Inside Molecular Pathology With an MD/PHD

Session 200

Dr. Vera Paulson is a molecular pathologist and an MD/Ph.D. Find out why she chose a dual degree and what makes molecular pathology such a rewarding subspecialty. For more information about this specialty, check out the Association for Molecular Pathology.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:44] Interest in Molecular Pathology

Seeing her mom was sick with breast cancer at an early age, she knew she was interested in curing cancer. But it wasn’t until her high school biology class teacher told her to become a genetics major in college that it all made sense to her. And then began a mentor relationship with her teacher.

As a freshman in college, she kept in touch with her professor and he even slid MD/Ph.D. applications under the door of the lab where she worked in during undergrad. She remembers putting them back under his door because she only wanted to be a Ph.D., not an MD/Ph.D.

The last time he slid one under the door, he sent it under with the story of Gleevec. It’s this whole bench to bedside and how we could find this targetable alteration and virtually cure cancer with a pill a day. He also assured her that she’s not taking any of the classes that are going to be on the MCAT. So she shouldn’t get disappointed if she didn’t score well and to just go for it and apply blindly. And that’s what she did.

Throughout her work in the Ph.D. lab, she was working with pediatric oncologists and molecular pathology people in pediatric path and she loved it.

Eventually, she chose her residency based on the fact that they had a pediatric path fellowship and a molecular fellowship. And that’s what she gets to do now seeing tumors and sometimes helping them with the diagnosis.

'People aren't exposed to molecular very much depending on where they do their med school and residency.'Click To Tweet

In many schools, people aren’t exposed to molecular pathology very much. That’s why Vera started a training curriculum for all of their residents coming through where they’ve created 10 cases that start out with the very basic things.

The last diagnosis is for them to understand that sometimes you’re not given the right information. And so, they would already know how to correlate what they see on the slide and what they’re seeing in the DNA level.

[05:55] What is Molecular Pathology?

'Molecular pathology can mean a lot of different things and it depends on where you train. It's basically this idea that you're looking at the nucleic acids.'Click To Tweet

Molecular Pathology is the study of diseases looking at the molecular building blocks. It can be the DNA or RNA, germline, somatic, or microbial.

[07:54] Finding Her Fit in Molecular Pathology

Vera says she knew she liked molecular but she felt she didn’t really understand it to a degree. Then she did the anatomic quality training thinking she could use it. Then she did the peds path thinking she’d have to use it. And so, she felt it was almost like a sunk cost fallacy. The first job she took, she didn’t last four months and decided it really wasn’t for her.

Then she realized that what she loved about the peds path on the anatomic side was how much of it had to do with genetics.

It was the correlation and understanding that she didn’t have to memorize all these disparate symptoms and signs of the syndrome. And she could look at something and identify mutations and their consequences. Ultimately, she thinks you will just know what fits you when you hit it.

The bottom line is choosing between being the person walking into the room and delivering the horrible news about cancer. Or being the person who finds the targets that would change how they treat patients. And for Vera, she preferred the latter.

Vera also emphasizes the need to ask questions to people who are authorities in their field and learn from it.

[10:55] Traits that Make a Great Molecular Pathologist

Vera says you have to be extremely detail-oriented and thoughtful about the data you’re reviewing and the databases you’re using. Understand who’s able to put what data into that.

“Understand all of the things that can impact the tests performed, and be highly suspicious when you don't find things.” Click To Tweet

There also has to be a great level of tenacity. For instance, Vera would have cases wherein the hit rate is really good. But she intuitively feels something is missing because she knows what should be found. So she tries to pursue other avenues and relentlessly go through all the databases.

And that one case can take her a week or more to sort out. And if she doesn’t have an answer, she would hang on to it and pursue it or come back to it.

[12:47] Degree of Patient Interaction and Admin Stuff

Vera says they occasionally get emails from patients where they’re asking more questions about their data. But a lot of that interface is through genetic counselors, and through the oncologist asking for more information.

“Generally, we’re referred to as the doctor’s doctor.”Click To Tweet

On rare instances, they’ve actually had people who also specialized in molecular asking questions about their molecular data. But generally, they’re referred to as the doctor’s doctor. They are the consultants for a lot of other people.

