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How can we learn pathology well
The first step: pathological techniques, histology and pathological anatomy.
Methods: Practice first, then theory, repeated practice and then theory.
Theory first, then practice, then theory, and then practice again and again.
Generally speaking, the former is better than the latter. As far as personal experience is concerned, I learn most other knowledge by the method of theory before practice. Only pathology, I found that it is not feasible for theory to precede practice.
After entering the Department of Pathology, 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 met, 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, consultation with 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.
In the remaining three months, you should make some efforts. You should learn the principles of tissue treatment, routine pathological section, frozen section, immunohistochemistry, special staining, sorting and archiving of pathological files, various working systems and operating routines in 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 department to make a scientific and reasonable plan for a new recruit in pathology department. 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 scheme, so we can adjust the scheme according to the actual situation. If they have a plan, they should carry it out according to the plan, allowing fine-tuning in the process of implementation.
Method of implementation as planned:
Wuduo: Look more, the watch here is not (watch but observation), the former is a casual look 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 "?" I will always be with you and try to eliminate these "?" Eliminating a question mark is an improvement, and you should be happy; Ask more questions. In the department of pathology, you can consult a more experienced technician or doctor if you don't understand or understand something. If you don't ask questions, you may never understand some questions, or it will take a lot of time to understand them. Do more, set up the program of the dehydrator in person, then restore it to its previous state, slice it in person, freeze it, change the dye solution, prepare hematoxylin, do an immunohistochemistry under the guidance, prepare the dye solution for books, and make several commonly used special dye tablets. Only when you have done it yourself will you have a deep understanding. Pathological techniques can not be learned by reading books or watching others operate. When learning pathological techniques, we must pay attention to the norms of operation and form a good habit of operating according to norms. 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 with paraffin stearate, fixed with acidic formalin, etc. ), of course, the operation you have learned is not standardized. As a recruit, you don't know and can't ask your supervisor to change the current operation method. But you should know what kind of operation is standard. If this is the case, you don't have 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. During this period, the books to be read are pathology, histology and pathological anatomy. Pathological technology books don't need to be read through, but they 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 are doing is standardized. Histology does not need to be read through, but the morphology of various organs and tissues in sections should be recognized and digested according to the teaching chapters. Pathological anatomy is a must-read book for pathologists and needs to be thoroughly read. 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 general 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, then understand the special laws of each system, and strengthen the general laws from them. For example, there are three main changes in inflammation: deterioration, exudation and proliferation. You may study tuberculosis in various theories, so recall whether tuberculosis also has the above three changes. In the future pathological research, if we can think in a universal (general)-specific way, we will get twice the result with half the effort. Learning pathological anatomy, the morphological characteristics of each disease or tumor is of course important, 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 1CM. Solid organs, such as spleen and kidney, were cut from cortex to organ door, and then immersed in 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. 1000 words are not as good as a photo (advertising language).
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.). Section (shape, color, boundary, texture, cavity organ and cystic mass describing the inner surface). ⑤ Relationship between pathological changes and surrounding normal tissues. ⑥ Anatomical position of the lesion. ⑦ The diseased parts and the materials taken should be drawn and marked.
2. Description order: ① Surface first, then slice, serosa first, then mucosa. ② When there are several organs, one organ should be described first, and then another organ should be described. ③ When there are multiple 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 materials, and replenish materials when necessary. The material selection criteria of different specimens are shown in the appendix at the back of Ackerman Journal of Surgical Pathology.
Step 3: Pathological diagnosis of common diseases:
This process is relatively simple, mainly on the basis of reading a large number of films, using a simple surgical pathology reference book to consult the relevant content, without having to "chew" a big book. The most common method is to read 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 past cases, 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. At this stage, we mainly cultivate the ability to perceive the shape, and also focus on the changes of the shape in general and under the mirror in the process of looking up books. 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 you work harder, you 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 have never seen before, and you can use your working hours to try to solve the problems of the day.
The three-month technical group and the three-month research on 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 you can see them almost every day and never forget them. However, relatively rare diseases and tumors may only occur 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. By understanding these mechanisms, we can understand and remember morphological changes more quickly. In the meantime, we should continue to accumulate knowledge about rare diseases. After one year, if you work hard, you can start.
2. From entry to depth
Step 1: Master the pathological diagnosis of rare cases and difficult cases.
Because it is 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 it go (because it is gold). This is not enough, we should also master the differential diagnosis of related diseases and confusing diseases, and 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. Read the teaching films in the department. If the department has teaching films, read and master the teaching film cases first.
3. I watched many clips of the film reading club. 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 final diagnosis results. These files are very valuable assets for new recruits. At first, you can read the reading meeting at the municipal or regional level, which is less difficult. In the future, you can watch the 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 when you encounter cases that have been read in the reading part at work, and 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 have a deep understanding of what you have learned and what you 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.
This is also the key to career success. Provincial hospitals are generally chosen for further study, where there are not only many cases, but also teachers with good theoretical level. 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 microscope. Production operations and reports as well as adult autopsies are standardized. Then study hard! For most pathologists, there is only one learning opportunity in a year, so make good use of it.
