The Unseen Pathologist: Why You Might Want To Meet Yours

The right smaller circle is normal breast tissue. The left are the donut-shaped glands, with white centers, that are the telltale signs of an invasive breast cancer. (Image courtesy Michael Misialek)

The smaller circle on the right is normal breast tissue. The bigger circle on the left contains the donut-shaped glands, with white centers, that are the telltale signs of an invasive breast cancer. (Image courtesy Michael Misialek)

By Dr. Michael Misialek
Guest contributor

“How much time do I have?” was the first question Mrs. C asked.

She had called me in a panic. Earlier in the week, I had diagnosed her with breast cancer. She called me after learning the bad news from her radiologist. A whirlwind of appointments with oncology, surgery and radiation oncology ensued, overwhelming her with information.

I knew her case — these cells and her pathology — well, having just presented the pathology at our weekly breast cancer conference.

I struggled to reassure her, telling her that treatment has advanced and catching it early was very encouraging.

But there was silence. I envisioned her on the other end of the line, nervous fingers playing with the phone cord. Finally she said, “It would give me great comfort to meet with you since you are a pathologist. I would like to review my slides along with you.”

Dr. Michael Misialek (Courtesy)

Dr. Michael Misialek (Courtesy)

It was an exceedingly rare request by a patient, but one I deeply welcomed.

I am a pathologist. I spend more time studying your cells and developing a diagnosis then your other doctors spend with you. For particularly tough cases, I ask my partners for help, even send images for another opinion to my academic specialist colleagues, who may in turn show them to still more pathologists.

Many eyes have likely seen your cells. Yet, I am often unseen by you, maybe even unknown. But it doesn’t have to be that way. You can request a meeting with me, you can ask — as Mrs. C did — to review your pathology, whatever the diagnosis, benign or malignant. No request is too small.

Will the health care system allow for this? Won’t it resist? My colleagues from other specialties have embraced it. But currently we cannot bill for these patient consults. That’s part of my reason for writing this: We pathologists are advocating to make our consultations with patients billable, like a patient’s consultations with any other specialists. Pathologists are taking on new roles, and the system needs to change to reflect the value of pathology.

My job is not just about diagnosing cancers. Anything that is biopsied, cut out of your body, scraped off, smeared, aspirated, coughed up, excreted or cultured will pass under my microscope.

I discuss treatment plans with every kind of doctor: primary care, surgeons, oncologists, gynecologists, gastroenterologists and more. Pathologists are quarterbacks, calling each play, just as in football.

With nearly 80% of medical care dependent upon lab tests, a care plan can only be developed with this information. This is the world of pathology.

We’re in the midst of great change in medicine. With the information gleaned from sequencing the human genome, we are beginning to unravel the mysteries of cancer and other diseases. Pathologists have been key players in this discovery pipeline. Care can now be individualized. This leads to quicker diagnoses, earlier and more effective treatments and improved outcomes. Buzz words like “personalized healthcare” and “precision medicine” are becoming commonplace.

‘Is this what breast cancer looks like?’ she asked me.

But this genomic revolution comes with a price tag. Most of these tests cost thousands of dollars, which creates a dilemma. The Affordable Care Act asks us to do more with less. There is emphasis on quality care that is both accountable and cost conscious.

So how do we balance the two? I would argue that the answer is pathologists. We help our clinical colleagues choose the right test, for the right patient, at the right time. Choosing the “right” test often begins when the diagnosis is first made.

Sitting with Mrs. C, I adjusted the light of the multi-headed microscope so she could see her cells more clearly. She was silent, but I could sense her anxiety.

“Is this what breast cancer looks like?” she asked me, as her eyes scanned her cells on a slide.

“These are cancer cells that grow as little donuts invading the tissue,” I said, hoping to make meaning out of the sea of cells for her.

A smile of relief lit up her face. “Dr. Misialek, that’s a great analogy.” Her cancer was starting to make sense to her, she said.

That’s exactly what I’m here for as a pathologist.

Mrs. C was undecided between lumpectomy and mastectomy. Seeing the pathology, seeing her cells, enabled her to make the decision. She chose a mastectomy, in fact a bilateral mastectomy.

The XXX microscope used by pathologists like the author.

The multi-lens microscope used by pathologists like the author.

Often when a slide is under my microscope I feel a sense of honor knowing I am the first one to make a diagnosis that will be life-altering. Each slide speaks to me. It is my job to listen.

I imagine the dominoes that will be set in motion when I pick up the phone to report my findings. It is not only bad news. Just the other day I couldn’t wait to report a benign diagnosis of a young woman’s breast biopsy. Her doctor had called me earlier looking for any preliminary information. She said the patient was in tears after the procedure, convinced she had cancer. She did not, and that made my day. A different outcome than Mrs. C., who is starting chemotherapy and radiation soon.

Just recently I received a thank you card in the mail from Mrs. C. She said that having had a tour of our lab, seeing her slides and understanding how a pathologist helped her was the best part of her entire experience. It extended a warmer touch, in a world filled with barcodes, sterile instruments and starched white lab coats.

