Seven Words Pathologists Shouldn’t Use Any More. Number 6 Says It All.

George Carlin set the standard. His “Seven Words You Can’t Say on TV” has lasted for more than four decades as both a comedy classic and as a listing of what American eardrums are too sensitive to hear being broadcast. Yes, there have been some breaks in the wall, and cable subscribers have moved well beyond his words both aurally and visually.

And now we have the seven words/phrases the CDC can’t use. Things like “science-based,” “fetus,” and that truly shocking word, “transgender.” I am sure some Trump bureaucrat wanted to add the word “truth” to the banned list, but that would have meant delisting an important word such as “entitlement.”

Not knowing what is coming next, in a pre-emptive move, I have decided to delete the following 7 words and phrases from my future pathology reports. With luck, this can become a nation-wide trend and we can all live happier, healthier, lives:

Breast: I don’t want any impressionable schoolboys tittering over my reports. “Mammary Gland” is an acceptable alternative, but cutting funding for mammography screening should help us eliminate breast biopsies, and we can forget about them entirely.
HIV: White, heterosexual Christian males don’t have to worry about this. On future reports, I will replace the acronym HIV with “The Gay Virus from God.”
Emphesyma: I will call those giant air spaces I see in miner damaged lungs “Parenchymal Pillows.” No way to link that to the rebirth of American coal mining industry.
Ovarian: Men don’t have ovaries. Therefore why report on them? No substitute word needed.
Malignant: People who know they have cancer want therapy. Freeloaders, such as Medicare recipients, expect the government to pay for the treatment. That just increases the national debt and forestalls more tax cuts for big donors. My future pathology reports will refer to cancer cells as “not-quite-normal cells.”
Diagnosis: Too much certainty. I will only use this word when accompanied by a totally loony “alternative diagnosis” agreed to by Sarah Huckabee Sanders.
Nuclear: To me, it means the center of the cell, but to others, it’s the sound of bombs away. “Round thing in the middle” will have to do for now.

Or maybe I should just retire now.

The opinions above are the opinions of the author and not of UroPartners LLC.
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It Is The Chocoholiday Season. Do You Love Chocolate Too?

I know this is the time of year to party. And that means eat and drink. Diets, be they caveman or Weight Watchers, go out the window. Champagne gets popped, in a morning Mimosa or a midnight toast. Rising hemoglobin A1C courses through bodies, riding on a chariot of elevated blood glucose. A time for moderation this is not.

It may be like this every year, but I can’t remember a past December month of merriment filled with so much chocolate. It is everywhere; it is everything. Nobody doesn’t like chocolate (ok, I once did meet someone who was not a chocoholic, but I purged that person from my memory banks.) Where is it popping up this year?

The first sign of the holiday binge was a consulting firm’s annual gift of a box of Frango Mints. This is a mixed blessing. Since Barb worked in the candy department of Marshall Field’s as a teenager and developed Frangophobia, these are forever banned from our home. Good thing they get delivered to the lab. 5 points to anyone who knows the original name of these chocolate mint delights.
This was followed by a giant milk chocolate bar from one of our clinical offices. As special decoration, the corporate logo was etched into the chocolate. This is a variation from years ago when the group etched profiles of their own faces onto the bars. I must say there was some satisfaction in the old days crunching on those heads.
Earlier this week, I received a text from the lovely people who bought our old home. A FedEx package for us had been delivered to them. Could I come by and pick it up? The delivery consisted of a nice note from a vendor and a box of, what else, chocolate. This time it was molded around caramel and nuts in luscious turtles. More treats for the lab.
Another vendor provided us with the largest box of Russell Stover Chocolates I have ever seen. Roughly the size of a carry-on suitcase and accompanied by a 12-page instruction manual, it was filled with enough chocolates to pave a new runway at O’Hare. Somehow all those candies were gone in 2 days.
Our toxic liquid waste hauler (yes OSHA Inspectors, we follow all the rules!) chipped in with several boxes of chocolate. I’ll let you come up with your own comments about the cream fillings.
Instead of an elf on a shelf, I had the pleasure of a choc on a chair. Somehow, with all that chocolate goodness floating around, a piece found its way to my desk chair from where it was ground it to the seat of my slacks and the driver seat of my car. There I found Barb trying to dislodge it with her nails. Manicure for her, carwash for me.

