The Pathfinder of Pathology

Christopher Fletcher is Professor of Pathology at Harvard Medical School, Senior Pathologist and Vice Chair of Anatomic Pathology at Brigham and Women’s Hospital, and Chief of Onco-Pathology at the Dana-Farber Cancer Institute. With an extensive history of awards and publications, his long-time focus is on the pathologic diagnosis and classification of soft tissue tumors.

His 35-year-long career has yielded wisdom in many facets of pathology, and he is highly regarded as a mentor by those who have had the privilege of learning from him. Now, Pallavi A. Patil – a fellow in gastrointestinal and liver pathology at Yale University – interviews Fletcher to spread his wisdom to those pathologists and laboratory medicine professionals who have not yet had the opportunity to meet him.

What inspired you to choose pathology?

I discovered I liked pathology in medical school. I did reasonably well at it but, truthfully, I did reasonably well in most subjects – pathology just somehow grabbed my attention. I realized that it’s important because it’s the underpinning of so many parts of medicine. I understood clearly that pathology was the field for me when I was taking the medical school final examinations. If you knew pathology, you could answer 80 percent of every exam paper. Pathology is incredibly important.

On several occasions, I have been fortunate to identify a new entity in soft tissue pathology. Although it can be a challenge to be the first to report such a discovery to the scientific community, it’s also a privilege – and it comes from two things.

First, if you are lucky enough to see a lot of consult cases, you have a better chance of seeing something new – and potentially seeing it more than once. I see cases every single day that I can’t identify; some are probably novel disease entities, but I don’t see enough of them to recognize them.

Second, a lot of it probably relies on visual memory. I am constantly amazed that we still see and describe previously unrecognized entities even now. We are currently working on a couple for which I started collecting the cases in the early 1990s, nearly 30 years ago. When I think something is going to be a novel disease entity, I try to use certain keywords to make it easier to retrieve the cases from our files. I find it astonishing that, for example, if we pull 50 cases of something that has never been described but is in my head, 45 of them usually look pretty much identical. Fortunately, the keywords make it easy to collate and describe them.

You’ve edited a key textbook in your field, the Diagnostic Histopathology of Tumors. How did that come about?

Everything in life is an accident – at least, I haven’t planned anything in my life. In the early 1990s, Nicholas Wright, Chairman of Pathology at the Royal Postgraduate Medical School in London, suggested to Churchill Livingstone the idea of publishing a new book focused only on diagnostic pathology of tumors. They contacted me and I, in turn, selected the contributors for each individual chapter. (I did, and still always do, edit every chapter to make sure they don’t feel dramatically different from one another.) My involvement in the book came about by serendipity, but it’s hard work that keeps it up-to-date and in print.

Elsevier eventually bought Churchill Livingstone and now expect a new edition every five years or so. An awful lot of new information is generated in that time; as a result, they considered an online edition that could be edited continuously, but that would be a full-time job for an editor – and no one has the time. Some have suggested delegating the task of keeping topics up-to-date to younger pathologists, but it’s important to ensure that each topic has high-quality contributors aware of the latest developments in their fields, because it’s works like these that inform how we and our colleagues approach diagnostic medicine. It’s not a responsibility to be taken lightly.

Personally, I spend the years in between editions collecting papers that I think are important. I am old-fashioned, so I have them printed out and filed in different folders instead of saved to my computer. When I get a new chapter, I pull out the relevant folder and make sure all of the new information is included. It’s a lot of work! Although the current edition is finished and in the proof stage, I still keep copies of important papers – I’ve been using this system ever since the first edition. I used to receive hard copies of journals, but now I just get content lists and have to view the articles online. It’s difficult to find that kind of time, and it makes adding references much harder.

I’ve just finished work on the fifth edition, but I foresee a change in the book’s future. People seem to like smaller books nowadays. It’s fashionable to have skinny books with bullet points rather than large amounts of free text. I don’t think people will want to use big, older-style books for much longer. Publishers aim to make money; they always want a new product and a new market, but no pathologist gets rich writing books – not even skinny books. Publishers did themselves a disservice by distributing digital editions; after all, if many users (usually in one pathology department) can share one book, why purchase multiple copies?