You might be hesitant to seek out your pathologist. However, with healthcare reform, pathologists are becoming more and more involved with direct patient care. We welcome the opportunity.

What can you do? Ask your doctor who is the pathologist and lab they use. Remember, you can always request a second opinion. Take the opportunity to look at your slides with your pathologist. It will be an enlightening experience. Be your own advocate. And know that if the system resists your efforts to meet with your pathologist, it’s not what your pathologist wants. We want to know you as well as we know your slides.

Readers, questions for Dr. Misialek? Wondering what sorts of requests are appropriate? Please ask in the comments section below.

Dr. Michael Misialek is Associate Chair of Pathology at Newton-Wellesley Hospital and Assistant Clinical Professor of Pathology at Tufts University School of Medicine.

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  • KW

    Thank you so much for sharing this story! I am about to begin studying pathology and this really clarified for me what I would be doing and how much of an effect I will have on people’s lives. What you do seems so interesting, and I can’t wait until I have a chance to go out and help people as well :)

  • Dr. Cap

    Dr. Misialek– gifted pathologists are gold. There is so much nuance and gray zones to wade through. I adore my pathologists, and in my experience they are acutely cognizant of the drastic effect they have on the lives of patients, charting courses of therapy, additional surgeries and the like. If you have a good one (and there are less talented ones, just like surgeons) hang on for dear life!!

    PS. If you know any (good) (breast) pathologists that want to set up shop in CT, please send them my way!

  • Giuliano Stefanello Bublitz

    Hi Dr. Michael MIsialek! I’m a young pathologist from Brazil and here things are not different. Some Doctors don’t know how a pathologist do a diagnosis…. what to say about the patients…. Can I “translate” your text to portuguese and replicate it. Thanks.

    • Michael Misialek

      Thank you for your comments Dr. Bublitz. It is interesting to hear the perspective from other parts of the world. In order to change these misconceptions of our field and raise awareness we need to spread the word. Please share the article via social media. If you translate it, please credit WBUR CommonHealth with the original version and provide a link so that people may log their comments here. I enjoy reading them and replying.

  • gliderpilotjohn

    This was a fascinating article for me. Here in Australia pathologists are seen as ‘back room boffins’. For a patient, there is never any suggestion of an option to have a consultation with them, despite their major role in diagnosis and influence on subsequent treatment decisions. I have felt frustrated on several occasions when I have asked questions or sought to have a conversation with my surgeon about my pathology results. Accessing pathology reports is difficult and, when I do get them, they are frustratingly difficult to understand. From now on, I will seek to have a consultation with the relevant pathologist, although I am convinced that they will be most surprised and may not agree to see me. Also, my health insurer may be reluctant to support me. Nonetheless, I feel that this would help me to understand important aspects of my disease and would help me to make much more informed decisions on treatment. Many thanks for your article.

    • Michael Misialek

      Thank you for your comments gliderpilotjohn. The concept to meet with a pathologist is very new here in the US also. Your frustrations as a patient trying to understand their pathology is shared. As you can see from other pathologists that have posted comments here, we are very eager to engage the public. Please share the story with others. I will be interested to hear your experiences.

  • JK

    I really loved this article. I had my first experience with pathology when my son had a lump removed from his leg this summer. It was benign–as we hoped and were counseled that it most likely would be, but couldn’t be sure until we got the report from “pathology” (which sounded so faraway and impersonal) after the surgery. It is so curious how something so life-changing and significant is relegated to the background in our medical system. Before reading this article, it never even occured to me that I could speak to the actual pathologist who looked at the cells under the microscope. I hope that this is way that things go–I would love to know how to advocate for this We need to create more personal connections in health care, now more than ever.

    • Michael Misialek

      Thank you for your comments JK. I am glad you enjoyed the article. That is great that your son’s lump was benign. There is an entire team at work in the lab behind the scenes not only on cases like your son’s but any tissue or blood sample, culture, etc. that comes from a doctor’s office or hospital. Pathologists are key members of the health care team, whether one knows it or not. As you can see from the comments here by other pathologists, we want you to know us. Please share the article with others. Also, you might be interested in my most recent article here on CommonHealth about HPV. Thank you again.

  • Mari Garcia-Moliner, MD

    Thank you so much for such a thoughtful article- great portrayal of the expanding role of the pathologist and their crucial role as we look at health care reform!

    • Michael Misialek

      Thanks for your comments Dr. Garcia-Moliner. Our roles as pathologists are certainly changing, and based on the comments here from others…it is something we all welcome.

  • AliceH

    Too often we don’t have a choice of pathologist. My breast cancer was misdiagnosed by the first lab. As a result I lost a lymph node along with the lumpectomy. I don’t wish to meet the pathologist who signed off on that one but I’d love to meet the one who got it right post-surgery. No one resommends a lab to a patient. We get whoever the doctors use.

    • Michael Misialek

      Thank you for your comments AliceH. Patients should ask about the pathologists and lab that are used by their doctors. It should be an accredited lab with board certified pathologists that are active participants and closely aligned with the care team. As you can see from the comments by other pathologists, we want to meet you.

