Listen in as Tim talks about flexibility, bread, overdiagnosis and shame. Dr. Timothy McCalmont is Professor Emeritus of the Departments of Pathology and Dermatology, University of California, San Francisco. He was Co-Director of the UCSF Dermatopathology Service for 25 years as well as the Editor of the Journal of Cutaneous Pathology. His BS in Biochemistry and MD are from Iowa State University, he attended medical school at the University of Iowa College of Medicine, and his residency in anatomic pathology was completed at Wake Forest University Medical Center. He subsequently started residency training in dermatology at UCSF, where he did his dermatopathology fellowship training as well. He is internationally renowned for his diagnostic skills that span the breadth of dermatopathology. Dr. McCalmont is currently a dermatopathology consultant in the private sector at Golden State Dermatology Associates, active on Twitter @mccalmo, and on KiKo.
Listen in as Tim talks about flexibility, bread, overdiagnosis and shame. Dr. Timothy McCalmont is Professor Emeritus of the Departments of Pathology and Dermatology, University of California, San Francisco. He was Co-Director of the UCSF Dermatopathology Service for 25 years as well as the Editor of the Journal of Cutaneous Pathology. His BS in Biochemistry and MD are from Iowa State University, he attended medical school at the University of Iowa College of Medicine, and his residency in anatomic pathology was completed at Wake Forest University Medical Center. He subsequently started residency training in dermatology at UCSF, where he did his dermatopathology fellowship training as well. He is internationally renowned for his diagnostic skills that span the breadth of dermatopathology. Dr. McCalmont is currently a dermatopathology consultant in the private sector at Golden State Dermatology Associates, active on Twitter @mccalmo, and on KiKo.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL Today, I'm very much excited to speak a second time with Dr. Timothy McCalmont. Dr. Timothy McCalmont is Professor Emeritus of the Departments of Pathology and Dermatology at the University of California in San Francisco. He was co-director of the UCSF Dermatopathology service for 25 years, as well as the Editor of the Journal of Cutaneous Pathology. His BS in Biochemistry and MD are from Iowa State University, and he attended medical school at the University of Iowa College of Medicine. His residency in Anatomic Pathology was completed at Wake Forest University Medical Center. He subsequently started residency training in Dermatology at UCSF where he did his dermatopathology fellowship training as well. He is internationally renowned for his diagnostic skills that span the breadth of dermatology, and Dr. McCalmont is currently a dermatopathology consultant in the private sector at Golden State Dermatology Associates. He is active on Twitter, and his handle is @mccalmo, and I'll put a link to that in the show notes. He's also very active on KiKo, and I'll put a link to all of his great posts in the show notes as well. Welcome to Tim.
[00:01:13] Tim McCalmont: Thank you. Thanks for the kind introduction. Good to be here.
[00:01:16] Christine Ko: Tim agreed to speak with me again. He's knowledgeable about so many things, and I wanted to ask him just some random questions that have come up for me in speaking with psychologists who research shame and emotions and meaning. First off, he is willing to share a personal anecdote.
[00:01:39] Tim McCalmont: The thing that I'll share is just how much I have learned to appreciate flexibility in work and flexibility in where I spend my time. Part of my feelings about flexibility actually came from the pandemic because it forced us to behave in different ways. But part of it is my family. I have two grandkids, now one who is three and a half who lives in Seattle, and one who is two and a half who lives in Portland. Having the flexibility to be able to be involved in their lives, absolutely anytime they wanted me to be, was important. Having a work structure that was permissive to that and having a life structure that was permissive to that were goals that I wanted to accomplish. One of. my goals was never to buy bread, and for a solid two years, I baked all of the bread that we consumed for two years. In my new position I can do something I could never do at the University, which is bring a dog to work. I babysit my brother's dog and bring the dog to the office. And digital pathology is just crucial for the modern pathology diagnostic workplace. One reason is flexibility, which translates into job satisfaction. So that's an important component, but it also archiving cases, dealing with telephone calls. It's easier to share cases in a precise way.
[00:03:19] Christine Ko: Yeah. Cool. I appreciate what you said about flexibility because the pandemic and the way it really overturned all of our lives made me value flexibility more than ever. I will move on to a different question where I wanted to talk to you about overdiagnosis in medicine and in dermatopathology. Thoughts on that?
