Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Slide Warriors: The Secret Life of Your Lab Results
Have you ever wondered who's behind those medical lab results that guide your treatment? Meet Dr. Jeff Melnick, St. Luke's Chief of Pathology and laboratory Medical Director, who pulls back the curtain on the fascinating world of "the doctor's doctor" in this eye-opening conversation.
Dr. Melnick reveals that pathology extends far beyond the familiar forensic work popularized by crime shows. With approximately 20 subspecialties spanning anatomic pathology (tissue examination) and clinical pathology (laboratory medicine), these physicians influence nearly every aspect of modern healthcare. While forensic pathology might capture public imagination, it represents the smallest slice of this diverse field.
The technological evolution of pathology presents a fascinating paradox. Core techniques like fixing tissue in formalin and staining with H&E remain largely unchanged after a century, forming the foundation of tissue diagnosis. Yet simultaneously, the field has been revolutionized by molecular pathology and genetic testing, enabling personalized medicine approaches that target specific mutations in individual patients' tumors. This precision has transformed cancer treatment, allowing oncologists to select therapies based on a tumor's genetic profile rather than just its tissue origin.
As laboratory Medical Director, Dr. Melnick serves as an essential bridge between laboratory staff and clinical providers. He describes his role as an "ombudsman" who translates between different professional languages, ensures quality testing protocols, and helps clinicians interpret complex results. Every hospital laboratory requires this medical leadership by law, though patients rarely realize a pathologist's involvement in their routine blood work.
The conversation touches on artificial intelligence's gradual impact on pathology, the scientific breakthroughs (like heat-resistant enzymes from Yellowstone hot springs) that enable modern testing techniques, and even the infamous Theranos scandal that promised revolutionary blood testing from a single drop. Through it all, Dr. Melnick emphasizes that the ultimate purpose remains doing what's best for patients: delivering high-quality diagnostic information at exactly the right time.
Join us for this illuminating glimpse into medicine's hidden experts who guide clinical decisions from behind the microscope. Subscribe to Doc Discussions for more conversations that reveal the fascinating intersections of science, medicine, and patient care.
Hello, this is Jason Edwards and this is Doc Discussions. I'm here with my good friend and pathologist, Dr Jeff Melnick. Dr Melnick is, like I said, a pathologist, which is also known as the doctor's doctor, Jeff, welcome.
Speaker 2:Thank you very much. I'm excited to be here.
Speaker 1:Yeah, I am excited too. I think in the lunchroom you and I have always had good conversations, and so I think this will be a nice episode for everybody Super. So I was reading about pathologists and I was surprised to see that there are about 20 subspecialties of pathology. You may be less surprised by that, but everybody knows the forensic pathologist. That's a big part. But what are some other subspecialties of pathology?
Speaker 2:That's a big part, but what are some other subspecialties of pathology? So yeah, a lot of times when a layperson asks me about pathology, I tell them it's the science behind a lot of medicine. Of course it doesn't touch too much on physiology, but it touches on lots of other areas. So within what we call the anatomic pathology arena you have a lot of subspecialties by organs or organ systems.
Speaker 1:So there's dermatopathology, hematopathology.
Speaker 2:There are endocrine pathologists, gu, obgyn pathologists certainly neuropathology is its own field and pulmonary pathology. A lot of these subfields have their own separate boards. Some of them do not, but there are still like fellowship training programs. In them you get some sort of certificate but not an actual separate board. But a lot of the ones I named do have separate boards. And then within the clinical pathology area, which is sort of more the wet lab, less the tissue area, and we can talk about that more if you want, you have pathologists that will specialize in chemistry or in hematology. You have coagulation people that will focus. Certainly. Microbiology is a well-known field, transfusion medicine, which is the whole area of blood banking, and these days molecular pathology is a huge thing.
Speaker 1:I think that's one thing people might not realize is it's the pathologist who runs the lab of the hospital. It does the testing on the equipment for just your normal day-to-day blood work.
Speaker 2:Yeah, that's correct. I mean by law you have to have a medical director of a laboratory, and pathology is the field that specializes in that, and it's hard to get the right credentials. It's possible by other routes, but pathology is the most common route. Yeah, yeah, so we are sort of behind the scenes, often making a lot of decisions, either that affect testing in general or about specific patients when problems arise.
Speaker 1:Yeah, and then there's the well-known forensic pathology.
Speaker 2:Yeah, I didn't or maybe I did mention forensic pathology. It's probably the highest profile field because of TV programs like CSI and all that, but it's probably the smallest field in all of pathology. The forensic area is very, very small, very narrow niche.
