An interview with a pathologist

Some days ago I was contacted by a pathologist who recently discovered Bizzarro Bazar, and said she was particularly impressed by the website’s “lack of morbidity”. I could not help but seize the opportunity of chatting a bit about her wonderful profession: here is what she told me about the different aspects of this not so well-known job, which is all about studying deformity, dissimilarities and death to understand what keeps us alive.

What led you to become a pathologist?

When I was sixteen I decided I had to understand disease and death.
The pathologist’s work is very articulated and varied, and mostly executed on living persons… or at least on surgically removed parts of living persons; but undoubtedly one of the routine activities is the autoptical diagnosis, and this is exactly one of the reasons behind my choice, I won’t deny it. Becoming a pathologist was the best way to draw on my passion for anatomy, turning it into a profession, and what’s more I would also have the opportunity of exorcising my fear of death by getting accustomed to it… getting my hands dirty and looking at it up close. I wanted to understand and investigate how people die. Maybe part of it had to do with my visual inclination, and pathology is a morphologic discipline which requires sharp visual memory and attention to macro and microscopic details, to differences in shape, to nuances in color.

Is there some kind of common prejudice against your job? How did you explain your “vocation” to friends and relatives?

Actually the general public is not precisely aware of what the pathologist does, hence a certain morbid curiosity on the part of non-experts. Most of them think of Kay Scarpetta, from Cornwell’s novels, or CSI. When people asked me about my job, at the beginning of my career, I gave detailed explanations of all the non-macabre aspects of my work, namely the importance of an hystological diagnosis in oncology, in order to plan the correct treatment. I did this to avoid a certain kind of curiosity, but I was met with puzzled looks. To cut it short, I would then admit: “I also perform autopsies”, and eventually there was a spark of interest in their eyes. I never felt misjudged, but I sometimes noticed some sort of uneasiness. And maybe some slightly sexist prejudice (the unasked question being how can a normal girl be into this kind of things); those female sexy pathologists you find in novels and TV series were not fashionable yet, and at the postgraduate school I was the only woman. As for friends and relatives… well, my parents never got in the way with my choices… I believe they still haven’t exactly figured out exactly what I do, and if I try to tell them they ask me to spare them the details! As for my teenage kids, who are intrigued by my job, I try to draw their attention to the scientific aspects. In the medical environment there is still this idea of a pathologist being some kind of nerd genius, or a person who is totally hopeless in human interactions, and therefore seeks shelter in a specialization that is not directly centered on doctor-patient relationship. Which is not necessarily true anymore, by the way, as often pathologists perform biopsies, and therefore interact with the patient.

Are autopsies still important today?

Let’s clarify: in Italy, the anatomopatologo is not a forensic pathologist, but is closer to what would be known in America as a surgical pathologist. The autopsy the pathologist performs is on people who died in a hospital (and not on the deceased who fell from a height or committed suicide, for instance) to answer to a very specific clinical inquiry, while the legal autopsy is carried out by the legal MD on behalf of the DA’s office.
One would think that, with the development of imaging radiology tests, the autoptic exam would have by now become outdated. In some facilities they perform the so-called “virtual autopsy” through CAT scans. In reality, in those cases in which a diagnosis could not be determined during the deceased’s life, an autopsy is still the only exam capable of  clarifying the final cause of death. Besides direct examination, it allows to take organ samples to be studied under the microscope with conventional coloring or to be submitted for more refined tests, such as molecular biology. In the forensic field, direct examination of the body allows us to gather information on the chronology, environment and modality of death, all details no other exam could provide.

There is of course a great difference (both on a methodological and emotional level) between macroscopic and microscopic post mortem analysis. In your experience, for scientific purposes, is one of the two phases more relevant than the other or are they both equally essential?

They are both essential, and tightly connected to each other: one cannot do without the other. The visual investigation guides the following optic microscopy exam, because the pathologist samples a specific area of tissue, and not another, to be submitted to the lab on the grounds of his visual perception of dissimilarity.

In my experience of autopsy rooms, albeit limited, I have noticed some defense strategies being used to cope with the most tragic aspects of medical investigation. On one hand a certain humor, though never disrespectful; and, on the other, little precautions aimed at preserving the dignity of the body (but which may also have the function of pushing away the idea that an autopsy is an act of violation). How did you get used to the roughest side of your job?

I witnessed my first autopsy during my first year in medical school, and I still remember every detail of it even today, 30 years later. I nearly fainted. However, once I got over the first impact, I learned to focus on single anatomical details, as if I were a surgeon in the operating room, proceeding with great caution, avoiding useless cuts, always keeping in mind that I’m not working on a corpse, but a person. With his own history, his loved ones, presumably with somebody outside that room who is now crying for the loss. One thing I always do, after the external exam and before I begin to cut, is cover up the face of the dead person. Perhaps with the illogical intent of preventing him to see what I’m about to do… and maybe to avoid the unpleasant feeling of being watched.

Are there subjects that are more difficult to work with, on the emotional level?

Children.

Are autopsies, as a general rule, open to a non-academic public in Italy? Would you recommend witnessing an autopsy?

No, all forensic autopsies are not accessible, for obvious reasons, since there is often a trial underway; neither are the diagnostic post mortem examinations in hospitals. I wouldn’t know whether to recommend seeing an autopsy to anyone. But I do believe every biology or medicine student should be allowed in.

