30,000 Consults Later: A Conversation with Andrew Rosenberg, MD, FCAP

What does it take to become a trusted expert consultant in pathology? 

In this episode, academic pathologist Edward Gutmann, MD, AM, FCAP, sits down with Andrew Rosenberg, MD, FCAP, to reflect on a career spanning approximately 30,000 bone and soft tissue pathology consultations. Together, they discuss the path to expertise, the demands of a consultation practice, and the commitment to patient care that drives Dr. Rosenberg's work.

Chapters

02:50 Choosing a Subspecialty
09:28 Becoming an Expert Consultant
15:30 The Responsibility of Being an Expert
20:18 Communicating with Patients
21:38 The Business Side of Consulting
30:01 Sharing Cases with Colleagues and Intradepartmental Consultations

Transcript

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Dr. Edward Gutmann:
I'm Dr. Edward "Eddie" Gutmann, cytopathologist at Dartmouth-Hitchcock Medical Center in New Hampshire. And we're speaking via CAP podcasts with Dr. Andrew Rosenberg, professor, University of Miami Miller School of Medicine. Happy to have the opportunity to speak with you, Dr. Rosenberg.

Dr. Andrew Rosenberg:
It's also my great pleasure to be able to speak to you and members of CAP.

Dr. Edward Gutmann:
So you're an expert in the pathology of muscles, nerves and fat, often referred to as soft tissue, and also an expert in bone pathology. And as a result of that expertise, you have a consultation service focused on bone and soft tissue pathology. So today I want to talk to you about the consultation service. Let me begin by asking you, how many consultations have you done?

Dr. Andrew Rosenberg:
Approximately 30,000.

Dr. Edward Gutmann:
Okay. And I presume that number for bone and soft tissue is about as high as for anyone in the world. Is that fair?

Dr. Andrew Rosenberg (01:14):
It's in that range. There are other soft tissue pathologists who may have some more because soft tissue neoplasms are more common than those [arising] in bone. And I think I'm viewed, even though I view myself as a bone and soft tissue pathologist, the external world, some may view that my expertise is more in the world of bone pathology. And so there are fewer bone tumors than soft tissue tumors.

Dr. Edward Gutmann:
Understood. So in an effort to make the conversation accessible to non-pathologists, I'm going to briefly describe a scenario to you. A patient has pain in his or her knee and that prompts some sort of x-ray and the x-ray shows that there's a mass at the knee and that prompts a biopsy. And so tissue is removed and sent to a laboratory. And I'm going to skip over the processing in the lab. And eventually microscopic slides are made from the biopsy and a pathologist will look at those slides under a microscope and try to make a diagnosis. That is try to explain what's going on in the knee. And you as a bone and soft tissue pathologist could be looking at those slides. And if someone wanted your opinion about what the slides show, he or she could send them to you for an expert opinion. I know I'm oversimplifying a complex process, but is that a fair sketch?

Dr. Andrew Rosenberg:
Yes. 

Dr. Edward Gutmann:
Okay. Pathologists, and I'm always trying to educate the public as you know about what pathologists do. We're sort of a hidden specialty. Pathologists are physicians, as obviously we know, who attend medical school, just like surgeons, just like internists, just like radiologists, just like anesthesiologists. Which medical school did you attend?

Dr. Andrew Rosenberg:
Temple University School of Medicine.

Dr. Edward Gutmann:
Okay. That's in Philadelphia?

Dr. Andrew Rosenberg:
It is.

Dr. Edward Gutmann:
Okay. And your degree is MD or DO?

Dr. Andrew Rosenberg:
MD.

Dr. Edward Gutmann:
Okay. And then you did your residency in pathology at Massachusetts General Hospital and I had to look up some biographical information about you to facilitate speaking with you, but I did not have to look up the fact that you did your residency at Mass General. Do you know why I did not have to look that up?

Dr. Andrew Rosenberg:
I do. And that is because you were a resident at Mass General while I was there. And that's where we first met each other and developed a professional relationship which has persisted for a number of decades.

