EP197: In Conversation with Dr. Ronald Barr: Stories and Career Advice

Navigating Dermatopathology with Dr. Ronald Barr: An Inspiring Career Journey

In this episode of The Girl Doc Survival Guide, Christine interviews Dr. Ronald Barr, a seasoned pathologist, dermatologist, and dermatopathologist. Dr. Barr shares his intriguing journey from his time in the Navy to his pivotal mentorship with Dr. James Graham. He explores the complexities of diagnostic discordance, the evolution of dermatopathology, and offers heartfelt advice for thriving in one's career. Personal anecdotes and insights into the field make this a compelling listen for both medical professionals and enthusiasts.

00:00 Introduction and Guest Introduction

00:39 Dr. Barr's Journey into Dermatopathology

03:35 The Influence of Dr. Graham

04:50 Consistency in Diagnosis

05:30 Thoughts on Diagnostic Discordance

11:32 Advice for Thriving in Your Career

13:54 Final Thoughts and Reflections

Transcript

Christine Ko: [00:00:00] Welcome back to The Girl Doc Survival Guide. Today I'm very pleased to be with Dr. Ronald Barr, MD. Dr. Ronald Barr is a pathologist, dermatologist, and dermatopathologist who spent much of his academic career at University of California, Irvine. He has been president of the American Board of Dermatology as well as President of the American Society of Dermatopathology, and he's written many articles and chapters. Currently he's in private practice at Dermatopathology. For those who don't know, I'm pleased to say he was my first ever teacher of dermatopathology. So it's really great to be able to talk to him today. 

Ronald Barr: It's very nice to be here with Christine. Looking forward to this. 

Christine Ko: Can you first share a personal anecdote? 

Ronald Barr: Oh, yes. I'm pretty good at anecdotes. I thought maybe it would be fun to talk about how I got into dermatopathology. I spent a couple years in the Navy on the hospital ship Repose, which was stationed in Long Beach and at the Naval Hospital in Long Beach. As a general medical officer, we were also allowed to spend some of [00:01:00] our time doing some specialty work that we were interested in. So I spent half my time as a general medical officer, but half my time in pathology. At that point, actually, I ran into Dr. James Graham. He was our attending for our pathology group, the three of us, at the Naval Hospital. And it was because of Dr. Graham I got interested in dermatology as well as dermatopathology. When I completed my tour of duty, Dr. Graham offered me a dermatology residency at the University of California, Irvine. But the thing is, I told him that I wanted to complete my pathology training at the time, and then would consider dermatology after. And the reason for that, in part, was I thought that was the best way to do things if I wanted to do dermatopathology. There was no dermatopathology fellowship at the time. So he was a little bit upset that I didn't accept the dermatology position, and I kept wondering after, Did I make a mistake? 'Cause even back then, although it was easier to get into a residency at that time than it's now, it was still [00:02:00] sought after. After I completed my pathology residency, the only dermatology program that I was interested in was the one at UC Irvine with Dr. Graham. But I thought too that maybe I needed at least a little bit of a backup. Dr. Richard Stoughton, who was Chief of Dermatology at UC San Diego, who I knew from my pathology residency, said maybe he would consider it. But at no pay. I also then decided I would apply to Stanford because it seemed like a fairly decent program. In April, I was contacted by Stanford that I had been accepted to their residency program. Remember I wanted to get into the program at UC Irvine. So I went ahead and spoke to Dr. Graham, and I told him I had been accepted at Stanford. What would he recommend? He said, If I were you, I would take the position at Stanford. A bird in the hand's worth two in the bush. I was hoping that he would say, [00:03:00] Listen, I can't guarantee you anything. Why don't you take your chances, stick with me? And with a little bit of luck.... so obviously I was a little disappointed. Fortunately there were two physicians with me in the Navy. I won't mention their names. Both of them had done at least one year of their dermatology training at Stanford. The second person I spoke to said, If you take the position at Stanford, I would rent by the month. So I figured I'd pass. Fortunately, May came around and Dr. Graham contacted me, and then from there, it was history.

Christine Ko: Nice. How come UC Irvine was the only place you really wanted to go? 

Ronald Barr: I think because of Dr. Graham in particular. That was really important to me. Even when I was in the Navy, I would sneak over to Orange County Medical Center and look at study set slides when I had a chance. 

Christine Ko: Dr. Graham's study set slides. 

Ronald Barr: Yeah, absolutely.

Christine Ko: What do you think it was about him that made you want to work with him so much?

