Do You Have a “Trigger” Song? Tell Us What It Is!

I heard one of my “trigger songs” this morning. You know what a trigger song is, right? It’s a bit of music that once you hear it, immediately brings back memories, good or bad. Some of those memories might be buried deep in your subconsciousness; hearing the song startles you into instant awareness. I probably have half a dozen of those tunes moored in the sulci of my brain, waiting to be untethered.

The trigger song I heard today was from David Bowie, a number from the early 1980s called Modern Love. It’s a bouncy, danceable, upbeat tune–though the lyrics don’t relate to me in any fashion. So why is it a trigger song for me? Here’s the story.

In the fall of 2005, I had just left my long-time position at Holy Family Medical Center, as the hospital converted from a general hospital to an “”LTAC,” a long-term acute care facility (think very ill patients on respirators.) I had begun my association with UroPartners and my first task, was the creation of a laboratory to process and read urological biopsies–mostly prostate biopsies, but bladder and skin biopsies, too.

The process was long and arduous, as step by step I first went through the design, and then the process of obtaining a contractor, necessary permits, and laboratory equipment.

After a month of working totally solo, and spending sleepless nights wondering if the grossing station I had ordered would fit through the front door (the lab space lacked a loading dock,) I was given a temporary office in the headquarters of a consulting group that was working closely with UroPartners on the integration of the various doctors and facilities that were joining together to form the “super-group.” I was also given a consultant/partner to help me on the business end of the lab set-up and though she knew nothing about laboratories, she was a steadying influence on my efforts.

So where does David Bowie fit into this scene? I never brought a radio to the office, but I did have a computer on which I streamed WXRT, my favorite radio station, into the space while I made my hiring decisions, argued with contractors, and chose paint colors. A quirk of streaming radio in those days was that the commercials that were being broadcast over the airwaves did not stream. Instead of ads, I would hear, over and over, a bit of saxophone from Modern Love.

So yes, when I hear the first few notes of the old Bowie hit, my mind immediately drifts back–and I remember how panicked I originally was, but then I also remember how well it all turned out.

Not all triggers are bad ones.

Send me some of your trigger songs at chidoc@post.com or comment directly on the post.

Lab Hiring 101– I Almost Flunked This Course

I was listening to SiriusXM today when I heard an old Broadway tune titled “I Feel Like I’m Not Out of Bed Yet.” It’s the opening number from the musical “On the Town” and is sung by a gruff workman not wanting to leave his wife and their warm bed.

It’s in the second verse that our sleepy workman calls his wife “his old woman.” Hearing that archaic and very non-wokish phrase (the musical dates to 1944) reminded me of an employment decision I once made–a decision that was certainly not the best one of my career.

It was in the first six months of the development of our private laboratory. We were in the process of creating a fairly specialized area of the lab, one dealing with small cells and colorful signals. The applicant pool was not a large one, and my decision was narrowed down to two candidates, both of whom looked good on paper.

The company had no Human Resources Department in those early days, so the decision of who to hire was all mine. I interviewed each of the candidates, first Pamela, and then Frank, running through their work experience and trying to assess their capabilities for creating and then leading the lab section.

Pam had solid experience and had worked in both the clinical and industrial aspects of the lab business. She answered all my questions appropriately and made no glaring faux pas. I had no formal rubric for evaluating candidates, but I probably would have given Pamela a score of 7.5 out of 10.

When I interviewed Frank, he was knocking it out of the park. Personable and experienced (though admittedly not quite as widely experienced as Pam,) he was well on his way to racking up a score 8.5 and a job offer. And then he did it…he referred to his life partner as “THE Wife.” I can’t explain it, and with no objective reason for it, my mental rating of Frank was sliced in half.

So yes, I hired Pamela. And yes, as you can surely predict, her tenure turned into a disaster. Rigid and inflexible, she did not play well in the sandbox with any of us. Although she wrote some excellent policies and procedures we all breathed a sigh of relief when she resigned to go back to industry, shortly before her lab section was to open for business.