  • Michael Gerber

    Great article. I work with 13 pathologists everyday as a Histotech in our Histology lab at KWB Pathology in Tallahasse FL. Alot of people don’t know the behind the scenes testing. It really is amazing!

    • Michael Misialek

      Thank you for your comments Michael. You are right. It really is amazing, and a team effort. We need to raise awareness of our field. Please share the article with others. Thank you.

  • toyeen

    wow, i am amazed by this lovely article and the diligence you have put in responding to all comments. it is a new era in the medical field, i am a trained histoscientist about to be inducted into the profession, looking forward to a great time in the field

    • Michael Misialek

      Thank you Toyeen for your comments. It is a team effort that involves the entire lab. When I have seen patients I will bring them through the lab so that they can appreciate all the work that goes on beind the scenes. Welcome to the field and best of luck in your endeavors!

  • Dr Sanghamitra

    Great article.I am a Pathologist and I am happy that someone has brought forward this issue.

    • Michael Misialek

      Thank you for your comments Dr. Sanghamitra. It is terrific that these feelings are shared with so many pathologists.

  • Napaporn Puripat

    Thank you very much for writting the story that makes me so proud with my career.

    • Michael Misialek

      Thanks for the comments. I am happy you enjoyed the article. Patients certainly do appreciate what we do.

  • Renato Torres

    Dear Dr Mislalek, I’m a brazilian doctor in the first year of anatomic pathology residence and I’m very pleased to know that things are changing and we will become closer to the patients, permiting some interaction, helping them understanding their illness. I really look foward to meet the patients and have the chance to help them get through some difficult times. If you have more articles, please share with us. Congratulations!

    • Michael Misialek

      Thank you Dr. Torres for your comments. It is great to hear that pathologists around the world share these feelings and are taking more active roles in the care team.

  • Guest

    Dear Dr Mislalek, I’m a doctor in the first year of anatomic pathology residence and I’m very pleased to know that things are changing and we will become closer to the patients, permiting some interaction, helping them understanding their illness. I really look foward to meet the patients and have the chance to help them get through some difficult times. If you have more articles, please share with us. Congratulations!

    • Michael Misialek

      Thank you for sharing your thoughts. It is great that these changes are reflective in the training programs as well. We need to foster this new role for pathology.

  • Mukul vij

    Sir this is an inspirational article. As a histopathologist I completely agree with you. I know that how much we care for patients and at times we devote hours to diagnose a lesion correctly as we understand the importance of our report and how it is likely to impact treatment. Thank you Sir.

    • Michael Misialek

      Thank you very much Mukul vij for your comments. I am glad you enjoyed the article. Patients will certainly benefit learning about our passion behind the scenes. It is time they meet us.

  • Dr. Anurag

    I am a resident in Pathology and I loved the article! Great job :)

    • Michael Misialek

      Thank you very much Dr. Anurag! By the comments here, you can see how much pathology impacts patients. It is very inspiring.

  • jan_dy md

    Wonderful article, Dr. Misialek. Only a few people really know what pathologists do. In my experience, the patient or their relatives are more curious in seeing their gross specimen rather than their slides.

    • Michael Misialek

      Thank you jan_dy md for your comments. That is a good point. We welcome patients in all aspects of their workup.

  • Micromom

    I am a pathologist and LOVE the idea of meeting with patients! It is an honor and a huge responsibility I take very seriously knowing what I say on a report will guide treatment. We often have a unspoken gestalt about a case, such as how a tumor may behave based on what is seen on the slide. This gestalt is often not communicated on the path report. And what is reported is filtered, watered down and sometimes overlooked by the treating physician.

    • Michael Misialek

      Thank you micromom for your comments. It is only with full engagement of pathology that the best care can be delivered. I am glad you liked the article and hope everyone spreads the word.

  • joejoe c.

    After a very long, winding journey to what specialization I will go into, this article inspired me to go back to Pathology, continue my training and be the best pathologist so I will be helping other doctors and their patients. A warm thank you would be the best gift, better than anything else.

  • joejoe c.

    I know how it feels, this article made me decide to continue my training in Anatomic and Clinical Pathology. The things that Dr. Misialek felt are the things I want to feel for the rest of my life.

    • Michael Misialek

      Thanks so much joejoe c. for your kind words. It is terrific that the world will see the wonderful talent and compassion that exists in our field.

  • Carolyn Wong

    Dear Dr. Misialek, thank you for the touching article. As a medical technologist, I work with pathologists and fellows all the time so when I was diagnosed with cancer, it was easy to find someone to show me the slides. It gave me a certain confidence to actually see what I needed to fight off. It really made a big difference to me and I am sure it would to many other cancer patients as well. Thanks again.

    • Michael Misialek

      Thanks so much Carolyn for sharing your story! I hope others follow in your steps in seeking out their pathologist.

  • Stephanie Rosen

    Thank you for expressing in words what I have always felt in my heart about being a pathologist. What an honor it is to me to be so intimately involved in the life of another person, even if they never know my name. I can count on one hand the number of patients who have contacted me regarding their pathology. I remember each and every one of them and I have seen how that little bit of communication makes such a difference. Thank you Dr. Misialek for putting this out there!

