Peer-to-Peer: Ivan Damjanov Interviews Henry Appelman

Henry Appelman has spent most of his long professional life at the University of Michigan School of Medicine in Ann Arbor. Even at 85 years old, he shows up every morning at his microscope in the surgical pathology department, signing out more than 5,000 routine gastrointestinal (GI) biopsies per year – not to mention innumerable outside consultations. Teaching residents and fellows, traveling the country as an invited lecturer, and writing books and papers has kept him busy for most of his life and he doesn’t see himself quitting anytime soon. How does he manage it – and what keeps him going?

At your age, you might be one of the oldest practicing academic surgical pathologists! When will you give up your practice?
I will be 85 in December and I think I signed out around 5,000 cases last year – although I don’t know the number for certain. I have no idea how many people my age are still signing out, but probably very few. When will I stop? When it is no longer interesting, when I find that I am losing my diagnostic capabilities, when I am too physically limited to function… or when my colleagues have had enough of me!

In the meantime, my work is still exciting and intellectually challenging. Every day, there are new things to learn and new experiences to try to understand. Besides, I have fabulous, brilliant, accomplished colleagues who teach me new things daily. I see no reason to give all these things up before I reach senility and develop dementia.

Do you still see many cases in consultation – and are they more fun than routine work?
We have a busy consultation practice, so we split the consult cases among our group of seven GI pathologists, each of whom covers the consultation service for a week at a time. It does not matter to whom a case is addressed. Before the COVID-19 pandemic hit, we received 3,500–4,000 consult cases a year and the numbers were steadily going up.

Which type of case is more “fun?” I am partial to the routine cases because of the far better clinical interactions. Too many consultation cases come with inadequate clinical and laboratory data for us to offer appropriate interpretation and help for the contributors. Unfortunately, many of the contributors get little or no information from the clinicians who send them specimens, especially biopsies. In contrast, in our routine practice, I established a system years ago in which every gut biopsy is accompanied by a copy of the endoscopy report, which serves as the accessioning form. This means that, for every biopsy performed in our endoscopy centers, we pathologists know the reasons for the examination, the endoscopic findings, the clinical impressions, and the recommendations for treatment and follow-up. For liver biopsies, we have immediate access to the laboratory data and clinical findings for every patient on our electronic clinical database. These features make dealing with routine in-house cases both easier and more pleasant for us – and, as a result, we can do a much better job for the patients and for our colleagues in gastroenterology.

We see over 20,000 in-house cases each year and, because of our specialized gastroenterology service, they are enriched for inflammatory diseases. That makes these cases both interesting and challenging – appealing features for any pathologist.

Are you as fast at signing out cases now as when you were younger?
I have no idea; I’ve never timed myself. My work gets done on time, which is all that really matters. No clinician has ever yelled at me for being too slow with a case!

What inspired you to become a GI pathologist?
It was purely accidental. I finished my residency in 1966 at the beginning of the Vietnam War and immediately had to go into the army. Like most of my contemporaries, I was in a plan sponsored by the Department of Defense that allowed resident physicians to finish our residencies without being drafted into the service – but then required us to spend the next two years working at our specialties in service facilities. I was assigned to serve my country at the Armed Forces Institute of Pathology, at that time the premier consultative pathology service in the world. The Institute was divided into specialty branches defined by body sites. I was assigned to the branch that covered skin and GI cases, neither of which particularly interested me during my pathology residency. (This was before the advent of endoscopy and biopsy using fiber-optic technology, which came into common use several years later when GI biopsies became the common tissue for diagnosis.) This gave me the chance to work with one of the giants in both skin and GI pathology – Elson Helwig, a brilliant diagnostician and fabulous mentor.

When I started in the Skin and GI Branch, 90 percent of the cases were skin samples. Of the 10 percent that were GI specimens, most were resections. The branch had three pathologists and three dermatologists who were essentially doing dermatopathology fellowships. The pathologists and dermatologists shared the skin cases, but only the pathologists handled GI cases. Because the AFIP was a consultation service, we received samples from all over the US as well as from other countries – meaning that both skin and GI cases were often challenging. It was the two years I spent at the AFIP, doing GI research and handling the most challenging and interesting clinical cases imaginable, that inspired me to become a GI pathology expert when I left the army – and that’s exactly what happened.

You’ve seen the rise of immunohistochemistry, molecular biology, and other techniques that have revolutionized surgical pathology. How do you answer your junior colleagues when they ask, “How did you practice pathology without these techniques?”
When I started in pathology, things were pretty primitive compared with today’s techniques. But I bet that, a few years down the road, what we have today will seem pretty primitive compared to the newest approaches. For anatomic pathology, we had a battery of special stains, but not much else – so we relied on careful gross analysis and detailed microscopic diagnosis. We also did not know about the many diseases and variations we do now, so there was much less to learn!

Many leading pathologists were your residents and fellows. Are they good because they were smart and talented, because they had a drive to succeed, or because you taught them so well?
Undoubtedly a combination of all three. They were smart and capable to begin with. Then they decided what type of practice was best for them, looked around, and discovered the keys to success. Finally, I probably did motivate some of them. All they had to do was to watch me and see how much fun I was having doing all the things I do! I suspect this was probably my greatest contribution to their success.

What makes a good surgical pathologist?
That depends on your definition of a “good surgical pathologist.” Obviously, you must master the understanding of tissue changes, including how they interact and what combinations of changes are needed for diagnoses, because we rarely diagnose any disease from a single microscopic change. You must also recognize the clinical significance of every diagnosis and know how to communicate effectively with clinicians.

Can you teach someone to become a good surgical pathologist?

I can teach them what I do and how I do it. I had role models growing up – especially Murray Abell, the best diagnostician in our department, and Jim French, a role model for a department chairman whom I emulated at the beginning. Over the years, I gradually developed my own approaches, but I probably kept using a lot of what I gained from my original role models. I hope my students will do the same.

How long does it take you to recognize a talented future pathologist?
Interesting question. Selection for our residency program has been pretty competitive over the years, so our trainees tend to be talented, highly capable, and highly qualified. Most of them are terrific future pathologists right from the start. Some are better at certain things than others – for instance, microscopic aptitude, literature review, lectures, or handling clinical laboratory problems. One of the things I look for in a trainee is curiosity and willingness to question me in diagnoses and concepts. However, overall, our trainees have done wonderfully in whatever type of practice they chose, which makes me proud to say that I had a part in their training.

People love your seminars and presentations. How many do you still give per year – and how did you get your reputation as a “funny guy?”
I used to give eight to 10 lectures and seminars a year outside my institution. As many as four were given during courses sponsored by national organizations such as the American Society for Clinical Pathology and the United States and Canadian Academy of Pathology. As I have grown older, the number of invitations for lectures and seminars has decreased as young, energetic, and entertaining GI pathologists have emerged. It’s appropriate for the invitations to go to them now and I’m pleased to see them receiving the honors.

I have never tried to teach anyone to present in my style. Everyone has to develop a style with which they are comfortable. Personally, I have a love of life and of the people in it, and I have developed a sense of humor about both. I also find that some of the things we do and say in our business are hilarious – or ridiculous – so I tend to make fun of them in my presentations. This is especially true of anything that has specific numbers of diagnostic or prognostic importance attached to them – for instance size, number of positive nuclei, or number of mitoses per square mile!