I called Frank and was delighted to hear him say he was still interested in our position. He gave his then-current employer his two-week notice and was with us for the section kick-off.

For more than 10 years Frank was a wonderful asset to our lab. He was a thorough and accurate technologist, an excellent section leader and organizer, and a great friend to all. He was truly the heart of our workplace.

Over those 10 years, I met Frank’s Sheila on numerous occasions. Frank and Sheila were a loving couple and treated each other well. She was “THE Wife”, he was her husband–and it was my mistake that I almost didn’t hire him.

Hey! Can you do me a favor? If you are a subscriber and enjoy my blogs, please email them to friends and contacts. And if you read my blogs on Facebook, please share them! We are always looking for new readers.

You can always get a hold of me at chidoc@post.com Look forward to hearing from you.

Ever Regret Something You Have Done As Part Of Your Job? I Do.

Sometimes an unexpected encounter can lead down memory lane. And not all memories are ones to be proud of.

Barb and I were walking through the parking lot of Charlie Beimlich’s Food and Tap, our not-quite-a-dive-bar go-to place when we are in the mood for a juicy burger. In the evening gloaming, I very briefly saw a couple walking ahead of us and mentioned to Barb that the pair looked like Aaron and Ruth Reynold, two fellow physicians that I hadn’t seen in years.

As Barb and I were led to our seats I glanced at each of the dozen tables in the restaurant but didn’t see the other couple. We ordered our burgers and distracted by the food and the Bulls’ play-in game on the restaurant TV, I forgot all about the possible sighting.

But as we were leaving, I took a look at the people sitting at the bar and convinced myself that Aaron and Ruth were seated there and were just finishing their meal. I walked up to the couple at the bar, tapped Ruth on the shoulder, and said hello. She looked surprised at first, but then recognized me and smiled her own greeting.

Barb joined us and after a brief reintroduction, Ruth, who was a former community pathologist like me, and Aaron, an internist, compared notes on our recent retirements, pickleball, grandkids, and the attraction of Florida. I reminded Aaron that we had been medical school classmates, the Class of 1979.

And as I drove home, I remembered a little bit more. Aaron and I had not just been classmates. We had both spent the summer between our M1 and M2 years as junior researchers in the lab of one of our professors, an Eastern European scientist studying the pharmacology of sleep.

I didn’t have a car that summer, so every day I would board the El at the Morse Ave stop and ride into the city. A long walk through an underground tunnel connected me to the train going west and in a few minutes, I was at the medical campus and the lab. That voyage prepared me for what was to come each day.

I had been assigned to a post-doc and together we perfected an assay to measure a chemical linked to sleep. That was fine. It was the other half of my duties that I now regret. Our subjects were cats. I won’t describe how we obtained our feline material for testing, but I assure you it was regrettably cruel, and would be wholly unacceptable today, and should have been then, too.

My most horrifying moment was when a cat I was working with escaped and ran into the office of the department chairman, a very severe, sharply dressed gentleman who was one of the few African-American professors in the medical school. I don’t know who was more frightened, the professor or the cat. That was the last live subject I handled in the lab.

The summer ended soon after that. I cashed my $1000 stipend and buried thoughts of those poor kittens. I never discussed the summer with Aaron, but our chance encounter at a hamburger bar brought it all back to me.

I wasn’t much of a friend to those kittens in the summer of 1976. I think I will give our cat some extra catnip tonight and donate to a pet shelter in the morning. It is the right thing to do.

May You Succeed In This Endeavor — A Message To My Successor

There is a tradition of American Presidents leaving a message on the Oval Office desk welcoming their successors to the highest office in the land. The convention is so strong that even Donald Trump left a gracious message for Joe Biden. While the transference of the Directorship of our laboratory isn’t quite as significant as assuming the Presidency, I still want to leave a message for Dr. Ken Beck, who will fill my place in the Square Office as I shut off my microscope for the last time.

