I spent my birthday cutting up brains

Yesterday, I asked myself a strange question.

“If I told me __ year old self that I would spend my 28th birthday cutting up brains, would I believe it?”

Yes, it was my birthday.  And Patrick got me all four seasons of Everwood and I had surprise birthday cupcakes and bowling with the Child and D and I capitalized on tons of discounts and bought too many books with the gift card my parents gave me.  I ate a free donair and had ice cream and even got a real latte on a weekday morning (very luxurious).  It was a good  birthday as far as birthdays go, especially for me.

But, I did spend a chunk of my day cutting up brains.

As I have mentioned before, I am on a Pathology rotation.

As a result, I spent my birthday cutting up brains.

The last few days were neuropathology.  That meant, well, brain cutting.  Complete with a scalpel, butcher knife, forceps and a pancake flipper (to put the brain pieces we don’t use for slides back in the bucket for storage).

I suck at neuroanatomy.  My med school took it seriously, but I forgot all of it promptly after escaping the fumes of formalin that came to be known in my house as, “smelling like brains” (there is no better way to start your marriage than coming home to your husband “smelling like brains” and being told to go take a shower because you are that gross).  I need to learn it, but unlike the neuropathologist and neurosurg resident I was working with, I have to know the anatomy of, well, everything and learn other stuff too.

So, not only do I have poor manipulative skills, but I struggle to name arteries or know what structure is where (beyond the obvious, which are very different for me and for the pathologist) or what every structure does.  I did know these things.  Often it sounds familiar, but clearly not familiar enough.  And it doesn’t help when the other “learner” knows everything about brain anatomy.

I felt stupid.

It seems that is a trend this year, I have had a few rotations full of feeling stunned.  I hate feeling stunned.

Turns out, though, I am good at cutting the stuff up.  I follow directions well and have the right level of not caring about every little structure, but not butchering the right stuff.  My poor manipulative skills are improving.  Unfortunately, I couldn’t learn all of the anatomy over night.

I spent my birthday cutting up brains.

It is a strangely fascinating thing to do.  To see the anatomy first hand.  To try to figure out possible causes of death.  To start the process of confirming dementia.  To see how such small structures control such important things.

The brain stem.  The epicentre.  Where everything goes through.  It is just a bit bigger than a thumb.

The pituitary gland that controls all of our hormone production.  So small, you could lose it.  Pearl small.

Our bodies are so cool.

I spent my birthday cutting up brains.

When I was in Nuc Med, everyone made me promise I wouldn’t do surgery because of my terrible intention tremor and accident proneness.  I agreed.  Then, they were shocked to hear about me having to rotate through surgery.  Then, I had to do it again.  I am pretty sure cutting up brains (dead or alive) counts in what we were describing as surgery.

I still have all my fingers.  No harm came to anything or anyone (well, except my pride).

Patrick says that I was so weird as a kid and teen, I probably would believe I would cut up brains because I was strangely fascinated with the body.

Maybe.  But, once I hit Nuc Med and realized that I didn’t like surgery or cutting things up, probably not.

I spent my birthday cutting up brains.

Not many people get to say that.

I do.

That makes me really fortunate.  Even if it isn’t my favourite thing.

My head hurts (welcome to pathology)

My head hurts.

Translation: Welcome to your Pathology rotation.

Yes boys and girls, despite me swearing after my med 4 pathology elective that I would not do pathology again, here I am back at it for the last 4 weeks of PGY2.

Pathology is neat.  I like knowing what things look like and seeing stuff that causes disease.  I really enjoyed my rotation in med school.

I do not like microscopes or formalin.

Neither does my head.

I had hoped that because I am on different migraine prophylaxis, off combined OCPs and in better shape this would not be as much of an issue.  It isn’t as much of an issue.  Day two and no migraines, which is shaping up to be better than the first time around where I had a migraine on day one or two and every couple days thereafter.  But, I have had daily headaches.  And those are still not cool.

I need to drink more water.  And maybe getting back to the gym will help.

Perhaps this is just a blip and it will get better.

I have already learned a bunch and I can sense I will enjoy this pathology rotation even more than my med school rotation by virtue of how much I have already learned and how many teaching sessions and interdisciplinary rounds are going on.  Plus, my learning is targeted toward oncology, not entirely randomness. I am okay with spending my evening reading about gastric cancer pathology reporting and staring in microscopes half the day when it means that I will better understand the disease in the end.

