EP182: Navigating Dermatopathology: Insights from Dr. Jag Bhawan

A Conversation with Dr. Jag Bhawan: Career, Challenges, and Lifelong Learning in Dermatopathology

In this episode of The Girl Doc Survival Guide, Dr. Jag Bhawan, a distinguished dermatopathologist from Boston University School of Medicine, shares his journey and accomplishments in the field. Dr. Bhawan recounts a significant anecdote from his early career, emphasizing the importance of maintaining an open mind, the value of perseverance, and the necessity of clinical-pathological correlation. He also discusses the inevitability of errors in medicine and the importance of owning up to mistakes. Additionally, Dr. Bhawan offers advice on achieving a work-life balance, the influence of serendipity in career success, and the enduring value of mentorship.

00:00 Introduction and Guest Introduction

01:41 Early Career Challenges and Anecdotes

05:49 The Importance of Open-Mindedness in Medicine

09:19 Handling Mistakes and Learning from Them

13:00 Career Advice and Work-Life Balance

17:13 Final Thoughts and Gratitude

Transcript

Christine Ko: [00:00:00] Welcome back to The Girl Doc Survival Guide. Today I am very pleased to be with Dr. Jag Bhawan. Dr. Jag Bhawan, MD is the Guido Majno Professor of Dermatology and Pathology, Head of the Dermatopathology Section, Director of Teledermatology, and Vice Chair of the Department of Dermatology at Boston University School of Medicine. He is Board Certified in Anatomic Pathology, Dermatopathology, and Dermatology. He has published over 275 original articles, authored several book chapters, and co-authored an interactive online dermatopathology atlas. He serves on the editorial boards of the American Journal of Dermatopathology and Dermatopathology. He is the 2006 recipient of the Walter Nickel Award for Excellence in Teaching of Dermatopathology and received the 2008 Founders Award from the American Society of Dermatopathology. In recognition of his longstanding contributions and commitment to the [00:01:00] institution, Dr. Bhawan was inducted into the Chester S. Keefer Society at Boston University School of Medicine in 2009. He received a Certificate of Appreciation from the International League of Dermatological Societies in 2015 and has been named a lifetime honorary member of both the American Society of Dermatopathology and the Indian Association of Dermatologists, Venereologists, and Leprologists. Most recently, in 2023, he was inducted as a Fellow of the William Fairfield Warren Society in recognition of his distinguished contributions to Boston University.

Thank you for being here today. 

Jag Bhawan: Thank you for having me. 

Christine Ko: You have had many accomplishments, only some of which I just listed. Could you share a personal anecdote? 

Jag Bhawan: So back in my early career when I just started dermatopathology service at University of Massachusetts Medical [00:02:00] School, I was thrown into a place where there was nobody else around me to consult, to discuss. Like we have now in most academic institutions, we have conferences and we have colleagues that we can bounce our cases off. In this situation I was alone, and I was very young. I just finished my training in 1975 and joined University of Massachusetts, and we had a case of a patient who had deep skin lesions in the thigh and buttocks, and a biopsy was performed. And as a young dermatopathologist, I look at the slide, and I found that within the vessels there was tumor cells. And these tumor cells resembled atypical lymphocytes. And I look at the history of this case. It turned out that the patient has a lymphoma. So very naively I felt that this is a lymphoma involving the blood vessels of the skin. It was simple, right? [00:03:00] Then the case was referred to outside institution for radiotherapy. The pathology department there reviewed the slides. There was a visiting English pathologist at that time who looked at the slides and said, Oh, this is wrong diagnosis. This is angioendotheliomatosis proliferans systematisata. For the sake of the rest of the talk, I'm gonna call it APS. I had not heard of this condition. I was petrified that I made a mistake early in my career, and I was quite upset, to be honest. However, I looked at the slides, and I felt convinced that these are really atypical lymphocytes and not endothelial cells. In those days, there was no immunohistochemistry to speak of. This is 1977, 78. Only specialized labs had something, but nothing what we have today. So I'm also an electron microscopist, so I decided to do electron [00:04:00] microscopy on this biopsy and actually showed that the endothelial cells were quite distinct than the tumor cells within the vessels. We also did electron microscopy of the buffy coat of the of the blood from this patient, and showed that the buffy coat showed cells similar to what were in the vessels. So we were convinced that this is really a lymphoma going in the vessels. So we try to publish it. And as you can imagine, there are big names associated with APS, including big master in Yale and elsewhere in Europe because they're the people who described this condition. So it was very hard. The cancer journal agreed to accept the paper if we put a question mark on the diagnosis. So we said intravascular lymphoma and APS, one disease ?. That is how it was published. As luck would have it two or three years later, [00:05:00] I went to do my dermatology training at Boston University and Tufts, which was the joint program at that moment. And we had a similar case this time, and the case came as no previous history of lymphoma. Only the skin lesions. A biopsy showed the same exact pathology. So I want to say intravascular lymphoma, but I said maybe this is whatever they call APS. It turns out two days later, patient has exploratory laparotomy because of acute abdomen, and she has actually a jujenal lymphoma. Now I'm prepared. So we, at that time, immunohistochemistry became available. I contacted my colleague at MGH, and he performed the immunohistochemistry and showed conclusively that these were atypical lymphocytes. So intravascular lymphoma came in existence.