Ken,

First and above all, I thank you for your dedicated, loyal service during the fifteen years we have worked together in this Little Lab by the Tollway. You have brought your professional expertise and some business insights as well. Your Information Technology knowledge has been invaluable to the laboratory and the organization as a whole. And I am still amazed by the quantum mechanics on your whiteboard.

You and Bev have five children. Over time, you will come to think of the laboratory as your sixth. As with your other children, it is important that you give the lab, and the people who work here, a sense of direction and a code of ethics to follow. I advocate a loose love–lead but don’t micromanage, delegate where you can to a dedicated staff who have proven they will come through when and where you need them.

You admire technology. Use it to move the lab into this decade where necessary; don’t use it for the sake of being the most up-to-date. I sense that you understand that.

Change is inevitable. Medicine changes and the business of medicine changes even faster. At times this can be overwhelming–or at least highly stressful. I hope that any changes that come bring opportunities as well as challenges. Make sure your voice is heard and that you and the lab make the most of those opportunities.

My phone will always be on for you — except when I am rambling over a tennis court, slicing a golf shot, learning the tricks of pickleball, cheering at a White Sox game, enjoying a Broadway show, or romping with the grandkids. Ok, I will be keeping busy, but I will always find time for you, Dr. Brown, and the lab staff.

May your years as Director be as long and as fulfilling as mine have been.

Best of luck and Happy New Year,

Les

The above are the opinions of the author and not UroPartners, LLC.

A Lingering Odor Brings Back Memories

The Anatomy Lesson, a 1632 oil by Rembrandt.

I needed to review a bit of anatomy to accurately describe and analyze a complex surgical specimen I had received in the lab. I opened the farthest cabinet in my office and pulled out a slim green volume that I had not touched in years, “ANATOMY A Regional Atlas of the Human Body” by Carmine D. Clemente.

And before I could even open the book I was carried away. The lingering odor of formaldehyde hiding the scent of slight decay filled my nostrils. I was immediately back at the University of Illinois Medical School in Chicago, a very young and raw first-year medical student, riding the elevator to another anatomy dissection.

Prior to medical school, I was ignorant and relatively uninterested in the interiors of the human body. Most of what I knew came from playing the game “Operation,” removing funny bones and Adams Apples while trying not to set off the electro-probe buzzer. If I knew my heart was on the left side of my body, it was only because I was used to placing my hand over it while saying the “Pledge of Allegiance.” It was pretty clear I was not headed for life as a surgeon.

But the anatomy lab was a fascinating place. The elevators took the 400 of us in my class to an enormous room with row upon row of elevated rectangular metal boxes. Within each was a human cadaver, semi-embalmed, semi-decaying. As part of a team of four, I was assigned a corpse, and given nine months to learn what had made her tick.

My squad had a mixed background: Nina, a short-bubbly brunette from the East Coast, Dwight, a downstater from Effingham, Tom from the outer ring of Chicago suburbs, and myself. We showed up for each session in our lab coats and reusable rubber gloves — only the lucky few in our class had access to disposables. In our pockets were small dissection kits in black plastic wallets; scalpels, tiny scissors, a set of forceps. And in my hand, the anatomy atlas, soaking up the odor of the room as I tried to soak up the knowledge.

Our lab section met two times a week. In each session we would focus on a different part of the body: one day dissecting out muscles, tendons, nerves, and arteries from an arm, then a few weeks later analyzing the chambers, valves, and vessels of the heart. Proctors roamed past the metal tanks, answering questions and making morbid comments.

We were expected to learn the position, name, and function of each item we came across. Every few weeks we had a practical exam, each student walking from cadaver to cadaver to identify structures that had been marked by the proctors with a snip of twine. Many times the twine was thicker than the tiny nerve we were asked to identify.

It was a privilege to have had the opportunity to examine, dissect, and come to know those bodies. I do hope I have honored that privilege throughout my career. I’ll always treasure my green anatomy atlas–for the memories and the scent of those earlier days.

