Pearls for the People From a Prostate Pathologist

A tray of prostate biopsy slides is ready for microscopic review.

As my career in pathology heads toward the home stretch, some pearls I have picked up along the way, particularly during the last 17 years as a prostate pathologist.

I Can Name That Surgeon in 3 Cores

You all know that no two people have the same exact fingerprints or DNA. I can tell you that no two surgeons send the same exact prostate biopsies.

I can look at a case and know right away who the urologist is. Fourteen cores? That tells me this case is from Dr. B. A ten-pack? Got to be Dr. M. Lots and lots of cores from every location in the prostate? Dr. Y must be the urologist of the day. Long, thick cores come from Doc A, while Doc B sends more fragmented specimens. Sixty different urologists, sixty different biopsy “fingerprints.”

It’s Not Over Until the …

I sometimes get a bit exasperated looking at 15 or twenty prostate biopsy cores from a patient, all of which look perfectly normal; well-formed acini with lots of basal cells, bland stroma, nice even spacing.

But today I got a reminder why I need to look carefully at each and every one of those cores, all the way to the end. In two consecutive cases, I found nothing, nothing, nothing, until the final core in each case demonstrated prostate cancer. And not the potentially insignificant Gleason 3+3 kind, but high-grade cancers that will require treatment to preserve the patient’s health and hopefully prevent a cancer death. It’s humbling to realize that the 12th biopsy found what the first 11 didn’t.

Statistically, Things Tend To Return To The Mean

There is a saying in baseball that a ballplayer’s batting average is going to match the numbers on the back of his baseball card. A .250 hitter might go on a hot streak, but eventually, he is going to go back to being a .250 hitter.

It’s like that in the lab, too. Some days every prostate I look at will be malignant and I feel like Dr. Death. Other times, every case is benign, and while that is great for the patients, I worry that I am missing things, that I have forgotten what prostate cancer looks like under the microscope. But over time, it all evens out. From month to month, the percentage of cases I diagnose as cancer is the same. The diagnostic peaks and valleys cancel each other out. Statistics just don’t lie.

Whatever Remains…

Sherlock Holmes once said, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” Over a long career, I have realized that a pathologist’s most valuable skill is recognizing the many faces of non-cancer. While scanning prostate tissue, my brain automatically eliminates the benign, the inflamed, the reactive.

Whatever remains is where my concentration needs to be focused. Those areas might not be malignant, but I need to look at them carefully to make sure they aren’t. When in doubt, a second look the next morning, or a special stain, or a consultation with my colleagues will guide me to the truth. The Holmesian method of diagnostics.

I am sure I have learned a few other things, but I will save them for another snowy day.

This blog is the opinion of the author and not UroPartners LLC.

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Have You Done Your Wordle Yet?

It is saturating. I have never been part of a trend that has spread this fast. Forget Ukraine, Voter’s Rights, the Goulding of Aaron Rodgers. This is all anyone wants to talk about.

Just give me my Wordle and go away for ten or twenty or thirty minutes. I will let you know when I have finished and you can disturb me once again.

I had never heard of Wordle until about two weeks ago when I read a New York Times article describing the newest fad. An online game, the official version of which can only be played one time a day, it is best described as Mastermind for word geeks.

Guess a five-letter word by guessing other five-letter words and seeing what letters match up with the secret word. It is not all chance. There is some logic involved and a decent vocabulary and knowledge of letter frequencies in words help in solving the puzzle.

The ‘net abounds with sites that tell you the best word to start with. I ignore those. I prefer to look around the room and pick the first object I see with a five-letter name. Or close my eyes and pick the first five-letter word that pops to mind. To me, that is more fun than using someone else’s prescribed starter.

Six misses and you are done for the day. Get it right in less than 6 attempts and you get…just about nothing. No balloons, no fireworks, no fanfares. But the one thing you DO get is the chance to post your results to your favorite social media.

And that is the super-spreader Wordle event. Post the little grid that shows how many guesses it took to nail the word of the day and watch the “Comments” pour in. Those in the know applaud your efforts (you got it in two!) or mock you (it took you 6????) And those who don’t know what you are talking about ask questions and are soon hooked. The proliferation of this thing makes Omicron look like a real piker.

