Pathology, the course that separates the physicians from the non-physicians

Our biggest and grandest course during my second year of medical school was Pathology. It was a year-long course that featured a mega-load of the things that physicians would spend the rest of their professional lives, dealing with. Our first semester consisted of Systemic Pathology and covered topics like Infection, Malignancy, Necrosis, Inflammation and Genetic Disorders. Our second semester covered all body systems and their pathology. This flagship course became my favorite because of the veritable “feast” of facts and tools that it would provide for my future practice.

Pathology was taught by a cadre of incredible professors, some of whom are internationally renowned. The single quality that all possessed was an ability to make the student as fascinated with their subject matter as they were. From our first lecture on Shock and Necrosis to our last lecture on The Pathology of the Male Reproductive System, our professors were just great. They came, armed with slides and the stories behind those slides. Many came with summary handouts that allowed review for USMLE (United States Medicial Licensure Exam) Step I, a breeze. I have every pathology handout and note sheet even today. If I need a quick review of every leukemia, they are literally at my fingertips thanks to my pathology professors.

To prepare for this class, I kept a very strict weekly schedule. We had a very thick syllabus that contained all lecture objectives and a very detailed textbook with readings for each lecture. By reviewing the syllabus and reading the test, I was able to sit in class and enjoy the explanations of every slide. I could take a note here and there which enabled me to remember the finer points of the pathology. My daily reading for this class was about 200 pages and my study for each lecture was about 250 pages. It was time-intensive but worth every second.

Along with lecture, we had pathology lab. These labs might be a conference (in the case of post mortem reviews) or might be our twice-weekly tutorial sessions. In our tutorial sessions, we were divided into three labs with each lab containing a pathology professor. The professors would shift but we would stay in our respective labs as assigned. We also had a wonderful gross pathology professor who provided a DVD video of every gross specimen presented for each exam. Those DVDs are golden because I can pop one in my computer and appreciate the fine points of a nutcracker esophagus or polycystic renal disease.

For each lab, we brought our slide boxes and microscopes so that we could follow along with the professor who was using the teaching microscope. These sessions taught us how to examine each pathological condition with the guidance of an excellent pathologist. Not only did we have the laboratory sessions but in between sessions, we could take our slide boxes home for review at home. Every Friday, I brought my microscope home for review of the previous weeks slides. I was also able to borrow additional slides from my professors in the pathology because I loved the study of pathology.

The other thing that I did that I believe made a huge difference in my approach to microscopic pathology, was develop a keen eye for the normal. During first year, I excelled in my histology class so that by second year, I was adept at surveying slides and identifying complex pathology. When I received a slide box, I took it home, got our a roll of lens paper and Windex. I cleaned every slide and arranged them according to lab and lecture. As each week went by, I had my slides clean and ready. I had also reviewed them carefully so that I knew what to look for in lab.

We were tested by microscopic and gross laboratory exam in addition to project and lecture exam. There were three exams for each exam period including the final exam period each semester. It is easy to see why Pathology took a major chunk of our attention during second year. I loved every second of these lectures, labs and conferences. To this end, the chairman of the department invited me (also based on my grades too) to apply for a well-paying Pathology fellowship that I would participate in during the summer between my second and third year.

The “catch” for participating in any second-year summer fellowship was that a student was required to take USMLE Step I, earlier than the rest of the class. I took my exam the second week of May after our classes had ended on April 28. Because I had excelled in Pathology, a solid review was all that I needed for this exam. I was very nicely suprised when I received my scores, at the end of June, that I had done quite well on this exam too. Pathology was indeed, a very good class to love and excell in.

My Pathology Fellowship allowed me to rotate as a medical student through two Offices of Medical Examiners. One of these offices was in a very large city and the other was quite suburban. I worked alongside the Medical Examiners (or a deputy) as we examined crime scenes and performed forensic post mortem exams. We were often asked to identify remains as human or non-human which was one of my favorite tasks.

