6 August 2020: Meet the Editor – Andrey Bychkov, M.D., Ph.D.

Please introduce yourself

I am the Director of Digital Pathology at Kameda Medical Center in Japan and have a visiting position at Nagasaki University. I consider myself an academic pathologist and am involved daily in clinical practice, research and education.

I attended medical school and did a surgical pathology residency in Russia, and started using English while teaching medical students from India. I obtained my Ph.D. from the Atomic Bomb Disease Institute in Nagasaki, where I became interested in thyroid disease. I then moved to Bangkok and was involved in establishing a thyroid pathology group for Asian doctors interested in thyroid pathology so they would have a voice on an international scale. Three years ago I moved to Japan to develop digital pathology in our multi-hospital network.

Why did you become a pathologist?

This was entirely due to a Russian professor who kept an eye on me and guided me from my undergraduate years.

What do you like most about being a pathologist?

I like the intellectual challenge and the breadth of surgical pathology. I like the need to stay updated, that I affect clinical decisions and that I drive the research.

What is special about your subspecialty?

Thyroid pathology is a relatively narrow field. Since thyroid specimens are rather uncommon, many general pathologists lack confidence in them. My other interest, digital pathology, helps me connect remotely and be more productive. For over 2 years in Japan, I have not even used a microscope, just a screen and a mouse, and feel happy with that. I also enjoy the artificial intelligence aspects of digital pathology, which are quite challenging.

How does your typical day go?

To balance clinical practice, education and research, I need to plan my days in advance to make sure nothing gets left behind. I tend to work better during the night, which works well with PathologyOutlines because of the time difference.

What is the most memorable experience you’ve had at work?

Although almost every week is memorable, some incidents stand out. In Russia, I was in charge of a small hospital when a deceased patient disappeared. I did my best to think rationally about where the body could be, and checked all the rooms and windows, with no answers. After two days, I learned that relatives came during the night and took the body for the funeral. Another time, my assistant cut his finger during an HIV autopsy. We quickly did research to learn what to do (start prophylactic treatment). It turned out fine but was very stressful. The most difficult times involved pediatric autopsies. Many parents were determined to blame the treating physicians, regardless of the underlying patient diseases, and dealing with them was difficult for me.

Regarding academia, it is always exciting to come up with ideas in the middle of the night, develop them into a project, share them with others, get support and ultimately confirmation of my ideas and a publication.

What most surprised you about being a pathologist?

I have been in this field since I was 19 visiting the pathology department, so there were few surprises. However, I do find surprising the enormous amount of new information that gets published. Just to update the Recommended Books page at PathologyOutlines.com requires that I screen 10,000 publications that appear annually just for thyroid disease.

Could you say a few words about your association with PathologyOutlines?

I first emailed Nat in 2008 and he kept responding; he is very approachable and easy to communicate with. At the time it was not related to being an author, but I kept track of how the website was developing. I noticed the increasing traffic and decided now was the time to become part of it. I was then in Thailand, and started actively writing, and put a lot of time into each topic.

Did you know that the Thyroid chapter was the first chapter written on PathologyOutlines.com? As the Thyroid chapter Editor, it is an honor and profound responsibility to maintain it to the highest standards. I want all users to be confident with its content so I review carefully its information and images. Based on my background, I am very particular about image quality, and this has spread to the entire website.

I actively promote the website in Asia, where many pathologists have limited access to journals or other publications. I am pleased to be the first Editorial Board member from outside North America.

Click here to stay connected with Dr. Bychkov on LinkedIn.

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Meet the Editor: Dr. Nicole K. Andeen

Please introduce yourself.

I’m a renal and surgical pathologist at Oregon Health & Science University (OHSU).

Why did you become a pathologist?

As a medical student, I did a pathology student fellowship/post-sophomore fellowship at OHSU, thinking it would enhance my knowledge base for another specialty. Through that hands-on experience, I realized how fun and stimulating pathology was.

What do you like most about being a pathologist?

We are in a position to study a wide spectrum of biology, both neoplastic and nonneoplastic. Subspecialized care has lots of benefits, especially when it doesn’t get too compartmentalized. We have opportunities to learn about diseases and research tools from colleagues in other disciplines that we aren’t directly involved in. For example, medical renal diseases can be secondary to carcinomas, lymphoproliferative disorders, hepatitis, autoimmune diseases, various medications including PD-L1 inhibitors, etc. We can be broadly aware but more narrowly focused.

What is special about your subspecialty?

