The first month of my residency is coming to an end, and here are the take-home messages I've, well, taken home.
-Pathology is all about self-motivated study. I've spent a month in the microbiology lab, and I've seen more Staph and Strep than I have bricks on a wall. A couple of other "known" bugs have shown up (Nocardia, Klebsiella), but there are plenty of bread-and-butter pathogens I haven't seen. And, of course, there are tons of rare guys I haven't spotted and never will. How to learn about them? Hit a book.
-It's the same story for surgical pathology. Even if you look at slides all day every day (which some of the residents feel like they're doing), you might not see half of the entities you have to be able to diagnose. So, study. Grab a book. Grab the study slides. Grab a colleague. And study. (After you've worked until 9 p.m., of course.)
-Books. So many books. I have bought three so far with my book fund, and I know roughly which other books I want to get this year. This leaves me with about six "must-have" books I need to get, and, oh, thirty or forty "should-get" books to pencil in somewhere on my list. In Internal Medicine, you can get by with Harrison's, Pocket Medicine, and a good PDA. In Pathology, you can get by after you've purchased a nice, sturdy bookshelf.
-Thank goodness I have four years to learn all of this. Or at least, enough to feel like something more than a total moron. I'll never know it all. It's not even remotely possible.
-The other residents are really cool. We've gone out to dinner and out for drinks, there was a 4th of July barbeque, another gathering is scheduled for this weekend, and then there's the big "beginning of the year" party next month. Pathology gives you time to be social, and while we feel for our colleagues in ob-gyn and surgery residencies, that doesn't stop us from enjoying our free time.
-I sold my oto-ophthalmoscope for cash. Sweet! I'm keeping my stethoscope, though.
-I need to carry around a little pamphlet that explains what pathologists are and do. It would cut down on the confused looks I get. Or, even better: I'll post about it on my blog! Stay tuned; it should be up later this week. No, really.
Tuesday, July 29, 2008
Saturday, July 19, 2008
answering some questions
Thanks to everyone who has been reading so far! A few people have posted comments with questions; I thought I'd just answer them here.
"I'm not a fan of digging through dead bodies"
LOL Really? So why Path then? I mean, you would expect that a Pathologist-to-be would at least be semi-excited about dead bodies. Unless you're aiming for clinical path.
I would call autopsy the part of my job I least look forward to. I don't hate it, but it doesn't fascinate me. I prefer investigating the body on a microscopic level, not a gross level. But then, I haven't performed an autopsy yet (I start in November), so perhaps I'll change my tune. Clinical path is neat, but I think surgical pathology is my calling.
just curious about the pronunciation of the Tsukamurella spp.
is it SOO-ka-myoo-rell-a? or some other such business?
I only heard it once, during a review session. I think it was SOO-ka-moo-rell-a.
And now a question for you folks out there -- any ideas how to promote this blog?
"I'm not a fan of digging through dead bodies"
LOL Really? So why Path then? I mean, you would expect that a Pathologist-to-be would at least be semi-excited about dead bodies. Unless you're aiming for clinical path.
I would call autopsy the part of my job I least look forward to. I don't hate it, but it doesn't fascinate me. I prefer investigating the body on a microscopic level, not a gross level. But then, I haven't performed an autopsy yet (I start in November), so perhaps I'll change my tune. Clinical path is neat, but I think surgical pathology is my calling.
just curious about the pronunciation of the Tsukamurella spp.
is it SOO-ka-myoo-rell-a? or some other such business?
I only heard it once, during a review session. I think it was SOO-ka-moo-rell-a.
And now a question for you folks out there -- any ideas how to promote this blog?
Wednesday, July 16, 2008
haven't quit yet
Sorry for going a week without posting. I've been pretty busy! Residency is hard enough on its own, but most of us are still settling into our new homes and trying to learn the city. Oh, and sleeping, sometimes.
I got my first "real" page today (not counting conference reminders and such). A swab made its way to the lab unlabeled. It was in a bag that contained the proper paperwork, but since the swab tube itself was unmarked, it was unacceptable (thanks, trial lawyers!). I had to contact the attending, who told me to tell the nurse to send another swab. So I called the nurse, and he said he'd try to do it if he could. Mission accomplished, I guess.
