The Beauty of Glass

Saul Suster is Professor and Chairman of the Medical College of Wisconsin’s Department of Pathology, and an unstoppable force in the world of pathology. Although an internationally known pathologist, a scientist, a prolific medical writer and the author of several well-known pathology textbooks, he decided he was not busy enough – so he founded, and is now the president of, a unique pathology club known colloquially as the “AMR Club.” I myself joined the club in 1996 and have attended several of its international meetings, including the June 2017 gathering in Krakow, Poland. During the meeting, I asked Saul if he would tell us a little more about his unique pathology organization – a club that has, over the last two decades, gained a global following and to this day offers postgraduate education in a traditional, yet novel, form.

Why the “AMR Club?

When I started the club in 1991, I named it in honor of my most influential teacher and mentor, Arkadi M. Rywlin – “AMR.” Arkadi Rywlin was born in Danzig (presently known as Gdansk), Poland, and trained as a pathologist in Geneva and later Chicago. Eventually, he settled in Miami to become Chairman of Pathology at the Mount Sinai Medical Center of Greater Miami and Professor of Pathology at the University of Miami School of Medicine. He was one of the most prominent hematopathologists of his generation, even authoring a textbook on the histopathology of the bone marrow (1). He was also an encyclopedic pathologist with a privileged eye for surgical pathology, but none of those counted as his greatest talent – that title was reserved for his passion for teaching.

He trained hundreds of residents with a teaching style so unique that his students had a term for it – “Rywlinian.” Arkadi Rywlin was an iconoclast who believed it was our personal responsibility to question everything – to pass all information through the filter of our intellect before accepting it as gospel. He taught by example and truly motivated his students to think. “Always exercise your largest muscle,” he would say – and by that, of course, he meant the brain. His prowess at the microscope was awe-inspiring, and to be a student of his, listening to his rationale for arriving at a difficult diagnosis was always a riveting experience. His was the only residency program where the Chairman of the department personally spent three hours of every day at the microscope with all his residents, discussing cases and expanding their minds through his challenging questions and constant prodding. Training under him was a real privilege and the highlight of my career. Is it any wonder that, when founding a club designed to encourage pathologists to think, I immediately thought to name it after Arkadi Rywlin?

Tell us some of his legendary “Rywlinisms…”

My favorite aphorism, and the most important lesson I learned from him, is that “the best lie is the truth.” He would often say that at the daily “show and tell” sessions he held at an 18-headed microscope in his office. During those three hours, he would review all of the interesting and challenging cases of the day with his staff and residents – and any time a resident tried to fib through questions instead of simply saying, “I don’t know,” he would resort to that phrase. It’s far better to admit a lack of knowledge and learn something than to hide it and end up no better off than you began!

Another favorite saying of his was, “We try not to worship the routine here.” What he meant was that we should always strive for excellence, innovation and constant improvement. However, one of his most important sayings was: “A paper cannot defend itself.” He didn’t want us to take anything for granted or to believe everything that we saw printed on a page; instead, he wanted us to constantly process and analyze information. He thought that the ability to challenge dogma was the optimal way to advance our knowledge.

What are the club’s goals?

The main goal of the AMR Club is to provide a platform for its members to exchange interesting and challenging cases in a friendly, noncompetitive spirit. The idea is to share and broaden our knowledge and experience in the different aspects of anatomic pathology. The organization’s official name – the International Pathology Slide Seminar Club – gives a better hint as to its functions. First of all, it is international; its purpose is to promote a discourse between pathologists from all parts of the word. If we had more histopathology exchange clubs and other forms of person-to-person contact across the globe, maybe we wouldn’t have wars and conflicts – but that is a topic for another discussion. True to its name, the club currently has 45 active members spanning the globe from North and South America to Europe, Asia and Australia; all are academic pathologists who share a passion for diagnostic surgical pathology and enjoy taking on challenging and difficult cases. The second key word is pathology; the club was founded by pathologists, for pathologists, in honor of a pathologist, and to promote pathology. We also use the word slide, which obviously refers to microscopic slides – not digital images, but the real, tangible glass itself. The hematoxylin and eosin-stained slide forms the backbone of our specialty and represents the essence of our profession. I learned to love H&E glass slides the same way as Arkadi Rywlin did. And that’s why the club is based on an actual exchange of representative histologic glass slides among its members, rather than the sharing of images or other media.

