Physician Q&A

20 Questions: Deborah J. Chute, MD, Pathology

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Deborah J. Chute is a staff pathologist in the Department of Anatomic Pathology at Cleveland Clinic in Ohio, as well as an assistant professor of pathology at Cleveland Clinic Lerner College of Medicine. She earned a bachelor’s degree in biology, graduating from John Carroll University in Cleveland summa cum laude (1998). She completed a student fellowship in anatomic and clinical pathology at University of Pennsylvania Department of Pathology (2001-2002). Chute received her MD from University of Pennsylvania School of Medicine (2003), then completed an anatomic pathology/clinical pathology residency at University of Virginia Department of Pathology (2003-2007). Dr. Chute completed a surgical pathology fellowship at Stanford University (2007-2008), followed by a cytopathology fellowship at University of Virginia (2008-2009).
Prior to her current employment, Dr. Chute was an associate staff pathologist at Cleveland Clinic (2009-2011). She has been published in numerous journals, including International Journal of Otolaryngology and Head and Neck Surgery, Radiation Oncology, Pathology, Head Neck Pathology, Diagnostic Cytopathology, and American Journal of Clinical Pathology. She is associate program director of the AP/CP Pathology Program at Cleveland Clinic, as well as chair of the Clinical Competency Committee for the Clinic’s Anatomic Pathology Dept. She is a member of United States and Canadian Academy of Pathology, American Society of Clinical Pathologists, American Society of Cytopathologists, North American Society of Head and Neck Pathology, Association of Pathology Chairs, American Medical Association, and ACGME Residency Review Committee for Pathology. Dr. Chute is a recent recipient of the John Beach Hazard Teaching Award for her work at Cleveland Clinic.
When did you first decide to become a physician? Why?
I always loved science; I always knew I wanted a career in this area. My three older sisters had finished college before I finished high school, so I could see the careers they had chosen. The oldest was a chemical engineer, the second was a college professor in mathematics, and the youngest (besides me) became a physical therapist. I found myself most drawn to medicine and other related careers, particularly after talking with my sister who was a physical therapist. Her stories about helping people resonated. I spent the summer after senior year of high school shadowing three different physicians in my hometown who were friends of my mom, to see what it would be like to be a physician. I shadowed a surgeon, an internist, and a pathologist, one month with each. It was exactly what I wanted to do; being someone who used science but also worked with people and helped them. No one in my family was ever a physician before, so I was very lucky to have the opportunity to learn about medicine so early. Of course, after that summer I was convinced I wanted to be a surgeon; I was absolutely sure I didn’t want to be a pathologist, because I wanted to work with people. It’s kind of ironic, now, given my final career.
How/why did you choose the medical school you attended?
Well, I was originally from Erie, PA, but I went to a small college in Cleveland on scholarship: John Carroll University. When I was applying to medical schools, my advisor suggested I apply to every Pennsylvania medical school. It was true then, and still true now; you’re most likely to get into a medical school in your home state. So I applied to the University of Pennsylvania (UPenn) in Philadelphia (along with every other school in PA, OH, and then a select few others that were in the top 10). At the time I didn’t think UPenn would be the right place for me – too ivy league. But when I went and visited it, it was everything I wanted. The campus just resonated with history, but at the same time the curriculum was very progressive. There was a lot of problem-based learning, which was still new at the time. The school was ranked in the top 10 in the country. The student body was very diverse. It just felt right. When I got the letter, I didn’t hesitate to accept.
What surprised you the most about your medical studies?
I think what I learned about myself was the most surprising. Nothing in the curriculum was ever that unbelievable, although sometimes it was scary and every medical student becomes a hypochondriac for a while. Things I discovered about myself were more surprising: I can stay awake for two days straight and still make good decisions, I can be in command of a difficult situation and keep my cool, things like that. And most importantly, that I wanted to help people, but I was in serious danger of burnout in any highly emotional service, because I couldn’t detach from the emotions of seeing people dying. That was probably the biggest reason I didn’t end up a surgeon.
Why did you decide to specialize in your field?
