Pushing Glass-The Doctor's Doctor

The Doctor's Doctor

James always remembers the first time he learned that the pathologist is the doctor’s doctor. It is during his third year of medical school during an M and M (Morbidity and Mortality) conference. Most conferences are simply another hour of lecture, a chance to sequester free donuts and coffee. M and M’s are different. It is one of the rare conferences where medical students are never pimped, never questioned incessantly about minute and obscure medical facts. On the contrary, attending physicians are on the interrogation stand and decidedly hate it. The hospital reviews all deaths and complications that occur in the hospital during the previous month. Other hospitals have different names for this conference: Quality Assurance, Tissue Review; whatever the name, it is widely loathed by any attending whose patient is being presented. In essence, the physician is being presented.

James strategically places himself next to the donuts and grabs the protocol outlining the cases that are being presented. He is familiar with some of the cases, since his current rotation is in general surgery. Dr. Ong, the chief of surgery, stepped to the podium, resplendent in a navy blue suit with vanishing pin stripes and a yellow tie decorated with a slightly lighter shade of blue dots. James barely recognizes him sans his surgical scrubs and cap. A surgeon in street clothes is an infrequent, but certainly eye-inviting sight in the hospital. A quick perusal of other surgery attendings finds a fashion display not out of place in the pages of GQ magazine.

“Let’s get started, we’ve got a lot of cases to cover. First case is Luke Santiago, Dr. Chan’s case. This is a 45 year old man admitted for acute cholecystitis. Laparoscopic removal performed without complications. Post-op day 1, he spiked a fever of 102F. Blood cultures grew out Methicillin-resistant Staph, and he was started on Vancomycin. In spite of this coverage, he continued to spike fevers. Chest x-rays revealed an interstitial lung infiltrate. Infectious disease was consulted but further sputum and blood cultures were negative. Wound cultures were also negative and the laparoscopic site was healing well. By day 6, platelet count began drifting lower to 80,000 and hemoglobin dropped to 7.5. Hematology was consulted and subsequent lab workup found increased fibrin split products and elevated LFTs. Their assessment at that point was DIC, probably secondary to sepsis. He was transfused 3 units of packed cells, given FFP and platelets which initially stabilized his values. By day 8, however, he had several episodes of bright red blood per rectum. GI consult was obtained but the patient was considered too unstable for endoscopy. Barium swallow was obtained and the radiologic impression was gastric stress ulcers and probable colon diverticuli. Patient’s condition continued to deteriorate, becoming obtunded by day 10. He died on post-op day 12. Consent for autopsy was obtained by the family. Dr. Chan, you performed the laparoscopic surgery, what was your diagnostic impression at the time you admitted him?”

“It was a straight-forward case.” Dr. Chan began. “He had a two month history of an intermittant low grade right upper quadrant pain that developed into an acute abdomen on the day I admitted him for surgery. Prior ultrasound revealed several gallstones and I presumed this was the contributing factor for the acute cholecystitis. Post-op was uneventful. Frankly, I am mystified by this tragic outcome.”

Dr. Ong nodded. “You saw the patient in your office two months ago, if you had operated on him a month earlier, we may not be discussing this tragic outcome.” Dr. Chan shifts uncomfortably in his chair. “Dr. Santos, you did the ID consult. Why do you think the patient continued to spike fevers in spite of appropriate antibiotic coverage?”

Dr. Santos shakes his head and mumbles inaudibly. Dr. Ong continues, “Did you consider changing antibiotics or consider a viral infection not detected by the cultures?”

“We were at a loss to explain the continued fevers and probable sepsis. Yes, we did consider a viral infection but titers to herpes, CMV, and adenovirus were negative.” Dr. Santos hopes the answer would appease his interrogator.

“And enterovirus titers?” Dr. Ong interjects.

“We did not order enterovirus titers.” Dr. Santos’ expression sank.

“How is that the infectious disease service does not consider enterovirus when three other patients admitted to this hospital over this past month had documented enteroviral infections?” Dr. Ong next turns to Dr. Chen, the hematologist.

“Dr. Chen, by the time you saw the patient, he was in DIC. You managed to stabilize him with transfusions. What are your impressions?”

Dr. Chen is the youngest of the attending physicians and one of the few women. Summoning her courage, she answers in a seemingly prepared statement, “Dr. Ong, I consulted with several colleagues including my mentor with whom I trained in Boston. I regret that we were all stymied by this complicated and disturbing case.” Dr. Chen’s gaze never wavers from Dr. Ong. She braces for the denigrating comments.