There is lots of holiday time ahead. By year’s end, I anticipate chocolate gelt for Hannukah, and Barb and I have decided a Portillo’s Chocolate Cake is in our future as well. I’ll pack on the pounds, but it will always be with a smile. How about you? Are you ready for some CHOCOLATE!
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Six Real Life Slides. Which Ones Show Prostate Cancer? Can YOU Make the Diagnosis?

A friend and I were reminiscing the other night about our high school biology class at Sullivan High with Mr. Dubin. That course was the first time I ever used a microscope. Believe me, I had no idea that staring at magnified pieces of tissue would be the basis of my future career.

What crosses my desk, or more literally my microscope stage, on a daily basis? Looking at five or eight or twelve sets of prostate biopsies, with multiple parts to each set, I may be examining over 200 slides in a day. There is plenty to see. But since the goal of 99.9% of prostate biopsies is to try to either confirm or rule out the presence of cancer, most of what is on the slide is background music, or sometimes just noise. Just as you tune out much of what you hear every day, I have to tune out the other “stuff.” It is on the slide, but like an Evelyn Wood trained speed reader, I try to hone in on the important and try to ignore the rest.

Remember that study a few years ago claiming pigeons could identify cancer on a slide? That was a lot of pigeon poop. But how about you? Could you think back to your own high school biology class and separate the benign from the malignant? Give it a try. Take a look at pictures A through F at the beginning of the post, make a diagnosis, and see how accurate you are. You can click on the picture to get an enlargement. Leave your number correct in the Comment field on the blog site or on Facebook. All the pictures are from cases I saw in the last day. A shout out to the great Anatomic Pathology Team at UroPartners Lab that keeps the slides coming.

Answers are below.

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A) You might have thought this picture looked very busy. Lots of cells here, but most of them are inflammatory cells. This patient probably has prostatitis, an inflammation of the gland. No fun to have, but not cancer. I am sure the patient was relieved to get his benign diagnosis.

B) Did you recognize this as normal prostate? Benign, with nothing to indicate the glands are at any risk to become cancerous. That’s all we identify in about half of our patients. It’s good to see.

C) Yes, those are cancerous glands. This is what we would consider a low grade (less aggressive) prostate cancer. Some men with this type of lesion may not need any treatment, just careful follow-up and a good relationship with their urologist.

D) No, these glands are in the biopsy, but not part of the prostate. They are colon glands. How did they get into the sample? To take the biopsy, the urologist passes the needle through the patient’s rectum, the end part of the colon. Little fragments of colon tissue frequently become incorporated into the biopsy. Nothing to worry about for the patient, and usually pretty easy to recognize on the slide.

E) See all those small dark cells? This is an aggressive prostate cancer. Tumors like this have a propensity to spread, so most men with a tumor formed by cells like this will get some form of therapy. Fortunately, there are some great new treatments, some even involving the bodies own immune system to fight the cancer.

F) This can be a tricky one. The cell nuclei look dark and irregular, often a hallmark of cancer. But see all that golden brown pigment? That’s called lipofuscin, and that easily identifies the glands as being part of the seminal vesicles, benign structures that sit on top of the prostate. I have often felt there must be some higher being that put that lipofuscin there to save me from making a bad diagnostic mistake.

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So how did you do? Could you separate the good from the bad? I’ll bet you could do better than a pigeon, but maybe not better than me!

Don’t forget to give your score in the Comment field of either the blog page or Facebook.

The opinions expressed above are the opinions of the authors, not UroPartners LLC.

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Our Biggest Fan Is Moving On, But Because Of Him We Will All Keep Blogging

The ChicagoNow Blogger Community has a little monthly ritual. On the last Wednesday of the month, Jimmy Greenfield, the Community Manager — the guy who keeps ChicagoNow clicking — announces a topic and gives all the participants one hour to write and publish a blog. He calls it Blogapalooza, because nothing is really big unless it is a palooza; I guess it could have been called Blognado, but maybe that name was already taken.

