Doctor's Lounge

I have been working at my hospital for almost seven years. That's a long time.

I walked into the lounge at about 9 something a.m. this morning to get hot water for a cup of black tea.

There were three women sitting at a table by the front door. I introduced myself to one of them two weeks ago - she is a newish PM&R doc. Works mainly at the rehab tower. The other two I didn't know. They looked young and hip - I imagined they were residents. I looked over at another table and saw a woman sitting with a man. Two women were standing at the food station getting some of what was left of breakfast. That's seven women, counting me, and one man in the lounge. Unprecedented.

I felt like climbing onto a table and dancing and singing at the top of my lungs. I didn't. That would have looked crazy. Instead I walked over to the table with the one doctor I knew in the room and said, "I have been here seven years, and I have never been in the presence of this much estrogen in the doctor's lounge."

It is usually an all Caucasian male crowd, with a few exceptions to the former descriptor. Rarely women. I could sit down and chat, but why? To listen to random sports talk I had nothing to contribute to? I usually just get my coffee and maybe a hard boiled egg if I forget my bean burger for lunch while eavesdropping. I leave quickly.

I wandered over to the coffee area to make tea, still resisting the urge to sing and dance something crazy and free and female-oriented. Alicia Keyes was running through my brain. "This Girl is on Fire"

After I made my tea, I walked back over to the table by the door. The PM&R doc said, "I was just telling them who you were." I introduced myself to the other docs by my first name. "I'm Gizabeth." They had super cool first names that complemented their appearances, which were not all Caucasian (I am Caucasian, but of the dark-skinned variety, so I'm not being prejudiced against that. But finally University melting pot in the doctor's lounge!). I learned that they were both new PM&R docs at my hospital. They trained all over the country. I thought of my friend Fizzy, and resisted the urge to say, "So what exactly does a PM&R doc do?" Because I knew. Thanks Fizzy. But I still don't entirely understand. No offense. My job is weird too.

After we chatted and I learned a little about them and they learned a little about me I really had to go. As I was leaving I said, "Looking forward to seeing you around here more often. There has been a dearth of estrogen around here for years. I think we need to create a balance. So that we can initiate our eventual takeover." We all laughed. Kidding. Sort of.

Apical Core

I was looking at an apical core a few weeks ago. The surgeons take these cores at the apex of the heart when they are putting the patient on mechanical heart support. Most of the time there is bizarre cardiac muscle nuclear change from hypertrophy. Fibrosis. Iron accumulation. Amyloid. Pathologists look for different things based on the clinical history we read in the chart. This core was clean as a whistle. No fibrosis, tiny box-shaped nuclei. I looked at the patient age - 20's.

I delved into the chart to read about it - a 20 something year old that needed mechanical heart support? Was this viral? Genetic? The history showed no clue. A previously vitally healthy human being had gone downhill to this moment in just a few weeks. She was a student, a daughter, a musician.

A couple of days later I was rushing to finish my cases to leave early for my daughter's fifth grade graduation. I wanted to do something for her - something simple and sweet and manageable. I walked over to the hospital flower shop to chat with the florist. It was under new management and I enjoyed talking to the young energetic successor to the former manager. I explained to her what I was wanting and she pointed to a small basket of flowers.

"I was thinking more along the lines of a single flower. Something that would be easy to carry and give. Maybe a Gerber daisy?"

Her assistant came out of the back room. "What are the school colors?"

That's a good question. I had to reach. "Green and yellow."

"We have one yellow Gerber left."

As the assistant began to package the flower and tie a beautiful dark green ribbon around it I chatted with the manager. She was asking me about what I did at the hospital. The assistant suddenly joined in.

"Do you ever look at hearts?"

"Yes, actually I have an interest in that area. I see lots of explanted hearts and look at biopsies for rejection of transplanted hearts."

"I am asking because I have a friend in the hospital. It's her daughter. We are very close. I'm wondering if you would have seen her pathology. She was just put on support and is waiting for a transplant."

Oblivious, thinking about my schedule and my daughter and my day, I answered, "Oh yes we look at apical cores for mechanical support all the time. I saw one just the other day."

"Oh I wonder if it was hers? She's young, in her twenties, and we are all praying for her. Do you think you saw it?"

I suddenly put two and two together and became hyper-aware of HIPAA in my head. I told her, "Well, a lot of us look at those and we see them all the time. I doubt it was your friend's, but it could have been."

I turned the conversation back to the manager as she was ringing me up. The assistant became increasingly desperate with her questioning. She seemed to really need to know if I had seen her friend's heart core biopsy. She didn't need to know about it, but her entreaties and interruptions into my conversation with the manager were too much for me. I didn't want to violate HIPAA. I didn't want to give out any information. The manager seemed to feel my pain and supported me. "She is a pathologist. She doesn't know the patients, she just reads the tissue." I recoiled in defense.

"Well, that's not exactly true. I read every patient history. I latch onto the stories. Of course I am reading the information to get a better handle on the tissue, but every clinician adds a new piece of personal information to help me see the patient. I don't meet them, but I feel like I know them - some more than others. I'm just a voyeur, but I'm present."

The manager and I started talking again and I did something I'm not entirely proud of but it seemed like the right thing to do at the time and I am glad in retrospect. To placate the assistant I managed to slip in the 20 something year old's musical area of expertise innocuously into the conversation I was having with the manager. Whatever I said or didn't say worked. She relaxed and smiled and interpreted my silent acknowledgement as some sort of reassurance. Suddenly she said, "I have to show you a picture of my friend's daughter. I just want you to see her, even if you weren't involved in her care."

The manager said, "She's busy and she is in a hurry."

I told her to take her time I would wait. I would love to see her friend's daughter. She pulled up a photo on Facebook on her phone and showed me. I was totally unprepared for my response. She was incredibly beautiful, and suddenly and surprisingly tangible in a way so much of the tissue I see isn't. I had seen a piece of her heart just the other day. I never get to see the patient. I read and read and read but there is never a human face connected to the tissue. My eyes welled up and I choked back a sob.

The manager told her assistant, in a loving but chiding way, "Look what you did you made her cry!"

I replied, "No, it wasn't you. I am a little emotional about my daughter." I looked the assistant straight in the eyes as mine were trying to clear of tears. "Thank you."

Online Mothering Mentor

Her name is Catherine Newman.

I've only commented on her blog once or twice.

I found her when I was pregnant with Cecelia, and she was pregnant with her daughter Birdy. That was 12 years ago.

I followed her weekly "blog" on babycenter.com before blogs even existed.

I read her book, even though I didn't need to because I read all those posts.

I followed her when she left to start her own blog.

She now writes on Dalai Mama, among other things.

She is a fantastic cook. She posts recipes, and when I try them once or twice a year when I have time they are fantastic.

Her crack broccoli is a fave go to at my house for a veggie on a school night. Her fried eggs with sizzling vinegar is one of my most beloved dishes.

I occasionally read what she is reading. Buy the games she is playing with her family. Recommend them to my friends.

I am still catching up on blogs from when I did not have internet on vacation last week. Catherine has been writing articles for New York Times on Motherlode over the last year or so. I read one today that brought me to my knees. It's not the first of her articles to do this to me.