What energizes you for your many tasks – managing administration, a large consult service, teaching, and editing a major book?

It’s nice to feel that I’m doing something useful. I enjoy helping young pathologists get into their careers. I never thought I would end up managing so many people, but it turns out that I quite like it. It does become somewhat tiring; here in anatomic pathology at the Brigham, we have around 70 faculty and 50 trainees! With so many people, you have to keep an eye on things like workload, logistics, interpersonal issues, trouble at home… In the end, people are important. If you don’t care about people, they will not do well.

There is one thing I often used to say about administration and leadership that I don’t say much anymore: that if you don’t do it yourself, somebody else will, and they may mess it up. There are all sorts of people I would not want to be my boss!

Multitasking has become part and parcel of professional life. What would you advise faculty and trainees regarding burnout?

If you think about it, that whole concept has emerged in the last four or five years. There isn’t really a good work-related reason why people should burn out more now than they did 10 or 20 years ago – except that society has changed. Now everybody wants everything fast. Sensory input is more immediate. People (not me) have to deal with social media all the time. I completely avoid social media because I think I would shoot myself. I find it hard enough to keep up with email.

I get 200 to 300 emails a day that are not spam and I do my best to take care of them. Nowadays, you can send a question to someone by email instantly and you often know exactly when they received it, too. In the old days, people would send a letter that took a week to arrive and then you would write a letter back. The pace of interaction was slower. Now, because access is so unlimited, everyone can find everyone else via email. I get emails from doctors and patients around the world every single day. I used to find it very stressful trying to fit them into my day. Now I usually just do many of them in the evening. But despite the stress, it is humbling to have all those people communicating with you – and you learn a lot about disease.

My advice regarding burnout would be: don’t overcommit yourself. I will be honest; I think a lot of it is simply a reflection of how modern society works, so it’s not something you can control. You will get bombarded with emails, texts, and Twitter messages – and, if that’s how you grew up, you think it’s a normal part of life. I am lucky not to have grown up dealing with that. I am old enough now that I can ignore them and get away with it. If you are 25 years old, you can’t do that or people may think you are a “weirdo.” Maybe what we call burnout is just becoming a part of life – there seems to be a constant level of overstimulation.

The other thing is that people nowadays seem to have unrealistic expectations, perhaps because so many things are instantaneous. When we get consults, people (usually clinicians, not pathologists) from referring hospitals start calling within hours of the cases’ arrival to find out if there is a report or diagnosis. This happens even when they themselves have worked on the case for a couple of weeks before sending it to Boston. When a case is that difficult, you have to be patient. The report will be sent when it is ready. Everybody wants everything right now; instant gratification is a very American thing, and the rest of the world always seems to end up copying Americans – have you noticed?

Physicians who directly interact with patients often undervalue pathology or lack a full understanding of how a report is generated. How can we change this?

Medical students see less and less pathology in medical school. They often have no significant pathology course in medical school and, because very few medical students do pathology electives, most have no idea what we do. They don’t know whether a test takes 10 minutes (like some blood tests) or multiple days (for a tumor that needs mutational analysis)! We have turned into the Wizard of Oz. We are behind the curtain coming up with a diagnosis and they don’t know where we got it from. That’s a big problem. For example, when you diagnose a synovial sarcoma, the oncologist might say, “Will you check to see if there is SS18 gene rearrangement?” In straightforward cases, the pathologist should say no – you only need molecular testing when you have a difficult differential diagnosis. But clinicians tend to believe in molecular testing because it appears to be objective, unlike relying on the pathologist’s brain.

My consults can be a nightmare in some respects – but, in others, very interesting and humbling. I get 120 to 130 new cases a week, and I have no idea what 20 percent of them are. I have to make my best guess as to what they might be or how I think they might behave, and, of course, that’s where some of the new entities come from. It is quite stressful. I find myself thinking about cases all the time but, in most instances, the extra thought brings me no closer to an answer. 

