I am always curious about how others continually improve, and Dr. Thomas Brenn gives good insights on this. Learning in whatever way works for you, getting exposure to new things in ways that you can remember, discovering true mentorship...it's definitely a fun journey. Dr. Thomas Brenn MD PhD received both his doctorate degrees in Germany. He completed postdoctoral fellowships in Genetics and Pathology at Stanford University, residency training at the Brigham and Women’s Hospital, and dermatopathology and soft tissue pathology fellowships with Dr. Phillip McKee and Dr. Christopher Fletcher. He has worked in the United Kingdom, Canada, as well as the US and is currently based at the University of Michigan.
I am always curious about how others continually improve, and Dr. Thomas Brenn gives good insights on this. Learning in whatever way works for you, getting exposure to new things in ways that you can remember, discovering true mentorship...it's definitely a fun journey. Dr. Thomas Brenn MD PhD received both his doctorate degrees in Germany. He completed postdoctoral fellowships in Genetics and Pathology at Stanford University, residency training at the Brigham and Women’s Hospital, and dermatopathology and soft tissue pathology fellowships with Dr. Phillip McKee and Dr. Christopher Fletcher. He has worked in the United Kingdom, Canada, as well as the US and is currently based at the University of Michigan.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today I have the honor of being with Dr. Thomas Brenn. Dr. Thomas Brenn has an MD and PhD and received both his doctorate degrees in Germany. He completed postdoctoral fellowships in Genetics and Pathology at Stanford University, residency training at the Brigham and Women's Hospital, and dermatopathology and soft tissue pathology fellowships with Dr. Philip McKee and Dr. Christopher Fletcher. He has worked in the United Kingdom, Canada, as well as the U. S. and is currently based at the University of Michigan. Welcome to Thomas.
[00:00:32] Thomas Brenn: Thank you very much. Pleasure to be here.
[00:00:34] Christine Ko: I'm so glad that you could be here. Could you share a personal anecdote?
[00:00:39] Thomas Brenn: Outside of medicine, really, my biggest interest is riding motorcycles and riding them somewhere where there's not a lot of people. My most memorable trip was from Cape Town up to Namibia and then touring Namibia solo. If you do this all by yourself, you meet some interesting characters, and you experience a lot of interesting things. The most memorable of that was going into a canyon. I think it's the second largest in the world. I really wanted to go, but there was no gas station. So I knew if I go in there, I was not going to make it out. But I went anyway, and it was really worth it, and human kindness, and you get a lot of help, and people are very creative. So I had these funny soap containers that people filled with gasoline, so it was like riding motorcycle bomb, but it was definitely worth it.
[00:01:28] Christine Ko: That's cool. Have you been on a motorcycle ride around the U. S.?
[00:01:33] Thomas Brenn: Not really, just wherever we live. We've been riding a lot around Boston, been riding a lot around Alberta, which isn't really in the U. S., but at least it's Northern America. But since we get so busy, it's hard to take out weeks out of your work and go away. So you have to make it happen whenever you get the time.
[00:01:54] Christine Ko: That's cool. I'm going to move on to your research. A lot of your research has focused on melanocytic and adnexal tumors. Can you talk about how you recognize or define something new?
[00:02:06] Thomas Brenn: Yeah, something new is, I think, it's like a game of memory. I observed that with Chris Fletcher. He was just phenomenal. He just sits in his office at sign out. And he's, Oh, I've seen that before. That was 2005. And then he goes to a drawer. So I don't have that capacity, but you just try to find where you've seen that before, and once you've seen three, I think the human brain connects, and all of a sudden we learned to recognize them.
[00:02:35] You have to know the range that has been described. But It's being aware of what has been described, the spectrum of entities, and then seeing something that doesn't obviously fit. A lot of that comes from referral practice where people send you just weird and wonderful things that they haven't seen. People who send you cases, they usually know at least as more or even more than at least I do. And I've learned a lot from the people who send you cases. If they struggle with it, there's usually a reason. So I think that's already pretty helpful.
[00:03:10] I think we do learn a lot from genetics these days, from molecular events. And all of a sudden, once we know what they look like with a given mutation or fusion we start to recognize them, and it's the same thing. New things like BAPomas that we had no idea existed, but we had seen them all the time. The brain connects the dots, we recognize them, and once you've described them, people see it in the literature, and then they see it in real life.
[00:03:38] I think the endocrine mucin producing sweat gland carcinoma that Artur Zembowitz really was the first to produce a larger study when he was at the Mass Eye and Ear.... I always wondered, where are these? I've never seen them. And ever since I've seen the first one consciously, they're everywhere. They're not rare tumors.
[00:03:57] Christine Ko: Yeah. That's the converse of it that we don't recognize it until we recognize it. They're still out there. We're calling them something else, probably, or just describing them.