Until a vaccine is discovered, I will keep up with the daily challenge. My best effort is solving in two turns (please hold your applause) and I have only totally shanked it once. I usually muddle along in the three to four range.

And I think it is time for today’s game–just leave me alone for the next half-hour.

______________________________________

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Jeopardy! for the Ages…the Senior Ages!

Barb and I take our birthday cards to each other quite seriously. They are always delivered first thing the morning of the day, and always to the same spot in the house. I leave my card for Barb on the kitchen island next to her beloved iPad, and I know exactly three weeks later I will find mine hooked on to my briefcase at the back door, ready to delight me before I head to the lab.

Of course, the content of the card needs to be just right as well, striking the right mood for what our lives are going through each year. The typical formula is loving but not overly mushy, emphasizing our closeness and how lucky we are with our wonderful family.

But this year Barb went a bit off script and she hit the jackpot. The card, pictured above, depicts a game of Senior Jeopardy!, and in case you can’t read it clearly, the name of the contestant on the left is Lester.

For those of you who don’t know, I was a Jeopardy contestant in 1988. My opponents weren’t Fern and Earl…they were Linda (the returning champion) and Neil (the winner of my single match.) But I was really there–and I am still campaigning to be the new permanent Jeopardy! host instead of KenJenningsMayimBialik. After all. unlike Aaron Rodgers, in the last year, I’ve been triple-COVID vaxed, double Pneumo-vaxed, and probably anti-anthrax vaxed, too.

But back to the birthday card. Barb didn’t place a special order for it or hand-write my name in that box. She found it on the rack and knew she had to have it for me.

Besides having my name as contestant #1, the categories are perfect for the “mature” me, almost 35 years past my Jeopardy! prime. “Facts I Forgot, ” “Where I Left My Glasses,” “Summer Sweaters,” “Early Bird Specials,” “Aches and Pains,” and “What Did You Say?”– all part of my daily life. The only categories I would add are “Lyrics to Songs from 1964” and “Back In the Day.” I suppose those might show up in the Double Jeopardy round.

That card is so perfect, Barb says she plans to give it to me every year. And why not–she knows I won’t remember!

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Man-People Take This Music Sh*t Seriously!

So I am a member of a few groups on Facebook. Groups about my old neighborhood, my new neighborhood, my schools, my occupation. And a handful about my love of music.

In one of the groups, people tend to ask questions like “name your favorite bass guitarist,” or “name a song with the letter Q in the title.” On occasion, I will volunteer an answer, and on rarer occasions, I will ask a question. During this past COVID-quiet weekend I asked a question. I didn’t know I was inciting a riot…

My question was pretty straightforward–“Name a song that contains the name of a non-USA city.” As an example, I listed my favorite Warren Zevon number, Lawyers, Guns and Money which includes the lyric “I was gambling in Havana.”

Pretty easy stuff, I thought. Not a trick question, not controversial. To my chagrin, I learned there is nothing in the cyber world that is not controversial. And nothing that can’t make people angry.

Sure, lots of people gave uncomplicated answers. No surprise how many people named Werewolves of London, another Warren Zevon track. Our great distaff vocalists were represented by songs such as Joni Mitchell’s Free Man in Paris (no one mentioned the Neil Diamond version!) And lots of other songs with non-USA cities in either song titles or lyrics were fun to reminisce about. The Comments reached into the many hundreds.

But then the arguments began. Everyone loves The Girl from Ipanema, but is Ipanema a beach, an area, or a city unto itself? Loads of people weighed in on that one–supporting their claims with Google maps and guidebook quotes. At least that debate was peaceful.

The fury rose when many people listed songs naming non-USA countries, but not cities. Songs like Never Been to Spain and Haitian Divorce. I will admit that for the first few minutes, I replied to posters pointing out the error, but after a while, I decided what the heck–let ’em list what they want to list and have fun. It’s not like I am giving away any prizes!

Yet one or two individuals assigned themselves to be the scourages of the list, pointing out every misattributed song, every spelling error, and every country-not-a-city-error.

The vitriol rose to a boil when discussing Back in the USSR, the Beatles rocker from The White Album. When Mr. Blue Pencil incorrectly* told a poster the song didn’t belong on the list, all hell broke loose. Name-calling, cussing, and sacrilegious comments followed in short order. WTF?????