Speaker 1:That people will specialize only in forensics, yeah, and they go on to become you know like, yeah, work for the city or the county and I, um, I may have told you this, but I thought at one point I wanted to become a pathologist. So I did a few rotations in pathology and forensics. Pathology was one of them and it was, I would say I had like nightmares the first two weeks and then I felt like totally comfortable with it the second two weeks. Um, but it was. It was a fascinating experience, for sure.
Speaker 2:St Louis University, right here in town, runs a program that's nationally known, that is, on stuff related to death and dying.
Speaker 1:It's primarily not pathology people that attend it, but I think it's run by the pathology department there At least it used to be and lots of people that are into being a coroner, or sometimes firemen and law enforcement, will come to this course and find out all the morbid ways people have of treating themselves themselves and their bodies you, you, you do get a a very interesting view of life that you really can't get in many other places probably police officers, you know, see this side of you, know society, but it's, it's, there's kind of no, the very few realms where you you kind of see what happens at the end of people's lives and you're're kind of told what the scenario is too around it sometimes.
Speaker 2:I agree. So I mean coroners and so forth. They often work very closely with law enforcement in terms of investigating the scene, and they'll even go to court.
Speaker 1:I remember we went to court once.
Speaker 2:They actually have first access to the body. Law enforcement can't touch or move the body. If there's I don't know the exact guidelines because, again, not my area yeah, but um, until the um, until the pathologist has given the clear, that kind of makes sense.
Speaker 1:Um, yeah, I do remember uh, working with the lawyers and the police officers to try to kind of figure out. I do remember working with the lawyers and the police officers to try to kind of figure out what's going on with the cases. And then you know you, in that job I remember you represent the victim of the crime or what it may be. You know, when you go to court you know you're not for the plaintiff or the defendant, you are advocating for the deceased. In that.
Speaker 2:Yeah, well, or the truth I was going to say. I think you're advocating for the truth as you see it, based on the facts that you uncover.
Speaker 1:Yeah.
Speaker 2:So I don't know if it's necessarily one side or the other.
Speaker 1:Yeah, it's not one side. You're nonpartisan, exactly, and so. But yeah, you know it's when you think about these things, just the breadth of medicine is, you know, pretty wide really when you look at it, especially when you I mean pathology, especially so the advent of AI, or of this, artificial intelligence. Has that made its way into pathology?
Speaker 2:Well, there's a lot of interest in AI in the pathology field, as, I think, in many areas of medicine. It's kind of limited so far, I think, in terms of what its actual impact is. We're still dealing in pathology a lot with digital pathology, which, of course, has made huge inroads in the field of radiology and has some applications in pathology, but perhaps going a lot slower than some people would have thought. I personally am not too surprised, I agree with you by the pace, but it's allowed people to do some things remotely on certain types of tissues and specimens, to get consults from afar, even international if you want, by showing images, rather than having to send slides to someone and wait for them to look at them and write you back or call you back.
Speaker 2:In terms of AI, I mean, there are a lot of possible implications. I think that a lot of the excitement is the excitement in medicine in general, which is mining the data, and a lot of the data is in the lab and so there's the possibility of mining. You know, the applications within pathology or within laboratory medicine are mining that data to look for trends or disease-specific implications that we may not have previously appreciated.
Speaker 1:Yeah, I've actually used it in my practice. I have a commercially available AI. I use Claude Sonnet, 3.5 is the version, but it's actually pretty good. I mean, it's actually pretty good you could put in. Now I actually don't diagnose very many things, but my wife has, and she's a physician as well, and you put in these symptoms and you say, give me a differential, and it'll kick out kind of all the things that you would expect, that an expert would expect, and so it's not bad and it's only going to get better, and so I think really it will be more of a co-pilot. It will be something that would assist you, but probably never take over a radiologist or a pathologist anytime soon is my best guess.
Speaker 2:Yeah Well, and one also always has to be wary of the databases on which it's trained. You know whether they have biases or blind spots.
Speaker 1:Yeah, and they do right. They will have biases, they will have blind spots.
Speaker 2:If they're reading other websites, then they're just as blind as whoever created those websites. Yeah, if they're reading literature, they're just as blind as whoever you know published that literature.
Speaker 1:So that's what one has to be wary of. Yeah, I think that, and humans have biases, so that's what one has to be wary of. You know, by 2027 or or or something like that, and so well, I guess time will tell. It's a, it's an exciting time, and hopefully we can kind of manage this technology responsibly. You and I were talking about a book and Um and um, uh with this. Um, uh, it was, uh, ishmael, is that right?
Speaker 2:That's correct. Um by Daniel Quinn Ishmael. I think it's about 20 years old or so. Yeah.