That's why I'm writing this post. To share this fantastic article. Give kids your undivided attention - Or no attention at all. I'm taking an evening weekly six week parenting class from a highly experienced social worker based on a book her husband co-wrote - Parenting the Strong-Willed Child.  She trained in urban Atlanta and rural Mississippi and has two grown children. Catherine's article reminds me of what I am learning there to supplement my own awesome but lacking in some areas (aren't we all?) parenting. Strategies to gain control of your relationship to your kids and help them prosper and grow with capability and responsibility and love. I've got fountains of knowledge from this class from both the social worker and other parents despite only being halfway through it.

Thanks for everything Catherine. You don't know me but I love you!! Thanks especially for all the substitute mothering.

Brain Candy

I met Fizzy here years ago, and long ago posted one of her first cartoons on my blog when she spun off this blog to create her own space at The Cartoon Guide to Becoming a Doctor.

I was amazed by this cartoon. It spoke to me about my experience as a resident/mom in such a good way. She made light of the angst and agony that I had recently been through, and made me laugh about it. I was already hooked to her writing here on MiM, but that cartoon drew me in to her blog and made me an avid follower to this day.

She's funny. She's droll. But most of all, she's unrelenting. I have periods in my blogging where I lag and shut down. She never stops. She's like the Energizer bunny of blogging, and her constant wit and presence amaze me. Not just me - she has built up an enormous following of readers that also recognize her talent. I like to secretly pat myself on the back for being one of her first readers. It doesn't surprise me in the least that she has come this far.

I bought her first book (see above) and it sat on my coffee table until I caught my daughter reading it and asking me questions I wasn't ready to explain. Now it's tucked away in the reading cabinet for easy access. And I had the privilege to beta read her first novel - The Devil Wears Scrubs. Do you read brain candy? I do. I don't watch brain candy on TV, but I read it religiously during stressful times in my life. Chic lit - it takes the edge off. The Devil Wears Scrubs is the best kind of chic lit. It draws you back into that horribly abusive space in time of training when you have no control and you are at the mercy of warped personalities. It allows you as a reader, like the viewer of her cartoons, to make lemonade out of lemons. Her razor sharp wit and her sarcasm brings a new element to the genre. She's a pioneer.

If you haven't read her book, you're missing out big time. I hear there's more coming down the pipes. I remember standing in line for hours waiting to see Guns N' Roses at the Memphis Pyramid (I had to pee really bad - good training for OR cases). I remember camping out all night in front of BeenAround Records to get my college boyfriend Metallica tickets (his band not mine). I remember pre-ordering the next Harry Potter book during residency and counting the days until it was released. Here I am again at 40 dying to read Fizzy's next book. I hope there's lots more to come. I can't wait.

*This post was based off of one I wrote last week on my blog.

Rocket Scientist

My daughter Cecelia (11) has never wanted to be a pathologist. She is completely disgusted by what I do. She likes looking under the microscope, but when I showed her the Blood Bank a couple of years ago with refrigerated stocks of blood and she saw an amputated leg (shrouded by a red biohazard plastic bag) one day when we visited the gross room - "What's that Mom?" - she was mortified. She wants to be a rock star. Fine by me. I'm all up for supporting dreams coupled with education.

Jack (8), has always wanted to design video games. But he's also great at math, graduated from struggling to read Skylander captions at the beginning of this school year to hungrily devouring novel series in weeks (Percy Jackson, Hunger Games - I know, but he begged for months and had seen the movies with his dad and sis so I finally gave in), builds lego sets, and loves winding down at night making me and his class Rainbow Loom bracelets. They adorn my wrists and serve as office decorations.

But no pathologist admiration yet. Over the weekend I bought Jack an air blaster gun and he has enjoyed building the flat paper characters into 3D figures to "blast" with the air gun. One he was working on this morning while I fixed lunches had a lab coat. "Mom, you have to take this one to work with you! It's The Evil Pathologist." He wrote it painstakingly and lovingly on the back of the head.

Cecelia chimed in. "Mom, you have to put it with your rocket ship microscope cleaner." So today when I went to work I created a moon scene to show them tonight. The Evil Pathologist, my rocket scope cleaner, some "moon" sand Cecelia made for me years back, and a nice bright Emergen-C background that looks I think a little otherworldly; planet like. C said it just looked like Emergen-C packaging. Oh well.

I don't need my kids to want to do what I do. But I'm happy they finally think it's kinda cool. Confession: I wiped the dust off of the shelf before I took the pic.

Consumer Driven Healthcare - Where is it Going?

After I read Red Humors blog on Open Notes, I struck up a discussion with a radiologist friend. We commiserate over laws and loopholes in laws that cause system abuse. I am so happy that Obama recommended to close the loophole in the Stark Law in his 2015 budget. That loophole has created some rampant abuse.

I worry about and applaud the possible effects of patients being able to read their notes online. We doctors need our own forum to make notes without worrying about hurting our patient's feelings. But patients also need to be able to review the discussion in the doctor's office in their own space, with all of their mental focus. Open Notes seems like a step in the right direction, but not entirely. We need two spaces. One for the patient, and one for the doctor.

When I was in CT, waiting on a specimen from the lung to review, I was telling the radiologist about Red Humor's blog topic. He told me that there is a push to the radiologists for the patient to be able to see their diagnosis online, as soon as it is available, before they have even discussed it with the clinician.

RED FLAG.

I wrote a post here before, called Poker Face. In a nutshell, it was about me accidentally conveying during fellowship a patient's negative diagnosis by delaying my answer too long when being probed directly by the patient. It was an excruciating experience that taught me to use expert words to delay the fact that I knew someone's cancer had returned or was diagnosed or had metastasized. After all, I am just a pathologist. I have no treatment options or good perspective on prognosis and treatment. That is Red Humor's job, not mine.

The radiologist worried, as I do, that all the great tools and information that our oncologists and clinicians have to offer a patient will not be there, in the privacy of their own home, while they are reading the ominous information. He worried aloud that the information might overwhelm them. As he was saying that he mimed a gun to his head. I completely agree.

There is way too much misinformation out there on the internet and you need an educated professional to reassure and guide you through it. I depend on my mechanic to fix my car. I depend on my accountant to do my taxes. As doctors, our patients need to depend on us to pick them up when all seems lost.

Last week the New York Times released a big article allowing patients to look up how much their doctors received from Medicare over the last year. It's telling information, but muddy. We doctors enjoyed googling each other to find out who is getting what. Pathologists are at the bottom of the list. If you consider Medicare reimbursement is about 30% of overall practice (in conjunction with private insurance), the information is not enough. It's a step in the right direction, but like many steps mentioned above, it falls short.

I see the need for change in healthcare. But the problems are multifactorial, and it will take lots of time and energy to fix them. In the meantime, let's try to keep a proper perspective to protect our patients. Let's delve back into the reasons we went into medicine in the first place. To help people, to protect and serve. Don't give them information in the privacy of their own homes that they aren't equipped to deal with, or anything that might hurt their feelings. That's a nasty can of worms that doesn't need to be opened.

Sentinel Lymph Nodes

Sen.ti.nel: A soldier or guard whose job is to stand and keep watch.