As a renal pathologist, I regularly think about things I can see, like patterns of injury, immune complex deposition, inflammation, scarring, and structural abnormalities. I also think about things I cannot see directly in a biopsy – metabolic disease, hemodynamic alterations, anatomic abnormalities, autoantibodies, infections, genetics and immune reactions to allogenic stimuli (transplant). I have to integrate what you know and do not know for a meaningful diagnosis. This interaction with complex medical processes and the relationships with nephrologists are very compelling and guarantee a career of lifelong learning!

How does your typical day go?

When on our medical renal service, I assess light and immunofluorescence microscopy from the daily kidney biopsies, and call and discuss the results with the nephrologist. This relationship is very rewarding; even histologically straightforward cases can be clinically complex or atypical, and you can deepen your knowledge on the spectrum of biology from each case. Depending on the week, in the morning I also sign out surgical cases with residents. I usually go for a midday run through the forest trails outside my office. I’m also involved with various research projects and try to make a little progress every day.

What is the most memorable experience you’ve had at work?

I had a very unusual kidney biopsy with distinctive, massive tubular basement immune deposits. I left the dark immunofluorescence room completely baffled at what I’d just seen, unsure if I’d interpreted it correctly. The light microscopic features were similarly confusing, didn’t fit anything I’d seen or heard of before. We treat all kidneys as rush biopsies and call on the same day; so, I called the nephrologist and told him what I saw, but that I had no idea what the diagnosis was, yet.

We deal with lots of gray zones in renal pathology, which keeps you humble, but this was a feeling of complete unknowing, which I have not experienced with a case before or since. To the nephrologist’s great credit, he was comfortable with this uncertainty. It took a few days of additional studies but we eventually made the diagnosis of anti-LRP2 nephropathy/anti-brush border antibody disease. At that time, only 12 cases had been reported since the 1980s. Although rare, more reports have surfaced and it is now better recognized.

What most surprised you about being a pathologist?

As a whole, the clinical and anatomic pathology laboratories provide the majority of diagnostic information for patient care in the US. Thus, although it is a profession of deep-thinking introverts, many of them are well compensated to rise to this more public role.

Is there anything you know now that you wish you had known when you began working as a pathologist?

No. Science is a self-correcting field and I appreciate the opportunity to keep learning.

What do you think you would be doing if you weren’t doing this?

Bike mechanic, repairing fixer-uppers for a new life.

Could you say a few words about your association with PathologyOutlines?

PathologyOutlines.com is a wonderful, free, encyclopedic resource for pathologists and trainees. I admire the mission of creating and maintaining this multifaceted website, which serves the international pathology community and our patients. I started writing for PathologyOutlines.com years ago as a resident, working on kidney tumor chapters with Dr. Maria Tretiakova. I currently work with residents to write and edit medical renal chapters.

You can follow Dr. Andeen’s institution, Oregon Health & Science University, on Twitter at @OHSUNews.

20 September 2019: Meet the editor – Dr. Genevieve Crane

Please introduce yourself

I am Genevieve Crane, a hematopathologist at Weill Cornell Medicine in Manhattan, NY. I grew up in the mountains of New Mexico, but have lived all over through undergraduate work in Houston, a Marshall Scholarship in London, MD/PhD training in Michigan, residency and fellowship in Baltimore and postdoctoral research in Boston and Dallas.I am enjoying Manhattan for its great mixture of cultures, opportunities and colleagues . . . perhaps some great shopping and food as well!I am named for my grandmother Genevieve, who was always able to find beauty and hope in even the darkest situation. That seems to be valuable in pathology as well as in any situation. I am proud to carry her name, but often go by the nickname, “Eve”. I can frequently be found wearing cowboy boots (yes in NYC), often with my own unique style in clothes created by my mom (who has her own twitter handle @sewing_sixties) based on fashion from the 1960s and 70s.

Why did you become a pathologist?

I have always been fascinated by mechanisms of disease and how normal processes of cell growth, death and differentiation may be altered to play a role in disease. My career choice was also heavily influenced by my father’s battle with a severe and progressive form of multiple sclerosis. It was a diagnosis mostly of exclusion at the time he developed symptoms in 1980. Treatments were also lacking for the majority of his lifetime. This experience instilled in me from a young age the limitations of current medicine and a desire to contribute to medical research. Even being able to slow or halt the progression of chronic diseases would have a tremendous impact.
I also remember the stress and uncertainty surrounding his initial diagnosis. It was not due to lack of diligence, but limitations in availability and specificity of the testing at the time. Even if the diagnosis of multiple sclerosis had been more certain, this can show a broad range in severity of symptoms.
While perhaps not considered the most exciting aspect of pathology, refining diagnostic criteria is critically important in moving our understanding of disease forward. A careful and consistent definition of a disease entity can help patients and families to cope with illness and create a more meaningful context to assess prognosis and therapy. Building on these criteria, pathologists are then in a unique position to be able to directly observe and integrate morphologic, immunophenotypic and molecular changes, potentially having access to a large number of cases to investigate disease mechanisms.