[00:03:43] Tim McCalmont: Yeah, I have a lot of thoughts. In my personal experience, there's been three waves of the dermpath overdiagnosis issue. In 1996, Bob Swerlick, who's a dermatologist in the Emory system, published about overdiagnosis, that melanoma diagnosis is rising, but melanoma mortality is not rising. And so the explanation for that is that we're making too many diagnoses of melanoma or we're calling things melanoma that we didn't used to call melanoma. We're definitely calling certain things melanoma that we didn't used to call melanoma. But I think it's actually complicated to attribute that all to overdiagnosis because there's also things that we downgraded the diagnosis. There's a lot of flux in both directions. In 2012, that was the second wave. Your colleague and our mutual friend, Earl Glusac, raising the concern that there's overdiagnosis, the same root issue raised. Melanoma mortality is not really rising, and melanoma diagnosis is rising. The third wave, a couple of years ago, Gilbert Welch and Adewole Adamson. A manuscript published in The New England Journal that got a lot of press and a lot of attention.
[00:05:12] And so why are we having so many diagnoses of melanoma and raising the issue of overdiagnosis Dr. Adamson was a Grand Rounds speaker when I was still at the. In the last year I was there and gave a talk. And at the time, I felt very swayed that that was right because the data in the way that it was presented, it made it seem like there was a strong case to be made. If you look at melanoma globally, which is probably not the sophisticated way to do it, it's true that melanoma diagnosis rates are going up, and melanoma mortality is relatively flat. But if you look at subtypes of melanoma, and if you look at melanoma in certain age groups, that's actually no longer an accurate statement. So there are certain subtypes of melanoma where the mortality has gone down. There are subtypes where mortality has gone up. There's age groups where we should be concerned, such as young people with melanoma where mortality has gone up. And so it's important to probably look more narrowly rather than more broadly and figure out areas where diagnostic criteria have created more melanomas that you might call meaningless melanomas and then also recognize highly meaningful melanomas.
[00:06:44] Christine Ko: Not all cancer is the same. But I think uniformly people who are not in medicine will hear the word cancer and just think that's an automatic death sentence. For us in diagnostic work, when we know that a certain cancer won't have a meaningful impact on someone's life, we should wonder if that's really the best term to use, although of course we have to use the diagnostic categories that we have right now.
[00:07:08] Tim McCalmont: It's interesting that you brought that up. If we have a diagnosis, and let's just stick with the term "meaningless melanoma". What "meaningless melanoma" is that on some basis, whether it's histopathologically or whether it's based on a molecular profile or both, it's melanoma, but it's never gonna hurt anybody. So do we want to rename that something else? I understand that motivation to not frighten people and to give an accurate representation of disease, but I still think it's very problematic if we are continuously changing the names of diseases.
[00:07:46] Christine Ko: I'm with you. When you think about how non physicians and even physicians talk when we're just talking. People will just say, oh, I had skin cancer, or I had breast cancer, or I had colon cancer. They never say, I had "microsecretory carcinoma". They don't even say, I have "invasive ductal breast carcinoma", or I had "melanoma". Occasionally people will get even that detailed, but usually they just say, I have "skin cancer."
[00:08:10] Tim McCalmont: Yeah. We don't need to change the name to a different category to emphasize that it's a low grade disease. It's just a matter of Improving understanding, but also having it make sense in terms of the established literature. So, it's complicated.
[00:08:28] Christine Ko: Yeah, it's complicated. Patients feel distressed if they get a diagnosis of some sort of cancer. They can also feel shame. Sometimes I will feel shame if I don't adopt using a new name because then I feel like I'm not, keeping up to date. The reason that I might adopt a new name is actually more because of shame than anything else. There's shame in medicine, I think, diagnostically and on the patient side. So doctor's side, patient side. Can you talk about that a little bit?
[00:08:57] Tim McCalmont: Shame is a very deep human emotion. I'm not an expert on shame, so I should say that at the start. The best way to avoid shame or avoid feeling that emotion is to stay in a quiet spot or a non edgy sort of medical practice approach. By being hyperemotional in work we can actually end up being diagnostically inconsistent, which can be a contributor to shame. What I do personally is that if I'm feeling emotional, I don't work then. I make every effort to feel very calm at work, to work when I feel calm, to work at the time of day when it's best for me to work. Creating strategies to be able to provide yourself with diagnostic consistency is the best way to feel proud of your diagnoses. Obviously we all are gonna make mistakes. Everybody makes mistakes. If your premise at the beginning of a career is, how do I never make a mistake? The only way you're gonna accomplish that is to never have an opinion.