I wanted to be a surgeon all before and through medical school. But after a month on trauma surgery and then a month on the SICU, I was emotionally drained. As I mentioned before, I was in danger of burnout. So I did a radiology rotation. I had always known I was a very visual, hands-on person – hence surgery. Radiology really appealed to that visual side of my personality, and I had enjoyed my initial experience in it during second year. I could help people, do something I liked, and not get too emotionally tied. So I was planning to go into radiology by the end of my third year of medical school. My advisor recommended that I take a year off to do research, as radiology was extremely competitive at UPenn, and at the time I wanted to stay in Philadelphia. I discovered that UPenn had a post-sophomore fellowship in pathology (although I took it after my junior year) that was very highly regarded. It paid a good salary for the year, offered protected research time for three months, and I figured that the extra experience in pathology would be helpful for radiology. And I knew I would like it, as I had shadowed a pathologist several years before.
That year changed everything for me. I got to see what being a pathologist was really like, and I loved it. Pathology is very hands on; we cut up stuff with scalpels, which appealed to the part of me that still wanted to be a surgeon. And pathology is extremely visual, but in color instead of black and white like radiology. And finally, pathologists are the final word. Radiologists give differential diagnoses based on abnormalities on the imaging studies. Pathologists tell you what it is. So I fell in love with pathology. I spent the three months of research doing a study correlating high resolution MRI imaging of prostates with the actual maps of prostate cancer, which was cool. But it was the actual work of pathology that was the coolest. A lot of times it seemed more scientific than any other specialty. By the end of that year, I was applying for pathologist residencies.
If you had it to do all over again, would you still specialize? Explain.
I think I was lucky to find the right place for me. If I hadn’t done the year out, I’m not sure I’d be a pathologist today, but I doubt I’d be as happy. I’d probably be a radiologist. Medical students get very little exposure to pathology as a career anymore, which is really a shame. Even the exposure I got as a first and second year medical student had very little in common with what I really do as pathologist. It seems like every year the medical curriculum at our medical school drops more and more pathology experiences to make room for more “clinical” rotations. And most other physicians have little understanding of all that we do.
Has being a pathologist met your expectations?
I had better than average expectations than most medical students going into pathology, because I had actually shadowed a pathologist in private practice before college, and had done a post-sophomore year in pathology during medical school. But, yes, it’s everything I expected. I guess one of the more surprising aspects of pathology to me was the sheer variation in the type of work available for pathologists, sometimes radically different in different jobs. Pathology residencies are usually combined anatomic pathology and clinical pathology for four years. Anatomic pathology is all about surgical resection/biopsy interpretation, cytopathology, and forensics/autopsies. Clinical pathology is largely about running a laboratory (chemistry, blood bank, microbiology) and specialized testing interpretation (molecular diagnostics, etc). I am an academic head and neck surgical pathologist and cytopathologist, which means I do research, specialize in head and neck surgical resection and biopsy diagnosis, and look at Pap tests and fine needle aspiration biopsies. But I have pathologist friends who range from running parts of the Red Cross Blood Bank, to forensic medical examiners, to private practice pathologists who do a little bit of everything. I worked for two years as a local medical examiner in Virginia. Some people only sign out gastrointestinal biopsies. Others are medical directors of laboratories across health systems. So, no two pathologist jobs are exactly alike, and there is a lot of opportunity to make your career what you want to be. Although you have to learn all of it for your board exam.
What do you like most about being a pathologist?
There are many great things about being a pathologist. I incorporate a lot of science into my daily work, its very hands on, its very visual, and I get to work with a lot of other physicians in various specialties. Some people call us the “doctor’s doctor”- but I don’t particularly like that phrase, as I view myself as taking care of many patients, every day. I love looking at slides, figuring out complex anatomy in surgical resections, and answering questions through autopsies. But in the end, my favorite is that I am the person who provides the definitive diagnosis. When we do a frozen section for a surgeon in the operating room and it changes the course of the surgery, that feels pretty good. And the hours aren’t too bad, either.
I should mention that the thing I most love about my job overall is teaching; I love teaching residents, fellows, and medical students, but that isn’t very specific to pathology, so I didn’t think it would count.
What do you like least about being a pathologist?
I don’t like the fact that few physicians understand what we really do. It’s a common problem. For example, a patient may have a resection and what the slides show is equivocal. Most people think “well, its either cancer or not cancer” and sometimes the shades of grey make them think we don’t know what we are doing. My pet peeve – a surgeon sends a specimen from the operating room for frozen section, I can’t freeze it because its bone, and then he gets mad at me. Really, people! I don’t have a magical blade that can cut through bone at five micron intervals. We have to decalcify bone by leaching out the calcium in acid overnight before it can be cut. If I break the cryostat trying to cut bone, I can’t do frozen section for other surgeons in the hospital until its fixed, and someone might get hurt when the blade shatters. So when I mentor medical students, particularly ones going into surgery, I try to get them to rotate in pathology so they understand us a bit better.
