Saturday, January 14, 2012

An American Pathologist in Malawi: Establishing a Baseline

           It seems that every specialty in medicine needs a baseline in which to compare.  Laboratory values, CT scans, nutritional intake, even mental status, all need a point of reference to which it can be compared to the baseline.  I can still remember back when I was a medical student on the wards, learning that certain patients were consistently outside of the “normal” values, and that there was no cause for concern, all attributed to the patient’s baseline.  It’s a funny thing, as each and every patient has a different baseline, and we, as clinicians, need to be able to gauge each one in the context of that patient.   What factor may be remarkably noticeable in one patient may be completely within the realm of “normal” for another.  The same goes for pathology, as strange as that may sound.  It is easy to think that a specimen is simply a specimen and slide is nothing more than a slide, and there should be no difference.  I must admit that I had that same line of thinking before arriving in Blantyre, Malawi.  While rotating on various BWH specialty consult pathology services, we as residents always have seen a wide variation of quality from outside hospitals, ranging from the gross description of the specimen to the H&E staining to the immunohistochemical methods used to come to the final diagnosis.  During signout of these cases, the pathology attending and I will usually discuss all of these aspects, and how fortunate we are at BWH to have consistent quality for processing the cases.  We constantly had to keep in mind that the cases from each of the different laboratories had a different baseline, of which we needed to be able to interpret accurately.

            With this mentality, I traveled to Blantyre fully expecting crystal-clear gross descriptions of specimens, as well as flawless H&E staining and an arsenal of immunohistochemical stains that would allow me to make the diagnosis with relative ease.  Much to my surprise (and naivety), my orientation to the pathology lab was not what I was expecting, or in my comfort zone.  My departmental tour started out like any other, having the program director show me the administration office and labs.  I found out that the department was in the process of switching to electronic records, so any prior pathology reports I would need were awaiting me in a neatly stacked pile of binders.  No big deal, I thought, as all the reports looked quite organized on those shelves, and this was their baseline for record keeping.  My tour continued through the lab, where I was shown where the specimens were cut and processed.  The space, which included an open-air view of the grassy quadrangle, was certainly adequate for the job that needed to be done.  I was introduced to an extremely friendly member of the laboratory, Kingsley, who was there cutting the paraffin blocks for slides.  I originally thought that he was the laboratory technician, but I discovered later that he is a board-certified cytopathologist that reads all of the Pap smears that come into the department. 

As I looked around, I couldn’t help but notice that there were no immunohistochemistry technicians.  Back at BWH, the immunohistochemistry lab for pathology consists of five full-time technicians processing over 200 custom orders each day.  It was at this point that is was casually mentioned to me that there was no immunohistochemistry lab.  No immunohistochemistry lab?  For all the times at BWH that I would settle in the comfort that any questionable issues (big or small) I had with a case could most likely be solved with immunohistochemistry.  That invisible crutch was suddenly taken away, and I had been thrust into a realm of relative insecurity.  What do you mean I can’t confirm this obvious squamous cell carcinoma with a p63 stain?  This department in Malawi had been diagnosing pathology cases long before I got there, without the help of immunohistochemistry.  This was the baseline in Malawi, and diagnoses had to be made, independent on ancillary studies.  I realized that this experience was going to force me to establish my new baseline, and I eagerly anticipated the challenge.  

I was left to the basics: hematoxylin and eosin stains and my armament of knowledge of medical school histology and my resident training in pathology.  Even after this initial shock, I remained confident that I would be able to handle the situation as I was subsequently shown to my workstation.  I was assigned to a nice multi-headed Leica microscope (the only multi-headed microscope in the department) and given my workload for the day.  This will be a challenge, I thought, as I placed the first slide down on the microscope stage.  Gasp.  There must be something wrong with this scope!  The H&E stain was faint, and nothing like the vibrant colors that I had become acquainted with back at BWH.  It’s as if someone had turned the contrast and intensity down on the slide using Photoshop.  For a while, I played with the focus, light intensity and condenser in a futile attempt at improving my perspective, ultimately realizing that the colors I was seeing were just another baseline that I would need to establish. 

The diagnoses were certainly there in front of me, and I was going to be forced to retrain my eye to be able to pick up these subtleties in order to make my correct diagnoses.  I’ve been presented with these sorts of challenges before, and I was confident that my prior training would serve me well.  After about five slides, my heartbeat slowed to a regular rhythm (back to its baseline) and I settled into my comfort zone, identifying familiar entities that I had seen back at BWH.  I had established my new baseline, and the anxiety of being outside of my comfort zone quickly subsided, as I continued through my cases for the day.

Kevin Golden, MD/PhD
PGY-5, Surgical Pathology Fellow

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