Notes on Practice of Pathology

**** Some Notes on the Practice of Pathology in Japan ****

Akio Hasegawa, MD
Pathologist

1. Certification in the Specialty of Anatomic Pathology in Japan
2. Who gross the specimen?
3. Turn Around Time for Routine Specimens
4. Forensic Pathology in Japan

1. Certification in the Specialty of Anatomic Pathology in Japan

Post-graduate education of pathology practice is different from one country to another. Actually, here in Japan, major career path for pathologists after graduation from med school is;

(1) National examination of medical license at the time of graduation from med school, that is M.D. (at least 6 years after high school graduation).

(2-1) 4 years of post-graduate course of pathology, providing education of research and practice (actually pathology residency or apprenticeship), which is probably equivalent of MD/PhD course of the US. After finishing original papers, i.e., thesis, we are usually given PhD (Strictly speaking, Dr.Med.Sci. degree).

(2-2) 5 years of experience of anatomical pathology as a clinical resident after graduation from med school is also valid, but this path is rather minor at least till lately.

(3) After receiving PhD, board certification of anatomical (surgical and autopsy) pathology diagnosis by the Japanese Society of Pathology is waiting, which requires 5 years of training in which 4 years of post-graduate course can be included.

In short, the interval from entering college or university to receiving the basic board certification of pathology is apparenly;

	College	Med School	Residency	Total (yrs)
US Japan	4 \|-----	4 total 6 ----\|	5 5	13 11

2. Who gross the specimen?

Pathologists are sometimes curious about persons to cut gross (qualifications) at other labs.

"Personally, I am happy with the techs doing the small biopsies. I dislike reporting larger specimens that I have not cut-up myself." (by one of UK practicing pathologists)

Our empirical rule in my current lab is as follows;

I do gross on,

all the frozen section specimens
larger resected specimens (GI, lung, larynx, gyne, uro, etc)
excisional biopsies of breast
colonic polyps which need bisection
gastric EMR specimens which need serial section
skin specimens indicated as "malignant" by clinicians, even if they are small

Techs do on, (with preparing diagrams for pathologists)

small endoscopic and punch specimens
needle aspiration (liver, thyroid, prostate)
tonsils, nasal and paranasal mucosal specimens
wedge-shaped skin specimens indicated as "benign" by clinicians
TUR-BT, TUR-Prostate
regional lymph nodes from resected specimens, including step sections in their entirety for apparently node-negative breast cases, which are submitted to the pathol. dept. after being dissected by surg/gyne residents

I have never seen techs (MLT/Histotechs) cut larger surgical specimens here in Tokyo/Kanagawa area, fortunately. At teaching university hospitals, smaller specimens too are usually grossed by pathology residents with assistance of techs. In Japan, no equivalent of pathologists' assistant (PA) in the United States exists. In the autopsy room, techs usually help us very positively in the general hospital settings, especially for solo-practice pathologists, while so-called dieners do so rather flatly at the traditional universities.

3. Turn Around Time for Routine Specimens

My group (1 full, that is me, and 2 part timers who cover half a day per week) is covering a local community hospital with 417 inpatients and 1,650 out-patients on average a day, the pathology dept of which is receiving with compliance circa 3,500 surgicals including 150 frozen sections, 2,000 cytologies and up to 20 autopsies a year.

I sign out all the surgicals and cytologies including those (about a quarter) read by part-time guys, which I check and counter-sign before reporting out. The turn around time (TAT) is within 5 workdays after requisition for all the surgicals including punch, gastrectomy, pneumonectomy, hysterectomy, etc. Punch biopsies are usually being reported out within 2 workdays, i.e., targeting within 36 hours after receipt. Usually, diagnoses of the report are written in English, and gross and microscopic descriptions are in Japanese. After negotiations with the corresponding clinicians beforehand, I occasionally write diagnoses in German and French for fun. I've made acquaintance with some skillful surgeons who prefer German here in Japan.
As for autopsies (PHA), preliminary report with gross findings is reported within 24 hours, sometimes through FAX modem from my home at night to the attending. Recently, deeply impressed by the paper by Prof. Rosai which appeared in Pathology Patterns, I tried to shorten this interval on an easy autopsy case such as a case with common hepatocellular carcinoma with cirrhosis, and finished it with micros on the 7th day. It is certainly possible, but usually TAT with full-body autopsy cases is within one month here.

Although our setting with minimal educational burden is completely different from those of large university hospitals, for one of which I had served up until a decade ago (it was fairly sluuuu-ggish), our data here are apparently still unsatisfactory judging from the information gained from publications by ASCP and CAP.

4. Forensic Pathology in Japan

I was asked on the mailing list PATHO-L ,

"Dr. Hasegawa, please tell us about FORENSIC MEDICINE/FORENSIC PATHOLOGY practices in Japan!" (by one of my colleagues in the US)

"What proportion/category of forensic autopsy examinations get brain tissue sent for examination by a neuropathologist in different countries? If this is small (as I suspect) what are the reasons?" (by a famous neuropathologist in the UK)

The following comments are just my conjecture, and are never based on any objective evidence. ;)

ME office is being put into effect (by law) only in the seven largest cities in Japan - actually 5, i.e., Tokyo, Yokohama, Nagoya, Ohsaka and Kobe -, where pathologists are supposedly overworked on low salary, So, my guess is that they are not interested in cases with complicated lesions such as neurodegenerative disease (of course, there are some exceptional guys, maybe), which might be overlooked, and the financial support and personal ties are probably scarce to consult with specialists, i.e., deficiency of consultation system. In this respect, forensic pathology for neuropatho-epidemiological analysis is not robust here in spite of the earnest endeavor by ME guys, I think.
In other areas (in almost all over Japan), death cases outside hospitals without signs of foul play are usually not autopsied, and death certificates are issued by local physicians, usually by family doc, whereas those with suspicion are brought into the forensic path dept of the local med school by the police, where docs are concentrating purely upon criminal aspects of the death and so probably not interested in academic and time-consuming neuropath. In my view, law enforcement autopsy is robust enough, partly because the number of felony cases has not overwhelmed the capacity of criminal justice, at least not yet. Japan is still a safe and carefree ISLAND (maybe too insular! It's a problem, though), so there is no need for commons to carry guns (As a result I have never seen on TV one more young John Doe shooting M-16 from the top of the college ivory tower, shouting jargons). The only problem may be BOREDOM,,,,

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Copyright 1997-1999, Akio Hasegawa. This material may be freely quoted via online services or other media, as long as it is not substantively altered, but I would ask for acknowledgment in any published work. Commercial use is not allowed without the prior written consent of the author.

version 1.22 2008/10/05

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