Letters to a Young Pathologist

Or: Things I wish someone had told me when I was in training

Rainer Maria Rilke was a Bohemian-Austrian poet whose mystical work explored the connections between art, disbelief, and the paradoxes human experience. His poetry has inspired countless other authors, from W.H. Auden’s poetry and Thomas Pynchon’s magnum opus “Gravity’s Rainbow” to modern self-help books. Besides his own poems, one of his most enduring legacies is a series of correspondences with a young aspiring poet named Franz Xaver Kappus, published in the book “Letters to a Young Poet” in 1929. While ostensibly about writing poetry and the literary life, his letters had an impact far beyond those realms. At the risk of sounding painfully earnest or mawkish, his wise words have inspired me and I hoped to share them with other young veterinarians and scientists who are earlier in their career. While some of the material below is specific to pathologists, I think that many of the ideas will resonate with a wide audience.

“Don't be too quick to draw conclusions from what happens to you; simply let it happen. Otherwise it will be too easy for you to look with blame... at your past, which naturally has a share with everything that now meets you.”

Trainees are often quick to wish things were different, to run an endless series of counterfactuals in their head.

“What if I had gotten into <idealized other school> instead of this place?”

“What if my faculty didn’t leave and we had to learn from relief/locum faculty?”

“What if I had gotten that grant funding or paper published?

Disappointments and setbacks are a part of life. They can be painful, and it’s OK to be upset when they happen. The good news is sometimes they take you in a different direction…if you’re willing to be curious and flexible.

Virginia Tech was my second-to-last internship choice. It was in a tiny town in Appalachia and when I visited ahead of applying, a lot of the interns seemed bitter and disillusioned. When I got my match results I was really bummed.

But I decided to go through it with the best attitude possible. I ended up really enjoying not only the town and hospital, but the whole internship. I made some great friends and learned from mentors who knew exactly what I needed to hear at that point in my career.

It also solidified my pivot away from clinical practice to pathology, and that ended up being a perfect fit for my interests and personality.

My career since has been a series of interesting coincidences and unique opportunities arising from circumstances I would have never predicted. My faculty mentor Pete got me in touch with an older pathologist Norm Lowes for sporadic consults. While I initially felt stressed at adding one more responsibility to my already crowded plate, it led to me taking over his company CytoVetStat when he was ill, and that in turn got me on the radar of the CSU guys who founded Lacuna Diagnostics.

Be open to the randomness of life; as Rilke says, “simply let it happen.”

“You ask whether your verses are any good. You ask me. You have asked others before this… Now (since you have said you want my advice) I beg you to stop doing that sort of thing. You are looking outside, and that is what you should most avoid right now. No one can advise or help you — no one. There is only one thing you should do. Go into yourself. Find out the reason that commands you to write; see whether it has spread its roots into the very depths of your heart.”

This is a wonderful description of the pitfalls of craving external validation. If you depend on someone else to tell you your work is good, your self esteem will always be contingent on the whims of others. You must learn to trust yourself and cultivate internal satisfaction.

Not only this, but you should seek to be process oriented, not outcome oriented.

Sometimes, you do everything right and the dog in front of you dies anyway. Sometimes your diagnostic thought process was right, but you end up getting the wrong diagnosis because of information you couldn’t have known, or just plain bad luck. You can’t let this throw you off course and change everything about how you practice.

The only North Star that should guide you is doing work that matters to you, the best you can, according to your values. If you can honestly saying you’re doing that then your work is good, regardless of what anyone else says.

“The necessary thing is after all but this; solitude, great inner solitude. Going into oneself for hours meeting no one - this one must be able to attain.”

Being any type of student is lonely business. It requires hours of reading books over and over to grasp tricky concepts. Writing papers, doing practice sets. This goes doubly for medical and graduate students. At least clinical specialists work in a hospital with lots of other people and animals they can interact with. Pathologists, on the other hand, are an introverted bunch who often spend a lot of their time in self-study in their offices and at home. (At least we don’t hide in the dark like radiologists!)

This is part of the process.