I have a close friend who was standing in the shower one day and noticed a lump under her arm. She is in medicine, and despite trying to blow it off she knew what it might herald, and eventually manned (I mean womanned!) up and made herself an appointment with a breast surgeon. Ten years ago she was diagnosed with metastatic breast cancer. She had a mastectomy with lymph node dissection. She had treatment. She got off her meds, had a child at 47. She has a handsome first grader. She is in her early 50's and she looks like a movie star in her late 30's.

I look at a lot of sentinel lymph nodes. Sure, there are other ones besides those in the breast axilla, but they are by far the most routine. The surgeon injects a radioactive tracer attached to blue dye around the tumor and follows the  path to the nodes that the tumor cells would take to locate them. There are a bunch of nodes in the axilla, but chances are if the cancer is not in the sentinel nodes - the guards - then it won't have traveled any farther. There are exceptions to the rule but like most rules the exceptions they are few and far between.

In the gross room we receive the sentinel nodes and our techs do a gross analysis. Lymph nodes are floppy and brown-grey, much the size and consistency of a kidney bean. Massive metastases are grossly obvious - stellate, white hard infiltrates scream positivity, which is easily confirmed by microscopic examination. But many metastases are insidious - not grossly obvious. We do step examination of multiple levels of sentinel lymph nodes (sometimes there are more than one) which can fill a tray or two of slides (20 slides per tray).

When I get a tray or two of sentinel lymph nodes I often wait until I have a cup of coffee to settle down and look at them - it takes time and major focus. The kidney bean shaped node is full of small round blue cells called lymphocytes with reactive germinal center follicles - white round circles dotting the blue landscape. The border contains the sinus of the node - the most likely place (a small space) for occult isolated tumor cells or clusters of cancer to sneak into. If you blink you might miss some. It takes slow and methodical cruising at high power. I occasionally sub at breast conference for my partner who presents at it regularly, and I am continually amazed at the tiny, almost invisible foci my partners unfold. I know how hard it is to really see that. I have great respect for the amount of time and effort it demands to discover it. I know, I do it too, it's part of the job, but it continually amazes me.

These days we routinely use pancytokeratin immunostains to look for small, isolated tumor cells and clusters. While this is a nice adjunct to help us sleep better at night, it is not a safeguard or panacea to allow us to slack on the job of the routine H&E slide. I have seen cancer cells on H&E that are cut away on the special stains. I have seen cancer cells on the special stains that are not on the H&E (this stands for hematoxylin and eosin - the pink and blue Easter egg colors that we use to stain all tissue for examination). It's enough to keep you up on a bad night, wondering what you might have missed.

You would never guess my friend had metastatic breast cancer - I didn't even know for the first few years I knew her - she was diagnosed before I met her. She has shared struggles with treatment side effects but doesn't touch on what I know I would obsess over - fears of leaving behind my children. She is a perfect picture of poise, elegance, and grace. But she has this underlying Tiger Mom thing, an aggressiveness and intensity that I know must have come with what she has faced in life and dealing with the unknown of the future. Sure, we all have unknowns - I could die in a car crash tomorrow but I haven't dealt with nearly as much adversity as she has in my own personal health arena (yet!).

I love the definition of sentinel. The guard. The lymph node that tries to hold it all in check. I can empathize, as I am sure my friend does too. We women in medicine, and mothers too - we are always on constant watch and hyper-vigilance. For our patient's health, and for that of our children. We can't protect our charges from everything, but that doesn't keep us from trying with all of our power and might. It's the best we can do, and it's good enough.

On the Move

A few months ago I bumped into a pulmonologist in the doctor's lounge I enjoy chatting with. She likes to travel, and I enjoy hearing about her latest trip - I like travel too and would much rather sock new car or house or clothes or jewelry money away and spend it all on traveling. As we were finishing up the conversation she cocked her head, looked at me straight in the eye with a slight smile on her face, and said, "I am so jealous of you pathologists. You get to stay put at your microscope. Do all your work at the same hospital. We are running around all day."

I was so shocked I didn't answer her, but as I walked away I thought "What a false impression she has of us!" We run around from hospital to hospital, covering different ORs and radiology rooms in shifts. Maybe not in one day, but certainly up to a fourth or more of the month. Increasingly, outpatient clinics are putting in histology labs, necessitating more travel to do cases - this can demand travel to two or three different places in one day. Furthermore, we dole out lab directorship amongst ourselves, covering the many different labs we service in our overall domain.  This requires weekly or monthly travel to fulfill clinical pathology duties, which are more and more demanding every year with increasing regulations and education requirements. As our designated lab inspector, I travel to different hospitals around the state and outside of it with teams of expert lab technicians as part of our duty to regulatory agencies that certify us as an "approved" laboratory, meaning we hold up to the scrupulous demands that we require of the labs we inspect in return.

This means that I know how to use many different EMR systems and up to four different sign out programs - some of which are hospital based and some of which are internet based. I can access my home computer remotely to juggle work couriered in from different hospitals in attempt to even out the workload amongst all of us, as it changes daily (I do not envy the math that the gross room has to coordinate daily based on workloads at multiple different hospitals and different clinics!). Yes, I am grateful that I am more of an information-gathering voyeur than an interactive participant in the EMR system, for the most part - we do write notes on fine needle aspirates we perform, as well as apheresis procedures. But I think we make up for this on the back end with our individual dictation and report release software. It's ever evolving and more and more confusing as the years progress.

The days of the hospital-based pathologist sitting (hiding) in the office behind a microscope are over, for better or for worse. We are on the move, my dear travel pulmonologist friend - someday I will explain.  In the meantime, envy me with your wrong impression and I will continue to envy your world travels. I'm starting to catch up. Conference in Hawaii in February and Spring Break ski trip last week to Colorado. I'll break the borders as the kids get older. In the meantime, I'm busy enough traveling for work.

Sick Day

The other night, my daughter Cecelia woke me up at 1 a.m.  The day after her 11th birthday. "I'm sick."

She took me into her bathroom. It looked like an emesis crime scene.  Buckets of puke on the toilet lid, leaking into every crook and cranny, spilling over onto the tile. Spattered walls, spattered glass shower barrier. Spots on the ceiling. I wondered briefly if I could leave it for my house cleaner the next day, and laughed at myself.  After settling her into my bed with water and Pepto pills, which she soon tossed elegantly this time into my toilet, I rolled up my sleeves and cleaned. An hour and two paper towel rolls and a carton of bleach wipes later, it was passable.

The next morning I asked her, "Have you ever heard the phrase 'Tossing your cookies?'"

"No Mom, But I can guess what it means."

She had quite a fill on her birthday - cookie cake at lunch and Baskin Robbins Grasshopper Pie after dinner. It had only a vague resemblance of its original splendor as I was mopping it up, pinching my nose against the odor.

I have been reading Generally Medicine's sad and sorry posts about sick children, congratulating myself about my children's overall good health. I must have jinxed myself. Jack threw up all last weekend. He is being treated for Strep, and has just regained his appetite after two weeks.

The upside - Cecelia came to work with me today. Luckily I found a comfy couch for her to rest on day one after the emesis escapade; my parents were in town and willing to help. I did not have the heart to send her to school when my mom went out of town today - she was puke and fever free but still nauseated and only up to clear liquids. So she came to work with me - an embarrassing first. It was a blast.

