See, Hear, Feel

EP47: Dr. Arnaud de la Fouchardiere on hard work and fun

February 01, 2023 Professor Christine J Ko, MD/Arnaud de la Fouchardiere Season 1 Episode 47
See, Hear, Feel
EP47: Dr. Arnaud de la Fouchardiere on hard work and fun
Show Notes Transcript

Dr. Arnaud de la Fouchardiere is a leading expert in melanocytic lesions. His papers are always illuminating, and he has a YouTube channel dedicated to teaching, with some videos related to his Non-Artificial Intelligence in Pathology, whereby he shows a classic example and then has a video where one can channel deliberate practice and look at more examples. Dr. Arnaud de la Fouchardiere, MD PhD has received training in clinical dermatology, surgical pathology and molecular genetics. His position in the pathology lab of the cancer care hospital of Lyon, France is centered on second opinion cases limited to melanocytic tumors (>2000 cases/year). He is specialized in the molecular classification of such tumors especially in children and in rare variants. He has described a number of new entities and genetic finding in this field. You can find him on Twitter @melanopath.

[00:00:00] Christine Ko: Welcome back to SEE, HEAR, FEEL. Today, I'm very excited to be speaking with Dr. Arnaud de la Fourchardiere who has received training in clinical dermatology, surgical pathology, and molecular genetics. He currently is in a pathology lab of the Cancer Care Hospital of Lyon, France, and he centers his practice on second opinion cases limited to melanocytic tumors, and he looks at over 2000 cases per year. He has specialized in the molecular classification of such melanocytic tumors, especially in children, and has studied many rare variants. He has described a number of new entities and genetic findings in this field, and you can find him on Twitter @melanopath. Welcome to Arnaud.

[00:00:47] Arnaud de la Fourchardiere: Hey. Hi. Thank you to have me today. I'm really excited about this podcast recording. 

[00:00:53] Christine Ko: Thank you. I'm very excited as well. First off, I will ask you to share a short anecdote about yourself to help us get to know you. 

[00:01:03] Arnaud de la Fourchardiere: When I started medical training, I was a dermatologist, and I had already completed most of my training. What really got me into dermpath is looking at the biopsies of the lesions I had seen. So I was looking at this patient. I had no idea what he had, and I just rushed to the lab, as soon as I knew the slides were out, to look at them under the microscope, and it seemed very obvious that this was cutaneous lichen sclerosus, which can look very clinically strange. And I really thought, wow. This is great because this tool is really powerful. It's better than my eyes. I should get interested in this. I really wanted to learn more about this, and that's how I slowly shifted from dermatology to dermpath. 

[00:01:49] Christine Ko: Oh, cool. In Europe, did you have to do a whole separate pathology training? 

[00:01:54] Arnaud de la Fourchardiere: It was two and a half years of training of dermatology, and then I did two and a half years training of general surgical pathology. 

[00:02:02] Christine Ko: In the US, you may know this, but you can do dermpath from dermatology training or from pathology training. I am derm trained, and very much I do sometimes get very excited to rush back and see the dermpath slides to see the diseases under the microscope. I'm gonna move on to a second question, which is, how do you define and use emotional intelligence? 

[00:02:25] Arnaud de la Fourchardiere: I think this can apply to all areas of life. I wanted to focus on team work. For me, this is related to the awareness of your professional surroundings and other people you are working with, and it's like really adapting to it, and it means caring about other people. Means that you know when to make a joke. And you're able also to say to someone when they need support or help, and give them help, and create a positive work environment. Maybe it relies on doing or saying what matters at one time in the day, when something happens. You're not delayed, you immediately understand the situation and adapt to it. Basically you're giving a lot of energy to other people and the hope of getting some back. But that's the way I really enjoy my team and all the different relationships we have on every level with them. That's what makes people happy at work, and they're happy to see you and discuss with things that are work related or not.