Dr. Edward Gutmann:
Right, right. You in fact were my chief resident when I was a first year. And when I was a senior resident and chief resident, you were a junior attending. And of course, it's been great to keep in touch with you over the years. How did you come to specialize in bone and soft tissue pathology? My recollection, and again, I was there around the same time, is that unlike today, there were no fellowships in bone and soft tissue pathology. So I'm trying to understand your path from a general pathology residency such as I did to becoming an expert in a subspecialty. So did you teach yourself? You read books, you read articles? Did you have mentors? Explain the path to me.

Dr. Andrew Rosenberg:
As a medical student, my initial goal in medicine was to form a mobile traveling health unit that would travel around the world and be stationed at disaster centers. My plan was to train in internal medicine, surgery, and I wanted to do two years of pathology because I wanted to have a greater understanding of the mechanism of disease. And I thought my resources with regards to medical colleagues would be limited. So I needed to learn a lot in a variety of different fields. When I applied to residency programs, I decided I would start with either medicine, so internal medicine or pathology. So I applied to both programs. I ended up matching in pathology. One of the aspects in medical school that I really enjoyed was the interaction with patients. When I started pathology, I felt a little disappointed because I started on the autopsy service for a number of months and there was no ability to interact much with patients and with other clinicians.

So as I rotated from autopsy to surgical pathology, I saw there were greater opportunities for interactions with clinicians in other specialties. During my first year of residency, one of the senior bone and soft tissue pathologists, who was like an emeritus professor. His name was Dr. Walter Putschar, was a relatively rigid, extremely knowledgeable pathologist who ran a radiology pathology correlation conference. Many residents who rotated on that conference had negative experiences because he was rigid. The chief resident needed a solution and asked me to rotate on that surface. So I did. It opened my eyes up to the fact that it required bone and soft tissue pathology required a lot of interaction with skeletal radiologists. And as I got more deeply involved, it showed that it required a lot of interaction with orthopedic oncologic surgeons, surgical oncologists, medical oncologists and radiation oncologists. And all of that began to satisfy my need of having communication with medical colleagues in the field.

Bone and soft tissue pathology is a very complicated, difficult area and not many people are interested in it. I tend to be interested in what people are not interested. It also requires a lot of hard work with regards to gain experience. You need to see many, many cases. You need to learn the radiology and the biology of the tumors. All of that was interesting to me. So I naturally fell into a niche of complicated pathology requiring communication. And so I accepted that and I developed a deep interest and love for the field that remains today.

Dr. Edward Gutmann:
But aside from that love, how did you master it?

Dr. Andrew Rosenberg (09:33):
The full-time bone and soft tissues pathology at Mass General at the time had a lot of other responsibilities, a lot of personal responsibilities leading to them to moonlight, putting me in a position of a lot of independence for my level of training. It required me to self-learn a lot of what I had to learn. And so I would say I taught myself I was my own teacher for most of what I learned, but I certainly had guidance from other pathologists and I learned a lot from physicians in the multidisciplinary team with regards to how best to care for a patient.

Dr. Edward Gutmann:
I just want a one or two word answer to the following question. Are most of the cases that you see in consultation bone or soft tissue?

Dr. Andrew Rosenberg:
It's roughly equal.

Dr. Edward Gutmann:
Okay. And then who consults with you? And where do the cases come from? So is it other pathologists, surgeons, patients, lawyers? So who's sending you cases? And you have an international reputation, you've lectured around the world, I'm almost certain. Are most of the cases from Florida, from throughout the United States, from throughout the world? So I'm asking you a who and where question.

Dr. Andrew Rosenberg:
So I'll start with the who. The vast majority of cases, I would say maybe 85% are coming from pathologists. About 12% are coming from surgeons followed by medical oncologists, followed by patients. So the patients account for the smallest percent of direct communication of, I want you to give me an opinion. What do I have to do to get it? With regards to their location, approximately 80% from the United States, 20% from throughout the world.