Luckily I had made it through the busy post-all-nighter (not a fun college one!) day one - overly busy with a lunch presentation to an audience of around 100. I was uncertain if the queasiness in my own stomach before the meeting was butterflies or bug onset. Butterflies, thank goodness, in retrospect.

This day was slower work-wise.  Not easy, but doable. I did not have a toddler, I had an 11 year old, ultimately savvy with her ipad - busily reading and making silent videos with props in my office while I read slides and made diagnoses. I spaced morning and afternoon visits to the gift shop (she had bday money to spend) around needles in radiology and the ED. We had a long blissful lunch. "Mom, I'm so excited to go to the place you eat work at lunch. I've heard you talking about it for years but have never been." Ugh, really? Am I that far removed? Her eating a turkey sandwich, me munching on a salad - both of us talking about the Divergent premiere I am taking her to next weekend. I'm reading the book so I can help her and her friend get dressed up for it. I wondered tonight what I'm going to wear - I'm that excited.

As I was releasing cases and she was packing up her pillows and gift shop loot she started to do this thing she does when fun things are ending. I used to get really frustrated about it. She focuses on the one negative thing in a day of overwhelming fun and positive. She was trying to leave me a secret fun note under my microscope and was getting angry and upset that I saw. I told her that I worry about leaving my microscope light on and obsessively check it as I'm heading out the door - it would not spoil the surprise because I had no idea what the note said. Last weekend my boyfriend and I took her and two friends to the Lego movie and shopping and she kvetched endlessly over not getting to spend enough time in the mattress store because they spent too much time in the shoe store. I think I'm finally getting it. It's just sadness at ending. It's better to empathize than get angry.

I'm going to miss the hell out of her at work tomorrow - I think she's well enough to return to school. I can't wait to see what that note says. And I am kind of looking forward to more sick days with both her and Jack, now that they are old enough that they don't need my constant attention.

Happy 11th birthday and recovery, sweet and wonderful Cecelia.

A Different Perspective

The title for this topic week is change; specifically how becoming a doctor alters one's life.  There is no question of change, only how.  For me, the most profound change is the perspective I have gained from training and experience, which has been both comforting and distressing.  The ultimate goal is to find a balance in the enjoyment of what you do despite the inside look at inherent system and personal flaws that are revealed on that long journey.

As a pathologist in a large group practice, I work intimately with my co-workers sharing tough cases.  As a fresh trainee I had a lot more defenses built up about showing a "stupid" consult.  Over time, as I have become more comfortable and developed relationships with my partners, it has become easier.  Some cases are diagnostically challenging, and just as a clinician doesn't always nail the patient's disease with the first test they order, a first glance at the tissue doesn't always provide clarity into the disease process.  Even though we are all trained to render similar services, we each have our strengths and weaknesses based on training level and personality types, and I am thankful that I do not practice solo because we are so much better as a team.  And I don't mean just us pathologists - I am also thankful that I can open the EMR and get input from radiology, pulmonology, oncology, and all the clinicians or just pick up the phone.  Communication often makes a difficult case crystal clear.

Numerous recent articles are highlighting the drawbacks of our medical system, and having inside perspective makes a lot of it ring true.  "You're Getting Too Much Healthcare" by Jamie Santa Cruz was published in The Atlantic this week and Elizabeth Rosenthal is doing an illuminating series in the New York Times I have been following called "Paying Till It Hurts."  Sure, every system has its positives and negatives, but it's easy to become disillusioned when you get first hand experience navigating the real world and jumping through all the hoops that seem distant from your idealistic image of yourself as a pure patient advocate.  One of the most challenging things I work on is finding value and purpose in the many things I do that help the patient, and not getting too frustrated over the more mundane and nonsensical aspects of medicine that I witness - many of which appear business driven.  Having a rich life outside of work with children, family, relationship, friends, exercise, etc. - all of that helps round out the negatives.  An alternative would be to bail on the system - something I have witnessed a handful or so of my classmates do over the last ten plus years since I have graduated.  They have found happy and fulfilling lives outside of medicine.  I don't think there is a wrong choice; everyone has their own path to follow.  Mine is certainly in constant evolution.

Up to this point in my journey, I have shed a lot of the insecurities of youth but gained insecurities of experience; the latter being much more tolerable and rationally tackled through knowledge and resources.  I have been elated by success and ravaged by missteps.  I have been buoyed by support from this community of women and also retreated from it to nurture myself and my kids.  Change is inevitable when you choose this road.  Although some of it feels reactionary, which can yield cynicism and doubt, the most important changes are those gained from knowledge and experience - lifelong processes - the kind of glacial change that affects your core being.  This kind of change brings a sense of control, purpose, maturity, and peace into your daily challenges and decision making, both inside and outside of the hospital.

Poker Face

As a pathologist, I am one step removed from the patient.  This is comforting for the most part.  I render my diagnosis and another clinician communicates it to the patient.  It is best this way - I have no treatment options in my own doctor toolbox to give meaning to the words I communicate.  I learned this the hard way - in fellowship training.

Once I was doing a fine needle aspiration on a small sub centimeter mass behind a patient's ear.  The patient had a history of melanoma, and they were very anxious.  After I aspirated some cells I looked at them under the microscope.  I had a good sample.  It was pretty obvious, despite needing stains to prove it.  Metastatic melanoma.  I sighed internally and turned around.  The patient asked, "Well, what is it?  Is it melanoma?"  I was nervous, still in training, and I hesitated a second too long.  The patient melted into tears, guessing the answer by my lack of words.  I communicated some soothing words and did not hesitate to ask a nurse to call the oncologist two floors above.  Wisely flaunting routine the doctor arranged to meet the patient immediately to discuss treatment.

I learned from that experience.  Now I tell the patient up front that we won't have results for at least 24 hours, although at least half the time I have a pretty good guess at the results when I triage the sample on site to see if it is good enough material for a final diagnosis.  The clinicians appreciate our discretion, and as I said, it is best overall as we usually need special stains or additional material from a cell block for a definitive diagnosis.  And most importantly, we cannot offer treatment options.  This leaves us and the patient at a huge disadvantage if we jump the gun.  Giving a diagnosis without a next step is mental torture.  I sure wouldn't want to be on the receiving end of that.

As a long time member of the community in the hospital where I practice, I encounter situations, not infrequently, where a family member of a patient will text me or facebook message me and ask if I can look at/triage/let them know when the results are out/ of a biopsy of a family member.  I am always happy to help but at a loss for many reasons I mentioned above, not to mention that to communicate results to someone other than the patient, even a family member, is a major HIPAA violation.  I try to offer support and information but fall short of giving away any information about the actual diagnosis - letting it fall naturally in the clinicians hands to communicate themselves.  I know this is for the best, and appropriate, but when your friends are in need diversion can't help but feel deceitful.  I have actually called clinicians, during working hours, letting them know that my report is out and I have a patient or family member calling me.  The clinicians are always gracious and helpful, despite my natural reticence to add to their workload.  I have usually fielded many calls from them about patients in their office - wanting a preliminary diagnosis or a personal phone call when the final results are out - so I understand it works both ways.  And once the diagnosis is out, I am more than happy to discuss it with a patient.  Although that doesn't happen very often it is a rewarding experience.

Sometimes I wish I was back in college when a poker face was just that.  A poker face.  Texas holdem.  Seven card stud.   I wasn't good at it then, bluffing is not my strong point, but I have developed a fantastic one in my field.  It's a skill I didn't anticipate having to master when I chose pathology.