Advanced skills:
1, "Get the teacher". This is the key to learning quality. We should not only "get teachers", but also maintain good relations 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 in place, and supplementary materials should be minimized; Descriptions 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 The superior doctor should make full preparations before reviewing the film, such as supplementing the medical history and making 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, etc. If you have time, please don't miss the consultation section. These suggestions were digested and absorbed on the same day, and the incomprehensible cases were recorded to find opportunities to consult teachers. 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, and the method is the same as before.
5, learn the correct technical operation and diagnostic specifications. Record the good 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 have encountered most tumors (or diseases) in the book, but there are always some tumors (or diseases) that you have never seen before. 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 before, then search these cases on the computer, and then transfer the slices to digest them slowly.
7. Learn the skills to deal with gray lesions and cases that may cause disputes. Pay attention to two aspects: first, properly grasp the diagnosis of frozen sections and delay the diagnosis; The second is the treatment of gray lesions.
Step 3: Learn from macroscopic pathology to professional 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. There is no end to the deepening of professional pathology. What you need to master is at least the classification of tumors in this system, the clinicopathological theories of various special types and subtypes (many 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: first, you need to accumulate a large number of cases; Second, you need to read a lot of literature; Third, you need 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 maybe I will 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. All pathological techniques were used for the study.
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, in soft tissue spindle cell tumors, spindle cells are nonspecific, while wavy and slender spindle cells are the characteristics of neurogenic tumors, while palisade arrangement and complete capsule are the characteristics of neurilemmoma. Ligamentlike tumor is characterized by spindle cells infiltrating and growing in the abdominal wall with a large amount of collagen. When diagnosing lymphoma, it is characterized by the destruction of lymph node structure, 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. Traveling north and south, weaving into a knowledge network: knowledge is not easy to forget after forming 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 should be based on finding 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 very difficult to remember these prone parts. If we can understand their embryogenesis, mechanical memory becomes understanding memory. For example, chordomas mostly occur in clivus (40%) and sacrum (45%), while other chordomas 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. If we understand the process from primitive mesenchymal tissue to mature adipose tissue and the morphology of each stage, it is easy to remember these morphological changes.
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 include 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 or even hysterectomy. In addition, whether the diagnosis of human papillomavirus infection may put a "hat" on patients with sexually transmitted diseases. There is no know-how and theory to learn gray lesions (if there is a theory, it is the morphological description written in the book). Only by watching more and practicing more can we master the 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 kind of lesions become very important. First of all, it is suggested to take another sample for biopsy in clinic. Second, it should be consulted. Thirdly, it is necessary to use descriptive predicates, such as suspected …, seeing a small number of atypical cells …, not excluding …, and thinking that it is probably … A senior pathologist once said, "Let clinicians call us stupid instead of rushing forward."
5. Eliminating "mines": There are some recognized "minefields" in pathological work. In fact, many pathologists have had the experience of "touching thunder". Finding "minefield" is the premise of eliminating "mine". As long as "mines" can be identified, it is not a difficult problem to eliminate them. 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 samples from multiple parts, making paraffin sections quickly, knowing whether the resection scope will be expanded in clinic after diagnosis, communicating with family members face to face with clinicians, and finally delaying the 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 cases with delayed diagnosis by freezing, we usually routinely "delay" (tell clinicians to do immunohistochemical examination or suggest higher-level hospital consultation), which can prove that this is indeed a difficult case, because conventional diagnosis can not make a clear diagnosis, 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. Correct thinking is often not the first feeling, what should I do? Then use the delaying tactics. I often encounter such a situation, and junior doctors take a piece and look at it in the mirror, hmm! Isn't it beautiful? I don't have a good idea, and I'm too embarrassed to look up books in front of junior doctors. Let them go first: take a few more pieces, or ask them if they have a medical history of …, or consider … suggesting to do immunohistochemistry … and send a report first … after returning home, think slowly, look through books or consult literature. With ideas and diagnosis, we can give them a whole set of theories the next day.
8. Pathology and probability: The age, location and incidence of diseases are all probabilities. Common diseases, predilection sites and predilection ages always account for the majority. You can't always have "good luck" and the probability is fair to everyone. Therefore, please be careful when you diagnose an uncommon disease or a disease that is not prone to location or age. Only by excluding common diseases or tumors and having a clear diagnosis basis can we diagnose 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, while "dualism" cases are 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.
No one solution is suitable for all antibodies.
All the tissues in the section are positive, but there is no positive.
Immunohistochemistry can't be better understood than users.
The key to the success of immunohistochemical technology is to select appropriate antibodies, strictly regulate the operation, correctly understand and explain the immunohistochemical results, and jointly apply similar antibodies.
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 negotiation: negotiation is inevitable, but it should not be too much. If you send out a report similar to "Suggest consultation in a higher-level hospital", it will make clinics and deans look down on you. But don't try to be brave. After all, safety comes first, and 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. Take micrographs.
2. Recording, registering and filing pathological files, one week: mastering general records, registering cases and filing pathological files.
3. Frozen section and general photography for one week: master frozen section and general photography techniques.
4. Cytological examination: 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 special dye solutions and make their own films.
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.
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