I have learned my lesson. In an effort to avoid furor in the future, I think I will avoid hot-button topics like music in future postings and stick to less controversial topics.

Does anyone want to talk about changing the Senate filibuster rules?

*Moscow is mentioned in the lyrics.

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My Year Of Magical Running

2002. Exactly twenty years ago. We were still reeling from 9/11. Our soldiers were fighting in Afghanistan, but not yet in Iraq. The world was changing. And a switch flipped inside of me. I became The Running Man.

Running was not totally new to me. Either alone or with a couple of friends, I had laced up my New Balances and gone for a 2 or 3-mile run a few times a week for years. I would have some 5K runs marked on the calendar, and once a year I would struggle to finish a 10K race through the ravines of Highland Park.

But I had a few internal “rules.” If I started a run and in the first quarter of a mile it didn’t feel just right– too windy, or too hot, or I was just too sleepy, I would put on the brakes and walk home. And I NEVER ran on consecutive days. It just seemed too tiresome.

What changed in 2002? I don’t really know. Early in my running season, I stopped my slow warm-up trot in front of a neighbor’s house, barely managing 200 yards from home, and decided I had enough for the day. I walked back to our driveway ready to go inside. But before I reached our backdoor a thought came to me. “This quitting is bullshit.” I turned around, tightened my shoelaces, and went for a 3-mile run.

From that day, the urge to run just grew and grew. My “no consecutive days running” rule fell by the wayside. I began to run almost daily. A handheld CD player, loaded with old rockers like “Born to Run” and “Sweet Child O’ Mine,” downloaded from Napster and burned to disc, became my soundtrack and companion. A beat-up running cap and a belt with two water bottles were my other accessories. And after each run, I made a notation in my spiral notebook

On many workdays, I would spend a half-hour before lunch in the Rehab Department of the hospital striding on my favorite treadmill. I pushed and pushed until I made 4 miles in those 30 minutes. That felt like just the right goal for a not particularly athletic 46-year-old.

The miles added up as I began leaving my running friends in the dust. My racing schedule grew with lots of 5Ks that were now not much of a challenge, as well as longer runs at Northwestern University and Oakton Community College. One race in Des Plaines had to be temporarily halted and restarted after an unscheduled freight train blocked the course. The extra miles didn’t bother me at all.

The Highland Park 10K was looming in September. I knew that this would be the year I would be ready for it. And I was. A long treadmill run the day before had left me loose and energized. I zoomed from the starting line and blazed my way through the first half of the race.

And then it happened. Sharp pain in my right leg. Something I had never felt before. My pace slowed; gingerly, I switched to a walk. I nodded to my friends as they ran past me, puzzled looks on their faces. In the recovery zone, while downing bananas and Carol’s Cookies, I let them know I was in pain.

An exam and bone scan at the hospital the next day revealed two stress fractures in my leg. I had overdone it; I was running on empty, and a winter of rest was in order.

I didn’t totally quit running. But the distances became shorter and the intervals between runs became longer. Last year I finally threw in the towel and gave up running for good. You may see me darting around on my new bike, but my running shoes have been retired. They are in heaven somewhere along with that cherished old CD player. I will listen to “Sweet Child O’ Mine” no more.

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I Get To Do This–Thoughts From A Veteran Teacher

I rarely have guest bloggers, but an experienced teacher I know sent me this, and in the face of all the hostility between the Chicago Public School System and the Chicago Teacher’s Union I thought I would post it.

Full Disclosure for total transparency:

The teacher, Laury Wolf, is a veteran high shcool math teacher, with experience in New York City and Chicago, but does not teach in the CPS System.
She is my daughter (and that is not her picture at the top of the blog.)

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“I get to do this.”

I never thought I would be one to write a blog post, but if anything, the last two years have allowed us to try new things. Also, time, time is just different. I haven’t had time to leave our house, see friends, try new restaurants or travel. I have had time to think, and I mean really think. I lot of the things have been related to my career. I am a math teacher, and I mostly love it. I have been thinking if I move on what would that look like, what else can I do?