Many of the ChicagoNow bloggers palooz on the given topic. I have never been one of them. When it comes to what I choose to write, I am a bit persnickety. I wait for a great topic, or a nifty headline, or an ear-catching phrase to enter my right cerebral cortex. The idea either ferments nicely and I sit and write, or it turns to vinegar and winds up in our toxic waste barrel here in the lab for appropriate disposal. It was the same in the years I gave the annual Board of Education High School Commencement Address. I would be stymied for days or weeks until the right inspiration hit the right synapses. So even though I always get the Blogapalooza announcements, I have never participated. It just isn’t my bag.

Nonetheless, I was aware the topic for last weeks ‘Palooza was (spoiler alert) “write about goodbyes.” A topic you can sink your keyboard into in many ways. I have penned a few goodbye blogs myself–to a missed mentor, to a marvelous mutt, to Thursday Tennis. But I now suspect Jimmy had a deeper motivation when he chose this topic.

This morning Jimmy notified the ChicagoNow blogger community that he was leaving his position and the blog site he had midwifed and nurtured to life. He is not leaving the Tribune, but moving over to the digital sports page. He is choosing a moment where Chicago sports is at a low point, so I know he isn’t doing it for fame and glory, but perhaps he is seeking a local journalism area that needs his expert touch.

Jimmy, thanks for the insight and guidance. Thanks for the technical know-how you shared. Thanks for being the champion for all of us, with our varied backgrounds, our different careers, and so many novel reasons for writing. Go do your digital sports thing. I know your love is for the Cubs, but don’t forget we are a two baseball team town.

So grab a cold one and remember, this blog’s for you!

———-

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“The Marvelous Mrs. Maisel”–“Mad Men” For Jews, and for Gentiles Too.

After reading some great reviews and hearing Laury tell us how wonderful it was, Barb and I sat down last night and watched the first two episodes of Amazon Prime’s new streaming series The Marvelous Mrs. Maisel.

Oy vey, did it feel good.

Mad Men set the bar for recreating the mood and atmosphere of the early ’60s. With Mrs. Maisel, we are back in 1960* New York City, but this time the setting ranges from the doorman managed co-ops on the Upper West Side to the shmatte factories and clubs of Lower Manhattan, all with a decidedly Jewish spin. Don Draper may have had a Jewish mistress in Mad Men, but with Mrs. Maisel, we take center stage, literally.

In the first two episodes, we see young marrieds Miriam and Joel Maisel each try their luck as stand up comedians. One of them steals material from Bob Newhart, the other finds humor in the catastrophes of everyday life, forges a relationship with Lenny Bruce, and learns to get a receipt for bail money. Want to guess which is which?

We care about the characters and their faltering (think not-too-bright secretary) relationship, but it is the atmospherics and little details that steal the show: Snaring the Rabbi for the Yom Kippur Break the Fast meal. Making up your face and getting the curlers out of your hair before your husband can see you in the morning. Bribing the club manager with a brisket and latkes. Meddling mother and father-in-laws. And the panic when someone dares to admit out loud there is shrimp in the eggrolls (something we all must surely know.) Universal touches for Jewish America early in the Age of Camelot.

With This is Us on December hiatus, Barb and I should have plenty of time to savor the remaining episodes of Season 1 of Mrs. Maisel. And word is that a second season has already been approved for production. So we will have the fun of seeing whether Miriam can make it on comedy club circuit and whether Joel gets over his secretary. And with every episode we can ask the primordial question, “but is it good for the Jews?”

*I know, some reviews say 1958. But the Bob Newhart never appeared on the Ed Sullivan Show before 1960. That is also when “The Button-Down Mind of Bob Newhart” album was released. So it is 1960 for me!

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Volvo Pledges No Fatalities. Ten Other Pledges for 2020 I Would Like to See.

Recently Volvo, the safety-first Swedish car manufacturer, has been advertising its safety pledge; by 2020, no one will die in a new Volvo automobile. Quite a bold promise to make! I applaud the manufacturer’s gumption, but question the likelihood of success. Especially since I despised the one Volvo I owned — one electrical failure after another. Let’s hope the company has made tremendous strides in quality control!

I don’t know if Volvo can pull it off, but I do know that there are lots of other promises, pledges, and guarantees I would like to see by 2020. Who is bold enough to make these commitments?

