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- 没有临床医生的经验，病理医生能成为医生的医生吗？
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临床医生和病理医生都是医生，有着一个共同的目标-救死扶伤， 只不过临床医生更侧重在治疗方面，对于诊断有多种指标，病理诊断只是其中非常重要的一项指标。病理医生是通过形态学去解释疾病的发生、发展、转归，去探索临床医生不能解释的临床症状、去研究新的疾病。个体化治疗的进展又要求病理医生为临床医生的治疗提供更多的个体信息。医学的发展是先有临床医生、再有病理医生。讲病理医生是临床医生的老师是片面的，仅在某种程度上可以这么认为而以。如果病理医生的知识不通过临床医生的实践去验证，您认为是有价值的病理诊断吗？
- xljin8
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本帖最后由 于 2010-01-25 18:54:00 编辑
在国外做病理医生是要考执照的，必须经过严格的住院医师训练。
不知道您提问“没有临床医生的经验，病理医生能成为医生的医生吗？”的具体意思是什么？因为病理学是桥梁学科，即要有临床知识、又要有基础知识，主要通过形态学将二者融汇贯通。
我曾经讲到病理诊断中的“二个回归”
IHC和分子病理要回归形态、病理诊断要回归临床。病理诊断最重要的是回答临床医生的问题，如病变的性质、病变的严重程度、病变的范围、病人的预后指标、对治疗的建议、等等......。
有些热衷于分子病理诊断的医生断言：将来传统病理医生要失业了，分子病理诊断可完全替代组织病理诊断。我认为那是非常非常遥远的事。举个例子，Hodgkin 淋巴瘤的研究已经有150多年，对其肿瘤细胞来源的假说是一种又一种，但是，R-S细胞还是R-S细胞，丝毫不变！人体太复杂，个体的发育、整体的神经体液调节，同样一种因子在不同的时间和空间，作用却不同。这是用一个分子或几条信号通路无法彻底解释的。病变的质变和量变问题、没有肿块的分子改变对优生可进行筛选、对于非实体瘤可进行诊断，对于实体瘤呢？ 当然，作为科学的进步，分子病理使病理医生能从DNA/RNA等分子的角度去探索发病机制、辅助鉴别诊断，比IHC（蛋白质水平）有了很大的进步。人类基因图的破译是一大进步，但是还没高兴几天又产生了更多的迷惑，上帝是如何创造人类的？
- xljin8
| 以下是引用xljin8在2010-1-25 16:49:00的发言：
…… 我曾经讲到病理诊断中的“二个回归” IHC和分子病理要回归形态、病理诊断要回归临床。病理诊断最重要的是回答临床医生的问题，如病变的性质、病变的严重程度、病变的范围、病人的预后指标、对治疗的建议、等等......。 有些热衷于分子病理诊断的医生断言：将来传统病理医生要失业了，分子病理诊断可完全替代组织病理诊断。我认为那是非常非常遥远的事。举个例子，Hodgkin 淋巴瘤的研究已经有150多年，对其肿瘤细胞来源的假说是一种又一种，但是，R-S细胞还是R-S细胞，丝毫不变！人体太复杂，个体的发育、整体的神经体液调节，同样一种因子在不同的时间和空间，作用却不同。这是用一个分子或几条信号通路无法彻底解释的。病变的质变和量变问题、没有肿块的分子改变对优生可进行筛选、对于非实体瘤可进行诊断，对于实体瘤呢？ 当然，作为科学的进步，分子病理使病理医生能从DNA/RNA等分子的角度去探索发病机制、辅助鉴别诊断，比IHC（蛋白质水平）有了很大的进步。人类基因图的破译是一大进步，但是还没高兴几天又产生了更多的迷惑，上帝是如何创造人类的？ |
- 博学之，审问之，慎思之，明辨之，笃行之。
Agree with Dr. Cao above.
培养方式 is to much difference.
In the US: before you become a pathologist, you need to have 4 year university study (mostly biology major), 4 year medical shool, 4 year pathology resident training and 1-2 year fellow ship training. During the resident and fellowship years (5-6 years), the main duties are to read many slides, cases with supervised by pathologists rotate in all subspecielties of pathology, attend many department educational conferences, present cases in department. One target for residents and fellows is to learn pathology. They can not sign out any single case independly.
