Pathologic Memories

As an anatomic pathologist, I am frequently in a dilemma when asked what kind of work I do. For non-physicians the answer almost invariably requires further explanation. Sometimes I include the explanation all in one breath, “I’m a pathologist. We do autopsies and analyze anything that is removed at surgery, like an appendix or a lung.” Most people outside the medical world have some vague idea of what a pathologist does, but this idea generally conjures up grisly images. For many, pathology is equivalent to blood and guts, and a pathologist is some sort of social misfit working in some dank and poorly lit basement. “OOO – doesn’t that have something to do with embalming?” asked one visibly nervous secretary.

During my residency, I had collected various specimens from autopsies that showed the evils of smoking and drinking, including lungs and livers riddled with cancer or hearts showing the effects of hypertension or atherosclerosis. They were all stored in a large bucket of formaldehyde that I would take to schools for a very vivid demonstration of the consequences of poor life choices. At one school, a student raised her hand and earnestly asked, “Is someone making you do this job?” One day my friend Rudd peered into my trunk and said “what’s in that big bucket?” She was so intrigued that we immediately had an “organ recital” on her driveway, but her equanimity was unusual.

Pathologists also don’t get much respect among the physician community. The image is typically of the socially inept or English-as-a-second-language misfit who can’t hack it on the front lines of medicine. It is perhaps not surprising that pathology departments are often located in the basement of the hospital. There is a long standing joke stereotyping the different medical specialties, “Internists know everything and do nothing, surgeons know nothing and do everything, psychiatrists know nothing and do nothing and pathologists may know everything, but they are always a day late.”

While television and the movies have generally portrayed physicians as over-sexed and overworked surgeons, pathologists have been largely ignored, with a few notable exceptions. In a 1972 movie, the “Carey Treatment,” James Coburn plays the title role – a pathologist, of all things, who sets out to investigate the botched abortion and subsequent death of a colleague’s daughter and predictably becomes embroiled in the violent world of a drug cartel. Dr. Carey embodies all the traits usually reserved for surgeons. He is handsome, assumes that M.D. stands for “major deity” and surrounds himself with beautiful women. He even mouths off to a surgeon over the OR intercom, “Do you want the diagnosis now or do you want it right?”

The high point of the movie is when Dr. Carey, hospitalized for stab wounds, tussles with a would-be assassin. When Carey gets the upper hand, the drug-crazed killer offers him a deal and begins to pray. Dr. Carey then says the immortal words that have stereotyped surgeons for decades, “There is no God in this room, I make all the decisions.” The writers of this movie must have thought that it was necessary to explain why a lowly pathologist had acquired the persona of a surgeon. Early in the movie Carey confesses to one of his girlfriends that all he ever wanted to be when he grew up was a surgeon, but that “it didn’t work out.” While the movie does manage to make a pathologist look like something better than a feeble misfit, one also gets the impression that such a career should not be anyone’s first choice.

While casting Carey as a pathologist seemed like a curious choice, it began to make more sense when I realized that as a pathologist Carey can be both a physician and a detective, blending two of the basic staples of TV. The TV show Quincy picked up on this theme. Quincy was a crusading pathologist who risked his life to investigate crimes. When we first met, my future husband decided to watch a “Quincy” episode to learn about what I was doing all day. He was aghast to learn that pathologists routinely got shot at in the course of their work.

In 1982 I looked forward to the premier of “St. Elsewhere” which was billed as a real life look at residents in a decaying urban hospital. However, from the first episode, it became clear that the writers had pegged the pathology department as the source of black humor. Dr. Kathy Martin is a totally spacey pathologist and incidentally a nymphomaniac. She seduces her living conquests on the mortuary tables and later gets raped there. Another particularly grisly story line featured a pathologist selling body parts, specifically severed heads. “St Elsewhere” didn’t do pathologists any favors by portraying this specialty as a type of punitive purgatory for wayward internists. When Dr. Peter White is accused of Dr. Martin’s rape, all other medical privileges are stripped and he is sent (to the basement of course) to dabble harmlessly in pathology until the charges are investigated. While he cannot treat patients, apparently he can practice pathology without any particular training.

CSI:Crime Scene Investigation is a current family of TV shows that builds on the basic Quincy formula, with a lot of extra sex and technology thrown in. Instead of the aging Quincy, the detectives are either hunky men or women with exceptionally tight low cut shirts. In Quincy, the opening credits featured the grizzly pathologist in front of a line of policemen. Quincy says, “Welcome to the wonderful world of pathology.” As he rips the shroud off one corpse, all the policemen faint like a row of falling dominoes. CSI certainly includes plenty of blood and guts, but manages to glamorize the whole mess with exquisite slow motion simulations of bullets splintering skulls and shredded arteries spurting blood. The set is filled with all sorts of prop machines with blinking lights while the cast meticulously recreates crime scenes in artfully underlit sets of dark blue light.

Now I have worked in the city morgue, and I can tell you it was nothing like CSI. Every morning we would file into the over air-conditioned morgue that was so brightly lit you wanted to put on a jacket and sun glasses. Corpses gathered from the previous day were arrayed on stainless steel autopsy tables. You were supposed to eye all the bodies and then go stand next to the one that you wanted to work on. It was like picking out a blind date, only a whole lot creepier. There was occasionally a murder case, which was a lot more work than the “DIBs” patients (i.e. dead in bed). It was assumed that these poor souls had died of natural causes and thus warranted no more than a cursory autopsy. Occasionally the chief coroner would sweep into the room like a minor deity, particularly if there was some case that might require a press conference. Dr. Stein had become a faddish celebrity in Chicago when corpses of dozens of victims were unearthed under the basement of John Wayne Gacy, who held the top spot of serial killer for several years. Dr. Stein also was in the news during a prolonged heat wave in Chicago that killed many elderly people. I remember his complaint was not so much that the people had died, but that he was running out of storage room in the morgue.

Certainly forensic pathology has advanced in the past 25 years with fluids and fibers taking center stage, but even discounting the march of technology, it didn’t look like Dr. Stein contributed anything to the examination, and certainly the pathologists in the morgue were no crusading crime fighters like Quincy or the CSI cast. I remember one beautiful spring day we all felt like a road trip, and someone suggested that we visit a crime scene and try to find a bullet. Four of us hopped into someone’s convertible and arrived at what looked like a peaceful leafy neighborhood. We walked around to the back to inspect a porch where the crime had supposedly been committed. A bunch of neighborhood residents were hanging out on the porch, some were smoking dope. When we explained who we were, the residents visibly relaxed, and one said out loud to the group, “Don’t worry, its not vice, it’s just homicide.” We chatted with the folks for a while, made a token look for an embedded bullet, and then called it a day, headed back to the office, and wrote up a report saying that despite a diligent search, no bullet was found. No estimating angles, laser beams tracing a bullet’s path, and no discussion of whether or not the weapon was a Glock with a right twist.

So what do I care if the TV shows are unrealistic? With three different versions of CSI on the air, all in endless reruns on cable TV, I should embrace the newfound glamour and respect for pathologists. When someone asks what I do, I will now say with pride and conviction, “I am a pathologist, like CSI on TV. We solve crimes and make the world a safer place.”