Jan

3

2022

Talking About Blood: What Does it Mean to Be a Hematopathologist?

By Helen Osborne

Parul Bhargava, MD graduated from Lady Hardinge Medical College, University of Delhi, India, and completed a residency in Anatomic and Clinical Pathology at Georgetown University, Washington DC. After completing a fellowship in hematopathology from Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston MA, she served as the medical director of hematology, flow cytometry and coagulation laboratories at BIDMC for 15 years. In 2017, she moved to University of California San Francisco, where she now serves as the Vice Chair and Senior Director of clinical laboratories. Parul is passionate about medical education and has authored several chapters and edited book sections on hematopathology, including in the Rubin’s Textbook of Pathology: mechanisms of Human Disease, Dabbs Immunohistochemistry, the College of American Pathologists (CAP) hematology atlas, CAP bone marrow reference guide, Practical lymph node and bone marrow pathology, and she has edited a textbook on infections and non-neoplastic hematopathology.

In this podcast, John Holcomb talks with Helen Osborne about:

  • The work of a hematopathologist
  • The value of blood tests
  • The importance of team work
  • The importance of always keeping the patient in mind

Music by Skilsel from Pixabay.

Producer and audio editor: James Aird

Transcript:

What does it mean to be a hematopathologist?

HELEN: Welcome to Talking about Blood. I’m Helen Osborne, host of this podcast series and a member of the Advisory Board for The Blood Project. I also host and produce my own podcast series, called Health Literacy Out Loud.

Today I am talking with Dr. Parul Bhargava, who’s Professor and Vice Chair of Laboratory Medicine at the University of California San Francisco. Parul is a pathologist with subspeciality training in hematology. She describes herself as passionate about medical education and has authored or edited numerous academic publications. Parul and I are both members of the Advisory Board of The Blood Project. Welcome to Talking about Blood.

PARUL: Hi Helen. Happy to be here.

HELEN: I’m so glad to be talking with you. I’m really enjoying getting to know people who are part of the advisory board for The Blood Project. Most of the ones I’ve spoken to are interacting directly with patients. Some form of clinical medicine, I think. But your background is more in laboratory medicine and pathology. Some people might know a lot about that, and some may not. Can we kind of take it from the top. What exactly does a pathologist do?

PARUL: That’s a great question, Helen. I’d like to share a story that my father, who’s a physician in India, shared with me about pathology as a branch in medicine. And he basically said that if medicine were a tree, then the roots are what we need to know about the normal body: the normal anatomy, normal physiology, and so on. Pathology is the trunk of the tree that connects…

HELEN: Ok, the big center part.

PARUL: That’s right. It connects what is normal to what is disease. So pathology in a nutshell is the study of disease, which is the basis of all of medicine. And then the branches are the different subspecialties. So you could be a specialist in one organ: the brain, or heart, or gut, and so on. But ultimately you need to understand the basis of it all lies in pathology.

HELEN: That’s really interesting. It’s giving me this visual image and when I think of a tree, a maple tree that has the sap running all through it – sometimes in the spring the sap comes out and we get maple syrup. I know there’s a lot going on inside the trunk that I cannot see. Is there any metaphor or equivalent to the role of blood in that?

PARUL: Absolutely. That’s actually a great analogy just like the sap has to run all the way up to the very tip and back. So does blood in our bodies. Blood is basically the essential elixir of life and it flows through every part of our body carrying nutrients to different cells and tissues and then bringing back any byproduct or any waste material back to be removed from the body. So in doing so, it’s not just a transport medium. It’s a very active, live, almost like an organ system that is carrying chemical signals also back and forth. So when we look at blood, we can actually tell a lot about what’s going on in a patient whose disease you might be trying to diagnose.

HELEN: I assume that’s what you do when I consider behind the scenes as a pathologist or in laboratory medicine. I’m speaking of this as not a physician, as just someone who has blood like every other person on this planet. I would go to the lab, they would take my blood, and I don’t know what happens. It goes in some little bottle and I don’t see it again. And then the doctor tells me, or I get a report somewhere, that my level is this or that and it’s worrisome or it’s not worrisome. You’re the one that blood goes to, correct?

PARUL: That is correct. Just to back up a little, a pathologist would look at practically any tissue that might be removed from the body. So it may not necessarily be just blood but if a surgeon takes a biopsy or if, all those materials would come to a pathologist to be looked under a microscope. But blood certainly forms a very important initial test that many people undergo – a blood test. And the people who look at it are specialized within pathology into fields we call hematopathologist or hematologist, which is what I practice.

