Juan Rosai - Transcript Summary

Juan Rosai Director, Centre for Pathology Consultations at the Centro Diagnostico Italiano, Milan;  Adjunct Professor of Pathology and Laboratory Medicine at Weill Medical College of Cornell University; and Visiting Professor of Pathology at Harvard University

Interview location:  Centro Diagnostico Italiano, Milan, Italy
Interview date
: March 12th, 2008


Key Themes: Attributes of a Pathologist, Autopsy, History of Pathology, International Perspective, Mentors and Influences, Research versus Clinical Work

 

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Section 1

  • Born in Italy in 1940.  Rosai’s family emigrated to Argentina when he was 8 years old.  His father was a plumber by trade, but the family had ambitions for their children: “the dream of every immigrant is for his sons and daughters to be doctors.”  A badly broken bone when a teenager took him to hospital for many months and kindled a fascination for medicine.
  • Decided to become a pathologist early in his medical training partly due to the influence of “a very charismatic individual – one of the best professors in the medical school.  His name was Eduardo Lascano.” He convinced Rosai that “pathology was the scientific basis of medicine” .
  • As he describes his career development he comments that throughout his professional life “many things have happened at the right moment”.  He left medical school just as Argentina instituted formal residency programmes. 
  • Rosai was one of a group of health care workers who rebelled against the inequalities of the two-tier, public versus private, system.  The minister of public health offered them the opportunity to try their approach in an empty hospital in Mar del Plata. “I have never worked with a more idealistic group of people in my life.”  Vested political interests intervened and Rosai was one of a number of people who then left to work in the USA.
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Section 2

  • After a “lucky” encounter with Dr Lauren Ackerman, who proved to be a life-long influence, he moved to St Louis, Missouri. The residency with Ackerman consolidated his interest in the clinical aspects of pathology: “I am not, and I have never been, a basic scientist looking for the fundamental mechanisms of disease.”  
  • His speciality is oncology: “Despite all the advances in molecular biology and other disciplines, the diagnosis of solid tumours today is still based in the overwhelming majority of the cases on what we see under the microscope.”
  • Discusses the effect on pathology of advances in technology, and to what extent this threatens traditional pathology.  “There is always someone predicting that tomorrow they will describe a DNA test that will put us out of business.  It hasn't happened yet, and I don't think it's going to happen any time soon.” 
  • He argues that microscopy remains the gold standard in diagnosis.  “Morphology is like a grand summary of all the genetic events that occur in a cell...  Any genetic event of any biologic significance is likely to translate into a morphologic change that one should be able to see under the microscope.”
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Section 3

  • Talks about “waste basket diagnoses”:  “The tendency of most of us if we see something is to try to put it into one of the boxes that have already been created.” A closer look can reveal new disease entities, and he describes in detail the discovery of non-malignant Rosai-Dorfman disease, previously included in the broad category of malignant reticulo-endotheliosis.
  • Gives another graphic example of where patients were saved from aggressive treatment for cancer by closer examination of specimens in which he spotted similarities.  “They looked like sarcomas, but in fact they were an exuberant reaction to the operative trauma. They were... benign reactive changes.”
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Section 4

  • This leads into a discussion of the importance of a ‘good eye’ and visual memory.  “Like playing tennis or chess, you can certainly improve...by practising and taking lessons, but if you have no inborn talent you will never be first rate.  The same is true of surgical pathology.” Rosai also emphasises the importance of imagination and courage to challenge received wisdom in making diagnoses.
  • Talks about taking over from Lauren Ackerman as editor of Surgical Pathology.  “To realise that through that book I am influencing and helping pathologists all over the world is a great source of pride and satisfaction.”
  • Discusses the complexities of making diagnoses.  “A very difficult thing in surgical pathology is to express in words the mental process you use in order to reach a diagnosis, because it works to some extent at a subconscious level.”
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Section 5

  • Outlines the history of pathology from its origins in Renaissance Italy to the present day.   Emphasises the pivotal role of Rudolph Virchow in the 1800s. “Almost single-handedly, he transformed pathology into a science – into the scientific basis of medicine.”
  • Describes how, in the early 1900s the USA became the dominant force in pathology, and how a dichotomy developed between academic pathology and “practical, clinically orientated” surgical pathology.
  • Describes his motivation for writing Guiding the Surgeon’s Hand. “The history of surgical pathology was very rich; nothing comprehensive had been written about it, and the founders of surgical pathology were fading out, so I thought that maybe somebody should record their experiences before it was too late...”
  • Discusses pathology in the medical curriculum, and the dilemma eventually faced by all those who choose to specialise in pathology: whether to follow the pure research or clinical path. “The problem is that it is very difficult to do even one well; to do both well is almost impossible.”  Rosai had a year in a basic science lab at NIH to try to resolve his own dilemma.  “I worked very hard and I liked it, but I realised that I liked surgical pathology better.”
  • The separation, however, is not watertight – he gets a lot of satisfaction from coming "up with ideas that I can transmit to [scientists] who have the means to explore them."
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Section 6

  • Explains his motivation is helping patients by making the right diagnosis, and teaching “young people to become good pathologists”.  Expresses some frustration at the lack of visibility of pathologists.  “If the surgeons were gracious enough to tell the patient, 'Our pathologist, Dr Smith, has concluded that this is…' maybe they would at least know that there is a pathologist in the hospital.” 
  • Rosai talks about the importance and pleasure of patient contact, which he found was not always welcomed in the USA, but is the custom in his current practice in Italy.  Not only do the patients appreciate it, but he finds that “they often provide me with information that the clinician has not given me and which is important for the interpretation of the slides”.
  • He describes in detail some of his most memorable cases, mostly new entities such as Rosai-Dorfman  and desmoplastic small cell tumour. Describes how, in identifying a new entity, both scientists and clinicians have a part to play.  Although molecular biology is crucial to the final analysis, the starting point is often the pathologist’s observations.  “You start with the morphology. You give them the clue.”
  • Recalls with affection Lauren Ackerman, one of pathology’s great characters.
  • In Rosai’s view the pathologist should do more than simply provide a diagnosis. “I think that it's our responsibility to provide the surgeons and oncologists with general information that we have learnt from previous cases of the same disease.”  Not all surgeons and oncologists agree!


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Section 7

  • Returning to the Renaissance, he explains that contrary to popular belief autopsies were standard practice.
  • Acknowledges that pathology has been a consuming passion, and expresses some regret at not spending more time with his family when young. Talks about his outside interests – predominantly literature which he can read in three languages.  Talks of his lifelong love of Italian poetry, and desire to return eventually to his homeland.  “I was warned over the years by many people, including my wife, that the picture I had of Italy was not real, that it was a nostalgic vision.  And they were right to some extent.” 
  • Nevertheless, he has few regrets about returning to Italy, although expresses frustration at the extent to which “political and social considerations [touch] every aspect of professional life”.  
  • Touches briefly on high and low points in his career – the latter being where he found himself “fighting the establishment” to get things done.
  • Ends by stressing the enduring interest of his profession.  “You never get bored. It almost seems like the variety of diseases is infinite.”

 

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