Pathologic Truth

“It’s time to start this glorious day.” Dr. Bertram Collins pushed open the front door of the pathology department with a small grunt. It was half past seven in the morning. He paused for a moment to assess his mood and realized he was a bit off-kilter. More anxious than usual perhaps. He probably just needed to get into his routine in order to grab happier thoughts. Many of his colleagues and friends would probably say that off-kilter was his natural state these days. However, they weren’t available for comment at that moment in time and Bert was not inclined to ask them for their opinions on this matter.

He strode past the Chairman’s secretary who was sitting as usual at her desk just off the main hallway. He nodded to her with a forced smile. She responded in kind. He then proceeded down the hallway toward his office and entered with dispatch, signaling to anyone watching that he couldn’t wait to get started with his work day. This was a bit of an unnecessary effort that early in the day. He dropped into his desk chair, happy to have navigated the hallway studded with potential misadventures like a more “energized” encounter with the Chairman’s battle-ax secretary.

He swiveled his neck as he reclined in his chair, examining the contents of his office with unexpected curiosity. Everything was in place. The furnishings were spartan, reflecting the culture of the department that did not encourage frippery in office furnishings. His desk was located at the far end of the room, near the window, with only ribbons of faint light streaming through at this early hour. A microscope and computer, the major tools of his trade, were sitting on the desk within easy reach. Few objects had moved so much as an inch in years and he liked it that way. Both static and perfect.

His office was a safe refuge for him and he felt the tension that had been building inside was suddenly released. “So far, so good.” He was ready to attend to the day’s work as a well-known and respected surgical pathologist. His work consisted of diagnosing disease in tissue that had been removed by surgeons. He accomplished it by scanning thin slices of stained tissue under the microscope. He took some pleasure in reflecting that much of this “technology” had been developed and refined by a few of his illustrious predecessors in Germany in the 19th century. He was walking in the footsteps of giants.

He briefly, and somewhat dismissively, glanced at the computer his desk. In the old days, his daily work and communication was performed mainly with paper. which now seemed to be on the verge of obsolescence. Paper was physical. It had heft and substance. No keyboard skills were necessary to get the daily job done. In those more concrete and previous times, he only had to dictate the findings of a case into a recording device on his desk. His secretary would bring back rough drafts for his edits with a pencil, an instrument that seemed to have now been relegated to museums. “Old days, indeed. Data has integrity and substance. It should be respected and not relegated to the nether regions. Screw the cloud and screw cloud computing.”

 As he continued to glance about, he was abruptly reminded of the numerous stacks of cardboard slide trays sitting both on his desk and around the room. In each of the twenty rectangular depressions in each of these trays nestled a glass slide. On each slide was a thin strip of tissue stained purplish blue and pink by dyes. Some of these piles of slide trays were perilously close to tipping over, requiring him to navigate slowly as he moved about his office. Some of these slides were from cases for which he had postponed his sign-out. Some also had been set aside for additional review during the quality control program in the department because of differing opinions about his diagnosis. These piles offended his sense of order and were only there over his continuing and strenuous complaints.

“What a farce this departmental quality control program is.” Most of these so-called ‘reviewers’ were many years his junior and lacked his experience in detecting subtleties in cases. “On the other hand, it’s probably better to play along with their silly little games,” he thought, “The truth will surely come out in the end that will reward my long experience and judgement. This farce can’t go on forever.” He would certainly attend to these lagging cases as soon as his busy schedule allowed it and get rid of the nagging cardboard “skyscrapers” arrayed around the room.

On occasion and certainly more often recently, Bert had entertained the idea of retiring from the department given that he was well past seventy. Quickly, however, he had dismissed such an idea as fanciful and unrealistic. He was certainly as mentally sharp as always, if not more-so. Moreover, he had no hobbies to speak of so his retired life, as he envisioned it, would be a bore. He was confident that he remained relevant for the daily work of the department. He was, after all, a senior member of the “team” with a sterling reputation. Hobbies, in his opinion, were just a waste of time. He was reassured in all of these personal reflections by the fact that there was no mandatory retirement age in his department.

Abruptly, he heard a light tapping at the door to his office that turned out to me his Chairman who twisted open the door and entered without acknowledgement. He stated talking immediately bur remained standing in the entryway. “I need to get right to the point, Bert,” he said. “We’re seriously bothered by the number of your late cases. Also there has been some issues with some of your diagnoses during peer review.” As he spoke, his eyes wandered about the room and focused for an unnecessary time on the scattered piles of tottering slide trays, to Bert’s discomfort.

 “I don’t want to make a big deal about all of this but can make an effort for you to get up-to-date on your cases so that I personally don’t need to spend any more time on this matter. Also, why don’t you drop in my office in the next few days so we can discuss your future career plans. The Dean of the Medical School is looking for someone of your stature and judgement to head up a newly formed committee to review the entire medical school curriculum and recommend needed changes. This would take you out of the day-to-day pathology activities, of course, but would be a great capstone to your illustrious career. We need people with your vision to sit on such committees. This is the future of our field and you need to be part of it.” 