I will have a good rotation.  Even if my head is trying to disagree.


Physics Avoidance

I have been eaten by physics.

Okay, I really like physics, but I have this exam coming up on Thursday (unless someone decides to move it again).  And unlike last year, I have to pass it this time around.  Silly world expecting me to actually know stuff.

Needless to say, I goofed off all last week on vacation with my parents visiting and such (and before that it was manuscript writing), so this week is hammer time with the physics books, well, that and showing up to my Molecular Genetics classes and labs and watching playoff hockey (please don’t let tonight be the last game for the Habs, please!?!?).

And yet, I am here, writing a post.  It will be short and sweet and simply some randoms.

I finished The Rosie Project by Graeme Simsion on Sunday night (it was my final act of vacation… That and staying up late to watch the hockey game, but I do that during the playoffs without vacation, so it doesn’t count).  It was one of the better books I have read recently.  I can relate to the main character who has a Sheldon Cooper-like (and thus, in some ways, a Trisha-like) personality.  Very funny, very easy read.  You should check it out.

The Child and I, after about 2 years of playing Super Mario Brothers on the Wii have made it to level 3.  If you can’t guess based on the timeline, we die a lot.  And level 3 is filled with us screaming “PENGUINS” and then dying.  I think it makes the death more fun.

My “nephews” turn 12 next week.  They are the same age as the kids Patrick teaches.  That makes me feel so freaking old.  It also makes me remember I need to get them cards.

I have discovered during this Molecular Genetics rotation that DNA is beautiful.  Especially when being analyzed by FISH or SKY.

Spectral karyotyping. I love the pretty colours.

BCR/ABL is an abnormal fusion gene that is found in leukemias. Image from Wisconsin State Laboratory of Hygiene.

My herbs are sprouting!  I have no clue what is what.  Hopefully that will become more clear as they mature.

On another plant related note, Jeter killed our orchid.  Snapped it clean in half.  Jerk.

Jeter broke a mug at 3am.  Well, we assume it was him.  Or we have a poltergeist.  Or a clumsy thief who forgot to steal stuff.  Really, this is another reminder why we shouldn’t leave stuff on the counter.  It is also why I am grateful that I sleep like I am dead because Patrick had to wake up and deal with it.

Speaking of my destructive cat, the Child showed me these videos on YouTube called Simon’s Cat.  I find them delightful.

Patrick is going on a field trip this week with his class overnight.  He is excited.  I can think of few things I would want to do less than hang out at a camp with a ton of 11 and 12 year olds.  That is what makes us different.

Burning flesh and other medicine related stenches

Today, I was in the breast OR assisting in some relatively clean and quick lumpectomies and mastectomies.  For me, it is a great learning opportunity, as I will see some similar women for consultation for radiation in the future.

During our last surgery, the smoke evaporator got plugged with a fat chunk and thus, when we used the cautery, the odor of burning flesh was a bit stronger than usual.  It was cleared quickly because people are not fans of operating with the burnt flesh smoke in the room… Kind of gross and like smoking can increase lung cancer risk with long term exposure.  All seemed to be well.

I left the OR and went back to my office to work on a presentation.  All I could smell was burning flesh.  The smell stuck with me until pretty much when I left work about 3 hours later.

It made me think of five other smells that really linger and are rather disgusting that we encounter in medicine.

Melena.  This is poop that contains partially digested blood.  It is black, tarry and has a stench that can be picked up for a disturbingly large radius.  It always smells that gross.  Once you smell it once, you always recognize it.

Formaldehyde.  The stuff may preserve dead bodies and organs and such, but I swear it also preserves your nose hairs.  When I was doing neuroanatomy, Patrick would complain that I came home smelling like brains.  When I was doing anatomy and pathology, I was relatively convinced that I always smelled formaldehyde.  I would question if I somehow got some on my hands or that I was eating it.  Everything smelled like formaldehyde. It was awful.

Anaerobes in pus.  There is something about bugs that don’t need oxygen to survive and the disgustingness of pus that is always extra nasty and distinct.  I was in on a surgery to clear out some liver and intrabdominal abscesses, one of which communicated with the large bowel (of note, this was one of the most disgusting surgeries I have ever been in).  When we broke into the first abscess a strange smell that was kind of like a cross between poop, onion soup and pus filled the room.  I smelled that abscess well into the night.

