How can we learn pathology well

The first step: pathological techniques, histology and pathological anatomy.

Methods: Practice first, then theory, then practice, then theory repeatedly.

First theory, then practice, then theory and then practice repeatedly.

Generally speaking, the former is better than the latter. As far as personal experience is concerned, I have learned most other knowledge by applying the method of theory before practice. Only pathology, I found that theory before practice is ineffective.

After entering the pathology department, I usually have about three months to learn pathological techniques. These three months are very important to you. You will encounter instruments, nouns, specifications, reagents, workflow and so on. People you've never been in contact with, and of course, all kinds of morbid people. At this time, you should enter the pathology department as soon as possible, including the items, workflow, personnel, names and uses of various instruments, the use of microscopes (it may take half a day or even longer to learn to read films with binocular microscopes) and so on. All these need to be understood within a week. Through careful observation, consulting different people and watching the operation of pathological technicians, it is best to do it yourself under the guidance of doctors and technicians. This week is generally not difficult to spend.

For the remaining three months, you should make some efforts. You should learn the principles of tissue processing, routine pathological sections, frozen sections, immunohistochemistry, special staining, sorting and archiving of pathological files, various working systems and operating routines of pathology department, review the textbooks of histology and pathology, and master the use of computers (including computer typing).

It's a good idea to ask an experienced teacher to make a plan. But we can't ask every director of pathology to make a scientific and reasonable plan for a pathological recruit. It doesn't matter. The following is the study plan of the graduates of our department for the first two months (attached). You can take it back for reference and modify it according to your own characteristics. Different hospitals can't have exactly the same plan, and they can adjust the plan according to the actual situation. If they have a plan, they should carry it out according to the plan, and fine-tuning is allowed during the implementation.

Method of implementation as planned:

Wuduo: Look more, the watch here is not (watching but observing), the former is looking at it without thinking, and it won't be very rewarding after reading it. The latter is careful observation; Think more (how about it? Why? Is this ok? ) these "?" Always by your side, trying to eliminate these "?" Eliminating a question mark is a step forward, and you should be happy; Ask more questions. In pathology department, consult experienced technicians or doctors for things you don't understand or don't understand. If you don't ask questions, some questions may never be understood, or it will take you a long time to understand. Do more, set up the program of the dehydrator in person, and then restore to the original state, slice it in person, freeze it, change the dye solution, prepare hematoxylin, do an immunohistochemistry under the guidance, prepare the special dye solution for books, make several common special dyes, and so on. Only when you have done it yourself will you have a profound experience. Pathological techniques can't be learned by reading books or watching others operate. When learning pathological techniques, we must pay attention to the standard of operation and form a good habit of operating according to the standard. The operation of your pathology department may be irregular (as far as I know, at least half of the pathology departments have irregular tissue treatment methods, such as omitting tissue washing, transparent paraffin stearate, acid formalin fixation, etc. ), of course, the operation you have learned is not standardized. As a recruit, you don't know and can't ask your director to change the current operation method. But you need to know what kind of operation is standard. If this is the case, there is no need to rush to "do it in one step". As long as you are a conscientious person, you will gradually understand what is the correct and standardized operation in your future work or study. Read more books. The books to be read during this period are pathology, histology and pathological anatomy. Pathological technology books do not need to be read through, but should be consulted purposefully in combination with the projects carried out by the department. Whenever you learn an operation, you can refer to the relevant chapters in the book to confirm whether the operation you have done is standardized. Histology does not need to be read through, and the morphology of various organs and tissues in the chapters should be identified and digested according to the teaching chapters. Pathological anatomy is a necessary reading for pathologists and needs to be read through. This book is mainly read in my spare time and it is also skillful to read. Some young people can recite this book, but those who can recite it may not be able to apply theory flexibly in practical work. The focus of this book is introduction and general introduction. The introduction introduces the definition, content and task of pathology, the position of pathology in medicine, the research methods of pathology and the history of pathology. The general part introduces the damage of cells and tissues, the repair of damage, inflammation, tumor, blood circulation disorder, immunopathology, hereditary diseases and so on. This part introduces the universal laws of various diseases (tumors). Each part tells the special laws of organs in each system, and these special laws also follow the universal laws. When learning, we should master the general laws first, and then understand the special laws of each system, so as to strengthen the general laws. For example, there are three main changes in inflammation: deterioration, exudation and proliferation. You may study tuberculosis in various theories, so think back to whether tuberculosis also has the above three changes. If you can think in a universal (general)-specific way in the future pathological research, you will get twice the result with half the effort. It is of course important to learn pathological anatomy, the morphological characteristics of various diseases or tumors, but when reading this book, we should try our best to talk about morphological changes and understand the concept, etiology, pathogenesis, occurrence and development law, prognosis and outcome of various diseases.