What do you like most about being a pathologist?

My favorite part of being a pathologist is when the whole puzzle comes together to provide a diagnosis for the patient that can potentially reverse symptoms. This is particularly gratifying when the ultimate diagnosis has resulted from a close collaboration with the clinical team, often reviewing slides and clinical data together at the scope. For example, in critically ill patients who present with symptoms of hematophagocytic lymphohistiocytosis in adulthood, it is typically due to an underlying cause such as infection or malignancy. Expediently identifying the cause is critical to directing therapy in what otherwise may lead to a rapidly progressive and fatal course.
My other favorite part of pathology is the online pathology community, which continues to grow on social media. It is a welcoming, enthusiastic group, with the majority incredibly passionate about teaching, learning or just sharing interesting and unusual cases. Many have become close friends, collaborators or coauthors. It is wonderful to have the chance to meet in real life, and the connections have opened a whole world of pathology to me outside my immediate circle of colleagues that I would never have expected.

What is special about your subspecialty?

I enjoy hematopathology because it is an area that perhaps most fully spans my interests from the realm of basic science all the way to clinical medicine. I fell in love with it during my first rotation as an intern at Hopkins, even though I had not expected to specialize in this area. Accurate diagnosis within hematopathology increasingly requires integration of morphologic, immunophenotypic, molecular, cytogenetic as well as clinical data. In addition, our understanding of these entities is rapidly evolving in ways that impact prognosis and direct therapy, opening numerous opportunities for translational research.

How does your typical day go?

I am still working to develop a rhythm for a typical day. I sign out solely hematopathology, where we currently have two clinical services at Weill Cornell: one focusing on bone marrow evaluation and a second on lymph nodes, blood and other tissues. Both tend to be fairly hectic between choosing flow cytometry panels, following up on testing and completing reports in the mornings and evenings with sign out with residents and fellows in the afternoon. The week is also interspersed with multidisciplinary tumor boards, research meetings and teaching. I have some days off from clinical service where I am working to develop a translational research program with interests in immunosuppression-related lymphoproliferative disease and the lymphoma microenvironment.

What is the most memorable experience you’ve had at work?

It is hard to narrow down a single experience. A happy moment was calling to let a physician know that her young patient with massive axillary lymphadenopathy and concern for Hodgkin lymphoma had a diagnosis of cat scratch disease. Additional clinical history had not been given, but the physician quickly followed up to let me know the patient had in fact been fostering feral kittens. Review of subsequent clinical notes revealed the patient was doing well on antibiotics . . . and keeping the kittens’ nails better trimmed!

What most surprised you about being a pathologist?

What surprised me the most was the intense teamwork that goes into the evaluation of every specimen. We are removed from the patients, yet in order to handle the specimen appropriately, especially on the frequently very limited small tissue biopsies, we must be acutely aware of the clinical situation. This is particularly true in hematopathology, where a patient with fevers and lymphadenopathy may have anything from acute toxoplasmosis to Burkitt lymphoma. In some instances, triaging material toward cytogenetics may be critical, other cases may be more informative by flow cytometry, advanced molecular testing or microbial culture. We are in frequent contact with our clinicians and always in close discussion with our technical staff.
Details such as fixation time, quality and thickness of tissue sections for morphologic evaluation and optimization of immunohistochemical stains can make a huge difference in arriving more expediently at the correct diagnosis.
I do not see pathology as a lonely or reclusive specialty – I am so proud and grateful for the team that I am surrounded by and incredibly reliant upon each day.

Is there anything you know now that you wish you had known when you began working as a pathologist?

Residency is a busy and intense time and I think I was often focused on the immediate tasks at hand. I definitely learned a tremendous amount, but looking back, I wish I could have taken even further advantage of teaching from the incredible pathologists who surrounded me at that time such as Dr. Peter Burger in neuropathology and Dr. Elizabeth Montgomery in gastrointestinal and soft tissue pathology. Fortunately, pathology has a culture of continual learning, particularly with opportunities to continue to discuss and interact surrounding challenging cases on social media as noted above. It is wonderful to be able to still interact with former mentors and colleagues in that realm.

What do you think you would be doing if you weren’t doing this?