Birth.  It is not the worst smell by any means, but it is indeed distinct.  Every delivery I have been to has a similar smell that I have labeled as birth.  It isn’t too bad… Except at 4am when you are already nauseous from being tired.

Image from anguishedrepose.wordpress.com.

Unwashed, unkempt person.  Often this is by no fault of the person in question, but a result of significant disability with no help or poor social circumstances.  But, sometimes I have to get uncomfortably close to an individual who hasn’t bathed voluntarily or not for a long time.  This, mixed with stale cigarette smoke is another smell that seems to linger on me even after leaving the scene and stands out as a similar experience every time.

There are some odors that do not sit well with people.  I am pretty much certain these are odors that do not sit well with anyone, but are necessary evils when working in the hospital.

What are some smells you just can’t stand or that stick with you in a not welcome way? 

Cellular inspiration

Today, in the Path lab, I was a tad on the distracted side.  Needless to say, I have been getting more and more antsy as the week has gone on with some impending vacation and interview time around the corner.   Also, despite learning and continuing to learn a great deal about pathology and lab medicine as a whole, I feel as if I could be doing more and that I am not getting everything that I could be out of the rotation.  I got what I expected and what I wanted out of the rotation, but it is very touch and go with regards to learning opportunities beyond self-study.  Thankfully, one of the pathologists took me under his wing this morning and showed me a ton of stuff.  Mainly ears, nose and throat things (given that was what he was told to review).  But then, in conversation, he found out that I am interested in oncology, so he cracked out a few more “cool” cases he has been reviewing  show me some of the subtleties in pathology.  I am grateful.  One, because I learned something.  Two, because he killed at least 3 hours of my day.

The rest of the day was consistent with yesterday.  I sat reading a textbook and taking notes waiting for something to happen.  In the process, I have learned a lot.  For one, I have at least skimmed the entirety of Robbin’s Pathologic Basis of Disease brought to us by Cotran, Kumar and Collins.  This is useful in many ways… I have reviewed almost every body system (handy for the LMCC, my big licensing exam to be written in April).  I also took notes on the various tumors that can happen in all of the body systems to prepare questions for a peer-reviewed quiz site for medical students and residents that I moderate (www.quiz.md).   Early on in the afternoon, I was starting to get really bored and frustrated, as I was starting to wonder if this is really the best way to be learning.  So, I took a break and ate a delightful square from the bake sale upstairs (thank goodness for bake sales) and prayed for patience and perseverance (and checked Facebook, my blog stats and my email for the billionth time today).  When I went back, nothing had changed.  Except my attitude.  I decided to try to find the bright side in all of this sitting and waiting and reading and looking at slides (some of which I already listed).

Cells stained for keratin and DNA: such parts ...

Cells specially stained to show keratin and DNA. Image via Wikipedia

Somewhere between staring into the microscope and reading about body systems processes, I began to think (well, think beyond pink and purple cells).  I was examining a few slides with laryngeal (vocal cord) cancer on them and noticing the inflammatory reaction taking place.  The body was trying to fight the cancer growing in itself.  It was failing, but it was trying.  Here I am looking at these tiny little structures and I realize just how amazing our bodies really are.  How complex.  Millions of tiny tiny cells that form together to form organs.   That synthesize all of the proteins we need to function.  That protect us from infection and heal us from injury.  And all of these processes are programmed into tiny little DNA molecules.

If you study the body, or almost anything else in God’s creation, you can see how intricately things are formed.  We still haven’t figured out how some diseases happen or why the body knows exactly what enzyme to break down what food (well, chemical structures, but not every facet of the process).   We can estimate the distance between the Earth and the Sun, but we still don’t truly know how many stars or planets there are.  Sometimes we just don’t know, even in our know-it-all science-based society.

I love having answers.  I am fascinated by how each body process works.  It is amazing and yet terrifying how just one mutated cell with tiny errors in the genome can multiply and cause widespread cancers in so little time.  How the flu strain this year will be ever so slightly different from the strains next year. Mutations… Survival tactics… How we and other living organisms get through.

Looking at cells under the microscope… Even normal skin, which in and of itself is the largest organ and a barrier to the outside  world… It is amazing how the structures form and work together.  How the cells know when to proliferate, how to migrate.

