Onion Skinning

I was at a Halloween party at the kids school on Wednesday, opening sticker packets for a craft.  I noticed a few moms I didn't know, so I wandered over to introduce myself.  It came out that I was a pathologist, and later in the party one of the moms pulled me over to talk in confidence.

"I really hate to bug you about work issues when you are on vacation with your kids.  A significant member of my family was recently diagnosed with probable cancer.  She is incredibly healthy, this is a big shock.  My kids don't know about it yet.  She has had a couple of biopsies, and they can't figure out what it is.  Since you are a pathologist, can you review the slides?  Do you think we need to send it for another consult?  She is in another state being worked up.  We feel so helpless and frustrated!  What do suggest we do?"

I was reminded of a case I had a couple of weeks ago.  Walked into CT - a second biopsy was being attempted on a patient with probable pancreatic cancer.  The radiologist was livid that he did not get the diagnosis on the first attempt.  The biopsy the week previous was called "Atypical."  The tumor marker serum levels were sky high and the radiology was practically diagnostic, but they needed our help to call it and start treatment.  I had a heads up in the morning, and had already reviewed the first biopsy, which was looked at by four pathologists.  It was a tough case.

Sometimes the clinician doesn't get at the heart of the patient's problem the first time the patient presents to the office.  Pathology is the same way.  I don't think people realize this - they think it is all black and white.  We absolutely hate to be wishy-washy, and will often gather our colleagues to try to push the call one way or the other - negative or positive.  I was doing a frozen on a laryngeal biopsy on call a couple of weeks ago.  It was scary and ugly but I couldn't go beyond atypical.  Called a colleague to help and he agreed, so I called the surgeon in the OR and gave him the worst kind of answer - "We don't know."  I was thankful the next day - it turned out to be completely reactive/negative.  It is much easier to look at a piece of tissue that is processed overnight than one that is quickly frozen, sliced and stained for a preliminary answer for the surgeon during the operation.

I told the mom the same story I told the radiologist, in an attempt to assuage their respective fear and anger.  "Sometimes it takes time to get there.  When we have definitive specimen, it is easy.  Once I had a case of a patient with probable lung cancer.  It was exceptionally hard to get the diagnosis.  The pulmonologist did two bronchoscopies with washes and biopsies, and despite seeing the mass, they missed it.  The following week the patient went to CT-guided biopsy twice.  Both times the radiologist missed.  I happened to be on frozen sections the next week, when the patient went to open lung biopsy.  It took the surgeon four frozen sections to get to the bottom of it.  I kept calling it negative, and he was frustrated.  'Giz, I'm standing here staring right at it.  Don't tell me you haven't got good specimen.'  He was speaking to me on the intercom in the OR, I was on the phone by the microscope in the gross room staring at the tissue.  He could see the tumor, as did the pulmonologist and radiologist, but he wasn't grabbing tumor, just reaction around it.  He finally got it on the fourth piece of tissue he sent."  That case was an exception - we can usually diagnose the patient more rapidly.  But sometimes it takes time.

I love the term my partner used once to help me.  She calls it "Evolution of Diagnosis."  I was particularly upset about a muddy specimen.  She said, "Gizabeth, our field requires patience.  It's not always clear from the get go.  It's not a failure on our part if we can't call it right away.  Don't internalize it."  In psychiatry they call this onion skinning.  Peeling the layers away to get to the meat, or the psyche.  The diagnosis.  The answer.  Some onions have thicker skins than others.

I reassured the mom that the doctors would most likely get her family member's diagnosis soon, and gave her my name and number if she had any questions.  Assured her that most pathologists are trained well enough to recognize when they are in their comfort zone, which is 95% of the time, and when they need to send something away to an expert.  I also shared that my kids and I recently lost my mother-in-law, their Nana, to cancer.  Told her about the poem my daughter wrote and read at the funeral.  Empathized about how hard it was for kids to experience loss of that magnitude - mine had to at a much younger age than I ever did.  She thanked me and we served orange ice cream punch.  She and her family are in our thoughts.

The radiologist got good pancreas specimen on his second attempt, and I was able to give a definitive diagnosis to the surgeon the next day so they could cancel the open biopsy and the oncologist could start treatment for the patient.  A lot of times our frustrations and anger, as clinicians and family members, are an expression of the emotion that we have surrounding the stress of getting an answer to alleviate the fear of the unknown for a fellow human being or loved one.  When you can step back and see that objectively, it's a lot easier to let go of it all and focus on the job.  Skinning the onion.  Which is not generally a process that can be performed without burning, stinging and tears.  But the answer is usually well worth the effort.