I Rarely Click Banner Ads

I rarely click banner ads. Until one New York Times ad caught my attention.

It wasn’t the headline. It was the picture. I had never seen anything like it in a public advertisement before. To most readers, it was probably nothing more than an abstract swirl of pink and purple. They likely scrolled right past it without a second thought.

I couldn’t. It was a photomicrograph, a photograph taken with through a microscope.

For forty-five years, this had been my world. While other physicians examined patients or interpreted X-rays, I peered through a microscope, searching for the subtle variations that separate healthy tissue from disease.

The reproduction wasn’t especially good. The image was small and lacked the crisp detail I was accustomed to seeing through a microscope. Still, I recognized it immediately for what it was: a photomicrograph of a tumor.

In forty-five years of pathology, I had never seen a photomicrograph used to draw the attention of the general public. So I took a screenshot.

Only later, did I follow the link to a story about a clinical trial for women with resistant ovarian cancer. The research was interesting, but it wasn’t what stayed with me. The image did.

For the past month, every time I came across that screenshot on my desktop, I found myself wondering why it had affected me so much. Eventually I realized it wasn’t really about my evaluation of the images.

It was about seeing one of the tools of my profession in a setting where I never expected to find it.

During my career, photomicrographs were tools. They appeared in pathology textbooks, medical journals, conference presentations, and tumor boards. They helped physicians make diagnoses and decisions, teach students, and communicate discoveries. I never expected to see one used as the visual hook in an online advertisement.

I thought I had taken a screenshot of an unusual ad campaign.

It turned out I had taken a screenshot that inspired this blog.

Scalpels to Stage Plays: Autopsies, Case Studies, and Blogging Adventures

Long ago I lost count of the number of blogs I have posted in the last nine years. My best estimate would be that it has been about 700 times that I have asked you to spend a few moments with me. But before I became a blogger, writing for pleasure (mine, if not yours,) I wrote a few articles published in medical journals–not enough articles for me to be considered an academic, but enough to have multiple mentions in Index Medicus, the Yellow Pages of medical articles in reputable journals.

What was I writing about? Much like my current blogs, every scientific paper was different from the last, with a different focus and frequently intended for a different audience. My earliest papers were predominantly case studies, reporting interesting and/or previously undescribed phenomena I encountered while doing my first 100 autopsies as a pathology resident. One of the papers integrated in-utero radiographic findings with autopsy findings in a condition known as polysplenia¹. A second case ² involved detective work à la Quincy, as a colleague and I traced a patient’s history to determine the source of a triangular portion of plastic in their stomach that had caused fatal blood loss. Our investigation and publication earned us our hospital’s Resident Research of the Year award–scant consolation to the family of the deceased.

While still in my residency, my next published paper dealt with the use of frozen sections on needle biopsies of the breast for the diagnosis of breast cancer ³. My paper, based on a series of cases at my hospital, took a position against this practice. This was significant in an era when a malignant diagnosis on a frozen section of a breast biopsy was frequently followed by a modified radical mastectomy. After the paper’s publication a nationally known pathologist asked me to contribute a chapter to his forthcoming book on breast pathology. In a major career faux pas, I passed on the opportunity.

As my residency closed, I was asked to contribute a thought piece to another national journal, discussing the future of pathology ⁴. 45 years later I don’t remember what I saw in my crystal ball, although I know I failed to predict the world of genomics, digitization, and artificial intelligence, all of which have revolutionized pathology.

Once in my career as a community hospital jack-of-all-trades pathologist, my paper writing tapered off significantly. A short piece on urine cultures ⁵ (fun stuff) was followed many years later by a detailed description of a simple inking technique to prevent mix-ups of biopsy specimens in the lab ⁶. Significant in its time, that method is now out-moded with the easy availability of bar-coding and DNA analysis to confirm specimen identity.

Throughout my career, the laboratory data I have provided has been used in countless conference presentations, abstracts, and journal publications. While my name appears on many of those, I don’t feel much personal connection with them. My hands weren’t on the keyboard or posterboard.

In retirement, my medical writing days are past–almost. My as-yet-unproduced play does have a medical aspect. As the saying goes, write what you know, and know what you write. So far, it has worked for me.