Speaking of swabs, we once again got an unnecessarily tiny specimen. We heard about a patient with a large abscess in his leg. The lab attending specifically requested a vial of the pus. We got -- yep -- a swab.
Lesson of the day: Do not smell plates that are growing Shigella. It's so infectious that you can get sick from even ten of the little guys. Most bacteria take a few hundred or thousand to inoculate you.
And now, this week's list of bacteria I had never heard of before:
Staphylococcus schleiferi
Moraxella osloensis
Enterobacter cancerogenus
Tsukamurella spp.
I know this is disjointed, but this rotation (and, I think, pathology in general) lends itself toward smaller stories rather than larger, detailed ones. In the next week or two, I hope to do some real posts, explaining what exactly pathologists do, and how the department is getting the new PGY-1s up to speed (they realize we know nothing).
I got my first "real" page today (not counting conference reminders and such). A swab made its way to the lab unlabeled. It was in a bag that contained the proper paperwork, but since the swab tube itself was unmarked, it was unacceptable (thanks, trial lawyers!). I had to contact the attending, who told me to tell the nurse to send another swab. So I called the nurse, and he said he'd try to do it if he could. Mission accomplished, I guess.
Speaking of swabs, we once again got an unnecessarily tiny specimen. We heard about a patient with a large abscess in his leg. The lab attending specifically requested a vial of the pus. We got -- yep -- a swab.
Lesson of the day: Do not smell plates that are growing Shigella. It's so infectious that you can get sick from even ten of the little guys. Most bacteria take a few hundred or thousand to inoculate you.
And now, this week's list of bacteria I had never heard of before:
Staphylococcus schleiferi
Moraxella osloensis
Enterobacter cancerogenus
Tsukamurella spp.
I know this is disjointed, but this rotation (and, I think, pathology in general) lends itself toward smaller stories rather than larger, detailed ones. In the next week or two, I hope to do some real posts, explaining what exactly pathologists do, and how the department is getting the new PGY-1s up to speed (they realize we know nothing).
Wednesday, July 9, 2008
D'oh
So, to celebrate the fact that I made it on time yesterday ... I promptly slept through my alarm this morning. Oops. I missed a presentation on two autopsy cases and a half-hour primer for the interns on how to gross a colon. I really need to get back on a proper sleep schedule, after staying up late and waking up past noon for most of summer vacation. Hopefully this will kick me in the butt a bit.
Besides not learning anything, I was counted absent for the presentations. We have to attend a certain amount of presentations over the year, or there are consequences, such as increased call or decreased book fund.
Wait, pathologists take call?
First-year residents have three weeks of CP call, taken a week at a time. It's usually home call, since we just field questions. In theory, we might have to come in and write orders. Most of it is blood bank/transfusion questions, and since we haven't had those rotations yet, we'll mostly be taking down information and contacting the transfusion fellow. Seconds years have two weeks, third years have half a week, and fourth years have no CP call.
AP call is different. If you're on surgical pathology, you have call every couple days, which is basically coming in and doing a frozen section if one comes up. If you're on autopsy, you have call every other weekend; if there's an autopsy, you come in and do it. Not paradise, but not surgery call either.
Holidays are also divvied up; each intern has to take call for one major and one minor holiday. I'm on call over Christmas and Memorial Day this year. Every remaining holiday, I don't even have to come in.
As for book fund -- we get a couple hundred dollars to spend a year on books. If you've ever seen a typical pathology program's library, you realize that this is almost chump change. There are dozens of books out there that people might recommend. Most residents will get one of the main surgical pathology references (either Rosai/Ackerman or Sternberg) and probably a CP book. Other options include Differential Diagnosis in Surgical Pathology (since we don't know what the diseases look like), Histology for Pathologists (since we don't remember what the normal tissue looks like), a grossing manual, and more organ-specific textbooks that you can shake a stick at.
Another "clinical faux paus" got discussed today during micro rounds. A patient had four out of four blood cultures come back positive for Bacillus, despite having a clinical presentation that wouldn't fit that diagnosis at all. Bacillus can be a contaminant, and if it shows up in one of four cultures, it's usually dismissed as such. Apparently, sometimes, the ER here will perform one blood draw (from one site), then inject the sample into four different culture vials. On top of that, they sometimes won't disinfect the top of each culture vial before injecting it. Voila -- one contaminated sample spread over four vials.
