Why are physicians often so clueless about the presence of disease, but pathologist cause of death reports are often so precise and definitive? The pathologists’ “patients” can’t verbally communicate, yet they have the advantage simply because they can cut open and take a look?
Physicians have many diagnostic tools at their disposal yet it often seems like the car mechanic takes more pains to properly diagnose what’s wrong with a car than likewise for the physician. There are some great physicians out there so I don’t imply that all physicians are unworthy diagnosticians.
What is the difference between an internist, a surgeon and a pathologist? An internist knows everything, but does nothing; a surgeon knows nothing, but does everything; a pathologist knows everything and does everything, but by then it’s too late.
“Tak(ing) a look” is a lot more involved than you imagine. “Looking” at the body or organs, even examining them, to make a diagnosis is the stuff of TV. The diagnostic action is in the microscopic approach. Think about it - how often does a diagnosis depend on the results of a biopsy; a biopsy of a small sample of the body or tissue of interest. Now imagine that the whole body can be biopsied (so to speak). Nothing escapes attention.
But even the microscopic approach doesn’t capture the whole thing. Nowadays, pathologists have zillions of specific “probes” with which they can identify various disease processes, infecting organisms, etc.
Plus, you don’t ever know how many wrong avenues the pathologist might have taken before they finally put their money where their mouth is. Part of the reason they look good is 'cause you only hear their final answer, not the real time agonizing they went through arriving at it.
Two nitpicks: pathologists are physicians, and pathology is not all about cause of death. While forensic pathologists focus exclusively on this issue, and anatomical pathologists spend most of their time on it, clinical pathology is a large and necessary field dealing with the causes of illness, as revealed by tests on samples of blood and tissue from living patients.
This is important to remember. I’ve spent days thinking over cases, it is part of my job. Also, many pathologists already have some of the results and conclusions that other professionals arrived to (if they have access to the records, I know I have access to the veterinary hospital records). So they may know what was suspected, or what the result of X or Y test was negative. In those cases, they already know to look elsewhere, or attempt other probe.
And yea, “looking” at the patient is more involved and requires a bit more training than what you may think, and many of the important findings are present at the microscopic or molecular level, and may show nothing at plain sight.
Said by the other Dr. KG, a veterinary pathologist.
I should have emphasized above, that knowing the cause of the disease is often not nearly enough to select the best course of action from among the many available. In fact, much of modern medicine is about dealing with and managing chronic diseases: the diagnosis is not in doubt; what to do about it is.
ETA: What the other Karl said - the accumulated data and opinions of the primary and consulting physicians is a huge aid for the pathologist.
Actually, I imagine most human anatomic pathologists spend their time on living cases (patients). Think of every single growth removal or cancer surgery. In most cases, if some chunk is taken out of the body, it is the anatomic pathologist who says what that tissue and what is the pathology present. All those cancer diagnosis? Most of them had to go to biopsy for identification and grading, and that’s a pathologist’s job. Heck, even I, a veterinary anatomic pathologist, prefer to work on biopsy rather than necropsies.
Clinical pathologists do not read (as a rule) biopsies, they read aspirates, smears, and fluids.
I forgot to add, though, that Nametag’s first point is very important and worth remembering. Pathologists ARE physicians (and veterinary pathologists ARE veterinarians). They went to med (vet) school like your surgerons, they just chose a different path (heh) from surgeons, pediatricians, OB/GYNs, etc. But they are heavily involved in two of the main areas of medicine: diagnosis (what it is) and prognosis (what will happen). And you cannot really develop an effective cure or treatment for a disease unless you darn well understand how the disease works on the human (animal). That is the pathologist’s kingdom.
I actually do know that pathologists are physicians and there’s a specific branch of pathology that I’m referring to. It’s strange to me that a basic disease can go undiagnosed for decades, but then be identified within 48 hours with such certainty after death. It almost makes me think I should go to a forensic pathologist for primary care, but I’d run like hell as soon as they picked up a scalpel. And as I said, some physicians are better than others, or take more pains than others, at diagnosis.
I’m not sure exactly what you’re getting at here, but many “basic diseases” may not cause any symptoms at all, and therefore wouldn’t be discovered before an autopsy.
And, I will repeat: diagnosis is not usually the problem. Managing the person with that diagnosis is.