    • Michael Misialek

      Thank you Dr. Rosen for your comments! It is inspiring that so many pathologists share your feelings, based on the comments here and from others I have received since the story was posted. Likewise, the public is equally interested in meeting us. It is the perfect time for us to come together! We all need to spread the news.

  • Kmbutt

    Very timely ,refreshing and informative. Thank you

    • Michael Misialek

      Thank you for your comments Kmbutt. I am glad you enjoyed the article.

  • Joelle Weaver

    This was incredible. Its about time tat people should have more insight and connection to their pathologists and their support staff.

    • Michael Misialek

      Thank you Joelle for your comments. Pathologists and the entire lab are a crucial part of the care team. You are right…patients and the public need to know this and recognize our value. Please share our message with others.

  • Emily Chenever,MS,PA(AAPA,ASCP

    I really enjoyed your article. It helps me explain my intermediary positions as a Pathologists’ Assistant to my friends and relatives. They understand that I work with the tissue and the slides go to the Pathologist to make the diagnosis. Somehow, the importance of the Anatomic Pathology Lab sometimes slips their mind.

    • Michael Misialek

      Thank you Emily for your comments. As a Pathology Assistant you are a crucial part of the team. When I see patients, I given them a tour of the lab to show how their slides are prepared, and meeting with Pathology Assistants is a must! Thank you for all you do.

  • linda

    That was a great article,,,because we are after all PHYSICIANS,,,,Treaters,,,and it is absolutely a patient right to have a closer view of his own body tissue and cells,,,to get to know what exactly going on in his body,,
    As a Pathologist,,,,I am a dicision maker,,,the decision of the patient fate in treatment modality and to let the patient and his clinician get to know what to expect,,,and how to manage or prevent bad sequences..
    I think this communication between the patient and his pathologist is very important that is it satisfies the patient and us as well ,,,and makes both of us feel important and precious,,important as a pathologist role in caring of his patients…

    • Michael Misialek

      Thank you Linda for your comments. This type of patient interaction is important for raising the visibility of the pathologist and demonstrating our value to patients and the public. As many have said here, it is this TEAM approach that benefits patient care. It is time our contribution to the TEAM is known and advertised for all.

  • Najla

    It is interesting. I spend sometime with few patients discussing their case and giving some advice. I know they feel better when I do. However, sharing the slides with them is the interesting part of your story. But my concerns is do we have the time for that? . Moreover, it sounds that you are suggesting that our offices will become clinics and this means appointment, fees, etc…, and Do you think insurance companies will be willing to cover such a service?

    • Michael Misialek

      Hi Najla. Thank you for your comments. I don’t think we will reach the scale of patient consults to significantly compromise our current workflow, at least in the near future. However, it would be a great problem to have! These types of encounters are not for all patients and likely self selects for those already deeply invested in their care. The value it does bring though is the added understanding patients acquire, and as mentioned several times here, the emphasis on the TEAM approach to care.
      You are correct in that it does require a time investment, and as such should be a reimbursable event.

  • Academic pathologist

    Thanks for this excellent article. As a subspecialized academic pathologist, I am routinely sent slides for second opinion from community practice pathologists and treating physicians and am often specifically asked to make treatment recommendations for unusual diagnoses. In my narrow subspecialty, I have no problem guiding patients toward the best treatment options, if they call or meet with me, though of course the final decision is between the patient and their treating physician. I might make several hundred diagnoses in a week and so am happy to leave it to the submitting physician to determine if the patient would significantly benefit from talking with me. In my experience, only the most sophisticated patients (usually physician patients) directly contact me, even though my phone number is provided on every report. Patients should know that pathologists are just as much their doctor as the primary provider and will do everything they can to ensure the highest quality care, this is certainly how I train my residents.

    • Michael Misialek

      Well said! Terrific comments “Academic pathologist”. I hope all readers take note and recognize the value of pathology. It is this team approach that ensures the highest quality of care. Thank you for all you do and passing this along to future pathologists.

  • Ali Chaudhri

    Dear Dr Misialek

    Thank you for your piece on the role of pathologists in patient care; as a pathology fellow I definitely appreciate anyone who would advocate for our profession to step outside the lab and into the patient arena. I have had rare to no occasion where a patient was interested in seeing their pathology firsthand, though they are always willing to discuss it with anyone involved in their care, pathologists included

    I think the one thing I would add is that, in conjunction to what was mentioned before, with most patients lacking basic medical understanding (basic histology, physiology, etc) I would be concerned as to the my influence affecting a patient making what could be seen as clinically equivalent decisions and how much of the science I am showing them is having an affect on them – which isn’t to suggest I don’t welcome the opportunity to show patient’s pathology.

    Moreover, an additional avenue for pathologists to be involved in patient care I have always felt would be to lead information sessions with large groups of patients to teach them about the basics of their diseases to give them tools to make educated decisions about their care. Despite all the education we give our citizens, people leave primary education without (i feel) a basic understanding of their own physiology and medical biology. I know clinicians have done this historically, on an individual basis and perhaps at the level of a classroom setting, but I think pathologists also have a role in this setting as well.