Step 2: Macroscopic inspection and material selection.

Three months later, I finally came into contact with the pathological diagnosis. The first level is the fixation, macroscopic examination and sampling of biopsy specimens. Fixed, macroscopic inspection description and drawing materials also need to be standardized.

The general fixative is 10% neutral formalin, the volume ratio of fixative to specimen is 1: 5- 10, and the fixation time is 16-24 hours. Hollow organs such as gastrointestinal tract were cut and nailed to the board. Large solid tumors and organs were cut along the largest surface, and multiple equal sections were made every 65438±0cm. Spleen, kidney and other solid organs are cut from the cortex to the door of the organ, and then immersed in the fixed solution. The lungs were fixed by perfusion or vacuum pumping.

The description of macroscopic examination requires correct, comprehensive, objective and accurate measurement. If necessary, tumors (such as endocrine tumors) should be weighed. Diagnostic language is prohibited, and it is best to take photos for archiving. A 1000-word description is not as good as a photo (advertisement).

Descriptive methods and skills of macro-inspection;

1. Description content and skills: ① specimen name. ② Form, size (weight), quantity and feel. ③ Surface condition (color, coating, smoothness, etc.). (4) Sectional conditions (shape, color, boundary, texture, intraluminal organs and cystic mass describing the inner surface). ⑤ Relationship between pathological changes and surrounding normal tissues. ⑥ Anatomical position of the lesion. ⑦ Draw and mark the diseased parts and materials.

2. Description order: ① Surface first, then slice, serosa first, then mucosa. (2) when there are several organs, describe one organ first, and then describe another organ. ③ When there are several tissues or masses, describe them separately.

Material selection: Different organs, different specimens and different pathological tissues have different material selection criteria. Take more materials and less, and make up materials when necessary. See the appendix at the back of Ackerman Journal of Surgical Pathology for the specifications of different specimens.

Step 3: Pathological diagnosis of common diseases:

This process is relatively simple, mainly based on reading a large number of films, using a simple surgical pathology reference book to consult the relevant content, without "gnawing" a large book. The most common way is to look at the files and applications reported in our hospital before. A microscope, a drawer file, a stack of application forms, a book and a notebook are enough. If you have to work during the day, you may not have time, so do it at night. Look at the cases one by one, first look at the film, then guess what the disease is, and then look at the diagnosis on the application form, yes, pass; ; If not, ask yourself why? Check the book again, and you can pass it if you understand it; Here it comes again; I don't understand. Write it down and consult your superior doctor tomorrow. This stage is mainly to cultivate the ability to perceive the shape, and in the process of looking up books, we will also focus on the changes of the shape in general and under the mirror. At the same time, when reading the application form, you also strengthened and mastered the format and specification of macro-examination description, micro-morphology description and pathological report. More theoretical knowledge can be put into the next step. If we work harder, we can master the morphological characteristics and report formats of more than 80% common diseases in 2-3 months, such as appendicitis, cholecystitis, gastric cancer and breast cancer.

After this stage, your daily work will be a little easier, because you have mastered more than 80% of common diseases, and it is very easy for your superiors to review your diagnosis. There are only a few undiagnosed diseases every day, some of which may be gray lesions (the diagnosis of gray lesions will be discussed in detail below). Then, in fact, there may be only a few cases that you haven't seen, and you can use the time at work that day to try to solve the problem.

The three-month technical group and three-month study of common diseases are over. So, half a year has passed, has pathology been introduced? No, I still need to work hard. Common diseases and typical diseases are easy to master, because they are so common that they are seen almost every day and will not be forgotten. Relatively rare diseases and tumors may occur only once every few months or even years. Even if you understand this time, you will forget the same disease or tumor in a few months. In addition, knowing how to diagnose and report does not mean that you have mastered pathology, because the task of pathology is not only to diagnose, but also to master the etiology, pathogenesis, occurrence and development law, prognosis, prognosis, immunohistochemical expression and the main treatment methods and effects at present. Pathologists are doctors, not cinematographers who only learn from morphology to diagnosis. In fact, clinicians or patients often come to ask questions such as etiology, prognosis and treatment. You don't know, how do you face clinicians and patients? In the future work, on the basis of mastering the morphological changes of common diseases, the focus should be on the theoretical research of common diseases. Pathological changes are only appearances. Why does this disease have such morphological changes? Why are there different morphological changes in different periods of disease occurrence and development? Generally speaking, there are bases and mechanisms such as etiology and pathophysiology. Knowing these mechanisms, we can understand and remember the morphological changes more quickly. During this period, we should continue to accumulate knowledge about rare diseases. After one year, if you work hard, you can start.