Speaker 1:Early nineties right 30 years old and I you know, if you're like me, uh, 1991 seems like it's like uh, nine years ago right In my brain. Um, but um. But it was this, so I read a summary of it and it's this book about kind of taking care of the world and technology and how that impacts the world, and I thought it was interesting and there was a little bit of tie-in. I mean there's, there's, I would say. The technological advancements in pathology have been relatively slow, probably up until the last 10 years. Right, I'm wrong as far as the molecular biology, as far as staining slides and stuff like that, but as far as like taking a slide and making a section and looking under a microscope, that hasn't changed that much.
Speaker 2:Yeah, so the basis for anatomic pathology, which is taking tissue sections, fixing them almost always in formalin, cutting very thin sections we cut usually at three microns micron being a micrometer and then staining them with H&E as the core stain. That's 80, 100-year-old technology and that's still the core for basically everything we do. And then we combine it with a lot of special stains that have been around for decades immunostaining that's been around for 20 to 30 years now, but the menu continues to grow. And then these days, combining it with a lot of genetic studies. And so the trick is you know what studies to do in what situations, you know, given that there are limited resources of money, if nothing else, the cost of the test. But yeah, so a lot of tumor diagnosis. These days we're doing genetic studies on either to properly classify the tumor or to provide either prognostic information or therapeutic guidance for the oncologist because that's the whole thrust of personalized medicine was to use therapeutic approaches that are specific to a patient's individual tumor instead of like a class of tumor.
Speaker 1:Yeah, not all breast cancers are the same.
Speaker 2:Pulmonary adenocarcinoma is too big of a category or breast cancer is much too big of a category, but rather to be able to subclassify it and even down to specific genetic mutations in a patient's own tumor that can predict either responsiveness to a certain drug or lack thereof.
Speaker 1:In the last 20 years that's been huge right.
Speaker 2:It has, you know, mushroomed in the last 20 years.
Speaker 1:I would imagine that the board study book for a pathologist has gotten like twice as thick over the past, you know couple of decades.
Speaker 2:I really don't know, but you're probably right. But I remember taking a list of like translocations on the plane to me as I flew down to Tampa to take my boards and cramming them on there. So, yeah, it's probably quite a bit larger now yeah.
Speaker 1:Yeah, I feel for the youngsters out there, and so that kind of ties in with this book. That's about technology. Ties in with this book, that's about technology and they, they kind of even, you know, go back like through the agricultural revolution, the industrial revolutions and like what humans have kind of done to the earth and and and kind of going through the philosophy of that the book is sort of.
Speaker 2:The book Ishmael is sort of a discussion between a kind of almost know-it-all teacher, who's actually a gorilla, not a human being, and a student who's very open and willing to learn and the gorilla. The teacher is broadening his perspective and opening him up to blind spots that the gorilla claims he's inherited as simply by being a human being, by being a homo sapien, and he doesn't see the world the way it is according to nature, and so it ties in a lot to the way, in his viewpoint, human beings are destroying the world and destroying the environment, and he claims that it's all going to basically come back to bite us one way or another. We're going to pay for it. Yeah, so it probably, in the scheme of things, was an early, perhaps, view of what we're doing to our environment.
Speaker 1:Yeah, you know, when I was, I read a few summaries of this. Actually, wikipedia had a nice summary of it and so I wasn't able to read the entire book, although there was a six-hour audio version on YouTube. But yeah, the and one of the lines was you may compete with other animals, but you may not wage war against them. And I thought that's you know, that's you know the agricultural revolution. You would look at fencing and cattle as they would probably consider that waging war, or the gorilla would. But I thought, you know, there's probably also this disconnect between a person's intellectual agreement after reading the book and actual practical action afterwards, meaning that you might read the book and say you know what, I agree with that philosophy and then go to McDonald's and get like a, you know a value meal.
Speaker 2:And you still don't know. You got to apply it to your own life or to your own community, and you have a local community and a national community and a global community and stuff like there. So obviously it's a lot harder to translate it into action, right yeah?
Speaker 1:Yeah, and I think we all have this cognitive dissonance where we have these beliefs, but when those beliefs are actually tested in reality, it just becomes kind of more convenient to keep doing the same old things, and everybody's, you know, does that to an extent, I agree, but it's good to at least kind of be aware of that.
Speaker 2:It is. It's an eye-opening story. The book it really is, yeah, and.
Speaker 1:I think any book that makes you kind of step back and think about something, especially something that's a blind spot, is a really cool thing. I mean to say you know what. I may have had that wrong. Or you know when your beliefs are challenged and you have kind of the maturity to change your mind. I think that can be a good thing and you've probably experienced this, as I have. As you get older and hopefully more wiser, you realize you kind of know less and the probability that you're wrong actually goes up with the more you know.
