Balancing Benchtop and Bedside – and Ball Games

What inspired you to pursue pathology as a career?

Actually, I was very much on the fence. I always wanted to focus on basic research applicable to human disease; I figured that would be the best way to maximize the contributions I would make to humanity (so idealistic!). That’s why I originally attended graduate school and earned a PhD in immunology. At the end of that process, however, getting the MD degree also seemed fairly important in moving the clinical-translational needle – so I headed off to medical school, where I found that treating patients was actually pretty interesting. At the same time, four years of medical school had buttressed my convictions that the exploration of disease mechanisms was what really excited me. In that regard, pathology offered a great opportunity to interweave basic research and patient care in a way that emphasized pathogenesis, as well as the excitement of the scientific sleuthing that comes during the diagnostic workup.

As luck would have it, my residency advisor was the late Ramzi Cotran, Chair of Pathology at Brigham and Women’s Hospital. After listening to me for a while, he suggested that I just do a medicine internship to get the idea “out of my system.” He predicted I’d be back within six months of starting internship, begging him to let me do a pathology residency… and he was right – but I think the year of medicine helped me to become a better pathologist. It certainly made me appreciate how the practice of pathology has allowed me to be a competitive researcher and an expert in a diagnostic area – and also have time to teach – and get home to coach my kids’ sports teams.

What’s the most interesting thing you’ve learned in your career?

Perhaps the most amazing thing I’ve come to appreciate is that the human body works reasonably well much more often than it doesn’t. Our daily routine in the hospital focuses on disease, and autopsies clearly don’t happen without a death, so as physicians we tend to lose track of the marvelous, resilient, homeostatic mechanisms that keep most of us ticking. In many ways, our bodies are over-engineered, with lots of tissue redundancy, regenerative capacity, and built-in fail-safes… and, perhaps even more remarkably, the entire structure is self-assembling and self-maintaining!

I think the most unexpected thing I’ve encountered is how incredibly complex the adaptive immune system seems to be. Yes, it has to have remarkable plasticity – and yes, it’s in a constant war against an incredibly diverse (and clever, and mutating) microbial world – and, most remarkably of all, everything had to develop through natural selection. Still, I’m not sure that, if one were to think about designing this de novo, it would look anything like it does now.

How are novel technologies changing the face of pathology?

Just as immunohistochemistry and cytogenetics became widely used tools for pathologic diagnosis, the same will happen with molecular diagnostics and with digital and computational pathology. Training programs are already educating residents to understand genomic data and, for subspecialty diagnosis, clinicians will expect the pathologist to have integrated genetic analysis into the final sign-out. I’m doubtful that every slide will eventually be scanned and read on a computer screen, but I do believe that we will increasingly embrace specialized application suites that can take on tedious tasks, such as counting mitoses or enumerating tumor-infiltrating lymphocytes.

Image analysis and artificial intelligence algorithms will also represent a terrific growth opportunity for budding researchers in pathology. And, to make sense of the data deluge, we will need to work with (and importantly, educate) computational wizards. As pathologists, we may not become expert in all of those areas, but we do need to understand their indications (and limitations) and be comfortable in applying them in patient diagnosis.

How do you balance your many tasks with a personal life?

My wife would probably say that I still haven’t figured out the perfect balance. There are many late nights and some endless meetings that take me away more than we’d like. However, I work at trying to be present when I am home. Although I may prep for a lecture or read papers, I rarely answer emails in the evening or weekends, and I try to stay off the computer. We have a weekly date night and enjoy movies, concerts, plays, and eating out. When we’re on vacation, I make it a point to stay off the Internet, even if it means a horrendous backlog when we get back.

Actually, being a pathologist gave me the latitude to pursue other things that a clinician (with live patients) might not have the opportunity to do. Consequently, I was able to coach baseball, soccer, and basketball with the kids and take on a bunch of home improvement projects. In retrospect, having those outside activities probably helped to keep me sane. A sense of humor also helps!

If I could go back and give my younger self one piece of advice, I’d say, “Do it the same way. Follow what you love doing, and the rest somehow works out.”