    As educators by trade, pathologists are well-suited to organize patient education on a wide variety of topics, not just cancer medicine. Pathologist work in all aspects of lab medicine, from genomics to immunology to infectious disease to autopsies, as well as research on these diseases origins and treatment options – who else to better educate people about their own pathology than pathologists?

    • Michael Misialek

      Thank you Dr. Chaudhri for your comments. I agree with you that pathologists are great teachers and as such, patient advocacy is a natural fit. We definitely need to fully embrace this role. I am encouraged by many who have posted here, sharing my feelings.

  • DVM PATH

    I am a veterinary pathologist and can relate. Because I work at a state diagnostic lab in some cases we work directly with the public / livestock producers without a clinical veterinarian involved. In many cases, I found myself “quarterbacking.” Which sometimes can be very rewarding. However, it can also be frustrating when it gets technical very quickly especially when there is not a clear cut diagnosis. In any case, I wish the public at large understood more what pathologist do and for that matter clinicians need a much better understanding of pathology. It has been my experience that pathology is not emphasized enough in veterinary education (may be also in human medical education) and that doctors would be much better clinicians if the practical aspects of pathology was better understood by them. Thanks again for a great article.

    • Michael Misialek

      Thanks for your comments.
      It all starts with education. We need to create better visibility for both patients and the public.

  • tom

    We need to get rid of exclusive contracts for pathologists. That way patients could have choices regarding who their pathologist is. Hopefully with bundled payments and ACOs this will happen.

  • Nora Laver

    Dear Michael,
    thanks for writing such an insightful and caring article about the role of pathologists – most of our work goes unnoticed by patients. Yet, every diagnosis rendered by a pathologist makes a difference in patients’ lives. It is very important for patients to ask pathologists to show their biopsy findings as you did in your story.
    Best,
    Nora V. Laver, MD

  • Dr. Rey

    Dr. Misialek is right on !! The work and knowledge of the pathologist is a quintessential piece of the diagnostic puzzle in any given patients condition. As a pathologist I have never met a patient in my office which has not been extremely receptive and thankful of having a conversation about their specimen or medical condition with me.
    Luis Rey, MD.

    • Michael Misialek

      Thanks Dr. Rey! I am glad to hear you share the same experiences. It goes beyond reviewing slides, it is answering lab questions, assisting in FNAs as Dr. Wu points out, etc…Patients do appreciate it.
      Michael

  • Dog Cancer Doctor

    Thanks for brilliantly summing up how I feel about veterinary oncopathology. I hope to see veterinary pathology follow this same trend!

  • HemeOncDoc

    I thought “HemeGuy” made a great point about who is the quarterback

    To elaborate on that, for example, a possible adverse consequence of patients meeting with pathologists, who may not know the treatment options that follow a diagnosis, is that the patient could perhaps be led to make an unnecessary or incorrect treatment decision

    Case in point, when Dr Misialek says “Mrs. C was undecided between lumpectomy and mastectomy. Seeing the pathology, seeing her cells, enabled her to make the decision. She chose a mastectomy, in fact a bilateral mastectomy.”
    I am unaware of any microscopic criteria that would help a woman choose between unilateral mastectomy and bilateral mastectomy. My concern is that the patient was unduly influenced by something she saw under the microscope, (but did not understand) or something the pathologist said, which may not have been based on any rational criteria
    I would be happy to see pathologists paid for spending time with patients, when appropriate, but would hate to see patients make irrational decisions because of undue fears about their cancer that might come from such meetings

    • Duff

      I completely agree, HemeOncDoc. Thanks for pointing this out. I also found this statement unsettling.

      • Michael Misialek

        See below for complete explanation. Let me know if you have any further questions.

    • Michael Misialek

      Hi “HemeOncDoc”. Thank you for your comments, You are correct in stating there are no microscopic findings that would support a bilateral mastectomy and drawing attention to this. For the purposes of simplicity, I did leave out a lot of complex info that would not have added to the basic messages of the article. To summarize though, before others also pick up on this, there were 3 lesions…DCIS, LCIS and ADH. As you know, there is the possibility of breast conserving treatment in multifocal disease that is closely adjacent, as an alternative to mastectomy. A lot of debate ensued during conference about the best course of action. She did not want radiation and wanted to see for herself how close the disease was. The recommendation was mastectomy. She was comforted seeing the pathology and realizing her that was her best option.
      My point is that the pathologist is part of a team and this is a team effort, that for those patients wishing so, they should be able to see their diease. It is not for everyone. Before seeing a patient we make sure it is ok with the clinicians (typically a moot point since their visit to the breast center includes multiple visits with specialists in the same day and they come over already wishing to see the slides). I will also ask what the patient has been told. I will never try to influence a decision and will defer to the team for definitive recommendations.
      I hope this makes sense for the readers. Please pardon my literary freedom for the purposes of making it a more understandable story.
      Thank you again.
      Michael

      • Michael Misialek

        One additional point, the choice for a bilateral mastectomy was the patient’s, for prophylatic purposes. I am sorry if the article’s intent was not clearer about this.
        Michael

      • HemeOncDoc

        Thanks or clarifying that

        While you make some great points, my concerns remain that most patients, and many pathologists, do not have the knowledge base to make the leap from lab findings to treatment decision making.

