Scott H. Saul, MD, Co-Chairman, Pathology and Laboratory Medicine
The Chester County Hospital and Health System

Published: November 12, 2012

Mrs. Jones was overheard to say, "My doctor diagnosed me with lung cancer." However, this diagnosis was actually made by a Pathologist, the hidden physician in Medicine. Who are these behind-the-scenes doctors, often called the "physician's physician?" Do they really have lives like "Quincy" or "Raymond Langston, M.D." of CSI fame?

In a nutshell, Pathologists are physicians who specialize in the diagnosis and management of human disease by laboratory methods. Using a microscope, they evaluate cells (Cytopathology) and tissues (Surgical Pathology) removed from the body in life, as well as after death (Autopsy Pathology). They are responsible for the appropriate testing of blood and other body fluids analyzed by a wide variety of sophisticated instruments (Clinical Pathology). Molecular Pathology (analysis of genetic material and proteins) crosses the boundaries of both disciplines. After medical school, the Pathologist trainee usually completes four years of residency, which is often followed by one to two more years of subspecialty fellowship.

Most Pathologists practice in groups of individuals with a varied, but overlapping skill set necessary to tackle the diversity of daily patient care problems. Seventy-five percent of Pathologists are community-hospital based, with a lesser number in medical centers, independent laboratories or other settings. Many function as Laboratory Directors and all are fortunate to work closely with skilled groups of other laboratory professionals who are essential for the day-to-day functions of the laboratory. Virtually all serve as teachers at some level, and some are researchers. While most Pathologists perform autopsies, only relatively few are specially trained to work in Quincy-like fashion as Forensic Pathologists (Medical Examiners), investigating the causes of unnatural and criminal deaths. Often depicted as introverted and "chained to their microscopes," Pathologists' personalities are actually quite varied and they are found out-and-about participating in hospital activities. Up until now, they have rarely been face-to-face with patients; however, in this ever-changing world, uniform patient access to electronic medical records and marketing of direct-to-consumer laboratory testing is likely to change this relationship.

Why then are Pathologists known as the "physician's physician"? In the Clinical Pathology Laboratory, they guide and update direct-patient-care physicians in appropriate ordering and interpretation of an ever-increasing number of lab tests. As diagnosticians, they evaluate difficult blood smears, assess the cause of unusual blood transfusion reactions, and troubleshoot many other problems. Much of the practicing Pathologist's time, however, is spent diagnosing Surgical Pathology and Cytopathology specimens. Evaluation of biopsy specimens has become increasingly difficult. While specimen size has decreased, the need for additional information from each specimen has increased.

Let us return to the hypothetical case of Mrs. Jones. A lung biopsy was performed, and the Pathologist diagnosed cancer. Additional specific tumor marker studies (immunostains that give certain cells a characteristic appearance) were needed leading to a more precise classification of a particular type of lung cancer called "adenocarcinoma" ("adeno" refers to glandular tissue). A positive molecular test for mutation of a gene, known as "EGFR," equipped the oncologist with information for specific therapy targeted to this patient's cancer. Like a tsunami, Molecular testing is rapidly revolutionizing Medicine. Finally, the Pathologist correlated all clinical and pathologic data, discussed it with the direct-care physicians and rendered a final report. Mrs. Jones' case was subsequently discussed in a Lung Cancer Multidisciplinary Conference held at her hospital.

Patients should be assured that Pathologists, while appearing to be hidden in the background, actually play a vital role in daily medical practice. They take pride in being the "physician's physician" and are privileged to work with their physician colleagues, a variety of caregivers and other laboratory professionals in the pursuit of optimal patient care.

This article was published as part of the Daily Local News Medical Column series which appears every Monday. It has been reprinted by permission of the Daily Local News.

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