There are some things in pathology that I didn’t really find appealing. Like microbiology – it just wasn’t my thing. But I was able to choose a career path and job that didn’t need that kind of work, so I love everything about what I do. Most people in pathology can do that.
What was it like finding a job in your field–what were your options and why did you decide what you did?
I didn’t have any trouble getting a job. I applied to both academic and private practice jobs after finishing fellowship, although really I knew I wanted to go into academics. I interviewed at three academic institutions, and never even interviewed for the private practice jobs because those went so well. I had three job offers, and picked the Cleveland Clinic for two reasons. The first reason was all about the place. Cleveland Clinic is prestigious, has great resources and has great people in the department (my boss is Dr. John Goldblum, author of several major textbooks, a world expert in soft tissue and gastrointestinal pathology, and a very down to earth and cool guy). Second, it was the closest to my family. Cleveland is only two hours from my parents, who are now in their 70s. They need me around more than when I was younger.
As an aside, I’ll comment on the whole “there are no jobs in pathology” stuff that is going around right now. There are definitely fewer jobs than when I was applying five years ago. This is largely because the recession forced a lot of older pathologists to put off retiring because their investments took a big hit. However, every resident from my program has gotten a good job. It just takes being a bit more flexible in the location you settle. Pretty soon, those older pathologists will have to retire, and when that happens there will be a huge glut of jobs. So in five to six years, when medical students today who go into pathology are looking for jobs, they should be golden.
Describe a typical day at work.
I arrive at work at 7:30 a.m. most days. I go through email, review any pending cases that had special stains come out overnight, and deal with any problems for the first hour. As the associate residency program director, there is usually at least one hour of meetings a day. And people stop by my office a lot to talk about things in the program. If I’m on cytology, from 9 a.m. to 4 p.m. I may be signing out Pap smears with a resident or fellow and doing clinical teaching, or going to other parts of the hospital to perform fine needle aspirations or adequacy assessments. (Adequacy assessments are when another physician performs a fine needle aspiration, and wants me to look at the slides immediately as they perform them to ensure there is adequate material for diagnosis). Every day from 4 to 5 p.m. in cytology there is a consensus meeting where pathologists look at difficult cases together. If I’m on head and neck, I spend the morning reviewing slides on surgical resections and biopsies, ordering special stains and dictating reports. Then I spend the afternoon on head and neck attending a consensus conference and reviewing cases with the resident on my service while teaching. During the day, I may also present at a head and neck tumor board, where I present the pathology to the oncologists, surgeons, and radiation oncologists and we discuss how best to treat each patient. I usually have some more cases to wrap up or problems to deal with after 5 p.m., and leave most days by 6:30 p.m.
On average: How many hours a week do you work? How many hours do you sleep per night? How much vacation do you take?
I work about 10 to 11 hours a day, so about 50 to 60 hours a week. Pathologists take call, but it’s from home. We have to come in if there is a surgery that urgently needs a frozen section or there is a rush biopsy on the weekend. I take call one weeknight per month, and three weekends a year. But I’ll admit, that is unusually low compared to most pathologists. I rarely get called in when on call.
As for sleep, I usually get seven hours minimum, and up to nine some nights. It’s rarely a problem, except if I get called in when on call. I get four weeks of vacation a year, not counting national holidays.
Do you feel that you are adequately compensated?
Definitely. The Cleveland Clinic is at the top of the pay scale for academic pathologists. I’d make more if in private practice, but I like this job better.
If you took out educational loans, is/was paying them back a strain?
I took out about $180,000 in debt for medical school. I didn’t have any from college because I was on scholarship at John Carroll University. It was hard when the three years of economic hardship deferment were over and I was still in residency and fellowship. Paying back the loans, even at the minimum payments, was hard then. But, now that I’m out of training, paying them back is easy. I have a mortgage, educational loans, and car loans, and easily have more money than I need per month to live. It might have been harder if my first academic job was at a place that paid significantly less – the Clinic pays its physicians well.
What would you say to yourself when you were beginning your medical career?
