Hidden Specialties
Meet the doctors of sleep, images, and microscopes
The focus of the "America's Best Hospitals" rankings is on medical specialties that most of us have come to recognize. From cardiologists to neurosurgeons to psychiatrists, practitioners of these specialties are stage front and center, the public face of hospital medicine. There's more to the story, however. Behind the scenes, doctors, nurses, and technicians you may never meet play vital roles in other specialties. This year we pull back the curtains for a closer look at anesthesiology, radiology, and pathology--three of the "hidden" specialties.
ANESTHESIOLOGY
The night shift is still on the job when Jeffrey Apfelbaum starts his normal workday. Pulling into a parking garage at the University of Chicago Hospitals at 6 in the morning recently, his car is one of only five. The other four, like Apfelbaum's, belong to anesthesiologists.
"We're the first to arrive and usually the last to leave," says the genial Apfelbaum, more pleased with the dedication of his fellow specialists than distressed by the long days. As chair of anesthesiology and critical care at the five-hospital complex on Chicago's South Side, Apfelbaum is a little miffed that his specialty has such a low profile. "Sometimes a patient will ask, 'Well, what does my doctor think?' and I have to explain that I am their doctor," he says. "A lot of people don't really know what it is we do."
The day officially begins with the swipe of a mag card through the ScrubStation, an automated vending machine that dispenses fresh sets of purple surgical scrubs. There are 25 operating rooms,and this particular Friday, the agenda will include complicated blood vessel grafts for Charles Christian, a retired police officer in his 70s suffering from severely limited blood circulation to his legs. Without treatment, he'll most likely lose his legs.
In many hospitals, anesthesiologists are becoming the human face of surgical care. "From the time patients are scheduled for surgery until they've recovered from the stress of surgery," says Apfelbaum, "the anesthesiologist is responsible for their medical care. Not the surgeon, not their internist or general practitioner." Christian's anesthesiologist, Jerome Klafta, and senior anesthesiology resident Annette Schure spend almost half an hour with Christian and his family before the surgery, conducting a final examination and answering questions. "The bottom line," says Klafta, "is that patients are usually scared and they want to talk." Taking the time to listen, he says, "is part of what we do."
More than sleep. But ministering to patients undergoing some 71 million surgeries a year in the United States is no longer all that anesthesiologists do. "People have this impression that we just put people to sleep and wake them up again," Apfelbaum says. "Thirty years ago, there might have been some truth to that, but we've made a lot of advances."
Besides conducting presurgery tests and assessments, five of the hospitals' six critical-care doctors in the surgical ICU--their "intensivist" subspecialty is relatively new--are anesthesiologists. Others work in the burn ward and the outpatient pain clinic. And because they're specialists in resuscitating patients, the anesthesiologist on call is often the first doctor to respond to "code blue" emergencies.
Many surgical anesthesiologists, in fact, now refer to their field as perioperative ("in and around surgery") medicine, which might not be easier to pronounce than anesthesiology but helps capture the scope of their responsibilities. "It means we're managing all of our patients' medical problems while they happen to be going through one of the biggest stresses in life," says Apfelbaum.
Klafta and Schure start working on Christian as soon as he is rolled into operating room No. 13. Stationed at his head, they variously attach and insert an array of sensors onto and into his body to monitor his condition through the coming ordeal, including a catheter placed directly into the radial artery in his forearm to monitor blood pressure with every heartbeat. Christian had a heart attack and coronary bypass surgery last November, so special care has to be taken to detect--and treat--even the slightest signs of heart trouble.
Through an IV, they administer fentanyl, a powerful narcotic, to deaden pain, and propofol, a hypnotic, to induce sleep--minus any dreams or memories. Throughout the complicated procedure, which involves using some of Christian's own blood vessels and a Gore-Tex replacement as grafts to restore blood flow, the anesthesiologists remain at the patient's head. They monitor his condition, maintain his body temperature, and administer a wide range of drugs: before surgery, cisatracurium, a muscle para-lytic, to help ease a breathing tube into place. Later, a shot of ephedrine, to correct a dip in blood pressure. Heparin, an anticoagulant, to prevent blood clots during the long surgery. And more. The risk of death or major complication from surgical anesthesiology has plummeted 95 percent over the past 20 years, says Apfelbaum, thanks to education and improved training, more-sophisticated monitoring, and fast-acting "rescue" drugs that address dangerous swings in blood pressure and other potential catastrophes. "I'll go an entire day and only use meds that have been introduced since I started my training," says Klafta, who started medical school in 1990.
