You are a great advocate for pathology – but, if you could start over, would you choose it again?
Without a doubt! To me, pathology is the perfect blend of basic science and clinical medicine (though I did consider pursuing psychiatry during medical school). At that point, both disciplines involved analytical thinking, but I’m glad I chose to pursue pathology and I would do the same again. I was trained in the “generalist” model of pathology, rather than as a subspecialist. I have always disliked learning something and then not using it, so I try to keep everything I learn practical in some way. Subspecialty pathology is here to stay, but it has its drawbacks as well as strengths.
Though I’ve always been an active practitioner, my experience in medical writing and editing has also had a significant impact on me. Contributing to and learning from the pathology literature has given me a great deal of satisfaction. My 22 years as Editor of the American Journal of Clinical Pathology were particularly valuable – so much so that I encourage all physicians to strengthen their language and writing skills in any way they can.
Tell me about your early days…
I completed my postgraduate training in 1978 at the Mayo Clinic in Rochester, Minnesota, during which time there were several illustrious people on the pathology faculty: David Dahlin, George Farrow, Louis Weiland, and others. I had no idea how fortunate I was to have them as teachers, but I quickly realized. The common thread was their firm grasp of the literature and how to practically apply it to hospital pathology. My love for doing projects and writing papers began during residency and definitely helped me in my future career. Every week, the Mayo Publication Office would issue a list of registered manuscript topics. People then had the option of contacting the responsible parties and discussing possible conflicts and cooperative ventures before the paper was finally formulated. My residency year group of five people collectively published over 50 manuscripts during our training. When I joined Juan Rosai and Louis “Pepper” Dehner on the faculty at the University of Minnesota, that love of publishing grew even more. We had a very stimulating and cooperative group there, as well as the time and facilities to follow our interests.
What were the strengths of your department at the University of Virginia?
Excellence in diagnostic work, availability of laboratory resources, good leadership, and an enthusiasm for doing professional projects and publications were just some of the department’s positive traits. The house staff were also exceptionally talented. We used the “generalist” sign-out system for most cases and every faculty member took on general cases as and when they came in. However, our main strength was an open-door atmosphere. If I was stuck on a case, my resident and I walked down the hall to show the staff member with a special interest in that area; both the resident and I learned and our colleagues got to see interesting and challenging cases.
You were one of the early promoters of evidence-based medical practice. Tell us more about it…
Evidence-based medical practice (EBMP) is based on the critical analysis and application of published literature, rather than on customs, habits, or personality traits. EBMP is the reason that, wherever possible, I try to provide pertinent references in my consultation reports. I believe pathology has made progress in implementing the principles of EBMP, but we still have work to do – for instance, teaching residents EBMP through journal clubs and interdepartmental conferences.
Throughout your career, you have tried to solve pathology’s technical problems. Was this out of interest or necessity?
It was both by inclination and necessity. Looking back on my time in practice, I am astonished at how effectively and extensively technology has been integrated into pathology. The issue now is to know when to use a particular technique – and when not to. For example, we have all experienced the “immunoconfusion” brought on by shotgunning immunohistochemical workups of difficult cases.
Do you think molecular biology will eventually replace immunohistochemistry?
Just as electron microscopy and traditional histochemistry still have (or should have) their places in pathology practice, I think immunohistochemistry will continue to provide value. Technologies are best used together and judiciously, rather than simply swapping one for another. For molecular biology, data management will be key. Medical statisticians are crucial to making decisions on the value of molecular methods and, although many genetic aberrations can now be identified, their biological significance is often still uncertain. We currently stand at a point where pathologists can begin to paint complete molecular portraits of various diseases – and that will only continue to improve diagnosis and guide personalized treatment.
What topics do you think will define pathology in the 21st century?
Several topics are disappearing from pathology practice for various reasons, but I believe the following traits will continue to define the field:
- excellence in morphologic analysis
- skills in medical statistics and medical economics
- critical evaluation of published literature, especially on “new” technology
- consolidation of resources and efforts
- renewed efforts to revive pathology education during medical school and beyond
- a return to honest, critical presentations of “new” information at pathology meetings
- efforts to return physicians to leadership positions in laboratory medicine and individual hospital laboratories
- finding innovative ways to give academics the time and resources to succeed professionally
The future looks bright for our profession – it remains only for us to lead the way!
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