The other day, a physician was teaching me about ovarian cancer and we got talking about how ovarian cancer spreads to this section of fat called the omentum.  The omentum is a layer of fat and blood vessels that is in the abdomen.  On top of the intestines and such.  The omentum is a common site of cancer spread because it has many blood vessels and just sits in the fluid in your belly.  It is a simple organ… Fat, blood vessels, a couple ligaments hooking it to the bowel.   But, it moves.  It wraps itself around sites of infection and inflammation in the bowel.  It has been said to plug a perforated ulcer, to surround cancer.  Nobody really knows why.   It doesn’t have muscle; it doesn’t have a nervous supply.  How does it know?   Studies suggest that the omentum is incapable of moving on its own (though it looks like it does) and that it moves based on the movements within the gut, diaphragm and position.  It is postulated that it sticks due to formation of fibrin on contact (basically a protein type glue) and stays stuck because the contact with inflammation causes more blood flow through the omental vessels, thus bringing along white cells and other cells that make more materials that help it to stick like fibroblasts (Florey, Walker & Carlton, 2005. The Nature of Movements of the Omentum, The Journal of Pathology and Bacteriology 29:1).  Still, there is debate as to whether or not another piece of the puzzle is missing and why it functions the way it does.

Omentum. Image via Wikimedia.

I can’t look at the body and how intricately it all works and say there is not a Creator.  It is too complicated and there are far too many intelligent people who cannot get it sorted out in full.  All of those cells working together.  Its craziness.

For you formed my inward parts; you knitted me together in my mother’s womb.  Psalm139:13

When you think about it, our body is like our communities, our worlds.  Bad things happen when one of the pieces stops doing its job or changes in a negative way (i.e. carcinogenesis).  The changes have nothing to do with who made the people or the cells.  They are caused by errors in how the cell reproduced or how the people made choices.  They are caused by things outside that should not have been allowed in.  When defenses are down.  And like our bodies, when we see that happening, we need to step up, to help to fix things or protect things. We need to be like an omentum and wrap ourselves around those who are hurting and protect them from the harm.  And for that matter, protect others from the harm.  We need to home towards the lost, the hurt and the wrong and heal it.  Like our physical bodies, we need help from the Creator, we need to follow the instructions laid our for us.  Sometimes we need others to help for us, like medicines.  Professionals who know how to address certain issues or needs in the world and aid us in healing as a community, as a nation.

Just as a body, though one, has many parts, but all its many parts form one body, so it is with Christ. For we were all baptized byone Spirit so as to form one body—whether Jews or Gentiles, slave or free—and we were all given the one Spirit to drink.  Even so the body is not made up of one part but of many. 1 Corinthans 12:12-4

The body is so intricate, so well-designed.  That is how we should be as a people.  Connecting, supporting, sustaining.

Who knew cells could be so inspiring?

Path crazy and footwear follies

You’re like a caged animal.  -Patrick

Animal... Not caged. Image via Wikipedia

I am Path Crazy.  Patrick helped to qualify that this describes my current state… Similar to bat crazy, but caused by too much time in the pathology department doing too much of not much of anything.  Meaning I am shack-wacky from sitting in a room reading a textbook for most of the day because everyone was too busy/uninterested to teach me (the physicians I was assigned to today were less than keen on teaching).  I have been a bit crazy after work most days.  It comes from the whole being left to my own devices staring at slides for large chunks of the day.  So, I am a bit more giddy and chatty and such.  Almost too giddy and chatty and such.

Thus, this post may be a touch on the random side.

First of all, it snowed today.  Enough to give Patrick a snow day.  Enough to make me strap on my giant green poofy parka and these puppies:

The boots. Warm, dry, tacky and semi-uncomfortable. What isn't there to love? So long as I don't have to wear them all day.

Yes, I bought them intentionally.  With a coupon too.  I was drawn to the pink and orange sides.  Not so much the largeness or ugliness of them as a whole.  Plus, they are waterproof… Important in the soggy winters we have in this area.

