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Sign Out

“What’s the diagnosis?” The voice from the other side of the microscope pierced the silence.

“You still don’t see it?”

A bead of sweat traced a path from his forehead to his nose.

“Look! It’s a low-power diagnosis! Even a medical student knows what this is! Did you look at these cases?”

“Yes, I- ”

“With a microscope?”

Dr. Irene Haas pushed herself away from the double headed microscope, whirled around from her chair, and marched over to her overarching stuffed bookshelves. She grabbed a textbook, flipped through several pages, then slammed the tome on the shared table between the two of them.

“Next time, be prepared when you present your cases for sign out! Read about this case and be prepared to tell me by the end of the day what additional studies we should order to confirm the diagnosis.”

This was sign out, the daily routine of the surgical pathologist. Every surgical resection or biopsy received a diagnosis from a pathologist viewing the tissue slides under the microscope. All therapeutic decisions began with the sign out.

Haas was in her mid-40s. Her raven black hair, perfectly in place, framed a still youthful countenance. She dressed in neatly tailored business suits, usually obscured by a lightly starched white lab coat, embroidered with her name over the left breast pocket. She was pretty but a stern face rendered her beauty a fleeting vision.

Her outburst prematurely ended the sign out and James quickly gathered the textbook, the stacks of slides and paperwork, and excused himself from her office. Dr. Daniel Rosenthal, the chief resident, grabbed his arm as he exited.

“Dragon Lady got you, eh? Those slap marks on your face are quite becoming!”

James reached for his face as Dan rolled his eyes. “Look, let’s go over some of your cases in my office.”

The words flew by James. It was two weeks since he began his pathology residency. The overwhelming vocabulary of surgical pathology was an instant stumbling block. He was comfortable with general medical terms but pathology utilized terms that most practicing physicians never encountered. English was the primary language of his college and medical school in the Philippines, at least this was familiar. The pace of speech was daunting. James found himself mentally replaying conversations, attempting to gain the gist of what was spoken. But it was the idioms for which he was totally unprepared. How could he assimilate all of this data when it was not presented in a deliberate textbook-like delivery from his medical school professors? His mind searched for answers.

Residents received their slides early in the morning, usually by 7:30AM. Each slide was labeled with the patient's name, case number, and site of the biopsy. The slides were arranged in numerical order by case number and placed in plastic slide holders, called flats, that accommodate 20 slides. Tucked into each flat was the corresponding paperwork for each case. There were two sheets, the original requisition sheet submitted with the specimen and completed by the physicians' office and the typed gross dictation of the resident who received the biopsy specimen. The resident's job was to review all of the cases before signing out with the attending pathologist, usually by 1PM. Any special studies to clarify or confirm the diagnosis could be ordered before signout. It was a varied case load but an average day would have about 40-50 cases.

“What you need to do is break your cases down by priority. First, your cancer biopsies should be signed out. Then proceed to the larger resections like breast and colons which are usually removed for cancers. Your last cases are your low priority ones like appendices, gallbladders, fallopian tubes, you know, cases the submitting physician will probably not be immediately calling for results.” Dan shuffled the slides and paperwork to achieve his desired result.

“All right! See, you have three core biopsies of the breast, two needle biopsies of prostate, a stomach and colon biopsy, and a lymph node removed for lymphoma. These cases all should receive your immediate attention. The rest of these are gallbladders, appendices, and bunions. These diagnoses won’t keep anyone up at night!” With a whirl in his chair, Rosenthal turned away from the microscope and proclaimed, “And now, the most important step!” A CD case was pulled from his shelf, and in a continuous motion, the jewel box was popped open, and the disc inserted into the CD player. The strains of a jazz guitar filled the room. “My man! Wes Montgomery !”

“First case is Clarkson, case number 16805, ultrasound guided core biopsy of the right breast.” Dan placed the slide on the microscope stage, turning the magnifying objectives into place. A colorful mix of red and blue tissue, identifiable as breast tissue, appeared before both of them. “Approach with low power magnification and decide where the primary pathology is. You’re scanning, deciding whether this is benign or malignant. If it is benign, is it neoplastic or infectious? If it is malignant, what kind of malignancy?"

The slides raced pass the microscope objectives, a blur except to the trained eye.

"What did you think about this case?"

"Ductal hyperplasia, no atypia."

Dan listened but did not lift his eyes from the microscope. "Are you sure, anything else?"

"Uh...I don't think so...." His voice trailed to a whisper.

"Don't you think this hyperplasia is a little unusual? Is this patient at risk for developing invasive breast cancer?"

"Could be...umm..."

"Look at the name of the patient." Dan turned the paperwork so James could see the name.