[00:04:09] Thomas Brenn: I get worried.
[00:04:10] Christine Ko: Yes. At our institution, for example, BAPoma, we were just describing them; often saying something like "atypical epithelioid melanocytic, blah, blah, blah". Now, I think that to have a separate test like the immunohistochemical stain for BAP1 or the genetics does give us that sort of feedback and help to be able to recognize something and feel reassured. You know that you're recognizing....
[00:04:35] Thomas Brenn: You have that feedback, and now you don't need the feedback anymore because you see them, and they're like a friend. You recognize your friends, but until they become a friend, you need to learn how to recognize them. So seeing them for the first time and then seeing them again and again, without any help. I think that's really the tricky part.
[00:04:55] Christine Ko: Yes, exactly. Let me know what you think. I think there's no trick really, in having things become your friend, you just have to see them frequently enough.
[00:05:07] Thomas Brenn: Yeah, there's like the, the cellular neurothekeoma is a good example. Or myoepitheliomas. If you've never seen them, you don't stand a chance. If you've seen them once, maybe you won't recognize the next time, but if you've seen them twice, three times, then all of a sudden the pattern, even though it's not really a distinctive pattern, the brain connects. So it's exactly, it's seeing things. And I think that's why this old fashioned teaching around the multiheader or like the ASDP multiheader session, they are really so important for seeing the spectrum of disease, seeing new disease and seeing an actual live case because textbooks, they're very static. You take a classic image, but you don't really see the spectrum. Where when you see live cases, you see they have a little bit of variation and you see the range of the entity much better, I think.
[00:06:00] Christine Ko: Yeah. Yeah, I like it. Okay. So I'm going to move on now to medical error and your thoughts on how you prevent it and how you deal with it.
[00:06:10] Thomas Brenn: Yeah. So that is obviously the biggest problem that we face. And I think it ties in with the previous question, because if it hasn't been described, you can't recognize it. But some have been described, and we still don't recognize it just because we haven't seen them. Nobody has taught us. It also ties in, how do we learn pathology once we're not a resident or a fellow? As a resident or fellow, we always get knowledge given. It's really great. As an attending, all of a sudden, nobody gives you knowledge. You sit in your office, you have a lot of boxes to get through and off you go. And you just hope that you don't get them wrong.
[00:06:51] I think there's a number of ways to keep learning and to prevent medical errors, and that's gaining more knowledge. There's a whole bunch of things. Going to meetings, listening to other people. I don't learn well from textbooks. Being with friends in a meeting and listening to them, I always pick up something, and I seem to memorize them better than reading them with a still image. Meetings to me are a great way to keep up with new entities, and especially when you casually chat. Friends, your colleagues, that is really the biggest help. I've learned the most from my colleagues and from the people who send cases in. I still remember. I was relatively junior out of fellowship in the UK. I got a lot of referral cases and probably a bit in over my head there. There was this pathologist sending me this beautiful epithelioid schwannoma. I'd seen them before, but the penny didn't drop. But he said, Thomas, I think this is an epithelioid schwannoma. What do you think? I was like, Wow, this is genius. That's exactly what it is. Thank you very much for teaching me.
[00:08:02] So I think there's so many ways of getting knowledge, but really asking around is probably to me the biggest learner. It's also the best way to prevent medical errors. Everybody wants to ,share the difficult case, but the difficult case is difficult for everyone. It's the easy case that wasn't easy in retrospect, and I think that's what we see in medical legal issues. It happens. We're busy. We have busy practices. You go through a lot of cases, and you will make diagnostic errors. I think we make them maybe not on a daily basis, but on a regular basis.
[00:08:37] Being aware of the implications of your diagnosis. I think that is one of the most important things to me. When you render a diagnosis, what else could it be? Is there something really important that I could miss, and is there anything I can do? And then thinking about, before I press go, What is the implication to the patient, and what is the possible harm I can do? That's often when I get stuck and think maybe I'll show this and that I don't mess this one up big time because the stakes are too high.
[00:09:09] Christine Ko: Yes. I think that's a really good point. We will make errors as you said. Hopefully the errors that we make are small, meaning like little to no impact really on a patient. Meaning, if I call something not cancer and I call it one benign adnexal tumor name, but it's really another benign adnexal tumor.... it's an error, but it doesn't actually really matter. One is benign and the other is benign too.
[00:09:34] But I wouldn't want to call something not cancer when it's actually cancer, and it could really harm the patient. So that's a good point.
[00:09:41] Thomas Brenn: Also, we always think of harming the patient by missing a malignant diagnosis. But to me, what I think a lot about also is, if it's benign, you got to call it benign and not create big holes in the human body for no reason whatsoever. So I actually think about the opposite as well. How much damage do I do with my diagnosis or my insecurity? And I think insecurity probably is a big factor in rendering a diagnosis. You kind of know it's probably benign, 90%, but oh, let's get it re excised. Do we really need to do this? I think that is the difficult part. How far to go, how big a hole to create when it's maybe not absolutely necessary.
