Go behind the scenes with a pathologist [PODCAST]

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“Clinicians want specific things from a pathology consultation. They want a short turnaround time and a clear and coherent report, which can be discussed with the patient and correlates with the clinical findings. Unfortunately, this does not always come to pass, particularly with some smaller or disrupted specimens, resulting from minimally invasive surgery.

It takes a cultural change to reach that balance between what pathology and pathologists are, and what the perception about the field is. Medicine has changed dramatically in recent years regarding disease understanding and test diagnosis. In the past year, pathologists played a crucial part during the COVID-19 pandemic and the laboratory medicine field has taken huge responsibility in our hospitals to support every clinical department. Addressing the pathologist’s role on the patient care team should be addressed in medical school early on.”

Albert Alhatem is a pathology resident.

He shares his story and discusses the KevinMD article, “Is pathology an ATM machine?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Albert Alhatem. He’s a pathology resident, and he co-wrote the KevinMD article “Is pathology an ATM machine?” Albert, welcome to the show.

Albert Alhatem: Thank you. Pleasure to be with you.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Albert Alhatem: Yes. I’m originally from Syria. I finished medical school at Aleppo University and then escaped the war to the U.S. with the hope of becoming a doctor here. When I first arrived, I didn’t know how to speak English, and I didn’t have any resources. I struggled a lot at the beginning, but slowly, slowly, I taught myself English and medical research.

Then I was fortunate to get accepted into the postdoctoral program at Harvard Medical School, where I finished graduate school and a postdoctoral fellowship, followed by another fellowship from Stanford Medical School. Then I was accepted into Rutgers University, where I’m currently finishing my residency in pathology, and soon I will start my fellowship in dermatopathology at Saint Louis University.

Kevin Pho: I don’t have very many pathology residents on my show, so describe to my audience what your pathology training looks like.

Albert Alhatem: Pathology is like radiology. It’s a diagnostic field, and we have two branches, anatomic and clinical. In many programs, pathology is four years of training. If you choose to become just an anatomic or clinical pathologist, you do just three years of training. You basically work in a lab, where you receive specimens to diagnose, to give patients a diagnosis of whether this is a cancer or not.

We are called the doctors of doctors because we deal with doctors all the time. So our job as pathologists is to be the consultant to surgeons or medical physicians who basically operate on patients, in order to diagnose disease.

Kevin Pho: And while you were in medical school, what was the general interest level in pursuing pathology for residency?

Albert Alhatem: Me personally, I was very interested. When I was studying medicine, in third year, I had the chance to work with a pathology resident, and combined with my passion for painting and art, I thought pathology would be a great fit for me, because you get to see pictures all day long. It’s very colorful. Also, you get to think a lot about your diagnosis. So I rotated in the lab, and I basically spent most of my time with the pathology team, and I became very passionate about this field. So when I got the chance to choose a residency, there was no question: It was pathology for sure for me.

However, I noticed that here in the U.S., and also in other parts of the world, pathology is not very popular, because in medicine they don’t focus on pathology while you are in medical school. That’s probably why most medical students don’t think about it much.

Kevin Pho: So let’s talk about the KevinMD article that you co-wrote. It’s titled “Is pathology an ATM machine?” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to co-write it?

Albert Alhatem: Sure. The article is based on a real-life story. I was working late in the hospital on a Friday night, and as I was ready to leave the hospital, a nurse showed up with a specimen for an intraoperative consultation for a liver transplant. The surgical team had flown all the way from a different state to procure the liver for a patient. After my attending and I gave the surgeon the good news that the liver could be transplanted, I didn’t expect that anything would happen afterward. But a few months later, the same surgeon came to our hospital with his patient to thank us. He had traveled a long distance to meet who had made the decision that night that saved his life.

I was honestly humbled and impressed and overwhelmed by his attitude, because not many people appreciate or know what pathologists do. Some clinicians view pathology as an ATM: You put something in, and something spits out. But the more enlightened clinicians view pathologists as consultants and partners. So that’s why I thought to write the article with Dr. Debra Heller, to give your readers some perspective, because I thought this is a very important issue to highlight.

Kevin Pho: You have a platform here. Tell my audience, what are some things about pathology that you want other clinicians to know?

Albert Alhatem: For a start, I would say, like what I wrote in the article, that pathology is not black and white. Most clinicians think that with pathology, they give you a specimen, and based on the specimen you will give them a short, concrete diagnosis that they can understand. However, sometimes the specimen, especially nowadays with minimally invasive surgery, is fragmented and small, and you cannot tell whether this is black or white. Sometimes the diagnosis is in the middle, in the gray zone area, and you try to communicate with your clinician about your diagnosis.

The other thing is communication. Most clinicians, and thankfully here in our place, they come to our lab and they look. Some clinicians sit with us under the microscope and look into the specimen, so when they explain it to the patient, they have some deeper idea about the meaning of the diagnosis.

Pathology is, I think, the basis of medicine, and this is not just my own view. If you read medical history, most of the big discoveries have been made based on pathology knowledge or based on anatomy knowledge. Unfortunately, nowadays, because of medical technology, we forget a lot about these basics. And even nowadays, with all the advances in technology we see in medicine, pathology has contributed a lot to the field of medicine. So because your platform has a lot of readers and viewers, I thought to send the article to this platform, because I knew that it would make an impact on non-pathologists as well as pathology clinicians.

Kevin Pho: Now, what would you say are some of the biggest challenges facing the field of pathology today?