A Pathologist Keeps Up With “I Love Lucy”– and Pen-Demonium Ensues

The Candy Line keeps Lucy and Ethel busy.

It is a classic. Lucy and Ethel, working faster and faster to wrap chocolate candies as the little morsels come shooting down the assembly line.

“If any get by you, you’re fired,” the boss has told the gals.

So to keep up with the speeding line, Lucy and Ethel sweep the candies into their mouths, their hats, and as a last resort, their blouses.

And then the boss walks back in, notices that no candies are escaping the girls, and calls to the man running the line “Speed it up, Paul.” Yes, the hamster wheel never stops…it just gets faster.

I suspect most surgical pathologists feel that they are on that wheel at times. I know on some days I do. The histotechs and cytotechs bring me stacks of slide trays. I grab the top tray and review each slide, carefully preparing my reports. And when I turn back to the stack it has only grown. My techs must have crept silently into the office to add a prostate case here, some bladder biopsies there, and more cytology everywhere.

Unlike Lucy and Ethel, we pathologists can’t hide slides in our hats or swallow them whole. Each slide, each case, and each patient needs as much undivided attention as we can provide. At least most of us are self-motivated enough that we don’t need a boss on our backs threatening to fire us.

I have to admit that some of the hamster wheel feelings are self-imposed. I work hard to get my slides all reviewed by a particular time of day. After that time the transmission of impulses from my retinas to my occipital lobe slows and my scribblings on biopsy worksheets become harder to decipher. A feeling of exhaustion creeps into me. There is only so much caffeine can accomplish…

I have lots of slides in my office, but I have even more pens. There are clickable ballpoints and capped ballpoints. Markers in red and markers in blue. Some with corporate labels, some with vendor labels, and some with labels apropos of nothing. I use them at my desk, at my microscope, and at my back counter–and after I have used one I leave it where it lays. Like chopsticks littering the table after Chinese take-out meal, the pens are everywhere. I just call it pen-demonium. It’s a good thing I have never owned a valuable pen, it would just get lost in the morass. As far as I am concerned, any old pen will do.

What do you have too much of? Let me know at chidoc@post.com

Count Rostov was Right. The Lab is Everything That Has Gone on in the Lab

I have spent my commute for the last month listening to A Gentleman in Moscow by Amor Towles. It is a long novel recommended by Barb, detailing the life of Count Rostov, a Russian nobleman, sentenced to house arrest in Moscow’s Metropole Hotel after the Russian Revolution. So far, I’ve covered about 40 years of his life, and I still have 4 more CDs to go. As I said, it is a loooong novel, but a fascinating and very quotable piece of literature.

At one point, the Count reflects on the Piazza, one of the hotel’s restaurants. In a discussion with a young artist sketching the scene, the Count proposes that while the room itself may be nothing special to look at, what is special about the room is “all the things that have gone on in it.”

So it is with the lab. Yes, it’s a hodgepodge result of multiple expansions and remodels, with wandering hallways and blind intersections. But for the last 17 years, it has been filled with people, experiences, joys, and sorrows.

The lab has been filled with the sound of some 50 employees (who thankfully didn’t work at the same time,) five different pathologists (who thankfully agreed with each other most of the time,) and at least one visiting cat.

The lab has been filled with the exuberance and fun of Lab Week–I still have flashbacks to being hit in the face with a pie as part of a fund-raiser, and the silence of Covid–as we went about our business masked and distanced from each other.

The lab has been the site of committee meetings, board meetings, and a national uropathologist session. The lab has been inspected, specimens have been dissected, and unlabeled cups of urine have been rejected. We have been doused in formalin perfume and withered at the petri dish of odors emanating from our microbiology lab.

