Three magic words to help conquer fear, that may also be a secret to having a long and productive career. I really enjoyed this conversation with Dr. Bruce Smoller, a giant in the field of dermatopathology and pathology. Also tune in next week for Part 2! Dr. Bruce Smoller MD trained in anatomic and clinical pathology at Harvard's Beth Israel Hospital and in dermatopathology with Dr. Scott McNutt at Cornell Medical School/ New York Hospital. He has worked at Stanford University, rising to the rank of Professor of Pathology and Dermatology as well as at the University of Arkansas, where he was Chair of the Department of Pathology and the Director of Dermatopathology from 1997 to 2011. In 2011, he became Executive Vice President of the United States and Canadian Academy of Pathology. Since 2014, he has been Professor and Chair, Department of Pathology and Laboratory Services and Professor of Dermatology at the University of Rochester School of Medicine and Dentistry. Dr. Smoller is a former Editor-in-Chief of the Journal of Cutaneous Pathology and served as the President of the American Society of Dermatopathology, receiving the Nickel Award, which recognizes lifetime excellence in teaching, from the American Society of Dermatopathology. He received a Lifetime Achievement Award from the College of American Pathologists in 2022. He has written over 300 articles and has primary involvement in 18 books.
Three magic words to help conquer fear, that may also be a secret to having a long and productive career. I really enjoyed this conversation with Dr. Bruce Smoller, a giant in the field of dermatopathology and pathology. Also tune in next week for Part 2! Dr. Bruce Smoller MD trained in anatomic and clinical pathology at Harvard's Beth Israel Hospital and in dermatopathology with Dr. Scott McNutt at Cornell Medical School/ New York Hospital. He has worked at Stanford University, rising to the rank of Professor of Pathology and Dermatology as well as at the University of Arkansas, where he was Chair of the Department of Pathology and the Director of Dermatopathology from 1997 to 2011. In 2011, he became Executive Vice President of the United States and Canadian Academy of Pathology. Since 2014, he has been Professor and Chair, Department of Pathology and Laboratory Services and Professor of Dermatology at the University of Rochester School of Medicine and Dentistry. Dr. Smoller is a former Editor-in-Chief of the Journal of Cutaneous Pathology and served as the President of the American Society of Dermatopathology, receiving the Nickel Award, which recognizes lifetime excellence in teaching, from the American Society of Dermatopathology. He received a Lifetime Achievement Award from the College of American Pathologists in 2022. He has written over 300 articles and has primary involvement in 18 books.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the honor of being with Dr. Bruce Smoller. Dr. Bruce Smoller trained in Anatomic and Clinical Pathology at Harvard's Beth Israel Hospital and in dermatopathology with Dr. Scott McNutt at Cornell Medical School, New York Hospital. He has worked at Stanford University, rising to the rank of Professor of Pathology and Dermatology there, as well as at the University of Arkansas, where he was Chair of the Department of Pathology, as well as the Director of Dermatopathology from 1997 to 2011. In 2011, he became Executive Vice President of the United States and Canadian Academy of Pathology. Since 2014, he has been Professor and Chair, Department of Pathology and Laboratory Services, as well as Professor of Dermatology at the University of Rochester School of Medicine and Dentistry. Dr. Smoller is a former Editor-in-Chief of the Journal of Cutaneous Pathology, which is one of my favorite dermpath journals, and he has served as the President of the American Society of Dermatopathology, receiving the Nickel Award, which recognizes lifetime excellence in teaching. He also has received a Lifetime Achievement Award from the College of American Pathologists in 2022. He has written over 300 articles and has primary involvement in 18 books as well as many book chapters and presentations. I'm honored to be here with Dr. Smoller. Thank you again for being here.
[00:01:28] Bruce Smoller: Thank you for that very gracious introduction. Appreciate it.
[00:01:32] Christine Ko: Sure. Could you first share a personal anecdote?
[00:01:36] Bruce Smoller: Sure. About 10 years ago, I started making noise about retiring and my wife said to me, you can't retire, you get bored on Saturdays. How are you going to sit around for 25 years? So I decided to take up a new hobby that would keep me occupied as I transition out of being a dermatopathologist and do something else.