Albert Alhatem: One of the biggest challenges is that people are not interested in the field, starting from medical school. Every year, if you look, for example, into the NRMP data, the matching data, every year there are some spots unfilled in pathology. Even if you look, for example, now, if you go to a website like PathologyOutlines and you look into the fellowships, there are a lot of openings, a lot of unexpected openings, a lot of new openings. Even if you look into jobs, for example, there are a lot of jobs for pathologists. The reason is that I think most medical students and doctors don’t desire to go and work as pathologists.

I think the most challenging thing in terms of our field is the shortage of pathologists in the future. As you know, most clinicians retire at a certain age, so at some point all the people now working in the field will retire, and it will create a gap if we don’t have a supply of a new generation. So I encourage everybody listening to this platform to consider pathology. You don’t have to choose it, but at least explore pathology. If you are a medical student, or if you are a resident in another field, explore pathology, learn about pathology, visit the lab, interact with your pathologist, and know more about what they do. Maybe this will inspire you to become a pathologist, or at least to become a better physician, even if you didn’t become a pathologist.

Kevin Pho: So walk me through a typical day of a general pathologist.

Albert Alhatem: The day for somebody who is in training is different from the day of somebody who is, for example, early career or later career. But most of them share the same kind of goal: Every day they come in with it in mind that they want to make a diagnosis. It’s a diagnostic field. You will be presented with a certain number of cases, and you have to review the history by looking into the medical record, and then we use, as you see in my background, the microscope to make the diagnosis. Some of us see between 10 to 20 cases a day; some of us see 300 cases a day. It depends on the volume of the place you’re working in, and it depends on the specialty. Some cases are easy. Some cases require extra staining or extra tests, like molecular testing or, for example, a special stain. So the case may go on for some more days until we receive those extra tests, and we put everything together, along with the clinical information, to make the diagnosis.

In academia, it is a little bit different, because you have the teaching component. You interact with medical students and residents, so your day also includes teaching. You may also be interested in research or interested in writing. For example, most of the papers I published during the past two years came from real patients. I was looking into a case, and this case was challenging or was rare, and the case proposed an idea for me that became a project. Then I collaborated with some of my attendings and some of the medical students that I worked with here at the university, and we worked on this research project. So your day becomes not just clinical practice or taking care of patients; you teach, and you also do research.

If you are in private practice, it is totally different, because you will be just sitting in your office. Most pathologists work in a group, so you will work with other pathologists in the same office, and you will be diagnosing: looking into the microscope, looking into the patient history, reviewing the radiology or maybe calling the clinician to discuss with them, and then looking under the microscope to look for, for example, specific histologic changes that might make you favor this diagnosis or that diagnosis. And then writing your report.

Kevin Pho: We’re talking to Albert Alhatem. He is a pathology resident, and he co-wrote the KevinMD article “Is pathology an ATM machine?” Albert, if I’m a medical student looking for a potential field, what are some characteristics that would best suit me to become a pathologist?

Albert Alhatem: I would say, first, you have to like to look at images. If you are a visual person and like to see things, I think pathology would be a good fit for you.

Second, pathology is an analytical field. I think medicine in general is analytical, but pathology takes the analysis to an even deeper level, because, as one of my teachers used to say, they give you the window and they ask you where this building is located. So you have to have some sort of three-dimensional analytical mind in order to like pathology.

Third, I would say the real test would be to go and rotate in a pathology lab and interact with pathology residents. It would be better if you rotate in a residency program, so that you see the residents, you see the attendings, you interact with them. And then it’s just basic attitude. Like for surgery: How do you know you like surgery? You go and you rotate in a surgery department, and you feel like, “Oh, I’m part of the club now. Everybody knows me, and everybody interacts with me, and I like to sit in an operating room manually operating on a patient who is asleep.” The same thing you can apply to pathology.

Some people think that we sit all day long under the microscope just looking into slides, which is not true, because we have to have certain criteria or characteristics to be able to communicate with physicians, to be able to talk to physicians, to be able to explain our diagnosis to physicians. So we’re not a bunch of weird people sitting in a room all day looking into our microscopes. We are very social, very active. We like to interact with people. We like to study diseases, as a matter of fact, but we also have basic human characteristics.

So if you are a medical student listening to this conversation, I encourage you first to visit the pathology lab, rotate there for a couple of weeks, and interact with people. Then, after that, see for yourself whether you like to study disease, because pathology, from my own experience, gives you a deeper understanding of medicine and gives you an opportunity to do research on a deeper level, more than just the clinical aspect of the disease: understanding the mechanism, understanding the treatment, how the treatment affects the tissue and the cells, and how we make a difference in the body. It is a very, very interesting field.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Albert Alhatem: Maybe it’s not related to pathology, but I’d like to say something from my own life experience, because when I came here to the U.S., I had many difficulties in terms of achieving my dream of becoming a doctor. I would like to use your platform to send a message of encouragement to all those who may be in unfortunate circumstances, to consider that life is meaningful, and don’t lose hope.

Van Gogh painted 1,700 portraits but sold only one piece, for 85, in his life, and nowadays his work is worth millions of dollars. He unfortunately was a victim of depression, because people did not believe in his work, and consequently he lost hope. Social media unfortunately has led people to work toward pleasing others rather than focusing on becoming the best version of themselves. If only we realize the good that we are doing while doing it, and how our work will impact the lives of the people we serve, we too wouldn’t choose all.

So I would like to thank you and thank your audience for listening to this conversation, and I encourage you, if you are listening to our conversation, to consider pathology for your plans.

Kevin Pho: Well said. Well, thank you so much for your time and insight, and thanks again for being on the show.

Albert Alhatem: My pleasure. Thank you.

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