“Dr. Chen…I am pleased by your dedication and compulsiveness to the care of this patient. Indeed, this is a complicated case, one for which I, regrettably, have no answer.” It is one of the rare occasions that Dr. Ong is humbled by the complexity of a case.

“As in all our complicated cases, we turn to Dr. Torres, our pathologist, who performed the autopsy.” Dr. Ong smiled as he looked in Dr. Torres’ direction. If hostility was hurled upon his fellow clinicians, it was clear that only praise was lavished upon Dr. Torres, who had earned Dr. Ong’s respect over the years.

Dr. Torres’ flowing white lab coat is neatly buttoned to just reveal a red striped tie. He is in his mid-50’s, medium-build, with a few wrinkles around his eyes, that otherwise betrays a face much younger than his true age. He is mestizo, with a fair complexion and brown hair completing a handsome visage. He carries a slide carousel which he positions on the projector as the lights are dimmed. The first slide reveals a color photograph of the patient’s gallbladder. Dr. Torres speaks in clear and precise tones.

“This 52 gram intact gallbladder revealed an acute cholecystitis but was truly remarkable for the numerous pigment-type gallstones, evidence of a chronic hemolysis. Pigment stones are distinctly unusual, usually seen in patients with a chronic hemolytic anemia indicative of ineffective erythropoiesis, of the type seen in thalassemias or sickle cell patients, not a clinical consideration in this patient.” James marvels at the enormous amount of information Dr. Torres conveys with each sentence.

Dr. Torres continues with photographs from the autopsy. “At autopsy, there were no significant gross abnormalities except for slight hepatosplenomegaly. However, on microscopic examination, nearly every organ exhibited extensive lymphovascular invasion with these pleomorphic cells.” The slides focus on the blood vessels of the lungs and liver, stuffed with the cells that have the characteristic hallmarks of malignancy. “These cells had hyperchromatic and enlarged nuclei with prominent nucleoli. Occasional multinucleated and bizarre tumor cells were present. The clue to the origin of these cells is seen on these next slides…Note, the faint brown pigment apparent in the cytoplasm of some of these cells.” The brown pigment is just faintly visible to those who are in the front row. Nonetheless, the entire audience nods in unison, faithfully believing the description.

“I performed additional immunoperoxidase studies on these tumor cells. Stains for S-100, Vimentin, and Mart-1 decorated all of the cells; they were uniformly negative for cytokeratin and leukocyte common antigen. Lights.” Dr. Torres surveys the befuddled audience and smiles. “This patient had disseminated malignant melanoma!” Dr. Torres, with a dramatic flair, stepped back while the audience visibly gasps. “The pigment stones in the gallbladder were the clue. This patient’s chronic hemolysis was secondary to the widely metastatic melanoma which produced the low grade disseminated intravascular coagulation. This led to a chronic destruction of his red blood cells and consumption of his clotting factors and platelets. This coagulopathy exacerbated his bleeding gastric ulcer. All of his post-operative complications were a direct result of this underlying malignancy. The medical literature documents rare case reports of a metastatic melanoma causing such a devastating outcome.”

Dr. Ong interrupts, “Where was the primary melanoma?”

Dr. Torres smiles confidently. “Once I discovered the cause of death, I returned to the patient and did a Wood’s lamp examination of the skin. Under this ultraviolet examination, I discovered a hypopigmented patch of skin on the patient’s back which I biopsied. This biopsy demonstrated findings consistent with a regressed melanocytic neoplasm, not an uncommon finding in patients with disseminated melanoma. This patient probably had a melanoma in this spot which subsequently metastasized leaving behind this biological calling card.”

The audience sits in awed silence before the compelling dissertation. Dr. Ong returns to the podium and effusively thanks Dr. Torres. “As always, it is the doctor’s doctor, the pathologist, who solves our most complicated problems and teaches us how to become better physicians!”

It is at that moment, the conversion of James occurs. “The doctor’s doctor!” Ringing in his ears like a preacher’s call to the pulpit, James accepts the invitation. None of the other physicians can uncover the real disease process. No denigration or belittlement of clinical judgment will solve the dilemma. Only a keen mind and superb diagnostic skills will suffice. The pathologist, the doctor’s doctor, is the final say. Pathologists are not removed from direct patient care. On the contrary, patient care is directly centered upon the decisions of the pathologist. As the years pass, James will fondly recall this event as “a reconstruction of his soul.”