Meanwhile, there are 24 other operating rooms to worry about. Coordinating all the procedures is no easy thing, especially when emergencies bump scheduled surgeries from the roster. The job of "running the board" --calling for a blend of maître d' and air-traffic controller --almost always falls to an anesthesiologist. Today, it's Tom Cutter's turn. "Surgeons make the rules," he says, "but we are the keepers of the OR. This is our house." When problems arise, he says, "they call us and we triage stuff. It requires a fairly sophisticated medical understanding to figure out which patient is in the most dire condition." This particular day, that includes an urgent craniotomy for Elijah Norman, a 2-year-old with signs of fluid on the brain. Cutter decides to postpone an elective surgery to free up an operating room and contacts a pediatric anesthesiologist. Elijah will need an MRI before going to the OR, and the doctors decide to give him a mild sedative before the procedure; fidgety kids and imaging devices that demand stillness don't play well together.
Anesthesiologists like to maintain they could make a lot more money in other specialties. But they also take considerable pride in the special magnetism of their field. Anesthesiology residency and post-residency programs are "often able to attract the best and the brightest" medical students, Apfelbaum says, even if many of them entered medical school with specialties that are more glamorous, like surgery, in mind. "You get to see physiology, pharmacology, all these things you studied in school, right before your eyes," says Apfelbaum. "There's the immediate gratification of seeing your intervention do something dramatic."
Beyond the OR. Until recently, gratification was mostly to be found in the operating room. But now anesthesiologists work throughout the hospital, from the ICU to the maternity ward, where Kenneth Rodino has spent all night helping to dull the pain that medical texts commonly label the most intense of all: labor. He administers epidurals, the shot of anesthetic near the spinal canal to numb the lower body. But that's not all. Especially when complications are a risk, he says, "the main thing is to take care of the patient," monitoring her condition and watching for trouble. Managing chronic pain is another recent mission (Page 54).
But it is surgery that remains anesthesiology's main focus. Back in OR 13, the surgical team is finally coming to the end of what turned out to be a very difficult case. Klafta and Schure have been adjusting drug dosages for an hour, gradually bringing their patient closer to consciousness. He begins to stir just as the final sutures go in. "Mr. Christian," Klafta asks gently, "how do you feel?" Eyes opening for the first time in eight hours, Christian blinks, shakes his head, and hesitates as if he can't quite believe the answer. "Fine," he says at last. "I feel fine."
RADIOLOGY
'Oh, there's always a patient" is what Emily Conant will say if asked if she has someone waiting. What? Don't radiologists lurk in windowless basement offices, safely shielded from the messy world of patient care by layers of X-ray films?
Most of them did, and many still do--the stereotype isn't completely unfair. A radiologist in a candid mood will even say it's one reason some fellow practitioners chose the specialty. But radiologists are moving out of the shadows. On any given day, Conant, chief of mammography at the Hospital of the University of Pennsylvania in Philadelphia, sees dozens of patients, not just to take a quick snapshot but to counsel and care for them. "Every patient is different," says Conant. "It's so important to spend time with them, so you can help make a potentially bad situation better in any way possible and help them move on to the next step."
Neat new tools. There are still plenty of X-rays of broken arms and sprained ankles to read, and such familiar work makes up the bulk of radiology practice at any general hospital. At Penn, that includes some 350,000 patient examinations a year, from prenatal ultrasounds to bone density scans to detect osteoporosis. The radiologist's tool kit has expanded, however, as new technologies have come onboard--CT scans in the late 1970s for creating 3-D images of hard and soft tissue, followed by MRIs and PET scans that can produce yet more detailed images and even detect and depict the metabolic activity of organs and cells. And the specialty itself is branching out in unexpected directions.