Later, we went over a few questions with the micro attending. He discussed proper sampling, and gave a talk about what is and isn't good to receive. Lots of people send swabs, which are really only good for a few things (nasal, throat, and urethral cultures, and perhaps a few others). A swab holds about 150 microliters of fluid, and only 3% of bacteria on the swab come off when culturing a plate. Tissue and fluid are much preferred. The attending said some doctors will draw a few cc's of fluid, then swab the fluid and send that. The lab would be much happier to receive the vial of fluid instead. He said he is trying to get the message out about stuff like this, with only moderate improvement.
The worst word I overheard today: "scrotectomy."
Besides not learning anything, I was counted absent for the presentations. We have to attend a certain amount of presentations over the year, or there are consequences, such as increased call or decreased book fund.
Wait, pathologists take call?
First-year residents have three weeks of CP call, taken a week at a time. It's usually home call, since we just field questions. In theory, we might have to come in and write orders. Most of it is blood bank/transfusion questions, and since we haven't had those rotations yet, we'll mostly be taking down information and contacting the transfusion fellow. Seconds years have two weeks, third years have half a week, and fourth years have no CP call.
AP call is different. If you're on surgical pathology, you have call every couple days, which is basically coming in and doing a frozen section if one comes up. If you're on autopsy, you have call every other weekend; if there's an autopsy, you come in and do it. Not paradise, but not surgery call either.
Holidays are also divvied up; each intern has to take call for one major and one minor holiday. I'm on call over Christmas and Memorial Day this year. Every remaining holiday, I don't even have to come in.
As for book fund -- we get a couple hundred dollars to spend a year on books. If you've ever seen a typical pathology program's library, you realize that this is almost chump change. There are dozens of books out there that people might recommend. Most residents will get one of the main surgical pathology references (either Rosai/Ackerman or Sternberg) and probably a CP book. Other options include Differential Diagnosis in Surgical Pathology (since we don't know what the diseases look like), Histology for Pathologists (since we don't remember what the normal tissue looks like), a grossing manual, and more organ-specific textbooks that you can shake a stick at.
Another "clinical faux paus" got discussed today during micro rounds. A patient had four out of four blood cultures come back positive for Bacillus, despite having a clinical presentation that wouldn't fit that diagnosis at all. Bacillus can be a contaminant, and if it shows up in one of four cultures, it's usually dismissed as such. Apparently, sometimes, the ER here will perform one blood draw (from one site), then inject the sample into four different culture vials. On top of that, they sometimes won't disinfect the top of each culture vial before injecting it. Voila -- one contaminated sample spread over four vials.
Later, we went over a few questions with the micro attending. He discussed proper sampling, and gave a talk about what is and isn't good to receive. Lots of people send swabs, which are really only good for a few things (nasal, throat, and urethral cultures, and perhaps a few others). A swab holds about 150 microliters of fluid, and only 3% of bacteria on the swab come off when culturing a plate. Tissue and fluid are much preferred. The attending said some doctors will draw a few cc's of fluid, then swab the fluid and send that. The lab would be much happier to receive the vial of fluid instead. He said he is trying to get the message out about stuff like this, with only moderate improvement.
The worst word I overheard today: "scrotectomy."
I'm official
My program director has officially OKed this blog. Hooray! I am, of course, keeping names out of it and changing minor details here and there (for example, I think everyone will be a "he" unless it's a breast/gyn patient), but that's just the standard CYA stuff.
Today was the first day I had to be there at 7:30 a.m. for morning conference (usually, we'll have to be there at 7:30 Mon.-Wed. and 8:00 Thurs. and Fri.). We had "unknown" conference, where the attendings give residents a quick case history and then slides to identify. Based on the differential, the resident also suggests what other tests to run. The main thing I learned this morning is that touch preps look like crap. Also, I will sound more intelligent at the scope once words like "monomorphic" enter my effortless vocabulary.
