A Day in the Life: Blood, Sweat, and Smears

Megan Nakashima, MD
Academic hematopathologist and Hematopathology Fellowship Director, Cleveland Clinic

In our newest series, hematologists working in a variety of settings provide a glimpse into their daily lives.

In this edition, Megan Nakashima, MD, peeks out from behind the microscope to walk us through a typical day in the life of a hematopathologist.


Megan Nakashima, MD

Institution:
Cleveland Clinic
Cleveland, OH

Specialty:
Clinical pathology

Years practicing:
8

In my experience, “what pathologists do” (besides sitting in a basement with a microscope – just kidding) is a bit of a mystery to people, even to other medical providers. The truth is, like any specialty, the work of a pathologist varies greatly based on your practice type, what type of cases you sign out, and your individual responsibilities.

I am an academic hematopathologist in a highly subspecialized department where I sign out bone marrow aspirates and biopsies and blood and fluid smears. I also have sign-out responsibilities interpreting coagulation studies and protein electrophoresis, have various administrative and teaching responsibilities, and work on translational research projects.

Here is how I spent a recent Monday:

6:00 a.m. I wake up, let my dogs out while drinking coffee, then work out in my basement. Next, I eat breakfast and get ready for work.

8:15 a.m. As I’m about to leave the house, a hematology/oncology colleague pages me regarding ordering flow cytometry on blood from a patient admitted overnight with a very high white blood cell count, hepatosplenomegaly, and extensive lymphadenopathy. Flow cytometry orders are triaged in our laboratory, typically by a resident or fellow (with attending physician support) to determine if flow is indicated and, if so, which panel of markers should be used. I promise I will call as soon as I have seen the blood smear.

8:45 a.m. I head to the large workroom we use for our “aspirate” service where the attending physician and the trainees on the service each have a workstation with a microscope. The smear for the patient is waiting. There are numerous small to medium-sized lymphocytes and many smudge cells, so I order our low-grade lymphoproliferative disorder panel and call my colleague back.

9:00 a.m. I have monthly quality meetings with the small laboratories located in some of our remote outpatient clinics, for which I am laboratory director/Clinical Laboratory Improvement Amendments (CLIA) license holder. We discuss key metrics (turnaround time, rejected specimen rate, etc.), adverse events, test volumes, and updates from the centralized laboratory operations groups (chemistry, hematology, etc.).

10:00 a.m. I answer emails, sign out cytogenetics reports from bone marrows I reviewed last week, and fill out evaluations for the residents and fellows I worked with on the last rotation.

In my experience, “what pathologists do” is a bit of a mystery to people, even to other medical providers.

10:30 a.m. I attend the daily huddle in the automated hematology and urinalysis laboratory where I am medical director. The technologists briefly report any issues with the analyzers or other notable events. Any major problem will get escalated to the department-level huddle.

10:45 a.m. I now start working on the aspirate service, performing reviews of blood smears and body fluids ordered by our clinical colleagues, examining synovial fluids for crystals, and interpreting hemoglobinopathy panels.

On-service trainees review dot plots from flow cytometry cases ordered over the weekend by the on-call resident. They then draft interpretive reports, which I review and sign out. The trainees also review peripheral blood smears and body fluids flagged for review by the techs and consult me if they have questions.

The bone marrow procedures performed today will be assigned to me; trainees review the aspirate smears today and decide if we need flow cytometry, and then tomorrow the core biopsies and clot sections will come out after overnight processing. When those are ready, we will review the whole case together, order any additional studies needed (such as immunohistochemistry or molecular assays), and dictate the report.

12 p.m. It’s time to eat lunch, while also remotely attending our House Staff conference. Two 3rd-year pathology residents are speaking today, one about acute myeloid leukemia and one about endometrial cancer.

1:00 p.m. The flow is back on our patient from this morning and the results are not what I was expecting, nor typical for any specific World Health Organization–defined entity. The fellow on the lymphoma/myeloma service and I discuss these unusual findings and conclude that a definitive diagnosis cannot be made based on a blood sample. We agree that the team should pursue a tissue biopsy for better characterization of the process. After I check that nothing else urgent is pending, I walk to the immunology lab a couple of blocks away.

1:30 p.m. I sign out serum/urine protein electrophoresis and immunofixation gels at the immunology lab, then head back to the aspirate room.

3:00 p.m. I briefly discuss with my colleague how to access a database for a research project we are starting, which will examine coagulation test results in patients with COVID-19.

3:30 p.m. I finish the work in the aspirate room. The service’s caseload is light today, so I have time to answer more emails and work on an “Introduction to Hematolymphoid Neoplasms” lecture that I am scheduled to give to the medical laboratory science students. We are facing a shortage of qualified medical technologists in this country, so having an in-house training program is a great way to recruit new techs.

6:00 p.m. We are expecting at least 18 bone marrows to sign out tomorrow, so I look for which six will be best to go to our overflow/no-trainee service. I glance at tomorrow’s schedule to start planning the day.

7:00 p.m. and later I get home, walk the dogs, cook and eat dinner (while watching TV), and finish some chores. In the evening, I scroll through #PathTwitter looking at interesting cases and articles people have posted, work on my lecture for a bit, and then finally go to bed.