Pathology

Instant credibility at a parties. Hushed respect from the public. Pathology is the coolest specialty. Sure, shows like Nip/Tuck and ER have made plastic surgery and Emergency Medicine seem glamorous but pathologists cut up dead bodies, man!

They certainly do, but not every pathologist does this regularly. Pathology is the study of disease. In this respect Pathologists are “Doctor’s doctors” as they are consulted by physicians. Much of a pathologist’s day is spent looking through a microscope, nailing down an exact diagnosis. But the public doesn’t know this…all they know is that they cut up dead bodies, man!

Let’s say a patient is having a tumor surgically removed. The surgeon takes tissues samples at the margins of his his resection and sends them to pathology. There a technician makes a frozen section of the samples and puts them on slides with the appropriate stain. As the surgeons stand around the patient talking about their golf-game, the pathologists looks at samples to see if there are “clear margins,” that is, no abnormal cells indicating that the surgeons have removed the entire tumor. If the pathologist detects abnormal cells, the surgeons take wider margins. The examination of tissue samples like these is a big part of a pathologists job.

Another function of pathologists is to make the rest of us slap our foreheads like country rubes and say, “Dammit, it’s so obvious given the symptoms and blood smear. Why didn’t I think of that?”

Pathology has two main divisions, anatomic and clinical. Anatomic pathology involves autopsies and examination of tissue. Clinical pathology focuses on diseases, particularly those that leave their imprint on a cellular level. A pathology residency covers anatomic and clinical pathology.

It is a lifestyle specialty. The hours are good in residency and there is almost no call. There are no, repeat no, pathological emergencies. The dead will keep and while some malignant cancers spread fast, they don’t spread that fast. I have never heard anybody say, “We need the pathologist and we need him right now!” It pays fairly well too once you get into practice. It is also one of the few non-surgical specialties which doesn’t worry about competition from mid-level providers. A Nurse practitioner may be very comfortable managing someone’s blood pressure but pathology is way, way out of her league. Heck, it’s out of my league if we get down to it.

The competitiveness of pathology varies, it seems from year to year. If you like pathology and want to do it (and are not a moron) you can probably match into it.

Neurology

You need a lot of tools. That’s why neurologists are the last doctors to carry the old-fashioned “doctor’s bag” which your mother may have bought for you as a present when you were accepted to medical school. For a good neuro exam you apparently need more tools than an auto mechanic even if most of get by with a reflex hammer, a pen-light and sharp stick. A tuning fork is necessary to assess the posterior column senses (or is it another column?) but I have rarely seen it deployed by anybody other than a neurologist.

One of the first real skills you will learn is to do a good neurological exam, everything from the cranial nerves (On Old Olympus Towering Top A Fat Veiled Girl Vends Ancient Hops) to motor and sensory. At first you will feel silly going through the motions but one day you will find a real, honest to God focal neurological deficit and you will be hooked. Then the CT or the MRI will confirm your finding and you can harumph and insist that those studies were unnecessary as you localized the lesion with nothing but your physical exam prowess.

Neurologists are kind of like that but on speed. As most of you know, the brain (and spinal chord) is an organ of bewildering complexity. Everybody should know the basics but the neurologist easily localizes a small lesion to an obscure section of the brain that you only dimly recall reading about. In a conscious patient, I don’t believe neurologists really need CTs or MRIs.

Neurology is a typically a four year residency. It is more competitive than internal medicine but somewhat less competitive than surgery. If you show an interest and do a lot of neuro rotations in fourth year you are probably in. There is some overlap with neurosurgery (and orthopaedics) but neurologists are not brain surgeons. It’s like the difference between a cardiac surgeon and a cardiologist. They usually work in concert, each consulting the other as required.

Bread and butter for the Neurologist? Alzheimers. Multiple Sclerosis. Strokes. 98 percent of the patients I saw on my neurology rotation fit into these categories. An occasional glioblastoma but most of these were referred to neurosurgery.

Neurologist are all a little “off,” at least I have never met a totally normal one. Every neurologist I have met had at least one annoying mannerism or a certain way of interacting with his patients that made me cringe. But I must confess my ignorance. I don’t know anybody who even considered matching into neurology. Nobody from my class did. I just don’t know what kind of person goes for this kind of thing.

Neurosurgery

Top of the heap and the most competitive of all specialties. The only job where you can say, “Well, actually, it is brain surgery.” The board scores, letters, grades, and general knowledge required to match into neurosurgery are so far above my capabilities that I blush to even comment.

For all that, I have never met a malignant neurosurgeon attending or resident. I think they are above all of that petty bickering and emotional masturbation which is typical of many other competitive specialties. I guess if you are spooning a lesion out of somebody’s brain, trying to isolate a ball of slightly dense yogurt from the background of less dense yogurt, you just can’t be bitchy and high strung.

The first rule when rotating on neurosurgery is to pretend you have been pulled over by a cop and keep your hands where he can see them. Don’t touch anything. One slip and there goes your patient’s ability to form coherent words. There is nothing in there you want to mess with. Put your eyes to the other eyepieces of the surgical microscope, keep your mouth shut, and laugh at all the attendings jokes.

A specialty of incremental success. Very few people escape serious head injury with no deficits. A bad outcome is a question of degrees. Grandma can’t talk but at least she’s alive.

Some overlap with orthopaedic surgery as both specialties work on the spine and the spinal chord.