The lab was slow today. The ID docs told us about a patient with pyomyositis -- basically, abscesses in his calf muscles and who knows where else. In molecular diagnostics, we got to hear the attending vent a little about how two of his machines aren't exactly compatible. One prepares a certain type of specimen in batches of 32 (an 8x4 grid), and the other analyzes them in batches of 24 (a 5x5 grid with the center hole blocked).
Female ID attending: "Well, that was clearly designed by a man."
Male lab attending: "Yes! In fact, it was a German man."
There was also a little issue with the HCV (Hepatitis C) PCR machine. Someone stuck himself on accident a few weeks ago, and the viral load came back in the low hundreds (which is very low for an acute onset). Turns out his specimen got ran after a specimen with a high load (millions), messing the test up; it actually should have been negative. Good news all around.
I managed to get a picture of that velvety yeast plate I mentioned yesterday. It was identified as Cladosporidium:
As a bonus, here's a "peanut butter" plate. This is Epicoccum nigrum:
And here's Epicoccum on a slide (who knew my camera could get such a good picture through the microscope lens?):
No, I'd never heard of Epicoccum either. Cladosporidium, mmmmaybe.
Today was the first day I had to be there at 7:30 a.m. for morning conference (usually, we'll have to be there at 7:30 Mon.-Wed. and 8:00 Thurs. and Fri.). We had "unknown" conference, where the attendings give residents a quick case history and then slides to identify. Based on the differential, the resident also suggests what other tests to run. The main thing I learned this morning is that touch preps look like crap. Also, I will sound more intelligent at the scope once words like "monomorphic" enter my effortless vocabulary.
The lab was slow today. The ID docs told us about a patient with pyomyositis -- basically, abscesses in his calf muscles and who knows where else. In molecular diagnostics, we got to hear the attending vent a little about how two of his machines aren't exactly compatible. One prepares a certain type of specimen in batches of 32 (an 8x4 grid), and the other analyzes them in batches of 24 (a 5x5 grid with the center hole blocked).
Female ID attending: "Well, that was clearly designed by a man."
Male lab attending: "Yes! In fact, it was a German man."
There was also a little issue with the HCV (Hepatitis C) PCR machine. Someone stuck himself on accident a few weeks ago, and the viral load came back in the low hundreds (which is very low for an acute onset). Turns out his specimen got ran after a specimen with a high load (millions), messing the test up; it actually should have been negative. Good news all around.
I managed to get a picture of that velvety yeast plate I mentioned yesterday. It was identified as Cladosporidium:
As a bonus, here's a "peanut butter" plate. This is Epicoccum nigrum:
And here's Epicoccum on a slide (who knew my camera could get such a good picture through the microscope lens?):
No, I'd never heard of Epicoccum either. Cladosporidium, mmmmaybe.
Monday, July 7, 2008
Still truckin'
I finally got some time at one of the plate benches today. It was really cool. I got to look at a bunch of culture plates and see what was or wasn't growing. I saw some alpha and beta hemolysis, some gold Staph colonies, and some nasty-looking mucoid Klebsiella growth. I also watched a latex agglutination test for Staph and an oxidation test for Pseudomonas. Later that day, I saw a yeast plate with an amazing growth pattern -- it looked like bunched-up black velvet. I really wish I'd had my camera with me.
We also learned a simple but valuable lesson during rounds. We had a sample from one patient with a liver abscess that showed Gram-positive organisms on the stain but no culture growth. From another patient, there was a plate with no growth in area 1 (the most dense), but as the sample was diluted, growth appeared. Lesson: take the sample BEFORE starting the patient on antibiotics.
I also discovered that people will send just about anything down to the lab for sampling. There was a patient with suspected infection of the spinal cord. He had an apparatus implanted in him that delivered pain medication to his spine. The doctors took the entire device out and sent it to the lab in a huge bucket. This is, of course, massive overkill (you can usually just send the tip that's most inside the patient), but the lab director remarked that he'd rather get the whole device than not get anything at all.
I still feel like an imposter, walking around the hospital in my long white coat (which doesn't even have my name embroidered on it). I think it'll be a long time before I feel confident and competent enough to walk around in it and not feel like I'm being deceptive.