[00:10:26] Christine Ko: Yeah. I think you're touching on over diagnosis a little bit there, and I agree. I think you're saying that we overdiagnose things, on the whole, as a specialty and subspecialty. [Probably.] And I think that's true. I do it myself. I try not to, but I think the way things are in the U. S., it's difficult, it's harder to call things completely benign, in the U. S., than to call it a little bit worse. The trend seems to be that you're protecting the patient more by over calling things rather than under calling things. That's the culture that I think we practice in, and it's difficult to push against that.
[00:11:09] Thomas Brenn: Yes, I think just being aware of it is probably the most important thing because I, as you, I do the same thing. I sometimes know, especially with melanocytic lesions, that maybe you don't need the formal re excision, but you still advise it. Not only for your own insecurity, largely for that, but also that the patient can rest in peace.
[00:11:33] In the UK, it was very different, at least at the time. Everything came out. Every atypical monocytic lesion had a little margin around it. It doesn't matter if it's mildly atypical, moderately, severely. Even if it's melanoma in situ, you would have been completely removed. So you breathe a lot easier than having a superficial shave biopsy of something that looks really horrible, but not horrible enough that it's outright melanoma. And then what do you do? And so, I think we all are in this together, and it's hard, but at least thinking about the consequences. So if it's a genital site, young girl's genital area. I try to word it in a way that they don't go back and force somebody to create holes at locations that are not that accessible. Maybe just watch it, and if it re pigments, then biopsy.
[00:12:25] Christine Ko: Yes. I think you're touching on the fact that genital sites have what we call site related atypia that is not necessarily significant to the patient, like it's not cancerous, even though the cells can look pretty wild and ugly looking under the microscope.
[00:12:42] Thomas Brenn: Yeah, and it takes a lot of guts.
[00:12:44] Christine Ko: Yes. Yeah. Yeah, exactly. Is there anything you wish you had known earlier in your career?
[00:12:50] Thomas Brenn: There's lots of things. That's the whole thing of life. It would be so much easier if you had known the things earlier. But then it takes the fun away because I think a lot of the fun is just moving along and opening doors, see what's behind them.
[00:13:06] To me, the most important thing is really mentorship. I wish I had known, really, to maybe seek mentorship, if that's even possible. I don't know, because to me, mentorship didn't exist until I came to the Brigham. And,, I didn't have to look for it. It was just there. And to me, this was eye opening. And I've always tried to do the same for fellows and residents with an interest. Mentorship is something that's very organic. You can't do it for everybody. There's only certain people who will be amenable, with you at least. So you're not a mentor for everybody, but when it clicks, I think it's something really important, and it has made my career.
[00:13:49] I think I've had the most amazing mentors that I could imagine. And I feel very fortunate for having met them. And to me, I have to say, these are the individuals that have shaped my career, my path, the way I think, the way I do things. And, I think to me, really, this is the most important part of my training. I don't think mentorship starts with training. It continues. It's a lifelong thing.
[00:14:17] Christine Ko: Yes, I think you're so right. But I particularly like that you said that you can't be everyone's mentor and also that it really has to be sort of an organic thing that happens. That you click with someone, in a certain way.
[00:14:34] Thomas Brenn: I think people have recognized the benefits of mentorship. So they had this buddy program where they get new residents together with junior faculty with senior faculty. The idea is good, but it's not mentoring really. You need to form this bond, really, in order for this to work. So you can give career advice, but mentorship is not career advice. Mentorship is something much more complex. It's just emulating, but not copying. And it goes both ways. So if you are a mentor to somebody, that person is a mentor to you as well, I think. It really goes both ways, which to me, I have learned so much from trainees, in many ways.
[00:15:18] Christine Ko: Yeah, I agree. I think the right kind of mentoring relationship really is mutually beneficial to both parties, in very indescribable ways. There's just no like real recipe for it. Do you have any final thoughts?
[00:15:32] Thomas Brenn: Final thoughts... When I thought about my career in pathology or my life I realized that I never had a plan. I never wanted to go into medicine. I never want to do dermpath, but this is where I belong. This is the happiest times. And again, you open doors, not all of the doors are great, it's trial and error. There were some big errors in there, but there's a lot of success in there as well. To me, it's a road that we travel on. I couldn't go to what is supposed to be the next big thing. I think it's just being true to yourself, is to me, is really the most important.
[00:16:06] Christine Ko: I like it. Thank you so much for doing this with me.
[00:16:10] Thomas Brenn: Oh, thanks so much. That's been fun. Thanks.