Christine Ko: That's cool. It's hard, right? To push back, especially when you're junior, when you're new, when you feel like other people have more experience. [00:06:00] And of course, we can all be wrong, too, no matter how long you've been doing a given career. 

Jag Bhawan: Absolutely.

Christine Ko: It's hard.

Jag Bhawan: I think this also illustrates that you should have an open mind. Don't be intimidated by books or papers. If you have made your observation, and you think you are right, you need to pursue it. You may turn out to be wrong. It's okay to be wrong, but at least you should pursue it. Don't be intimidated by people about you, or senior to you, or more experienced than you.

Christine Ko: Yeah. I like what you just said. You said, it's okay to be wrong. Do you, this sounds like a stupid question, but I really mean it. Do you really believe that? 

Jag Bhawan: Yeah, absolutely. Because it's impossible not to be wrong. If you are honestly practicing anything in your life, right? Medicine or otherwise, there will be some decisions or some things that you will do, even in your personal life, that you will realize later on, oh, that was the wrong step I did. When you're doing [00:07:00] some research or you're studying a case, you go with a hypothesis, but it doesn't turn out to be right. So what's wrong with that? It's okay. 

Christine Ko: I agree with you. I think that I've realized though, that because as physicians, if we make an error, if it's a significant error, then it can have a impact on patients. 

Jag Bhawan: Of course.

Christine Ko: Not that you are saying this, that it doesn't matter. Not at all. And I agree with what you're saying, but I think that's my struggle with it, that even the way the medical legal system works, physicians are expected to be perfect. To Err Is Human came out in 2001. To Err Is Human talked about medical error and that all physicians, all medical professionals, unfortunately, will make mistakes, . We should be able to be more honest about [00:08:00] error. I think it's true the way you phrased it, that if we could do that and just say from the outset, this is my hypothesis, or this is my working diagnosis, and keep an open mind because maybe I am wrong even if I am the world expert who's been doing it for 50 years.

Jag Bhawan: Absolutely. And also when you are looking at a scenario or case, then if you're not sure, then you ask for help. Get an opinion from somebody else. Now that opinion may or may not help in the long run. As you know very well, in melanocytic lesions, on a difficult case, five will go in one way and the five will go in the other way. And the one who speaks loudest sorts of carry the weight but doesn't mean he is right. Or she's right. 

Christine Ko: Yeah.

Jag Bhawan: Only time will tell.

Christine Ko: Yes.

Jag Bhawan: Patient's outcome will tell. 

Christine Ko: I know that you have a consensus conference for dermatopathology at Boston University, and we have one too, where we do, we pull [00:09:00] all of our heads and eyes together and look at difficult cases and give our opinions. It can be hard to not be influenced by whatever is said first. The group think phenomenon is for sure true. Sometimes when we are all able to be honest, we're split. Some people think one thing and some people think another. So do you have a way, a method, that you deal with error since it will happen?

Jag Bhawan: Own up. Accept it, because that's the fastest way of coming out ahead in the sense that otherwise you'll keep on thinking about it. Or what should I say? Is the right word, feeling upset about it, and try to make excuses, but it's best that you own it. And if the mistake is done with your full idea of what you thought was the right one. Then I do not believe that is truly a mistake. It may turn out to be a mistake, but it's not.

But if you do [00:10:00] a mistake because of your negligence, because you are trying to do 200 cases in a day, then that's a different issue, right? We have to first recognize what kind of a mistake we made. Is it because of my sloppiness, or is it because of my interpretation? I think the latter is more tolerable in the sense because that's my interpretation. The former is not, and if I really did that, then I have to apologize. I have to accept, and I have to say that I'm going to be extremely careful next time. 

Christine Ko: Yeah.

Jag Bhawan: I have to minimize. It's not gonna be a hundred percent. I wish it was.

Christine Ko: Yeah. So think of ways to avoid that in the future. So if you realize unfortunately it was because you're, what you called sloppiness, like you are distracted or doing too many cases or trying to multitask or something, you should avoid that kind of thing in the future. If it's your interpretation, though. So say like for [00:11:00] example, your initial story, it had gone the other way. Like it was really this angioendotheliomatosis, this APS, and as you said, you hadn't heard of it. Or even, if we take the example of COVID, when no one knew about COVID, initially, right? There's something completely new, and there isn't really a way to know about it until someone describes it. Just like you with the intravascular lymphoma. To put a name on it, with your open mind, and now we can recognize it more easily.

Jag Bhawan: The learning is lifelong. One can't say, I learned it enough, because that will be the death of your career. You have to learn. I'm learning every day, and I'm learning more from my junior colleagues, my trainees, residents and fellows, because they ask you questions, and sometimes there are tough questions. I'm sure in your practice, you'll see a case, my God, I'm never seen anything like that. It can be as mundane as a BCC, but it has some [00:12:00] peculiarities that you have never seen about it, and you wonder what happened here. So yeah, learning is a lifelong process.

