Many people, including medical students and physicians, harbor misconceptions that pathologists are unsociable and work only with the dead, says Melissa R. George, DO, who believes she was the only member of her class of some 250 medical graduates to pursue residency training in pathology. A broadly trained pathologist with two primary specialties and two subspecialties, Dr. George aims to dispel such notions through educating and mentoring others and leading by example.
The medical director for blood bank and transfusion medicine at Penn State Milton S. Hershey Medical Center in Hershey, Pa., Dr. George notes that her responsibilities are hardly solitary. She has direct contact with patients who are undergoing apheresis, manages a staff that includes nurses and technologists, and communicates constantly with physicians in other specialties. She also teaches and mentors residents, fellows and medical students.
A 2004 graduate of the Philadelphia College of Osteopathic Medicine (PCOM), Dr. George served a four-year combined residency in anatomic and clinical pathology at Thomas Jefferson University Hospital in Philadelphia. Preferring clinical pathology, she then completed two consecutive one-year fellowships—in hematopathology and blood banking–transfusion medicine at the same hospital. Her allopathic graduate medical training and certification notwithstanding, Dr. George, who is 33, strives to incorporate osteopathic principles into the practice of pathology
Following is an edited interview with Dr. George.
When did you decide to specialize in pathology?
My PCOM classmates and I were introduced to pathology during the first year of medical school, and I immediately took to it. Our pathology professor, Robert M. Fogel, DO, stressed how pathology is at the center of all other medical fields—a discipline that is pivotal to every physician’s decision-making. As Dr. Fogel put it, the pathologist is “the doctor’s doctor.” That really appealed to me.
Why didn’t any of your PCOM classmates choose to specialize in pathology?
While a lot of med students find pathology classes interesting, most don’t see the discipline as a career. Many people think of pathologists as just performing autopsies, which is simply one aspect of the field. Or they think that pathologists are chained to their microscopes. Partly from TV shows such as “Scrubs,” people often picture a pathologist as someone who produces reports and doesn’t like talking to people.
Many med students don’t realize that although we do a lot of lab work, pathologists need good interpersonal skills. As with radiologists, many pathologists don’t deal directly with patients. But pathologists are always on the phone with other physicians and interact in person with many different tiers of staff. We help other clinicians do their jobs. And at academic medical centers, pathologists often teach students and residents.
What’s more, those who steer clear of pathology because they want to interact with patients often aren’t aware of the subspecialty of blood bank–transfusion medicine, which calls for considerable physician-patient contact.
Because there are no AOA-approved residencies in pathology, did you opt to take the United States Medical Licensing Examination (USMLE) rather than the Comprehensive Osteopathic Medical Licensing Examination—USA (COMLEX-USA)?
This is an issue I have very strong feelings about. I did take Step 1 of the USMLE, as well as all parts of COMLEX-USA. But as I began to think about the matter more, I decided that I would not be comfortable at a residency site that does not accept or is not familiar with COMLEX. Academic medical centers that are DO-friendly—such as Thomas Jefferson University Hospital, where I trained, and Hershey Medical Center—do accept COMLEX scores.
I knew that I would not be comfortable at a place that doesn’t place DOs on an equal footing with MDs. I did encounter such bias at times. When I had an audition rotation at one pathology program, people asked me questions I thought were ignorant, such as “Can DOs prescribe medication?” If someone really doesn’t know about osteopathic medicine and is asking out of curiosity, I don’t mind answering the question. But when the question is asked in an arrogant manner that suggests DOs are inferior, I take offense. I knew I would not be happy in that particular program.
What led you to subspecialize in blood bank–tranfusion medicine and hematopathology after your residency?
Most physicians, including pathologists, don’t even think about the blood bank. They seem to assume that blood magically appears for surgeries and lack any understanding of all the effort that goes into the blood banking process. And there is even less awareness and understanding of apheresis—the process of withdrawing blood, separating it into its components, and returning certain components to the patient. It wasn’t until I was a third-year resident that I was exposed to blood banking, and I really loved it. I’m fascinated by immunology, by how blood cells work. That’s also why I subspecialized in hematopathology.
I also like the fact that unlike other facets of pathology, blood banks provide a product rather than just lab results. Blood is considered both a biological agent and a drug by the U.S. Food and Drug Administration and is inspected and approved accordingly. Because I understand the importance of FDA and other regulations and standards, I actually enjoy the details of ensuring compliance. And I take great satisfaction in providing patients a product that can save or improve their lives.
But another reason I served two fellowships was simply to broaden my expertise and enhance my career prospects. Although you can set up a private practice as a pathologist and contract out your services, most pathologists are employed by hospitals or large practice groups. During the economic slump, pathology positions have been harder to come by.
It’s a low-turnover field to begin with. Because the specialty is not physically demanding compared with surgical specialites, for example, pathologists often can practice well into their 70s and even into their 80s if they remain mentally sharp. When the stock market fell and everyone’s retirement savings took a hit, many pathologists who were planning to retire in their 70s chose to stay in practice longer. Because pathologists are retiring later in life, fewer jobs are available for younger pathologists. My four certifications have increased my marketability.
