Friday, December 18, 2009


Sometimes I wonder if the more experienced a pathologist I become, the hedgy-er and weirder my sign-outs will get. I start to see mistakes that people make, and the culmination of past history makes me hesitate more and more with my diagnostic words. This is vague, I know. I'll try to make it a little more clear.

When you first come out of residency, you have a nice set of rules to work from. A follicular lymphoma is a follicular lymphoma because it looks like this, it marks like that, and the flow cytometry fits perfectly. So you type that into your diagnostic line (or dictate it for the transcriptionists). Follicular lymphoma, grade 1 or 2 or 3. Depending on the rules you read in your fancy book. The ones you memorized to take your boards.

But then life gets messy. People are messy. They don't always follow the rules. There are articles you can find on pubmed to deal with the messiness - ones that people publish about these five cases that don't quite fit the rules but we are going to call it this. You read the well-known academic author, and feel confident in following their lead. Sometimes you send it to them to get their name on it, pay lots of money for back-up. After all, you want to get the proper diagnosis for the patient, so they can get the proper treatment.

Then, a few years into practice, a new book comes out, and come to find out that thing you used to confidently call this is no longer considered this. New molecular information has come to light, and now they call it that. You squirm uncomfortably in your $1200 chair, the one you purchased with your continuing medical education money to prevent slipped discs and chronic pain issues you have seen your partners deal with. You think of all the cases you used to call this, and wonder how in God's name you could ever go back and call them all that. You look at partners that are good, solid, hard-working people, and understand all the quirks and strange habits they have developed over the years to help them sleep at night. You wonder, two years into practice, what you will be like ten years down the road.

This week, I was asked by a medical oncologist to review a case I signed out last December. It was a simple question, "Can you grade this lymphoma?" I had the case pulled, but didn't have time to review it for a couple of days. We were slammed with record high block counts all week long, everyone trying to get in their surgeries before the holidays and new year. Add in trying to rearrange schedules to make it to my kids amazing Christmas programs, and John's febrile illness that finally peaked in the middle of the night last night, and wow. I love having tough days, because work is stimulating, but it is nice to balance out hard days with light ones. Hopefully next week will oblige.

When I finally got around to looking at the biopsy, I was mortified. I won't bore you with the details, but I had confidently called a GI biopsy this, and I didn't feel so confident about my diagnosis in hindsight. I sounded like I knew the patient had already had this diagnosis, but failed to explain anything about past history or clinician communication in the comment I made. I told my partner I shared it with, "This isn't like me. I am not that much of a cowboy, on a first time diagnosis. Something is missing."

I was further alarmed to read in a GI note I had faxed from a clinic that the patient did not have a pathological diagnosis, prior to mine. He was being treated presumptively, based on radiology, according to the note. I searched his history in the archives on our computer. No previous. What have I done.

I resolved to call the oncologist and explain the situation. I talked to her before - she is based in another town, and she seemed reasonable. I would tell her we needed more tissue to make a diagnosis. Maybe I jumped the gun. I should have called it suspicious. Hopefully it would all be OK. Unfortunately, she takes Fridays off. I talked to her nurse.

"Can you fax me all of his records in the chart, please?"

Two hours later, a transcriptionist came into my office. "Here is your book." I laughed. "You are right, she faxed me an entire tree."

I pored through the history searching for old path. Luckily, it was there. Five years ago, two people in my group had good tissue with good flow. I must have had this information a year ago, and forgot. I was so hell bent on figuring out what I did wrong, and the GI note really threw me off. Because the path was in the small town, it wasn't easy to find in our computer records. I sighed with relief. Suddenly, my cowboy, slipshod sign out made sense. I did the right thing. The diagnosis had already been made, as was evident to me in my sign out, but I had to play detective to find it out. I resolved to make more all inclusive sign-outs in the future.

Last night, I was up until midnight addressing Christmas cards. I just ordered more online, because I ran out. I looked at the pictures I took frantically in front of the tree last week, when I started receiving cards and realized I hadn't done mine yet. I was very proud of the ones I chose - the kids look great, happy and real - not posed, just having fun. I thought of how my past experiences with them shape the way I deal with them currently. My set of parenting rules is constantly shifting and changing based on new information. Life has so many parallels. I hope they don't think I'm hedge-y and weird. Fluidity is probably a good trait, in work and life.

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