James is of Chinese ancestry, growing up in the Philippines and a member of the vibrant subculture of Chinese-Filipinos. Stereotyped as businessman and professionals, as a group, they are well-educated and prosperous. They are fiercely loyal to the Chinese-Filipino culture, patronizing each other’s services. The vast majority attend Chinese schools, learning Mandarin. However, the Fukien dialect is readily spoken by the entire group, a direct result of the initial immigrants arriving from the Fukien province in China. In a predominately Catholic country, many Chinese-Filipinos are Protestant. Yet, even amongst them, a liberal acceptance for some of the Catholic traditions interweave with their traditions. James is devoutly religious and since college, increasingly focuses on understanding the Bible and its relevance to his life. Interestingly, James gravitates to Nehemiah as a role model. Even among evangelical Christians, Nehemiah is not a common reference. He was the cupbearer to the Persian King who oversaw the return of the Hebrews to the Holy Land after the Babylonian exile. Nehemiah orchestrated the rebuilding of the Holy City and surrounding wall, by bringing together disparate and hostile groups. His success was a testimony to his steadfast reliance on prayer and God’s word, affording him the skill to succeed. James will never forget the lesson. Here is a man chosen by God, in the right place at the right time. Here is a man, elevated from humble beginnings to lead an emerging nation.

The oldest of six children, James is the son of a well-known oncologic surgeon in Quezon City, a suburb of Manila. He is the only child who follows in his father’s path, pursuing a career in medicine. Like his father, he attends undergraduate and medical school at the prestigious University of the Philippines. Although bright, James is not considered a gifted student. An evaluation by his pre-med college advisor is particularly prescient.

He makes the most of his God-given talents and works very hard to keep up with his more gifted classmates. His attitude is positive and his work ethic strong. His strengths include an expansive global viewpoint, enabling him to perceive connections between disparate subjects. However, he may have an inflated view of himself, envisioning ever greater accomplishments and setting unattainable goals. I worry he may find the fall to reality an uncomfortable descent.

James, if aware of his shortcomings, did not readily acknowledge them, focusing instead on finding his place in the world. It is a manifest destiny, he reminds himself. His thoughts are often peppered with ringing and grandiose expressions, phrases culled from great works of literature and rousing speeches. Indeed, James faithfully keeps a journal recording his thoughts, in the tradition of the great men and scholars who went before him. Someday, these works will document my emergence to greatness, he confidently predicts. Vanity, however, if apparent in his own thoughts, is not evident in his conversations or relationships. On the contrary, James is often viewed as shy and reticent, especially in larger groups. Yet, in smaller groups, his amiable nature is evident and his apparent shyness emerges as an endearing quality.

Although his father never insists, it is expected that James will pursue a professional career in medicine, dentistry, law, or pursue an entrepreneurial business, like his siblings. When James does chose medicine, his father is nonetheless pleased and hopes he will also pursue a career in surgery, studying in America like he did, and returning to join him. Although James does find surgery interesting, the strenuous lifestyle is unappealing. In fact, he is attracted to pediatrics and is preparing his application to several children’s hospitals when his career conversion occurs. To James’ surprise, his father is again quite pleased with his choice, even citing a quotation by Sir William Osler, the father of modern American medicine, that still rings true today, “ As is our pathology so is our practice...what the pathologist thinks today, the physician does tomorrow.” Ironically, James’ father once considered a career in pathology but experienced severe motion sickness when viewing the slides under the microscope. Nonetheless, as part of his training as an oncologic surgeon, there was a mandatory rotation through surgical pathology, an experience he immensely enjoyed. Even today, it is not uncommon for him to consult with the pathologists for guidance with his cancer surgeries. The pathologist guides the surgeon’s hands, he often remarks to his colleagues.

Once James decides upon his career choice, his father’s paternal instincts take over and he contacts the chairman of surgery at St. Louis Memorial Hospital. He and the chairman trained together in oncologic surgery at the Memorial Sloan-Kettering Hospital in New York and still remain good friends. He inquires whether James could pursue a few years of research in his laboratory while he awaits approval for his foreign medical graduate license, a necessary pre-requisite for entry into American residency programs. As a favor to his old friend, the chairman also persuades his counterpart in the department of pathology to “look favorably upon this bright young doctor with a promising future in pathology.” All of this transpires without James’ knowledge. The only clue is his father’s insistence that he apply for a research position with his old friend.