For those of you who are curious:

¹Arch Pathol Lab Med. 107:202-203, 1983
² Southern Medical Journal. 74:900-901, 1981
_³ Breast. 8:11-13, 1982
⁴Pathologist. 37:1983
⁵ Laboratory Medicine.1985
⁶ Arch Pathol Lab Med. 2009;133:295-297

Zoom, Ghosts, and the Case of the Elusive Joe: A Comedy of Professional Errors

“Hi Les – We are currently looking into an investment in the pathology space and are looking for an expert that can engage with us as an advisor and potential board member. Are you open to an opportunity like this? Would be great to schedule some time to chat this week or early next week. Best, Joe“
LinkedIn

The LinkedIn invitation came early this week. As you have read in a previous post, I’ve been puttering around in various professional capacities since retirement, and this sounded like a possible puttering opportunity. I messaged back expressing potential interest, but warning “Joe” that I wasn’t a big fan of venture capital and private equity funding, particularly in health care. Joe assured me that his company took good care not just of the investors, but of physicians and patients as well.

I retained my doubts, but after Joe and I exchanged a few more messages, I accepted his invitation to a Zoom meeting on Thursday morning. In preparation, I researched Joe and his Capital partners (all seemed legitimate) and cleared my schedule (sorry Cooper, no morning walk for you.)

Just before 9 a.m. I booted up my balky desktop computer, focused the camera, and logged in on the prescribed Zoom link. I was alone. Fearing I had logged into the wrong site, I logged out and logged back in. Still no Joe.

Staring at the blank screen, I typed a LinkedIn message to Joe, very politely asking him where the hell he was. After 20 minutes of patient waiting, I exited Zoom and said goodbye to my opportunity to become “an advisor and potential board member.”

After 24 hours there was no apology or explanation from Joe. Now after 48 hours, he has remained a ghost. I have concluded that either:

Joe was hit by a car
Joe was fired
Joe found a better candidate
The whole thing was a scam

Am I cruel to hope a speeding SUV was involved?

It’s not the first time I have been ghosted. A bookkeeper disappeared on me a few years ago. A bookkeeper/pilot, I think she flew the coop. That episode was more significant; I had to scramble to get my corporate income tax completed on time that year. Am I foolish to think people involved in commerce would be more reliable?

How about you? Professional ghost stories? Reply or email me at chidoc@post.com and I’ll collect and publish the most unusual tales.

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“Do We Know Doug Rhone?”

“Babe, do we know anyone named Doug Rhone?” Barb asked me as she got out of bed this morning. “I was having weird dreams again. Jews were being rounded up and a man named Doug Rhone was telling us to escape to Texas or Canada.”

During this current spate of antisemitism, having a nightmare of Jews being rounded up, although tragic, is easily explainable. The more startling part of Barb’s dream to me was her mention of Doug Rhone. I did once know Doug, but Barb had never met him. Through the strange workings of the subconscious, Barb had brought up a name she had probably not heard in more than 40 years.

I first met Doug in 1976, when I was a 2nd-year medical student at the University of Illinois in Chicago. With a class of over 400 students, many of us were exiled to surrounding community hospitals for our 3-month long course in pathology. I was assigned to Illinois Masonic Medical Center in the Lake View neighborhood. Our handful of instructors were led by Dr. Douglas Rhone, the new Chairman of Pathology at Masonic.

The students were a rowdy bunch; most of us had no interest in pathology and were more interested in our simultaneous P-Dog (physical diagnosis) lectures and our first experiences examining patients. It would have been hard to predict that two of us would wind up as pathologists.

But by the time my third year of school rolled around, I had chosen pathology as a career. I spent a month doing an elective rotation in the lab at Masonic, as well as months at Northwestern Memorial and Evanston Hospital.

When it came time to rank hospitals for our upcoming residency training, I opted to put Evanston at the top of my list and I landed there on the notorious “Match Day,” the day when medical students around the country learn where their internships and residencies will be. I told Dr. Rhone my decision, and while he was disappointed with my choice, he made me promise to look him up in four years when my residency would end and I would be looking for a permanent position.

It only took three years until Illinois Masonic needed an additional pathologist. Dr. Rhone selected someone from my program at Evanston who was completing his residency a year before me. When I finished my residency the next year I contacted Dr. Rhone, but he told me there were no positions in his department. I wound up practicing at a suburban Chicago hospital.