An ER doctor must be able to stay calm in the midst of triaging admissions and crashing patients. But the trade-off to paying attention to everything, everywhere, all at once, is chronic ADHD and impatience with rambling histories and minor details.

Pathology is the art of noticing minutiae.

Finding a single tiny bug in a lesion can make the difference between survival and death. One time I saved a dog from being euthanized for suspected cancer relapse when I found Anaplasma bacteria in rare neutrophils. Cultivating the ability to slowly comb through samples for those close catches requires a zen-like patience. It is not easy, but it can be learned through practice, often in solitude.

“Have patience with everything that remains unsolved in your heart. Try to love the questions themselves, like locked rooms and like books written in a foreign language. Do not now look for the answers. They cannot now be given to you because you could not live them. It is a question of experiencing everything. At present you need to live the question. Perhaps you will gradually, without even noticing it, find yourself experiencing the answer, some distant day.”

One of Rilke’s most famous quotes, this gets to the matter of how to live with uncertainty and ambiguity, which is endemic in medicine (as it is in life).

During school and your early career, you will find yourself frustrated by gaps in your knowledge and itching to learn everything about everything all at once. Vet students, interns, and residents often feel embarrassed when they don’t know an answer asked by a faculty member. They are terrified when they see an unfamiliar case they have no idea what to do with.

This is normal.

It’s OKAY not to have all the answers yet. It takes time for some concepts to make sense.

The infamous Y-shaped coagulation cascade might seem like a confusing mess of molecule names that has little real world relevance. But it will click into place when you see a dog that just ate rodenticide that has a prolonged PT, but a normal PTT.

Differentiating all of the different bizarre fungi under the microscope may seem impossible…until you work in an area where Blastomyces is common and you recognize the classic blue budding yeast in cytology from a dog with the classic chest x-ray pattern.

A related point—Sometimes your mentors won’t have the answers either!

There are so many cases in the clinic I remember that remained undiagnosed mysteries, and only now do I know what was wrong with those patients in hindsight because of research papers or conference talks that came out years later. I share these hard-won practice pearls with the new generation of trainees so they can know more than I did.

It may be hard to believe, but I promise you one day you will wake up and realize you in fact know a lot and have become the expert mentoring younger professionals.

“Be happy about your growth, in which of course you can’t take anyone with you, and be gentle with those who stay behind.”

Take the small wins! Whenever you are feeling low, remember how far you’ve come. The learning curve early in your training is exponential, and within those first months and years, you will quickly go from novice to near expert. Diseases that mystified you on day one will become second nature soon enough.

Likewise, going hand-in-hand with cultivating internal validation is remembering that everyone learns at a different pace. It’s not a competition and comparing yourself with other pathologists or trainees is bound to make you feel bad one way or the other, either feeling inferior or coming across as an arrogant know-it-all.

On that note, keep in mind that you can’t learn something for anyone else. Some people will only grow through making their own mistakes. Trying to correct them or prove them wrong when they are not in the right headspace to listen will only lead to frustration for both sides. Obviously, offer help when other people ask, but you also have to accept when they say “No thanks…” Pick your battles to maintain your sanity.

“It is good that you will soon be entering a profession that will make you independent and will put you completely on your own, in every sense... I myself consider it a very difficult and very exacting one.”

Above all, I want to leave you with this message: You will be OK.

You are entering an amazing profession that will open many doors to you. As a pathologist in a diagnostic lab you might end up helping tens of thousands of patients through reading your biopsies. You may contribute to lifesaving new drugs and medical devices in the biopharmaceutical industry. You might end up teaching the next generation of vets in universities, or some combination of all of these!

If you find yourself frustrated by where you end up initially, you can always pivot and change directions. Beyond the traditional job routes, your training in cell biology and the mechanisms of disease provide the fundamentals for a variety of even more esoteric roles if you are willing to stretch yourself. My own career has taken me through running my own small businesses, working in software product management, and now, independent science writing.

Welcome to a corner of medicine with near infinite variety and constant new challenges.

I wish you more than luck.