PLEDGES I WANT FOR 2020: NON-TRUMP DIVISION

The airline industry will promise to utilize artificial intelligence to devise a system in which no passenger traveling from Chicago, Illinois to Fairbanks, Alaska gets routed through Miami, Florida.
The recording industry will pledge that I recognize at least one song nominated for the Record of the Year Grammy.
The Sox, Cubs, Bears, Bulls, and Blackhawks will each pledge not to be in Year 1 of a 5 Year rebuilding plan.
While the airlines are making pledges, how about a guarantee that there are no bumped passengers hauled off a plane by air marshalls, or better yet, no bumped passengers at all?
The Democratic Party will pledge to have a viable Presidential Candidate. (I know this one is a b-i-g stretch!)
Progressive Insurance and Toyota will pledge to swap Flo and Jan for a month. Just because it would be fun.
Brian Urlacher will promise to readopt the shaved head look so we can get rid off all the awful hair growth billboards along I-294.
NBC will pledge that “Chicago Streets and Sanitation” will be the last show in it’s “Chicago” pantheon, and will return the streets of Chicago to the residents of Chicago.
Wisconsin will pledge no new shootings by 8-year-olds legally licensed to carry a weapon.
Chip and Joanna, Jonathan and Drew, and all those House Hunters will promise to take a year-long sabbatical so my TV sets can take an HGTV sabbatical too!

What pledge would you like for 2020? Leave your comment on Facebook, or email me at les.raff@post.com. And check out our new Facebook FanPage!

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I Give People Cancer, Part 2

(In Part 1 I discussed being the man who “gives people cancer.” I promised that Part 2 would be a little background as to how I got here.)

July, 1977

A hot day during what will be a steamy summer. The elevators in the University of Illinois Hospital are always too slow and too crowded. So I take the stairs up to the 13th floor, catching glimpses of the West Side Medical Center through the stairwell windows as I climb. It’s a long way up, but likely to be the only exercise I will see on this day.

It is the fifth day of my medical student rotation in Internal Medicine. There are three others on my team: Jerry, a second-year resident, Madelyn, a newly-minted intern, and my classmate Paul. We are E-Service, one of five trainee groups responsible for the diagnosis and management of all patients admitted to the UIH. Most patients are indigent or close to it; the paying patients in the area are down the block at Rush-Presbyterian-St. Lukes Hospital. We have an attending physician, a “real” doc, as part of the service, but she dips in and out of the ward, eager to get to her Infectious Disease consults at one of the other local hospitals.

The day is a mirror of the last four and presages the rest of my two-month rotation. We care for a young man who has lost an eye to a muscle tumor and is in for his monthly chemotherapy. A woman with Behçet’s Syndrome, suffering from ulcers from her mouth to her colon, gargles viscous lidocaine, without much relief. It is all that we have to offer to her.

In contrast to our Behçet patient, we are having much better luck treating Mr. George, an older fellow with stomach ulcers. We are using an experimental drug named cimetidine, the first of a new class of drugs called H2 antagonists. It is working wonders. By the end of the summer, Mr. George will be pain-free, and cimetidine will be released as the blockbuster ulcer drug, Tagamet.

I sweat throughout the summer. I examine patients. I take medical histories. I draw blood, do EKGs, and hold emesis basins. And I come to a realization. I don’t want to be doing this. I am good at book learning, but patient care is “not my forte and not for me.”

Following those long, hot, months, I investigated the non-patient care fields; pathology and radiology. Glass slides seemed more tangible than shadowy images on a piece of film, and I became a pathologist. It was the right choice for me.

I recently queried physicians throughout the US, Canada, and the UK about what led them to pathology. There was a unanimous consensus that a student didn’t enter medical school aspiring to be a pathologist, though one respondent had fond memories of a childhood microscope. Analogous to me, some became disenchanted with treating patients during medical school or internship. One felt that if he had to see one more patient he would wind up “in the stairwell with a straitjacket.” Some admired pathology professors and decided to emulate them. Others discovered they wanted to be detectives and learn the truth, and that truth was in the tissue.

All of us admit to liking the lifestyle, with the minimal call and only rare midnight hours. And a good friend tells me she feels like “an angel behind the scenes.” Who wouldn’t want that?