I had no more opportunities to speak with Dr. Rhone since that day in 1982. In truth, I rarely thought of him. A brief survey of the Internet shows that he passed away in 2011, a death I was not aware of.

You can imagine how stunned I was to hear Barb ask her question this morning. How was it that her brain had held on to Doug Rhone’s name and it appeared in a dream more than 40 years after she had last heard it? The future may be the era of artificial intelligence, but can that ever be as complex, as surprising, or as astounding as our own minds at work?

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.

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.

The Packing Boxes Are Filling Up And Moving Out

The packing up has begun. Fifteen more working days, but I have never been one to wait until the last minute. One box a day (and a lot of paper shredding) should get the office cleared out by the end of the year.

This lab office has been my home away from home longer than any previous office. I was a pathologist for more years (22) at Holy Family Hospital, but my office location changed there several times, once following a lab redesign, and then three times as my star ascended in the department hierarchy, from a scrub with a pole in the middle of my office to the Chief with “the corner office.”

I have spent 17 years at the UroPartners Lab. My office here is spacious, large enough for a decent desk, a roomy countertop for my microscope, plus a few computers, a row of file cabinets, and a small round table where I have sat with and consoled many employees having a rough day. I have collected plenty of knick-knacks for the window sill, hung more than a few pictures, certificates, and awards on the walls, and added to my collection of bobbleheads on the bookshelf. All these memories of a job (hopefully) well done will be heading home with me where I will try to find a place for at least some of the most essential bits and pieces.

While my office has been in the same place for 17 years, the world of pathology has been moving forward at a dramatic pace. Microscopes everywhere are being supplanted by video screens as digital and remote pathology are becoming the keys to surviving an impending pathologist shortage. Artificial intelligence is making inroads, and prostate biopsy pathology, the field where I spent most of my time, should be one of the first to feel its impact.

Even more stunning is the rapid progress in molecular pathology. It is now possible to analyze and assess the DNA of tumors almost as soon as they are diagnosed, allowing more accurate predictions of patient prognosis as well as the usefulness of various chemotherapeutic and immunologic agents for treatment. These molecular techniques can help put the pathologist on the frontline of patient care, working hand-in-hand with cancer-treating clinicians.

The 21st Century Cures Act has also increased pathologist-patient interaction. This federal law gives patients much greater access to their medical records and patient portals. More patients than ever are speaking directly to pathologists to gain insight into their disease process. Pathologists are learning to become communicators and educators. (I somewhat anticipated this trend with Pathwise, my pathology translation service in 1990’s.)

Pathology and all of medicine will keep changing. I will keep packing. Transitions will occur in this office. And in a few weeks I will drive off into the sunset and the future

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

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

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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We Save Lives (and I Apologize)

Words have an impact. Whether the speaker is a politician, an entertainer, or a blogger, they must think about the words they choose–and choose carefully. I try to do that, but despite my scrupulous care, I made a blunder in my word choices in a previous blog and I want to apologize for it.

You may recall my last posting conveyed some thoughts on my profession, ranging from Sherlock Holmes to surgeon’s “fingerprints. And in a section dealing with statistics, I said “Some days every prostate I look at will be malignant and I feel like Dr. Death.”

I really should have known better. Within a few hours of posting, I received the following from Marty, a friend, and prostate cancer warrior:

What?

No, no. Better to realize you are giving these men (myself included!) a 2nd chance at life as they and their doctors learn that they now need to enter the “treatment phase” of their now discovered prostate cancer.
And B’ruch HaShem may that treatment extend their lives for many productive years to come!

We MUST stay positive.

Marty was so right. The diagnosis of prostate cancer is absolutely not a death sentence. By far, most men diagnosed with prostatic cancer will live long and fruitful lives, enjoying careers, family, and free time.

So instead of referring to myself as Dr. Death, I should have chosen an honorific like Dr. Decision Tree (I know, I know, it doesn’t have much zing.) My diagnosis is a key piece of the data set that guides the patient and his medical team as to whether to treat (surgery, radiation, hormonal modulation, immunotherapy) or not to treat (active surveillance) the patient’s cancer.

(And while we are talking about prostate cancer, here is my annual plug for PSA testing. Ask your physician if it is right for you and the men in your life.)

Marty, you have improved my mindset. I will watch my words with the focus of a laser beam. You reminded me that, as one of my previous partners used to say, “We are pathologists. We save lives!”