The lab has been our setting as pathology has changed in the last 17 years. In our journals, photomicrographs of interesting tumors have been supplanted by details of their genetic sequence. The value of PSA screening has been challenged (I say keep on screening) and recently the idea of reclassifying some prostate cancers as benign has been floated (I say sink the idea.)

Sadly, the lab has seen us mourn, not once but twice — firstly over the loss of a tech who was taken from us by leukemia in the short span of a month, and secondly for a cytologist who valiantly fought an unremitting high-grade brain tumor over the course of over a year.

Returning to Count Rostov–as my career is racing towards its end I see how right he was! It’s not the floors or walls or instruments that make our lab memorable. It isn’t the technology. As the count said, our lab is made of all the things that have gone on within it.

And there are just a few more months for me to take it all in.

The views are those of the author and not Uropartners LLC.

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A Prostate Pathologist Pencil Pusher. Making a Better Diagnosis.

Using a pencil in the laboratory? Absolutely verboten. If you write down something in the lab, make sure it’s in indelible ink, magic marker, or perhaps blood. Something, anything, that can’t be erased.

Does a tech need to make a change in what they see on an instrument printout? Our accreditation regulations (courtesy of the College of American Pathologists) are pretty strict:

Original (erroneous) entries must be visible (ie, erasures and correction fluid or tape are unacceptable) or accessible (eg, audit trail for electronic records).
Corrected data, including the identity of the person changing the record and when the record was changed, must be accessible to audit.

In layman’s terms, that means carefully drawing a line through your mistake, initialing, and then dating your correction.

So what am I doing wearing pencil after pencil down to its nub? I am making sure I am the best pathologist I can be.

Through this part of my career, looking at multitudes of prostate biopsies, I have developed, inaugurated, and continuously improved a printed, unofficial worksheet that I use for every prostate case. At the top of each sheet our laboratory information system prints the patient’s name, age, medical record number, and pathology case number. I then search the medical record and add in relevant clinical history, such as previous biopsy findings, PSA values, and results from imaging studies.

The sheet then contains a row for every biopsy location. After looking at each slide I can quickly pencil in whether I think the biopsy is benign or malignant, what the Gleason Grade is, the extent of tumor, and any special studies I want to perform. It is really a very efficient way for me to work.

And I do it in pencil. Why? Because diagnostic pathology is not all ink–it is an art as well as a science. Cancer cells don’t actually have a big “C” on them under the microscope. Malignant changes can be striking, but they can also be subtle, and first impressions can sometimes be misleading.

Sometimes looking at the 7th core in a patient’s biopsy series can affect how I view what I saw on the 3rd biopsy. Sometimes special stains are going to nudge me to call a biopsy malignant that I had originally noodled in as “atypical.” Sometimes viewing a core the next morning will clarify my thinking, or a word from my associates will lead me in a better direction. When any of those things happen I grab my worksheet and out comes my pencil, eraser end first. And I mark down my new, improved, diagnosis.

Eventually, the worksheets get turned into our administrative team, entered into a digital pathology report, and following my electronic signature, become very official. Corrections can still be made, but only through a very regimented procedure, with documentation of every step. No more pencils, no more erasers.

But rest assured, the next morning I will be at the sharpener, getting my favorite diagnostic tool ready for another busy day.

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Every Paper Clip Is Another Life Changed

A small cylindrical plastic container sits on the desk behind me. I am not sure what it originally contained but now it is filled with paper clips. A quick glance tells me it must have a couple of hundred clips inside it, and every day I add a few more. I empty the receptacle a few times a year, but in the meantime, each clip tells me that someone’s life has been changed.

How is that so?

Medicine is more and more digital these days. You complain to your friends about how your internist spends more time typing into their laptop than they do talking to you. Your prescriptions go out to the pharmacy electronically, and reminders about your next appointment zip to your cellphone, instead of coming on a little postcard in the mail.

Here in the lab, we are digital too…but we still use a lot of paper. While most of the blood tests we do are managed without anything written down (each analyzer “talks” directly to the interface that sends results to our docs), we handle our biopsies quite differently.