I'm Nervous, And I Think That's a Good Thing

I've been practicing pathology for about 6 years, after 4 years of medical school and 6 years of training.  Cases that I used to pore and sweat over have become routine.  Sure, there are always cases to challenge your brain, share with your colleagues, or send out for expert consultation, but after 6 years I have cruised into a "more comfortable" zone.  I can triage efficiently, and getting called to radiology for wet preps or to the OR for frozen sections is no longer a paralyzing experience (for the most part).  The wall I built around myself, the mask of confidence hiding insecurity, has slowly come down.  I can relax and banter with my colleagues while deciding if there is cancer on the slide or not.  I think this is true of all pathologists that are a few years in - I laugh when I think back to what I agonized over during my first two years in private practice.

Last year the partner in charge of CAP (College of American Pathology) lab inspections retired.  I volunteered to take his place, as a team leader.  We are in charge of lab inspections for three hospitals - every two years each hospital assembles a team to lead an inspection.  I did my first one last November - whew it was a blur.  I had a veteran compliance officer leading me through.  "Even a blind pig can find an acorn every once in a while," I kept thinking as I went through that inspection.  I was prepared, but shell shocked by the strange experience.  This time she is on vacation.  I am in charge.  Luckily I am leading a brilliant, experienced team that will make my job much easier.

I became a pathologist to hide behind a microscope.  With a few exceptions, such as being interviewed on TV with the Swine Flu breakout, I've been able to maintain my anonymity.  Lab inspections fly in the face of anonymity.  I interview the hospital CEO's, the lab directors, the medical Chief's of Staff.  The team has specific information to mine and report in a very short amount of time.  We summarize our findings in a large room at the end of the day.  Then we go out to dinner and celebrate a hard day's work.  That's the part I'm looking forward to.

I find, as I am preparing for this inspection, that I am grateful for new challenges and experiences to shake me up. It's what got me here in the first place, but it's easy to forget when it becomes, all too soon, remote.  And as the butterflies circle in my stomach as I am going to sleep, I wonder and hope that my fellow MiM's also have new experiences to keep them from banality and boredom.  They must.  It's a part of the job description.

So if you are reading this today, wish me silent luck.  I'm inspecting.

Birthday Party Beef

Since when did birthday parties become glorified babysitting?

My son celebrated his 8th last month.  I invited his class (18).  One mother stayed.  Luckily I had enough family to help control the kids.  One mom dropped off three children - I realized in retrospect that her son was in another class and hadn't even been invited!

I was complaining to my partner, who always throws big parties.  He once decorated his entire backyard in the theme for CandyLand.  Last year he switched his kids to my school.  He told me that he had one birthday party for his daughter, she is in the second grade, and it was such a disaster he will never do it again.  He invited all the classes - 50 kids in all, and got 40 drop offs.  One mother stayed for the party.  It was such chaos that it scared and angered him.  One dad came to pick up his child at the end of two hours and was angry when he asked "Where is my child?" and my partner was not able to answer exactly where right off the bat.  "I thought I saw her entering my study a half hour ago but now, who knows?"

We both empathized.  Of course that child was found in a bedroom happily and healthfully, but how can you expect two parents, much less one (I am a single) to manage an entire party for two hours alone?  Is this a cultural thing?  Is it age related?  When my kids were younger, I had big events with bounce houses and arts and crafts booths and all the parents stayed and enjoyed getting to know each other.  I, like my partner, will never host a birthday party again in my own home.

Thoughts?  Experiences?  I think this is insanity.  Am I the crazy one?

Summer Vacation

Last summer I was picking vacation
And I vowed there would be no staycation
I would travel far and wide
To have friends and family by my side
I wasn't going to wallow at home in frustration

The pinnacle choice was tough
What could I do for my kids that would be enough?
I was dissecting an arterial branch
When I decided, "Maybe a dude ranch!"
That would surely get us off of our duffs.

I imagined us astride marvelous steeds
And Mom and Dad reluctantly agreed
So I researched and planned
Thinking of gold being panned
And lots of farm animals to feed.

Last week my plan came to fruition
We embarked on our tour of Colorado nation
With cowboy boots and hats in tow
We were ready to hit the rafts and row
Our way into Yampa River's gestation

Day 1: After only thirty minutes on my steed
He decided to fall to his knees
He rolled over in supplication
I had to scramble to avoid suffocation
Luckily the only casualty was a bruise on my knee.

As the bruise bloomed into its own planet
I vowed, "No more horse for me damn it!"
I biked, kayaked and hiked
While the rest of the family liked
Their horses so much I couldn't stand it.

They walked, they trotted and they loped
They learned how to corral cattle and rope
I smiled from the water and ground
Control I had found
I made peace with my lack of ability to otherwise cope.

Now I'm back in my office at the scope
With guarded but optimistic hope
It's time to pick vacation again
It cannot be a sin
To change course to avoid looking like a dope.

Alaska cruise anyone??  Disney??!!

Alas, Cecelia wants to go back to the dude ranch, "Way better than Disney, mom."  I have to admit I loved Colorado in the summertime - wildflowers and Aspens with fluttering leaves that looked like a million chartreuse bug wings in the wind.  Luckily there is plenty to do that does not involve large animals with minds of their own.  Good vacations inspire cheesy poetry.  And they generate lovely pics.

Moments When Mothering and Medicine Don't Mix

This post was inspired by one I just read from Genmedmom, on her own blog.  It is called Falling off the Work/Life Balance Beam, you can read it here.  I was oozing empathy, after all, she is going through this in real time, and it made me remember one of my worst moments.

When Cecelia was 5 and Jack was 3 (or thereabouts), I got a page on clinical pathology call.  It wasn't a good time - I was just telling the kids we had to find a new home for our almost one year old dog Mason.  Long story short he was a bullish German Shepherd that kept getting out of the gate and terrorizing the neighborhood animals.  Even though we were within city limits, there was a family down the road that had a chicken pen with 6 or 7 chickens - I walked down with the children and visited them on occasion.  They are a wonderful family - the wife has a healthy local business.  My family had been celebrating someone's birthday the night before - extended family - and one of the kids announced "Oh look!  Mason's in the back yard playing with a stuffed animal."  It wasn't a stuffed animal.  It was a chicken.  Emphasis on WAS.  That was the last straw.

After a bad first home we placed him with a medical student who was going to be alone for a year in her parent's house while they traveled abroad; she needed a good guard dog/companion.  She wanted one that was house trained.  It was a good fit - Mason did not need to be around small kids, being like a bull in a china shop - I was forever tightly wound if he was in the back yard when my kids were navigating the flagstone steps from the deck to the patio.  He was a sweet dog, but one squirrel sighting and he shot off like a rocket with no heed to anything or one in his path.

So I was telling the kids about Mason, and they started crying, and I got paged.  It wasn't just a, "Here's a critical value and I can't get in touch with the doc could you help me" from the lab page, it was a "we need an emergency plateletpheresis now, they're over a million!" page.  Ugh.  The kids were howling so loud I stepped out on the front porch to listen to the heme/onc tell me the patient history so I could contact the dialysis nurses with the right amounts/formula to get things going while I was getting there.  I called my sis-in-law who agreed to come over and watch the kids while I went in.  Then I turned to the front door to go back inside.  It was locked.

