An ordinary citizen's "ideal" breast biopsy, hour by hour
Here is a rough, idealized timeline for a small biopsy of the breast, taken at a private physician’s office at 1:00pm on Monday for submission to a nearby facility that afternoon. [Re-visit a more detailed narrative under “An Ordinary Citizen Revisited”] The specimen, say 1.0cm in diameter, is accompanied by a requisition slip on which may or may not be written key clinical information about the patient. Let us assume that (1) all writing is legible (a risky assumption); (2) the facility is an academic center that trains residents in pathology, and (3) there are no unforeseen hitches.
Monday
1:00pm Biopsy taken, placed into delivery box.
3:00pm: Transport courier retrieves specimen.
4:00pm: Biopsy delivered to laboratory, enters a line of other specimens.
5:30pm: Laboratory assistant gets to container with patient’s material.
The assistant checks the identification and enters the demographic data into a software program. The assumption is made that the assistant knows at least the rudiments of medical terminology.
6:00pm: Specimen received by the pathology resident, within a batch of other samples.
The resident performs a naked eye examination at a station where essential gross observations are made. This part of the laboratory is therefore aptly named the gross room, where the resident dictates a gross report. The entire specimen is placed into a plastic cassette, a flat box-like cartridge, which has slits for permeation of fluids. One edge of the cassette is slanted, for the imprinting of identifiers (Fig. 1).
Figure 1
7:30pm: Cassette placed into tissue processor for automated treatment of specimen.
10:30pm: Cassette removed from tissue processor.
Tuesday
5:00am: Histotechnologist creates a solid paraffin block that contains the specimen.
7:15am: Histotechnologist places paraffin block on microtome, and starts shaving the block.
The paraffin blocks from hundreds of specimens are handled by a histotechnologist, one at a time, on a microtome, which has a blade that shaves off extremely thin veils of paraffin, each containing a flimsy cross section of the biopsy sample, about half the thickness of a red cell (Fig. 2). Obviously, it is impractical to shave through an entire block in this way. Doing so would generate thousands of slides, and no laboratory could possibly cope with such a load.
Figure 2
7:20am: Veils of paraffin (including thin section of specimen) placed onto glass slides.
7:50am: Slides stained to illuminate microscopic details. Coverslips applied.
8:00am: Histotechnologist organizes hundreds of slides for delivery to pathologists.
8:15am: Resident matches slides to dictated gross reports, typed by secretaries.
Depending on the biopsy load, there may be 200 to 300 slides in the batch. Since the hospital is a teaching institution, it is imperative that the resident gets first crack at the slides. The reason is that the only way that the pathologist can judge the evolving ability of the resident is via the latter’s written account of each case. Putting the diagnosis on paper is a commitment to an opinion. The organization of the words on the page, the choice of terms to convey subtleties, statements that reassure, all are integral to the process. It is from the written words that one discovers whether the resident is independently able to render credible interpretations. Working on her own, consulting appropriate texts, making pertinent phone calls, and owning each case, the resident matures from being merely the shadow of a pathologist into someone whose emerging competence can be quite remarkable and gratifying. Unfortunately, financial constraints (related to turnaround time, length of hospital stay, the need to issue a bill) have cut down the amount of Time that residents are afforded alone with each case. Their scope for designing comprehensive independent reports is therefore limited, which partly explains why, in my opinion, many of them lack good communicative writing skills when they graduate (see “Authentic Experiences”).
It is worth re-stating that a surgical pathology diagnosis is always based on an examination of representative material, and never involves microscopic scrutiny of the entire specimen. When a specimen is large, only representative portions are selected for microscopic evaluation. During microscopic analysis, only representative levels from the tissue block are studied. What the pathologist sees under the microscope is therefore really a representation of a representation, the only practical and reasonable way to proceed. When a pathology report states that “all” of the tissue has been examined, that can never (using current methods) be literally true.
After examining the batch of slides for two or three hours, the resident brings them to the pathologist, with the paperwork. The one-on-one session that follows between resident and pathologist at a double-headed microscope is the crucible of microscopic training. The resident gradually comes to his or her feet under the supervision of teachers, who themselves underwent identical experiences a generation before.
1:00pm: Pathologist makes final adjustments to report, hits “send” button. The report will be autofaxed to the clinician when the next batch of faxes is set to go.