Neurology vs. Pathology

[Enkidu]

Did any of you consider going into pathology before you ended up in neurology? I had always planned on becoming a neurologist, but I think it was more related to the prospect of diagnosing strange neurological diseases than it was related to the long-term management of those disease... So I'm now leaning more toward neuropathology. I'm just wondering if any of you were thinking along these lines and why you eventually decided to go into neurology.

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[curlygirlie106]

While I can't say I ever toyed with path (I was actually between peds/peds neuro/adult neuro), I have a classmate who did and eventually chose path. A big thing to consider is your desire to see patients- which is what it came down to for my classmate. He's really interested in disease and research but in no way wants to spend 45 minutes teasing out details on a new patient visit. He's much more cut and dry in his approach (what's the current clinical picture and what can this tissue tell me) than I am (talk to a new patient and hear their life story/put clues together/count performing a compelte neuro exam as one of my favorite pastimes). If it's neurologic disease that interests you, but not so much the actual patient interaction or patient management, neuropath could be a great option for you!

As always, the best thing you can do is try to spend some time with physicians, fellows, and residents in a specialty you're considering. Path isn't a rotation that you'll experience as a third year, and you'll likely be waiting until 4th year (read: right before making that huge what-residency-do-I-apply-to?! decision) to get any exposure. You may or may not get a lot of neurology exposure (my school only has us rotate for a week!) and odds are, even if you do a monthlong rotation, you won't get to do much, if any, neuropath. Just ask if you can hang out with someone for a day or two- 99.9% of the time, they'll be thrilled you're interested! Good luck!

 

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[Enkidu]

Basically, if you like dealing with people, neuro offers that. If you don't want to deal with people, path or rads are good options.

It seems like a lot of people go into neurology because they like the intellectual challenge. Patient care aside, would you feel intellectually challenged in a field like pathology?

 

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[starmoon]

I think neuropath is awesome. It's a fantastic field, tons of interesting research, great lifestyle. I know several neuropathology fellows who are really happy with their career choice.

That said, I really like the whole patient interaction thing so it's not for me. But if you find yourself hating clinic but still loving neurology, I think neuropath is a really good choice.

 

[Enkidu]

Another thing to think about is this - if, for some reason, you cannot make it to your ultimate training goal (say... neuropathology) and have to settle for something along the way, would you rather be a neurologist or a pathologist? This may be a glass half-empty way of thinking about it, but it's realistic and provides some perspective. Personally, I would like to get specialized training in any number of fields of neurology (e.g. neuroradiology, just an example), but realistically there may not be enough time, money, energy, focus, etc etc etc. If I end up being a general neurologist, I can accept that and be happy with it. I would not accept being a radiologist. If I have to get off the train early, I'll take neuro, even though it would mean that I would also have to take half the salary of a rads.

That's a good point. I think that my interest in medicine is really related to the diagnostic process in general, whereas my interest in research is in neuroscience... I suppose that if my research career were to never take off, I'd prefer being a pathologist to being a neurologist.

Ironically, the old stereotype about neurologists being "diagnose and adios" is not true enough, at least for me. That's what I'm looking for in medicine.

Well, what do you guys prefer: Diagnosing a patient with a neurological disease, say MS, or managing her disease and medication side effects in the long-term? I think that diagnosing it is cool, but afterwards it seems a little frustrating with the moon facies and buffalo hump and titrating doses up and down... is this your experience?

 

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[Enkidu]

Interesting. What is the role of neuro-onc in diagnosis? I would expect that those patients would be diagnosed by neuropathology.

But my question was really more about how neurologists view their field. is the long-term management the frustrating part or the fulfilling part?

 

[Enkidu]

Oh, maybe they diagnose things like paraneoplastic syndrome?

 

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[Enkidu]

Elderly man has increasing headaches, focal neuro deficits -> family doctor -> neurologist (possibly onc) is suspicious based on hx and exam -> MRI shows a mass -> biopsy/pathology/management by neuro-onc.

The neuros I've worked with enjoy the repeat patient interaction, a little less so the imagers and stroke/critical care.

But in this example neuro-onc didn't diagnose anything. Family med referred to neurology, who ordered a CT, which lead to a biopsy, which led to a diagnosis by pathology, and then the patient was managed by neuro-onc.

Is this what you meant?

 

[aaddnl]

Interesting. What is the role of neuro-onc in diagnosis? I would expect that those patients would be diagnosed by neuropathology.

But my question was really more about how neurologists view their field. is the long-term management the frustrating part or the fulfilling part?

Neuro-oncologists and Oncologists in general don't diagnose a lot. Typically their patients come to them with a tissue diagnosis. In fact, some oncologists even state that they would prefer a tissue diagnosis be made before the patient is sent to them. Neuro-onc is typically involved in the complex treatment of CNS cancer and managing complications of the disease and treatment.

Paraneoplastic syndrome is diagnosed almost exclusively by neurologists, usually a general neurologist (rarely a GP or Internist makes this dx). For some reason, paraneoplastic and autoimmune encephalitis are entities much more widely acknowledged and described in Neurology literature than in Internal Medicine literature.