My frantic kids were trying to get to me and accidentally locked the front door.  My heart skipped a couple of beats until I realized I could flip the mail slot and see them, touch them, talk to them.  They were sniffly but ok.  I coached my daughter on how to unlock the door and when we eventually were successful I tumbled in and we all collapsed on the floor in tears.  Mason.  Needing Mommy.  Loss.  We were a big mess.  Sis-in-law walked in thankfully when we were on the downswing, drying our tears, and I announced, "I think milkshakes are in order!" I pulled out the ice cream and was happy to see smiles as I was walking out the door.

I cried all the way to work that evening.  I think I called a friend, hard to remember.  I think I was crying more for my children's loss than my loss - I don't know it was all rolled up together, emotions indistinguishable from one another, muddied and blended.  And I was crying for Mason, even though I knew he needed a better fit.

Good luck Genmedmom, it gets better when they get a little older, or at least easier.  And the moments where mothering and medicine don't mix are just that.  Moments.  Most of it is incredibly awesome.  Although us MiM's have unique challenges, I think I can speak for all of my mom friends, SAHM or mothers not in medicine, to say that all of us have these moments.

Don't Trust Me, I'm a Doctor

Yesterday I got coverage to go to my kid's school to bring birthday treats - they are celebrating Summer birthdays before the end of the year, and Jack turns 8 on June 3.

I stopped at the hospital gift shop on the way out and bought a beautiful balloon, a "double bubble," it had clear plastic surrounding a pretty pink flower with a purple and blue butterfly on top.  The effect, I thought, was breathtaking and I couldn't wait to share it with Jack's class.  I considered sending the treats with him and skipping the class party in the interest of my large workload, but that morning at breakfast Jack asked eagerly but guarded if I thought I could make it so I determined that even if it meant staying late at work, I would.  He was thrilled.

It was raining cats and dogs when I pulled into the school parking lot at 9:35 - designated time was 9:45, so I covered the treats with my yoga mat and darted in the double doors briskly.  I stopped to check in with the secretary.

"I'm just going to bring these treats for Jack's birthday celebration."

"What are they, do they have nuts?"

"Um, I don't think so - we've been eating them for years.  My kids hate nuts, and it's a fave, but I've never asked the bakery.  I got them from Sweet Love - they are called Ninja Turtles.  They are condensed cookie dough around homemade caramel with chocolate drizzled on top, they are amazing."

"Oh, never mind, I think the kid with bad nut allergies is in the other class.  But I'm going to have to ask you to take the balloon to your car.  It's a choking hazard.  I had to turn away a Mom bringing 18 balloons to the class the other day."

I looked at her perplexed.  "I'm so sorry, I had no idea."  She softened.  "Well, if you just bring it for the party, then take it back to your car, I guess it's ok, just the one."

"Oh thank you, I promise I'll do that."

I walked into the classroom with the box of treats.  The teacher introduced me, Jack gave me a hug.  She then said, "Do those have nuts?"

"I don't think so, but I've never asked.  My kids hate nuts."  The teacher pointed to a kid with nut allergies, the first kid that my son was excitedly indulging with treats.  I watched him take a big bite.  Jack finished passing out all the Ninja Turtles, and gave one to his teacher.  The children were munching happily; Jack was on Cloud Nine.

The teacher walked over to me.  "Can I see another one of those?"  I mistook her mood - thinking she loved them so much she wanted another.  She started dissecting the Ninja Turtle.  "I think these have nuts in them.  I got that nut caught in the tooth sensation."  I told her, "I'll call the bakery and find out for sure."  The baker confirmed a small amount of crushed pecans, and I relayed silently to the teacher in alarm.  She walked over to the boy with the allergy.

"I'll need to take you to the nurse."  He protested, saying that nothing was happening, while I reeled in horror but assured her that I would watch the classroom while she left.  I was in scrubs, pager on my hip, wishing I was back in my office at my scope, but worried about the kid.

I was at the helm, and I did well.  Another boy stood up, announcing his nut allergy.  Luckily he had already done this earlier and I watched the teacher artfully blow him off, so I didn't have a heart attack on the spot.  I asked him, "What happens to you when you eat nuts?"

"The tips of my ears turn bright red."

"Well, that is not happening right now, but I'll be sure to be on the lookout for it."  He smiled and sat down.  Most kids were simply alarmed that they had enjoyed a treat that contained hidden nuts.  Jack said, "I've never had any idea that these had nuts!"

I entertained the kids by showing them a picture, one by one at their tables of a wax couple - Queen and King of Hearts, that made Jack laugh so hard the other weekend I thought he was going to explode.  Got similar laughters from the children.  It was fun and calming.

The teacher returned, apologetically.  "I'm sorry it was my fault, I should have checked into it more.  He is in a nut challenge study and is building up his resistance, so this is probably a good test for him.  His nut allergy is not that bad.  It will be OK."  Whew.  I melted with relief inside and resolved to text the mom, who I knew, who was equally relaxed in return texts.  Note to self - No more Ninja Turtles at the school.

The teacher also said, "I can't believe you even came, you're a doctor!"  I embarrassingly replied, "Yes, so you trusted me, about the nuts.  Because I'm a doctor!  That makes it even worse."  She laughed.

As I drove back to work I realized I had left the balloon in the classroom in my tizzy and called the school to tell them.  The secretary said, "Thank you so much for calling.  I'll run get it out of there right away."  I imagined my beautiful balloon as a menacing creature in disguise, exploding into tiny suffocating bits that were about to fly directly into each child's larynx, creating mass chaos and asphyxiation.  I hoped she would get there in time.

It was hard for me to get back to work - the experience was so traumatizing.  I texted my friend about it, "I think they might call me in on the child abuse hotline.  Next birthday I guess I'll just bring a carton of cigarettes and a case of beer.  I've set an awful precedent.  I'm THAT mom."  He and my partners empathized and laughed.  "You're experience is so 2013.  So different from when we were growing up."

I recall back when my kids were 3 and 5, at Montessori School, I had a rare fit of baking resulting in peanut butter balls.  I used the wrong chocolate that melted at room temp.  I proudly brought them to school, freshly refrigerated, only to be turned away with consolation and mild reproach.  "This is a peanut-free school, remember?"  Fail.  It was winter, temps in the 20's and 30's, so I kept the peanut butter balls with chocolate that needed to be refrigerated in my car passenger seat, and ate them all over a week.  You'd have thought I learned my lesson.

I hope to in no way belittle the seriousness of peanut allergies by this post.  It served to remind me of the importance of checking in on ingredients.  We are baking a tres leche cake this weekend for a Spanish project for my daughter Cecelia, and I checked and double checked the ingredients as there is a serious nut allergy kid in her class. But I am a nut hound, and I forget.  If you look in my office food drawer right now you would find almonds, pistachios, and pecans.  I apologize for any perceived but not intended insensitivity and understand the seriousness of the topic, but found the incident today quite amusing, with a luckily happy ending.  Here's to the King and Queen of Hearts.  Who look as alarmed and upset as I did, when I found out about the hidden nuts.

General Practice Pathology

This post is dedicated to an amazing clinician, MomTFH.  You are The Wind Beneath My Wings.