Ronald Barr: He was an [00:04:00] exciting person to deal with. You could tell he really enjoyed his work and that then becomes contagious, no question about it. It was so pleasant to work with him and do something that I really enjoyed.

I should point out that for Dr. Graham, we were under a tremendous amount of pressure taking the in-service exams. As a matter of fact, he expected us to get at least 90 percentile. I remember with one of the residents who'd gotten less than 90 percentile, I said, Gee, Dr. Graham, you're not dealing with a bell shaped curve. This is a dermatology residency. It would be like if you took a test with nine other people just like you, one person would have to turn out to be number one, and also one would have to be number 10. So when I said that, he said, Yeah, but it wouldn't be me. Okay. I give up on that one. Anyways. That's why I stuck with Dr. Graham, and I learned a lot.

Christine Ko: Okay. That's lovely. So one of the things that I know about you from doing residency at UC Irvine and seeing you read [00:05:00] dermatopathology slides. Every once in a while, there would be a case from even 10 years ago that needed to be reviewed for some reason, and you would be reviewing it without knowing what you had said whatever amount of time prior, and you would end up saying basically the same thing. You are so internally consistent.

Ronald Barr: If I'm internally consistent, it's only because, like my wife would put, it because you're extremely conservative. That's why you're still married to me. So maybe that has something to do with it too.

Christine Ko: Maybe. I wanted to ask you about your thoughts on diagnostic discordance, even if it's just within one person or from dermatopathologist to dermatopathologist. What you think about discordance.

Ronald Barr: When I first started, everything was just H&E. You can imagine what the discordance could be at that point. If you had a spindle cell proliferation, you could get a variety of of opinions. As another anecdote, Dr. Lebo, whose area of expertise was [00:06:00] pulmonary pathology. He was in fact a international expert. But those were the days that the best we had was histochemistry. I was on a panel with Dr. Juan Rosai, a internationally well-known surgical pathologist. I remember mentioning Dr. Lebo to Dr. Rosai, and Dr. Rosai said to me, Ron, he said, every lesion that Dr. Lebo described turned out to be wrong. And that was because, of course, as we got into immunohistochemistry, et cetera, et cetera, we realized that his bronchoalveolar tumor was actually an epitheloid hemangioendothelioma and so on. So it wasn't fair, really. And then, along the same lines, you could read articles, say from, I'll use the Mayo Clinic as an example. A large article, I think they called it malignant or destructive necrobiosis lipoidica. There was a huge article written about that. And then I think it was about 10 years later, they'd put together probably the same cases that were now necrobiotic [00:07:00] xanthogranuloma. And so you could follow these cases, the names changed, and in part presumably maybe we got closer to what these lesions really were as the diagnostic techniques became more sophisticated. 

Christine Ko: Yeah. 

Ronald Barr: Yeah. I'm not sure that says anything about discordance.

Christine Ko: A little bit because you're saying that sometimes discordance comes because at that moment in time you maybe can't really diagnose it accurately 'cause we don't have the diagnostic category for it.

Ronald Barr: Yeah. And I think when it came to melanocytic neoplasms, discordance often was greater than with epithelial lesions, simply because of the fact if you took, say, cervical cancer, you could do pap smears and make diagnoses on the basis of pap smears. You could make a cytological diagnosis on just scattered cells. You really could never do that with nevomelanocytic. When it came to nevomelanocytic, you couldn't use just cytology as a criteria. [00:08:00] You had to use additional criteria. And say with Dr. Ackerman, people learned to look at low power pattern, and then you had to look at a host response, and then you had to look at cytology, and so it became more complex. Because it became more complex, there was probably at times greater discordance. Maybe you had to look at a variety of different parameters to make a more definitive diagnosis.

I think today one of the problems we run into is actually overdiagnosis because of the use of PRAME. I think that becomes a significant problem, particularly with these lentigo lesions on elderly individuals like myself. We've learned now I think that almost anytime somebody biopsies these and we do, in fact, PRAME, there are often some PRAME positive cells and to go ahead and issue diagnosis of early evolving melanoma in situ, I think in many cases probably doing the patient a disservice. Maybe they are very early precursors, but I just had one of my fellow dermatologistS, Dr. Jeff [00:09:00] Klein, go ahead and freeze off a bunch of my lentiginous lesions. I made it very clear that he couldn't biopsy any of them, just simply freeze them, unless he actually saw something that he would figure would in fact kill me. I had to remind him that I was 80 years old. So he had to put that in perspective too. As a result, I didn't biopsy any of them, but I think I've seen, with our own group here, you have to be very careful with these lesions and put things in perspective, and I really wish that a lot of the dermatologists wouldn't even biopsy some of these lesions.

