Pushing Glass-Sign Out

Sign Out

“What’s the diagnosis?” The voice from the other side of the microscope pierces the silence.

“You still don’t see it?”

The silence provides the obvious answer.

“Look! It’s a low-power diagnosis! Even a medical student knows what this is!”

At this point, James would rather be an ignorant medical student than a responsible first year resident. He is now branded with an M.D. and suddenly decisions that were previously forbidden to him are now expected.

“Did you look at these cases?” The shrill voice grows more pressured.

“Yes…” James answers meekly.

“With a microscope?”

The sarcasm squashes any remaining self-respect into oblivion. Dr. Irene Haas violently pushes herself away from the double headed microscope, whirls around from her chair, and marches over to her overarching stuffed bookshelves. Without hesitation, she grabs a textbook, flips through several pages, then slams the tome on the shared table between the two of them.

“Next time, be prepared when you present your cases for sign out! Read about this case and be prepared to tell me by the end of the day what additional studies we should order to confirm the diagnosis.”

This is sign out, the daily routine of the surgical pathologist. It is here that every surgical resection or biopsy receives a diagnosis from a pathologist viewing the tissue slides under the microscope. All therapeutic decisions begin with the sign out.

Dr. Irene Haas is in her mid-40s. Her raven black hair, perfectly in place, frames a still youthful countenance. She consistently dresses in neatly tailored business suits, usually obscured by a lightly starched white lab coat, embroidered with her name over the left breast pocket. She is pretty but a stern face renders her beauty a fleeting vision.

Dr. Haas’ outburst prematurely ends the sign out and James quickly gathers the textbook, the stacks of slides and paperwork, and excuses himself from her office. Leaving the office, he bumps into Dr. Daniel Rosenthal, the chief resident.

“Dragon Lady got you, eh? Those slap marks on your face are quite becoming!”

James reaches for his face as Rosenthal rolled his eyes. “Look, let’s go over some of your cases in my office.”

Dr. Rosenthal’s office is two doors down from Dr. Haas. Not as commodious as hers, it shares the same stuffed bookshelves, filled with journals and textbooks. His desk has a large return, upon which his microscope is placed. Each attending pathologists' office has one double headed microscope. Unlike microscopes utilized by lay people, these scopes have two eyepieces connected by a horizontal metal tube varying from two to three feet in length, supported by a stand. This conveniently allows two pathologists to simultaneously view what is on the microscope stage. Most teaching programs have several multi-headed scopes that accommodate more than a dozen participants. Many of these microscopes also have a video camera attachment allowing a connection to a separate video monitor. In this fashion, an entire roomful of people may also view the microscope slide.

“What you need to do is break your cases down by priority. First, your cancer biopsies should be signed out. Then proceed to the larger resections like breast and colons which are usually removed for cancers. Your last cases are your low priority ones like appendices, gallbladders, fallopian tubes, you know, cases the submitting physician will probably not be immediately calling for results.” Rosenthal quickly shuffles the slides and paperwork to achieve his desired result. “All right! See, you have three core biopsies of the breast, two needle biopsies of prostate, a stomach and colon biopsy, and a lymph node removed for lymphoma. These cases all should receive your immediate attention. The rest of this are gallbags, appys, and bunions. These diagnoses won’t keep anyone up at night!” With a whirl in his chair, Rosenthal turns away from the microscope and proclaimes, “And now, the most important step!” He deftly pulls a CD case from his shelf, pops open the jewel box, and inserts the disc into the CD player. The strains of a jazz guitar fill the room. “My man! Wes Montgomery !”

Signing out with Dan Rosenthal is a lesson not only in diagnostic organization but a comprehensive overview of the history of jazz, particularly jazz guitar. James enjoyed how surgeons operated while listening to various musical genres in the operating room. Rosenthal also desires a musical serenade during his “operation”.