If it’s a lesion in another specialty, such as pulmonary or gynecologic pathology, I happily show it to experts in that field in our department– but for soft tissue entities that are just plain weird to explain, there often isn’t anybody who can really help! Many patients come to the sarcoma clinic here now, and a significant subset of them come because they got a pathology consult from me first. Our sarcoma oncologists have become very good at understanding that, for many cases, there is no black and white answer. Some patients who get my consults go to other disease centers, which may not be familiar with my reports and call me to ask, “You just say it is malignant; you don’t say anything else. How are we supposed to treat it?” I have to explain to them that I don’t know what specific entity it is, and – although I discuss options with them – it’s their job to figure out how to treat it. They seem astonished that pathology cannot definitively identify the disease entity, so I try to educate them that it happens almost every single day. It’s a big responsibility when “the buck stops here,” and it falls to me to explain that not every slide results in a definitive diagnosis.

How can we address this? We need to educate people. Clinicopathological conferences are an opportunity to teach clinicians how we do what we do, and how long the testing and subsequent reports may take. Pathologists are not handmaidens. In many places, pathologists just do whatever the clinicians ask for. But we are not servants; we are equal players in the care of our patients. Sometimes we must remind them that they don’t know what they are talking about. If they have never heard of a particular disease entity, make them realize how dependent they are on us.

You once ran a fee-for-service consultation service in the UK. What happened?

In the UK, where I am from, nobody pays for healthcare except the small minority who use private practice. It’s a socialized system – but there was a time in the early 1990s when the government wanted to make healthcare market-driven. They wanted the referring hospital to pay the receiving hospital for every patient or case that went from one district to another, even though it was all one central budget and the hospitals were all a part of the National Health Service. I was unlucky because they picked me as a pilot project for consultation services. They instructed me to send bills for the consults, starting with those from the UK. Nobody in the UK or Europe had ever billed for a pathology consult before. As you can imagine, people were very angry and called to say, “What is this bill? Nobody else sends bills.” I spent hours on the phone explaining that it was the government who wanted to send the bill, not me!

I had a soft tissue tumor unit with two histotechnologists and a secretary. The hospital administrators were instructed to close the unit down if I didn’t bring in enough money to cover salaries for the technicians and secretary, as well as lab costs (which, of course, I never did). They put the staff on monthly renewable contracts instead of annual ones. It was quite stressful. European patients generally didn’t have to pay for healthcare in other European countries – but then the UK Department of Health decided that I should start billing for European consults as well. That was funny, because cases from Europe were sent anyway without ever sending payments. In the UK, people were wondering whether they could keep sending cases or not, what was going to happen with the bills, and whether they were going to get into trouble. It was in the newspapers and on television. It was horrible – but the government scheme failed and was eventually dropped.

There is an increasing trend in the USA towards mergers and corporatization, particularly in pathology. How do mergers affect pathology?

Medicine in the USA has become more and more corporate, and less and less a profession where you try to heal the sick. Physicians are often employees of a company that is trying to make money. Even not-for-profit organizations need funding to put up new buildings or to buy the latest technology. It has various negative consequences. For example, many places want doctors to do more and more work with less and less support. Even hospitals here in Boston cut back on support staff, such as histotechnologists, secretaries, and so on. They make changes in the name of efficiency – things like asking us to use voice recognition rather than typing assistance. It just puts pressure on doctors to do more with less help.

To maximize billing revenue, administrators want the most complex cases to be done in the big hospitals. Big teaching hospitals have hundreds of trainees, complicated equipment, and lots of expenditures. In hospital networks, they try to push smaller procedures to the smaller hospitals – for example, lumpectomies, herniorrhaphies, or varicose vein surgeries – because their overhead isn’t so high. It changes the pathology as well. I have been here at Harvard for almost 25 years and the case mix is constantly changing. I see less and less simple material. Our trainees rarely see a hernia sac, an appendix, or a gallbladder. A lot of the simple things have just disappeared because they’re now done in the community hospitals.

How much should pathologists interact directly with patients?

Decades ago, I established a patient consultation practice in the UK. I had no plans to do so, but I had started getting quite a few consults and people wanted treatment advice. We didn’t have a sarcoma clinic in the hospital I worked at in the late 1980s. I persuaded an orthopedic surgeon to be interested in limb tumors, a general surgeon to take care of trunk and retroperitoneal tumors, and an oncologist (who did both radiation oncology and chemotherapy back then because there wasn’t much chemotherapy) to handle that side of things. This group of practitioners began seeing patients and it grew into an actual scheduled sarcoma clinic. I would see the patients with them, and on my own if they were out of town. If the patients got lung metastases, they often sent me into the room to explain about metastases!