Going back historically with Dr. Graham, the percentage of pigmented lesions we got out of our entire, what, specimen numbers in any given time, although we were a referral center, the pigmented lesions, were a relatively small component. Now, that's no longer the case, but at that time, we would only biopsy lesions where we wanted to rule out melanoma. Now the thing is, individuals are biopsying lesions that are atypical. It's [00:10:00] very good, in terms of profitability of dermpath practices to see all these lesions. But I still really am wondering why biopsy some of these things in the first place. There's a responsibility, I think of the dermatologist, in terms of doing these things. Particularly when it comes to these pigmented lesions, it's nice to know at least how large the lesion was so we know if the biopsy we got is adequate. Is it an appropriate sampling? That becomes significant at times. 

Christine Ko: Yeah. Because also, if there's more than one thing to look at, like you were saying, cytology, but also architecture, also host response. How you weigh those things and interpret them and put it all together into one diagnosis can vary.

Ronald Barr: Yeah. After a while everything maybe just falls into place. In the beginning, you probably look at those things individually. At times the clinical becomes very important too. The head of pathology at the Naval Hospital in San Diego made it quite clear that in terms of when you come up with a final [00:11:00] diagnosis, it's important to incorporate everything you possibly can incorporate.

Christine Ko: Yeah. You used to say this when I was a resident, you would tell me, Christine, sometimes this is just gestalt. It sounds like you are saying that a lot of the diagnoses, and even your internal consistency, is because you rely on this sort of instant fast processing that is subconscious. 

Ronald Barr: I think that's correct. Absolutely. If somebody asked me to dissect why I'm doing it at that particular point in time, I think I can probably do that.

Christine Ko: Yes. Can you share any advice on thriving in your career? 

Ronald Barr: On thriving? I think the most important thing is to try, if you can, to focus on that area that's really most interesting for you, that's most enjoyable for you. And in dermatology and dermpath we're so fortunate, particularly like in dermatology 'cause there's so many different aspects of what you can do. For example, when I was at UCI, I really enjoyed much more so [00:12:00] the dermpath and also the teaching. So I think try to find something if you're lucky enough to be able to do the things that you enjoy the most. Now the thing is sometimes not that easy to do. And it depends on what environment you're in. I left the university in 2006, which I can't believe it was what, 19 years ago. When I went back to the doctor's dining room at the university, I remember some of the guys said, How does it feel now that you're no longer the professor, you're no longer this and that and stuff? And I just said, Listen guys, I feel like I did when I got out of the Navy. I feel like a free man again. I can kind of do what I wanna do. So yeah, if you're fortunate enough to be able to do what you really like, that's what I would focus on. And then I would also tell the graduating residents, don't get yourself into a financial situation where y ou have such a fancy car and a fancy house that your medical practice depends on your income. Don't get yourself into a position where that [00:13:00] determines how you practice. And it happens I think quite frequently. 

Christine Ko: Yeah. Is there anything you wish you had known earlier? 

Ronald Barr: Yeah, that's a good question. I'm not sure. Sometimes I thought maybe it would've been nicer to maybe to figure out that I wanted to go into dermatology at an earlier stage. At Johns Hopkins where I went to medical school, the only dermatology exposure that I got was when I came back from a European trip, and I had been using topical steroids on basically a jock itch. I developed a rip roaring scrotal candidiasis and was seen by Dr. George Brook, who was the head of dermatology at Johns Hopkins. And that was about my only experience. So maybe I don't know if I would've become a better doctor. I'm not sure, actually. Maybe I wouldn't have gone into a pathology residency had that been the case. But yeah, maybe if I would've started a little bit earlier. 

Christine Ko: Yeah. Do you have any final thoughts?

Ronald Barr: I never was very good at PowerPoint. Had I been better at [00:14:00] PowerPoint, maybe I would still occasionally give a lecture here and there, which I'm really somewhat reticent to do because of that. So that's something that I probably should have just tackled. It wouldn't have really hurt me to do. Got a little spoiled because I could have the residents help me out a little bit. It was an easy enough technique that I should have learned it earlier. I should have learned it, period.

Christine Ko: Thank you so much for spending time with me. This was really fun. 

Ronald Barr: Okay. I enjoyed it. I don't know if anybody will appreciate any of the things that I've said, but I love to tell stories.

Christine Ko: Yeah. Your stories are always fun to hear.