I’m pretty happy with the course of my life and career. I’m not sure I’d want to change anything. I was pretty lucky, and made some good choices. I might tell myself not to be quite so stressed out about step three (getting a job), but I doubt I’d have believed myself! I currently tell my residents not to worry so much about the job market, but I’m sure they don’t listen to me either.
What do you wish you had known when you were beginning your medical studies?
Keep yourself balanced. It’s easy to get totally stressed out in medical school, because everything is so serious. And yes, sometimes it really is serious, but many times it’s not that bad. It’s never going to change – residency, fellowship, eventually a job – they will all be hard work and have serious things going on. Learning how to keep yourself balanced and dealing with stress is essential, and if you can figure it out in medical school, you’ll be better off than if you don’t figure it out until later. I might not have come so close to burnout if I had figured that our sooner.
From your perspective, what’s the biggest problem in health care today?
The cost of health care, and delivering cost-effective quality care to people who need it. The reduction in payments by CMS and insurance companies is making a lot of hospitals go out of business. But then where will people go for quality care? A lot of pathologists are losing their practices as well, as the reimbursement for our services in the laboratory has been hit hard recently. Our health care payment system in America is pretty broken, and if we don’t fix it, it will eventually fall apart. I think that the concept of Accountable Care Organizations is a good one, but we’ll see over time if it actually contributes to better care, or becomes some meaningless red tape that makes it harder to work.
Where do you see your specialty in the future?
Pathology is always rapidly changing. In particular, the last 10 years have seen an explosion in molecular diagnostics. I think that this is going to continue to increase in the next five to 10 years, and pathologists who understand these tests are going to be at the front of this revolution. Currently some cancers respond to different chemotherapy regimens based on the mutation present; for example EGFR and ALK mutations in lung cancers, and BRAF mutations in colon cancers. This will probably also exponentially expand, and pathologists will be more involved in determining what treatment patients with cancer get.
Another big change is the revolution in whole slide imaging. Instead of pushing glass slides, perhaps in the near future we’ll be looking at scanned whole slide images from home, or from patients halfway around the world. I already look at consults from China this way. Understanding the informatics and computer systems necessary to do this type of work is another potential vanguard career in pathology.
What types of volunteer work do you do?
I mentor local college students who are pre-med in Cleveland and help them work through the applications for medical school. I don’t try to convince them to do pathology, but I do help to arrange experiences in the hospital so they get a better understanding of different physician careers. I also am a mentor for high school students who are interested in a health sciences career. The Cleveland Clinic has opportunities for high schools students to work in a laboratory and explore various professions, ranging from medical technologists to physicians. I help to bring students in and coordinate their experiences in pathology. Finally, I mentor medical students who are interested in a career in pathology, but that is less like volunteer work and more like recruiting my next generation of colleagues.
Do you have family? How do you balance work and life outside of work?
I married my husband one year ago, and have two step-kids who are 13 and 15. Figuring out how to balance work with family life is the hardest thing I’ve worked on for the past two years. Previously, if I had to work all night for some research project deadline, it was no problem. Now I try to be home for dinner every night by 7 p.m., and work from home for a few hours in the morning on the weekends before the kids get up. I always wish I had more time for my family, but I think no matter what my hours were, I’d still think that. And my hours are pretty good. It’s partly because the kids are so much older when they became part of my family, I feel like I have less time to forge a strong connection with them.
What final piece of advice do you have for students interested in pursuing a career in your specialty?
For medical students who don’t really think pathology is for them: If there is any chance you might be interested in pathology, do a rotation. Even if you don’t think you’re interested in pathology, when you are on your surgery rotation, ask to accompany a specimen to pathology to see us do a frozen section. Understanding what we do will make you a better surgeon, for sure.
For medical students who are sure they want to go into pathology: Do at least one pathology rotation, the earlier the better. I don’t even look at residency applications that don’t have a path experience listed – if your path rotation is going to be later in the interview season, put that in your application, so I know you are trying. Too many people apply to pathology as a safety program, in case they don’t get into something else. Make sure you stand out from those people. If you are looking to go to a specific program, consider doing a rotation there. Try to find a pathologist to mentor you, and work with them so they can write a good letter of recommendation. Be very proactive on your pathology rotation – ask the program director for slide sets to review, stay late for interesting conferences, ask to give a presentation on a topic, etc. I love enthusiasm. If you leave as soon as possible every day, be sure it will be noted. And I hope that you will enjoy a career in pathology as much as I do every day.
 

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