An autopsy never lies
Pathologist Mikhail Travin on man's rich inner world 06/11/2013, 16:44
The figure of a pathologist is so shrouded in stereotypes and misconceptions that it seems to exist solely outside the material world – in jokes, friends' stories and TV series. At the same time, the unsightly image of a Ripper and latent cannibal seems much more plausible than a simple expert in a white coat holding a microscope. At Sib.fm's request, Mikhail Travin, pathologist and associate professor at Novosibirsk State Medical University, told us about the accuracy of his diagnoses, impressions from his first autopsy, professional cynicism, humour and dreams.
In the eighth class, I got an A-plus in my first anatomy lesson and was drawn to medicine. It's quite a trifling reason, of course, but it stuck in my memory. In addition, I always had an interest in the natural sciences: I chose the advanced Medical and Biological class at school, and from there it was a straight road to medical school. My father is an engineer who graduated from Novosibirsk State Technical University, so by "family tradition" the same fate awaited me. Although I'm not exactly backward in mathematics and other exact sciences, they never attracted me. But I was attracted to medicine.
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I remember that there were joint projects with the medical institute in the last years of school: you'd go to their department and there were jars everywhere, people were conducting experiments on animals. Pretty cool. Although, other than that A-plus and some more anatomy knowledge, I don't remember anything in particular. I didn't want to be a pathologist. I wanted to be a doctor.
Guy in a plastic apron
I know that in the collective consciousness a pathologist is a guy in a lab coat and plastic apron who stands and cuts things open from morning 'til night. Then he wipes his hands on his trousers, picks up some bread and starts cutting up some sausage. Due to my character I try to keep up these stereotypes and legends, and even exaggerate them on purpose. I tell everyone: "Yeah, yeah, we're all like that, if not worse." It's all nonsense, of course. Pathologists are the most joyful people on Earth. We're easy to recognise: hopelessness in the eyes and joie de vivre in the voice.
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Pathologists are few and far between. It's a suitable career for a handful of people. There are 55-60 of us in the whole region, at the most. Of course, in some ways we're all alike: a certain mindset, keen eye and a good visual memory.
Perhaps some people will be surprised, but a pathologist performs biopsies, analysing the tissues of living people, much more often than autopsies, determining causes of death. No surgeon would ever write a final diagnosis without our histological examination. From an appendix or gallbladder removal to a limb amputation due to gangrene – everything goes through us. Why? Doctors at the clinic see changes in features, we see changes in structure – molecules, cells and tissues. People say that the pathologist's diagnosis is always the most accurate for a reason. It sounds ridiculous, but it's a fact. Our diagnosis is the most verified, the most reliable.
For example, you get a stitch in your side. What could it be? Absolutely anything.
Our work is most valuable in the treatment of cancer: is it a benign or malignant tumour, is the process inflammatory or reactive. For example, a lump has been found on the skin. The surgeon or dermatologist isn't always sure what he's dealing with. They need the results of a histological examination. Treatment tactics, the patient's prognosis and so on often depend on our conclusion.
Pure detective story
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Doctors have always made mistakes, make mistakes now and will always make mistakes. It's unavoidable. The question is how to reduce these errors to a minimum. Back in the 13th century, one of the principles of the Salerno Medical School (the first medical school in Western Europe – Sib.fm comment) was "let the dead teach the living". What doctors used to be able to "see" using tests and electrocardiography can now be seen with their own eyes. That's called experience. For example, I can't read autopsy reports from three years ago with dry eyes. I open them and think, 'Oh my God, it's so basic! How could anyone write something like that?!' But that's normal, it's the by-product of professional development.
At medical school I was always more interested in the things before the diagnosis: solving the puzzle, breaking everything down, performing practical examinations. What comes after – treatment and so on – isn't that interesting, it isn't for me. The mystery of the diagnosis is the whole point. If you solve it – you've won, if you don't – you've lost. It's a pure detective story.
Sometimes the diagnosis has to be changed. Let's say, I see a picture of disease N, but the person is being treated for disease X. You see, I don't know why he's being treated and what's wrong with him. So I see N and write: "This is disease N". My colleague calls me and says, "That's all very well, of course, but disease N occurs at 15 years of age, and this is a 70-year-old grandfather." Write that down then! It's the usual story: a lack of data. Sometimes you struggle to work everything out for two days and then it turns out that the research referral was written incorrectly. If everything had been put together properly, I could have given the diagnosis in ten minutes.