I get frustrated.  At the financial interests that pit private practice general pathology against subspecialty academicians.  It seems to happen a lot more these days than it did in the past.  Some cities get it.  They work in concert. Unfortunately, it is rare.

I have written here before about my brother.  He has an intractable case of Crohn's disease, one that has plagued him his whole life.  He has lost most of his small intestines and all of his colon.  He has been in a coma in the PICU.  He has received many infusion therapies.  He holds a Ph.D. in food science from Cornell, and a degree from the Culinary Institute of America.  He is crazy smart, a leading authority in his field.  He has overcome many health obstacles to get there.

He called me the other day.  "Hey Giz!  Guess what?  I got a family doc.  Not just any family doc, but the golden ticket one.  He works at Harvard, he is a liver specialist, but he loves family medicine so much that he devotes half of his practice to it.  He is incredibly hard to get into, but I got a referral and I got lucky.  I can't wait to get plugged in."

My brother has had a lot of issues with the fragmentation of medicine, as a patient.  He used to thrill in the bypass of the generalist - his insurance allowed him to go straight to the specialist.  And he has had a lot of specialists; derm, infectious disease, gastroenterologists, surgeons.  But now, in his mid to late thirties, he has come to the realization that he needs someone to tie it all together.  He is tired of that being him, the patient - he holds a lot of knowledge in his head but is not a trained physician.  "Giz, they don't talk.  I bounce from one to the other and get great individual therapy in their area of expertise, but communication is poor.  So I end up navigating the system, poorly as a non-clinican, and it is tough.  I'm tired.  I realize what I need is a good family doctor.  I am thrilled to finally have one."

I remember a letter recently on MiM, one from a med student looking for advice.  She clearly said, "family medicine is out - they get no respect."  I think this is a big fail in our current society. They don't get enough respect, but they should.  They should be seen as the glue that holds it together.  The ones that sweat and toil and advocate for their patients.  The ones that tie it all up in a neat knot, so that their dependents, their clients, their patients, can sit back and relax in the knowledge that they are getting good care and someone out there is advocating for them.

I empathize with the family docs because like them, as a general practice pathologist, I do everything.  I inspect labs.  I am the head of microbiology.  I look at GI biopsies every day, alongside breast biopsies.  I get called to the OR to triage unknown cases that end up being rare sarcomas or common cancers, but I don't know what until I get there.  The knowledge base I have built up over the last 7 years in private practice of the entire human being, of all of its tissues, is immense.  And I like to think that by studying everything, by getting to see all aspects of the patient, that I have become a great diagnostician.  Not a specialist by any means, but still.  I have heard the term, "Good at everything, great at nothing."  That sounds derogatory, although I can relate.  But I'll take it a step further.  I'm pretty good at everything.  And I am finally coming to the realization that my knowledge base, although not entirely specific except in my area of expertise, is good enough for what I do on a daily basis.

Global vision: knowing your whole patient, being a pathologist or a family doc, trumps tunnel vision in many ways.  But by saying that it feels that I am slamming subspecialists.  I am not.  We can work in concert, but we are all equally valuable to the patient.  And that's all that really matters here - the patient, I mean.  My brother, and the millions of others out there like him navigating a fragmented health care system.  Our patients deserve our respect.  Family medicine, our glue, deserves our respect.  If I am allowed one wish in my lifetime, I think it would be that family comes back around, and gains back the respect it deserves.  Like me.  A general practice pathologist.  We are all, patients and doctors, in the trenches together working for each other.  That is how it should be.

Imperfection Trumps Perfection

I used to think that being perfect was the ideal.  Now I embrace imperfection.  It all started a few years ago, when I got divorced.  I have written here a little about my divorce before, not wanting to repeat myself, but time and experience brings fresh perspective to the past.

My marriage to my physician ex, my kid's dad, started to go downhill when I was in residency and we started a family.  Neither of us were equipped to have intelligent discussion about it, so we shoved our problems under the rug, I as much as he.  I projected an image to the world, my world - residents and attendings and future job possibilities - that everything was peachy keen.  Turns out the person I was most fooling was myself.  It took a long time and a lot of counseling to admit that; first to myself, then to him, then to our world.

I feared honesty.  Mostly for my kids.  Sure, all marriages struggle, but ours was gasping for air.  My daughter, Cecelia, at age 4 could see it.  "Mom, how come we never do things as a family?  I do things with daddy, and I do things with you.  Aunt Annie and Uncle Dave seem so happy - they touch and hug.  Why don't you and daddy do that?"  Children's words cut to the quick.  There comes a point when you worry that the fantasy you are creating for yourself and those around you is detrimental to your children.  What was I modeling?  Certainly not good relationship.

I recently read a book from one of our guest posters, Melissa Yuan-Innes, called The Most Unfeeling Doctor in the World.  She writes comical and insightful short essays in this one of her many books about medicine.  The essay I am remembering while writing this post describes her desire to switch from a Type A to a Type B personality.  She takes it on, Type A style, both successfully and unsuccessfully.  Which is to say she mostly fails, but in her failure she wins awareness.  We can't really change who we are, but we can damn well try and usually gain something from the effort.  I empathized with her as I read, jokingly (um, half seriously actually) thinking of her as my Canadian twin.

I hike.  I do yoga.  I run.  I read voraciously.  I drink way too much coffee.  I am a single mother.  I am a doctor.  I burn the candle at both ends.  I do the best I can with the Type A personality that was hard-wired from birth.  Everything I attack is Type A - parenting, relationship, and work.  If I find myself with a short block of free time I reflexively fill it with activity, only later reflecting that I might have spent it better sitting on the couch and staring into space.  It's hard for me to unwind.  I can't change that, but I can change how I view outcome.  I am not perfect, no matter how hard I try.  And I'm finally coming to the conclusion that it's all right.

I am the epitome of imperfection.  A few years ago, it would have killed me to admit that.  Now it is freeing.  I am free to embrace my kid's stepmom as a wonderful addition to our lives.  I am free to embrace my true feelings around life situations.  I get mad, I get sad, I get happy.  My children experience this, the messiness of me and my life, whereas before I was a shell of a human being covering up all my emotions.  I think this allows them the freedom to express themselves as well, warts and all.  If I can allow myself to brag on my kids (this is the perfect forum) my daughter is a Duke/TIP scholar in math, an avid late into every night reader, and a creative singer/songwriter who hits the mike running every week at a recording studio.  My son is a math genius (according to his teachers), another avid reader, and carries so much emotional intelligence in the first grade that I get e-mails from his teacher about specific incidences with peers and adults that transform the classroom into a mini-utopia.  But my oh my those siblings can Fight with a capital "F."  And sometimes Cecelia gets into moods that rival the worst teenagers - Ack, at 10 already, who knew?  Sometimes I get ruffled - she is wildly intelligent and preys unconsciously on my weak spots - and yell back.  But we ride it out, and we learn from it.  It makes us closer as a family.

I created all this.  We created this.  The good and the bad.  Me, their dad, their stepmom, all of our extended family and support.  It's not perfect, it's perfectly messy.  But there is something amazing underneath.  Perfection, bah.  Toss it out.  Until you do, you cannot fully embrace life; because life is imperfection.  When you accept that notion, all you Type A MiM's or future MiM's out there - that is when life truly begins.

