The Waiting is the Hardest Part

I may have borrowed that title from a song, whose meaning was entirely different, but the words also hold true when talking about test results.

At our Cytodiagnostic Center, one of our driving principles is to deliver accurate results in real time to our patients, so that they don’t have to wait for a report.

As a pathologist, I can tell you how it usually goes.waiting-room1

You visit your doctor on a Monday. According to a study you recently had, a nodule in your thyroid needs to be biopsied. Your doctor recommends the biopsy and refers you to a radiologist to do it. You call to make the appointment, and the radiologist can’t see you until the following Thursday. The biopsy day arrives and you’ve already been thinking about it for over a week, worried about the procedure and the results that may come from it. You have the biopsy at the radiology practice, but the specimen that the radiologist takes has to be sent out to a laboratory to be processed and read by a pathologist, who will issue the final report with the diagnosis. The specimen will not arrive in the laboratory until Friday, and will be processed over the weekend. On Monday, two weeks after you have seen your doctor, the specimen is on the pathologist’s desk and is ready to be signed out. Because it is a busy day and a lot of work has been processed over the weekend, the pathologist might not get to your specimen that day, and your final report may not be ready until the following day or the day after that. When the final report is issued it will be faxed to your doctor and then you need to come in to discuss the results. You may have to wait another week for an appointment.

How long has this whole process taken? THREE WEEKS! What have you been doing all this time? Worrying, stressed out, thinking you have cancer or something worse (I don’t know what that could be….).

The physiologic affects on your body that are associated with waiting time for a diagnosis were documented in a 2009 study from Harvard published in the journal Radiology. It seems that distress associated with knowledge about biopsy results and lack of knowledge of results is reflected in abnormal salivary cortisol profiles in women who received breast core needle biopsies from a radiologist. Cortisol is part of the family of glucocorticoids, and stress induced imbalances in the secretion of these hormones have been associated with the immune response and impaired wound healing.  In fact, the salivary cortisol profiles of women who have not been informed of their diagnosis by day 5 after their biopsy procedure were abnormal to the extent that they were essentially indistinguishable from the profiles of women who have learned that they have malignant disease.

The bottom line is: the longer you wait, the more stressed out you become, the more impact it has on your overall health and well being.

At our Cytodiagnostic Center, we strive to give you the most accurate diagnosis with the least amount of waiting time. We obtain diagnostic material, process it on site, read it immediately and give you the answer you came for all within one visit. Our final reports are issued within 24 hours, in most cases.

Treatment begins at the time of diagnosis. We know how important those results are to our patients.

The Most Important Doctor You Will Never Meet

Most of the time when I tell people that I am a pathologist, the typical response is: “You do autopsies all the time?” or “I guess your patients don’t talk back because they’re dead, right?”. Maybe pathology gets that reputation because the pathologists most known in popular culture are the pathologists associated with death and forensics. Two examples are Quincy (entirely fictional medical examiner character from the 70’s TV show of the same name) and Jack Kevorkian (the proponent of assisted suicide who went to jail for it). Another example is Michael Baden, a former NYC medical examiner who had a show on HBO for a while.

The truth is, I haven’t performed an autopsy in many years, and most of the pathologists I know haven’t either.

Pathology is an extensive field of medicine. There are two broad categories of pathology: anatomic pathology and clinical pathology. Clinical pathology has to do with blood banking, microbiology, chemistry, molecular pathology, immunology, hematopathology and cytogenetics. Need a blood transfusion? That’s blood banking. Getting blood tests? That’s chemistry. Have an infection, need a blood culture? That’s microbiology.jack-kevorkian

Anatomic pathology covers anything that comes out of the operating room or any tissue or fluid that comes from a person. Anything that can be made into a slide, stained and looked at under a microscope.  Have you had an operation where something was removed? Chances are a pathologist was looking at your specimen and there is a report with your name on it. Have a biopsy by your friendly neighborhood gastroenterologist? He or she sent your tissue to a laboratory where a pathologist looked at it and said you have inflammation or reflux. Have you had cancer? A pathologist was the person who made your diagnosis and set in motion your treatment plan by guiding your oncologist and surgeon. In most cases you will never see the pathologist, but know that the pathologist has thought about you, seen more of you than you may realize, and talked about you with your doctor. As pathologists, we know that every slide represents a patient who is waiting for a diagnosis, and sometimes that diagnosis is life changing.

If you are a patient at our Cytodiagnostic Center for a biopsy, you will see me, a pathologist, who will perform your biopsy procedure and look at your slides under the microscope. After reviewing your slides, you will receive your preliminary diagnosis directly from the pathologist, and you will know what’s going on even before your doctor does. In cases of significant or positive findings, your doctor will be called with the results. Otherwise, final reports are issued usually within 24 hours of the procedure, expediting communication of vital information that directly impacts your treatment, should treatment be required. And you will know why the pathologist is the most important doctor that patients never get to meet.

Once Upon A Breast

You might be wondering why a person would choose this profession. How does one come to the decision that they would like to stick needles into people’s lumps and bumps and look at their cells under a microscope? Well, I have an up close and personal answer for you.

At the end of my second year of pathology residency, I rotated through the pathology department at a community hospital. It was there that I met a cytopathologist who had been classically trained at the Karolinska Institute in Sweden, where he learned the technique of fine needle aspiration biopsy (FNA). It is a specialized technique where the pathologist obtains the FNA sample, prepares the slide, processes it and then renders a diagnosis on the spot. Miraculous!

During my rotation, I had the opportunity to see many patients, many of whom were around my age, women with breast disease, including breast cancer. Feeling a bit anxious, I decided to get a baseline mammogram. One thing led to another and soon I found myself on the exam table getting an ultrasound guided FNA biopsy! Once the sample was obtained, off I went to the lab to stain my slides and review them with my mentor under the microscope. It turned out to be benign (a fibroadenoma), but the relief I felt was indescribable. It was then and there that I decided that I wanted to do the same thing for other patients who have the same fear and anxiety waiting for a biopsy result. I found that I could be a pathologist and have the direct effect on patients that I had always wanted to have since going into medicine. I could be a clinical cytopathologist!

Since that time I have completed my pathology residency, went on to a fellowship at NYU where I was trained by those who taught me in the same Swedish tradition of FNA biopsy. I learned how to perform FNAs, process specimens, provide immediate diagnoses and give patients their diagnoses. I have evaluated over 25,000 FNA specimens, and worked with the best in the field. All the while I have maintained my passion for this field, and never forgotten the reasons why I chose it in the first place.