Dr. Edward Gutmann:
Okay. And then very briefly, without getting into the diagnostic process, what are the logistics? The slides are sent to you maybe by FedEx. Nowadays, one can send slides electronically, slides that have been scanned in. And I presume they need to get logged in. And then what? I mean, do you look at them right away? You have a number of other duties in terms of diagnostic work and administrative work at University of Miami. So when are the cases done?

Dr. Andrew Rosenberg:
Okay. So as you mentioned, the case is received. It will include slides with or without paraffin blocks. In a number of cases, it may include a CD with radiological imaging studies. It's accessioned to the Department of Pathology at University of Miami. And I also have my own database and it's accessioned into that. Once that is done, it's received by me. My goal is to try to turn it around within several days, depending on its complexity, depending on whether ancillary studies are being done or required. And as you mentioned, I do have a number of administrative responsibilities. I do have to look at the clinical material at University of Miami. And I think more recently over the past several years, it's been frustrating because my turnaround times have gradually increased and I'm now introducing ways to modify that increase so I can still be within a time limit of several days. But sometimes it may be a week or longer.

Dr. Edward Gutmann:
And how do you communicate your... Once you've arrived at a diagnosis, how do you communicate it? Is it by phone call? Is there an official report? Is it a letter?

Dr. Andrew Rosenberg:
I would say the majority of the time it's by faxing a letter that becomes my report. And so it's a letter directed to the pathologist in which I obviously give my diagnosis. I provide a brief description of my interpretation of the morphological findings, the results of ancillary studies and my interpretation of radiological images that are included to correlate them with the pathological materials. And I also try to include a recommendation regarding therapy.

Dr. Edward Gutmann:
I want to ask you about the responsibilities associated with having and running a pathology consultation service. So you're kind of a rock star in the pathology world when you gave grand rounds, gave a talk here at Dartmouth a couple of years ago. The residents wanted to have a photograph with you. So you obviously have some celebrity status. And look, I've known you for years. You're not timid. You don't have a tiny ego. And I'm sure you enjoy that recognition. On the other hand, I infer that there are significant responsibilities in addition to the accolades, so to speak, that you received. So what are the responsibilities of maintaining that service? The burdens, maybe that's too strong a word. And I know from being in academia for a long time, when there's a difficult case shown around the department and there's a decision to send it out to an expert, we tend to know who the experts are in breast pathology, neuropathology, bone and soft tissue pathology, renal pathology and alike.

And we write a letter and we say, we would like your expert opinion. Thank you very much. And we usually don't even call the consultant and ask if they're available. So the expectation is that you're available. So that's just my insight into what the responsibilities may be, but obviously you're better suited to speak about what the responsibilities are and any burdens you feel in maintaining that service.

Dr. Andrew Rosenberg:
Well, it's certainly related to why I went into medicine to help take care of patients. So I always have that feeling of responsibility, whatever I'm doing. So when I'm at work, it's easy to be able to follow through on that responsibility by looking at the cases, giving my diagnoses and reports. The issue is that the volumes can be high and that sometimes I do commit to traveling. And so I always feel in my office, there are patients waiting to be seen, but I'm at home eating dinner, but the patients are still waiting to be seen.
So it results in I work long hours. So I am working now, and this is realistic, 12 to 16 hours, five days a week. On Saturdays and Sundays, I come in for two to six hours. When I travel, urgent cases, I ask my fellows to Zoom cases with me in which I'll review them wherever I am in the world, dictate letters and sign them out remotely. So I always am having this feeling of responsibility. I do not take much vacation time. I lose my vacation time because there's limits on what can be carried over. And even when I'm on a true vacation, I am frequently doing work in relationship to the consult service because I'm thinking there are patients in my office and here I am in Petra Jordan looking at ancient civilization, which are beautiful and remarkable, but there's still patients waiting for me to walk into the office.

