning to normality hinges on the creation of a vaccine or finding an effective treatment. There have been some attempts to use convalescent plasma, however it is unclear how much of a benefit it will provide, in addition to there not being enough plasma available (in addition to the usual transfusion risks although it is generally tolerated well). Like many things about this situation, convalescent plasma from recovered Covid-19 patients has not been extensively tested.
Unfortunately, there has been a lot of misinformation circulating about which treatments may be effective against the virus, ranging to medications to homeopathy. This is troubling and misguided because it can lead to shortages in essential medicines needed to treat other diseases that are not related to the pandemic.
As difficult it is to stay away from loved ones and conduct our daily lives from home, it is necessary to take precautions to prevent the spread of this highly contagious virus. I hope that pathologists and researchers will be able to contribute to scientific knowledge about Covid-19 as things progress, in order to prevent morbidity and mortality. Now more than ever, we must cooperate to prevent this pandemic from worsening.
How have you been effected by Covid-19?
Have there been changes to your workplace (or pathology laboratory) as a result of the coronavirus pandemic?
Feel free to share any thoughts or comments.
The coronavirus pandemic has caused many changes in the last month or so in the United States. People are advised to stay at home and maintain distance from each other, not travel, see their family and friends, in addition to wearing masks, in addition to staying away from large gatherings. Most non-essential businesses such as hair salons have closed and restaurants are either closed or only offering take-out. Elective surgery and non-emergent doctor's visits have been canceled or rescheduled.
Many people have filed for unemployment. Covid-19 has upended livelihoods and caused social changes which may last for the next 1-2 years, not to mention the massive government financing of companies and businesses here in America. Thankfully, of the people I know personally, they have kept their jobs and are working from home or going to the office very rarely.
In terms of medical training, the consensus among medical schools, in general, is that medical trainees should not be in the clinics/hospital during this time. My medical school's policy is that medical students should not physically attend rotations for the time being. The educational components are being completed from home virtually. In my masters of public health, all the classes are being taught remotely.
It has been interesting to compare the public health response of different countries and the actions they have taken against the novel coronavirus. In some countries, aggressive contact tracing and widespread testing has managed to curb or contain the spread of the virus. In the US, the government's sluggish and piecemeal response has made it difficult to effectively contain the virus. An example is the use of a smartphone app to trace the people a person could have been in close contact with, if they are found to test positive for coronavirus.
Hospitals and healthcare workers in New York, the epicenter of the pandemic in the North East US, have been overwhelmed by Covid-19 cases. In addition, the shortage of PPE (personal protective equipment) such as facemasks, gowns, and gloves in addition to other healthcare equipment has exacerbated the crisis.
Many features are being uncovered as the pandemic progresses. One example, that has come out recently is that Covid-19 can cause a coagulopathy leading to strokes or pulmonary embolism in young people. Another is that the virus may cause cardiac symptoms in individuals, causing medical examiners to erroneously attribute their deaths to cardiac cause without sufficient testing of the decreased. Without testing, there is likely an undercounting of deaths related to coronavirus here in the United States.
One fear is that the virus will mutate as it passes from host to host and grow more and more virulent as time passes. The other fear, is that we will not be able to find an effective vaccine for the virus. The hope of returning to normality hinges on the creation of a vaccine or finding an effective treatment. There have been some attempts to use convalescent plasma, however it is unclear how much of a benefit it will provide, in addition to there not being enough plasma available (in addition to the usual transfusion risks although it is generally tolerated well). Like many things about this situation, convalescent plasma from recovered Covid-19 patients has not been extensively tested.
Unfortunately, there has been a lot of misinformation circulating about which treatments may be effective against the virus, ranging to medications to homeopathy. This is troubling and misguided because it can lead to shortages in essential medicines needed to treat other diseases that are not related to the pandemic.
As difficult it is to stay away from loved ones and conduct our daily lives from home, it is necessary to take precautions to prevent the spread of this highly contagious virus. I hope that pathologists and researchers will be able to contribute to scientific knowledge about Covid-19 as things progress, in order to prevent morbidity and mortality. Now more than ever, we must cooperate to prevent this pandemic from worsening.
How have you been effected by Covid-19?