The Chairman then removed himself from the office, leaving Bert, again, in an agitated state of mind. “Medical school committees, indeed.” He was certain that his personal value was determined mainly by sitting in front of the microscope. In this regard, his long-held opinion about the role and value of surgical pathology was not dissimilar to that of many of his colleagues in the department. The pathologist was, and has been since the early days of modern medicine, the final and undisputed arbiter of surgical diagnoses. 

Medical truth regarding, say, cancer, was enshrined in the reports generated by the pathologists. Such a demanding diagnostic role had never been assigned to, say, surgeons who had a limited ability to sort out subtle cancerous changes from normal tissue under the microscope or even grossly. He giggled out loud like a little girl about a recent encounter he had with a surgeon in the office, sharing a two-headed scope and looking at a tissue from a patient. “Show me which part is the cancer,” the surgeon said, looking at the image. “It’s all cancer, Doc-tor,” Bert said in a caustic tone.

“Well, it’s time to get rolling with today’s work,” dragging himself back into the present. He picked up the first slide and looked at the computer screen for the case history: a fine needle aspiration of a lymph node from the axilla for a patient with a history of small pulmonary opacities. He placed the slide on the stage of the microscope and adeptly pushed it around the microscope stage with the fingers of his left hand and under the lens of the microscope. “No doubt here. It’s obviously a small cell lung cancer metastatic to a lymph node. A very bad actor.” As he was pondering the exact phrasing he would use to describe the cancer in the report, his gaze drifted to the patient’s name on the computer screen. 

“Oh my goodness. The patient’s name is Bertram Collins, the exact same as mine. What a coincidence. But, it’s a relatively common name. Easy to explain. This other Bertram Collins needs to get his affairs in order quickly.” At this moment, he did faintly recalled his own recent appointment with an oncologist regarding his persistent cough. There ensued some discussion with the doctor about some vague but undoubtedly benign X-ray findings in the lungs. “No sir,” Bert said to himself. “You don’t take opacities on lung X-rays lightly. You deal with them with dispatch. Medical truth always remains the order of the day.”

It then occurred to him that he might want to take another look at the other Bertram Collins’s slides, a task to which he turned to with some urgency. He scanned the slides again, but for some reason and this second time around, he felt that he might have arrived at his previous diagnosis too hastily. And for some reason, he also felt some degree of mild sort of obligation to his namesake, someone who was totally unknown to him. But after all, he did need to take pains too render the absolutely correct diagnosis for all patients. This, after all, was the pivotal role in his professional life.

Slowly it dawned on him. as he scanned the slides again, that this was a more challenging case than he had initially realized. Sure, there were some larger cells with hyper-chromatic nuclei mixed with the expected lymphocytes but, after all, he now suspected that these larger cells were mostly angry lymphocytes due to an infection and therefore not malignant. 

“Whew! That was too close for comfort. I could have blown this one. I’m glad I took a second look. I will report it out as a benign inflammatory response. However I need to take one more step to avoid any more confusion with this case.” He pushed himself away from his desk and walked into the hallway. After a brief hesitation, he tapped lightly on the door of his next door colleague.

“Phil,” he said when the door was opened, “I have an unusual situation here. It’s a case with a patient who has the same name as mine, if you can believe that. This could lead to confusion that I am anxious to avoid. I have been under some scrutiny lately because of some problems.” He handed Phil a small piece of scrap paper on which he had written the the name, hospital registration number, and surgical pathology case number of the “other” Bertram Collins written on it. 

“Would you sign this case out over your name — it’s an obvious benign aspiration biopsy of an axillary node. There’s no need for you to look at the slides. It’s pretty straight forward. I just think the best course of action would be for it to be signed out by someone with a different name than mine.” His colleague Phil smilingly agreed to comply with the request and Bert returned to his office.

He glanced at the clock on the wall. He had completed what he had set out to do for the day and he would surely try to whittle down the size of the backlogged cases the next day. Besides, he felt stiff and a brisk walk in his home neighborhood would do him well. He viewed the quick reversal of the malignant to benign diagnosis of his “namesake” to be fortuitous. “This other Bertram will know nothing about the chain of events that occurred this day but will certainly be far better off in the end without the burden of a false diagnosis. Better not to know how the sausages are made.”

He glanced at his watch and noted that his work day was coming to an end and breathed a sigh of general satisfaction. It had turned out to be a very good day. Putting aside his malaise about the messiness of his office and the questions in the department about his work ethic and now some proffered and useless committee assignment. 

Luckily and in the nick of time, he had been able to intervene to correct a cancer diagnosis that would have nagged on his conscience. “Pathologic truth wins the day once again,” he muttered as she shut off the light switch in his office and proceeded back down the hallway toward the exit. The Chairman’s secretary was nowhere to be found so he could stroll down the corridor without being on high alert for any further assaults on his person or on his professional integrity.