Our Laboratory Information System (fancy name for lab computer) contains all the necessary information about patient age, and gender, and the site from which a bladder or prostate biopsy has been taken. But when I am looking at cases from 15 or 20 different patients, it really helps to have this data printed out. Also, I like to create paper worksheets for my prostate cases on which I can mark my findings for each of the dozen or so cores from each patient.

When my final diagnosis for the case is benign prostate, I can enter my findings from the worksheet directly into the LIS myself with a few keystrokes, and then add my electronic signature. No extra trees need to be cut for those cases.

But for patients in whom I find cancer, I turn my completed worksheet over to our administrative team. They keyboard the complex findings into the LIS and then print a copy of exactly how my report will appear to the clinicians.

When those printed cancer case reports come back to me, I review the information, correct the rare typos, have one of my colleagues concur on the malignant diagnosis, and affix my electronic signature in the LIS. The report can fly off to one of our urologists through an electronic labyrinth.

But because I need to select the appropriate charge to the patient for the laboratory and pathologist services, the reports are paper clipped to a billing slip. When I separate the report from the billing slip I toss the paper clip into the little container behind me. The container fills, each added clip representing another person given the diagnosis they were dreading and hoping to avoid.

Making those diagnoses is a pretty awesome burden and at times a humbling experience. I just hope that I can be as consistent as a bucket-full of paper clips; doing my job, holding it together, and remembering that there are people whose lives may be altered by every one of those diagnoses. They all deserve the best that I can be.

The above is the opinion of the author and not UroPartners LLC.

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“Friends” Don’t Let Friends Skip Their Prostate-Specific Antigen (PSA) Test

There has been plenty of talk about the reunion of the Friends cast earlier this month. Maybe you were a fan of the show during its original run and wanted to see how the actors had aged, or maybe you discovered it online and wanted to see something new. In any case, it was good to see your friends hale and hearty.

But then news broke this week that James Michael Tyler has advanced (Stage 4) prostate cancer. You may remember that Mr. Tyler played Gunther, the Central Perk manager who appeared in more episodes of Friends than anyone other than the Big Six. Call him The Magnificent Seventh.

So as I do anytime the chance arises, I remind you, or your partner, or your father, brother, uncle, our second-cousin-twice-removed to please get screened for prostate cancer (PCa). PCa is by far the most common cancer diagnosed in men in the USA, and the second leading cause of male cancer death.

The Prostate Specific Antigen blood test is still the most common test used in prostate cancer screening. It isn’t perfect, there are false positives and false negatives, but it is inexpensive, readily available, and when used intelligently to guide the patient-physician relationship it is useful in alerting to the possibility of prostate cancer. And there are lots of other associated lab tests such as Free PSA and Prostate Health Index (PHI) that can help make blood testing more specific.

Suppose you and your doctor decide a diagnostic biopsy is needed. There are techniques now that greatly reduce post-biopsy infection, once the biggest risk of the biopsy procedure. MRI studies can increase accuracy by pointing out suspicious areas to sample. And pathologists are great at making the correct diagnosis.

And if you wind up told you have prostate cancer? Treatment options abound – including no treatment in certain situations. And as in other cancers, the ability to test your DNA for abnormalities in both your cancer cells and in your non-cancer cells have lead to new treatment paradigms as well as assessment of the risk of prostate cancer in other family members.

If you are Black, your risk for prostate cancer death is even higher. US Too, the Chicago-based organization fighting prostate cancer (I am on the Board of Directors) has launched The Black Men’s Prostate Cancer Initiative. Check it out.

To all my friends with prostate cancer (and there are many) keep fighting the good fight. To the rest of you, black, white, or brown, with a family history of prostate cancer or without one, get screened.

Mr. Tyler, thank you for this opportunity for me to speak out once again. I wish you the best, and know that you have lots and lots of Friends!

The above is the opinion of the author and not necessarily UroPartners LLC or US Too.

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