So I don't want to call it a burden, but I take it as a very serious, heavy responsibility. And to some degree, the way I describe it to people, I'm in prison or I'm a prisoner of my consult service because I've accepted the responsibility and I need to follow through.
Communicating with Patients

Dr. Edward Gutmann:
I want to go back to something I asked you previously about communicating your diagnoses. You mentioned that there's a small percentage of cases that you get from patients. And you know pathologist patient communication has been an interest of mine for several decades. In fact, I interviewed you for a paper I wrote around the year 2000. How do you communicate with patients? Is it the same? I presume it's not the detailed letter that you send to other pathologists. How do you handle that?

Dr. Andrew Rosenberg:
I do send a detailed letter and I often have a phone conversation with them. So to give them an opportunity to ask me any question for me to make sure that they have a complete understanding of what I'm trying to communicate. And from time to time, the patients will actually come to Miami and review the slides with me.

Dr. Edward Gutmann:
And you feel comfortable with those encounters?

Dr. Andrew Rosenberg:
I feel very comfortable. I like it. I enjoy it and would prefer to do it rather than not do it.

Dr. Edward Gutmann:
Okay. That's great to hear. What about the business aspects of this? I think most pathology consultants are at academic medical centers. There are exceptions. And they're basically paid a salary to do diagnostic work for their medical center, to teach residents, fellows, to teach medical students. They're not being paid to have, so to speak, private consultation services. And I know from speaking to people over the years that this has created conflicts. I'm not asking you to be specific about how you worked this out at Mass General or how you're working that out at University of Miami, but do you have some general comments about this potential conflict of interest or maybe it's more accurate to say a conflict of time and energy?

Dr. Andrew Rosenberg:
Yeah, I do. I don't view it as a conflict. It's more complimentary. And I'll explain that. Yes, there is a business side because the accessioning, the handling of materials, receiving them, sending them back all requires personnel and they need to be paid. I've always advocated for my billing to be on the low side because I don't want the cost of my opinion to be an obstruction to receiving a case. So within the spectrum of invoices, I would say that I'm on the low side. And there are arrangements that I've been fortunate to have where the two institutions that I've worked, it's shared revenue. So the department takes a piece and they need to, to cover their cost of handling. And I take a piece for the time and effort that I am devoting. Academic salaries are on the low side compared to salaries of community pathology.

So it is a useful way to supplement a salary. But a very important aspect of having a consultation service is the academic use of the material. Because that material is usually extremely interesting and becomes a very important source to be included in research projects that lead to publications that help move the field forward with regards to having a greater understanding of the disease the research is focused on that leads to better treatment strategies and patient outcomes. The fact that I have the material to do research increases my publications and provides a positive incentive to me. So for academic medicine, you need to publish to be recognized by your peers to receive consults. Receiving the consults provides incentive to me with regards to modest supplementation of my salary. And it provides a resource for publications again, which are useful to me for a promotion and for helping move the field forward. So it's a win-win situation.

Dr. Edward Gutmann:
I think there's some potential additional wins that I thought of in that a residency program that has several consultants as you have at Miami could be attractive to applicants or it may help the medical center recruit better trainees. And it also may help recruit patients actually if they know that there's an expert pathologist there. Is that fair as well?

Dr. Andrew Rosenberg:
Yes. And those are important points. It also results in requests from other pathologists. I've even had orthopedic oncologists who request to come and spend varying amounts of time to sit and look at my consults as learning material because I try to maintain representative glass slides on all cases that I receive. I scan all the paperwork. I scan my letter. So an individual can take a drawer of slides, PDFs of all the paperwork so they know all the information I receive, can look at the slides, see how I interpreted it to facilitate their learning. It certainly is an important resource for bringing patients into the medical system because frequently I may get a call from a patient, "I read your letter. Who would you recommend I'd be seen by? Where should I go for the best care possible?" And that can open doors and spread the name for University of Miami or Mass General when I was there.

Dr. Edward Gutmann:
Understood. And interesting. I didn't ask you how you grew the service. How did you grow the service? I mean, you didn't put out a shingle, you didn't have Twitter, you don't have a website at which you advertise.

