Oh No! Mr. Elf!

Read it: at MIM.

Topic Week

It's Topic Week over at MiM! So I was forced to break my dry spell, which has been induced by the holidays, work, and cocooning with the kids. And too many novels to count.

Read it: HERE.

Fan Mail

I've had a handful of readers over the past couple of years e-mail me to ask me questions about pathology and advice about medicine but no one, until last Thursday, has ever prefaced their question as "Fan Mail." I was tickled pink. A first year medical student from a far away institution asked this, and kindly allowed me to answer in a post:

"My question for you is, are there times when you wished non-pathologist physicians remembered more about histology? What would you like them to know?"

The short answer is this: NOTHING. That's job security, right there, in an age where everyone is stepping on everyone else's toes. Radiologist doing surgeon's jobs, interventional cardiologists threatening the cardiothoracic surgeon's lifestyle, general surgeons delving into plastics, etc. etc. Nothing makes me happier than when a radiologist peers into the scope while I am doing a wet read on a lung biopsy and acts like it is all voodoo. Or when a gastroenterologist comes to the lab to look at a biopsy and I can tell, even when they act like they understand what I am describing to them, they really haven't a clue. I'm certainly not claiming superiority, here. When a patient starts to hemorrhage during a lung biopsy, or when it comes to treating the many diseases that I diagnose, I haven't a clue. That's not my job, and I am not interested in any of it unless it helps me help the patient. I like to know the implications of my call, that is very important - if I upstage this cancer what will it mean for the patient? Extra chemo? A grimmer prognosis? But beyond that, I have little interest in the details, I have my own wide scope of practice maintain current knowledge in, and that already stretches me to the limits.

In a subsequent e-mail the first year is lamenting over an upcoming histology test, but simultaneously pleased with her status as a first year med student - we were all happy miserables, in med school. I hated first year histology. It was one of my few B's in medical school. Those old neck-breaking 1960's scopes with blurry eyepieces staring down onto old, overused slides - that was a nightmare. My first month of pathology residency confirmed that I retained nothing - I used to take random slides from my autopsy cases to test myself on normal histology. I still remember mixing up the pancreas and the pituitary gland. I think the first couple years of med school are important - but especially the first year seems to be a test of endurance, much of it is not really applicable to daily practice. Biochemistry about did me in, especially since I was a psychology major in college. Since I have graduated from my med school, they have re-vamped the curriculum to a systems-based approach, which I hope is less abstract than our disjointed basic science review.

My second year of medical school was better - everything seemed more practical. That is where I realized I had a talent for pathology. I was an "upper quarter" student, but was rarely at the top of the class. This changed when I took pathology - a two semester course. There was a bulletin board where all of our grades were posted next to our "super top secret" numbers that designated us, a number known only to the individual. The Wailing Wall. I still remember how long it took me to find my own number on the first pathology test - searching for my grade. After many frustrating, anxious minutes I finally found it - at the top. I was standing in a throng of med students. Someone said, "Who is that? Who made the highest grade?" I smiled quietly, still in utter shock and amazement, and slipped away. I was never at the top before, but it was consistent for me, in pathology. So although my route was circuitous - I had an ophthalmology residency in the bag, I was glad that I came to my senses because this is clearly my calling, and I am happy.

Thanks much for the "Fan Mail." It made my day! And good luck on your histology test, J! It is a means to a, hopefully wonderful, end. You never know. You might have a knack at it.

Happy Halloween Eve

Who needs a costume when you can just artfully arrange a towel and channel a vague Star Wars-like character?

Waffle fries make the best vampire teeth on the planet.

Thanks to talented neighbors, Ce-Silly has been decked out in seasonal style with blinking pumpkins on her skirt. Hope everyone has a safe and happy Halloween.

Sober Driver - Dengue Fever

It's been too long since I posted music. Been listening to this old one all week on the way to work.

Floaters

The other morning I was looking at a prostate. I love getting prostates - it is a huge chunk of work that normally sails by. Not the biopsies, they can be excruciating - it is easy to miss a small tumor gland so perseverating inevitably sneaks up on you, whiling away the time. But whole prostates are nice. Certainly you have to note the important things - apical margin, base margin, peripheral margins, extracapsular extension, seminal vesicle involvement - but overall it is generally pretty easy.

Floaters require a little explanation. I always thought it was funny that floaters on glass slides carry the same name as the slang term for dead bodies found in the water. I don't see floaters very often in my practice - our histotechs are very good. After the techs cut the thin slice of tissue embedded in wax after overnight processing, they float the wax/tissue square in a cold water bath prior to placing it on the glass slide with forceps. The water is changed regularly and very clean, but occasionally a stray piece of tissue from another case will find its way onto your slide. Most of the time it is so obvious that we just circle the stray tissue on the slide (thyroid in an endometrial biopsy??!!??) and write "floater." If it becomes a diagnostic dilemma (does this cancer really belong here!!??) it is easy to check the wax block and do a recut if necessary - the floater will not be there the second time around.

Floaters can be so anomalous to what you are doing at the time, and such a surprise, that your brain is sent into a gentle tailspin until you wrap your head around it and realize what you are seeing. I was looking at the prostate, following my little mundane protocol, and I picked up the urethral (penile) margin. No cancer, but what was that fuzzy pink stuff off to the side? Was that brain? Just as I realized it must be a floater I grinned from ear to ear. I ran into my partner Michelle's office.

"This is the best floater in the history of floaters. This is a penile urethral margin in a radical prostatectomy."

She threw it up on the stage, and started laughing so hard she almost fell off of her chair. I joined her, and when we finally caught our breath, I said, "Maybe I should send it around? Show everyone?" She looked alarmed. "Not the guys." I said, "OK, just the girls, then."

A few minutes later she came in my office. "Maybe most of the guys. Not all of them." We were both thinking about a senior member of our group. He can definitely take a joke, but he has an air of decorum about him that rebuffs tasteless humor. I said, "Let's try it out on Rex." She agreed, and we wandered to his office next door with the slide. I gave him the intro, and he was quiet for too long, while Michelle and I were unsuccessfully suppressing giggles, like junior high school girls. I looked at her, "Maybe he doesn't get it."

Rex said under his breath, peering down into the microscope, "Yes, I get it."

I said, "Oh," as he handed back the slide. Gave a sideways glance at Michelle. "Well, he was our test guy. It didn't go over too well. You were right, maybe we should just show it to the girls."

Later in the day, Rex came into my office to render his opinion on a breast case I had consulted him about. "I'm not sure why you want my opinion since you called me a dick brain earlier." I smiled. "Not you, Rex! It is a joke about the male species in general." He wasn't supposed to take it personally. Just enjoy the wonderful pathology spin on the age old joke. I have enjoyed the license to call him a dick brain, the last couple of days, and I think he has mellowed since the original presentation. I can't wait until my parter-in-crime, Dr. Woods, returns from vacation. To see his response.

A Day at the Arkansas State Fair

Read it, over at MiM.