[00:03:32] Christine Ko: I like that. I like how you said it's about energy. You can give energy, and you can get it back, and you can read emotions as, is this low energy? Is it high energy? What's needed? You shared with me before we started recording that you lived in the US for a little bit. Do you find that reading the emotions or reading the energy in certain situations is different in the US versus France? 

[00:03:57] Arnaud de la Fourchardiere: Yeah, I do travel a lot and see different cultures and I think, yeah, that is true. I did notice that. 

[00:04:04] Christine Ko: Okay, so we're gonna move on to another question: how you hone your visual perceptive skills, because you've done a lot of really amazing work. You have a certain visual perception that is very sharp.

[00:04:20] Arnaud de la Fourchardiere: Thank you. Really what got me into medicine was scientific curiosity at first, because no one in my family was a doctor or even a nurse or any kind of paramedic. I quickly realized that I wanted to learn as much as I could, and there is really no limit to what you can learn. For pathology I tend to think that you are as good as the number of cases you've seen. So as you always have this curiosity to see more cases, and if I just have a tray of new cases, and I see there's a large tumor, I cannot resist looking at it. For me, it's like minimal talent, but it's a lot of commitment, and that means really hard work. Lots of hard, work.

[00:05:04] For rare tumors, like the ones I see, there's not enough examples for people to look at just from one paper. So I'm trying to collect data banks of images of cases that can help pathologists, so they can have a shot at looking at the things. The way I would like to structure this in my videos: one video giving a typical example, and then there would be just examples back to back just to try to train and show you all the variants because in the papers you only show the nice pictures, the nice IHCs, and sometimes it's difficult or there are subtle variations. And if you want to illustrate all this, it never fits in books, and so I'm working on this type of program. It's called Non Artificial Intelligence in Pathology. What do you think? 

[00:05:57] Christine Ko: I love it. For me, it is a lot of hard work. As you said, I think it's really repetition and seeing multiple examples of the same thing. For me, it takes a while, and I admit, I actually am not able to recognize the things that I think you can recognize in terms of these melanocytic, predicting what genetic alteration there may be. It's something I'm trying to work on. Your idea of a lecture like that and showing a classic example and then having multiple others, that's, I love that it goes along with deliberate practice.

[00:06:33] Arnaud de la Fourchardiere: It's really funny because sometimes you find a new sign in the lesions and then you start seeing it, and you say, how come I did not see that before? I've really been taught to do something from low power. And if you don't have an idea from low power, usually high power would not give you a better idea. That's the way I was taught. There are different ways; people have different strategies to diagnose things.

[00:07:00] Christine Ko: You've trained yourself to be able to see them at low power. What's your low power gestalt? 

[00:07:04] Arnaud de la Fourchardiere: Yeah that's the idea. If you don't have one idea from low power... I'm in trouble when that happens. It happens a lot.

[00:07:11] Christine Ko: How often do you think that initial gestalt is wrong, though, versus right?

[00:07:17] Arnaud de la Fourchardiere: I do a lot of multi-head discussion of cases I've never seen that I'm discovering in front of everyone. So this is where this kind of kick in, because I'm talking as I'm looking through the case, and it's a really interesting exercise that I've been doing for years now. And so I made some mistakes. Sometimes you say, okay, here's my low power impression, and then you zoom and then immediately you know that you're wrong, but it's just like I had the idea, and then I checked at high power; that idea was wrong. So I go back to low power. It's different than having no idea at low power.

[00:07:50] Christine Ko: Okay, so this segues into my next question, which is, do you have a diagnostic process?

