Death by (lack of) pathologists

We are the doctors no one sees. While many folks don’t know pathologists are physicians, the impact we make on patients’ lives patients should not be discounted.

By STEPHEN FRIST
So there is a shortage of pathologists in Israel (“Errors in treatment possible from lack of pathologists,” May 9, 2011) and the situation is getting worse. For most, this is not the most distressing news of the day. After all, when does the average person spend a second thinking about this group of somewhat macabre practitioners? And with good reason. Pathologists are the doctors no one sees. While many folks don’t know that pathologists are physicians – medical school graduates who chose this specialty in the same way others choose pediatrics or surgery – the impact we make on the lives of patients is not something that should be discounted.
I remember one Shabbat meal at which I was introduced as a pathologist. A sweet-faced octogenarian suggested: “Why don’t you learn some other line of work?” My take is that pathologists have not done a great job of explaining our vital role. True, pathologists occasionally perform autopsies.
It may be argued that, historically, the post-mortem exam ushered in modern medicine. Finally, doctors could compare normal and abnormal organs, describe the changes, and define disease entities. This led to diagnostic advances, treatments based on scientific evidence and, importantly, a way of assessing the value of medical intervention. With current technology, lab tests and imaging, for example, a lot of this information is now determined during life. The number of autopsies has declined significantly.
THE SURPRISE for many is that pathologists choose the field primarily to help living patients. The first step in medical care is making the right diagnosis. It might be a skin biopsy, a Pap smear or a segment of colon removed in the operating room. A pathologist must analyze the tissue or organ. Frequently the urgent question at hand is “is the growth benign or malignant?” It doesn’t end there: If the tumor is completely removed, are the adjacent lymph nodes involved, and if so, how many... and the malignant tumor – is it aggressive or indolent, is it sensitive to radiation therapy, is it isolated, or does the pattern indicate that it is multifocal; might there be another growth hiding somewhere? Questions such as these cross the clinician’s mind and pathologists provide the answers.
Here’s the bottom line: providing these life-and-death answers takes expertise, and Israel doesn’t have enough experts. It also takes time – swamp pathologists with an unreasonable case load and risk delays or errors. Over 90 percent of patients should receive a pathologist’s opinion within 48 hours, not a week or more. It can be done with adequate staffing.
Lastly, pathologists practice the art and science of medicine – cancer cells are not wearing T-shirts with a capital “C” across the front.
It is subtle, and there are differences of opinion. Some time ago, I saw a gentleman who was to undergo a major operation for pancreatic cancer, a Whipple’s procedure.
Before surgery the slides were reviewed and we corrected the diagnosis to pancreatic inflammation. The inflammation made the pancreatic cells appear “angry” (normal cells react to inflammation) and they were mistaken for cancer. The patient responded well to relatively routine antibiotic treatment.
For this reason, pathologists need a large dose of humility – enough to ask for a second opinion when there is any doubt.
Having an acceptable number of pathologists is a vital need for the Israeli medical system. These are the doctors charged with identifying and diagnosing some of the most serious diseases known. If pathologists are overworked and underpaid, we will all pay the price in the quality of medical care we receive. This is definitely a challenge that should be examined – and resolved.
The writer is a veteran pathologist who moved to Israel from America several years ago. He firmly advocates independent ‘second opinions’ by qualified pathologists in most life-threatening cases.