The radiology department at the Hospital of the University of Pennsylvania, one of the largest and most diverse anywhere, is a case in point. There are hands-on types like Conant. Then there's Mitchell Schnall, an MRI expert and head of Penn radiology's research division. (Schnall does have a darkish basement office, but like most radiologists these days, he reads his images on a computer screen.)
"I'm about as close to a researcher as someone who still practices medicine can be," Schnall says. Like anesthesiology and pathology, radiology is a cerebral field. It hooks doctors as interested in the science of medicine as they are in the art and practice of it. Schnall says he might well have become a physicist had he not come from a medical family. As an M.D. with a Ph.D. in biophysics, he's a critical link in the "translational medicine" chain of collaborations that take discoveries from the lab bench to a patient's bedside. Radiologists like Schnall work with physicists and engineers to develop more powerful, safer, and less expensive imaging techniques. "Radiology is moving beyond showing the fact that something is there to finding out what's happening to tissues at the molecular level," he says.
Using special radioactive probes targeted at specific cellular activities, for example, radiologists can use a PET scan to judge how fast cancer cells are growing after chemotherapy. The scanner tracks the decay of subatomic particles called positrons--the "P" in PET, or positron emission tomography--as they fly out of a small amount of radioactive dye injected into the patient. "You can see if metabolism is shutting down after chemotherapy," says Schnall, "so you'll know early on if it's working." That can give an oncologist early warning if a treatment isn't working, and it also helps evaluate the effectiveness of experimental drugs without waiting to see if a tumor in a patient enrolled in a clinical trial continues to grow.
Drawing a line. In another form of this "molecular profiling," radiologists are starting to use an MRI-based technique called MR spectroscopy to detect and characterize prostate cancer. By manipulating the MR machine's magnetic field, says Schnall, he can tease out the faint "resonance" signals of specific biological molecules. Coupled with a knowledge of cell chemistry, that can tell radiologists what sorts of cells are present. Normal prostate cells, for example, contain high levels of a substance called citrate, while rapidly growing cancer cells are loaded with choline, an important ingredient in cell membranes. The two compounds, says Schnall, mark a precise line between healthy tissue and cancer in an MR spectroscopy image.
While radiology is a specialty given to fondness for ever more esoteric imaging beams and force fields, Schnall is working with a team of physicists on a new imaging technology that uses plain old light. Near-infrared light rays--those at the low end of the visible light spectrum--can pass through up to several inches of tissue without harm (think of the red glow through your cheeks if you put a flashlight in your mouth in a dark room). Schnall hopes they can capture images of breast lumps and other abnormalities. During a recent visit, he was using a green dye (which absorbs reddish light) injected into blood vessels that supply a volunteer's breast to see if a prototype optical imaging system could detect specific patterns of blood flow that indicate the presence of a tumor.
"Imaging with light is very complicated," Schnall says. Unlike X-rays and other high-energy beams and particles, light is absorbed or scattered by all sorts of tissues and cellular components. The challenge, says Schnall, is to transform a scattered signal into a sharp image. If he can solve that mathematical trick, Schnall says, the research may lead to safer, cheaper, and less painful breast-imaging devices. They could even be used by a patient at home.
Neck-up specialists. A new subspecialty, interventional radiology, has moved beyond using forms of radiation to find and diagnose diseases to treating them (story, Page 59). Neuroradiologists, who specialize in imaging everything from the neck up, do some interventional procedures as well, says Elias Melhem, Penn's head of neuroradiology, although most of their work is still diagnostic.
Say a patient is referred to a neuroradiologist with symptoms indicating a possible brain tumor. Neurosurgeons used to spend hours trying to deduce the tumor's location before opening the cranium. Now, says Melhem, "what used to take 13 hours of examinations and thinking takes 10 seconds. We have the tools to tell the surgeons exactly where the tumor is" --and to aid in removing the entire tumor but none of the brain. Intraoperative MRI s, miniature wand-shaped versions of the more familiar room-size magnetic rings, can make 3-D images of brain structure right in the OR so the surgeon can see whether all possible vestiges of the tumor are gone before closing up the cranium.