HELEN: This podcast is Talking about Blood. Can you just start describing, and let me tell you about the audience, tWhhe listeners for this. Yes, I hope there are many practicing pathologists and hematologists who are listening to this – practicing physicians and clinicians. I also hope and expect we have many people newer in the field who are thinking about being a doctor or maybe who are in the early stages in their training. And then there are people, and I feel I can speak for them in some ways, who just have this tremendous curiosity about blood. So I hope you can address some of the features that can resonate with all of us. When you look at blood in the lab as a pathologist, what are you looking for and what can you learn?

PARUL: I’d love to answer that question because that’s what I’ve spent my entire life doing. So the blood essentially has two main components. There is a liquid component which we call plasma, and that is like a straw-colored liquid. Floating in it are cells, so there are multiple types of cells but three main categories: white cells, red cells and platelets. So when a blood test is drawn, we can do multiple things with it. We can run the blood through different machines and study the chemical composition, which is in the liquid part. And we are looking for chemical derangements, which can give us clues to what is going on in the patient’s body. For example, if someone comes with chest pain and we are worried about there being a heart attack, there are certain chemicals that elevate in the blood, so then we can measure them and even serially trend them to see if there is heart damage. So that is the chemical part.

And then there is the cell part of the blood. The cell numbers are tightly regulated but when the numbers go up or down, they indicate certain diseases. So we can measure the number but we can also make a smear of the blood on a glass slide and look at it under the microscope to look for abnormalities that are not of count, but of appearance.

HELEN: Oh, ok, because I hear a lot of the hematologists in our group talking about blood smears and then I see pictures of them and there are arrows pointing… isn’t this a really interesting one. They’re looking at the cell structure of that?

PARUL: That’s right. They are looking at the types of cells that are floating in the blood and whether they are normal or abnormal in appearance. Sometimes there are young immature cells that live in the bone marrow and are not normally present in blood that we start to see in blood, so they can tell us different things about what is going on. Some of diseases are of the blood or of the marrow itself, meaning the marrow is not producing things properly or is producing too much of a thing. Sometimes the cells are reacting to something. For example, if someone had an infection, a bacterial infection somewhere, the white blood cells are our fighter cells, so they will typically go up in number and change their appearance so they are ready to attack that bacteria. So we can look at that and tell you “Oh you might be having an infection. Let’s look at your urine, or let’s look at your teeth, and see that infection there.”

HELEN: This is fascinating. I’m just seeing you as this great detective. You and your colleagues and there’s so much more to it. I get my test results and I have to have someone explain them to me, but you’re the one who’s really doing the deep investigation. I’m curious what happens next. But I want to kind of go to the side. What happened to disease and detection of disease before there were such sophisticated blood tests and pathologists like you?

PARUL: Most of the time it was a clinical examination that you know, the very early clinicians or physicians, that’s what they did. They would listen to people’s sounds of the body. They would tap and see if they can feel any fluids anywhere. They would take temperature. They would see if there was pain. Mostly to do with physical examination. There were clues, for example, you’ve often seen doctors look at people’s eyes and they can tell if there’s paleness, which means there’s anemia, which now we can diagnose objectively by saying “Ok yes, the red cells are low in number,” which is what anemia is.

HELEN: So what you’re doing, is there a lot changing these days because of the all technology and tools that we have.

PARUL: Absolutely. There has been an explosion of knowledge and you know the blood lends itself, it’s really at the cutting edge of diagnoses these days because it is the most easily obtained tissue with sort of minimal disruption to the patient’s body. You know we’ve come a long way from the days of looking at things under microscopes, which is still a very, very important tool but nowadays we can go so much deeper. We can look at protein expression on the cells using sophisticated analyzers. We can look at the genes. We can look at the molecular-level derangements that could happen that are deriving what we are seeing under the microscope. That is so important because once you know the genetic basis of a certain disease, one can then develop therapies that target that genetic basis and cure people, and there are many examples of that.

HELEN: So somebody, a clinician, has a person have a blood test. And I’m just using blood. It could be any part of the body but since we’re focusing on blood. And then your lab gets it and you are learning so much about all the components of the blood. How do you close that loop and get back to the person who is treating that person.

