“What is the organ cut in the slide?” asked the pathology examiner in the practical exam after looking through the microscope.
“Liver”, I said.
“Naaah”, he said and gave a smile dipped in a barrel of sarcasm.
I was hopelessly lost. It looked so much like liver to me. The dear internal examiner chipped in, “It is the lung, isn’t it?”
I replied, “Yes, yes, it is lung.”
The external gave a harsh look to the internal examiner and scowled at me. “Really? Then why did you say it was liver?”
My theory knowledge came in handy here. I instantly replied, “In pneumonias, the lung looks like liver on the cut histology sections, and it is called ‘hepatisation’ of the lung”.
The external was not too happy.
“Ok. Then what stage is this?”
The internal examiner whispered something from behind the external examiner. I thought I heard the word “red”, and everything on the slide under the microscope appeared very red to me.
I said, “Red”.
The external shook his head and gave a hearty laugh that rankles me even today after four decades.
He said, “It is grey hepatisation”.
“Ohh”, I said.
“Yes, ohh”, the monster said, made a face, showed his tongue, and passed along. The poor internal examiner looked helplessly at me.
I scraped through with some passing marks. I missed a crucial lecture on histopathology on the twenty slides to be kept for the practical exam, so the fault was mine. A few days back, our dear professor explained to the class how to identify the organ and the pathology correctly by identifying the clear marks on the slide: The right upper part of the slide chipped away, a dark mark to the left side, a small mark on the left bottom, a red dot here, a blue dot there, and so on. Each slide had a specific mark, and that would take us right to the pathology, he instructed.
Anyway, monsters whom we encounter with regular frequency in all medical colleges across time and space are generally external examiners in pathology and anatomy. It is always a toss-up who is the more berserk one. Anatomy and pathology examiners would have shaken and stirred most doctors, leaving them with extremely vivid memories.
Today, in memory of those pathology examiners, I occasionally extract revenge on the entire group of pathologists by sending them surgical specimens without disclosing the organ source, patient details, or surgical findings. Nothing gets their goat more than sending request forms without these details. I do mention the name of the patient, of course. The reasoning, as I told you before, is simply revenge.
If the examiners expected us to identify everything just by peering under the microscope, why do the pathologists need all the information in the world to come to a diagnosis? If the surgeon writes, ’10-year-old boy having fever, loss of appetite, loss of weight, and a family history of tuberculosis having a slow-growing neck lymph nodal mass with caseating necrosis, raised ESR, and a positive Mantoux test’, then Duh, one does not even need to cut, fix, and slice the biopsy specimen and put it under the microscope to make a diagnosis of tuberculosis. This exercise happens to be my little way of getting back and deriving immense pleasure, especially when the harried and irritated pathologist calls and requests me to provide the clinical details.
When someone asks, “Are you a doctor or a dentist?” the dentist would perhaps snappily reply, “Wait until you have a toothache.” The pathologist would similarly reply, “Wait until you get sick, get operated on, or die”. After enduring many years of rigorous study and addressing complex issues, the pathologists are forged by fire as much as the more glamorous brethren, like the surgeons and the physicians. How can you identify a pathologist in a busy hospital? Place your bets on a wonderfully dressed person smelling not of Louis Vuitton but of formalin.
They are the true heroes who do not wear capes (though they may have an unpleasant aroma). It is said that 70% of clinical decisions depend on the expertise of pathologists, who analyse various fluids (including blood) and tissues within the body. Any fluid secreted by an organ, tissue, or cell—no matter how unpleasant—will be examined for any elements from the periodic table to assist doctors in diagnosing the patient’s condition. When a piece of tissue is surgically removed, it undergoes even more rigorous investigation to reach a diagnosis. Surgeons await the pathology report with as much anxiety as the patient, hoping to confirm “tumour-free margins”. Decisions regarding chemotherapy and radiotherapy hinge on the pathologist’s findings. Their reports serve as the foundation for subsequent treatment and can make a lot of difference for the patient in terms of quality and quantity of life.
Silent, dedicated, and working in the background, the wonderful pathologists constitute one of the most dynamic and challenging fields of medicine. Pathology is a broad term that encompasses various fields, each with its advancements and precision technologies, including anatomic pathology, which focuses on tissues and organs; clinical pathology, which involves laboratory medicine that analyses body fluids such as blood; as well as chemical pathology, haematology, microbiology, and virology. The latter two are involved in studying infections and guiding antimicrobial therapy. Infection of any kind is the commonest reason for a person to become sick inside and outside the hospital setting. A dear friend of mine is a foetal pathologist. The pathologist’s importance in medicine cannot be overemphasised, and one can safely say that they form the crux around which modern medicine revolves. The patient’s treatment is intricately linked to the pathologists, yet patients often do not know the names of these silent workers who work without credit behind the scenes.
Surgeons and pathologists have a complex relationship. Actually, surgeons have a complex relationship with most of the other specialities in medicine. When a pathologist issues a report like “lentiginous compound dysplastic nevus” or “pseudoangiosarcoma”, the surgeon generally stands with an open mouth and feels really dumb and small. The simple-minded surgeon divides his/her whole world of removed tissues and organs into two simple groups: benign and malignant. If it is the former, he/she will go home and have a drink. If it is the latter, he/she will push the patient to the chemotherapists or radiotherapists, go home, and have a drink. When the pathologist screams in excitement at discovering “Michaelis-Guttman” bodies or erythrophagocytosis on the slide, the simple surgeons (loved by all and hated by none) simply blink their eyes in deep incomprehension.
Most surgeons maintain a positive relationship with pathologists because nothing is more frustrating than when a surgeon removes what he believes is “acute” appendicitis and a disgruntled pathologist provides a vague, generalised report, stating everything but mentioning “acute appendicitis”. A term like “lymphoid hyperplasia” is a euphemism for what the anaesthesiologist in the operation theatre always knew as “a cute appendix” and not “acute appendicitis”. A sure way for the surgeon to start sweating when he faces his patient in the post-operative period is when he stands accused of performing an unnecessary surgery.
For the medically ignorant, it is still acceptable to have a 10% negative rate for appendicectomy (the number is coming down with the advancements in radiology, though). This is because the consequences of missing appendicitis, which can lead to life-threatening complications, are significantly greater than the risks associated with performing surgery, and the appendix turns out to be normal. However, a meandering report by the pathologist can be distressing, especially with today’s mentally imbalanced hyper-informed patients who google until their eyes are torn out from their sockets. And their speed-dial list includes more lawyers than the near and dear.
There are legendary surgeons who are even more careful with potentially surly pathologists when they encounter a normal-looking appendix. They gently rub the appendix between their fingers for a few minutes to produce some stimulatory inflammation, and the pathologist would have to stick to his findings. But most pathologists are kind and gentle beings and do not require such extraordinary measures. They are kind to the surgeons while reporting, despite sometimes wanting to place them with the other tissues on the slicing board.
Anyway, a big salute to the field of pathology with its myriad sub-domains working relentlessly and standing as the silent, strong pillar of modern medicine. Pathology and pathologists are critical for clinicians; they are equally important for patients. Unfortunately, the former do not adequately acknowledge this, and the latter are often unaware of its importance. Thank you, dear pathologists of the world. May your tribe increase and prosper forever. May you always remain kind to the simple surgeons.
RANDOM MUSINGS 