[00:07:57] Arnaud de la Fourchardiere: I work in a field where it has a reputation of high difficulty, and I know I've made mistakes. I will make mistakes. So I really thought this through on how to reduce the errors. The method I have developed is to have some redundancy. And that means I will look at the cases three times. This is very time consuming, and it's going to be three different days. Everything turns around a staff meeting I organize once a week on Wednesday afternoon, where we look at all the cases I've received for second opinion. I will try to look at the case before the staff, just the gestalt, and ordering some IHCs. And then the staff will have the case. And this is very open, everybody can talk, and we have a lot of fun. It's a friendly discussion on the cases. And if someone does not agree, I will write their name and what they're said, and then after the staff I will look at it the third time, when I'm going to make the report, at a different moment. And I'll remember the two previous times. The most important part is humility because often we don't have all the clinical knowledge we would need. But if you're always confident that you've done the best that you could at the moment you're making your diagnosis, that's the way you will not stay awake at night. And sometimes, I'm too tired. I think that's very important to know when you've reached the limit. That's when you're at risk to make errors. 

[00:09:30] Christine Ko: This is so fun for me to hear your process. You're using Thinking Fast, which is System 1 according to Daniel Kahnemann. [Yeah.] And then Thinking Slow, which is System 2. I think it's amazing that you do that. 

[00:09:42] Arnaud de la Fourchardiere: And it does happen that I changed the diagnosis on the third time from the first and second time. You can be influenced by, it's sunny outside, so everything is benign and things like that. It's not always it's going to be the same idea on the three times. And like the third time I would look like all the sections, everything. I really think that it's really important not to be hard on yourself for these difficult cases. 

[00:10:08] Christine Ko: I also like what you just said about the weather that, Oh, today it's sunny outside, so maybe I'm influenced by that. A lot of cognitive psychology literature showing that biases really are influencing us when we're looking at a case. You're very aware.

[00:10:25] Arnaud de la Fourchardiere: Yes. So on the third day would be morning. I would be alone in the lab. And it's a very quiet environment at that time. That's when I choose to make the reports of the most difficult cases. 

[00:10:38] Christine Ko: So you're fresh, and you have quiet, and you're not really being interrupted. Is there a lesson or lessons that you wish you had learned earlier?

[00:10:46] Arnaud de la Fourchardiere: The knowledge that nothing is set in stone, and it's a great challenge. During med school, you're looking at your professor, and you envision them as they're the owners of knowledge. And if you had that knowledge now, it's going to be only the knowledge at that time. You have to be aware that new things constantly emerge and there's some shift in science. You have to understand that this will probably change how you will work in one year from now, or five years from now, or 10 years from now. It's very important to have the idea that things can change ,and that you can change them with your practice. And at least you have to try to understand what is changing, the way. You cannot go against these waves, you have to deal with that. That's very important. 

[00:11:39] Another point is that the perfect colleague rarely exists. At first you really think, oh, I want someone like this, but you have to realize that you're never going to find that person. You never find exactly what you need, so you accept everyone who wants to work with you to help. You just have to embrace that, and you have to be happy that someone wants to help you. I've had people that I tried to mentor, but it did not work out in the end. But it's okay. I taught them some stuff, and I think they really helped me at that time. 

[00:12:13] I try to put a lot of fun in what I do. When you can, because for me, you can do a lot of very serious work in a fun environment. It's not antagonistic, as some people perceive it. That's important for people to be happy with their job or coming just because they know they're going to spend some good time and also do some serious work.

[00:12:35] Christine Ko: I agree. I think it has to be fun. It's not sustainable if it's not fun. Do you have any final thoughts? 

[00:12:42] Arnaud de la Fourchardiere: We talked a lot about hard work. There's always gonna be a risk of burnout if you don't know your limits. I'm quite lucky because I always have this little tingling in my head when I've started working too much and I know I have to do something. Personally, I do a lot of video games to exhaust all the pressure; I go into something completely different and that really is important for my brain. 

[00:13:06] Christine Ko: That's cool. Thank you for sharing that. 

[00:13:09] Arnaud de la Fourchardiere: I really had a good time discussing. 

[00:13:11] Christine Ko: Yes. Thank you so much for spending time with me. Really enjoyed it.