"Clarkson....Robert....this....is a man!"

"This...is a man!" Dan mocked his answer. "Yes, men get their breast biopsied! You didn't recognize this was male breast tissue, no lobules. Now, what's the diagnosis?"

A quick succession of diseases of the male breast passed through James' mind.


"Gynecomastia...correct. Male breast enlargement."

"Before you decide on the disease process, make sure you know the sex and organ of the slides you are looking at! I'll dictate."

Dan stepped on the foot control under his desk, connected to the dictating machine on his desk. "Sections of male breast show scattered ducts lined by bland epithelial cells with a well defined myoepithelial cell layer. Periductal stromal fibrosis with edema surrounds many of the ducts. No calcifications or malignancy is identified. Diagnosis...right breast....needle core biopsy.....gynecomastia. Next case...Tilson, case number 16810..."

A heaviness descended upon his chest. He hoped Dan was ridiculing his surprise rather than his accent. James labored at eliminating his accent but a slight trace betrayed his foreign origin as blatantly as his appearance. It was only two years ago, since James arrived in St. Louis to work in the research lab of the chief of surgery. The memory of the initial encounter in the human resources department was vivid. On that day, he awakened to his uniqueness.


"James Deetan?"

"D...Ton? Is D your middle initial?" She lifted her eyes and looked at James. Her reading glasses were perched on a red and greasy nose. Her hair was a dirty blonde, curled with a tight perm that layered to her neck and disappeared in three folds of fat. It was a wondrous but peculiar sight. Scanning the office, he noted that obesity was the fashion norm. Were all St. Louis women like these, he wondered? Perhaps they also thought he was different. James was of medium build with short black hair, wrapped around a long tan face, conditioned by years of Filipino sunshine. Although he did not think he had a youthful appearance, the lack of any significant wrinkle and smile lines belied his true age. That he was Asian was no mystery. His high cheekbones and slightly slanted eyes confirmed this for all. Yet, even for other Asians, his appearance was a bit of an enigma. In Chinese restaurants, there was no mistaking his Chinese heritage. But in Filipino restaurants, he was mistaken for Filipino. In Korean restaurants, he was a Korean. And so it continued. James concluded that he had a generic Asian face, probably an asset giving the tortuous relations between the various Asian nations. In America, it only served to confirm the majority impression that all Asians looked alike.

"No ma'am. It's pronounced Deee...Tahn, but it's spelled D-e-e-t-a-n."

"What kind of name is that?"

"It's Chinese."

"I've never heard of any Chinese name like that! I thought you had names like Lee and Ching...Chang...Chang-a-Lang." She laughed at her joke. How odd, James thought. He needed to understand their sense of humor. It eluded his comprehension.

"Kathy! Laura! Come here and meet Dr. Dee...tahn!" The other girls in the office trundled over, fat jiggling behind blouses too small to contain the overstuffed contents.

"He's cute!" one of them giggled.

"He looks so young! Are you sure you're a doctor?"

"Of course I'm a doctor, " James shot back. "I'm working with Dr. Carter, the chief of surgery."

"Well, excuse me! Don't get uppity with me, James."

The informality of these women was annoying. In the Philippines, he would never be addressed in such a manner. This is America, he sighed. This is his opportunity, not theirs to degrade. They were simply unaccustomed to meeting other Chinese, he reassured himself.


"What?" Dan's words jolted him from his recollection. James' eyes were riveted to the microscope.


"I thought it was a simple hyperplastic polyp...did I miss something...again?"

"Mmmm..." The slide whipped by James' eyes. "Laid back...really laying behind the beat!"


"The music! Listen to that! Only Wes can lay back like that and make it swing! Oh...man!" Dan bobbed his head in time to the beat, his eyes closed, lost in the moment.

"Still gives me goose bumps....yup...hyperplastic polyp."

The cases passed into the evening hours when a growl from James' stomach was heard over the music. He wanted to suggest a break for dinner but knew it was not his decision to make. He was the resident. He didn't have the privilege to dictate the pace of his training. Another growl from his stomach announced its disapproval.

Dan looked up and smiled. "They got catfish tonight....Mississippi sushi! Let's quit and get some dinner."

James nodded and gathered the flats and paperwork. "I'll put these cases on my desk and meet you down there."

As the door closed behind him, James' eyes widened as he attempted to walk by Haas' office without being noticed but at the critical moment, an overhead page blared caused Haas to look up to spy James.

"I've been waiting..."

"I'm ready..." James maneuvered into the office and placed the flats on the table next to her microscope. As James peered into the microscope, he caught a glimpse of Dan flagellating himself.

The sign out began again.

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