Authentic experiences
Here are some experiences I underwent as a resident and that were once available to senior pathology trainees in the USA. The loss of these experiences contributes towards what I have referred to as infantilization in the training of surgical pathologists. After about nine months of training, I was placed on the roster for frozen sections. Responding to a call, I would drive from medical school to hospital, to be alone in a small lab with a histotechnologist. If help was needed, I would ask a staff pathologist to get into his car and come over. I will always remember the first time I diagnosed a cancer that led to an immediate mastectomy. The slide showed an obvious malignancy. Yet, just to be sure, I opened the book, then checked the slide. Back to the book, then the slide. Finally I switched on the intercom and told the surgeon that I had a result. "What is it?" he asked. "Carcinoma" I replied. "Ah, carcinoma. I see. Thank you!" There was a click, and that was it. My words could not be withdrawn. Mastectomy. A day or two later, I received the permanent sections, confirming my interpretation.
On another occasion, things did not go quite so well. Again, I was on frozen sections, this time with tissue from a man's palate. I made a diagnosis of squamous carcinoma, and an excision was performed. When the permanent sections arrived, I was horrified to learn that the lesion was benign. Fortunately, the operation was not significantly different from what would have been done had I been correct, but the effect of the mistake was crushing. I thought that my career would end right there, but I was surrounded by supportive pathologists who nursed me along.
Every day at 2:00pm, the completed pathology reports would be laid out on a countertop for signing. The diagnoses and comments had been written by residents, whose signatures accompanied those of their supervisors. One day, as I took my seat at an interdepartmental conference, the professor of dermatology, Walter Gordon, his hair standing up wildly, strode in, waving a yellow piece of paper. He went into a huddle with one of the pathologists, who looked sternly in my direction. In my report, I had had the temerity to advise the professor that in order to improve his chances of sampling the actual lesion, future biopsies should be performed at the edge of the blister and not at its center. The storm blew over, and I advanced in my learning of how best not to write a comment. While some programs in the USA do allow residents' names to appear in the final diagnosis section of a report, many are too worried about the legal risk to extend this privilege.
In further training at the University of Minnesota, I was assigned to what they called the "hot seat". Given a microscope, a notebook and a telephone, I was responsible for issuing provisional diagnoses on every case coming through the department on a given day. It was like operating a switchboard, receiving calls from physicians who needed an immediate word on their patients. My interpretations would later be checked against the final report issued by a staff pathologist. The hot seat either improved or wrecked the confidence of anyone who underwent the experience. After two months, I was farmed out to the VA Hospital to recuperate. Here, too, I had opportunities for independent decisions. Once, I had the audacity to diagnose a rare laryngeal lesion on a frozen section, and was proved right. However, I also single-handedly messed up another case in which a surgeon working on an abdominal mass wanted to know whether he had obtained sufficient tissue for a diagnosis. He had given me a small scrap of tissue that I thought represented part of a malignant tumor. I told him that there was enough for an interpretation, whereupon he closed the abdomen. Next day, the permanent sections showed that I had been wrong, and the patient needed re-exploration. Since then, I have never been shy about pressing for more tissue from surgeons.
I was on daytime frozen section duty with another Fellow in surgical pathology. A prominent politician was undergoing a biopsy. The senior pathologists were out of town at a conference. The two of us rendered an interpretation. The surgeon came in, asking for the chief of pathology. We told him that the chief was out of town. He asked for the next in command. "Actually, he's also out of town." It then dawned on the surgeon that the correct diagnosis had been made by a couple of rookies.
Some years later, when I was a staff pathologist at The George Washington University Medical Center, we would allow Fellows in surgical pathology to sign out a certain percentage of cases by themselves, over our signatures. However, the latitude and responsibility that we allowed those trainees ended because of the increasing medicolegal risk.