[00:01:56] And I started taking courses in wine. I can't be a sommelier because I can't stay up late enough to work in a restaurant, but I love to teach. And I love learning about wine. So I've taken, I don't know, 25, 30 progressively more difficult courses in wine, the science of wine, et cetera, the tasting of wine. And at this point I teach a lot of college classes in wine, and I give a lot of lectures around this part of New York State, the Finger Lakes, about all aspects of wine. I can tell you that the hardest exams I've taken in this wine business are actually more difficult than any of my medical boards were.
[00:02:36] Christine Ko: Wow. Outside medicine, there's so much knowledge that's actually very difficult to learn as well. In some ways, it's very limiting to be in medicine, even in the relatively small field of dermatopathology.
[00:02:51] Bruce Smoller: One of the things that I've learned is the remarkable amount of degree of parallel in a completely disparate field. I've given a talk several years at the Association of Pathology Chairs called On Diagnosing Cabernet Sauvignon, and that sounds ridiculous, but actually, it's true. The thought process you use to make a diagnosis of, what wine is this? is very similar to the mental scheme you go through to make a diagnosis under a microscope, except instead of just using your eyes, you use your eyes, your taste and your smell, and it's a very much more complicated thing to do, and I'm not nearly as good at it, I don't think. But I try, and I have a good time.
[00:03:33] Christine Ko: You seem to have a great deal of energy as evidenced by all the work you've done, in your CV, and then, in the last couple of years, taking all of these wine courses and actually teaching it and everything. You clearly, I think, love and have a great deal of passion for dermatopathology. Why wouldn't you just continue on? Like, why are you making plans for retirement?
[00:03:56] Bruce Smoller: It's an interesting question, and it's one I've thought a lot about. I'm a baseball junkie, and there is a parallel here. As I watch baseball players go through their careers, some guys retire when they've had a really good career, and you think, why did they retire? They're still doing great. Others, they retire; their last two, three, four years, you can see them dwindling and getting worse and worse. And you think, it's too bad that guy didn't retire two or three years ago. I don't want to be the second category. For all I know, I already am the second category, but I don't want others to perceive that, he used to be something and now he's not what he used to be. So I would rather go out at the top of my game, whatever that is, rather than have the dwindles. I feel this acutely as we move more and more into molecular medicine, away from pink and blue. I was fine for my entire career with immunohistochemistry and new markers coming out every year. I could pivot around and start using SOX10 instead of HMB45 or whatever, those kinds of things. But as we get to more and more molecular, I find myself less and less interested. I recognize absolutely that this is the wave of the future. This is where we are going. I just have run out of energy to learn all that new stuff. And before I become a dinosaur in everybody else's eyes, I would rather acknowledge that I'm not up to it.
[00:05:33] Christine Ko: I love that answer. Yes, I love the honesty. That makes a lot of sense to me.
[00:05:38] Bruce Smoller: I say around the scope all of the time, I can limp across the finish line without knowing which molecular aberration is associated with which histologic subtype of melanoma. But, you guys can't. You need to know that. And as soon as I feel like my interest and my enthusiasm for the latest, greatest new thing is flagging, it's time to just say, I know who I am. I know where I am. You know what? Let's pass the baton to the next generation and graciously step aside.
[00:06:08] Christine Ko: Yes. You're right. I absolutely do need to learn all this molecular. I find it difficult. I don't find it not interesting, but I do think it's sometimes I think it's like a little bit of almost like cheating that you can't necessarily tell, from the H&E of something that's Spitzoid, exactly what translocation there may be. Once you see a certain pattern enough, it's just like IHC, you can guess, okay, it might be this one. But molecular, still not 100 percent.
[00:06:38] Bruce Smoller: So when I started my residency, we were one of the few labs in the country that actually had an immunohistochemistry laboratory. And there must have been on the order of four or five markers. That was it. And was it cheating that if you do S100, the only melanocyte marker anywhere around, you could actually make that distinction, atypical fibroxanthoma and a spindle cell melanoma on the ear of an older man? Is that cheating? Kinda. It's just enhancing our diagnostic abilities.