Have there been changes to your workplace (or pathology laboratory) as a result of the coronavirus pandemic?
Feel free to share any thoughts or comments.
Monday, February 10, 2020
Forensics & Injury Prevention
Hi everyone,
It has been forever since I made a post, so I figured I might as well write something here.
As my acquaintances and friends may know, this year I am pursuing a masters in public health as a dual degree with my medical degree. I have learned a lot so far that I think will be useful in the future. One of the topics which I am concentrating on in public health is injury prevention. This is essential the study of what causes injury/death and how to prevent such things from happening. Some topics which we cover are gun violence, drug overdose/opioid crisis, and other social woes. Many of the issues which effect injury prevention on the child population actually has to do with product design (toys, cribs, window blinds, etc.) P.S. Don't buy metal straws.
On the side, I've been reading more books about forensics.
Some of the titles I have enjoyed so far (in order of reading):
What I learned from watching videos/crime scene reconstructions, digging deeper into some of these cases is that the press sometimes gets the details wrong in their reporting.
Then again, I suppose there is a great asymmetry in information when it comes to this subject in particular.
Some interesting sub-fields are forensic anthropology and forensic entomology (the study of insects).
What books/novels do you recommend?
It has been forever since I made a post, so I figured I might as well write something here.
As my acquaintances and friends may know, this year I am pursuing a masters in public health as a dual degree with my medical degree. I have learned a lot so far that I think will be useful in the future. One of the topics which I am concentrating on in public health is injury prevention. This is essential the study of what causes injury/death and how to prevent such things from happening. Some topics which we cover are gun violence, drug overdose/opioid crisis, and other social woes. Many of the issues which effect injury prevention on the child population actually has to do with product design (toys, cribs, window blinds, etc.) P.S. Don't buy metal straws.
On the side, I've been reading more books about forensics.
Some of the titles I have enjoyed so far (in order of reading):
- The Poisoner's Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York by Deborah Blum
- Mortal Evidence: The Forensics Behind Nine Shocking Cases by Cyril Wecht
- Morgue: A Life in Death by Vincent DiMaio
- Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner by Judy Melinek
- Dissecting Death: Secrets of a Medical Examiner by Frederick Zugibe
What I learned from watching videos/crime scene reconstructions, digging deeper into some of these cases is that the press sometimes gets the details wrong in their reporting.
Then again, I suppose there is a great asymmetry in information when it comes to this subject in particular.
Some interesting sub-fields are forensic anthropology and forensic entomology (the study of insects).
What books/novels do you recommend?
Monday, September 23, 2019
CAP meeting
Hi everyone,
I want to share resources which I encountered at the College of American Pathologists (CAP) meeting in Orlando, Florida this year.
PathPresenter
Please check these out, I think they are both outstanding.
(Path presenter is incomplete in some sections. They need help annotating some parts actually, so if you would like to help you can contact via website.)
If you are a medical student, see CAP for medical students.
CAP Foundation has started a Lunch & Learn program for medical student pathology interest groups. Please see site for more information.
There is also the Travel Award, which awards up to $1200 to attend the annual meeting!
If you are helping coordinate the pathology interest group at your medical school, please see PathologyTraining.org (aka ICPI, Intersociety Council for Pathology Info). They provide $600-$500 dollars annually for Pathology interest groups.
These are great opportunities, and I encourage those interested to apply. ^_^
I want to share resources which I encountered at the College of American Pathologists (CAP) meeting in Orlando, Florida this year.
PathPresenter
Please check these out, I think they are both outstanding.
(Path presenter is incomplete in some sections. They need help annotating some parts actually, so if you would like to help you can contact via website.)
If you are a medical student, see CAP for medical students.
CAP Foundation has started a Lunch & Learn program for medical student pathology interest groups. Please see site for more information.
There is also the Travel Award, which awards up to $1200 to attend the annual meeting!
If you are helping coordinate the pathology interest group at your medical school, please see PathologyTraining.org (aka ICPI, Intersociety Council for Pathology Info). They provide $600-$500 dollars annually for Pathology interest groups.
These are great opportunities, and I encourage those interested to apply. ^_^
Wednesday, June 5, 2019
Bones
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?
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?
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. =)
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