2. From entrance to depth

Step 1: Master the pathological diagnosis of rare cases and difficult cases.

Because it is relatively rare, it is not easy to see at work. It is relatively difficult to master the diagnosis of rare and difficult cases. Here are some common techniques.

1. When you encounter a case, you should thoroughly understand a case, record a case, and never let go (because it is gold). This is not enough, but also to master the differential diagnosis of related diseases and confusing diseases. It is best to write a reading note or case report on the basis of consulting relevant books and documents. At this time, the rare or difficult diseases you encounter are not really rare or difficult diseases. Writing a case report may not be published, which is not important. It is important that you can fully grasp the clinical and pathological knowledge of the case through the process of "writing". This is the purpose of "writing".

2. Watch the teaching films in the department. If there is a teaching film in the department, read the case of mastering the teaching film first.

3. Read a lot of books. Reading files from shallow to deep will slice them. Hospitals with a little history have accumulated a large number of pathological reading materials at all levels, and generally have the final diagnosis results. These files are very valuable assets for new recruits. At first, you can read a book club at the municipal or regional level, which is less difficult. In the future, you can go to a provincial reading club according to your own situation. After a lot of reading and slicing training, the knowledge will be greatly expanded. Professional ability can also be significantly improved, especially in the case of reading section at work, you make a correct diagnosis, you will have a great sense of accomplishment. If you really have this experience of "achievement". Congratulations, you have become interested in pathology, which is the first and most crucial step in your career.

4. Don't let go of every piece every day. If you work in a bigger hospital, congratulations! There are often many doctors in big hospitals. You can't be on duty every day, but whether you are on duty or not, you should "scan" all the slices of the day and get to the bottom of what you have learned and haven't seen.

5. surf the internet. Not much to say, go directly to China Pathology Network. Don't be afraid, just ask any questions and post any cases. The teachers here are all good people.

So, another year has passed, maybe two years or more, and you are already a pathologist with a good theoretical diagnosis.

Step 2: Further study.

It is also the key to career success. Generally choose provincial hospitals for further study, where there are not only many cases, but also teachers' theoretical level is good. Generally speaking, there are many teaching films. There will be regular or irregular lectures on subsystem pathology. Pathological diagnosis will adopt advanced pathological techniques such as immunohistochemistry, molecular pathology and electron microscopy. Production operations and reports as well as adult autopsies are standardized. Then study hard! For most pathologists, there is only one opportunity to study once a year, so we should make good use of it.

Advanced skills:

1, "Take care of the teacher". This is the key to learning quality. We should not only "get the teacher", but also have a good relationship with other personnel in the pathology department (including technicians and other trainees). How to "deal with teachers" Different teachers have different methods, which is a topic of public relations. The following are some principles: ① Don't just do pathology, but also do hygiene and chores. The things assigned by the teacher must be completed with good quality and quantity within the specified time. (3) Materials should be standardized and in place, and supplementary materials should be minimized; Instructions and reports should be standardized to reduce the workload of teachers' revision. ④ Pay attention to efficiency and speed in work. ⑤ Be fully prepared before work. ⑥ Make full preparations before the superior doctor rechecks the film, such as supplementing the medical history and issuing an immunohistochemical list. ⑦ Pay attention to personal appearance. ⑧ Others (vary from person to person).

2. Check the slices every day. Whether it's the section in your class, routine section, frozen section, immunohistochemical section, positive cytology section and so on. Don't let go of the consulting section if you have time. These suggestions are digested and absorbed on the same day, and the incomprehensible situation is recorded to find opportunities to consult the teacher. Teachers here often have a high level of theory. They may only talk about a disease for a few minutes, but the effect is good and easy to remember.

3. Take notes during class. It mainly records the main points of various diseases (tumors) and the teacher's own experience. Sometimes reviewing notes is more effective than looking up books.

4. "Clean up" teaching slices. During the first 1-2 months of further study, read through the teaching slices of the further study hospital in the same way as before.

5, learn the correct technical operation and diagnostic specifications. Record the operation and diagnostic specifications of the superior hospital and bring them back to your hospital. This is a valuable asset.