[00:07:11] Immunohistochemistry is now completely widespread. It's ubiquitous. Everybody does it, and it's part of the way we work up a case. I can see molecular basically following exactly the same pathway. At some point, I think it will be mass marketed and will be ubiquitous. Everybody will have their little molecular lab where they'll do the same things, and it will become almost like a reflex. We have this, it looks like a melanoma. We should probably do this, and we'll have a new answer. It's medicine moving on, getting more sophisticated, and our diagnostic abilities becoming more sophisticated, using more than just pink and blue or even brown.
[00:07:50] Christine Ko: Before actually you had those four stains, and you have a tumor on the ear that could be an atypical fibroxanthoma or melanoma, you would just describe it, I presume?
[00:08:00] Bruce Smoller: Actually, no, we would make a diagnosis. We would. There was much more time spent looking for the subtlest of little tiny clues, lost by many of our trainees. They are very quick to immediately want to order a panel of immunostains.
[00:08:16] But, if we turn the clock back even farther, my professors were great at gross pathology. If you're looking at gross pathology of the big specimens that used to come into our labs, the full professors were great at gross diagnosis. My generation got away from that because we can do it with all these other things, and I think that the generation now uses immunos as a crutch in a way that I didn't learn to do. I don't see that as necessarily lesser medicine. I think it's just the specialty has moved on, and the specialty is going to continue to move on. Right now, the latest greatest shiny toy we have is molecular. What's going to happen 10 years from now? I don't know. Maybe molecular will be surpassed by something different that none of us can necessarily foresee. And that's okay. That's fine.
[00:09:08] Christine Ko: Yeah. Maybe some sort of AI related thing or something.
[00:09:11] Bruce Smoller: Exactly. And I don't think that's the kiss of death for our specialty. I don't see a doom and gloom. I think that as long as we continue to embrace whatever the next new tool/toy that we have to work with, we're fine. And where I see myself is that I don't feel like learning the next new tool, particularly. So let the next group do that.
[00:09:36] Christine Ko: Yeah. To touch on something you just said, I think the reason I think molecular is, or even immunohistochemistry is " cheating" is when you said that the newer generation or generations that are used to using the newest thing, you lose the ability to really examine the gross, like you said, or really examine for those smaller microscopic clues that people used to know.
[00:10:01] And I think the same thing happened to medicine, the physical exam, once all the imaging was so much more available. Students, including me, didn't learn the physical exam - heart, lungs, abdomen, et cetera -as well, just send the patient off for a CT scan or MRI or something.
[00:10:17] Bruce Smoller: The fact that stuff gets lost. I'm not a very good gross pathologist. At this point, I haven't looked at anything but a skin biopsy in 31 years, but I would say 31 years ago, I wasn't a really good gross pathologist because by then we were spending more time on H and E's, learning this whole new world of literally hundreds of antibodies, that we were all trying to grapple with, that my senior faculty barely had heard of. They didn't need to know that stuff. They could look at what we used to call man in a pan, an autopsy. They never went downstairs for the gross dissection, but they would come downstairs, and we'd have all the organs pulled out in a tray. And they were able to put together the person's entire life story with remarkable accuracy. Wow. I can't do that. So the fact that they could do that, they didn't know the difference between MART 1 and SOX10, and they didn't care. We have a level of expertise on different things than they had, and I suspect that subsequent generations may not care about SOX10 versus MART 1 because, oh stop with all of that, we can just do a molecular profile and tell you exactly what this is.
[00:11:26] I think that's all part of civilization. It moves on. On the clinical side of medicine, where we actually have patient contact, unlike, say, pathology, I think the thing you have to fight against is the loss of the human aspects of being a doctor. Getting a CT scan is wonderful, but there's actually a patient sitting in front of you. On the pathology side, we don't have to convey that to patients that they're not just a melanoma. They're a person with a melanoma. But every day around the scope, I find myself at least once a day stressing this. Someone will blow off a seborrheic keratosis and say, Oh, We're busy. Can we just sign this out tomorrow? Or something like that. And I'll have to say, actually, this is not a seborrheic keratosis. This is a 47 year old man who was scared to death that he's got a melanoma. The fact that it's a seborrheic keratosis is great news. We have to tell him that so he doesn't lose sleep tonight. This is a person. And I think the farther you get away from the people part of medicine, the worse it becomes for our entire specialty.
