For this episode of Karger’s The Waiting Room Podcast, we spoke with Dr José Cândido Caldeira Xavier-Júnior, who is a pathologist focused on surgical pathology, teaching and research. Dermatopathology and cytology are his areas of interest; skin melanocytic lesions, thyroid fine needle aspiration and cervical cytology are his areas of expertise. He works at the Instituto de Patologia de Araçatuba and at Medical School of the Centro Universitário Católico UniSALESIANO Auxilium, Araçatuba, Brazil. He is also a Karger ambassador for health sciences.

Pathology is a kind of invisible field in medicine. It happens behind closed doors – in the laboratory and in the morgue. Mostly, pathologists are depicted as the ones who determine cause of death. However, this is only one side of the coin! A not so well-known fact is that pathologists are indispensable in helping clinicians to diagnose a condition and to decide on the best cure, especially in cancer.

On the role of a pathologist, Dr José Cândido Caldeira Xavier-Júnior also wrote three blog posts for The Waiting Room blog which you find here:

• The Role of a Pathologist in Diagnosis and Treatment: What Does a Pathologist Do in General?
• The Role of a Pathologist in Diagnosis and Treatment: What Does a Pathology Report Contain?
• The Role of a Pathologist in Diagnosis and Treatment: Pathology Is a Varied Medical Field

Note: The statements and opinions contained in this podcast are solely those of the speaker.

Podcast Interview

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Transcript

Welcome to The Waiting Room, Dr Xavier.

Thank you for having me, Susanne.

It’s a pleasure. So, first of all, could you please let us know why you chose pathology as your area of expertise?

It’s funny to say that, but when I started med school, I have never heard about pathology. And it happens with most of my students. But it’s funny, because just at the beginning, I was looking for something in medical science that explained the diseases and explains us how to make the diagnoses. And it’s also important, because if you want to make a good diagnosis, you should learn the human body from a biological perspective. As a machine, a so complex and fascinating machine.

So, I started to study, looking for the answers to my questions, and I found part of them in my pathology classes. And I can see, and I agree with this perspective, that pathology is the trunk of the tree that will connect the basic science, anatomy, histology, genetics, cell biology – the roots – with the clinical ones, dermatology, gastroenterology, gynecology. And it’s so nice that we have, like, this connection with the clinical specialties can be made by some specific areas of pathology. For example, dermatopathology is the part of pathology that is focused on any kind of disease that occurs on the skin – the cancer, the inflammatory, the infectious ones.

And I try, as a professor, to show my students how this specialty is important to medicine, and how it’s beautiful to try to understand the cell language, to translate it into diagnoses that influence the patient’s treatment and follow-up. And this is the reason that I decided to choose pathology as my area.

So, in other words, you just couldn’t decide what field of medicine would be the most interesting. You chose them all when you chose pathology. Is this right?

Yes, it is. This is my perspective, of course. But I try to share this with my students.

Very good. And I think they appreciate it. I would like to ask you, what does your typical workday look like?

It depends where you work, and how many jobs you work. You can work inside a hospital, or in your private laboratory. You can work as a member of a police team, and you can work as a researcher and professor also at the university. Yesterday, for example, I spent my whole morning at the university. After lunch I went to the clinic to perform FNA, fine needle aspiration procedure. It is one of the times of my workday that I spend in touch with patients. And after that I went to the laboratory and spent the whole afternoon analyzing slides.

But during my days, sometimes I spend some hours supervising my students and even studying. Because, you know, the tumor classifications are changing all the time, and I have to save time during my workday to study the new entities and the new criteria, in what I can do to make a better diagnosis. And, I’d like to say also that at the university nowadays we work with active learning. Many years ago, people spent, professors spent most of the time with theoretical lessons, like presenting slides. Nowadays, I like to stay with my students hands-on on a multi-head microscope, analyzing the slides with me. And I think this is important to show them what is our real-life job as a pathologist.

And I like also to explain what is possibly misunderstood about a pathology workday. Because some people think that it’s boring and quiet because we stay inside the office, the laboratory – that’s not true, because you are all the time analyzing different species. One slide is for a lung biopsy, the other one for a skin tumor, the other one for a gastric lesion. Then you are all the time analyzing different species, what is very exciting.

And it’s even when pathologists don’t do procedures, we don’t lose the patient’s care, because we know that each slide is a different patient, and it’s someone’s life, and we should, like, provide the better diagnosis to them. Then, we keep on all the time with the patients in our minds, because they are the focus of our job as physicians.