Given the extensive utilization of the microscope by pathologists, it is surprising that James initially loathes the microscope. His first real introduction came in a first year histology course. After spending two fruitless and excruciating hours attempting to identify the different layers of the stomach, James returns home and glibly declares to his father, “Well, I guess I won’t be a pathologist!” James did not lack the necessary skills to become proficient at the microscope, rather it is the lack of seeing the completed picture. James always needs to see the relevance of what he is learning before he will be willing to show an interest. First year of medical school is dedicated to how the body works, with courses in histology, gross anatomy, neuroanatomy, immunology, and biochemistry. It is a year that James finds boring and repetitive, totally disassociated with what he perceives as clinical medicine. Second year of medical school is dedicated to learning how the body goes wrong with courses in microbiology, physical examination and an introduction to clinical medicine, and pathology. As James learns the plethora of diseases, he gains a renewed interest in the earlier courses he so bitterly despises. He also gains an interest in clinical research learning several valuable analytical techniques that will later serve him well in St. Louis.

The two years of research with the chairman of surgery are surprisingly enjoyable, producing several well-received papers and abstracts presented at two national surgery conferences. The chairman is favorably impressed with James’ dedication and attitude and half-heartedly attempts to persuade him to enter surgery. He sometimes chides James saying, “Ah, I see you prefer to deal with your patients in small pieces!” The reality is James did not view pathology as a lack of patient contact so much as a decision to elevate the quality of patient care by improved and accurate diagnosis. He views his role as no less vital than a surgeon removing a diseased organ or a cardiologist inserting a catheter into a diseased coronary artery.

It is arguable whether James would have been able to secure this residency spot by his own efforts. As an undergraduate and medical student, James labored in a cardiovascular research lab publishing a few minor papers. His grades in medical school are good though not the stellar achievements of the other applicants to the pathology program. St. Louis Memorial has a reputation of only accepting graduates of American medical schools and of these, only the very top of their class. James’ acceptance is not a unanimous decision among the attending staff. Indeed, Dr. Irene Haas, one of James' future pathology attendings, vehemently argues for his rejection. A heated debate is finally overridden and decided in James’ favor by the chairman.

James arrival in St. Louis coincides with the worst recruiting year for American pathology training programs. Although numerous reasons abound for the disinterest, critics often cite the lack of positive role models during medical school as a glaring deficiency. Most medical schools have a second year general pathology course usually taught by pathologists, employed by the medical school and engaged in full time research. James’ medical school is no different. The one notable exception is a visit from a community pathologist who brings a fresh placenta and female breast and proceedes to explain how these organs are examined, dissected, and sections taken for histopathologic diagnosis the next day. She is a surgical pathologist, she explains, distinguishing herself, at least in her mind, from the pathologists who teach the course. James, although fascinated by the demonstration, believes her job is an aberration amongst pathologists. He, like the rest of the medical students, is convinced that the pathologists' life revolves around a never-ending stream of autopsies and research, far removed from main-stream medicine.

As Medicare reimbursements continue to decrease, many unfilled pathology programs have training positions removed or face complete closure. Some training programs, in an effort to maintain viability, readily accept foreign medical graduates from the ever-expanding pool of eager applicants. While some foreign graduates, like James, truly desire to pursue a career in pathology, others use pathology as an entry into the American medical system, desirous of later transferring to another more competitive specialty or simply to obtain sufficient post-graduate training to become licensed and practice clinical medicine. These latter residents stain the reputation of pathology and further add to the declining prestige of the specialty.

James is always proud and grateful for his appointment at Memorial. Even before arriving in St. Louis, James is aware of the excellent reputation of the St. Louis Memorial training programs. Memorial is a private, non-profit hospital, unaffiliated with any major medical school. This provides the hospital with a unique mix of physicians possessing superb clinical skills with a gift for teaching and clinical research. What the hospital lacks in prestigious “name” researchers, who can usually bring in additional grant money, but eschew a hospital with no direct academic ties, it is blessed with a well-endowed research foundation, supported by numerous wealthy patrons, all previous patients of the hospital.

There are training programs in nearly every clinical discipline and pathology is one of the best. The pathology residency is renowned for producing well-rounded pathologists capable of admirably performing in any private practice setting. Although the attending pathologists are not as well known as some of their counterparts in academic centers, within the hospital and the mid-West, they are without peer and universally admired and respected.

Until he begins his training program, Dr. Torres remains James’ role model for the doctor’s doctor. Urbane, intelligent, with a flair for melodrama, he exemplifies the relevancy of pathology to medicine like none other. At Memorial, Drs. Haas, Nomura, and Rosenthal were his primary attendings. Each is a gifted and excellent teacher. Yet, it is with Dr. Nomura, perhaps the most reserved of all of them, that James feels an instant kinship. Circumstantially, an outsider may conclude the common shared Asian heritage is the reason. Only to another Asian, would such an association appear ludicrous. In fact, James, as a Chinese-Filipino, has nothing in common with Nomura, a Japanese-American, except for an M.D.