New uses for medical scanning technologies are everywhere these days, it seems. The worried well can walk into private clinics for whole-body CT scans, to make sure their bodies are not harboring tiny lung tumors, colon polyps, or some other nascent problem. And for expectant parents who can't wait to get started on the family photo album, ultrasound booths are popping up in shopping malls, selling prenatal portraits for $200 or more a session (probably safer than the X-rays shoe salesmen in the 1940s and '50s used to take of their customers' feet to ensure a good fit in a new pair of Oxfords, but the FDA warns that there could be unknown risks to the fetus from repeated exposures).
Schnall doesn't see anything wrong with people electing to pay for a full-body scan, just in case--so long as they know they might be asking for trouble. Sophisticated multislice and electron beam CT scanners are great at detecting unwanted growths, as well as lots of false positives--blips on the images that look bad but turn out, after needless worry and perhaps even surgery, to be nothing more than spots of scar tissue and other harmless stuff. "Yeah," says Schnall, "you might find something bad. But you're more likely to find lots of stuff you're better off not knowing about." Stamp this one "buyer beware."
PATHOLOGY
For much of the day, the pathologist's world is painted in swirling blues and orangy pinks. Every tissue sample removed from a hospitalized patient, from an entire massive tumor to a small clump of cells, makes its way to the pathology lab to tell its story under the microscope. The task of coaxing forth the narrative seems surprisingly uncomplicated, at least at first. A specimen is dipped into two dyes. Hematoxylin highlights cell nuclei in purple-blue, and eosin stains other parts of the cell in variations on orange.
In fact, it's not quite that simple. The palette can be much broader--there are hundreds of ways to stain cells to help distinguish diseases--and some pathologists use chemistry rather than microscopes to make their diagnoses. But whether tracking blood-chemistry changes on a computer printout or scanning colorful microscope slides for signs of disease, the pathologist's eyes rarely encounter a patient's face.
Hidden from view. Long considered "the doctor's doctors," pathologists are perhaps the medical specialists most hidden from public view, yet almost all hospital visits include their input. "Other physicians decide when it is worth it" to biopsy a tumor, says Tristram Parslow, pathology chair at Emory University in Atlanta. "But the only way to make a cancer diagnosis is for a pathologist to look at it under a microscope." At Emory's network of hospitals, Parslow says, that means some 250,000 colored microscope slides each year--and more than 3 million urinalyses and other chemical tests.
The process starts when a physician orders a tissue sample. Although some pathologists take their own tiny samples of a few cells using a technique called fine needle aspiration--a rare case of direct patient contact--most biopsies are done by surgeons. Then, says Sharon Weiss, director of anatomic pathology at Emory, it's "straight to the gross room," named not for the abundance of bits and pieces of the ill but for gross anatomy--the naked-eye description of the tissue--before being passed along for microscopic inspection. In the histology lab next door, specialized technicians like Kimberly Brown prepare specimens for the microscope. They start by embedding the tissue in paraffin, a wax used in canning fruit, and with a microtome--too similar to a deli counter meat slicer for the squeamish to contemplate--they shave off a ribbon of tissue just a few cell layers thick. An automated gizmo stains and mounts the specimens on microscope slides. Brown and her colleagues can process 500 to 700 specimens a day.
Deft interpreters. That's where the automation ends. "People think that you just feed a biopsy into a machine, and you get your diagnosis," says Weiss. "But it's a person who decides whether there's disease present." That work is done in a warren of "sign out" rooms (named for the pathologist's signature taking responsibility for the final diagnosis), where Emory's three dozen anatomical pathologists can be found working with nothing but microscopes and notepads, just as pathologists have done since German doctor Rudolf Virchow first turned a microscope to the study of disease in the mid-19th century. Basing their work not on quantitative tests but on years of experience, they interpret the slides, making thumbs-up and thumbs-down decisions that can spell the difference between chemotherapy and a clean bill of health.