No, I don’t give people cancer, and neither do any of my hard-working pathologist colleagues. We search for the truth, and if at times we help vanquish cancer and other diseases, we can be happy with our lot.

The opinions above are the opinions of the author and not the opinions of Uropartners LLC.

Link to Part 1

Link to Some Thanksgiving Thoughts

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I Give People Cancer. Part 1

benign-and-malignant-prostate-glands — Benign (left) and malignant (right) prostate glands

I had the following conversation with a new acquaintance at a recent dinner party:

“I do merger and acquisitions, it was slow for a while, but now it is heating up again. I do OK. How about you, what do you do.”

“I guess I do OK too. I’m a pathologist. I run a medical diagnostic lab for a big group of urologists.”

“What does that mean. You run blood tests?”

“Oh, we do some blood testing, but I spend most of my time looking at biopsies. As a urology group, we get mostly prostate biopsies to decide if they are benign or malignant.”

“So you give people cancer.”

It is not quite accurate of course. I don’t pass out diseases from a punch bowl. I am not Typhoid Mary reincarnate. No need to quarantine me. But a few dozen times a week, yes, I am the first to say “Mr. Kranz has prostate cancer, Mr. Ferrick has prostate cancer, Mr. Blaine does not.”

I have the best staff and equipment to assist me, I have my valuable colleagues to verify my work. But in the end, it is my electronic signature on a report that is going to set into motion life-changing events. In that way, I DO “give people cancer.”

About half of the patient biopsies I see I will diagnose with prostate cancer. It is “flip-a-coin” likelihood, and like a coin flip, it sometimes feels very random. An eighty-year-old retiree with a firm prostate on the urologist’s exam may have a negative biopsy, while the 50-year-old executive with a slightly increased blood PSA level may have an aggressive tumor filling each core of the biopsy.

As with a coin flip or with the spin of a roulette wheel, things sometimes get “streaky.” There are days when I am merciless, with case after case receiving a malignant diagnosis. I feel as if I am a curse or have developed an evil eye. At other times, each biopsy I look at is bland and harmless.

After a few negative diagnoses in a row, I begin to wonder if I have suddenly forgotten what prostate cancer looks like under a microscope. I begin to worry about each minor aberration, each slightly enlarged nucleus or shrunken gland. I take a deep breath and regain my balance, knowing that over the course of a few weeks, the numbers will even out. The statistics I calculate every month tell me so.

Of course, the urologists have a harder role to play than I do. They must tell the patients with cancer the news, apprise them of the risks and benefits of the various therapies, hold their hands and dry their tears. But they also get to pass our the good news when a biopsy is benign or when treatment is a success.

So why would I go into pathology, and deal with cold glass slides instead of warm-blooded patients? In Part 2, I look at what brought me, and other pathologists around the country, to this field. We didn’t all start out this way…

In the meantime, read up about PSA.
Rather read a shaggy dog story? Here’s the link to our previous post: It’s A Dog’s Life

I Give People Cancer, Part 2

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The opinions expressed above are those of the author. They are not those of UroPartners LLC.

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Dog Days are Here Again-And We Couldn’t Be Happier

A Catholic Priest, a Protestant Minister, and a Jewish Rabbi are all asked the same question on a TV talk show. When does life begin? The Priest quickly answers “at conception.” The Minister wrinkles his forehead and says “when the Lord blows a soul into the tiny fetus.” The Rabbi grins and replies “When the kids leave for college and the dog dies!”

It’s an old joke, but it has been on my mind a lot recently. As you all know, our faithful companion and gentle giant Max passed away in April. Our sadness was profound, but there was a degree of freedom that we gained that we have not had in the last 33 years of child and/or dog parenting. Weekend days and nights out became more long and leisurely instead of “Oh, we have to get home for the dog.” But there was an emptiness when we did make it home…

I am not the “dog person” that Barb is. When we lost Max, she said she never wanted to again face the trauma of putting a loving pet down. And for the first 6 months, she held to that. But I could see her resolve was weakening and that she was beginning to ache for a wagging tail and a cool, wet nose when she returned home from work or from a day of babysitting. The kitten tried to impersonate a dog as best she could, but for Barb, it just wasn’t the same. I knew the tide had turned when Barb began reading out loud the dog histories from rescue center postings that popped up incessantly on her Facebook stream. I didn’t try to fight the urge, I just stipulated that anything under 10 pounds didn’t meet my criteria for a good dog pet.