I also worked the pathology end and performed Bone Marrow Transplants. This consisted of the harvest and infusion of stem cells. In addition I studied granulocyte transfusions and transfusion reactions. My pathologist mentor for Transfusion Medicine had a profound influence on the manner in which I practice medicine today. He was an excellent professor with a wonderful staff who was quite willing to show an eager medical student all aspects of Transfusion Medicine.

I was also required to attend all clinical conferences with the residents. These conferences generally entailed a discussion of the most complex cases that had come in for the week. A pathologist could call a conference within 24 hours if there was a great case. Our GI pathologist was trained at Massachusettes General Hospital and took great pains to make sure that the pathology residents (and me too) approached the complicated cases in a systemic manner. This was great teaching. At conference, we all sat around a table with microscopic viewers while the presentor “drove” the slides. At first, it was difficult to keep up but one of the residents spent an afternoon getting me up to speed. After his tutorial session, I could keep up with the slide driver and learn far more that I thought possible.

The best part of my experience during that summer was securing crime scenes with my mentors in the Medical Examiners office. I would hear news reports about the crime scenes that we had investigated and would often chuckle at how the news media would “get it wrong”. I also went along with the deputy medical examiner had to provide court testimony. This was a good learning experience too. It wasn’t like “Crossing Jordan” because the Medical Examiners office was not involved in the actual detective work. The M.E. provided as much information as could be gathered from the body and crime scene as it involved the body. I learned how these reports are put together and how important scientific observation and experiments are to solving a crime, not to mention, that I know how to “secure” a crime-scene so that valuable evidence is not lost.

As I entered third year, I was strongly considering becoming a pathologist. I certainly had a strong interest in the body of work and my graduate degree was an asset as I was well-versed in designing experiments and making observations. Even today, I always review my surgical pathology slides with the pathologist. All of the pathology residents and pathology attendings know me quite well and joke that I am a “closet” pathologist. I also include my surgical pathology slides in my presentations during Mortality and Morbidity conference (more about that in a later blog).

The study of medicine is unlike the study of any other body of knowledge. It requires an insatiable curiosity and anal perservance to “get it right” every time. There is a mountain of facts and experiences that a medical student must have to become a good physician. I was fortunate enough have some great professors who guided me through the learning process. I was also fortunate to have the energy to spend the hours needed to master my coursework. Pathology took many hours to master and pushed my discipline to the limits. In the end, it was worth every second because Pathology is the single most important pre-clinical course for any medical student. Pathology coupled with the rest of our pre-clinical studies made us physicians. In the end, it was great to see the transformation.

Second Year of Medical School

The second year of medical school was, by far, the most interesting year for me. After learning all of the basic science of normal human processes in the first year, second year presented us with the abnormal. In other words, second year was the didactic exposure to all of the things that we would learn to “treat” and “fix” as physicians. It was also our first introduction to Physical Diagnosis and learning to examine living human beings.

Our major courses during the first semester of second year were Systemic Pathology, Microbiology (Virology) and Pharmacology. Our minor courses were Abnormal Psychiatry and Introduction to Medical Practice. Of these courses, Systemic Pathology was definitely the course that would absorb most of our time. This course was presented by lecture and then laboratory in the afternoon. We were given a huge syllabus, a box of slides (for home study) and a requirement that we attend at least one post-mortem examination. I was hooked on Pathology from the first lecture.

My strategy for Systemic Pathology was to be totally prepared for each lecture. I would read the objectives in the syllabus, read the syllabus and read the text looking very carefully at any of the photos. Next, I would attend lecture, taking notes on the Powerpoint slides as they were presented by the professors. At home, that evening, I would study my syllabus and lecture notes and then preview for the next day’s lecture. I would also carefully review my slides from lab in addition to any notes that I had taken during the lab demonstrations by the professor. It was a totally awesome lab experience.

I observed a post-mortem examination of a young man who had died of testicular cancer. The pathologist performing this exam took great care to explain to me and two other students, why she performed the post morten in the manner that she did. She first examined the body from head to toe, carefully dictating detailed descriptions of any scars or marks that she found. She then, with the help of her assistant, a first-year pathology resident, rolled the body over and repeated the process.

