Sunday, February 05, 2006

cons of path

- Being pestered by clinicians:

Point #1: A pathologist is the doctor's doctor.
Point #2: Doctors are the worst patients.

- As for call, regardless of the call, call is call. Call blows. Home call is nicer than in house call but what sucks about home call is that some calls will require you to get your ass back into the hospital. That sucks. That being said, clinicians have it worse than the pathologists, generally speaking. Clinicians take call more often. And it's in house call. Clinicians also get more calls when they are on call and I feel for them. But that's their problem...and why I went into pathology. I don't like my pager. I am tempted to destroy it.

- Medicolegal issues - pathologists too have to carefully word things and document the stupidest of things just so that it doesn't come back to bite them in the ass later.

Inappropriate usually consists of an intraoperative consultation that will have absolutely NO IMPACT on what they will do during that surgery.

For example, I received a frozen on a lymph node for a renal cell carcinoma. Reason for said frozen: hem-onc wants to plan course of post-op treatment (said they get more of drug x if the node is positive). Didn't change a damn thing surgically, in fact they were closing when I reported it back 10 minutes later (I at least figured they would take some more nodes, but they already had those out when they called). I have run into many surgeons who do not use the frozen results to manage their patients intraoperatively, rather, they like to have a diagnosis for their patient when they see them that afternoon in recovery.

I think the worst is when your attending will read these non-sensical frozens. I remember talking with a surgeon when I first started in July for like 5 minutes about why he was getting this thing, only for my attending to cave and allow it (and telling me that there is no reason for this). It makes it hard to tell the surgeon "inappropriate" when your attending wont back you up.

Word up man. Regarding your renal cell carcinoma story, I experienced an identical event this past Friday. Surgeon wanted a diagnosis on a metastatic RCC to a lymph node in the chest wall. The diagnosis we gave him was "consistent with metastatic RCC." What difference did this make in surgical management? None. I suppose that if the lymph node was negative for tumor, he might have dug around a little more. However, based on reading pre-op notes there were no other suspicious lesions except for this enlarged node. Doing the frozen was easy. But having to stay in the hospital just for this one case was the difference between me going home at 6 pm versus 8 pm. Wasn't very thrilled about this


And in addition, diagnoses are more appropriately made with fixation and the time taken for good histologic sections. The frozen is basically a throwaway that is only glanced at during the real signout, and only to make sure nothing weird showed up on the slide that wasn't on frozen. The unfortunate thing is that if it is a small lesion (like thyroid or something) the bulk of the lesion is on frozen, and the final diagnosis becomes that much more difficult.

This is why breast frozen section has mercifully become much less common over the last few years. Surgeons have been taught now that doing a frozen on breast lesion destroys a lot of margins and diagnostic tissue.


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