When I did my surgical pathology fellowship many, many decades ago, I did a two-month stint at what was fondly named, the ‘Hot Seat.’ The Hot Seat duty was not pleasant. In fact, for a person with performance anxiety or any sense of perfectionism, it was brutal. Essentially, the Fellow on the Hot Seat was the first person to view the slides of every single case every single day of the week. This meant that the preliminary diagnosis on any case seen in the department was given by the Hot Seat. We didn’t even have an actual, personal name during those two months. We were just called “the Hot Seat.”

Laying the first eyes on a case, at the time, seemed to be a huge responsibility. I was only 31 years old…a kid…at Stanford University Hospital, a place where you could not fuck up and go to work the next day. We saw weird and wondrous things at Stanford, a tertiary care hospital that took in referrals from around the country. Nobody ever wanted to wait for a final diagnosis. That could take days. A ‘final’ was only signed and official after the Hot Seat saw the case, then the resident, and then the resident together with the attending physician on the case. Sometimes, additional opinions were needed before the attending was comfortable enough to sign the ‘final.’

Much of the time the Hot Seat was on the phone with other physicians who wanted to have an answer, now. Were the margins clear? Was it malignant or not? I mean, come on, how hard can it be?

Well, it turns out that sometimes it is really, really hard. The body’s cells don’t come with signs imprinted on them that say, “I am cancer.” The Hot Seat would write her/his impression in a book at the desk, and all day long interns and residents or sometimes attending physicians would consult the book to read the Hot Seat’s opinion. It was such intense pressure. I mean, if you were wrong, absolutely everyone would know it. Usually, the Hot Seat wouldn’t kill a patient with an error, because it would be caught by the attending on the case. But no error would ever go unnoticed.

Maybe I should first explain what it even means to work as a surgical pathologist. So here is Path 101: Any tissue taken out of a living body, whether during surgery or just a simple biopsy of a skin thingy (professional term), the tissue is always sent to Pathology. I like to think of the Path Department as the place where things are named, hopefully accurately enough that appropriate medical care is given.

If the slides of a given tissue viewed under the microscope possess enough indicators of badness, it is given one of the hundreds of names depicting cancer, when growth of a cell goes unchecked and can lead to imminent death. Fortunately, much of the time it is safely called ‘WNL’ (within normal limits) or given the blessing of some benign thing.

The job deserved its moniker. You were either looking through a microscope desperately hoping you knew what you were looking at, or you were consulting one of hundreds of textbooks describing all of the various things that could go wrong in a body. When you weren’t doing one of those two things, you were on the phone, reading your diagnosis, preliminary though it was, to the hungry ears of physicians with no patience (do you see what I did there?). Sometimes, they would come to the department so they could view a case with you on the Hot Seat multi-headed microscope, and then proceed to argue with you, even though they only passed histology in medical school by cheating because they got motion sickness.

Another adrenaline boosting assignment for the Hot Seat was frozen section duty. The frozen section Fellow was the one who was called to the operating room(s) during surgery to consult with the surgeon. Sometimes, they needed to know if their margins were clear on a tumor. Or sometimes they needed a preliminary diagnosis in the moment, to dictate what they would do next in surgery. In these cases, we would flash freeze a small piece of tissue and slice it in thin sections with a very sharp knife called a microtome. Then a slice could be put on a slide, stained, and viewed through a microscope. This all was done fast, in a few minutes, while a patient lay under anesthesia in the next room. Of course, there was always an attending physician in the room as well as the fellow, so a HUGE mistake could only be made if the attending was wrong, or if no attending was working, as in late at night when only the Hot Seat was available.

This wasn’t a good job if you were prone to ulcers. Also, if you were in any way neurotic about not making mistakes or being judged by your peers, you would want to avoid the Hot Seat.

But the duties were almost never boring, and sometimes it was downright entertaining. The following story is true, I swear. A woman was having surgery for a pelvic mass during my stint on the Hot Seat, at a time when I was on frozen section duty. I knew nothing in advance, but when the secretary handed me a small slip of paper and said, “Julie, frozen in OR 7, I was not prepared for what was written. It said, “Bring a gurney .” 

My friend and fellow Fellow, Matt, and I trekked down the hall wheeling a gurney to the OR, where we gowned up and prepared to go into the surgical suite. When we entered the patient was lying on her side and the surgeons were trying to figure out how to move a gigantic mass of a tumor that had been excised off of the table. They clearly needed our gurney.

The tumor was the size of about 20 basketballs, glistening white and grey with a multi-loculated appearance like caviar, but in some sort of horrible, monster caviar movie…like instead of fish eggs, we are talking Godzilla eggs. It was clear that this multi-cystic thing was largely fluid filled, and it was also very, very heavy. 

We rolled the gurney adjacent to the operating table and, with the help of the entire surgical team, successfully transferred it. It took a few very large sheets, but we managed to cover it up and proceeded to wheel it into one of the hospital medical wards, to weigh it on a scale they used to measure very heavy people. We could not get an accurate weight any other way. And we were Pathologists! Weighing, measuring and naming accurately was what we were paid (little) to do!

Have I mentioned yet that Matt was the most hilarious of all of the pathology fellows when I was doing my three years of Surgical Path? He was Danish, and had a fabulous accent as well as a wicked sense of humor. As he and I were wheeling this mass the size of Arizona down the halls of Stanford Hospital, he kept making the most ridiculous faces and trying in vein to make this all seem normal. The entire mass was covered in sheets, and it must have looked like we were wheeling a very obese dead body to the autopsy suite, with a quick side trip to a hospital ward scale.

In a sense, we were. We had to take it to the autopsy suite in order to drain it. I can’t remember exactly how many buckets of fluid we drained from the thing…it was in the twenty to thirty range. We also needed to examine it thoroughly, both grossly and with a few frozen sections of the more solid areas to give the surgeons our best guess as to what this was. Fortunately for the patient, it appeared to us to be a benign growth, and the final agreed with this assessment.

Stories were written in tabloids about this event. The surgeon was hailed as having excised the largest tumor in history. In one story Matt and I were referred to as her “hefty assistants,” a term that sort of made sense although it ignored our medical student loans and about eight years of specialty training. Plus, it was the first and only time I have ever been described as hefty.

Whenever I tell others about this experience, I am always asked what happened to the patient, of course. And…how did she let it this thing get so big? I have no answer to any of this, so I usually say, “Well, she was 300 pounds lighter.” And that brings me to the point of this entire post:

I feel at least 300 pounds lighter than I did during those months on the Hot Seat. The re-emergence of this blog is so that I can write more about how this has all unfolded in the past few years. It still isn’t clear to me how the writing will play out. I guess I’ll just have to wait and see.

}