My undergraduate major was in chemical engineering and I was always fascinated by polymer science. I briefly worked in developing degradable materials for cellular scaffolds and drug delivery and still hold a patent for a modified alginate for controlled drug release.
Whether or not a physician, I had hoped to work at the interface between medicine and science to make a difference for patients.

Could you say a few words about your association with PathologyOutlines?

We frequently used PathologyOutlines.com during residency and valued it as a quick and concise method to help develop an initial staining panel for our differentials or refresh our memory of unusual entities, particularly on our surgical pathology rotations where we would see a broad range of material. The resource has continued to grow since that time as a true living textbook, and I am particularly
excited about the breadth of excellent authors who have contributed to the sections on hematopathology to continue to build that area. I am also proud to be part of PathologyOutlines.com as it continues to establish itself as one of the most frequently accessed resources for trainees and practicing pathologists around the world. 

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You can follow Dr. Crane on Twitter @evemariecrane She also contributes to the @SocforHemepath account, where she serves on the education and communication committees, as well as acts as the current head of the Video Tutorial subcommittee.

7 June 2019: Meet the editor – Dr. Raul S. Gonzalez

Please introduce yourself
I am a surgical pathologist specializing in gastrointestinal pathology. I’m an Assistant Professor at Harvard Medical School and the Associate Director of Gastrointestinal Pathology at Beth Israel Deaconess Medical Center. I’m also the Membership Chair for the Rodger C. Haggitt Gastrointestinal Pathology Society (GIPS).
Why did you become a pathologist?
I shadowed physicians in several different specialties while in medical school, and everything clicked during my day with a pathologist. I had considered other fields, but after that experience, my mind was made up.
What do you like most about being a pathologist?
I enjoy the pace of pathology. In general, if I need to spend a lot of time on a difficult case, I can do that. I can grab a textbook off the shelf, get opinions from colleagues, and ponder as I put my report together. This naturally lends itself to academic inquiry and teaching opportunities as well.
What is special about your subspecialty?
I love both the variety and the volume of gastrointestinal pathology. It’s one of the busiest services in our department, so there is always plenty of material to tackle and learn from. Plus, we deal with about a dozen organs, and each has interesting neoplastic and non-neoplastic pathology. Nothing keeps you on your toes quite like spending 5 seconds signing out a tubular adenoma, then counting mitotic figures in a GIST resection, then wrestling with a complex medical liver biopsy for 30 minutes!
How does your typical day go?
Once I get to work, I spend 30 to 60 minutes in the morning catching up on all the emails that pour in at the start of the day. If I am on signout, that will fill my next several hours, usually with a resident and/or fellow (which allows me to teach as I go). Afternoon is when I can work on whatever else tops my to-do list, whether that’s collecting research data, writing or revising a manuscript, putting together a lecture, photographing interesting cases, or tackling paperwork.
What is the most memorable experience you’ve had at work?
Last year, I posted a “Tweetorial” about gastrointestinal neuroendocrine neoplasms on Twitter. It was about 50 short posts, with photographs, discussing current understanding of the disease topic. I had aimed the posts at pathologists, but in addition, I was contacted by several patients who had follow-up questions and who expressed gratitude for the information. I was even contacted by the Carcinoid Cancer Foundation. It was wonderful to have this opportunity to interact with the people truly impacted by our work.
What most surprised you about being a pathologist?
I admit that before entering the field, I had braced myself to prepare for the stereotypes I’d heard – that pathologists are just nerdy weirdos that hide in their office and never talk to anyone. Fortunately, this has absolutely not been my experience at all! Pathologists come in as many varieties as any other group of people – you have athletes, musicians, chefs, extroverts – anything and everything. Plus, I spend plenty of time outside my office, interacting with other pathologists, support staff, and physicians in other fields.
What do you think you would be doing if you weren’t doing this?
I spent some time as a section editor and copy editor for my college newspaper, so that was on my mind for a while. Luckily, I still get to do editing now and then, including through Pathology Outlines.
Could you say a few words about your association with PathologyOutlines?
I am the gastrointestinal pathology editor for the website. My responsibilities include editing any updated GI/liver/pancreas topic, seeking out skilled authors to update important topics, and reviewing chapters to make sure everything is organized properly. I also update topics myself when I can find time. By working with Pathology Outlines, I can keep hundreds (if not thousands) of pathologists up to date on the newest information and diagnostic criteria. In that way, it’s more efficient than one-one-one teaching with a resident at the scope! I also relied heavily on Pathology Outlines when I was a resident, so I enjoy being able to give back to the website.
You can follow Dr. Gonzalez on Twitter @RaulSGonzalezMD, and join his Facebook group for gastrointestinal pathology at https://www.facebook.com/groups/GIpathology.