[00:12:31] Christine Ko: Do you have any advice related to diagnosis, or balancing strengths and weaknesses, that you wish you had known earlier that you could pass on?
[00:12:43] Bruce Smoller: Look at as many slides as I possibly can get my hands on, because experience can't be replaced. The only way you can get experience is to look and look and look, so every opportunity you have to broaden your horizons, broaden your exposures, the better chance you have of making a diagnosis. And I think clinical pathologic correlation is absolutely crucial. So the more chance you have to look at things and drill them into your brains, the better equipped you are to deal with this as your career moves on. It's all about experience.
[00:13:19] My real passion from college, all I ever wanted to be was a professor or a teacher. Dermpath is just the substrate. I actually am much more interested in the process of teaching than in the subtleties of dermpath diagnoses.
[00:13:35] So yes, my residents have to listen to all this kind of thing all the time, because this is what has always been interesting to me. How do we convey something to someone in a manner such that 30 years later, they may remember what we said?
[00:13:50] You walk into a room and you say, Oh, that's obviously GA. Okay, is it? It's an annular lesion. It's obviously GA, but did you think of all the other annular lesions to say, yeah, but it's not those. Okay, great. But your instantaneous thing was, oh, that's GA. We all do that.
[00:14:06] Christine Ko: Yep. This whole System 1, System 2 thinking has become more mainstream only really in the last 20 years, but maybe really just 10 years. Another favorite thing that I want to touch on with you is emotional intelligence. It seems like you have a comfort level with not knowing something, being willing to learn from a trainee. Your initial reaction at not knowing something is not shame and, Oh, let me turn away from that, but you're willing to go forward and really say, okay, just tell me, what is the newest thing?
[00:14:42] I think, especially in medicine with the hierarchy, the power differential, it's hard for a medical student to say, I don't know just tell me, you know, like, instead of feeling like, oh, ashamed and, Oh, why don't you know this? Do you have any comments about that?
[00:14:54] Bruce Smoller: First of all, it's all about the patient. You're supposed to check your ego with the door, and you say, it doesn't matter what I look like. Yeah. There's nothing wrong with saying, I don't know.
[00:15:05] We got to do right by the patient. And if the resident comes up with a cool diagnosis that I didn't know, Okay. Oops, my bad, but it's not about my ego. I have to be willing to say, interesting. I didn't know that. Thank you for sharing that with me. So yes, I agree. That's easier to do when you're at the top of the dung heap, you're a full Professor, you're the Chair of the department. It actually looks good when you say you didn't know something. You're not an arrogant jerk. You're willing to admit it. It's harder to do when you're the medical student or the resident or an assistant professor, because you don't want to be ashamed that you didn't know something that maybe you should have known, whatever that means.
[00:15:45] I know when I'm coaching my trainees to give a talk at the ASDP or the USCAP or whatever, I always tell them, so why are you so nervous? You're probably not going to forget how to speak English in the next 10 or 12 minutes. The first 10 or 12 minutes are easy. You've got the floor, you've got the microphone, and you know how to speak English. There's no big deal there.
[00:16:06] So what are you afraid of? You're afraid of the questions at the end. You know what takes away all of the fear? There are three phenomenal words that make it, you don't have to be afraid. I don't know. Thank them for the question, say, that's a really good question. Honestly, I don't know the answer to that. I'd be happy to take it offline and discuss it with you. I'd be happy to go home and look it up and get you an answer. I don't know. What's wrong with, "I don't know"? And the residents are terrified to say I don't know because they'll look stupid.
[00:16:35] As soon as you take your ego out, and you accept the fact that nobody on earth knows everything, be comfortable about what you do know. And be comfortable about what you don't know and just accept it. I don't know that.
[00:16:47] Christine Ko: We are going to end this conversation here as part 1. We'll continue next week with part 2. We will delve into visual recognition and diagnosis even more. Don't miss out on part 2, next week! Thanks!