I grew up with a dad who was a first-generation American, understanding the importance of education. My grandparents escaped Nazi Germany and created a life in Chicago, instilling in my dad the value of learning. Throughout my years of schooling, my dad was president of our high school’s school board. My mom always encouraged me to further myself too. No matter what, you could always learn. I learned the value of education, and not just to get into a “good” college. I am very grateful for my upbringing.

It’s hard to define what exactly drew me to teaching, but I think I liked the constant motion in the school building. Everyone has a role, responsibilities, and a general sense of purpose. Every day was a challenge, and every day I came in determined to be better. The relationships and watching the students growing in front of me made it worth it.

As I reflect on my role as a teacher, I am amazed at the craziness of the last two years. Classes that were remote, hybrid, in person, asynchronous, on a park bench? And sometimes I question what makes this worth it. Why do we subjugate ourselves to emails overnight, bad professional development, little sick leave, constant changes, and most importantly a lot of disrespect?

I think back to a conversation I had at a math conference a few years back. I was sitting next to what I call a baby teacher (someone who is new to the profession). The workshop was about using your own interests in the classroom. Supposedly if I create word problems about watching The Office, my students will double their engagement. The first prompt was to ask your partner why they chose to teach, the baby teacher’s response still resonates with me.

“I get to do this”.

That’s right we are lucky as educators. Every day we get the opportunity to shape, better, and learn from the next generation. I am not sure where in education I will end up, but I know I will still be thinking.

“I get to do this.”

_________________________________

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A Song, A Memory, A Sad Discovery

“I wonder what happened to Mark.”

Barb and I were eating dinner, Pandora music playing on our kitchen speakers. “One For My Baby” began to play. It’s been one of Barb’s favorite songs ever since Bette Midler sang it to Johny Carson on his penultimate night as host of The Tonight Show. But what we were hearing was the classic Frank Sinatra version. And it brought back different memories to me, leading me to a sad discovery.

My memory was of the mid-’60s, sitting in my family apartment, listening to the radio–rock’n’roll on WCFL. Joel Sebastian, the morning DJ on Super ‘CFL always ended his shift turning over to airways to fellow jock Dick Williamson, as Ol’ Blue Eyes crooned “one for my baby and one more for the road” in the background.

I never knew Joel, but I did know his son Mark. When I was a pathology resident at Evanston Hospital, Mark was one of several dieners, the hospital employees who, in addition to other duties, helped the pathologists perform autopsies.

The dieners kept the morgue clean and supplied, transferred the deceased from the refrigerator to the autopsy table, and helped with incisions and evisceration–the process of removing organs for examination to determine the cause of death and other morbidities. They then had the responsibility of cleaning the body and preparing it for delivery to the funeral home.

A good diener is invaluable to pathologists-in-training, and Mark was a solid one. He was a cheerful, smart, young man with a good grasp of anatomy, taking a post-college Sebastian Sabbatical while waiting to go to medical school in a year or two. Eyes twinkling, he would keep us newbies from making too many rookie mistakes.

Mark became my friend and confidante as well, teaching me how to debone a chicken for the surprise dinner I made for my 3rd wedding anniversary. We had a side-hustle doing autopsies at a few neighboring hospitals and even went on a double date or two–sometimes on the same day as our autopsy rounds.

After a year or so, Mark moved on. I completed my residency and began my long-term gig as a staff pathologist at Holy Family Hospital. I hadn’t thought much about him until the other night, listening to Sinatra, remembering the Joel Sebastian connection, when the thought popped into my head.

“I wonder what happened to Mark,” I said.

It didn’t take long to find out. The Google search combination of Mark and Joel Sebastian quickly brought me to all the information I was seeking. Mark had indeed become a physician, an Associate Professor of Surgery at the University of Connecticut, and Director of Trauma at Hartford Hospital in Hartford, Connecticut. And no surprise to me, he was an award-winning teacher of medical students and a profound doer of good deeds

But as you may have guessed the article I was reading was in Memorium. Mark had taken his own life in 2013 at the age of 55.

I don’t know the path that took him to that point. I only know the sadness that hit me as I read of his passing. He was truly one of the good guys.

So Mark, whenever I hear “One for My Baby,” be it Sinatra, Midler, or anyone at all, please know I will be thinking of you.

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