Dr. Andrew Rosenberg:
Okay. When I was in Boston, a young bone and soft tissue pathologist, some of the best patient care was occurring at Mass General. A lot of the surrounding hospitals, when the pathologist had a case related to bone and soft tissue, they knew that the patient would eventually or frequently come to Mass General. So I started in an organic fashion receiving cases for my opinion because the pathologist wanted a consensus on what the disease was, knowing that the patient was eventually or likely going to come to our institution. So it started that out in the very early stages. And then over time, as I began to publish, my reputation moved from local to regional to national. And as I began to publish more and more, I would get invitations from academic institutions and have the opportunities to offer courses such as in CAP and other organizations where I had greater one-to-one or one to multiple interactions with my peers. And that also became an important resource for pathologists to send me many cases.
Sharing Cases with Colleagues and Intradepartmental Consultations

Dr. Edward Gutmann:
So you're an expert and people consult with you, other pathologists, clinicians, as you said, sometimes patients. Do you ever consult with other pathologists about cases that were sent to you in consultation?

Dr. Andrew Rosenberg:
Yes, I do. I would say it's now infrequent, but I've developed the following. I've developed a weekly international bone and soft tissue Zoom conference for bone and soft tissue pathologists around the world. And where it gives an opportunity for bone and soft tissue pathologists to show a case that they're currently working up or they've already worked up and to get input. So I try to contribute to that by showing some interesting cases that I have, many of which may be consults. But to answer your question directly, do I send my case out to Doctor X, Y, or Z for their opinion? It's extremely uncommon. And the reason why is for the most difficult cases, it comes to the point of it's an opinion and I have an opinion. And I generally don't do that. If I felt I had to, I would not be reluctant to do it.

Dr. Edward Gutmann:
What about if you look at a bone biopsy and there's something abnormal, you perceive something abnormal in the marrow? Do you consult with a hematopathologist or does that never happen?

Dr. Andrew Rosenberg:
No. If it involves a field that's not in my expertise, say for instance, the differential diagnosis is lymphoma or not lymphoma. I would contact or interact with experts in my department or say it's a breast mass and the differential is sarcomatoid carcinoma versus sarcoma. In those instances, I definitely get an opinion from an expert in another field. And I will show my bone and soft tissue colleagues here at University of Miami. For instance, I have a challenging case. I have a differential. I'll look at the case with them to see what their differential is and what their thoughts are.

Dr. Edward Gutmann:
So again, to conclude, we've been talking about extramural consultations, but on a daily basis in academic departments, there are intradepartmental consultations. So for example, a few minutes ago, one of my cytopathology colleagues who's a superb diagnostician asked for my opinion on a couple of cases. And earlier in the week, I had actually asked his opinion on a couple of my cases. So those are intramural consultations. And you're co-head of anatomic pathology there at University of Miami. I think you had similar positions at Mass General. How important are intradepartmental consultations and having collegial relationships in the departments to facilitate those consultations to make sure patients get the best possible care? You've mentioned several times how important and how obligated you feel to the patient. So I'm broadening the discussion a little bit to consultations writ large and how we operate with regard to consultations in pathology and ensuring that patients get optimal care.

Dr. Andrew Rosenberg:
Yeah. I feel that sharing cases with colleagues is an essential component of optimal patient care and that it should be done very liberally in that how I guide our faculty, if the individual has any question about the interpretation, I encourage them to share the case with a colleague. And I try to set that example. I know that I recently said I rarely send a case out. I would say I rarely send a case out to another bone and soft tissue pathologist for a formal interpretation. It's very uncommon, but I frequently share my cases with my colleagues at all levels of training for their education, for my education, for the care of the patient. So again, extremely important to be done and it's extremely important to have the attitude in a department and in the individual faculty that it's expected they should be open to it.

The door should always be open. They should do it in a timely fashion and that everybody should feel free to give their interpretation, whether it's in agreement or in disagreement with other opinions. Open and free.

Dr. Edward Gutmann:
Okay, great. Great final comment. And I agree with you of course. And I think those attitudes need to be fostered, as you've said. Thanks very much for speaking with me. It was interesting conversation. And again, I hope it's of interest to other pathologists and maybe to some of our clinician colleagues and possibly even to lay people.