Speaker 2:Yeah, I agree, it's humbling. I think that's often what they call wisdom.
Speaker 1:Yeah, yeah.
Speaker 2:It's the humility that comes with life.
Speaker 1:Yeah, I agree, and I think it's a good thing to have some humility and realize I could be wrong my position on this. I shouldn't be so entrenched. Actually, before we started the podcast, todd our producer here, we were talking about Robert F Kennedy and one of his quotes was some people wake up in the morning and try to go to bed believing the same thing they believed in the morning, and some people are willing to change their minds. And I think it's good to be willing to listen to others and, you know, realize that you could be wrong on something.
Speaker 2:Yeah, I agree, and Ishmael the book, I mean I would recommend it. It's a very unusual style of narration or presentation because the teacher sometimes it's Socratic. I mean probably his whole philosophy could have been summarized in a few pages. I mean probably his whole philosophy could have been summarized in a few pages. But you know he's trying to make the student think about it and then you as the reader are thinking about it as you go along.
Speaker 2:Yeah, and by Socratic you mean he's asking questions to the character. He's asking questions to his student, yeah, and in a lot of ways, as you're reading the book, you're taking on the role of his student and trying to answer those questions, figuring out what he wants you to figure out. You know, thinking about what he wants you to figure out.
Speaker 1:Yeah, that's fascinating. Yeah, I think a lot of books do that, where there's kind of a central theme that you can summarize, like you said, within even a page and then it just kind of beats that, Fleshes it out. Yeah, I was going to say beats it to death, but yeah, fleshes it out is a better way to put it. So, Jeff, what is your role in the pathology department?
Speaker 2:So I'm the chief of the Department of Pathology and I also serve in the role as medical director of the laboratory. Medical director is required by law that there be a medical director and in that role there are kind of a whole number of things to do. There's the macro level in terms of running the lab, so I work very closely with our administrative director. So I don't actually deal too closely with HR issues or the financial issues, which is nice, but some medical directors in some labs might end up having to do that if people own their own lab, but not in a hospital setting like this. But I'm involved in a lot of the macro decisions like what type of equipment to buy, what types of methods should we be looking to bring in. Equipment decisions will impact what tests you can add in the future, how you can configure, what kind of specimens you will need to collect it, so how it integrates in a larger picture. I am responsible for the overall quality of the running of the lab, and that's by law and in practice. So overseeing the whole quality assurance program, which involves everything from you know daily or multiple times a day quality control what we call QC for a specific assay to all kinds of process improvement initiatives and then that kind of ties into another role.
Speaker 2:A lot of times I see myself as an ombudsman between the laboratory staff and the professional caregivers, the doctors and and other licensed caregivers in the hospital.
Speaker 2:To be someone who can translate from one set of language to the other, understand the process, understand the needs of physicians and caregivers and translate that into the way the laboratory actually functions and to try and understand, when there are problems or friction, how we can make it better. And all that has got the ultimate goal of doing what's best for the patient. So trying to optimize patient care, of course, keeping the costs in mind, what's realistic and keeping the efficiency of the process in mind as well, but ultimately making sure we do the best for the patient. So we want high quality results, we want them in a timely manner, we want them at the right time. There are certain tests that shouldn't be drawn in certain situations because it doesn't mean anything in an acute setting. It's based on, you know, a chronic thing, so a lot of coagulation risk factors, for example, for thrombosis. You don't want to draw an acute setting of a thrombosis because your whole coag system is messed up.
Speaker 1:Yeah.
Speaker 2:And so it's not the right time to draw that, on the other hand. So that would be true of a functional test, but on the other hand, if it's a genetic-based test, you can draw that at any time. Their genes aren't changing when they're thrombosing. So knowing things like that, right tests, right time, and let's see what other roles. Then there's individual interpretations or problem solving. So physicians sometimes will order a test because they read that that's the next thing they should do, and then they don't know how to interpret it. Or they got a result that's outside the simple plus minus positive, negative that they were expecting, and they don't know what it means, and so they might call me for help, guidance on interpreting it. Or they don't believe the result. So that kind of translates is there some sort of interference? So I have to learn about the patient's history, look at other lab results what was the acute setting? In order to try and find out if there's some limitation or some interference that would give a falsely elevated or falsely negative result.
