Pathology and Laboratory Medicine

Open journal

ISSN 2996-5942

The Swan Song of a Pathologist: “Why Do I Love Thee, Pathology? Let Me Count the Ways….”

Bhagirath Majmudar*

Bhagirath Majmudar, MD

Emeritus Professor of Pathology and Associate Professor of Obstetrics and Gynecology, Emory University Atlanta, GA, USA; E-mail: bmajmud1962@gmail.com

Having retired from the active practice of pathology after 50-plus years, I thought I should share my career experience. The word post-mortem slips in habitually, but the word is inept to express the feeling of joie de vivre (joy of living) I uninterruptedly experienced during my wakeful period of more than half a century.

Selection of Pathology in My Career

In my medical school in India, there was literally a bridge that connected to the large hospital complex with the Pathology Department. The bridge was busy as ever during the daytime, trodden by the fast footsteps of medical students, residents, and clinicians. The chairman of the Pathology Department had established an academic aura that resulted in a constant cluster of clinicians drawn to him for consultation, as if by phototaxis. Pathology thus occupied a distinct place of respect in my beginner’s mind. The textbook of pathology for my undergraduate rotation was written by William Boyd, a Canadian pathologist with an uncanny ability to write science books as if they were fiction. He had a mastery of language, expressing concepts and images, punctuated with poetic reflections that sculpted indelibly in the minds of readers. The cumulative effect of all these factors irresistibly drew me to pathology.

Pathology: A Pathfinder in Medicine

The dean of my medical school, who became a rabbi in his post-retirement period, called me personally to dissuade me from going into pathology. This was not a solitary example, as I later saw similar examples in the USA. My dean was looking at the negative image as in earlier photography, whereas I was looking at the positive print into which it would develop. I now look upon clinical disciplines as seemingly separate islands connected with an ocean called pathology; this ocean connects every discipline except psychiatry! The modus operandi of pathology is, “To tell the truth, the whole truth and nothing but the truth.” Having said that, pathologists relentlessly go on searching for a Higher Truth. When proven wrong, they openly share it to thwart its further propagation. In pathology, the ego has to go! Our history of pathology substantiates that we changed our belief system when emerging truth belied it. Pathology is an endless pursuit of validating and invalidating the stored data of knowledge. The path keeps on leading without ending.

The arborization of pathology to accommodate the rapidly expanding knowledge is conceivably inevitable. In earlier years, the chairman of the Pathology Department was the ultimate authority over all aspects of pathology. With the ceaseless and assiduous efforts of global pathologists working as a team, the sign of Nes Plus Ultra (no more beyond) is transformed to Plus Ultra, (more beyond). Accordingly, pathologists are now further classified as neuropathologists, gastrointestinal (GI) pathologists, gynecologic pathologists, and so on. When clinicians enter a pathology lab now-a-days, they do not look for a generic pathologist, but want to date their own subspecialty pathologist. It is necessary at this point that arborization should not lead to each subspecialty being walled off from one another. The branching specialties should be buttressed by an intense training in basic pathology. If the patients cannot be divided based on their symptoms, microscopic pathology cannot be divided by systemic pathology alone. Such a fragmentation can be deleterious to the total patient care. The most glaring truth that pathology taught me is that the integrity of the whole body is maintained by diverse but harmonious pathways. There is an intricate and innovative unity among all the units of the body, the parts combining cooperatively to impart a functioning whole.

Learning Inconvenient Truths

Medical school admissions: I was a full-time member of the Medical School Admissions Committee for 26 years. I interviewed thousands of medical school applicants, but none of them planned to be a pathologist. They had an initial plan to be a surgeon, family physician, pediatrician, etc., but pathology was not even in their remote thoughts. There were sporadic examples of choosing Forensic Pathology, prompted by its glamor displayed in TV shows. It is most likely that by far and large, people do not even know what a pathologist’s responsibilities entail. They usually connect a pathologist with autopsies, which is not appealing to them! Additionally, the media presentations related to medicine highlight only clinicians, keeping pathologists quite invisible or behind the scenes. We do need to let the people know how valuable, critical, and intriguing is the role played by pathologists in patient care.

Medical school curriculum: It bothers me to observe that it is possible for a medical student to get a medical degree without ever seeing a pathologist at work! Lectures on pathology touch them only tangentially, and the Lecture system of teaching is losing its hold over students anyway. Integrating pathology during clinical rotations or lectures (Osler’s Approach) can have a forceful impact on patient care. The role played by pathology in clinical care will be self-evident if the students get a chance to observe frozen sections, microscopic pathology from their patients, autopsy correlations, and radiology-pathology correlations. This is an essential part of the micro- and macro-management necessary for ideal patient care.

Training pathology residents: It is gratifying to note that the quality of our pathology residents is getting progressively upscale. They are turning to pathology by choice rather than a lack thereof, which places a special responsibility on the shoulders of the faculty. The residents will thrive only when increasingly more challenged. It was disgruntling to see a fourth-year surgery resident independently undertaking a radical surgery, while a fourth-year pathology resident had to helplessly solicit the opinion of his attending in a similar situation. I am fully cognizant of the special circumstances in which pathology operates, but at the same time, we have to prepare our residents to be progressively more independent. We have to transform our residents from being observant to the self-observant.