Admin-wise, they have a lot of it as well. It never ends.

[14:35] Typical Day

Vera describes her typical day as a little bit of everything ranging from germline to cancer testing and tissue selection. And so, she gets to use her anatomic skills. She could also be working on research papers and putting together things for teaching.

She may also come in at night and look at all the cases, circling the tissue on the slides that they’re going to test somatically that comes out. The she would sign out her cases. If she’s on germline service, she looks at things like cystic fibrosis or pregnancy screenings to see what’s going on. So she never has a standard schedule.

[15:28] Taking Calls

Taking calls doesn’t exist for them. Residents will call them if they have a genetics question. But there’s not in the traditional sense where they would have to worry about someone phoning her up at two in the morning and asking for a result or how to send a test.

[17:40] Training Path

Vera’s training path was the MD and Ph.D. route followed by a pathology residency. She chose to get out a little bit quicker because she already had a longer path. She did three years of residency, one year of pediatric pathology fellowship, and another year of molecular fellowship. Then she finally got a job at 35.

Other people that come through the Ph.D. route get jobs when they’re 30. And so, there’s a quicker route, but it depends on what you want to do.

Vera adds they collaborate across degrees. She may ask her Ph.D. colleagues to look at things or her other MD, and MD/Ph.D. colleagues. They have consensus conference at least once a week. They look at the data and ask each other questions because everyone has nations of knowledge that can save time.

[18:58] Is a PhD Necessary?

As alluded to earlier that there’s a different set of knowledge involved, Vera thinks you can learn it over time.

For someone to come in on the genetic side, she has seen people who have come through as an MD only. But they haven’t been exposed to molecular in the program or done a research project so they don’t know the language.

And so, for her the Ph.D. made it easier for her. Although an MD or DO only is totally doable.

[20:10] Life Outside of the Hospital

Vera makes sure she prioritizes having some downtime. She loves teaching so much that she keeps volunteering to do all these different teaching things. And she winds up lecturing in five or six different classes, hitting at the same time.

And one of the big reasons she moved from Texas to Boston was that she was looking for work life balance.

[21:03] Opportunities for Subspecialty

Vera has niche knowledge and she subspecializes, seeing virtually all pedia molecular. They also have one person who is the authority on all things prostate cancer.

'There's definitely a niche. But we also have to know all the backgrounds too.'Click To Tweet

[22:14] Message to Future Primary Care Doctors

Vera talks about the importance of the timing of things. And she hopes primary care physicians understand that it’s a long process for a biopsy and that histories are helpful. In fact, they have genetic counselors that go into the medical record to collect all that information.

[24:34] What She Wished She Knew

Vera alluded to sunk cost fallacy she mentioned earlier. Her advice is to pick what’s right for you and don’t stay in something if you’re not loving it.

'Do something you love and if it's not for you, don't be afraid to leave. You haven't lost anything, you'll only lose more time by staying in something that maybe it's not quite the right fit.'Click To Tweet

[25:47] The Most and Least Liked Things

Vera loves being able to figure something out and put together all the pieces of the puzzle. It’s a great feeling especially if she figures out a particular treatment for a certain cancer for example.

On the flip side, she doesn’t like the idea of having to think about billing and insurance. for things that are standard of care. And it’s frustrating.

[27:27] Future Major Changes Coming to the Field

There are currently ultra rapid PCR tests, which has cut down the turnaround time from several hours to only 20-30 minutes.

They’re also taking blood and looking for tumor DNA and do a testing for that. That being said, a drop of blood is such a small amount of DNA, and she doesn’t think we’re going to get that for diagnosing tumor for a while.

[28:53] Final Words of Wisdom

If she had to do it all over again, Vera would still be a molecular pathologist being the right fit for her.

Finally, she wishes to tell students that if they’re still in college, take some genetics to see if you really like pathways. And if they’re thinking mutations, see if they can shadow somebody.

When they’re in med school, they can also do rotations through clinical and away rotations that can give them more exposure to molecular. Otherwise, they’re really not going to get that access so they have to be actively seeking it.