        Everything you mentioned absolutely adds value to the decision making progress, but is also discussed (or should be) by the treating oncologist and surgeon.

        There are certainly patients who get some value from seeing things with their own eyes, which is why I share x-rays with them when I can, but even then, what they see, and what they understand (and what a doctor understands) about those images are very different things. The same can be said about microscopic images.

        The most important use could be in a patient who did not (want to) believe they really had cancer, but even then, if they had enough denial to doubt that, they would not necessarily believe that the microscopic images before them were really cancer, unless they were already so trained
        I still appreciate your article and your community is fortunate to have you helping them manage their patients

        • Michael Misialek

          Thanks for the follow up. I agree that it is a team effort. Every case is unique, which is why each specialist adds something to the discussion. The treating clinicians should be the ones making the final recommendations to patients, which is how we practice. Seeing the pathology is not for every patient. In this article Mrs. C literally had to “see it for herself” to be empowered to finalize the decision process in her mind.

          • Micromom

            Actually, as a pathologist, I am VERY aware of the treatments for each cancer I diagnose. We are trained to be consultants for our MD colleagues. So, yes, I have the knowledge base to make that leap from lab value to treatment plan and do so many times per week. I am also routinely contacted by surgeons and primary care MDs asking my opinion on how their patient should be treated or what they should do next. Healthcare is a team approach. I would welcome discussion of histologic findings and providing useful information that can help guide treatment.

    • R Dewar Et al.,

      Dr. Misialek, Hemeguy and HemeOncDoc: Great points. We published an article about this complex relationship (Pathologist-hemonc/surgeon-Patient), in the context of a medical error. We call it the Dual-Hybrid paradigm. The reviewers raised identical points. (Apologies for pathologists R Dewar et al).

      I think it is important to recognize that a ‘team approach’ to minimize errors and maximize patient care is the best for everyone. (as other readers point out, these diagnoses trigger a set of downstream events at the individual patient, family and community level; the role of health care is to provide exactly that – Good health Care). Thank you Dr. Misialek, for a wonderful article.

      • Michael Misialek

        Thank you for your comments. I agree that the team approach is the best, not only in providing quality care, but also being cost conscious. This only works in an integrated system where there is information sharing, common clinical systems and active collaboration.
        Thank you for the reference!

  • Rose Wu

    As a cytopathology fellow, I feel fortunate to be training at an institution that has a fine-needle aspiration clinic where we see patients and are able to offer adequacy assessments and rapid diagnoses. However, I’d like to see the pathologist’s role expand to encompass such encounters as described in this article. I look forward to a time when patients are able to schedule pathology consultations just as they do with any other medical specialty!

    • Michael Misialek

      Thanks for sharing your experiences Rose! It is great knowing that our training programs are putting emphasis into this area.
      I think our readers will see the passion and care in your words, that might go against some of the older stereotypes of what a pathologist is.
      Thank you.
      Michael

  • PJBinMichigan

    As a trained Breast Cancer Advocate and one who has been living with metastatic breast cancer for over nine years, I find it interesting that this is the first article I have seen suggesting a face to face meeting between pathologists and patients. I would love to have met with the pathologist who made the cancer diagnosis for me, an invasive lobular E+ P+ her2neu – breast cancer. I would probably have asked much different questions then than I would now, but having more information about what these cancer cells look like and how they behave would have been both empowering and reassuring. Of course, then nobody expected me to be alive 9 plus years later! Last month I asked to see the radiologist when I had my annual mammogram. I was refused. Mammograms have yet to show breast cancer even when we know exactly where and what it is! Frustrating.

    • Michael Misialek

      Thank you very much PJ for sharing your personal story. Congratulations on your milestone! It is stories like yours that give further support for why we pathologists need to be directly connected with patients. Like you mention, seeing the cells, gives patients a sense of empowerment and a face to their disease, not to mention understanding factors such as margin status, size and grade…I wish you the best.
      Michael

    • Tatiana

      Please share this wonderful article with your breast cancer advocates. Encourage them to post, Tweet and Like on FB. I have been spreading the news since my family was helped so much!

    • Jenny Libien, MD PhD

      You might want to read The Language of Cells: Life as Seen under the Microscope (I think same book with different subtitle is The Language of Cells: A Doctor and His Patients) by Spencer Nadler, 2002.

      • Michael Misialek

        Thank you Dr. Libien for the tip. I will definitely check it out!

  • ro

    This makes perfect sense. I am so glad to know that a patient can make this request.

    • Michael Misialek

      I am gld you enjoyed the article!
      Yes, patients can certainly ask to review their pathology. We are happy to be involved. We want you to know what it is that we do!
      Michael

  • Yael Kushner

    As another pathologist, I am grateful to Michael for writing this article. Thank you for taking the time to show that many of us went into the field of pathology to advocate and care for patients, not to avoid them. We are deeply invested in their care and welcome any consultations that may be helpful to them in their healthcare journey.