Through a continued observation of 50 years, I learned that all residents are not alike. If two human faces are not alike, and two human diseases are not alike, then by a link of logic, no two residents can be alike either. By traits and talents, they are bound to be polymorphic, and efforts to force them to be monomorphic may do more harm than good. They are destined to pursue different courses in life, and we have to help each one to follow his or her own pathway. By allowing them to talk fearlessly, I found out that they had their own dreams in their private world. Besides or even instead of pathology, they wanted to be businessmen, painters, photographers, politicians, cartoonists, historians and so on. The fear that such distractions will make them that much less of a pathologist is debatable and questionable. Our constitution permits the pursuit of happiness. As educators, we help our residents define what makes them happy. The human mind eventually circumvents fear and pursues passion. An evening that allows them to speak their minds without reservation can unlock many unexpected doors. A small but steady flow of pathology residents seeking an MBA, JD, and other clinical residencies should indicate to us that there are strong underground currents that need to be recognized and fostered by the faculty. We also see many clinical residents from surgery, Ob-Gyn, Internal Medicine, etc., joining our pathology force in midstream. To blossom fully and with each petal is the very mission of education.

Following My Pulse and Impulse

Chekhov, the famous writer cum physician, described his medical profession as his lawful wife and writing as his mistress. While spending most of the time with his wife (medicine), his joy to see his mistress (writing) was always abounding. If we siphon off the moral and ethical scruples from his metaphor, I can see his point. Despite my unswerving loyalty to pathology, I had so many other interests pulsating within my framework. I also was a Poet, Philosopher, Professor, Playwright, and a Priest, the letter “P” being the only common denominator. I was deeply fascinated by languages, and by English and Sanskrit in particular. When I was told that Sanskrit is a dead language, I said that it would perfectly suit a pathologist. I now understand “life” as a physician, “death” as a pathologist, and the union of both as a priest.

Priest Cum Pathologist

Sanskrit gives me spiritual insight in the same manner that Hebrew gives to my Jewish friends. The idea of interfaith weddings; however, had an anomalous origin. One morning my pathology colleague brought with him his 12-year-old daughter. Inspired by the microscope, she started drawing some cartoons related to the microbial world. In one such cartoon, the Daddy bacterium, with an upturned nose, was angrily shouting at his daughter, “We are from the high-class of bacteria. I will not allow you to marry in that lowly virus family!” The humor germinated within me a thought to consequently pursue a subspecialty of priesthood: interfaith weddings.

To date, I have conducted about 350 such marriages with a post-marital follow-up in all couples. They send me the pictures of the homes they bought and the babies they brought into this world. My joy was boundless when some of these marriages involved my own medical students and residents! Like all humans, they were having tremors of nervousness that were affectionately tranquilized by me. I like all our young people to be productively engaged and harmoniously harnessed in marriage. I amalgamate the wisdom of both faiths in a wedding ceremony to impart an appeal of both a global and spiritual nature.

It is interesting to add that my roots in pathology peep through, even when I am officiating a wedding ceremony. In the Hindu tradition, I describe the veil interposed between the bride and the bridegroom as a semipermeable membrane with an interplay of osmosis/cosmosis. And I describe the sacred rounds of the couple as GRAND ROUNDS! I now realize that pathology has become a part of my systematic and systemic thinking.

Swan Song Summary

Retired life has let me feel my freedom to its fullest. I do not have to seek promotion by writing or publishing. I can write in a milieu of a free field, with all fences off. It was necessary; however, to learn the discipline of scientific writing, the form and format that is conducive to a common language of meaningful communication. I am so very thankful to pathology for developing my left cerebral hemisphere of logic and strict methodology. However, I am grateful that it did not interfere with my right hemisphere in thwarting my essence of human warmth and emotions. The corpus callosum bridging my right and left hemispheres has toughened, softened, and broadened, all at the same time. In the examination of the brain, we look for bilateral symmetry. We need the same symmetry in the two hemispheres during life to rule out the pathology of asymmetry. I wish that quality for all our emerging pathologists today.

My final point addresses the relationship of pathology to the sensitive subject of death. I recall my pathologist friend, who was the first one to read his own liver biopsy showing an unexpected metastatic carcinoma. He thought it was a colonic primary, which it was. He was totally objective and unperturbed about the implications. This and many other similar instances exemplified the fearlessness that one can develop upon impending death. Witnessing so many deaths, like the process of vaccination, can induce an immunity from the fear of death itself. Pathology taught me how to look upon death as a happenstance in a biodegradable body. I am profoundly thankful to pathology for that simplified Truth of Life.

In a hypothetical swan song, the swan dies after the song. In the unexplainable miracles of life, the swan may fade away, but the song continues from generation to generation just as the phoenix obtains new life by rising from the ashes.

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