If the specimens are cut and dried, interpreting them often is anything but. "To misdiagnose has severe consequences," says Weiss with calm understatement, "so the desire to get a second opinion is high." An expert in diagnosing rare soft-tissue cancers, Weiss says her typical day includes "about 20 jaw-breakingly hard cases from around the country." Emory's pathologists literally put their heads together over especially difficult cases, using a multiheaded microscope that lets a dozen doctors and residents peer simultaneously at a specimen. "Pathologists can differ in their opinions," says Weiss, so group sessions and second opinions are "a very important part of quality control."
The process usually takes about a day, but when a surgeon encounters an unexpected mass during an operation, only a near-instant turnaround will tell the surgical team what must be done next. Pathology labs are often situated alongside operating rooms, separated by what looks like a double-sided version of an ice-cream parlor's freezer case in between. "The surgeon opens the OR side and puts the tissue in," says Parslow, "and the pathologist opens the other side" in the path lab. The sample freezes in place, and the pathologist can cut a thin section, stain it, and look at it under a microscope--all contained within the freezer--getting a diagnosis back in 15 minutes instead of overnight. "Crunch time happens about 12 to 15 times a day," says Parslow. "That's what really gets an anatomical pathologist's adrenaline flowing."
No offense intended, but to be certain about the flow of adrenaline--or any other hormone--calls for the expertise of a clinical pathologist. These subspecialists are the doctors who take delivery of the thousands of samples of blood, urine, wound swabs, cerebral spinal fluid, bronchial washings, and other body fluids even less pleasant that are routinely sent for analysis. The heart of clinical pathology at Emory and many other hospitals is the "core" laboratory, a central analytical clearinghouse where the bulk of routine blood and chemical testing is done. Put thoughts of lab-coated chemists pouring fluids from beaker to flask and back again aside; this is a high-tech, highly automated operation.
Expanding world of tests. Samples in safely stoppered test tubes arrive from throughout the hospital by way of a pneumatic tube system, like those used in bank drive-through lanes. Labeled with a number and bar code, the tubes are fed into what looks like a conveyor track from an assembly line. Their journey spans only 30 feet or so, often in under 10 minutes. But in that time, the automated chemical analyzer will retrieve the order for specific analyses from the hospital's database, conduct as many as 41 different tests, and spit the results back into the database, available to physicians anywhere in the building. In addition, says James Ritchie, Emory's associate director of clinical pathology, the hospital has a dozen specialty labs for molecular diagnostics, immunology, high-sensitivity drug testing, and other specialized tests done in small numbers. "There's an expanding world of tests," Ritchie says. "Very rarely does a new one come out so perfect that it does away with previous tests completely."
It's not surprising, then, that the third major arm of pathology is experimental. Pathology, says Parslow, "was born as a research enterprise." In keeping with the specialty's laboratory roots, pathology remains highly academic and research oriented. Because of their day-to-day duties, pathologists have become custodians of large collections of human tissue. Logically, they often take a leading role in studying the diseases that produced the samples in the first place. For example, says Parslow, "we have the tissue, and now thanks to the human genome project, we have the genes as well. It's incumbent upon us to do the genetic research" to find genes that can indicate whether disease is present and what drugs it might respond to.
Genetic research--often conducted in collaboration with other specialists--has already transformed the diagnosis of infectious diseases. (The study of infectious diseases is a subspecialty of internal medicine, but microbiology labs are often housed in pathology departments.) Not so long ago, diagnosing an infection had to be done by growing bacteria, fungi, or viruses from a patient in the lab and performing metabolic tests to distinguish one organism from another--a process taking days or even weeks. Such tests are still performed, but now microbiology labs can also use the specific genetic profiles of different organisms to identify the problem--and recommend the best treatments--in hours or less. "Infectious genetics has totally transformed microbiology," says Parslow. "Using genes is now the way to go."
Pathologists are working with geneticists and other researchers to do the same thing with cancers and other noninfectious diseases with a genetic component. Still in its early stages, the research, says Parslow, "has the potential to enable us to do much more powerful things than we've ever done before." It's hardly the small, closeted role of a specialty generally unknown to the public. Pathology, especially at hospitals that push the frontiers of research--including many of those in the U.S. News rankings--may have to become accustomed to the spotlight.
This story appears in the July 12, 2004 print edition of U.S. News & World Report.