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A Promising Career

Dr. Nomura is in a quiet mood this morning. James arrives at his office 5 minutes before 8AM, quietly places the flats of slides next to the double-headed microscope and separates the paperwork, carefully turning the sheets so that Nomura will be able to view them unhindered. The muted strains of piano playing a a Chopin sonata casts a melancholy pall over the room.

"Well, are we ready?" Nomura's face is pleasant, a slight smile always merging with the wrinkle lines around his mouth and disappearing around his nose.

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

"Let's see..." Nomura swiftly positions the slide on the microscope stage. James marvels at how Nomura's fingers precisely move the slide, his observant eyes capturing every subtle detail of the stained tissue before him. James had placed a dot on the slide with a marking pen, pointing out the significant pathology. Nomura momentarily pauses at the dot then continues his passage through the rest of the slide.

"What did you think?"

James begins slowly. "It is a punch biopsy of skin. I dotted an area of a vascular proliferation, which resembles the promontory sign. The history is given as 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. "

Nomura did not look up from the scope but continues his passage. "Very good. So this patient needs a test to rule out AIDS." Nomura picks up his marking pen and proceeds to dot another area on the slide. "We need to add a second diagnosis."

James peers at the slide through the other head of the microscope. Nomura's dot highlights an enlarged cell with a characteristic blue-red inclusion within the nucleus.

"CMV!". Both state the diagnosis at the same time. Nomura continues, "I thought the history sounded strange for Kaposi's, which usually does not present with a rash. 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 forces a smile at Nomura's last compliment. Nomura's method of teaching always gives the resident credit for a diagnosis that Nomura himself makes, regardless of the complexity or rarity of the case. He is revered by attendings and housestaff alike for his skill in bringing out the best qualities from each new resident. Haas teaches by intimidation and fear. Nomura teaches by enhacing self-esteem.

Dr. Masao Nomura is a surgical pathologist with subspecialty expertise in dermatopathology. For many pathologists, dermatopathology is considered a challenging subspecialty. For years, it was almost the exclusive domain of dermatologists who also wished to practice pathology by diagnosing their own cases. The language of dermatology, with it's obscure diseases and latin monikers, intimidates most physicians. Pathologists who pursue this specialty must train for at least a year in clinical dermatology while dermatologists must train for at least a year in general surgical pathology. Nomura did most of his colleagues one better. After completing his general pathology training, he completed a clinical dermatology residency program. Thus, he was quadruple board certified in anatomic and clinical pathology, clinical dermatology, and dermatopathology. His skill in synthesizing the complicated clinical presentations of dermatological diseases with the subtle histologic changes on the microscope slide is legendary. His skill in dermatopathology is unquestioned but for other pathologists, his skill as a general surgical pathologist is equally impressive. Nomura prides himself on his broad diagnostic expertise. His encyclopedic memory has impressed scores of residents.

The three hours of signout swiftly pass. "Good signout today, James. You are 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."

James is embarrassed by the compliment but eagerly receptive of the praise. "Thank you Dr. Nomura. It just seems as though everytime I get close to getting a handle on the cases, there is always something I overlooked, or some disease I didn't think of."

Nomura smiles. "There is always something you don't think of, that's why pathology is so difficult and exciting at the same time." Nomura pauses, 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 roam 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 pulls the textbook from his shelf. "And that was just the start! It took me 3 hours just to read that section."

James finds it difficult to believe that a time existed when Nomura was a student, much less unsure of a diagnosis.

"You'll be fine, James. You have the makings of a promising career."

James is startled, his mouth breaking into a broad brin. For a few minutes, his life is validated only by Nomura's praise. He quickly picks up his cases and paperwork and heads toward the door.

"Thank you Dr. Nomura. It was a good sign out." Nomura's voice still rings clearly. It is a good day.

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