I went off to work this morning ranting about winter and snow and cold and how there are no windows in the cave that is the lab, so I won’t actually know how much snow we are getting until lunch time.   It wasn’t until I got in to the hospital that I realized I was missing something.  Well, my lunch for one thing, but I realized that when I left the house (I forgot to make one last night… oops).  My bag was light, but my feet were heavy… And a bit uncomfortable.  Yes, I forgot shoes.  I dragged my feet (quite literally… those boots are heavy) to my locker where I discovered my other option.  I have this delightful pair of knock-off grey converse sneakers.  They are several years old and dirty.  I wear them to the OR and on call… They go well with scrubs.  Not so much dress pants.  Grey dress pants.  But not the same shade of grey… Enough that they would clash.  Nonetheless, the prospect of wearing sneakers all day seemed better than giant winter boots, so on they went.    I went most of the day without anyone noticing (or at least saying something), though I noticed every pair of shoes everyone was wearing.  Then, at the end of the day, I was on the hunt for the person who was supposed to be teaching me something, when another pathologist, who I don’t know, said, “nice shoes… forgot real ones, eh?”  Busted.

The shoe error happens often to me.  Different versions.  Another classic is forgetting to bring OR shoes (thus the pair that have now taken up permanent residence in my locker).  Then, you end up wearing cute little flats with scrubs.  And people point out that you probably shouldn’t do that because the tops of your feet are exposed.  Yum, body fluids in your shoes!

A few years ago, when I first moved here, I had four roommates.  All girls.   As you can imagine, there were a lot of shoes.  So, this one morning, I was getting ready to go catch the bus and I was in a bit of a hurry, so I put on my shoes (in the dark, of course) and head to school.  Whilst sitting on the bus, I realize one of my feet feel funny.   That was because I was wearing two different shoes.  And one of them was not mine.  It was clinical skills day.  How professional.

Mix-ups like my shoe things don’t happen much in the path lab.  They check, check and recheck everything semi-obsessively.  And with good reason.  Mixing up specimens is significantly more critical than mixing up shoes.  In fact, they reject everything that is improperly labeled or mismatched. Last year, they rejected something like 200 Pap smear specimens because of incorrect or missing information on the labels and requisitions.  Its a good reminder to be more careful with documentation, not just with specimens, but in all areas.  Mistakes happen.  Although, I might argue that at face value, the specimens would be easier to mix up than a pair of shoes, though the specimens significantly more critical.

I am not the only one to inadvertently wear two different shoes... though mine was more subtle. This is Patrick sporting two very different shoes on the way to one of our wedding showers.

In other news… Patrick surprised me with a shoveled driveway, flowers and cooked supper tonight.  A product of his snow day productiveness… And the fact that it really didn’t snow that much at all.  What a welcome to someone going a little path crazy.   This is why God gave me someone who is not and has no interest in becoming a doctor and happens to get snow days.  So that I get little hints of real-world sanity when I emerge from the cave.

The flowers. That are so green they look artificial in a water bottle (we really need to get another vase). I love them!

Seeing pink and purple/blue… Lessons in Pathology.

This is a hematoxylin and eosin stained slide ...

Sea of pink and purple. This is normal skin. Clearly. Image via Wikipedia

Week two of the Lab Medicine rotation.  Much to my surprise, it is not as bad as I thought it could have been.  It has some elements that I dislike (for instance, eyestrain and lack of patient contact), but overall it is reasonably interesting and relevant to my future career.

Pathology is a bit of a black box.  In medical school, we learn a fair bit about pathology in our first two years, but I feel like we never really got the detail or clarity that we get from other specialties.  Pathology is not a core rotation, so we have the option of covering it in a two-week non-core selective in fourth year.  I am one of the 5 people in my class who opted to do this.  A lot of what I expected from Pathology was based on the glimpses from the first two years of school and what I saw of it from the media and my other rotations.

From my other rotations, I heard a lot about how they work with pathology.  Generally, this includes complaints about how long they take to get reports out and questions about the integrity of said reports.  I learned a lot about documenting specimens and proper collection of specimens.

The site I am working at has been the centerfold for several pathology inquiries, one of which made national news.  There have been many changes to the way the department is run, how and where certain tests are done and how they communicate data to the physicians on the floors.  The aforementioned inquiries came down to systems issues (overworked, under resourced… the unfortunate usual in healthcare).   Unfortunately, there is still a great deal of tension in the community as a result, with distrust of the pathology system at times.