Most Embarrassing Doctor Moments

I'm a tall girl.  Not an amazon (wish!) but a healthy 5'9.5".  So I like the handicapped toilet better than the regular toilets.  I feel like I am sitting on a regular chair, rather than a child's seat.  Much easier to get up afterwards.

Once, about five years ago, I went to the bathroom at work.  Stopped in a public hallway one on the way to a thyroid needle in another building.  Walked straight back to the handicapped stall and got situated.  All of a sudden I heard someone speak.  "It's ok Mom, just try to hold it.  The stall is occupied.  I am sure they will be out soon.  Sorry for your wait."  I looked down through the gap under the bathroom door and saw wheels.  I was mortified.

I quickly attended to my business, all the while sweating and stressing.  Not only was I an able bodied, ambulatory individual, I also had my doctor's coat on.  I flushed, got dressed, and decided no way in heck could I walk out wearing that coat.  I took it off, rolled it up, and stuffed it underneath my armpit.  Took a deep breath, opened the door, and muttered my apologies as I escaped the bathroom to my needle.

I am still guilty of using the handicapped stall in restaurants, but not until after I have cased the area for those who might need it for reasons other than comfort.  I have not since used the handicapped stall at my hospital, despite never having seen another wheelchair in that particular bathroom in the last five years.

Things Aren't Always As They Seem

I saw a thoracic surgeon in the doctor’s lounge today.  I have read his cases and frozens for a year or so, but never introduced myself.  I still get intimidated in that man’s world of the doctor’s lounge.  It's not just me, my female partner was urged by her male recruiter to eat with him every morning in the lounge when she started seven years ago, and chit chat with the men.  She said although she realized he was trying to be nice, it was excruciating and she bowed out politely after a few weeks.  Walking in there is like walking into an all male club room.  The thoracic surgeon was sitting around the table with a cardiologist, an OB/GYN, a surgeon, and a hospital administrator.  All men I knew individually, but I’m a silent parasite in the lounge, at least during the morning rush.  I breeze in, grab my coffee, smile and wave occasionally, and breeze out.  I wanted to talk to the surgeon about a case, so I waited until he finished regaling an entertaining story about his son’s report on a holiday for school, took a deep breath after grabbing a couple of hard boiled eggs for my lunch in a few hours, and walked over to the table. 

“Hi, I’m Gizabeth Shyder.  I don’t think I’ve met you before.”

A couple of hours earlier I had read a frozen for him.  I called him on the OR bat phone.  Gave him my diagnosis.  “Abnormal lung.”

He countered me sarcastically from the OR.  “Um, abnormal lung?  Is it benign or malignant?  Do you see signs of DAD (Diffuse Alveolar Damage)?”

I took a deep breath.  We use the words Abnormal Lung as a catch all for interstitial lung diseases, which are notoriously difficult to diagnose on frozen section.  Of course I had combed the patient history and knew that cancer wasn't high on his differential.  He wanted more, however.  I gave it to him.

“Well I don’t see any hyaline membranes on frozen section, but they are much easier to see on permanents.  There isn’t much well developed fibrosis in this section.  Or inflammation.  There are a lot of macrophages, I’m wondering about DIP (Desquamative Interstitial Pneumonia).  But that’s not something I would ever diagnose on frozen.  We need to see a lot of tissue to get a good reading on interstitial lung diseases.  I’ll be able to tell you more tomorrow.  I can tell you it is not malignant.  There is no cancer here.”

I think I gained his confidence.  At least his ear.   He replied, “OK, thanks.”  I hung up the phone.

In the lounge, he shook my hand and I struggled briefly to maintain my composure now that I was the center of attention.  I was happy to find that my excitement about the case relaxed my nerves.  “Remember that case we had the other day?  Mediastinal lymph nodes?  The one that was granulomatous inflammation?  All the frozens showed just that, and I reviewed them ad nauseum because you questioned me, thinking there was more, from the OR.  When I got the permanents I found more.  Not on anything you froze, but on your fourth specimen.  D2 to be exact – there were swarms of classic Reed-Sternberg cells.  Not the Owl’s Eye type that's always on the boards, but the mononuclear version.  There were also mummified cells – ones that looked like the nuclei had been squashed by the palm of my hand.  It’s Hodgkin’s.  Hodgkin’s can have granulomas, but I’ve personally never seen them so diffuse and confluent.  They masked the disease entirely in your frozens.  I turfed the case to a lymphoma specialist, and the stains were still pending yesterday, but I’m confident that’s what it is.”

The thoracic surgeon was listening and became energized.  He stood up and walked me to the door – opened it and held it for me.  “I knew there was something more!  Thank goodness it’s lymphoma.  I always tell my patients that’s a much better diagnosis, with a much better prognosis overall, than carcinoma.  Is the report out yet?”

Suddenly I became nervous.  I hadn’t seen the stains, what if my hypothesis hadn’t borne out?  What if it was some sort of rare T-cell lymphoma, with a worse prognosis, that mimics the Hodge (as we affectionately call it)?  I covered up my doubts with confidence.  “I’ll check on it for you.”

Turns out my partner had released the report as Hodgkin’s, just as I suspected, a half hour previous.  Whew.  The surgeon had followed me to the lab and I reported this to him.  We chatted about some other difficult cases he had that week that I had signed out, marveling at the combination of clinical and pathology; patient details he revealed to me matching findings under the scope that I divulged in detail to him.

No matter how far along we get in our careers, it isn’t always easy to handle cases. I’m learning that good communication helps.  Experience and confidence can make a dicey situation more smooth and clear.  But just when you let your confidence allow you to stand up a little too straight, a challenging case will take it down a notch.  This is probably a good thing.  No matter how good we get at diagnosing and treating diseases we will always be reminded that each human is unique and patterns, while helpful, aren't always predictable.  There is a larger design, one that is not in our control, as much as we would like it to be.

The hospital I work at is large.  We no longer have town meetings, we don’t get to know our colleagues easily.  But the extra effort can make a difference.  Now I've got one more person I can speak to informally on the bat phone.  "Hey, this is Giz.  Here's what I see.  Does that fit with what you see?  With the clinical picture?  With what you are thinking?"  The more informal and comfortable we are with our colleagues, the easier and quicker we can diagnose our patients.  There is no room for fear or intimidation in patient care.  Things work best when smart, well-trained people put our heads together to solve the puzzle.  Puzzles aren't single cases necessitating week long work-up, like on TV.  They come hard and fast and in massive daily numbers.  We are all trained intensively over many years to handle it, and we step up to the plate every day.

I got the permanents on the interstitial lung, and was glad I was hedgy on frozen.  With more to look at, without all that nasty frozen artifact, there were loose balls of fibrous tissue filling the alveoli and mild chronic inflammation.  An organizing pneumonia pattern, classically patchy - somewhat nonspecific histology findings that nonetheless direct patient care.  In this case there was a clinical scenario that fit like a glove.  One of the things I love about my specialty is that there is quick satisfaction of closure - 95% of cases are turned around in 24 hours.  99 plus% in 48.  But a first glance, without the clinical and radiographic picture to fill in the gaps, can send you down the tubes if you don't keep an open mind.  Things aren't always as they seem.  A wise clinician holds that thought in the back of his or her mind.