One of the aspects that always fascinated me about pathological anatomy museums is the vitality of disease, the exuberant creativity with which forms can change: the pathological body is fluid, free, forgetful of those boundaries we think are fixed and insurmountable. You just need to glance at some bone tumors, which look like strange mineral sponges, to see the disease as a terrible blooming force.
Maybe this feeling of wonder before a Nature both so beautiful and deadly, was the one animating the first anatomists: a sort of secret respect for the disease they were fighting off, not much different from the hunter’s reverential fear as he studies his prey before the massacre. Have you ever experienced this sense of the sublime? Does the apparent paradox of the passionate anatomist (how can one be a disease enthusiast?) have something to do with this admiration?

To get passionate, in our case, means to feel inclined towards a certain field, a certain way of doing research, a certain method and approach which links a morphologic phenomenon to a functional phenomenon. We do not love disease, we love a discipline which teaches us to see (Domine, ut videam) in order to understand the disease. And, hopefully, cure it.
And yes, of course there is the everyday experience of the sublime, the aesthetic experience, the awe at shapes and colors, and the information they convey. If we know how to interpret it.

Speaking of the vitality of disease: today we recognize in some teratologic specimens a proof of the attempts through which evolution  gropes around, one failed experiment after the other. How many of these maladies (literally, “being not apt”) are actually the exact opposite, an adaptation attempt? Is any example of mutation (which a different genetic drift might have elected to dominant phenotype) always pathological?
What I really mean to ask is, of course, another one of those questions that any pathological anatomy museum inevitably suggests: what are the actual boundaries of the Norm?

The norm is established on a statistical basis following a Gaussian distribution curve, but what falls beyond the 90th percentile (or before the 10th)  is not forcibly unnatural, or unhealthy, or sick. It is just statistically less represented in the general population in respect to the phenotype we are examining. Whether a statistically infrequent character will be an advantage only time will tell.
The limits of the norm are therefore conventionally established on a mathematical basis. What is outside of the norm is just more uncommon. Biology undergoes constant transformation (on the account of new medicines or therapies, climatic and environmental change, great migrations…), and therefore we are always confronted with new specimens coming in. That is why our job is always evolving, too.

I didn’t expect such a technical answer… mine was really a “loaded” question. As you know, for years I have been working on the concepts of dissimilarity, exoticism and diversity, and I wanted to provoke you – to see whether from your standpoint a mutant body could also be considered as a somewhat revolutionary space, a disruptive element in a context demanding total compliance to the Norm.

Ask a loaded question… and you’ll get a convenient answer. You’re talking about a culture demanding compliance to a social norm, I replied in terms of the biology demanding compliance to a norm that is established by the scientific community on a frequency-based statistic calculation — which is therefore still conventional. In reality, deformity appears in unexpected ways, and should be more correctly described following a probabilistic logic, and not frequency. But I’m beginning to sound technical again.

I have seen respected professors lighten up like children before some pathological wet specimens. The feeling I had was that the medical gaze in some ways justified an interest for extreme visions, usually precluded to the general public. Is it an exclusively scientific interest? Is it possible to be passionate about this kind of work, without being somehow fascinated by the bizarre?

There could be a little self-satisfaction at times. But in general there is sincere passion and enthusiasm for the topic, and that surely cannot be faked. It is a job you can only do if you love it.
All our discipline is based on the differential diagnosis between “normal” and “pathological”. I could say that everything pathological is dysmorphic in respect to the norm, therefore it is bizarre, different. So yes, you have to feel a the fascination for the bizarre. And be very curious.

The passion for the macabre is a growing trend, especially among young people, and it is usually deemed negative or cheap, and strongly opposed by Italian academics.  This does not happen in other realities (not just the US, but also the UK for instance) in which a common element of communication strategies for museums has become the ability of arousing curiosity in a vast public, sometimes playing on pop and dark aspects. Come for the macabre, stay for the science. If young people are drawn to the subject via the macabre imaginary, do you think in time this could lead to the education of new, trustworthy professionals?

Yes, it’s true, there is a growing interest, I’m thinking of some famous anatomical exhibitions which attracted so many visitors they had to postpone the closing date. There is also my kids’ favorite TV show about the most absurd ways to die. I believe that all this is really an incentive and should be used as a basis to arouse curiosity on the scientific aspects of these topics. I think that we can and must use this attraction for the macabre to bring people and particularly youngsters closer to science, even more so in these times of neoshamanic drifts and pseudo-scientific rants. Maybe it could also serve the purpose of admitting that death is part of our daily lives, and to find a way to relate to it. As opposed to the Anglo-Saxon countries, in Italy there still is a religious, cultural and legislative background that partially gets in the way (we have laws making it hard to dissect bodies for study, and I also think of the deeply-rooted idea that an autopsy is a violation/desecration of the corpse, up to those prejudices against science and knowledge leading to grotesque actions like the petition to close the Lombroso Museum).

Has your job changed your relationship with death and dying in any way?

I would say it actually changed my relationship with life and living. My worst fear is no longer a fear of dying. I mostly fear pain, and physical or mental decay, with all the limitations they entail. I hope for a very distant, quick and painless death.

With your twenty years experience in the field, can you think of some especially curious anecdotes or episodes you came across?

Many, but I don’t feel comfortable relating episodes that revolve around a person’s remains. But I can tell you that I often do not wonder how these people died, but rather how in the world they could be alive in the first place, given all the diseases I find! And, to me, life looks even more like a precariously balanced wonder.