[00:10:15] So a better model is, how do I minimize mistakes? How do I make my mistakes be small mistakes? How do I end up in a position of lifelong learning so that I can continue to expand my repertoire? That's really a more healthy way to frame a practice career in terms of being able to accomplish what we should accomplish as physicians.
[00:10:41] Christine Ko: I love that. This is a separate question, but do you have advice on how to best face a mistake when you've made one? Because I think that's part of shame in medicine, that we don't tend to talk about our mistakes.
[00:10:58] Tim McCalmont: First thing, in terms of mistakes, point number one is, try not to make very many. Point number two is if you make a mistake, own up to it, and own up to it directly. But point number three is, don't presume you made a mistake until it's absolutely clear that you did. In terms of my third principle, don't give up on a diagnosis until it's absolutely clear that it's wrong because that is a hyperemotional moment. They actually start to solve the problem before it's absolutely clear that there is a problem to solve. It takes a little bit of bravery if you have a case where you're suspecting that maybe it is problematic. The best thing to do is to work through the case until the diagnosis is absolutely clear, and then at that point, if your diagnosis is wrong, face up to it
[00:11:58] Christine Ko: When you say own up to it, if you know you are wrong and you do the due diligence and you are wrong. What does that mean to you, to own up to it?
[00:12:06] Tim McCalmont: There's multiple layers to that. There's a legal aspect. These are complex issues. Part of owning up to it is actually in our own heads. It's not getting emotional about that. It's an opportunity to learn. I went that direction and I didn't see that I should have gone a different direction. How do I improve? In terms of owning up to it, it's really that kind of thing. It's making sure that you yourself accept the diagnosis because that's important. It might be going to a colleague, and saying, I didn't really believe you when you suggested this, but I found out that your diagnosis was actually right. If we live in the right kind of workplace where there's mutual respect, you can have those kinds of conversations, and it can be a good and rewarding thing for everybody when that kind of dialogue can happen.
[00:12:56] Christine Ko: In terms of social and emotional learning, what you were talking about in terms of owning up to a mistake, to not get overly emotional about it, and be able to admit it, and logically go through it in your head in order to hopefully not do it again.
[00:13:13] Tim McCalmont: As pathologists, if we see something unfamiliar, we can always make it familiar by creating an analogy to things that we know. The problem is, if and when that analogy works, it's brilliant. It gives us a great diagnosis, but I think sometimes we extrapolate beyond what is really realistic. And then we can cause ourselves problems because we can end up in a weird spot where we shouldn't have gone there.
[00:13:40] Christine Ko: Yeah, it's cognitive bias, it's not intentional, but if I look at a slide and I think it's say a basal cell carcinoma. Something common. I'll just see something blue and I'll immediately think, oh, it's a basal cell carcinoma. And then there's confirmation bias where I'll just, maybe think, yeah, it's on the face and it's a 70 year old. Sure. It all fits. But I don't take enough time maybe to think about what other things can look like a blue thing on the slide.
[00:14:10] And there are other things, and there are other things that are blue and can be on the face. Merkel cell carcinoma, other cancers that are worse than basal cell carcinoma. For me, the challenge sometimes is in the mistakes that I'm completely unaware of making.
[00:14:26] Do you have any final thoughts?
[00:14:29] Tim McCalmont: I always enjoy talking to you. Thank you very much for reaching out and talking to me. We're in a time of great flux. We're in political flux, post pandemic flux, stagnation economically and politically in America right now. There's just a lot of things that feel stuck, and then medicine is stuck. It's kind of a difficult time. What I've done in terms of changes to my own life over the last couple years is I've found myself greater work flexibility while still doing largely the same thing.
[00:15:09] The principles that I think really make us the strongest as physicians, in addition to paying attention to our own personal health, are diagnostic consistency and learning and participating with colleagues, whether that's online or in the office, or preferably both. And just trying to find the joy that makes work a fun thing to do and a part of life rather than the only thing in life. When there's too much work and too little play it, it can be problematic.
[00:15:46] Christine Ko: Yeah. I love that. Thank you. Thank you so much for spending the time.
[00:15:51] Tim McCalmont: Good to talk to you. Always enjoy it.