    • Michael Misialek

      Hi Yael,
      Thanks for writing and sharing your views. There is so much pathologists do that impact patient care indirectly, it is time to show how we are equally skilled in direct patient care.
      Michael

    • Micromom

      Brilliant! We pathologists care deeply for our patients. We are very much aware of what the treatments are for each diagnosis and so that is carefully weighed when the report is written. I will agonize over margin status and lymph vascular space invasion which is exceedingly difficult to tell at times when the cells of interest have been fried beyond recognition by cautery. There are many gray areas, spectrums and thresholds in pathology and in many ways its permits subjectivity. Many patients are not aware of that fact. I would welcome the opportunity to consult with patients!!

  • Luis Muñoz

    Very interesting article, Dr. Misialek:
    The other side of the coin is to convince pathologists to assume their role as doctors and to incorporate as a healthy and fruitful professional behavior the direct contact with the patient.

    • Michael Misialek

      Thanks Luis for posting your comments. As you can see from other pathologists who have posted here, we are willing and eager to take on this role.
      Michael

      • Luis Muñoz

        I took a year of internal medicine before my anatomic pathology training and some colleagues ask me if I consider useful the clinical training to work as a pathologist with the microscope. My answer is “Well, I think you don’t need a year of internal medicine to be a superb morphologist, but, clinical thinking and reasoning helps you a lot to deal with clinical and surgical colleagues and to understand and communicate with the patients.

  • Ann Rosas

    I saw my own mammogram when the doctor found calcification. I’m glad to have seen it, seeing the image assured me that I needed to have a biopsy and investigate further. The image made it ‘real’ for me, something I couldn’t deny or ignore. Good news – it was benign, at least this time!

    • Michael Misialek

      Thanks for posting Ann.
      I am glad to hear that everything turned out well. Delivering good news is a special feeling for us as well.
      Michael

  • Shweta Shinagare

    That is a great article Dr. Misialek! I really enjoyed reading it.
    It correctly describes the importance of our role in patient care.
    I completely agree that we, as physicians diagnosing a lesion, are in a better position to explain the rationale behind our diagnosis and should be formally consulted when needed.

    • Michael Misialek

      Thanks Dr. Shinagare,
      I appreciate your comments. It is an enlightening experience for both patients and myself every time I go through a case. I hope interest builds in patients seeking to experience this opportunity.
      Michael

  • Antonio Martinez

    Excellent Michael, very well written, I really enjoyed this piece. We pathologists should welcome the opportunity to speak to and see patients. I personally have had few opportunities in my seven years of practice to meet patients face to face, but the few times have been great experiences and I absolutely welcome them. Another excellent point you make is the role we (can) play in this landscape of high quality/cost effective medicine. Thanks for sharing and for caring about our profession! AM

    • Michael Misialek

      Thanks Antonio. I appreciate your kind words and feedback. The time is right for pathologists to embrace this new role of direct patient care. You are also right on with the test utilization argument. This is a big cost on the system and who better to control then pathologists!
      Michael

  • Erika

    This is such a rich, refreshing take on a very important and not necessarily known or recognized part of the process. It certainly will wake me up to ask to see what an expert sees, if or perhaps when it comes up for me again. Thank you so much for the informative article.

    • Michael Misialek

      Thank you for taking the time to post your comments Erika. I really appreciate it! Michael

  • Jon Hunt

    Great article.
    As a registered nurse it has always amazed me that patients have spent more time choosing a surgeon without regard to the pathologist reading their slides.
    Patients should be aware of the entire medical team.

    • Michael Misialek

      Thanks Jon,
      As an RN you know well about the pathologist’s value.
      Let’s share with patients and the public.
      Michael

  • pathologychief

    Great story, and I too have taken the time to go over slides with the very rare patient who does as Mrs C has done. However, this does raise an interesting point about the future of medicine and pathology in particular. Consider the amount of time that was spent with her, which no doubt you both enjoyed, but was definitely NOT REIMBURSED. I’m not saying that should be the primary consideration, but if our clinical colleagues spent this amount of time with her, they would submit the appropriate billing codes and get reimbursed for their time.

    • Michael Misialek

      That is a great point. Proving and showing our value is the first step!
      Thanks for your comments.
      Michael

  • Walter Klein

    Nice piece Michael. I am with you 100% and wish more pathologists would see the big picture as you and I do.

    • Michael Misialek

      Thanks Walter. Let’s help spread the word!
      Michael

  • HemeGuy

    As a hematopathologist in an academic medical center, I don’t see myself as the “quarterback”. I just don’t know enough about the different chemo regiments, XRT, prognosis, etc to have a discussion with the patient. In addition, I have seen some clinicians become VERY defensive or dismissive when discussing their patients. I have shown slides to only one patient in 6 years, but that person was very medically/ scientifically sophisticated. I would like to do more consultations, but only in conjunction with the treating oncologist.

    • Michael Misialek

      Thanks for the comments HemeGuy. I do see how the term “quarterback” could be controversial. Perhaps a better way of stating it would be that we are “critical members of the team, without hierarchy”. I am sorry if anyone takes offense to this. It was certainly not my intention.