If patients feel they don’t understand their disease and need to talk to somebody, clinicians should always consider directing them to pathologists – and pathologists should make themselves available. These interactions happen more by email in the US, which is difficult because you don’t necessarily have precise or complete patient details (especially if you’re talking to somebody thousands of miles away). You have to be very careful about how you phrase things if you don’t know the specific circumstances.

That said, patients here sometimes want to come and look at the slides and are generally appreciative. If they ask, I don’t think we should ever say no or be shy of talking to patients. I know there is a community hospital in Lowell, Massachusetts, where they recently had clinicians offer patients, after a diagnosis of cancer, the option of talking to the pathologist. Most of the patients who met with the pathologist loved it and felt they knew more about their disease. The conversation helped them visualize the disease and feel better about it. Clinicians like to appear to be the ones to know whether something is benign or malignant, when in fact the pathologist makes the diagnosis. The patients end up appreciating the clinician for work the pathologist has done. Many clinicians don’t talk about pathologists too much, so I appreciate the ones who offer patients the opportunity to speak to us – even if not every patient takes that offer.

One problem is that a lot of people think of pathology as something vaguely creepy that has to do with death. I find even now, when I go to social events, people don’t talk very much if I say, “I am a pathologist.” If I say instead, “When you have a biopsy, people like me decide whether it is benign or malignant,” then they become interested. When their perception is that pathology is autopsies or “weird stuff,” they don’t want to hear about it. We have an image problem, and I don’t know how to change that except to say that we shouldn’t hide.

My father, a surgeon, wasn’t very pleased when I went into pathology. Remember, this was in 1982; for him, pathologists and anesthesiologists were like servants. Fortunately, he changed his mind after about 15 years! I find that, when I meet residency applicants or new residents, their families may not have much idea about their profession, and some don’t even understand that pathologists are “proper” physicians!

People have a lot of ideas for improving the image of pathology. There was a time, about 15 years ago, when pathologists thought it might be a good idea to make FAQ lists for diseases that we could give clinicians to share with patients. That never really caught on, because clinicians didn’t necessarily understand the answers or how to explain them. They didn’t use them because they felt uncomfortable. If we make the effort to answer patients’ questions in person, we can avoid that discomfort and spread awareness of our profession and its value.

How can we encourage medical students to apply for pathology?

The drop in applications is very troubling. I think that, to solve the problem for the long term, we have to restore more pathology to the medical school curriculum. That will be hard because, in modern education, they shorten the curricula and pack far too much into them. In the way that pathology used to be taught (40 years ago!), systematically, I had a full three-month pathology course in my fourth year of medical school. We learned about etiology, pathogenesis, and microscopic appearances. There was no immunohistochemistry or molecular biology then, but we learned about outcomes and complications of disease. So much of that pathology was invaluable in taking exams across most other medical specialties!

Over the last 20 years, everybody has been focused on social medicine and training good family practitioners. In almost every medical school, pathology (and histology and anatomy) teaching is much more limited than it used to be. The Medical University of South Carolina in Charleston does still have a three-month pathology course just like I had at medical school, and 10 to 15 students go into pathology there each year because they’ve had that exposure. But here at Harvard, only two or three students each year go into pathology – so the impact is obvious. Those students who do come into pathology residency, no matter how smart they are, often have very little idea what they are doing. It’s not their fault; they have probably never seen normal pancreas under a microscope! I think it’s very hard to learn pathology from that kind of starting point, and I find it worrying that this is the new normal.

How could pathology training be improved?

Residency programs are successful when faculty like to teach. It’s no good when trainees are taken for granted; they shouldn’t just be grossing specimens with little guidance or passively sitting on the other side of the two-headed scope. Modern medicine sometimes takes away teaching time; faculty are frustrated by the number of commitments and demands placed on their time and teaching falls by the wayside. Insurance companies often demand shortened turnaround times as a “quality measure,” so trainees don’t always get to preview things – but that’s how I think residents gain the most knowledge. When I met with some insurance company representatives 20 years ago in Massachusetts, they wanted our turnaround times to be shorter. They were trying to find a way to pay less if we didn’t meet the turnaround times they wanted to set. Somebody questioned the need for resident preview time to be factored in. I said, “Those are the people who will be looking at your prostate biopsies in about 15 years. Do you want us to teach them or not?” They hadn’t thought about it that way. As soon as they realized it could be their specimens under the microscope, they changed their minds!