PARUL: Yes, so we are actually forming a full detailed comprehensive report that is available to the physician as well as to the patient in most cases, that ties together everything we see. So not just what we are seeing under the microscope. But if we did additional studies like study the protein expression or study the genetic basis. We put all of it together and then come up with a unified diagnosis. So in some ways a pathologist is like the doctor’s doctor.

HELEN: That’s terrific. And are you helping to give suggestions about how to treat too?

PARUL: Yes, so these days it’s a close collaboration. It’s very strong teamwork that we have with the clinical team. We are constantly reading and learning about new therapies that are available and if that therapy happens to target a particular protein or a particular genetic marker, then we would look for that and then in our report we would say that it expresses this or does not express this, so the clinician would then know if targeting that would be effective.

HELEN: Wow, I’m so delighted to be talking to you and really hearing about the teamwork including the people I would never be seeing in person. So since I described our listeners and we come from all ilks, I would love to hear what you would like to share with practicing physicians, with those new to the field, and with those of us just curious about the role of pathology, and hematology, and all of that. Should we start with the practicing physicians? What would you want them to know that perhaps they don’t already?

PARUL: So to the people who are already practicing in the field of hematology, especially in say pathology. Even though they are behind of the scenes, they should never forget that there is a patient, a family, behind the samples that you are seeing even though we are not seeing the patient directly. You know, I have to tell you a little anecdote. So I had a very, very excellent, meticulous technologist whose job it was to make smears from patients’ bone marrow samples. We have a lot of quality checks in the lab every day so we make sure that the stain works properly and everything is done perfectly, which becomes sort of matter of routine after some time. But unfortunately that technologist had a condition that required her to undergo a marrow. When she was on the other side and she came back, she came back and told everyone, “I now treat everything like gold. It is so precious”. Because she experienced the agony, waiting for that result, so you know we take for example, one of our quality metrics is to make sure our turnaround times for our report stays under a certain number. So it hits home that you know every day that there is a delay, there is a patient whose anxiety is going up. So even though we don’t see the patients directly, keeping that human factor in mind is so important.

HELEN: Oh, thank you. And as I’m thinking of all the experiences that I wait for test results and certainly other people I know wait for test results. That waiting is excruciating. So thank you. Thank you for taking that into account, sharing that story, and reminding us all about the people behind the sample. What about someone thinking about being a doctor, or in the early years of their career. And not just a doctor, anyone in the health professions. What would you want them to know about some of the work you do?

PARUL: I think the work we do is such a privilege to be able to do what we do. And I love telling stories so if you don’t mind indulging me.

HELEN: Please share one more!

PARUL: One more. So I have a daughter who is in college and maybe thinking of going into medicine. She called me earlier today and you know just asked me what I was doing. So I told her I’m looking at the bone marrow of a little child who’s two years old. So she was a little saddened and she said “Well what do you see?” So I said “Well the child had leukemia but they were treated and I see now the marrow in follow up and it is free of disease.” And that gave her such joy and she’s like “Wow! Doesn’t that make your day?” And it certainly does.

HELEN: Oh, I’m getting goosebumps with every one of your stories. I don’t know the physiology of goosebumps but I’m getting them as you relate to the humanity and humanness of doing all of this. Last bit of advice or what would you want to share with everyday people like me who just have a curiosity about blood.

PARUL: Well the blood is such an important window to what is going on in the body and it is a wealth of information that one can derive from a blood test. So when you go there and those tubes are drawn, and patients are sometimes wondering why do I have to give so much blood? Well think about how much science has advanced that nobody has to go open a body and find something, that we can look at the blood, just a little tiny pinprick and tell so much, gather so much information about what’s going on in the patient. And that information is just growing. So you know, while we want to thank the patients for being part of their own care, but also realize that giving that tube of blood is actually giving so much information about what might be happening.

HELEN: I will be doing exactly that the next time I’m doing it, not just grumbling that I have to do this or that or that it hurts a little bit. But really think of that team. And I hope I keep that image too, of that tree, and that how our sap or blood running through it is just, tells us so much about life and living, illness and health. Parul, thank you, thank you, thank you for doing all you do and talking with us about it on Talking about Blood.

PARUL: Thank you Helen. It was an absolute pleasure.

HELEN: To learn more about The Blood Project and explore its many resources for professionals, trainees, patients, and the lay public, please go to https://www.thebloodproject.com. I invite you to also listen to my podcast series about health communication called Health Literacy Out Loud at https://www.healthliteracyoutloud.com. Please help spread the word about this podcast series and The Blood Project. I thank you for listening. Until next time, I’m Helen Osborne.