To be honest, very few people know how hard it is to just go and make a diagnosis. Especially with children's diseases.
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I remember my first autopsy well. It lasted, I think, about two hours, and all my muscles went numb. I was very nervous. I remember exactly what I did and which diagnosis I made. It was after lunch and I was sure that no one was in the morgue, so I worked carefully and with concentration. I raise my eyes – my supervising professor is stood there, smiling. Nearly dropped the knife. That moment was probably the most dramatic emotional experience of the two hours.
(On the picture above: enign rat, malignant rat, suspected malignant rat)
In fact, even by the sixth year of med school (if you don't freeload and partake in all the delights of studying) you start to react calmly to a lot of things. I worked in an ambulance, so I've seen a lot. When second and third year students ask to come to an autopsy, I say, "Why? If you want a show, you've come to the wrong place." You need to attend these procedures for training, not for thrills.
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Deep into the cell
The more knowledgeable I become, the more stupid I feel. It seems like as soon as you gain some experience and start to consider yourself an expert, destiny gives you a case that makes you hit the books again. That's how life teaches us, anyway. Because the more you read and learn, the more interesting it becomes. Everything won't physically fit into one brain, we have to consciously limit ourselves in some things. Although this dissatisfaction spurs us on very strongly: you're always developing and never reach the end. That's pretty cool in my opinion.
You know, it's amazing how many incomprehensible things happen in the human body.
I've just come from an autopsy where we had a real pathoanatomical find. Over ten years I've never seen anything like it or read about it anywhere. There's either a tumour or some sort of polyposis in the right atrium of the heart – it's not clear yet. Me and the clinician are currently waiting for the histological analysis to look at everything through a microscope and finally decide what on earth it is.
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Very interesting things are happening now in the field of technology. Pathologists have come to routinely use methods that used to be the exclusive domain of elite research institutes and closed laboratories. As I see it, medicine in general and diagnostic medicine in particular are going deeper into the cell. Before, we could look through a microscope to see a cell and its nucleus. Now it's possible to find out not only what a cell looks like, but also what proteins are located in it. There are new methods, new classifications, new treatment guidelines, new drugs. A great breakthrough has been made. When I was studying, it all seemed like space-age technology. Now, it's the norm, everyone uses them.
All the same, a cold sweat runs down my back when I hear the phrase "healthcare reform".
People don't want to come into our profession, there's a serious shortage of staff. Students are still coming to us, but it gets worse and worse every year. First of all, it's a financial issue: money talks when it comes to keeping hold of specialists. With a salary of 8,000 roubles a month ($250), I'm sorry, but no one will last very long. Secondly, working conditions. They leave much to be desired these days. There's a good, quality microscope in my office, but in other places they're ancient. How can you work with them? You'll just ruin your eyesight.
I don't like the constant lack of time. Routine examinations and other things occupy most of my day. My whole desk is piled up with this monotonous material. After that, it's hard to make a step forward in the profession. It's emotionally hard too because only a few people understand the complexity of our work and the degree of responsibility that we bear. We're always in the dark, our work isn't visible. Despite all the ambition and pride in the profession, we're just the eyes of the doctor who then prescribes a course of therapy based on our conclusions.
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Nine circles of hell
The stories about pathologist's dreams aren't just myths. However, you only see what you've already encountered in real life. I had nightmares a couple of times in the first year, it was emotionally tough. Now if I have any dreams at all, they're pretty professional: I just carry on "cracking" the diagnoses. We have some not-so-serious professional rules too.
Typically, your first idea of the diagnosis is the most accurate. When you mess around for a long time, study a pile of books and go to consult with everyone, you're just unnecessarily doubting yourself.
It's calmer like that, of course; more often than not everything is confirmed. It's like going through the nine circles of hell just to come back to square one. Plus there's an unwritten rule, as for doctors in other fields: don't treat your relatives and don't get involved with people through “connections”.
Read this interview
Pathologist humour does exist, although it isn't as black as it may seem from the outside. The emotional component of the profession remains on the sidelines. In a sense, you could call it cynicism, but there's no other way to survive in our line of work. If we start to feel sympathy for everyone, we won't last long. Sometimes you feel more sorry for the doctor: he applied so much effort, all his abilities, did everything he could. But man is still mortal.