To answer your original question, yes, I think most Neurologists are interested in and enjoy long-term management of disease. If you are a general/epilepsy/MS/Movement/Dementia/HA/Neuromuscular neurologist this will be one of the main aspects of your clinical work. It is an art and can be quite rewarding to see patients' chronic diseases managed well and to maintain a good outcome/quality of life for patients that you establish a relationship with. I would consider it fulfilling.
Now some ppl may consider long-term management frustrating. Typically Neuro-ICU, interventionalists, Stroke neurologists, and Neuro-hospitalists dont have a lot of patients they follow long term. But this is another example of how neurology offers a wide array of career choices.

As for "moon-facies and buffalo humps", MS patients are not typically placed on chronic steroids anymore and there are several new treatment options for MS. Choosing the best treatment option for a particular patient (and making adjustments if necessary) requires a detailed knowledge of the disease, the medications, and other factors.

 

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[Enkidu]

More or less, yes. It also depends on how you look at what a diagnosis is and who participates in determining the diagnosis.

How important is the clinical judgment to recognize that something is wrong and should be examined/scanned/biopsied? A pathologist may think that a clinician is a glorified triage nurse who simply identifies a particular type of physical deficit and takes a tissue sample. How important is it for the pathologist to recognize the tissue abnormalities and pinpoint the type of pathologic changes that is occurring? A clinician may think that a pathologist is a glorified technician who simply looks at a slide and compares it to a description/picture in a book of diagnosis. So, who's diagnosis is it? Well, it's the patient's diagnosis, of course, but it took a chain of events to get there. I think it's matter of deciding where in that chain of diagnosis/treatment you want to sit.

OMG, did I just describe a chain that is only as strong as the weakest link?

gag... gag... gag...

Okay, I see what you mean. I guess that when a clinician suspects cancer and orders a biopsy, there's a sense that when the pathology report describes a type of cancer the clinician can say that they diagnosed the patient with cancer. I'm not used to thinking of the process in that way, so I didn't catch your meaning at first. I tend to think of a biopsy as a pathology consult, rather than a lab test.

I suppose that this conversation has helped me with my dilemma. It seems like the fields of neurology that don't do long-term management, like stroke and neurocritical care, also don't make those cool neurological mystery diagnoses that drew me to the field. I suppose I'm better suited for pathology. Thanks for all your comments.

 

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[Sir James Bond]

I'd rather be the doctor's doctor.

I've watched oncologists tell patients and their families that cancer is the diagnosis. Given a choice, I'd much rather make the diagnosis than deliver it.

 

[Mattchiavelli]

Try to at least shadow some pathology residents to get a feel of the day-to-day work. I seriously considered Pathology [good teaching opportunities, very visual-based, no waking people up at 6am to give your fingers a good hard squeeze] and did a Path elective in October. It made me realize a few things that turned me off, like how much time you will spend looking through a microscope and how much I missed clinic. I was surprised that the autopsies weren't as bad as I'd thought and making findings missed while the patient was alive was very interesting [more for me than the patient, obvs]. Doing frozen sections and grossing tumors/harvesting for the tumor bank was as amazing as I thought it would be, but ultimately not enough. So try before you buy. A good tip I got from my adviser is to look at a few of the big journals in the field and see if it interests you. Pathologists deal a lot with prognosis based on findings, refining those, and discovering new biomarkers to use as data for prognosis. You will at some point get to see slides or tumors with a big WTF is this factor but it's definitely a different flavor than clinical diagnosis.

The weird thing the rotation made me realize was how much we're encouraged to look at and interpret our own imaging, but no one is ever saying we need to be looking at the slides of our histological diagnosis. Not that I don't trust pathologists, I just want to see cells sometimes [not 5 hours at a time].

 

[Enkidu]

The weird thing the rotation made me realize was how much we're encouraged to look at and interpret our own imaging, but no one is ever saying we need to be looking at the slides of our histological diagnosis. Not that I don't trust pathologists, I just want to see cells sometimes [not 5 hours at a time].

I think that its a lot easier to casually read an image than it is to casually scroll through multiple slides along with with various immunostains and spot cytologic atypia. Not to belittle radiology, but a lot of conditions can be diagnosed by first year medical students. I'd say that it takes considerably more expertise to even notice that a slide is abnormal. Of course, a lot of radiology is really hard, but it is undeniably more accessible to the average clinician.

 

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[Mattchiavelli]

I think that its a lot easier to casually read an image than it is to casually scroll through multiple slides along with with various immunostains and spot cytologic atypia. Not to belittle radiology, but a lot of conditions can be diagnosed by first year medical students. I'd say that it takes considerably more expertise to even notice that a slide is abnormal. Of course, a lot of radiology is really hard, but it is undeniably more accessible to the average clinician.

