How Re-Taking the Pathology Boards Ruined My Year

With all due respect to the American Board of Pathology last year sucked.

I am both lucky and unlucky. I only have to re-certify every 10 years (so sad for my 6 year OB/Gyn friends and my 7 year Peds friends). Lucky. I was the first class in pathology - they were a little behind the rest of the specialties - to have to re-take my boards. Unlucky. I could combine my general and subspecialty re-certification into one test. Lucky. I think this whole process is a ridiculous money making scheme like most other doctors in the country. Unlucky.

I started studying in early 2015 on a plane on the way back from a lab inspection. I wanted to take it a year early in case I had to do it again. I was really frustrated that I would have to take it in Tampa - most other specialties could do it at a testing site in their city. I signed up to take a half a week off and fly there in August. My path bro-in-law was going to do it with me, and a friend. We learned early on that there was a study guide online, which made me so happy I took a deep breath and a couple of months off. Path boards are very comprehensive, and while I sailed through the first time, I've never studied so hard for a test in my life.

I geared back up again in the Spring until I got an e-mail from the Board at the beginning of June. They were offering for me to be a part of a pilot program to take the test online. Not in August, but probably in September. I was so excited (no flying to Tampa!) I signed up right away and took a breather. Still, having that test loom over your head is like that kid in Peanuts with the rain cloud over his head, even on a sunny day.

Even with the study guide it wasn't easy. There were three hundred topics. Some of the topics on the general re-cert were so broad - "drugs and their metabolites" and "cerebrovascular disease" - that it left a lot of material to cover (in the case of the latter - it left me wondering what the heck to cover). On the cytology subspecialty exam guide it listed topics like - "thyroid, benign nodules" and "thyroid, malignant neoplasms" - um ok, so pretty much all of thyroid. I took notes during the summer.

It is a lot easier to study for your boards when you are coming out of your residency and you are so stoked to finally be doing what you set out to do and getting a decent salary for it after years (10 in my case) of training. Stuffing tons of minutiae into your head for months is a challenge but hey! You are at the end - so close to the carrot. Ten years later you have the carrot - you are living the life. And it's hard, it's different than what you expected, there are unexpected challenges but if you are like me you also get really excited by what you do and that helps you get through the hard days. Studying ten years into your practice is hard because you know that all that minutiae is at your fingertips whenever you need it and it is so pointless to stuff it all into your head again just to spit it out and get a certificate saying you can continue to do what you are already damn good at doing. But we doctors are mostly type A by the book individuals. So we do it anyway. But it doesn't mean we are happy about it.

August came and went and I got a call from my brother-in-law, who did fly to Tampa in August. I was so jealous of him being done. "You'll do all right, but I'm sure glad I studied." When he found out he passed and elatedly called me in October, I was still waiting to get my two week window to take it online. The computer program they were using was delayed, still working out kinks. The woman in Tampa I corresponded with in frustration was very kind and empathetic, but still. Rain cloud.

October passed into November and we pilot computer people finally got a nice extended window right around the holidays. Again many apologies and an offer to let us take it in March this year because of the delays and inconvenient timing. Hell no. I was getting that monster over with. I downloaded the program with the link - can't remember now why but that process took hours. And I did it on my own mac laptop - no hospital PC would take it. My brother-in-law had a partner taking the same pilot and their group had to buy her a laptop with a camera because she did not have one.

The technology blew me away. I was able to sit at home - they recorded me taking the test and there were all these rules for bathroom breaks and such. I was sitting in the exact same room I am in now typing this blog. I did set up a desk and chair instead of sitting on the couch because it felt more official and I was so nervous. It was nice to be able to have a glass of water next to me, and being at home was a lot easier than being at a testing site. I took it in late November. I felt really good about part of it but not about others. Anyone who has ever felt like they aced a general exam I'm jealous; I always feel like crap after they are over.

Here's another beef and I know I was a pilot but come on ABP 6-8 weeks??!! My friend who took the peds boards re-cert a month before me knew she passed within that week! It's on the computer how hard can it be to grade? I waited over the holidays and finally got an e-mail in mid-January learning that I passed. I was so elated I couldn't get my work done for two hours and had to stay late.

When I look back at last year - skipping weekly lunches with my partner to squeeze studying in, ruined weekends of cramming because I refused to study on vacation or on my time with kids, and overall being more testy in general and pessimistic about life I get really angry at this whole process. I know that pathology is closely following what internal medicine does, and I hear rumors of making this process a lot more palatable (shorter intervals, smaller tests, more related to your current practice), but the nice woman at the ABP who was my phone buddy last year tells me that is years down the road. I hope not ten. I don't think I can do that ever again.

Thanks to my sweet boyfriend and wonderful kids for putting up with me last year. And congratulations to my friend Trishie who found out she passed her MOC boards today (that she took at the beginning of March!) on the way to Disneyworld. She got me thinking and inspired this rant.

