so ... what do pathologists do, anyway?

One of the reasons I started this blog is that most people don't really know what pathologists do. When I was a medical student, patients would ask me what field I wanted to enter, and my answer usually gave them a puzzled look. A few people replied, "So you're just going to work with dead people?"

A lot of physicians also don't seem to understand what pathologists do, or at least aren't aware of their full range of skills and limitations. So, here is a quick rundown. If this is too long to read, just know that anytime something gets sent to "the lab," a pathologist is responsible for the results that are returned.

ANATOMIC PATHOLOGY

There are actually two halves to pathology: anatomic and clinical. AP is the branch that most people are more familiar with, and that medical students study during second year. The three main "sub-categories" are surgical pathology, cytopathology, and autopsy.

Surgical pathology is the preparation and evaluation of patient tissue. This includes both surgical specimens (a gallbladder removed during surgery, for example, or a breast cancer mass) and biopsies (a mole removed at the dermatologist's, or a polyp plucked out during a colonoscopy). These tissues are sent to pathology, where they are "grossed," or cut into and prepared. They are then stained with colorful dyes, and a pathologist looks at them under the microscope and determines what exactly is going on.

This is a topic for another post, but I do want to mention that this is rarely cut and dry. Medical students may learn that basal cell carcinoma of the skin looks one way, but a pathologist knows that it can have many different appearances. Furthermore, many diseases exist along a spectrum, and determining where exactly something sits on the spectrum can be as difficult as looking at one spot on a spectrum of 1,000 colors and identifying the corresponding crayon. Fortunately, there are ways of getting answers, usually through staining the tissue with dyes that only stick to certain entities.

Autopsy is what everyone associates with pathologists. There's not much to say here, except that there is a lot more to the field than just this. Some pathologists gain additional training in forensics and do these all the time, but some just cover them occasionally for their hospital or practice, and others probably manage to avoid them altogether. Autopsies are also performed less frequently than in the past, for a few reasons.

Cytology is similar to surgical pathology, except that the specimen being looked at under the microscope is a cluster of cells instead of a firm piece of tissue. Pap smears are a good example of this. Cytology also offers pathologists patient contact, as they perform fine needle aspirations (FNAs) to suck out the cells that are going to be examined.

CLINICAL PATHOLOGY

This covers such a wide variety of fields that I'm pretty sure I don't know everything that's involved. Pathologists oversee or consult on labs running tests on bodily fluids. This includes microbiology labs, clinical chemistry labs (where routine blood tests get sent), and many more. Disciplines such as transfusion medicine and hematopathology also fall within CP.

Some of this is just oversight and troubleshooting. Techs do the day-to-day work in the lab, but when a weird test result pops up, a machine is clearly producing bad results, or a clinician has a question to ask, the pathologist steps up to the plate.

Pathologists also oversee the blood bank and approve giving out blood products. As a good example, my institution is really, really short on a particular blood type right now, so we have to be stingy with it. A surgeon may call and ask for twenty units, and the pathologist on call will approve five (sounds bad if you are that patient, but not if you're the car-crash victim coming in ten minutes from now).

This aspect of pathology is poorly communicated to most medical students (we had one guy come in for an hour and mumble about a bunch of tests the lab ran; if you'd asked me then, I wouldn't have been able to identify him as a pathologist). Most nonmedical people probably aren't aware that doctors oversee all the labs, either, since on the surface it doesn't seem like you'd need a doctor down there.

That's everything in a nutshell. I'm only one month into my four-year residency. Maybe 47 months from now, I will write this essay again in light of what I've learned and what I think is important to emphasize.