Tales of a Medicine-Watcher are true stories from 50 years in medicine. Names and dates changed, staff names real (unless otherwise noted). The term Medicine-Watcher is used in The Youngest Science, the autobiography of Lewis Thomas, which I use with respect.
“I’ve brought you a present, John”. I hadn’t seen Pete (not his real name) for about 3 months. Pete was a wonderful anatomical pathologist in Melbourne, working in private pathology, with a special interest in cancers. When other pathologists had difficulty diagnosing a cancer under the microscope they would bring the microscope slides to show him. As I did often. “Wine?” I asked, hopefully. “Yeh, right. What do you make of this” and he pulled out two slides.
As I slid them under the microscope, I understood his position. He knew the answer, but felt obliged to run the slides past the Pathologist at the Royal Victorian Eye and Ear Hospital. Me. Because I saw lots and lots of laryngeal biopsies. If we agreed, then it was all sorted. Consultations between anatomical pathologists in difficult sections are common.
Back in 1983, 90% of biopsy diagnoses were done on looking at the microscopy only, whereas now the subdiscipline of immunopathology has resulted in the application of immune markers to the microscopic sections. These can be specific for certain cancers and cells. Back then, it was mainly a visual diagnosis. “I’ve seen this slide before”. “No you haven’t, said Pete “we received the tissue 3 days ago”.
There are two ways that microscopic diagnoses are made when looking at the tissue. One is pattern. The other uses the detailed appearance of cells, The first is right-brain recognition. The second is a systematic analysis using the left-brain. “I have seen this before, hang on a mo”. My right brain had taken over. I rummaged through about 12 trays of slides, a total of about 100 slides, found the one I wanted, put it under the mike, and Pete, who was looking through a second optical arm, said “Holy Moly” We checked the patient’s name, and the surgeon, and the specimens were the same. Pete and I agreed that the lesion was premalignant but benign. We also agreed that the surgeon had divided a 4×3 mm laryngeal biopsy in half and sent half to Pete and half to me.
I was on the phone to the surgeon that afternoon. He was a young surgeon. I was younger. And a little brash. I informed him, using as many simple four letter words as I could, that his action was stupid and unprofessional, as he risked separating out a malignant area with his cut, and risked crushing and distorting the tissues, and what would he do if he got two different opinions. He said he wanted two opinions and thought that was what he was doing. “No. That’s not the way it works. If you want more opinions, you ask the pathologist to submit it elsewhere”. He got the message.
“Thou shalt think, though he divide the realm and give thee half, it is too little” (King Richard II)
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