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A Road Less Traveled: Becoming a Transplant Pathologist, from the Perspective of a Current Trainee


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Sarah Voss, MD
University of Pittsburgh
Pittsburgh, PA, USA
Vosssm@upmc.edu



Seemingly ubiquitous in Pathology training today are subspecialty fellowships in which residency graduates engage in one- to two-year immersions in areas of individual interest. Fellowships are generally applied for and obtained within the third of four post-graduate years of pathology residency training; application often being aided, at least in part, by physician mentors who inspire areas of interest and encourage particular strengths. However, the road to becoming a transplant pathologist, or a subspecialist in any field, is not always straight and narrow. Even among various members of the transplant team, the path toward a career in transplant medicine is often poorly understood due to the wide variety of opportunities which can provide for focused training. In this month's issue of Links, attention is focused on the broad topic of training in transplant medicine; therefore, I will attempt to describe my own experience training to practice transplant pathology.

Most medical colleagues would agree that often an enlightening experience or engaging mentor initially piques our undifferentiated minds as medical students; ultimately drawing each of us down tapering roads within the heavily partitioned medical community. Indeed, this was my personal experience; one that still impacts my journey today. As a third year medical student, fixated on pursuing a future career as a surgeon, I unexpectedly happened to cross paths with Dr. Tibor Nadasdy, a nephropathologist at the Ohio State University Medical Center, during medical and transplant co-disciplinary conference. A seemingly enigmatic world of kidney disease, which, to be quite frank, I had previously thought far too complex to trouble myself with, suddenly came to life through this small-statured, lively man, with an enjoyable accent and unfathomable expertise. Given that I "grew-up" in an age of medical education in which the joy of microscopy labs and faded slides had been virtually replaced, this was my first experience being navigated about a tissue biopsy from a live patient whose clinical picture was known to me. After approximately four more weeks in nephrology and amassing a small number of encounters with Dr. Nadasdy and his clinical colleagues at the microscope, I knew I'd enjoy being a part of these tissue-based inquires in the future and I ultimately turned toward a less-well traveled road to become a pathologist.

During Pathology training I again found myself mystified and intrigued by minute differences in inflammatory pathologies, especially within the realm of medical lung, liver, and kidney disease. Trusting the persistent encouragement of my residency advisors, I applied for and was offered a fellowship in Transplant and Hepatic Pathology at the University of Pittsburgh Medical Center (UPMC). While a majority of transplant pathologists train in subspecialty areas which provide for transplant expertise in one organ system, the one-year fellowship in the Division of Transplantation and Hepatic Pathology at UPMC, in conjunction with the Starzl Transplant Institute, is unique in that it provides for comprehensive training across all pathology transplant subspecialty areas with opportunities to work hand-in-hand with leaders and pioneers in the fields of transplantation pathology, transplant surgery, cardiology, hepatology, and nephrology. The fellowship experience has far exceeded my expectations in its ability to provide mentors who motivate, encourage, and deeply care about the professional growth of those they teach. As experts, their teaching is tailored not only to standard requirements but also to resolve misconceptions and weaknesses, enhance strengths, and sponsor inquiry into realms of cutting-edge research challenging conventional boundaries within our field. To this extent, the fellowship at UPMC provides glorious opportunities for active participation in research programs including immune tolerance, antibody mediated rejection, BK virus infection, biliary and hepatocellular neoplasia, and digital imaging and multiplex labeling techniques, among others. Furthermore, fellowship trainees are expected to develop skills in critically evaluating research publications as they engage in bi-monthly fellow-led journal clubs that provide insights into the approach to scientific literature taken by experts who routinely review topical publications.