I like especially that you mention the patient again, because sometimes one could get the impression, well, it’s only slides, and it’s the microscope, and you’re alone in the lab. But, so I now learned that your job is really diverse and exciting, obviously. And in all you do, you have the patient in mind. And I really like that you said this at the end of your answer.

Yes, they are the focus of our job.

And now could you tell us what is your favorite aspect of pathology?

I can say a lot of things, like the ability to see beyond what the naked eye can see. It’s, like, awesome for us. And the possibility of being in touch with the cutting-edge knowledge of distinct areas is something very nice. It’s also interesting to translate the cell’s language – I would like to say the expression – and the cell’s morphology into something meaningful to treat and to guide the patient’s follow-up.

And also, the feeling that we are saving lives when we are analyzing slides. And I usually say that people sometimes don’t notice, but everyone, when you are submitted to a skin biopsy, this specimen was analyzed by a pathologist. If you go to a gynecologist and he collects the Pap smear, the pathologist will analyze them. Then pathology presents in people’s lives in many different ways, and sometimes people don’t notice.

Exactly. Sometimes you are just unseen. But you’re a very important presence, not only in the background, but also at the bedside, obviously.

Yes. Yes. We are like in a multidisciplinary team, and we are an important part to make the diagnosis, because we know that many diseases have a pathological background, and we don’t have, for example, cancer diagnoses without a pathological report.

So, you are not only a detective in a white lab coat, but you’re also a translator.

Yes, I like to say that we are translating the cell’s language into something meaningful to clinicians and surgeons to keep on treating the patients.

This is a new picture I take with me from this interview with you. Now, could you tell us what has been your most surprising discovery in a cell or in a tissue sample?

We can answer this question in different ways. For example, thinking about modern pathology, it’s quite nice when you can translate, for example, the cell’s morphology in a genetic alteration. And nowadays, we know that some specific genetic alterations transform the cell’s morphology. Then I think it’s nice when you can predict, watching out the cells, what is happening in their genes. But from my background in med school and even my experience with my students, I think it’s so touching when you see for the first time a mitosis process.

Could you please explain what mitosis is?

Mitosis is the process of cell division. And we can say that if it’s not the most important, it’s one of the most important processes in life, because you need the cell’s division since we were an egg until now. Then when you see it under the lens of the microscope, a mitosis picture, it’s something so surprising that I can see in their eyes how amazing it is, because we have heard about mitosis during high school, elementary school.

But when you see the picture, you like, becoming real, you can materialize this process, and it’s so touching when people start to say: “Oh, I am also seeing the mitosis picture!” And it is something so important that I spend part of my first classes showing them this process. Because I think to see them, like making more close to them to understand and to study this amazing process.

Okay, so they watch something new beginning, and I can understand that this is really fascinating.

Yes, it is.

So, what are your tools apart from the microscope?

I usually say that the microscope is our third hand. But nowadays it’s a little different, because you can scan the slides and you can analyze the slides on your computer. There are some hospitals in Europe, for example, the pathologists spend their workday on computers and not on microscopes. But you need this, another machine, to scan, to provide this image. And it’s quite nice because you can share your cases with people in different parts of the world.

Aside from that, I can say that our computers and tablets are quite important, because we have a lot of digital books, and you can consult them when you are in doubt, and you need to make a research, for example. And the cell phones, we use some apps. You are in touch with the other doctors in our team and they are important to discuss with them: “Oh, I am thinking about this hypothesis, what do you think about? Do you have CT image to share with me?”

Because people think that a pathological report is something black and white. And the benign and malignant, it’s not so easy sometimes, and we need to join all the pieces of this puzzle with our colleagues from other areas to – at the end – find a good diagnosis. And aside from that, when you do procedures, for example FNA, we need a syringe, needles, gloves, and other things. The pathologists’ tools are more than just a microscope.

But a microscope is the basis of everything. It starts with the microscope, but it does not end with a microscope – you need more.

Yes, you’ve got a point.

Then we come to the last question, and this is, what further developments do you expect in pathology?

The implementation of artificial intelligence, I think, will change our routine. But I don’t believe they will substitute us. They will help us to make better, faster, and more accurate diagnoses. For example, talking about mitosis. Sometimes we spend half an hour counting them in a tumor. If you have artificial intelligence helping you, you can have this result in a few seconds, and you can make the diagnosis. Then I think AI will help us in pathology to make a faster diagnosis.

So, this is a wonderful last sentence for this interview. And, in my words, it means, AI, artificial intelligence, you look at it as a friend or a helper and not as the enemy in future.

Yes, this is the point.

Okay. Thank you very much, José, and I’m looking forward to speaking with you soon about further developments, maybe.

Okay, thank you, Susanne, for having me, for such a great opportunity.

It was a pleasure.