Getting Out From Behind the Paraffin Curtain

摘要

In the course of a 30-year practice, I have had the opportunity to track the professional trajectories of more than a few pathologists, from entry level to midcareer and beyond. Patterns of success and failure emerge, so I am compelled to share some of my observations with trainees and newly minted practicing pathologists. It should go without saying that among the first obligations of any physician is mastery of the technical approach to the specialty. This is especially important in pathology, as from day one we are expected to deliver accurate and timely consultations with a very low error rate. I am pleased to say that the cognitive skills of newly trained pathologists have only risen steadily with time, and most all of them pass over that first very high bar with little apparent difficulty. The fractional distillation of careers—from failure, to mediocrity, to excellence—seems to be more a function of other personality traits and practice habits. I can summarize the most desirable of these as an eagerness to get out from behind the paraffin curtain, that zone of comfort at the microscope, where the well-trained pathologist can relax with a cup of coffee and a stack of slide folders. As viewed from behind the curtain, the ideal workday is one in which the biopsies are adequate, the histologic findings pathognomonic, and the diagnoses brief, definitive, and powerful.As we all know, those ideal workdays are infrequent. Biopsies are unrepresentative, histologic findings ambiguous, and important clinical information absent and difficult to obtain. From 23 years of practice in a general community hospital, I am all too familiar with the frustrations that arise in handling those very nontextbook cases. I discovered early on that relief would come only by venturing out from behind the paraffin curtain. I started by spending time with the radiology staff, reviewing images and discussing biopsy strategy prior to the procedure. I also encouraged the gastroenterology staff to call me to the endoscopy suite when they encountered any puzzling or otherwise unusual finding. Additionally, I began to spend time in surgery, reviewing the operative schedule the afternoon before, noting cases that were likely to attract consultation, and appearing in the operating room as the procedure was getting underway. These ministrations outside the laboratory, although time consuming, were eventually rewarded not only with specimens of greater technical quality but with a boost in my own self-confidence as a diagnostician. An unexpected side effect of these adventures was an introduction to hospital politics.Also see p 9.There exists an unfortunate stereotype of the pathologist who eschews human interaction in general and institutional politics in particular. On the contrary, I take heed of Plato's admonition, “The punishment that the wise suffer, who refuse to participate in government, is to live under the government of worse men.” Another way of putting it directly to the reluctant politician is, “You may not be interested in politics, but politics is very interested in you.” I view politics as nothing more than a means by which we seek agreement to elevate the operational and ethical standards of the institutions we serve. The first step in politics is to develop a sense of empathy, a deep understanding of the challenges faced by others. Real empathy requires knowledge, and I have found service on hospital committees to be a good source. Particularly rich in information on how things work outside the laboratory are the proceedings of the utilization review and pharmacy and therapeutics committees. The utilization review committee provides insight into practice patterns, both efficient and wasteful. Service on the pharmacy and therapeutics committee affords a view into the use and misuse of drugs, often an atrophic segment of the pathologist's knowledge base. Both committees have significant impact on the financial well-being of a hospital, and enth