Look: diabetes, heart failure, coronary disease, cancer, Alzheimers, chronic obstructive pulmonary disease, HIV/AIDS, cirrhosis, . . . Most of what most internists do is on this short list. Chances are that most people reading this will die from one of them. And making that diagnosis, well, a second year med student could do that. The skill and ongoing challenge is knowing what to do once the diagnosis has been (readily) established.
If your GP could crack your chest pull out your heart, open up all of the chambers and actually SEE where something failed, got plugged up, etc he could be alot more accurate too. Surgeons find undiagnosed problems all the time just because they are in there looking.
Ohmigod. You’re not the same person. I suddenly understand how people feel when WotNot and I reply to the same thread. How many times in the past have I confused one of you for the other?! Sorry about that…
This study can be faulted for selection bias in a big way, so should taken with a grain of salt, but
But also note: of course that which is the answer key, the “gold standard” by definition, will be right 100% of the time; everything else less so.
The op seems to be asking how come those who have unwrapped the box and opened it up are so much better at guessing what was inside than those who can only look at it from the outside, lift it up, shake it a bit, and listen really closely? It’s really a silly question and hard to believe it was seriously made.
I suspect he’s a victim of CSI style “diagnostics” where the MRI’s are pristine, 3 dimensional and float four feet above a table so that you can see everything from bone chips to undigested food in the stomach, and complicated computer models can recreate an entire crime scene from the angle of a bullet trail in the drywall. In reality, MRI’s are very cool, but often inconclusive, ultrasounds can be blurry, and lab values tell you a lot about what’s going on, but what’s causing those lab values is still educated guess work.
Tests are great, but they just don’t replace poking inside dead things with a stick.
Yes, there are a number of studies showing a discrepancy between antemortem and postmortem diagnoses; I can’t dispute that. Still, in my estimation, the diagnoses that had been missed were often clinically irrelevant (usually because they weren’t responsible for the symptoms/pathological processes at hand). More to the point, and as you alluded, autopsies tend to be performed precisely in those circumstances where questions were to be answered, or where there was at least a suspicion of more going on than met the clinical eye. So, of course, things will be found that were not known.
In my practice, admittedly skewed to what is tantamount to a practice in ‘palliative geriatrics’, i.e. teaching hospital general internal medicine, the diagnoses are staring you in the face - diabetes, CHF, COPD, etc. Whether the last insult is a missed infection or infarction is seldom relevant.
As far as autopsies go (and they are a very minor although time-consuming and annoying part of the pathologist’s job), it is not uncommon for pathologists to be unable to precisely cite the cause of death. Some mysteries remain even after autopsy. There are many cases where significant findings go undiscovered until autopsy, though less than in the days before CT, MRI and so on.
Even with the bulk of our work as anatomic pathologists (tissue biopsies and excisions) there are exceedingly difficult cases that require ample special studies (such as immunostains) and recourse to outside consultants who subspecialize in an organ system. Other physicians who refer biopsies to us sometimes have difficulty understanding why we can’t supply a definitive diagnosis in absolutely every case (for instance, always pinning down the site of origin of metastatic cancer). 100% certainty still eludes us.
By the way, it is absolutely true that pathologists depend a great deal on getting good clinical information about patients from their primary caregivers. I’d be fumbling in the dark a lot of times without knowing the clinical history, results of imaging studies and so on. There are still physicians who send in biopsies with vague or no history (either through laziness or not wanting to “prejudice” the pathologist) but they are fortunately in the minority.
Speaking of “CSI-style diagnostics”, I am always impressed by the forensic pathologists on TV who harvest tremendous amounts of information within hours of completing their post-mortem exams, including drug screen and DNA analysis results which take days or weeks in the real world and are not always cut and dried. (I’d bet there’s lots of eye-rolling among forensic pathologists watching their counterpart on Law And Order - SVU for example).
Pathologists lose very little if they’re wrong. But you can find lots of examples of autoposies that are simply wrong. Poisons go undetected, that should’ve been, and wounds that are attributed to one thing, get the real diagnosis much later.
But if a physican is wrong with a live patient, there’s more to lose, so they are smart not to be totally commited to a diagnosis that may or may not be correct
And as I said, some physicians are better than others, or take more pains than others, at diagnosis.
I’m content with someone poking and giving me a piece of what’s inside (and leave the patient alive).