Did you have to take four examinations to become certified by the American Board of Pathology in anatomic and clinical pathology and the subspecialties of hematology and blood banking–transfusion medicine?
Yes, and they were awful. My primary certifications are in anatomic and clinical pathology, which involved two separate days of exams. Lasting from 8 a.m. until 5 p.m., the anatomic exam consisted of reviewing slides, answering computerized multiple-choice questions, looking at virtual slides that were scanned into a computer and, afterwards, making a diagnosis. And the next day was all clinical pathology, which involves interpreting different results and understanding disease processes, as well as looking at slides and making calculations. It was a grueling two days.
The exams for my subspecialties were one day each as well. When I took my blood bank boards, a fire alarm went off halfway through the exam, which only added to the stress of the experience.
Your persistence seems to have paid off, however. What do you like about being the medical director for blood bank and transfusion medicine at Hershey Medical Center?
With my varied responsibilities, I have the best of all worlds. I get to do what I love to do and what I’m skilled at. For one thing, I take satisfaction in providing a consulting service to other physicians in the hospital, in the communication and teamwork required in often life-or-death situations. A physician might call to ask for my opinion because a patient has an antibody in his blood that could affect his response to transfused blood. Or during a surgery, I might get a call because a patient is having a massive bleed and the surgeon needs to know immediately what blood products to get and how much plasma to give versus the number of red cells. Having the expertise to resolve these issues is rewarding to me.
I’m atypical for a pathologist in that I have considerable contact with patients, namely those undergoing apheresis. With the neurologist or other referring physician, I will determine the type and number of treatments a patient needs. For each candidate for apheresis, I take the patient’s full history, including complications, and do a quick physical exam. I explain the apheresis process to the patient to make sure he or she understands it and consents to have it done. A procedure can take anywhere from an hour to six hours, with stem cell collection for bone marrow transplants requiring the most time. Although a nurse specializing in apheresis runs the machine and remains with the patient throughout the procedure, I check in on patients periodically and remain nearby in case there is a problem.
In the two years I’ve been at Hershey, I’ve seen many patients with chronic conditions again and again. For example, patients with myasthenia gravis, who need to have antibodies removed, might come in for apheresis treatments once or twice a week. Patients with sickle cell disease, who need their red cells exchanged, typically come in once a month. So I get to know many of these patients.
But the best part of my job is teaching. Because Hershey is an academic medical center, I get to instruct medical students, residents and fellows. It is especially neat to see someone bond with a subject they previously knew little or nothing about.
Generally, residents come into the blood bank tentatively, nervous because we make relatively quick decisions that can result in life-or-death outcomes and we give out a product that must meet multitudinous standards. I love seeing residents grow in their understanding of what we do and become more confident. Since I’ve been at Hershey, two pathology residents decided to go into blood banking. This makes me very happy because they both were excellent residents who will be outstanding in the field when they get out there.
In addition to instructing residents, fellows and students on rotation at Hershey, I give several lectures a year to PCOM students. One of my recent talks was titled “A Day in the Life of a Clinical Pathologist.” Medical students don’t often get the chance to speak with someone who is relatively fresh in practice. Instead, they tend to interact mostly with the people who are teaching in their medical school, who usually are well-established and accomplished educators. Students may feel more free to ask me questions than they would someone who has been out practicing for more than 20 years. I like to encourage students and hope I can mentor some of them in the way I was mentored.
How do you incorporate osteopathic principles and practice into your career?
I try to bring an osteopathic approach to my patient care. For example, when I take a history and examine a patient prior to apheresis, I recognize that a complaint of neck pain or back pain may be unrelated to the patient’s main disease; it may instead be something musculoskeletal. I believe my whole-patient approach and skill at palpatory diagnosis promote better outcomes and prevent some unnecessary testing.
As part of my training in pathology, I did bone marrow biopsies. In this procedure, you need to palpate the patient’s hip to identify the best place from which to draw out a core of bone. Because of my osteopathic medical education, I was better able to locate the right anatomical landmarks to obtain good biopsies.
Besides the knowledge and technical skills to excel as a clinical pathologist, what traits are needed to thrive in a career like yours?
Management skills are essential, and they really can’t be taught. You need to have basic interpersonal relationship skills to begin with, and then you can hone them finer with guidance and practice. As I stress with residents and fellows, you should always treat your staff members fairly. When you manage a lab, you should be the one who arrives at work first and leaves last. You need to set a good example and be a leader for the lab, so that your staff will have faith that you are going to make the right choices for each patient.
I manage almost 30 people in the blood bank, many of whom are older than I am and have a lot of experience at what they do. I always try to show respect for their experience and ask for their input in decision-making. I might say, “You’ve seen this type of case before. Do you agree with this approach to handling it.” Or if I’m considering purchasing a new instrument or piece of equipment, I will always consult ahead of time with the people who will be using it.
To be honest, the experience I had waitressing in high school and college was great preparation for being a blood bank manager. As a waitress, I had to deal with all types of people and I had to multitask. Pathologists, indeed all physicians, need these skills.