We also learned a simple but valuable lesson during rounds. We had a sample from one patient with a liver abscess that showed Gram-positive organisms on the stain but no culture growth. From another patient, there was a plate with no growth in area 1 (the most dense), but as the sample was diluted, growth appeared. Lesson: take the sample BEFORE starting the patient on antibiotics.
I also discovered that people will send just about anything down to the lab for sampling. There was a patient with suspected infection of the spinal cord. He had an apparatus implanted in him that delivered pain medication to his spine. The doctors took the entire device out and sent it to the lab in a huge bucket. This is, of course, massive overkill (you can usually just send the tip that's most inside the patient), but the lab director remarked that he'd rather get the whole device than not get anything at all.
I still feel like an imposter, walking around the hospital in my long white coat (which doesn't even have my name embroidered on it). I think it'll be a long time before I feel confident and competent enough to walk around in it and not feel like I'm being deceptive.
Saturday, July 5, 2008
One week down, 207 to go
This week has been nice and slow. In theory, I'll usually be showing up at 7:30 in the morning for conferences, but since things are just starting out, some of them have been canceled. Micro is a slow rotation by nature, so I'm usually done with "work" by 3 p.m., though I have to stay until 5 just in case. I had the 4th off, and I'm free this weekend too. Oh, and I have no call until September. The interns on surgical pathology are getting slammed -- one girl didn't go home until 9 p.m. the other night -- but they don't have to work weekends either. This is in stark contrast to my friends in other fields, who are all already pulling their hair out.
The micro lab has had a few technical issues this week, preventing me from observing what I've been scheduled to observe. I have three months to get it done, though, so the lab directors aren't fretting in the least. We have rounds at 1, which consists of the pathologists and the ID docs going over interesting cases. A lot of it is still over my head, but I'm not completely lost. The molecular lab also had some interesting dilemmas facing them, such as calibrating new tests. It quickly became clear why they need doctors overseeing the labs.
Thursday's "highlight" was sniffing some bacteria. Pseudomonas did indeed smell to me like grape -- fake, cough-syrup grape. The other intern (who is of Mexican descent) said it smelled like a corn tortilla; this is apparently a known and acceptable alternative. Streptococcus milleri smells like butterscotch.
The program in general is working hard to get us gradually acclimated. There are always upper-level residents helping you out; the micro fellow has been especially kind to us. The first few weeks' worth of morning lectures will be on how to gross, how to survive CP call, and other similar topics. There was an autopsy Thursday morning that all the interns were asked to watch. It was straightforward but very helpful. I'm not a fan of digging through dead bodies (grin and bear it ...), but seeing a massive pulmonary embolus wriggled out of a pulmonary artery is pretty darn cool.
I went out for drinks with the other interns and some PGY-2s Thursday, and there was a cookout Friday. For the most part, everyone's really friendly and laid-back, which makes the program even better.
So basically, no complaints so far! We'll see how I feel when I start surg path in October.
The micro lab has had a few technical issues this week, preventing me from observing what I've been scheduled to observe. I have three months to get it done, though, so the lab directors aren't fretting in the least. We have rounds at 1, which consists of the pathologists and the ID docs going over interesting cases. A lot of it is still over my head, but I'm not completely lost. The molecular lab also had some interesting dilemmas facing them, such as calibrating new tests. It quickly became clear why they need doctors overseeing the labs.
Thursday's "highlight" was sniffing some bacteria. Pseudomonas did indeed smell to me like grape -- fake, cough-syrup grape. The other intern (who is of Mexican descent) said it smelled like a corn tortilla; this is apparently a known and acceptable alternative. Streptococcus milleri smells like butterscotch.
The program in general is working hard to get us gradually acclimated. There are always upper-level residents helping you out; the micro fellow has been especially kind to us. The first few weeks' worth of morning lectures will be on how to gross, how to survive CP call, and other similar topics. There was an autopsy Thursday morning that all the interns were asked to watch. It was straightforward but very helpful. I'm not a fan of digging through dead bodies (grin and bear it ...), but seeing a massive pulmonary embolus wriggled out of a pulmonary artery is pretty darn cool.
I went out for drinks with the other interns and some PGY-2s Thursday, and there was a cookout Friday. For the most part, everyone's really friendly and laid-back, which makes the program even better.
So basically, no complaints so far! We'll see how I feel when I start surg path in October.
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