Getting Out From Behind the Paraffin Curtain

Abstract

In the course of a 30-year practice, I have had the opportunity to track the professional trajectories of more than a few pathologists, from entry level to midcareer and beyond. Patterns of success and failure emerge, so I am compelled to share some of my observations with trainees and newly minted practicing pathologists. It should go without saying that among the first obligations of any physician is mastery of the technical approach to the specialty. This is especially important in pathology, as from day one we are expected to deliver accurate and timely consultations with a very low error rate. I am pleased to say that the cognitive skills of newly trained pathologists have only risen steadily with time, and most all of them pass over that first very high bar with little apparent difficulty. The fractional distillation of careers—from failure, to mediocrity, to excellence—seems to be more a function of other personality traits and practice habits. I can summarize the most desirable of these as an eagerness to get out from behind the paraffin curtain, that zone of comfort at the microscope, where the well-trained pathologist can relax with a cup of coffee and a stack of slide folders. As viewed from behind the curtain, the ideal workday is one in which the biopsies are adequate, the histologic findings pathognomonic, and the diagnoses brief, definitive, and powerful. As we all know, those ideal workdays are infrequent. Biopsies are unrepresentative, histologic findings ambiguous, and important clinical information absent and difficult to obtain. From 23 years of practice in a general community hospital, I am all too familiar with the frustrations that arise in handling those very nontextbook cases. I discovered early on that relief would come only by venturing out from behind the paraffin curtain. I started by spending time with the radiology staff, reviewing images and discussing biopsy strategy prior to the procedure. I also encouraged the gastroenterology staff to call me to the endoscopy suite when they encountered any puzzling or otherwise unusual finding. Additionally, I began to spend time in surgery, reviewing the operative schedule the afternoon before, noting cases that were likely to attract consultation, and appearing in the operating room as the procedure was getting underway. These ministrations outside the laboratory, although time consuming, were eventually rewarded not only with specimens of greater technical quality but with a boost in my own self-confidence as a diagnostician. An unexpected side effect of these adventures was an introduction to hospital politics.