What do you do?

First and foremost, the club is built on an active exchange of glass slides and comments contributed by members to each other’s cases. Approximately three times a year, I receive a set of H&E recuts from the cases being contributed. I collate them into sets of slides and mail them back out to all members for their review, at which point I also ensure that the information for the cases is posted on the AMR website. Each member then reviews their set of slides and sends their comments, queries and opinions to me by email. Finally, I gather all of these thoughts into a single document and post it on the website (amr-seminar.org) for everyone to read.

After the initial success with our internal exchange of cases, it was suggested by some members that, given the cases’ high education value, perhaps we could share them with a broader audience. This led to a proposal that we organize an actual seminar in which to present the cases to the public. The first International AMR Slide Seminar Symposium was hosted by one of our members, Michele Bisceglia, in 1991 in San Giovanni Rotondo, Italy. The event was a great success, with broad participation by pathologists from Italy and several other countries, and the positive outcome encouraged us to make further plans. So far, there have been 11 international events, including two presentations at International Academy of Pathology meetings. We’ve held seminars in Italy, the Czech Republic, Mexico, Australia, Turkey, Sweden, Israel, Japan, South Africa, Slovakia, and Poland, with one in Croatia scheduled for May of 2018.

Nowadays, our events are designed as extended slide seminars in which members of the club present short cases. We use those cases as a platform to discuss the different entities and controversies in surgical pathology and present a state-of-the-art discussion on the various topics. About 70 to 90 cases are presented at each three-day meeting, and the first 120 attendees receive not only a detailed syllabus, but also a complete set of H&E glass slides from all the cases being presented. The meetings have been enormously popular (with nearly 2,000 pathologists from 30 countries having attended so far) and serve as an opportunity for the AMR members to bond with one another, as well as take an enjoyable trip with their families.

One of our former club members, John K.C. Chan, was the founding editor of Advances in Anatomic Pathology. Thanks to him, the journal has a section devoted to presenting selected cases by members of the club. Juan Rosai, a founding club member, has also digitized the entire collection of glass slides contributed over the years in conjunction with the United States and Canadian Academy of Pathology and incorporated it into the Juan Rosai Collection of Surgical Pathology Seminars (2).

How do you benefit from the club?

More than anything, all of the club members enjoy the discussions about the slides. They aren’t the only benefit, though. Many of us use the slides we encounter at the AMR Club to teach our residents and fellows, and we widen the net by showing the slides to our colleagues as well. That way, the entire pathology community has the opportunity to participate in the conversation. Some of us use the club’s slides as references, comparing them with ones we encounter in our daily routine service. Many of them have been photographed for teaching purposes – some have even ended up as textbook illustrations! And they stimulate further study, as well. I would estimate that about 50 publications have been inspired by interactions that first took place within the context of the AMR Club.

The Club is a not-for-profit voluntary organization; membership is free, but by invitation only. Most new members are recommended by existing ones, based on their suitability to participate and the quality of their potential contributions. Most – possibly all – of our members are academic pathologists, many of whom are chiefs of service at their respective departments, as well as recognized experts in their fields. Other than that, the only requirement for membership is active and enthusiastic participation and regular contribution of cases and comments.

Of course, it’s not only members who benefit from the AMR Club’s operations – and I’m very proud of the fact that we have been able to provide engaging, educational content both within and outside the boundaries of our club membership.

Saul Suster is Professor and Chairman in the Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, USA.
Ivan Damjanov is Professor of Pathology at the University of Kansas, Kansas City, USA.