“First case is Clarkson, case number 16805, ultrasound guided core biopsy of the right breast.” Rosenthal places the slide on the microscope stage, turning the magnifying objectives into place. A colorful mix of red and blue tissue, identifiable as breast tissue, appears before both of them. “Approach with low power magnification and decide where the primary pathology is. You’re scanning, deciding whether this is benign or malignant. If it is benign, is it neoplastic or infectious? If it is malignant, what kind of malignancy?"

The slide races under the microscope objectives, features discernible only to another pathologist.

"What did you think about this case?"

"Ductal hyperplasia, no atypia."

Rosenthal listens but does not lift his eyes from the microscope. "Are you sure, anything else?"

James hesitates. "Uh...I don't think so...." his voice trailing to a whisper.

"Don't you think this hyperplasia is a little unusual? Is this patient at risk for developing invasive breast cancer?"

"Could be...umm..."

"Look at the name of the patient." Rosenthal turned the paperwork on the current case so James could see the name.

"Clarkson....Robert....this....is a man!"

"This...is a man!" Rosenthal mocks James' answer. "Yes, men get their breast biopsied! You didn't recognize this was male breast tissue, no lobules. Now, what is the diagnosis?"

A quick succession of diseases of the male breast pass through James' mind.

"Gynecomastia?"

"Gynecomastia...correct."

"Before you decide on the disease process, make sure you know the sex and organ of the slides you are looking at! I'll dictate."

Rosenthal steps on the foot control under his desk, connected to the dictating machine on his desk. "Sections of male breast show scattered ducts lined by bland epithelial cells with a well defined myoepithelial cell layer. Periductal stromal fibrosis with edema surrounds many of the ducts. No calcifications or malignancy is identified. Diagnosis...right breast....needle core biopsy.....gynecomastia. Next case...Tilson, case number 16810..."

Rosenthal's dictation flows effortlessly.

Residents receive their slides early in the morning, usually by 7:30AM. Each slide is labeled with the patient's name, case number, and site of the biopsy. The slides are arranged in numerical order by case number and placed in plastic slide holders, called flats, that accomodate 20 slides. Tucked into each flat are the corresponding paperwork for each case. There are two sheets, the original requisition sheet submitted with the specimen and completed by the physicians' office and the typed gross dictation of the resident who receives the biopsy specimen. The residents job is to review all of the cases before signing out with the Attending pathologist, usually at about 1PM. Any special studies to clarify or confirm the diagnosis should also be ordered before signout. The case load varies but an average day would have about 40-50 cases.

"There....yeah...."

"What?" James' eyes are fixated to the microscope.

"Yeah...complex..."

"I thought it was a hyperplastic polyp...did I miss something...again?"

"Mmmm..." The slide whips by James' eyes. "Laid back...really laying behind the beat!"

"Huh?"

"The music! Listen to that! Only Wes can lay back like that and make it swing! Oh...man!" Rosenthal bobs his head in time to the beat, his eyes closed, lost in the moment.

James never knew what to do in these moments. He isn't a particularly big fan of jazz so he would never be able to have an intelligent conversation with Rosenthal about the music. One had to put up with these musical interludes if one wanted to learn pathology from the chief resident.

"Still gives me goose bumps....yup...hyperplastic polyp."

The cases pass into the evening hours when a growl from James' stomach is heard over the music.

"They got catfish tonight....Mississippi sushi! Let's quit and get some dinner."

James nods and gathers the flats and paperwork. "I'll put these cases on my desk and meet you down there."

The door barely closes behind him when James catches a glimpse of Dr. Haas in her office. His eyes widen as he attempts to walk by without being noticed but at the critical moment, an overhead page blares causing Haas to look up and spy James.

"I've been waiting..."

"I'm ready..." James deftly manuveurs into the office and places the flats on the table next to her microscope. As James peers into the microscope, he catches a glimpse of Dr. Rosenthal flagellating himself.

The sign out begins again.