6, gleaning, file search. In the later stage of further study, your level will be significantly improved. You may encounter most tumors (or diseases) in books, but there are always some tumors (or diseases) that you have never seen. Take a copy of Surgical Pathology, turn from the first page to the last page, record all the tumors (or diseases) you have never seen, then search these cases on the computer, and then adjust the slices and digest them slowly.

7. Learn the skills of dealing with gray lesions and cases that may cause disputes. Pay attention to two aspects: first, properly grasp the timing of diagnosis and delay diagnosis of frozen sections; The second is the treatment of gray lesions.

Step 3: Learn from macroscopic pathology to specialized pathology.

If all goes well, it may be more than five years. When you have mastered the macro-pathology, you can enter the in-depth study of specialized pathology. Choose a clinical specialty in your own hospital, study deeply, accumulate experience and constantly sum up. The deepening of professional pathology is endless. What you need to master is at least the classification of tumors in this system, the clinical and pathological theories of various special types and subtypes (with a lot of contents), the process of understanding them in history, the latest research progress at home and abroad, and your own unique views on the scope of specialized pathology. There are three points to learn professional pathology well: one is to accumulate a large number of cases, the other is to read a lot of literature, and the third is to do a lot of research.

Three. From in-depth to expert

Because I am not an expert, I can't talk about this experience. I really want to be an expert, but I may never be an expert. It's best to ask Ji to talk about this problem specifically. If possible, I think the following will help you become an expert:

1, take every opportunity to contact difficult and rare cases.

2. Do everything possible to find in-depth theories.

3. Use all pathological techniques for research.

4. Others ...

Some skills in clinical pathology research;

1. Memory Clinicopathological Points: Every disease has a series of clinicopathological changes, some of which are nonspecific and some are unique. Then remember the latter. For example, spindle cells in soft tissue tumors are nonspecific, wavy and slender spindle cells are the characteristics of neurogenic tumors, and palisade arrangement and complete capsule are the characteristics of neurilemmoma. Ligamentlike tumor is characterized by spindle cells infiltrating and growing in abdominal wall with a large amount of collagen. In the diagnosis of lymphoma, the structure of lymph nodes is destroyed, and whether lymphocytes are atypical often leads people astray. When distinguishing T-cell lymphoma from B-cell lymphoma, whether there is vascular hyperplasia (epithelioid venules) is often easier than distinguishing cell morphology. In the diagnosis of well-differentiated chondrosarcoma, the clinical location and tumor size are more accurate than simply judging from cell atypia.

2, criss-crossing, woven into a knowledge network: knowledge is not easy to forget when it forms a network. The so-called analogy is the method of weaving a web. For example, the diagnosis of thyroid cancer can not be judged by the size of tumor cell atypia, but based on the discovery of capsule, vascular infiltration or distant metastasis. This principle is also applicable to adrenal gland and other endocrine tumors. Adenoid cystic carcinoma of salivary gland has special morphological characteristics and can also occur in lung, breast and gallbladder.

3. Help memory through embryology: Most tumors have certain prone parts, and it is difficult to remember these prone parts. If we can understand their embryogenesis, mechanical memory becomes understanding memory. For example, chordomas mainly occur in clivus (40%) and sacrum (45%), while others grow along the spine. If you understand that the notochord structure of the embryo is located in the midline. There is no need to remember more than one group of places. Another example is liposarcoma, which has many subtypes and various adipocytes ... It is also very difficult to remember these morphological changes. It is easy to remember these morphological changes if we understand the process of adipose tissue from primitive mesenchymal tissue to maturity and the morphology of each stage.

4. Learning and treatment of gray lesions: There are many gray lesions. Gray lesions not only refer to a kind of lesions between benign and malignant, but also refer to many benign gray lesions. If atypical tuberculosis is misdiagnosed, it will lead to unnecessary anti-tuberculosis treatment. Similarly, whether it is endometrial hyperplasia is also a gray lesion, because it may cause unnecessary endocrine therapy and even hysterectomy. Also, whether the diagnosis of human papillomavirus infection may give patients a "hat" of sexually transmitted diseases. There is no trick or theory to learn gray lesions (if there is a theory, it is the morphological description written in the book). Only by seeing more and practicing more can we master gray matter lesions and cultivate our perception of gray matter lesions. When you are a novice and have to face gray lesions, the skills to deal with this lesion become very important. First, it is suggested that clinical samples should be taken again for biopsy. Second, we should take it out for consultation. Third, we need to use descriptive predicates, such as suspecting …, seeing a small number of atypical cells …, not excluding …, and thinking that it is probably … A senior pathologist once said, "Clinicians call us stupid, so it is better to rush up."

