"I think [the status of pathology] is better than it was.  A lot better than it was, with the emphasis now being on multidisciplinary teams and trying to collate all the evidence, and with the pathologist always being part of such teams. And it’s often the information that the pathologist provides that is the crucial thing"
David Levison (UK)

  MMore quotes on Relationship with Clinicians

A number of interviews trace the relationship of pathologists with their colleagues and how pathology’s status within the medical establishment has waxed and waned over time.  Although often referred to as “backroom boys”, they have not always worked behind the scenes.  Francisco González-Crussí describes how “in the past…we were called into the operating room, and we had a close rapport with the surgeon.”

When you lose the personal contact you lose something else.  It’s not the same as talking face to face.For a number of reasons, including the advent of new communication technology and increasing pressure on time and budgets, there has been a gradual separation between labs and wards.  Despite the advantages of new technology, González-Crussí feels that “when you lose the personal contact you lose something else.  It’s not the same as talking face to face.”

Another unfortunate effect of this separation is that the general public has virtually no idea that pathologists are, for example, involved in over 70% of diagnoses made in the UK.  This is sometimes a source of frustration.  Commenting on a similar situation in the USA, Juan Rosai says: “If the surgeons were gracious enough to tell the patient, ‘Our pathologist, Dr Smith, has concluded that this is…’ maybe they would at least know that there is a pathologist in the hospital.” 

This invisibility contributes to the misunderstanding of the role of pathologists as ‘doctors of death’, despite the fact that their work is primarily concerned with treating the living.  This misunderstanding is not confined to the general public.  Maesha Deheragoda, talking about her decision to move from paediatrics to pathology, describes the reaction of her colleagues:   “ ‘Oh, you’re going to be a baby killer’... And these were doctors!”

Part of the lack of appreciation of pathology’s role is due to the declining amount of time in the medical curriculum devoted to the subject.  “Pathology was considered to be a factual, science-based subject, much like anatomy, physiology and biochemistry, so that was the target for fact-cutting in many curricula,” says Paola Domizio. 

We've become more important on the clinical teams again.“Because of the down-spiral in pathology education, you've got a whole group of new consultants in their mid thirties, in all aspects of medicine, surgery and what have you, who've never actually seen an autopsy at all,” adds Sebastian Lucas.  It is one reason, he says, why there has been such a decline in requests for autopsies.  There are signs, however, that the pendulum is beginning to swing back towards science in medical education. 

Another positive development is the establishment almost everywhere of multidisciplinary teams.  “We've become more important on the clinical teams again.  If the pathologist isn’t there at one of the meetings it gets recorded.  It's one of the standards by which the multidisciplinary teams are assessed – the presence of a pathologist.”  (Paola Domizio).

Despite occasional frustrations, many people describe good rapport with their clinical colleagues.  Elaine Jaffe, a specialist in lymphomas at a research hospital in the US, comments: “We work closely with the clinicians and I would say they're great people to work with -- they're very interested in the pathology and trying to understand the pathology, particularly because there are always 'strange' patients.”

Key intervieweesSebastian Lucas, Francisco González-Crussí, Paola Domizio

See also: Research versus Clinical Work, History of Pathology

 

QUOTES

Sebastian LucasToday pathologists are a central part of management; we see our clinical colleagues on a weekly basis. I'm going to see all the lung people tomorrow morning. They will know what pathology is because I'll be sitting there right in the middle, reading out the answers. No longer are we invisible... But that wasn't the case 10, 15 years ago when we all did it kind of by post, and by just letters and things. We weren't a face in the team... And so the pathologists really were back-room boys, and often relatively invisible. (There are huge exceptions of course, many famous people who were very much more prominent.) But that would be inconceivable now. We all do multi-disciplinary meetings. In fact they're the bane of our lives!
 - Sebastian Lucas (UK)

James IronsideI think [the use of new technology] helped change this idea that, you know, "Pathology is an art; medicine is an art generally; you look down the microscope and you form a very subjective impression based on how you're feeling at the time." Maybe that is true some days, or was true in the past, but now we have so much more hard evidence. And I think it's using this hard evidence has enhanced the status of pathology.
 - James Ironside (UK)

