October 2009

Stephen N. Bauer, MD

Keeping our eye on the big picture

I enjoy M.C. Escher pictures, particularly those that feature tessellations—repeating closely tiled shapes that can transform visually with a shift in focus. To fellow mathematicians, Escher’s art represents applied research in the logic of space and plane geometry. For the rest of us, his pictures challenge perceptions regarding what is real and what is not.

Escher’s work has dual citizenship in the disciplines of art and mathematics, and it demonstrates the benefits of stepping outside our comfort zones. Because no computer program can duplicate the dynamic between an Escher tessellation and the mind of the viewer, his art has been described as a testament to the power of the human brain. I’m fascinated by the images that look entirely different from different points of focus. It’s amazing that we can see the big picture at one moment but only the small components the next instant. And I’m always a little surprised by how difficult it can be to shift from one perception of an image to the other. The transformation is a natural one, but we still have to make it happen.

Thinking about Escher’s tessellations might help us understand the psychology and geometry of our evolving position in the shared professional space. Certainly the landscape of medicine is shifting quickly, disturbing the comfortable symmetry of the real world as we have known it. Like Escher prints, technologies that radically alter our ideas about diagnostic and therapeutic capabilities are sure to disrupt assumptions about the big picture and our place in it.

More than 35 years ago, when I was a budding internist heading into my third year at the University of California San Francisco School of Medicine, I ran into Howard, an old friend from undergraduate years, and we got to talking about electives. Howard told me he was going to be a pathologist and he suggested that I take the pathology clerkship at San Francisco General. I was skeptical because I was sure I was going to be an internist and I hadn’t particularly enjoyed second-year pathology. In addition, the attending pathologist for the elective had been my section leader for the basic course; he had a sarcastic style that could be off-putting. Howard insisted that all great internists are trained in pathology, and besides, he said, it’s fun. I wasn’t sure about the role of pathology in my future, but a fun elective did sound nice for a change, and I signed up.

As it turned out, the professor’s sarcasm had disguised a droll sense of humor that mirrored my own. He turned out to be my favorite attending and a mentor who persuaded me to take a longer pathology elective my fourth year. Long story short, I am a pathologist today because I bumped into an old friend who made an offhand comment that I didn’t want to hear and I was fortunate enough to find a professor who inspired me. Knowing what I do now, it’s hard to imagine that I would have been as happy with career plan A. I came to pathology via the side door, and it proved to be exactly what I didn’t know I was looking for.

It’s a real blessing to be able to do what you were meant to do, and most of the pathologists I know do love their work. We who are blessed are obliged to give back, which in this context means we must actively mentor and lead. Leadership involves encouraging transformation among those colleagues who are so fully engaged in what they must do to survive today that they have not yet stepped back from the microscope to see what is just over the horizon. As for mentoring, it is incumbent upon each of us to ensure that residencies continue to draw top candidates because medical students are consistently exposed to the power, relevance, and elegance of our specialty.

Not long ago, the laboratory was its own space and most of us had relatively little direct patient contact. Today, we have opportunities to work with amazing new technologies that bring us closer and closer to our patients and clinical colleagues—a welcome development from any point of view. The decision to introduce a new technology may involve changes that challenge our traditional view of our work. These are legitimate (small picture) concerns that we need to consider from a proper (big picture) perspective.

External forces are prompting changes we might not have sought but are likely to welcome once they are in place. We might find partners at our side that have been there all along, waiting to be revealed when we make the effort to see them, prepared to work with us when we make the effort to include them. We don’t always recognize that one of the easiest ways to get closer to what you want is to listen closely to what you would rather not hear.

We can look at transformational pathology from a dozen points of view, but if we are true to our calling we will continue to focus on the big picture: what is best for our patients. If we don’t listen to what we don’t want to hear, if we fail to embrace the emerging technologies, someone else will take our place. A shortage of trained pathologists and an abundance of disruptive technologies could result in the use of artificial intelligence to fill the cognitive gap between what technology reveals and how the physician uses it. Artificial intelligence will discern patterns, but it cannot accommodate the human perspective. The importance of the pathologist in safeguarding the safety and utility of innovative technologies cannot be overstated.