After the external examination, she made a Y-incision where the Y ended at the symphysis pubis. The bones of the chest and abdominal organs were visible at this point. She made note of any fluid in the abdominal cavity and descriptions of the organs in situ. Following these descriptions, she and the assistant, used special cutters to separate the ribs from the sternum and open the chest. She noted a description of any fluid in the chest too.

One by one in a systemic fashion, she removed and weighed each organ while dictating a description of her findings. She also removed tissue samples from each organ that she examined. These tissue samples would be made into slides for the microscopic examination. She then turned her attention to the head, where she peeled back the scalp from the base of the skull and opened the cranial cavity.

With the aid of her assistant, she carefully removed, weighed and examined the brain. A sample of the medulla was taken for microscopic examination later. The brain was carefully placed in a preservative solution so that it could be sliced at a later date. The cranial cavity was closed and the skin sutured in back so that there was no visible appearance of the cranium being opened from the anterior view of the body.

While she finished her dictation, the assistant carefully placed all organs back into the body cavity and sutured it closed. The body was then returned to the morgue cart and morgue for release to the funeral home that had been designated by the young man’s family. We then left the morgue as she explained that she would be reviewing the microscopic slides in 48 hours and that we were welcome to sit in on that review with the Pathology residents.

When we went to the conference, it was remarkable to see how this very invasive cancer had moved throughout the body and had caused death. My knowledge of pathology increased exponentially by attending this post mortum examination and conference. There are many things that can be learned that help in treating every patient, from attending an autopsy. It was far from being disgusting or demeaning to the body being examined. The pathologist and resident treated the patient’s remains with great respect and care.

Microbiology involved learning how microbes participated in disease processes. We reviewed the pathology of every virus and and learned why viral illnesses are very difficult to treat and eradicate. This was quite a change from the Microbiology that we had during first-year where we learned to perform gram stains and identify bacteria from patient specimens. While there was no lab, the details of the replication schemes of every virus and how these led to the pathology of viral disease was very absorbing not to mention the huge volume of information that we were required to learn and assimulate.

Pharmacology was another huge course that demanded much of our time. We started with Autonomic pharmacology and moved to classes of pharmaceuticals. This course layered atop of Biochemistry, Neurophysiology and Physiology. Again, the material was very interesting and added to the tools that we would need to treat our future patients.

Our Psychiatry lectures presented the abnormal for us to examine. Since our Psychiatry professors were in clinical practice, they often brought patients who would explain how their illnesses had affected their lives. There is no experience that can compare to having a patient explain how a disease affects them or participating in an examination with the professor taking the lead. It was great. We also studied topics like sexuality and substance abuse. Needless to say, when the Human Sexuality tapes were broadcast, it was “standing room only” for a seat in the classroom. That was always a running joke with our class. (I will write more about this in a later blog).

Finally, during second semester, were were farmed out to the hospital to learn Physical Diagnosis. Many of us, had already learned to take a very detailed patient history from our first clinical rotations during first year, so our tasks were learning to examine living human beings. We were armed with tuning forks, stethoscopes, diagnostics kits and reflex hammers. It was great to actually learn how to use those tools.

My preceptor was an Endocrinologist. The first thing that you have to know about any Endocrinologist is that they are all very, very smart. My preceptor was able to teach me many fine points of performing a detailed physical exam. He required us to look at the optic fundi of every patient. At first, he said that we might only see the red reflex of the retina, then we would find a vessel. After that, we would learn to follow that vessel back to observe the discs. His motto was: “If you never use your opthalmoscope, you will never learn to use your opthalmoscope”. The learning curve for this instrument is very steep.

Still today, as a surgeon, I am probably the only resident who will perform a optic fundal examination on my patients. In my opinion, I am able to judge the severity of the vascular damage by diabetes etc, in my patients with vascular disease. The retina is a direct observation of the central nervous system. By examining the retina and optic fundi of my patients, I can gather much clinical information. At this point in my career, I am a trained observer and my patients reap the benefits. Not to mention, I enjoy hanging out with my opthalmology friends.

Well, that’s my snapshot of my second year. I will write about some of my specific experiences in later blogs.