The Making of an Anatomic Pathologist
The Residency
In the USA, students of anatomic pathology must enter a residency program approved by the Accreditation Council of Graduate Medical Education (ACGME). Training programs are allocated 18 core months in which to bring a novice to a level of competence such that he or she is fit to serve the American people. A further six-month period is usually devoted to optional electives. My thoughts about the application of the Competencies are found on the pages within The Quest for the Holy Grail of Competence.
Running on Fumes
A person licensed to interpret tissue specimens must be able to offer an accurate diagnosis, which requires the following attributes: skill at making observations; possession of sufficient relevant knowledge; experience; the art of rendering an opinion orally and in writing. The novice lacks all of these, except some general knowledge brought forward from medical school. There is no way that he or she can yet render a credible opinion or offer any experience. Those who educate pathologists must therefore begin by teaching trainees how to (1) make accurate, detailed observations; (2) accurately record those observations; (3) accurately interpret the observations to form plausible opinions. Residents must learn which observations may be trusted, after which they must further learn the importance of committing themselves to the opinions that flow from trusted observations. Beyond that, they must be able to reasonably defend their opinions against those of others. Further, they must be ready to abandon an opinion when faced by convincing countervailing arguments. Above all, (and this is the hard part) they must be taught to openly admit their errors in interpretation, appropriately alter their opinions, learn from their mistakes, and move on, safe from unfair retribution. The rendering of a diagnosis is ultimately the expression of a reasonable opinion, not necessarily a statement of truth. One way or the other, this opinion must be communicated in a timely fashion to someone authorized to receive it, and phrased in such a way as to elicit the desired response from the recipient. One day, if and when the evaluation of tissue specimens can be conducted safely in measurable and objective terms, independent of the human eye, then perhaps the value of an individual opinion will recede. I would not count on that happening anytime soon.
The process of learning to develop credible opinions in anatomic pathology occurs during an apprenticeship (the modeling mode), during which the student is guided on a one-to-one basis by an experienced tutor, the qualified pathologist. In doing so, students learn at close quarters when it is all right to move faster and when it is necessary to put on the brakes. This they can absorb only from physicians who are themselves patient and unharried, and who have reasonable opportunities to continue enlarging their own knowledge. The pathologist who cannot continue to learn cannot continue to teach. Pathologists who aspire to be good teachers need substantial Time to re-charge their batteries. In this way, they maintain credibility in their fields, teach well, and provide effective support for their clinical counterparts and thereby for patients. The favorable conditions I encountered for teachers of pathology when I arrived in this country in 1976 have, for the most part, evaporated. The tank of gas on which the teaching of pathology once ran is almost empty and we will soon be running on fumes.
Small observations, big returns
It is not so easy to teach someone to make critical observations that have clinical consequence. Medical students do not automatically grasp the importance of translating a minute observation into meaningful clinical action. I realized this as a beginning resident, when I watched my teachers struggle with difficult problems, drawing critical inferences from the barest microscopic details, infusing their reports with communicative language that had a huge impact on patient management. Complete mastery by the individual, one realized, would always remain an elusive and receding goal.
The novice cannot distinguish crucial observations from trivial artifacts and contaminants. It is only after one has become familiar with the microscopic anatomy of every nook and cranny of the body that slight deviations from the normal can be appreciated. Biopsy samples tend to be very small, perhaps displaying only a glimmer of the tissue of origin, but a good pathologist will usually be able to recognize the general neighborhood when only a minute portion of the whole is available to the eye. To complicate things further, the living body occupies three dimensions, but pathologists examining tissue slides have only two dimensions at their disposal. They are forced, therefore, to visualize and enact the missing dimension from a field that runs in only two directions.
The human body, when it goes wrong, produces a constant array of confounding and difficult microscopic variations. Every trainee must spend countless hours studying innumerable slides on innumerable conditions. It would not be sufficient to study, say, 50 slides on breast cancer and then say that’s enough. Breast pathology is unyielding in its ability to challenge even the most experienced observer. Like the ballerina who takes a three-month break and feels clumsy upon returning to the stage, the pathologist who disengages from the constant examination of slides and the clinical meaning of what is on them, will become rusty. Beyond breast cancer lie thousands of conditions affecting other organs of the body. Consequently, some academic pathologists subspecialise and spend entire careers devoted to the pathology of only one system, reporting, for example, only on diseases of the skin, or lungs, or brain, or lymph nodes, and so on.
I make a fuss out of learning to observe because without that keen ability, no interpretations could possibly occur. This is as true for anatomic pathology as it is for astronomy or psychiatry, or any human endeavor. To create an effective anatomic pathologist is analogous to making a new hunter out of a junior pygmy. To become the hunter, junior must go out with dad, not once or twice, but over and over again, and then again and again, until junior finally knows his way around the forest. Beyond knowing the trails, junior must also learn to discern all of the intimate secrets of the jungle, its shades of color and tone, the ways in which prey blends with foliage, clues to be derived from imprints in the trail itself, the medicinal usages of plants, and so on. In short, before junior can be let loose, dad must be sufficiently confident that his boy can truly look after himself in the jungle. The new graduate of the wild will have a swath of real and effective knowledge that no text could possibly convey. In having learned to make observations, through trial and error, he has acquired not only knowledge but also experience, and is in a position to render a credible opinion, as in advising one on the difference between a vine and a snake.