When I tell people I’m a pathologist, their first comment is usually about autopsies. Most people are only exposed to the field through watching forensic pathologists on television – the people who perform autopsies on murder victims. Admittedly, forensic pathology is the most exciting, cocktail party-ready aspect of our job. But it’s not what most pathologists do.
Most pathologists practice surgical pathology, which is diagnosing disease from tissue removed from your body. Perhaps our most important job is diagnosing cancer. Nearly every cancer diagnosis a patient receives was made by a pathologist, though the news is often delivered by an oncologist or surgeon who has read our report. We are called “the doctor’s doctor” for that reason. Ultimately, however, we are the patient’s doctor, and patients should know that they might benefit from talking to their pathologist.
I practice medicine in the U.S., but pathologists in Canada also write similar diagnostic reports. Pathology reports are always sent to other doctors, but they are becoming more accessible to patients as well through electronic medical records. This expanded access is welcome, but these technical reports may be confusing to patients. As I write diagnoses in medical jargon, I often consider how patients may interpret these words.
At first glance, a pathology report may seem like any other laboratory test result. But unlike an automated laboratory test, a pathologist’s cancer diagnosis is an interpretive act in the same way a clinical diagnosis is. We start by reviewing the patient’s history by looking at the medical records and talking to their doctor. We then examine the patient’s tissue. Finally, we make a judgment about the patient’s most likely diagnosis. Much of this interpretive process remains undiscussed in the final written report.
The doctors who receive our reports recognize this, which is why we often field their phone calls or visits. This multi-disciplinary discussion is increasingly recognized as valuable, and formalized “tumour boards” are becoming the standard of care. At these meetings, oncologists, surgeons, pathologists, radiologists, and other doctors meet in one room to discuss a patient’s care together. Yet there is one person conspicuously missing: the patient. I hope that one day, patients will be able to participate more actively in multi-disciplinary care discussions. For now they may wish to reach out to all their doctors – including their pathologist – to get the whole story about their cancer diagnosis.
Consider this situation. A patient goes to the dermatologist because he has an unusual mole on his arm. The dermatologist is concerned this mole may harbor melanoma, and she takes a biopsy to send to the pathologist. The pathology report comes back with bad news: the mole is indeed melanoma. The patient then goes to a regional medical center for treatment. This center, like many others, requires an in-house pathologist to re-evaluate every cancer diagnosis before treatment is given.
The patient is still in shock about this troubling diagnosis, but is thrown further into turmoil when his oncologist tells him that their in-house pathologist examined the biopsy and does not believe it’s melanoma, but rather a benign mole. How could this be? Does he have cancer or not?
In fact, disagreements between pathologists about melanoma can be common, and melanoma is not unique in this regard. Patients are understandably confused in situations like this. Some patients may find it comforting to talk to their pathologists. While understanding treatment options is an important part of dealing with cancer, understanding how their cancer came about and how it was diagnosed are also important to many patients. I have witnessed patients unable to accept their cancer diagnosis until they saw it with their own eyes under the microscope. Pathologists can contribute to the patient’s understanding and acceptance of their disease.
Pathologists sometimes harbor the stereotype that we joined our field because we “don’t like talking to patients.” Doctors choose to specialize in pathology for the same reason they choose to specialize in primary care or surgery: they enjoy the field. Pathologists, like other doctors, completed medical school, which involves extensive training in patient communication.
With that said, scheduling a visit with a pathologist is not as straightforward as scheduling one with your family doctor. Some pathologists and clinicians worry that patients may receive mixed messages about their diagnosis. Others are concerned that pathologists may not be aware of all the clinical history or treatment options available. We will be able to answer questions about our diagnostic process, but will need to defer answering questions that are outside our area of expertise. Not all pathologists may be used to regularly talking to patients, but many are eager to and are working with clinicians to create a welcoming environment for patient questions.
Through modern technology, today’s patient has access to so much information, yet we’re sometimes leaving out the most traditional source of knowledge: talking to your doctor. Some patients may not care to know the details of the diagnostic process, but others will. If you are considering talking to us, you can find the name and contact information of the pathologist who made your diagnosis on their report. You may wish to let your treating doctor know that you are going to talk to us, so we can better coordinate. When facing a challenge such as a cancer diagnosis, knowledge can indeed be powerful.
The comments section is closed.
Rename DCIS “DIN” to help avoid overtreatment of atypia and DCIS https://medicine.yale.edu/profile/fattaneh_tavassoli/
Great article however my brother had three biopsy done in his GI trac. The initial CT scan did not confirm just needed further testing. All the lab work done on that day all lab work out of range was suggestive of cancer. Then they do biopsy four months latter with report done by GI Doctor “authenticated”. I explained to her we were not comfortable with that report never seen one like it, don’t even know who the pathologist was. She explained it was perfectly good report. I told her the problem is that she was not a pathologist and does not truly diagnose cancer. We still have no clue what pathologist did report or see any documentation from one. I ‘m truly amazed ! I feel like my brother has every right to see the report written by pathologist. I’m not sure who to talk to about resolving this issue. I guess I can file compliant with medical board. If you could give your thoughts it would be appreciated.
Nice piece Dr. Mazer. I agree with your assessment and call for pathologists to take an active role informing patients about their disease and treatment options, being mindful of their treating physicians’ roles at the same time. As a Yale Pathology alumnus, best of luck the rest of the way and kudos to your active participation on twitter on this issue.
Hi
Can you tell me when a CD57 NK+ Flow Cytometry test would be useful and what a very low count (below 26) could indicate? Would it be appropriate to have anther CD57 NK+ test a few weeks/months later to ascertain if Treatment is working, and that there may be in increase in these cells during and after treatment.
Thank you
Jane Bailey
Excellent post Mazzer. I love the part that explains that we choose the field because we enjoy it. Sadly many doctors, and worst some pathologist believe that we do not like communicating with patients
Great piece. I would only submit that the statement “…forensic pathology is the most exciting… part of our job” requires a deeper reflection. I find exciting many other aspects of working in Pathology. Pathologists are also researchers, and discoveries made through research create significant excitement, certainly more than the somber environment of autopsy rooms in forensic centers.
The other comment I have is regarding the suggestion made to patients to try to speak with their pathologist, an idea I fully support. However, certain institutions not only do not support that, but even forbid that. Some of our colleagues in the clinical disciplines may feel anxious or even threatened about having their patients talking directly with other doctors providing care (the pathologists, in this case).