Miguel Reyes-MúgicaWhat I am trying to say is that medicine is now a practice in which a lot of specialists lose track of [the big picture], and frequently it is only the pathologist that can try to bring all these little loose ends together. I try to do that frequently. And I try to do that even at the biopsy cases, when I work not with dead patients but with living patients, and this is much more important for the patient himself or herself.
 - Miguel Reyes-Múgica (Mexico and USA)

Sebastian LucasWhat we still don't have, and I don't understand why, is the full-hearted support of our clinical colleagues. I'd lay this on the line: we don't have the full-hearted support of our clinical colleagues as absolute equals...We're still treated rather differently, slightly hands-off because we're lab boys, we don't touch the patients so much, specially if we are kind of death-tainted as well, which would apply to me because I do autopsies. 
We'll still have the rather condescending: "We're not going to give you all the clinical details because you can probably work it out from the biopsy yourself, or you should be able to." That still happens, and I do find this very odd.
 - Sebastian Lucas (UK)

It's only really in the last 40 years that diagnostic histopathology has become truly respectable. Prior to that, surgeons would take out breasts and colons and say, "That's cancer", and throw it in the bucket -- not have it confirmed and evaluated for stage and for what you might do next.

 - Sebastian Lucas (UK)

Chris FletcherThere's a sense among clinicians [at the Brigham and Women's Hospital, Boston] that pathology is very important. I think, actually, the concept of surgical pathology -- which is what you're really talking about, diagnostic histopathology -- was partly created in [the USA].  And it was created largely by surgeons, believe it or not, who wanted to have diagnostic answers. 

Pathology was always a research thing, with a [diagnostic] report being a secondary phenomenon, and I wonder if in England that problem was never really addressed.  I mean, there were always these serious academic types that people respected, but maybe somehow the pathologist was never really integrated into the fabric of clinical care in the same way that they are here.  I really don't know…that's a tough question.
 - Christopher Fletcher (UK and USA)

You know, if you’re willing to share uncertainty…I try to teach pathologists to share uncertainty with clinicians, because surgeons, as you know, are pretty dogmatic, and they want to know: ‘Benign or malignant?’  But life isn’t like that, and the more experienced ones know that. The surgeons and oncologists that understand pathology are much better doctors than the ones that don’t, because they have a much more realistic sense of what they’re dealing with, and the uncertainties that exist. 

 - Christopher Fletcher (UK and USA)

David LevisonI think [the status of pathology] is better than it was. A lot better than it was, with the emphasis now being on multi-disciplinary teams and trying to collate all the evidence, and with the pathologist always being part of such teams. And I mean you can’t get away from it, it’s often the information that the pathologist provides that is the crucial thing. Not always. Okay, with imaging techniques coming on as they are at the moment, getting better and better, they can often see the extent of a disease process even better than we can. But they’re still only looking at grey and black and so on….
 - David Levison (UK)

Francisco Gonzáles-CrussíI belong to another era… We were called into the operating room, and we had a close rapport with the surgeon. Sometimes he'd even say: "Look in here. What d'you think this is?" while the patient was being operated on. "Where should I take the biopsy from?" It was beautiful! An experienced pathologist working with an experienced surgeon and having a friendly and harmonious relationship with him is in the best interest of the patient, no? Now, as I say, they have said there was too much waste of time. Pathologists have other things to do. And now…there is a television camera, and the pathologist is maybe half a block away, in another part of the hospital… and you talk to the surgeon by the microphone… I suppose if the camera is very good… it's probably alright. But somehow I think that when you lose the personal contact you lose something else.
 - Francisco Gonzáles-Crussí (Mexico and USA)

Paola DomizioThere's no question that pathologists are the people who make the diagnoses in most cases, and who therefore form the platform on which subsequent management of the patient occurs, and on which prognosis can be given to the patient. So we are a very important part of the multi-disciplinary team, and without us I think the clinical doctors would flounder in a lot of cases.
 - Paola Domizio (UK)

It's gone full circle in a way. Again, it's probably before my time, but pathologists were one of the main specialties in a hospital along with medicine and surgery. Pathologists were really prominent and the professor of pathology was one of the most important doctors in the hospital. Then it changed to being the ‘backroom boys’ and nobody taking any notice of you. Now, the fact that the Cancer Plan has insisted that multi-disciplinary meetings occur for each patient with cancer, we've become more important on the clinical teams again… But that's yet to translate itself into medical education.
 - Paola Domizio (UK)

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