Writing the Book on Pathology

Where did your interest in pathology originate?

I began my medical career in internal medicine, but I soon realized that I was more suited to an intellectual discipline in which I could engage in both practice and research. Pathology turned out to be my cup of tea. To mix metaphors, I slipped into it like a well-tailored suit.

My mentor, Hans Popper, was an outstanding pathologist and an expert in liver diseases. My initial research projects were morphologic studies, demonstrating the spontaneous evolution of micronodular into macronodular cirrhosis and describing the etiology of primary biliary cirrhosis as a disease of bile ducts. When I began my pathology training, alcoholic cirrhosis was attributed to nutritional deficiencies. I was able to show that alcohol – independent of nutritional factors – was toxic and injured the liver directly. This concept has guided alcohol research ever since.

Since those days, practice and research in pathology have been revolutionized by technological advances. It’s a different world.

How did you get involved in medical education?

When I became chairman of pathology departments – first at Mount Sinai in New York and later at Jefferson in Philadelphia – I also became responsible for the pathology courses at those institutions. I had always had an interest in medical education, so I quickly realized that the same deep thinking required for significant research could be applied to the transmission of knowledge to future generations.

An academic pathology department should not only provide outstanding services to patients and other health care professionals, but also excel in basic research and medical education. When I became Chairman of Pathology at Jefferson Medical College in 1986, I was fortunate to be surrounded by young, energetic collaborators who were also interested in medical education. It helped that the Dean, Joseph Gonella, was also the Chairman of the Department of Medical Education – which meant that he had a sincere interest in supporting our reforms and initiatives.

We informed our students that the pathology faculty was not there simply to instruct them by rote, but rather to help them learn. We emphasized that pathology was the bridge between science and clinical medicine, although the route might be long and difficult. In that context, we explained that they would be exposed to more than 6,000 new terms – a situation similar to learning two foreign languages. Like the relationship between Virgil and Dante in The Inferno, we would serve as their guides into a lifetime career focused on the distinct culture of medicine. The result? At Jefferson, the scores on the National Board examinations rose from the 30th percentile to the top five in the country.

My colleagues and I published quantitative studies of factors that influenced student performance in the pathology course. Mostly, we concluded that student attitudes were more important than the nature of the curriculum or the popularity of the faculty. I was quite friendly with Stan Robbins, so when these endeavors earned the 2018 Robbins Distinguished Educator Award, I was honored by the recognition afforded me in his name.

What do you think of new trends in medical school curricula?

The traditional curriculum comprises a series of departmental courses, beginning with basic science and pathology, and proceeding to medical specialties. The student is expected to combine this information and synthesize new knowledge as he or she transitions to clinical practice.

The current fashion is an “integrated curriculum” in which all subjects are taught together in blocks devoted to organ systems. Compared with the traditional responsibilities of individual departments, the latter serves as a full employment program for assistant and associate deans, committees, coordinators, and secretaries. Despite the additional expense, personnel and time required for the integrated curriculum, I am unaware of any conclusive evidence that it results in a better graduate. Absent such evidence, the integrated curriculum can be viewed (by skeptics) as a species of human experiments carried out without informed consent or permission by a Human Subjects Committee.

Your textbook is foundational in the pathology field – how did it come about?

A representative of the Lippincott Publishing Company appeared in my office and told me that they were interested in publishing a new textbook of pathology – and that a number of academic pathologists had suggested I might be the one to undertake this task. I informed her that I saw no point in simply constructing a compendium of known facts; if, however, the publisher was willing to underwrite a new heuristic approach that used diagrammatic graphics and combined morphology with basic science, I might be interested. About a month later, she informed me that her superiors had approved my suggestion and that they would pay for a medical artist and the costs of reproduction. That was the beginning of Rubin’s Pathology.

In the second edition, I received approval to substitute color photographs for black and white. These presentations were original at the time, but are now standard. The textbook has a worldwide distribution and has been translated into numerous languages. I have relinquished my administrative duties, but still contribute by writing and editing. I am dedicated to the proposition that students who master Rubin’s Pathology should be able to integrate basic science and pathology with clinical medicine. We are currently working on the eighth edition – a task I consider a labor of love.