5. Eliminating "mines": There are some recognized "minefields" in pathological work. In fact, many pathologists have had the experience of "touching thunder". The discovery of "minefields" is the premise of eliminating "mines". As long as the "mine" can be identified, it is not a difficult problem to exclude it. Common "mines" are: osteosarcoma and callus; Nodular neuritis and sarcoma; Highly differentiated chondrosarcoma and chondroma; Ductal carcinoma of breast and adenopathy of breast; Lipoma and lipomatoid liposarcoma; Infectious mononucleosis and lymphoma, etc.

6. Skills to reduce the risk of freezing: supplementing the medical history, taking materials from multiple parts, making paraffin sections quickly, knowing whether the scope of resection will be expanded in clinic after diagnosis, communicating with family members face to face with clinicians, and finally delaying diagnosis. All of the above are common means to reduce the risk of pathologists. Too much delay in diagnosis often leads to the dissatisfaction of clinicians. For the case of delayed diagnosis of freezing, we often routinely "delay" (tell clinicians to do immunohistochemistry or suggest higher-level hospital consultation), which can prove that this is indeed a difficult case, because the conventional diagnosis can not be clear, and freezing will of course delay the diagnosis.

7. Organize thinking: When encountering difficult cases, the thinking of diagnosis is very important, and the correct thinking often leads to the correct diagnosis. The correct thinking is often not the first feeling, what should I do? Then use the delaying tactics. Often encounter such a situation, lower-level doctors take a piece and look in the mirror, hmm! Doesn't it look good? I don't have any good ideas, and I'm embarrassed to look up books in front of junior doctors. Let them go first: take more pieces to see, or ask them if they have a medical history of …, or consider … suggesting to do immunohistochemistry … Send the report first … Go home, think slowly, look through the books or check the literature. With ideas and diagnosis, they can be given a whole set of theories the next day.

8. Pathology and probability: The age, location and incidence of onset are all probabilities. Common diseases, prone parts and prone ages are always the majority. You can't always have "good luck", and the probability is fair to everyone. Therefore, please be careful when diagnosing uncommon diseases or diseases that are not prone to occur at the site and age. Only by excluding common diseases or tumors and having a clear diagnosis basis can we make a diagnosis of rare diseases. Again, "You can't always have good luck". Grasping the probability can reduce most misdiagnosis. The problem of "monism" and "dualism" in pathology is also a probability problem. In the case of uncertainty, monism is always used to explain the lesions, and "dualism" is often rare.

9. Rational application of immunohistochemistry: immunohistochemistry is not omnipotent, and it is absolutely impossible without immunohistochemistry. A famous pathologist once said the following words:

No biomarker is completely applicable to all tumors and cells.

There is no solution for all antibodies.

All tissues in the section are positive, but there is no positive.

Immunohistochemistry can't be better understood than users.

Selection of appropriate antibodies, strict and standardized operation, correct understanding and interpretation of immunohistochemical results, and joint application of similar antibodies are the keys to the success of immunohistochemical technology.

10, supplementary materials, continuous sections and supplementary medical history: making full use of these simple means can reduce a considerable number of consultations.

1 1. Grasp the scale of consultation: consultation is inevitable, but it should not be too much. If you send a report similar to "Suggest a consultation in a higher hospital", it will make the clinic and the dean look down on you. But don't try to be brave. After all, safety comes first. Only you can master this degree.

12, cytology study, looking for a stem cell teacher.

13, Internet cafe, China Pathological Network is a very good school.

14. Take an active part in film reading and discussion.

Attachment: Training Plan of Pathologist Technical Group in our department (February)

1. Histology, routine section: three weeks. It is required to make a set of histology teaching films with rabbits, including 2-3 special dyes. Make micrographs.

2. Record, register, pathological files, one week: master general records, register cases, and file pathological files.

3. Frozen section and general photography for one week: master frozen section and general photography techniques.

4. Cytology: one week. Master all kinds of cytological production and staining methods.

5. Immunohistochemistry: one week. Understand the principle of immunohistochemistry and its application in clinical pathology, understand the operation skills of immunohistochemistry and make immunohistochemical tablets.

6. Special dyeing: one week. Understand the principle of special staining and its application in pathology, and master 2-3 special staining methods. It is necessary to prepare a special dye solution and form a film by yourself.

7. Undergraduate teaching materials for studying pathological anatomy and histology. Microscope can identify the normal tissue structure and cell morphology of various organs.

8. Proficient in computer typing skills.

9. Understand the pathology system and operation process.