Nothing 'Gross' About it: The Work of a Pathologists' Assistant

It’s 9:05 on a Wednesday morning and a group of apron-clad pathologists' assistants (PAs) are gathering for morning rounds.

This is a daily meeting during which the pathologists, PAs, and residents meet on the floor of the gross room at the University of Rochester Medical Center.

Raman Baldzizhar, a resident doing his Surgical Pathology rotation, reads the schedule aloud for the group. He states the age and gender of each patient along with their procedure and the name of the doctor doing the surgery.

Today’s agenda includes a prostate, a pancreas, a kidney, a spleen, esophagus, and two stomachs.

After hearing the schedule, the team decides how they’ll divide up the day's work. Moments later, a colleague walks through the door carrying a frozen section specimen. It's a dark brown piece of tissue that was removed just moments ago from a patient's thyroid.

The team has to move quickly: A frozen section specimen is sent for immediate analysis while a patient is in the operating room (OR) under anesthesia. A diagnosis must be made within 20 minutes, which will help the surgeon make a decision during the procedure.

For this procedure, the tissue is literally frozen in a chamber called a cryosat. Once frozen, it is cut into extremely thin slices. A section of the tissue is placed on a glass microscope slide and stained with dye. The pathologist will examine the tissue under a microscope, render a diagnosis and report the results to the surgeon in the OR.

Each day, the PA team works against the clock; tissue specimens start to deteriorate soon after it is removed from the body and deprived of oxygen. For instance, breast tissue has a one-hour window before it must be submerged in formalin fixative to help preserve it.

The hospital’s Accessioning Unit is responsible for transporting specimens between the OR and the gross room. Technicians use an air-powered tube transport system similar to outdoor teller stations used at banks. Or, if the specimen is too large, it will be hand delivered to Surgical Pathology.

On this particular day, Dennis Dening, a PA, is examining a portion of tissue removed from a heart. I ask, What made you want to become a PA in the first place?

“I knew I wanted to do something medical, and I always enjoyed dissection,” he said, keeping his eyes fixed on the specimen.

Specimens come in all shapes and sizes. On average, the Surgical Pathology unit at URMC receives an average of nearly 500 specimens a day. They may be malignant or benign and can vary from small biopsies, such as an atypical mole removed by a dermatologist, or polyp removed during a colonoscopy. Other times, a specimen will be an entire breast or lung removed.

The PAs are responsible for dissecting and describing the specimens, in a process known as "grossing." A detailed gross examination includes information about the appearance of the specimen such as size, shape, color and consistency.

In cancer cases, the PA must identify the tumor and describe the relations of the tumor to the surrounding normal tissue. Once the gross description is completed the PA will determine what sections of the specimen will be examined microscopically by the pathologists.

Laurie Baxter was hired as URMC's first PA 21 years ago and now serves as the supervisor for a team of eight full-time PAs. During her time, has seen a lot of changes in the gross room as more people have shown interest in the profession.

"Once people come here to shadow and realize this is what they want to do," she said.

Since Baxter started her career, she's seen a greater number of students choose to go into the field. She has had four employees that started as biopsy technicians and returned to school to become PA's - and expects more will follow suit in the future.

Currently there are 10 PA training programs in North America with all but one culminating in a 2-year master's degree.

“This is a pretty satisfying job,” said Baxter. “Although we never come face to face with patients, PAs play a critical role in patient care. What we describe and submit for diagnosis directly impacts future treatment options for the patient."

In addition to grossing, PAs train residents and sometimes assist in autopsy procedures. The workflow in the gross room is steady, so the team must work together productively.

Biopsy specimens have the quickest turnaround time (one to two days) but larger specimens can be more work intensive and take several days to complete.

“Every specimen represents a patient," Baxter said. “We can't ever forget that."

And don’t be fooled by the term “gross.” The human body is amazing, after all, she tells me with a laugh.

"Who says it's gross?" 

In photos (from top):

1. Dennis Dening, a PA, dissects a ventricular core (a heart tissue specimen).

2. Trista Skedel, a PA, checks dictation reports in the gross room at URMC.

3. A frozen tissue sample that will be cut, stained, and examined under a microscope by a pathologist.

4. Hilary Haefner, a PA, grosses a breast specimen.

5. Elizabeth Sharratt dissects a uterus at the grossing station in Surgical Pathology at URMC.