In China we can be called pathologists after we graduate from medical school and find a job in pathology department. Think about how much pathology knowledge you have remembered. Of cause I know that many people will continue to study for master or PhD in pathology. This may improve the quality of pathology. However, Master or PhD study is more for sciense and research, not true clinical diagnosis.
Correct me if I am wrong.
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本帖最后由 于 2010-02-02 07:32:00 编辑
1）我国的住院医师培养制度将恢复到以前的欧美模式。上海市已在2009年启动医疗卫生改革试点，上海市政府规定沪属任何医院停止招收新住院医师，医学生必须经过住院医生培训基地培训合格后才能被医院录用。
2）我国还有一个错误的概念：M.D.+ PhD 〉= M.D + 3年住院医师培训。非常荒谬！科学研究不能代替住院医师临床技能培训，这完全是两码事。当然，决策者绝对不会愚蠢到让一个医学院刚毕业2年的具有PhD学位的外科副主任医生给自己和家属开刀！
3）在美国许多医生是先获理科PhD学位后，再去考医学院获 M.D.再经住院医生培训后成为临床医生的。真正由医学院培养的具有医学 M.D. 和 PhD 双学位的皎皎者，即使是在美国也在搞试点！
4）在英联邦国家,病理住院医师要经过7年培训，才有可能获得病理专科医生执照，获M.D.学位还要有15年左右的拼搏。
- xljin8
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举这几天的几例来说明一下我是怎么帮助临床医生的：
1：82 years old woman with diarrhea and weight loss for months. I got her gastric biopsy which showed sheets of plasma cells. I spoke to the GI doc and he said the stomach looks very nodular and funny. I ordered giemsa and immunostain for H. pylori, both negative. Did immunostains for immunoglobulin ligh chain gamma and lamda, and there was no light chain restriction. These results basically exclude plasma cell dyscrasia. The patient had a gastic biopsy 10 years ago and the morphology and immunostains of ligh chain were the same. Anyway, i think she had RUSSELL BODY GASTRTIs. I spoke to the GI doctor and he was clueless what i was talking about. I briefly told him what it means and sent his some references to read. I believe though this case, i educated this GI doc about RUSSELL BODY GASTRITIS. He has been a GI specialist for 20+ years.
2. Last Thursday, i diagnosed a GLOMUS TUMOR on a skin biopsy from forearm. The 60 years old surgeon rushed to my office and said: are you sure? I havn't seen a glomus tumor for 20 years! I pulled out the slide and opened the book, the clinical presentation and morphology match perfectly. The surgeon was very happy. Actually the patient and surgeon both thought it was foreign body because the lesion was very painful. I have been doing pathology only for 10 years, much younger than the surgeon, yet i knew glomus tumor hurts like hell and the morphology was characteristic.
3: I gave a diagnose of RETE CYST of ovary to a senior OB/GYN doc. She scratched her head and said" Gee, i have to go back to my books during residency". I opened my book and showed her, it was a perfect match again.
I learn from clinicians. But they really respect and trust us. Today i got a breast biopsy with a note: please do FISH. But the biopsy is pseudoangiomatous stromal hyperplasia. I called the surgeon and told him that. He said: "The note is not from me. I never order anything before i get a pathologic diagnosis". I also explained to him that pseudoangiomatous stromal hyperplasia often presents as a mass. He is happy to know that.
Today i had a ganglioneuroma from GI. I faintly remembered from my residency time that ganglioneuroma can be part of a syndrome (Gardner's?). I will read about it and talk to the GI doc about this diagnosis. Another day, i got 6 epidermal inclusion cysts from a 39 years old man. I told the clinician that multiple epidermal inclusion cysts may be associated with Gardner's syndrome. He was glad to know that and he is sending the patient to see a GI doc.
The clinicians i learn the most from are ophthalmologists through corneal explants. Many times i was clueless. Then i call them ask why the patient had corneal tranplant. The doctors always tell me the diagnoses with certainly. One time, the eye doc told me it was a healed herpetic keratitis, another time it was MRSA infection. THen i open my eye pathology book and match the pictures. I have learned so much from them.
