Did you always want to be a pathologist?
I actually did. When I was a little boy, I wanted a microscope. When I was given one, I enjoyed using it so much that I said, “This is what I want to do when I grow up.”
My mom said, “Oh, I'm sorry, honey. There is no job where you just look through a microscope.” She did not know about pathology – but I chose my path and stuck to it.
What would you be if you weren’t a pathologist?
I would love to own a winery or work in the wine industry, like my father. Growing up in California, I enjoyed visiting the wine-producing areas with my family, while my dad sourced produce for his wine shop in Los Angeles. I've loved wine ever since, and could see myself as a winemaker.
What’s the one discovery that has made the biggest difference to your work?
As a liver pathologist, it has been interesting to live through the entire lifecycle of hepatitis C. When I started my career, it was unnamed and unknown – simply non-A or non-B hepatitis.
It was finally identified as hepatitis C while I was doing my residency at a large liver transplant unit. We continued to perform liver transplants, primarily for hepatitis C, for several decades.
Then a cure was found. And now, hepatitis C, which used to occupy 60 percent of my work as a pathologist, is essentially eradicated. When I tell our residents and fellows about that disease now, it's simply a history lesson. It's unbelievable.
What’s exciting you about diagnostics right now?
I'm really excited about the use of molecular techniques to diagnose medical liver diseases. Molecular techniques are well-established, powerful tools to classify tumors, but the idea of applying those techniques to the diagnosis of medical liver diseases is something that's just emerging – and it's very exciting.
I'm also a GI pathologist. We are now looking at the molecular mechanisms of inflammatory diseases in the GI tract. So molecular pathology is transforming both my fields.
Which specific techniques have been most transformative to your work?
Next-generation sequencing (NGS) and human leukocyte antigen (HLA) typing are powerful new tools for investigating drug-induced liver injury. We used to believe that drug-induced liver injury was simply an idiosyncratic reaction – that a few of the millions of patients who took a particular drug were just unlucky to have an adverse reaction to it.
Now, thanks to techniques like NGS, we understand that susceptibility for drug reactions is actually tied to the patient's DNA, and the allelic variants within it. With that knowledge, patients with an HLA allele that makes them susceptible to drug reactions can be counselled on which drugs to avoid.
The knowledge even extends beyond drugs, to substances in herbal remedies and supplements. Green tea extract is a great example. For most people it's a harmless supplement, but in the small percentage of people with a particular HLA allelic variant, green tea extract could cause liver injury. HLA typing can pick up those susceptibilities and help guide patients on what to avoid.
Aside from clinical work, what else has shaped your career?
I run a fellowship program for people pursuing academic careers in GI and liver pathology. The most interesting and exciting thing for me is working with my fellows – I've had over 35 over the years.
After completing the program, they go to academic medical centers all over the US and Canada, practicing, presenting, and becoming leaders in their fields. That's one of the reasons I really love attending meetings – I get to see them again. It's great to have the opportunity to reunite once in a while, catch up, and hang out together.
What have been the highlights of your work with the United States and Canadian Academy of Pathology (USCAP)?
I particularly value the opportunity to meet people from all over the world at the annual meetings. It's always a great opportunity to exchange views with the most powerful minds in the field.
During my year as president, I worked on trying to bring in new groups from around the world, adding the national pathology societies from countries like China, South Korea, and India. We also brought in other specialty groups, such as digital pathology organizations.
How does the current political environment affect the work of organizations like USCAP?
USCAP exists for pathologists worldwide so, naturally, we try to encourage worldwide participation. At this year's meeting, while we did have 70 countries represented, delegate numbers were limited by travel restrictions. We're now working on strategies to overcome these obstacles.
In 2028, USCAP will host the International Association of Pathology (IAP) meeting. The decision to hold the meeting in Toronto, Canada, was based on the fact that there are fewer visa restrictions for participants to travel there than to the US. Toronto is also well connected with the rest of the world in terms of air travel. So, in October 2028, hopefully we'll have every country on Earth represented at our meeting.
What have been your favorite places to visit for work, and why?
China was a particular favorite because that was an area I had never been to before. I have been lucky enough to visit various regions of China. San Sebastian, in Spain, was also an amazing location.
It's incredibly nerdy, but I think some of my favorite trips are when I go to other pathology departments as a visiting professor. I enjoy looking round the departments and meeting the residents, fellows, and attendings there. It's always cool to look at the gross room, ask how they're applying digital pathology, see their new techniques, visit their molecular lab... I love doing all that.
What gets you out of bed in the morning?
Interacting with the fellows and sharing cases with them is always great. I get a lot of consultation liver cases from around the country. They're always really cool, difficult cases, and we get work through them as a team, and try to figure them out together. It's always a great learning experience for the residents and fellows.
So that's what I like to do every day, and it's why I keep coming back.
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