While educational opportunities during subspecialty fellowship training abound, the experience of procuring knowledge from experts in a field can often leave the learner initially perplexed. Unlike residency, fellows spend uninterrupted time inside a single subspecialty department working with a small number of expert teachers. While collectively conveying similar information in pathology reports, expert pathologists, like musicians or artists, often interpret biopsies with individual styles. A significant task as a fellow is to learn and incorporate each mentors' style while attempting to cultivate appropriate preferences of their own. This task is facilitated via semi-independent service work in which fellow responsibilities include correlating diagnoses with clinical and laboratory data, ordering and evaluating ancillary testing, and formulating informative diagnostic comments, culminating with mentored sign-out of cases. Additionally, knowledge is not simply handed down by an expert in a neatly organized filing system with categorical labels; instead, expert knowledge is gleaned throughout the year by collective experience and thoughtful comparisons that are assimilated with up-to-date research and literature reviews. At UPMC, this collective experience involves all aspects of transplantation pathology including: evaluation of native disease in transplant candidates, intra-operative donor organ consultation (frozen sections), examination of native explanted organs and evaluation of post-transplant biopsies for anatomical complications, ischemia, infection, cellular and humoral rejection, recurrent disease and post-transplant malignancies. Former graduates have uniformly gone on to careers in which they can use and master their new skills. The focus on transplantation pathology provides a unique outlook in which the similarities and differences among patients who receive transplants across different organ systems such as heart, lung, liver, intestine, kidney, pancreas, small bowel and composite transplants become apparent. As a side benefit, one develops enhanced diagnostic skills beyond a single organ system. Venturing along the less well-travelled road has deepened my understanding of disease processes beyond what I could ever imagine.

In addition to my audacious opportunity described here at UPMC, many transplant pathologists instead train in subspecialty areas including pulmonary pathology, gastrointestinal pathology, and renal pathology fellowships, of which transplant pathology is a significant component. Given that prospective trainees reading this article might have a specific interest in lung transplantation, a list of pulmonary pathology fellowship programs that provide exposure to transplant pathology are provided. In addition, contact information for the University of Pittsburgh Medical Center comprehensive Transplantation and Hepatic Pathology fellowship is also listed below.

University of California, Los Angeles
Cardiovascular Pulmonary Pathology Fellowship
Fellowship Coordinator: Annetta Pierro
Phone: (310) 825-5719 Fax: (310) 267-2058
Website: www.pathology.ucla.edu

University of Chicago
Aliya Husain, MD, Director, Pulmonary Pathology Fellowship
Department of Pathology MC 6101
University of Chicago Hospitals
5841 South Maryland Avenue
Chicago, IL 60637
Website: http://pathology.bsd.uchicago.edu/education/pulmpath.html

Johns Hopkins Pathology
Cardiovascular - Respiratory Pathology Fellowship
Program Director: Charles Steenbergen, MD, PhD
Johns Hopkins University School of Medicine
Department of Pathology, Ross 632
720 Rutland Avenue
Baltimore, MD 21205-2196
Phone: 410-502-5167
Fax: 410-502-5167
Website: http://pathology.jhu.edu/department/training/fellowinfo.cfm

Brigham & Women's Hospital
Corson Thoracic Pathology Fellowship
contact: Christopher D. Fletcher, M. D.
Department of Pathology
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115
Phone: 617 732-7530
Fax: 617 277-9015
Website: http://www.brighamandwomens.org/pathology/Medical/CorsonFellowship.aspx

University of Michigan Medical Center
Pulmonary Pathology Fellowship
Jeffrey L. Myers, M.D.
A. James French Professor and Director, Division of Anatomic Pathology
Department of Pathology
2G332, University Hospitals
1500 East Medical Center Drive
Ann Arbor, MI 48109-0054
Website: http://www.pathology.med.umich.edu/residency/fellowships.html

Mayo School of Graduate Medical Education
Pulmonary Pathology Fellowship
Inquiries to: Marie-Christine Aubry, MD
Director, Pulmonary Pathology Training Program
Department of Pathology
Hilton 11, Mayo Clinic
200 First St.
Rochester, MN 55905
Phone: (507) 293-3839
Website: http://www.mayo.edu/msgme/lm-pulmonarypath-rch.html

Memorial Sloan-Kettering Cancer Center
Thoracic Pathology Fellowship
Program Director: Bill Travis
Location: New York City, NY
Phone: 212-639-6336
Website: http://www.mskcc.org/mskcc/html/73459.cfm

University of Pittsburgh School of Medicine
Thoracic Pathology
Director: Samuel A. Yousem, MD
Department of Pathology, Room C610
200 Lothrop St.
Presbyterian University Hospital
Pittsburgh, PA 15213
Phone: (412) 647-6193
Fax: (412) 647-3399
Website: http://path.upmc.edu/fellowship/thoracic/index.htm

Transplantation and Hepatic Pathology
Director: Michael Nalesnik, MD
Department of Pathology, Room E733
3495 5th Ave.
Montefiore Hospital
Pittsburgh, PA 15213
Phone: (412) 647-7645
Fax: (412) 647-2084
Website: http://path.upmc.edu/fellowship/thoracic/index.htm

Disclosure Statement: The author has no conflicts of interest to disclose.




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