I think the most important thing is to get good training. One of the reasons residency training in the US was shortened to four years was financial – to save paying for that fifth year. But being well-trained is critical to what we do. It doesn’t matter how smart you are, you can’t learn without seeing enough cases. There is a tendency for places to use trainee logbooks to tick off, for example, that they have seen 20 colorectal carcinomas – but then the trainee may wrongly imagine that they don’t need to see any more. That’s not true, because the more you see, the more you realize how heterogeneous human disease is. There is no substitute for experience. The more you see, the better you get, and the more you realize how much you don’t know.

People go through phases; quite a few have little or no self-doubt in their 30s or 40s and think that they know almost everything. Most of them, if they are smart, will eventually discover that they don’t really know as much as they think. By the time they are in their 60s, they will hedge a little more often or admit to being unsure. As you grow older, it becomes okay to say, “I don’t know.” People don’t like ambiguity when they are younger; they want everything in black and white. But many things about pathology (and life!) are ambiguous. There are always shades of grey.

What do you foresee in pathology’s future?

Genetics and genomics will play a significant role – but they won’t be the right solution for everyone. I think every new technology becomes very important for a subset of patients. For example, finding a new therapeutic target via next-generation sequencing is great for 7 to 10 percent of cancer patients, but the other 90 percent don’t benefit at all. In most tumors, it is currently of limited help. It is fashionable to try to find something when there are no options. Patients read newspapers or leaflets in oncologists’ offices and ask to have tests done. Physicians order the tests because the patients (customers!) want them – and so, medicine is changing. We have become more responsive to what patients want, rather than explaining to them what should be done. I sometimes deal with patients who demand tests. If the test they want is completely irrelevant to their disease, I try to explain that it is not useful and that all they are doing is throwing money away. Clinicians don’t say no very much these days – and sometimes that can lead to crazy tests. When Gleevec came out, people around the country wanted to test for KIT (CD117) expression in tumor types without any known KIT mutations.

American medicine is not very good at saying, “I am sorry. There is nothing more we can do, so let’s concentrate on making you comfortable, reducing your pain, and finishing your bucket list.” Instead, patients get endless chemotherapy, complications, and ICU stays. I don’t know if it is the patients who refuse to give up, or society that has created false hope. It is not good. I wouldn’t do it. Most doctors, when extremely sick with cancer, avoid crazy testing, and instead focus on pain relief and support, and know when there is nothing more to be done. It is very telling that most doctors don’t want these aggressive or protracted treatment efforts – so why do we do it for so many of our patients?

Telepathology may also become a routine part of our work, but that depends on the specimen type. For a small biopsy with a single slide, it could be very useful – but if you have 30 slides of a pancreatic resection, for example, current digital technology is still slow and challenging to use. The technology keeps getting better, so I think it will probably become useful, but right now I don’t like it much. When we look at a glass slide under the microscope, we all scan the slide at low power – perhaps subconsciously – before we decide what’s worth focusing on. It’s usually much harder when you have a digital slide to realize what is important at low power, because software is often slow to focus when scanning. When people send me weird cases as digital slides, I find I usually can’t make a definitive diagnosis. It takes me much longer than when using a microscope and glass slides.

It would be great to get an opinion on a frozen section consult from someone who is off-campus if you have good software. We set up a system here more than 10 years ago but, in the end, nobody used it very much. Why? Because the person on the receiving end wasn’t comfortable enough making a diagnosis that way and would drive to the hospital to make it in person. We older folks grew up in pathology the old-fashioned way and it’s hard to change brains that are wired that way. Millennials, on the other hand, have grown up using technology since early childhood, so they may more easily become proficient in using digital images! By the time they are my age, digital pathology may be entirely routine, and pathologists may sign out cases from home without having to come to the hospital. Society changes!