  • Kyle

    This is a great opportunity for patients and pathologists. Give patients the chance to see the disease for themselves, and let them make the decision whether or not they would like to speak with the doctor whose knowledge directly effects their treatment. Unfortunately, just like any large system, any improvements will be met with scrutiny, and it will take a large push on the efforts of physicians to make this possible.

    • Michael Misialek

      Hi Kyle,
      Thank you for the comments. I know I speak for many pathologists…we want to see you! The more information, the better for patients. Another benefit I have noticed in my patient encounters has been that seeing the disease gives patients a tangible entity that they can focus their energies on and fight. It is very empowering.
      Thanks
      Michael

  • Linda

    I appreciated this article and Dr. Misialek’s caring attitude. I wish that the pathologist who’d first identified my breast cancer cells had such an attitude. I’d made the mistake of going for a “routine” mammogram on a Friday afternoon; the pathologist refused to meet with me, just telling the medical assistant that I should make an appointment with my doctor for Monday. (I was able to see both my doctor and a surgeon the same day). It’s good to know that there are caring human beings doing the screening.

    • Michael Misialek

      Hi Linda,
      Thank you for sharing your comments and the kind words. I am sorry you had a bad experience. All my colleagues have embraced this new role. The feedback from patients has been terrific. I do wish you the best.
      Michael

    • Nadia

      Pathologists aren’t the ones who interpret mammograms – that is radiologists. So, if this was before your biopsy, it would be the radiologist who told you to make the appointment. It takes 1-3 days to interpret biopsy specimens because the tissue has to be processed and put onto slides for the pathologist to review. Sorry that you had a bad experience.

  • Cindy Krasnecky

    My guess is Mrs. C was led to pathology by a nurse navigator; often in oncology nurse navigators are the first to interact with a patient who has an abnormal finding; it is the nurse navigator who explains to the patient the care pathway they are on and the specialist they will meet to understand their diagnosis. Pathology is THE key and oncological care should not happen until final pathology is back; it only makes sense that these patients are offered to meet the expert who has made the diagnosis. Patients need to be empowered to ask to meet the Pathologist.

    • Michael Misialek

      Cindy,
      You raise a great point. There is a lot that goes on behind the scenes that most patients do not even realize. It is a team effort. My colleagues and I certainly appreciate this and all that you and everyone does!
      Thanks you.
      Michael

  • T.

    What an excellent article! Pathologists really are the wizards behind the scenes when it comes to caring for patients. I hope National NPR picks up this story and shares it with everyone.

    • Michael Misialek

      Thank you for the comments T. It would be great to get this message out to an even larger audience! Let’s do our best to share with as many people as we can.
      Thank you.
      Michael

  • Tatiana

    My Aunt was recently diagnosed with breast cancer. My family and I never considered meeting with a pathologist…until now.
    Your article illuminated a new path for us. We feel empowered to take more control of her medical care. This article made a huge difference to our family and also gave a new perspective on healthcare. Cheers to the doctor who took the time sharing this with the general population…we have been in the dark for too long.

    • Michael Misialek

      Thanks Tatiana!

  • Linda

    Thank you for writing an article which simplifies a patient’s journey through the health care system when faced with an important decision. The pathologist is the doctor with the answers – test interpretation and treatment choices. Everyone should have access to their pathologist!

    • Michael Misialek

      Thanks so much Linda for your comments!

  • BAhmad

    Thank you, Dr. Misialek, for the incredible insights. As a practicing pathologist in a community hospital I too welcome the opportunity to meet with patients. Many of the patients with whom I meet to discuss their benign or malignant pathology tend to be physicians, nurses or their relatives. The “secret” of pathology, the insights we can provide, right now are limited to the few that are intricately involved in the healthcare field.

    This must not be a service offered to healthcare professionals and their relatives alone. This is a service that must be provided to all patients from all walks of life. Your article makes it clear that this must be the future of our profession and of medicine in general.

    • Michael Misialek

      Very well said Dr. Ahmad. We need to get the “secret” out. I appreciate all you are doing.
      Michael

  • Geri

    Great article. We literally have our lives depend on a Pathologist and never realize it!
    To you and your other colleagues “Thank you” . Great article !

    • Michael Misialek

      I appreciate the compliments Geri. Thank you for posting your comments.
      Michael

    • Dolors Fuster

      And, please, remember histotechnicians and histotechnologists too.
      Without their (our) accurated job diagnotsis would be, at least, a bit more difficult :o)

      • Michael Misialek

        Thank you Dolors. Yes, everyone in the lab is part of the team. Each member is critical to our job of patient care. I know I speak for all pathologists in saying we appreciate all you do!

  • Vincent

    It makes good common sense to me that I fully understand why the regimen of treatment discussed with my particular specialist is recommended. Who better to help with that understanding than the pathologist? The more fully we understand our illness and the reason for treatment, the better. Since, as Dr. Misialek writes in his article, the pathologist is willing to participate directly with the patient, then it would seem to me not only the patient, but the specialist and insurers would be better served. In the past I never gave this idea much thought, but it does make good common sense.
    Thank you Dr. Misialek for enlightening me.

    • Michael Misialek

      Thank you Vincent for your comments. Yes, we definitely need to recognize the value of pathologists in the health care system.