When a free Saturday afternoon rolled around on Thanksgiving weekend, it felt like all the planets were aligned. With one of our granddaughters, we checked out an adoption “event” at a local Petsmart but saw no dogs that interested us. On our own later in the afternoon, Barb said: “Let’s check out Kay’s.” Meaning Kay’s Animal Shelter in Arlington Heights, the shelters from which both Max and our first dog Murphy had found us. It was pretty clear our dogless days were coming to an end.

It wasn’t without a bit of a battle. There was only one dog that moved us. He was 18 months old, not a puppy (good,) and he weighed more than ten pounds (even better,) but we had competition. A young couple had seen the pooch a few minutes before we had, and seemed infatuated with him. They were only concerned that there might be a “situation” between this pup and Gimlet, their beloved Irish Terrier. The wife went home and brought Gimlet back with her. The two dogs played together well at first in the fenced-in yard at Kay’s but after a few minutes, some teeth were bared and the dogs decided they didn’t care for each other all that much. Barb and I looked at each other, knowing what the other couple would decide, and that the little four-legged fellow would be spending his life in our home.

The shelter called him a Pomeranian mix. With his curly tail, Barb has him pegged as a Shiba Inu. On a call from her Thanksgiving break in Palm Springs, Laury named him Milo, adding to the litany of “M” names for our dogs. He has been a prince since Saturday, readily adapting to our house and yard. Yes, we had to do some schedule rearranging, and quickly hire a dog walker for those days when we both work. And carry out dinners replaced restaurants over the weekend. But the smile on Barb’s face when Milo cuddles up in her lap proves that life begins when it begins in your heart.
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What I Hope to Give Thanks For on Next Year’s Thanksgiving. It’s a Different THC.

My vision for Thanksgiving 2018.

The Oval Office, Monday, November 26, 2018, the first workday after Thanksgiving. President Donald Trump (R), meets incoming House Majority Leader Nancy Pelosi (D-CA), and incoming Senate Majority Leader Charles (Chuck) Schumer (D-NY.)

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Schumer: Now that all the disputed districts have been finalized, I think it is pretty clear Democrats are going to have a majority in both Houses, Mr. President. That doesn’t mean we won’t work with you. We aren’t veto-proof, we know that.

Pelosi: It’s been two years Mr. President, and we now agree it is time to Make America Great Again.

Schumer: And we know where to start Mr. President. We are ready to reach across the aisle and with our Republican partners, we will fulfill your greatest election promise. We, the Democrats of Congress, with your help, are ready to repeal and replace Obamacare.

Trump: You’re only ready to take this step because I am the master negotiator. I’m the one with the biggest balls. I stared down that little punk Kim Jong-Il. I stared down that little punk Al Franken. I stared down that little punk Paul Ryan. I’ve got no problem staring down the Democratic Party. So what is your timeline?

Pelosi: First we repeal the Affordable Care Act. And then we replace with a plan that includes great features.

Schumer: We’ll include portability.

Pelosi: We’ll cover all pre-existing conditions.

Schumer: Kids until age 26, no problem.

Pelosi: Medicaid expansion, millions of additional people covered. And a government option across all states.

Schumer: Nancy, don’t forget to tell the President about the individual mandate, we talked about the mandate.

Pelosi: Yes, the mandate. We’ve got to have the mandate. And we pay for it all with a 2% increase in the inheritance tax.

Trump: This is a disaster, this is worse than Obamacare. If you ever pass this I’ll veto it and kick your asses out of Congress.

Schumer: But wait for the best part.

Trump: Best part? There is no best part, this is all terrible. You’re all insane. You’re all fired.

Pelosi: The best part is…

Schumer: …we name it THCAmerica.

Trump: THC?

Pelosi and Schumer: TrumpHealthCare

Trump: I love it. It will be HUGE. Where do I sign?

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Well, I can dream, can’t I?
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