Speaker 2:And then advise is there an alternative method? You know, because a lot of times I mean, people order things and there are multiple methods on how to do it. Yeah, so sometimes physicians don't even know exactly what they want. They just heard about something or read about something, but they don't know whether they need, you know, an enzyme, a measurement of the protein level or the enzymatic activity or a mutation in the gene for the enzyme? Yeah, you know.
Speaker 2:so, um it just, it has a name on it and and they just pull the trigger so, um so, helping people to decide what to do about that or how to interpret that, and sometimes, yeah, the issues and one example is I.
Speaker 1:I remember when I would do floor work, which was a long time ago, but they would draw blood and then we would say, oh, there must have been hemolysis. Like when they drew the blood some of the red blood cells were sheared, and so now you have some um, differences in potassium and things like that.
Speaker 2:That would be indicative of hemolysis or or, you know, there's some reason that the sample's not true.
Speaker 2:Or the specimen sat around too long, yeah, glucose got consumed, or it wasn't cooled properly, or the serum wasn't separated in time or, like you said, hemolysis during drawing. That's a really, really common problem and a problem we try and monitor. But like, people don't always think about the implications so they want to have a rapid point, you know, very rapid test, which means trying, may mean running it on whole blood. So point of care tests are always done on whole blood. No one's separating the serum there, you know. So one potential drawback right away is you don't have an opportunity to examine the blood for hemolysis, just a gross hemolysis. So that affects some assays and when people are running that test on the whole blood, often at the point of care, they forget about that limitation.
Speaker 1:So one thing that was in the news was this company, theranos, where Elizabeth Holmes was saying that she had this product where she could take one drop of blood and do all these tests on, and I think Perkin Elmer, a company that makes machines that test blood I may be saying the name wrong, but threw up some red flags in order. It's like there's no way this can be done and she ended up being on Harvard's board of directors and having all these huge roles and then it came out. It was all a sham. Were you following this when that happened?
Speaker 2:So I didn't follow it really closely, but I knew about it and saw headlines from time to time. It's a wonderful dream, it's a wonderful goal and maybe at some point we'll do it. I don't know if it'll be from one drop of blood, but maybe we'll be reaching to that point. But the problem they had was they cut a lot of corners on quality and they made false claims, yeah, and they didn't follow a lot of FDA regulations. They were so busy, I don't know, raising money.
Speaker 1:It was more of a sham. It was more of a sham operation, right? So that's what it turned out to be, or it seemed, yeah.
Speaker 2:Well, that's certainly what the government claimed, and she was convicted for it. So it was. But you know, we can do a lot with one drop of blood or one piece of tissue in terms of genetics. These days, we can examine for hundreds and even thousands of different mutations by amplifying the RNA or using mRNA to amplify.
Speaker 2:So, again, if you're looking for mutations in the genes, you're usually looking at DNA. But genes rearrange, you get translocations that result in a fusion gene, and that's often better looked at by doing RT-PCR instead of PCR on the RNA. So, there again, there are situations where we'll want to examine the RNAs, the RNA products, the mRNA, instead of the DNA, and so that again, that gets forgotten a lot. And if you want to do both, then that's even more and you need two drops of blood instead of one drop of blood.
Speaker 2:And then there's a lot of interest in what we call proteomics, which is like a protein fingerprint of all the proteins that are in your blood or in a tissue and you can look at fragments of proteins to see what's going on. So that's reality in the field of microbiology. But prokaryotic cells are a lot simpler than eukaryotic cells in our cells. But, yeah, we do a lot of bacterial identification now by what's called MALDI, where you basically it's a mass spectrometry technique where you fragment the proteins that are in a pure colony of that bacterium and you do mass spec on it and you get a charge and mass profiles of all the fragments and then what you do is you match it to a huge database and say okay, this one comes out to be e coli and this one comes out to be jason edwards it has a characteristic signature that, but you have to have that huge database.
Speaker 1:Yeah very cool um you have to have that huge database the one thing is I remember it was like, uh, thermos aquaticus or something like this was the the uh enzyme, uh, that they found in like these cauldrons in Yellowstone. That was this heat-resistant protein, and that's what allowed them to do reverse transcriptase PCR, and so it heats up, it cools down, it heats up, it cools down, but that enzyme stays the same. But if somebody wouldn't have discovered this bacteria in these geysers, they would have never had this enzyme to do this technology, and so it's amazing how these fields of science kind of come together.
Speaker 2:Right, and that obviously was a huge scientific breakthrough for someone to recognize that DNA polymerase or associated enzymes were heat resistant, and that they were heat resistant up to a level that would be required to denature DNA and so therefore could be used for PCR.
Speaker 1:Yeah, pretty cool. Well, Jeff. Thanks so much, buddy, it's been a pleasure.
Speaker 2:Thank you.