Going down to the lab is in and of itself an adventure.  The architects that built the hospital felt it was clever to build the floors so that no more than two staircases connected (to prevent smoke from travelling) and that hallways should not all run parallel or perpendicular in a reproducible fashion.  I had a vague idea where the lab was based on where we drop off stat specimens, so I wandered down there and was hoping for the best.  I picked a random door that was marked specimen receiving (promising, no?) and realized it was locked.  So, I tried my trusty key card and shockingly it worked.  I never knew that I basically have swipe access to all of the labs.  Not that I usually need it.  But now, in case I ever have a compulsion, there we go.  There I am, wandering aimlessly through the lab.  Nobody asks who/why I am there.  Finally I found the pathologist’s office I was supposed to report to.

Prostate cancer

Prostate adenocarcinoma. I spent an entire afternoon looking at and for this with one very enthusiastic pathologist... When people get biopsies of the prostate, it usually includes upwards of 7-10 biopsies, each of which are sectioned into several pieces. Each one gets examined. That means for each patient, there can be 40 or more sections to look at. Image via Wikipedia

I have been bounced between various people to see different aspects of the lab.  One of the most interesting (not really) things that happened has been when I get placed at a desk in the resident room and told to look at these slides and see what I think.  I don’t even know what body part I am looking at, let alone thoughts.  Pink and purple.  That is about it.

A few of the pathologists and residents are ridiculously pumped to teach.  Well, as excited as they get.  They really don’t get many clerks, so there is a great deal of puzzling about what to show me and how much detail to go into.  They all ask if I want to do pathology when I grow up.  And I say no.  And they look sad.  There are a few people in my class going into path and a couple of the residents are excited to get more “normal people” in path… Not sure what they were going for there.  Needless to say they teach me, especially the oncology side, where we will be working together in the future.

The pathology people are different than some of the others I have worked with.  More quiet, on the whole.  More social too… But in a quiet way.  For instance, it took two days before I actually spoke to most of the residents because they are so engrossed in doing their own thing amongst themselves.  I was convinced they all just didn’t really converse and when they did, they were awkward (not that I am a social butterfly, but I was trying because it was weird to me).  Then, they realized I wanted to learn.  And they became more friendly and open.  They show me the cool cases now and suggest the interesting rounds to attend.  They are big on consulting amongst themselves and showing cool cases.  I think we in clinical medicine could learn a lot from their collaboration.  They have a different work ethic too.  I noticed that they pace themselves more.  Not running with their heads chopped off.  They work later, though.  Not actually later, but I have been in until after 5 every day, whereas on the floors or clinics, if you are fortunate enough to get done early, you peel because you don’t know when it will happen again.  They love what they do, just like the people on the floor.  I have had several of the pathologists look at cases for hours with me on the multihead microscope.  Long after I am getting an eyestrain headache and am doing the sleepy head bob.  I appreciate the enthusiasm.

Funny thing is that I have somehow absorbed something.  I have never been able to see things well under the microscope.  It is a miracle I passed our histology course in first year.   I still can’t see through the microscope with both eyes simultaneously (despite people telling me how to properly adjust it and such).  But then, I was doing the whole look at random slides thing today and some of them made sense.  I can pick out obvious tumors.  I was giving myself imaginary high-fives today.

Histopathology: microscopic appearance of inva...

Invasive ductal carcinoma... aka breast cancer. This specimen would also have slides sent for special stains to determine hormone receptor status (influences treatment). In my neck of the woods, that would involve them being sent to another hospital many hours away. Thus, these things take time. Image via Wikipedia

Many people in my class have asked why I wanted to do a path selective.  I love clinical medicine, so why bother?  Why not do something “cool” like anesthesia.  The thing is… I will work with pathologists every day.  I will trust their reports.  I should know where they come from.  What they need to know from me when I send specimens in (it is amazing how terrible some of the requisitions are… clinical information does affect pathologic diagnosis).  Why sometimes they send things away for further analysis.  Why they aren’t always 100% certain on diagnoses (most different cancer subtypes have only subtle histologic differences, but sometimes significantly different treatments and prognoses).

They say medical school is when you get to see your options, when you can explore medicine.  That is what this path selective is doing.  It is showing me a world I have never seen this closely.  It is decreasing the stigma of the unknown.  It is increasing my trust (but in an educated manner) in those I depend on for definitive diagnosis.  Cells and specimens can tell a whole story if you pay enough attention.  The pathology people see the forest through the trees and are trained to interpret that to those of us who may not always be able to see it for ourselves.