Eureka Moment

I was wrapping things up at a rare early 3:30 today and filed my slides. What to do? Attack the pile of journals three months thick sitting in the far left corner of my desk. I flipped through the Journal of Arkansas Medical Society, the latest CAP Today, and the Arkansas State Medical Board newsletter. Picked up the August edition of Archives of Pathology and Laboratory Medicine. Hit an article titled "Smart Phone Microscopic Photography: A Novel Tool for Physicians and Trainees."*

I'm a sucker for the latest tech tools, so I read the easy page article eagerly. I was flabbergasted. I could hold up my iphone to the left eyepiece, steady the camera, and take a microscopic pic? One that rivals my $2K microscope camera that is so complicated I get anxiety whenever I decide to use it? Without an app or anything? Unbelievable.

I practiced the image capture that the article described - they were right the steadying of the phone while taking the pic at just the right moment took a bit of practice but five minutes later I had this:

Which I found in a gallbladder. Just kidding. It's a honeybee mouth. I got it at a local science store a few years back, along with a planaria and an ant and a couple of other fun bugs for the kids to play with under my scope when they came up to the office with me occasionally on the weekends.

I used the zoom function on my phone and got rid of the shadowed vignette, just as the article recommended:

Well it is still framed by iphone bars but I imagine this can be taken care of easily. Note how little energy bars I get in my lab basement. The ease and accessibility of this is astounding. Conferences. Sharing hard cases with co-workers (HIPAA restrictions intact and observed, of course). And as the article mentions, high-quality images suitable for presentations, posters, and publications. With your phone.

I ran around in nerdy glee showing off my newfound skill to my fellow pathologists - all as excited and disbelieving as I was and practicing with varying levels of immediate success. My fraternal rival good friend partner caught on quicker than I did capturing a fantastic picture of the lung pleura he was examining (he crowed that it must be his new workout routine). I copied the article and placed it in everyone's box, and noticed that it was written by a dermpath doc I haven't met who works at the University of Arkansas at Medical Sciences - he is a recent transplant and although I spent a day last week visiting all my former attendings and fellow residents (below me!) who are now attendings I haven't met him yet. I hear he's quite good but dermpath is one area I stay away from so I hesitated outside his door and decided familiarity was more important in my limited time off. I enjoyed chatting with a former co-resident who was just hired as chief of pathology at the VA, as well as many others. Man time flies.

*Smart Phone Microscope Photography. A Novel Tool for Physicians and Trainees. Morrison, A.S. and Gardner, J.M. Archives Pathol Lab Med - Vol 138, August 2014.

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.

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.

Orienting Hemorrhoids?

Last week I was covering our cytology rotation, which can be very demanding.  There are a lot of diagnostic radiology needles.  We are also responsible for junk surgicals, as we nickname them - gallbladders, tonsils, breast reductions, hemorrhoids.  We call them junk because they are easy to look at and sign out, most being very routine cases with only one or two slides.  Occasionally there is a surprise tough case (gangrenous toe chock full of melanoma, for example) but overall they go quick.

One day I had a tray full of hemorrhoids.  They are usually easy cases, normal sign out being "Dilated submucosal vessels, consistent with hemorrhoids."  You have to check out the overlying epithelium to make sure there is no dysplasia, being ever vigilant.  Some breast reductions have carcinoma in situ.  It happens.  Some hemorrhoids have overlying HPV (Human Papillomavirus) changes.  Whenever I have a surprise like this, I generally contact the clinician.

I usually have a hemorrhoid or two, but a whole tray?  I spoke to a friend.  "Either the surgeons are having a blue light special or there is an epidemic of which I am unaware."  I have written of hemorrhoids in the past.  Gangrenous hemorrhoids, to be exact.  I won't rehash that in this post, but you can read about it here, if you want. I thought that was the most interesting hemorrhoid case I would ever see, but then I came across one that was oriented.

Orientation is necessary in pathology for many cancer cases.  Here's a good example.  In all breast excisional biopsies, the techs will ink the margins according to the surgeon's marks.  Sometimes the surgeons use long and short pieces of thread tied to the tissue.  "Long superior, short lateral."  Since a breast biopsy looks like a technicolor version of a lump of scrambled eggs, this is helpful to us in the gross room.  The tech inks the margins according to the surgeon's notes, and describes it to us in their gross description.  "Black anterior, blue lateral/posterior, green medial/posterior,"  for example.  That way, when we see the slide the next day, if the cancer is plowing into a margin, we can see the green ink and note it in our report (invasive carcinoma transected at the medial/posterior margin) so the surgeon can go back and get a clear margin.

But I was very surprised to see a case of oriented hemorrhoids, my first.  There were three different specimens.  The first two were "left hemorrhoid" and "right hemorrhoid."  Left and right hemorrhoids?  Are you the surgeon looking at the person?  Is the person supine or prone?  Or are you the sitting person?  And the third one was the kicker.  "Left posterior hemorrhoid."  Really, posterior?  Aren't all hemorrhoids posterior?

And why does a hemorrhoid need to be oriented?  If you don't get a clear margin on an invasive cancer, sure, you need to know, because it can recur.  But a hemorrhoid transected?  I imagined a transected hemorrhoid, dangerously spreading and growing out a patient's ears.  Ha ha.  Doesn't happen.

So I'm wondering if any surgeons out there can enlighten me.  Or maybe it was the surgeon's joke on me.  In any instance, I enjoyed wondering why on Earth a hemorrhoid needed to be oriented.