A pathologist’s reflections after visiting a zipper factory

Commentary

Edward J. Gutmann, MD, AM

June 2025—Some years back, I flew south from New England, where I work as an academic cytopathologist, to North Carolina. My destination was an academic medical center where I was to give a talk on fine-needle aspiration biopsies. On my drive from the airport, I detoured to a small city that housed a company that manufactures zippers. There, on the factory floor, I watched newly made zippers exiting from rows of heavy steel machines. I asked myself: How is that like what we do as pathologists?

During my childhood, my father, a mechanical engineer, was the chief—and only—engineer for a small zipper company in the New York metropolitan area. The company moved to North Carolina when I was in high school. It grew and, while far smaller than the largest, is now one of the major zipper companies in the world.

This was the company I visited during my academic trip, and this explains why, on an unannounced visit, the company’s president welcomed me graciously. After the greetings, I was ushered to the factory floor. There I learned that some of the machines from which products—zippers—were issuing were designed and built by my father a half-century earlier. In the words of the president, in captions to photographs (of factory workers, me, management, and machines) he took that day to commemorate my visit and later sent to me, those machines were “still running.”

Zippers are indispensable and ubiquitous. They function and are present on our slacks and dresses, our backpacks and luggage, our mattress covers, and our astronauts’ spacesuits. They are a tangible product. Moreover, good zippers last—and last (we discard our favorite jeans when the denim has worn out in the knee or rear, not typically because the original zipper failed). Since visiting the factory, I have occasionally pondered what we, as pathologists, can claim as our products. And, as a corollary, I have wondered whether any of these products, like many zippers (and the machines that produce them), might endure.

We became physicians because we wanted to care for patients.

In our unique specialty, our pathology reports manifest that care. Given their direct impact on patients, these documents are arguably our most important product. The reports result from a complex physical and cognitive process, including moving and focusing on slides, assessing cells, correlating the assessment with data in an electronic health record, formulating a diagnosis, and composing and then issuing a written document.

The significance of reports for individual patients cannot be overstated. Yet, destined to be sent from computers in our offices directly to the EHR, a pathology report, unlike a zipper, is an impalpable product. Further, reports are not necessarily durable; guidelines state that they, along with the glass slides upon which they are based, can be discarded after 10 years. A better fate awaits a good zipper on a well-made coat. Paradoxically, some current reports and slides might be used to inform machine learning algorithms that will help patients well into the future.

Our residents and fellows, whom we have patiently trained over many months or years, can be viewed as a second kind of product. Carrying the facts, pearls, and admonitions with which we have equipped them, they fan out to jobs across the country or other continents; many will be “lost to follow-up.” Yet a part of us might live on via the subset of them in academia who will impart to the next generation some of what we have taught them. Henry Adams famously affirmed this possibility in his autobiography: “A teacher affects eternity; he can never tell where his influence stops.”

Our publications are a third type of product. Our reports on clinicopathologic studies, while not garnering the publicity of a blockbuster new drug, can potentially help patients now or in the future. These papers are a mix of words and figures; to be sure, they are products far less tangible than, for example, zippers. Indeed, as journals have shifted from print to online publication, we rarely physically hold our publications in our hands. As with our reports and slides, the fate of our articles is uncertain; some will and some won’t be cited in the future. While citation indexes claim to reflect the importance of papers, the true life and effect of a paper, like that of a teacher, is unpredictable. (What a pleasant surprise it was for this author to see his very rarely cited paper about stereotypes of physicians [Gutmann EJ, et al. Mod Pathol. 1999;12(1):95–97]—published a quarter of a century ago—referenced recently in an article about artwork and pathology [Labiano T, et al. Cytopathology. 2024;35(3):432–437].)

What then might we conclude about the durability of our putative products—the reports, the trainees, the publications—which reflect, respectively, our endorsement of the classic academic triad of patient care, teaching, and research?

We could have little to show for our efforts if our reports are trashed, our trainees vanish as they span the globe, and a subset of our articles is destined to be ignored. Perhaps these possibilities should instill within us a sense of modesty about our importance. But if our reports, our trainees, and some of our publications promote the good care of patients, now or in the future, then we might take pride in our products, some of which will prove durable. Since we can’t be certain which of our specific products will be “still running” years from now, perhaps the wisest course is to try to do our best work each day—look carefully at slides, point out salient features to trainees sitting on the other side of the microscope, and be alert for those cases that merit study and publication—and not look too hard into the unknowable future. Or, as Thoreau advised, “. . . to stand on the meeting of two eternities, the past and future, which is precisely the present moment; to toe that line.”

Dr. Gutmann is in the Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, and associate professor of pathology and laboratory medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.