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A Promising Career

James arrived at Nomura's office 5 minutes before 8AM, and quietly placed the flats of slides next to the double-headed microscope. He separated the paperwork, turning the sheets so that Nomura could view them unhindered. The muted strains of a Chopin piano sonata cast a melancholy pall over the room.

"Well, are we ready?" A smile merged with the wrinkle lines around Nomura's mouth and disappeared around his nose.

"Yes sir! I put a very interesting case for you to review first." James maneuvered the slide and paperwork in front of Nomura.

"Let's see..." As he positioned the slide on the microscope stage, James marveled Nomura's fingers moving the slide, his observant eyes captured every subtle detail of the stained tissue before him. A previously positioned dot on the slide, pointed out the significant pathology. Nomura momentarily paused at the dot then continued his foray through the rest of the slide.

"What did you think?"

"It's a punch biopsy of skin. I dotted an area of a vascular proliferation, which resembles the promontory sign. This is a 34 year old IV drug abuser with a persistent rash on the trunk. Putting it together, I think this is the early patch stage of Kaposi's sarcoma. "

Without looking up from the scope, Nomura continued his passage. "Very good. So this patient needs blood work to rule out AIDS?" Picking up his marking pen, Nomrua proceeds to dot another area on the slide. "We need to add a second diagnosis."

As he peered at the slide through the opposite head of the microscope, Nomura's dot highlighted an enlarged cell with a characteristic blue-red inclusion within the nucleus.

"CMV!" The voices cried in unison. "I thought the history sounded strange for Kaposi's, which usually does not present with a rash," Nomura began. "There is definitely Kaposi's here in this biopsy but there is a co-infection with cytomegalovirus. It's uncommon but has been reported. I bet if we biopsied the other sites we would pick up more CMV infection than KS. The clinicians probably biopsied this site because it was larger and more atypical looking because of the Kaposi's. You were right, good case!"

James reluctantly smiled as he recalled Dan's comments, "Haas taught by intimidation and fear; Nomura taught by enhacing self-esteem." Nomura had a penchant for giving the resident credit for a diagnosis that Nomura himself made, regardless of the complexity or rarity of the case. Each signout with Nomura was an affirmation. Three hours passed in a moment.

"Good signout today, James. You're getting the big picture, putting together what you see on the slide with the clinical history. You do that better than most residents at your level."

"Thank you Dr. Nomura, " James gushed. "It seems as though everytime I get close to getting a handle on the cases, there's always something I overlooked, or some disease I didn't think of."

Nomura smiled. "There is always something you don't think of, that's why pathology is so difficult and exciting at the same time." Nomura paused, seemingly unsure whether to continue with his thought. "When I was a medical student, I took an elective in surgical pathology. I remember doing a frozen section with the residents. The diagnosis was fibromatosis. I thought I misunderstood what he said and asked him if he meant fibrosis. But no, I heard correctly, it was fibromatosis. After the case was finished, I went back to the general pathology textbook I used in medical school to look up fibromatosis. I found a paragraph on it, under the chapter heading of soft tissue tumors."

Nomura's eyes roamed his bookshelf. "I remember my medical school professor spending about 15 minutes on the entire topic of soft tissue tumors. My resident handed me an entire textbook on soft tissue tumors to read up on fibromatosis. The section on fibromatosis alone was over 30 pages long." Nomura pulled the textbook from his shelf and handed it to James.

"And that was just the start! It took me 3 hours just to read that section."

How could there be a time when Nomura was unsure of a diagnosis? James refused to believe his admission of mortality. "You know, Dr. Nomura, I thought I would never be a pathologist. I remember the first day of histology in medical school. I spent two hours attempting to identify the different layers of the stomach. I remember going home that night and telling my father, 'Well, I guess I won’t be a pathologist!'"

"Why did you continue?"

"I didn't see the big picture. When I took pathology in my second year, everything made sense. I saw how the different layers related to the disease process. I went back and relearned everything, but this time with a different purpose."

"I understand. I'm like you, I have to see the overall picture before I am willing to learn the minutia. Most pathologists shy away from dermpath, too much latin names someone once told me! When I took my fellowship, I was the only pathologist, everyone else was a dermatologist. Back then, before cosmetic surgery took hold of dermatology, dermatologists loved to do this additional fellowship so they were well equipped to read out their own slides, increase their income."

"Today most dermatopathologists are pathology trained, right?"

"Correct. So back then, the other dermatologists looked down on me, thought I couldn't see the big picture. Thought I wasn't a real doctor, " Nomura grinned.

"And that's why you did an additional dermatology residency?"

"One of the reasons. Fact is, I enjoy clinical dermatology, seeing patients. I just enjoy pushing glass a lot more."

Nomura rose from his chair, his eyes fixed on James. "You'll be fine, James. You have the makings of a promising career."

A broad grin emerged on James' face, lifting the strain. It was two weeks since his last encounter with Haas. It was two weeks since he had last smiled. Nomura had lifted the cloud of despair.

"Thank you Dr. Nomura. It was my relief."

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