A Day In The Life: Pathology

I'm approaching the halfway point of my four-week pathology rotation, which (second only to radiology) is the least service-oriented rotation of my year. At times the "self-directed" aspect (i.e. lots of unscheduled time) can make the hours drag on, but I'm so grateful to be basically getting paid to learn that I'm making sure I use my time (fairly) productively. Here's what a typical day looks like:

0830 or 0900 h -- I arrive at the hospital (coming from general surgery last block I feel so spoiled by these start times!).

0900 - 1200 h -- Depending on the day, I may go to the FNA clinic, observe an autopsy, or spend some time watching specimen grossing (slicing up of surgical specimens for (after multiple other steps) mounting on slides).

the FNA clinic

the pathologists bring their own microscope, slides, stains, & other supplies to the FNA clinic

Autopsies are interesting from an anatomical standpoint, as all of the organs are removed (eviscerated) and grossed; despite seeming a little morbid, it really is fascinating and is one of those surreal things you should try to see as a med student or resident.

Specimen grossing is also pretty intriguing -- from gallbladders packed with stones to hearts to cancers, it's very neat to get a close look at surgical specimens (on gen surg I actually saw very few -- they were either hidden (e.g. breast cancer within a mastectomy specimen) or whisked too quickly into formalin buckets!)

grossing station

1200 - 1300 h -- I spend some time working through some of the required self-study material (we have 12 sets of notes and microscope slides to study, each followed by a quiz). I usually eat my lunch while studying (just kidding, I usually eat it at 11 am because I can never wait!).

making notes (the provided study notes are brief...but I'm being a dork and making my own study notes from them!)

some of the teaching slides

1300 - 1400 h -- Often I'll have a teaching session with one of the pathologists, where we look at slides through the ten-headed (!) microscope.

ten-headed microscope (now if only I could look at slides without getting nauseated!)

1400 - 1630 h -- I may spend the rest of the afternoon doing some more studying. If the pathology residents come across interesting cases they're awesome and grab me to do some teaching. Generally I get to leave before 5 pm :)

my temporary desk in the residents' room (the tabletop has a cutout so that you can get closer to the microscope!)

I think the main objective for an off-service resident rotating through pathology is to gain an appreciation of how the lab works -- how specimens are processed; how labour intensive, time consuming, and delicate the work is; and how challenging making a pathologic diagnosis can be. I think a lot of med students and residents have the impression that the diagnosis printed on the path report is unambiguous; in reality though, there is so much gray area! I've learned that certain pathologists have lower thresholds for calling things malignant and that there are tons of equivocal cases.

Another misconception is that pathologists sit behind their microscopes all day. Of course they don't. The ones I'm working with exhibit a high level of clinical interest and collaborate with other physicians at tumour boards and by phone. They look through the patient charts and know a tremendous amount about medicine, including anatomy, oncology, infectious diseases, dermatology, gynecology, and all kinds of other stuff. If the histologic diagnosis is not apparent, they have to piece together the clinical picture and assemble a differential diagnosis so that they may order the appropriate immunohistochemical stains to make the diagnosis. They are seriously so clever (and I think often so underappreciated!).

Even if you don't have time to do an official pathology rotation, it would be worthwhile to visit the lab for an afternoon to see what goes on "behind the scenes" in the preparation of your path reports!

Study Resources
I've been relying mainly on the study notes that have been provided to me during this rotation. Otherwise, Robbins & Cotran is the pathology bible (it's how the path residents study!...but too dense to be anything other than a reference for most of us). I used and liked Netter's Essential Histology in medical school (the authors are on faculty at UBC, so it was the assigned textbook). In terms of rapid path review for the USMLE Step 1, I am currently using Pathoma and its super helpful accompanying videos (which I actually torrented, sorry Dr. Sattar). I know Goljan is another popular USMLE Step 1 study choice, but felt that it would be too detailed for the amount of time I've left myself to study.

Have you done a pathology rotation? Do you have a preferred pathology study resource?