Christine Ko: Is there anything you wish you had known earlier in your career? 

Jag Bhawan: Things happen a lot of times by chance, whether it's research, whether it's your personal life, or your career. Things really happen by chance, not necessarily that you are any smarter than somebody else. Sometimes being in the right place at the right time makes a huge difference. i've been very blessed. Very fortunate. I've been very blessed with having great mentors who've helped me along to reach the stage where I am. 

Christine Ko: Yeah, I like that. I do think we don't account for serendipity enough. When we're like asking kids, even five year olds, what do you wanna be when you grow up? There is a big factor of serendipity, like who your English teacher is or who your dermatopathology teacher [00:13:00] is. Do you have any tips for having a successful career, whether in academia or otherwise?

Jag Bhawan: As I mentioned, keep an open mind. Never give up. If you set a goal about something, if you fail the first time, don't give up. Try again and again. A lot of young people come and ask me, they want to go and do a fellowship in dermatopathology, and it's very hard to get in. I say, Okay. So try again. Make yourself better. Do some more work. Make more publications. Make yourself so competitive that people will want you. So if it means it takes you an extra year or two, what's the big deal? Age or the time factor is not important if that's what you want. 

Christine Ko: The younger we are, sometimes time seems longer, but then the older you get, you realize, Oh yeah, an extra year for something that I really want would have been or is worth it. 

Jag Bhawan: There are some socioeconomic [00:14:00] factors that play into today's time of people trying to make it shorter. I was blessed that I didn't have any loans. So today's graduates, they have loans, and obviously they will like to start their career so they can start earning money so they can pay off their loans. I understand that aspect of it, but one year in life is not going to make that much of a difference. 

Christine Ko: That's a really good point. No one's ever talked about that before. It is true. My training was in the UC system, and I think we were paid the lowest in the whole nation despite California having a very high cost of living. It was hard. I had loans, and I think it was a factor in when I was trying to decide how long to make my training extend for. But I think I only believed this once I experienced it, but really I think for most physicians, within three years of working full time, I think a lot of my [00:15:00] financial stress did diminish. I wasn't so worried all the time about money. That segues into another question of mine. Do you have tips on work life balance, like balancing that kind of financial consideration with what we wanna do in work? 

Jag Bhawan: Yes. I would say strongly that people should take time off for their own self. At least an hour a day. In 1992, I had a major accident in which I could have been paralyzed or even lost my life. And when I came out of that, thank God that I did, I said to myself, I'm going to be selfish for one hour a day, whether I go for a walk, I go to a gym, I do whatever. Because we all are so obsessed with our work, and sometimes not because we want to do that, because that's how it [00:16:00] is. Our lives are busy, and we are doing 500 things at the same time. You are writing papers, you're seeing patients, you're seeing slides, you are teaching, and so on, but somehow you need to make that time. From that time on, I made a decision that I'm gonna spend an hour . You have to carve out time. We are all very busy, so that's not an excuse. Sleep less if you have Two but you have to do your hour of whatever makes you feel better. If it means you're playing golf, let's go and play golf. But you have to do something for yourself. 

Christine Ko: Yeah, something for yourself, you mean, that's not work,

Jag Bhawan: Right. 

Christine Ko: Yeah. That's great advice actually. I said it that way about something that's not work because when my kids were younger and I felt, as you implied just now, that I had no time, I felt like, because I love my job, that is doing something for myself. Because I dropped my kids off at daycare, and I felt [00:17:00] somewhat guilty at times. I would go to work, and I would feel very happy and free at work. But I do think now that I should have still been doing something else for myself. I completely agree with you. You're so wise. Do you have any final thoughts?

Jag Bhawan: One, in dermatopathology, do not forget CPC. Clinical pathology correlation is of utmost importance. i'm known in my department as a CPC person. 

Christine Ko: That's good. I think that also CPC, clinical pathologic correlation, becomes so useful because it makes me think again about a case from a different perspective, right? The clinical, the way the patient presented. I agree. That is really useful. 

Jag Bhawan: Also, as I mentioned before, I've been very blessed to have a great career. A great number of colleagues, trainees that have gone all over the world and doing phenomenal things in [00:18:00] their lives. That's the biggest reward that one can expect. It's based on mutual respect and honesty and kindness to our colleagues, to our trainees, to our mentors. I feel very strongly that we should never forget about mentors. Very frequently in today's time, people move on, and they would forget where they came from, where they were being taught, who was responsible in their life. I'm not saying universally people do that, but that seems to be the trend. I'm an old fashioned person. I try to honor my mentors both in India and here, and I feel good about that. 

Christine Ko: That's good advice. Thank you so much for your time, and I appreciate all the teaching that I have had from you over the years.

Jag Bhawan: It's always a pleasure to speak to you. Thank you. Thank you for having me.