I think that's mainly a result of the education focus in med school today. Clinical radiology is a graduation requirement, clinical microscopy isn't. I wouldn't expect someone who is not specialized to be intimately familiar with all histochemical stains, but for example cytology of a pulmonary nodule tumor vs abscess isn't rocket science. I guess my original comment of biopsy I would extend to basic microbiology as well [I think I was one of the few people that thought wet preps in OBGYN were cool]. There are also multiple imaging modalities and protocols/tweaks to augment those basic modalities with more being developed, I think those could be comparable to some of the more esoteric staining techniques.

Pertinent to the original question, there are some aspects of Path that will be far removed from clinical practice as a Neurologist, which include but are not limited to the subtleties of diagnosis by microscopy. Pretty much all of the Neurologists I've worked with interpret their own images but I have yet to see one bust out a microscope.

 

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[Enkidu]

If the slides were scanned digitally, do you think clinicians would be more interested in clicking on them and scanning through to double check the pathologist?

 

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[Enkidu]

Absolutely. The neurologists I've worked with look at almost everything. Scans, EKG, EEG. If there were path pics I think they'd also look at them too, and it would engender more interest as well if they were more available and relevant (i.e. stroke docs probably won't look at them).

Maybe something for the future. Digital pathology images are ridiculously huge, so we'd need to make some technical advances.

Actually, even pathologists read their own images, at least in neuropath. It's a pretty neat correlation when I go to pathology conference. The neuroradiologist seems to be wrong in a significant number of cases.

Do you guys tell patients that they have cancer based only on radiology reports, if the radiologist explicitly calls it, or do you tell them that their lesion is suspicious for cancer while you wait on pathology?

 

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[Mattchiavelli]

Maybe something for the future. Digital pathology images are ridiculously huge, so we'd need to make some technical advances.

We had all of our path slides for MS2 available both physically as slides and virtually via a program our path professor put together. I'm at a university that is big on IT so that might have something to do with it. The slide scanners I saw in surgical path looked like they were relatively inexpensive [compared to, say, a DaVinci robot]. I think this could happen sooner than you think To me, it seems like they could be scanned and saved in a PACS system like radiology studies.

 

[Enkidu]

We had all of our path slides for MS2 available both physically as slides and virtually via a program our path professor put together. I'm at a university that is big on IT so that might have something to do with it. The slide scanners I saw in surgical path looked like they were relatively inexpensive [compared to, say, a DaVinci robot]. I think this could happen sooner than you think

Well, what I'm talking about is scanning a slide in its entirety to be analyzed by a pathologist, not just to take a picture or to show to students. It has to be scanned at incredibly high resolution to prevent it from pixelating at high magnification. The problem is that the image files are massive, and you potentially need dozens of them per case and you have to store them long-term. It would be great for pathology though, you could sign out from home.

This would also allow for certain digital analyses of the image too, like measuring nucleus size, or eccentricity, so it has a lot of potential applications for imroved diagnostic accuracy.

I don't think this will happen soon though, because the hospital still has to store the tissue anyway, so the digital image is a little redundant... a great technical advance is probably needed for it to become the new standard. Could be wrong though, we'll have to see.

 

[Jorje286]

Well, what I'm talking about is scanning a slide in its entirety to be analyzed by a pathologist, not just to take a picture or to show to students. It has to be scanned at incredibly high resolution to prevent it from pixelating at high magnification. The problem is that the image files are massive, and you potentially need dozens of them per case and you have to store them long-term. It would be great for pathology though, you could sign out from home.

This would also allow for certain digital analyses of the image too, like measuring nucleus size, or eccentricity, so it has a lot of potential applications for imroved diagnostic accuracy.

I don't think this will happen soon though, because the hospital still has to store the tissue anyway, so the digital image is a little redundant... a great technical advance is probably needed for it to become the new standard. Could be wrong though, we'll have to see.

I'm really surprised that more computerized techniques haven't taken off. If a picture can be analyzed statistically and give you raw numbers, I think it will be of great help and greatly reduce time of diagnosis instead of a person staring for hours(?) at a slide. I imagine though pathologists may not be very open to this kind of advancement. I know that computerized techniques for analyzing microscopic images are already quite utilized in research. If you have software that can count number of cells, look at deformaties...etc. Of course one still has to make sure of the diagnosis.

 

[Enkidu]

I'm really surprised that more computerized techniques haven't taken off. If a picture can be analyzed statistically and give you raw numbers, I think it will be of great help and greatly reduce time of diagnosis instead of a person staring for hours(?) at a slide. I imagine though pathologists may not be very open to this kind of advancement. I know that computerized techniques for analyzing microscopic images are already quite utilized in research. If you have software that can count number of cells, look at deformaties...etc. Of course one still has to make sure of the diagnosis.

Yeah, I think that its very plausible for computer programs to be able to quantify features of an image. There is work being done on it, but not yet ready for clinical use. I think we are a long way off from computers just making a diagnosis by image processing, though, so I don't think pathologists will be too threatened. Identifying images is one of the hardest problems in computer science.