Dr LeBoit is a professor of pathology and dermatology at the University of California, San Francisco (UCSF), where he has been a full-time faculty member since 1985. He founded the UCSF Dermatopathology Service in 1987, which he currently co-directs with Dr Timothy McCalmont. He has served as editor in chief of the American Journal of Dermatopathology, as president of the International Society of Dermatopathology, and as a co-editor of Seminars in Cutaneous Medicine and Surgery.
Years in profession: 34
Skin specialties: Dermatopathology
Awards and honors: Ackerman Award from the International Society of Dermatopathology; Founder’s Award, Herman Pinkus Award, and Walter R. Nickel Award from the American Society of Dermatopathology; Neil Smith Award from the British Society of Dermatopathology; and honorary lifetime memberships to the British Society of Dermatopathology and Mexican Academy of Dermatology
Education: Sarah Lawrence College; Albany Medical College; UCSF; and Mount Sinai School of Medicine (pathology residency), New York University and Cornell-New York Hospital (dermatopathology)
Q. Which patient had the most effect on your work and why?
A. It was likely a young woman who presented at the San Francisco Dermatologic Society in 1984, who had lax, pendulous, erythematous, and scaling skin in her axillae and groins due to granulomatous slack skin. I proposed the diagnosis, which was not widely heard of at the time, and did some investigative work to establish that it was a lymphoma. She clearly had suffered immense damage from the condition. Working on the puzzle that her condition posed seemed significant, and the recognition from doing so gave me confidence that I had the right stuff to have a future in the field.
Q. What is the best piece of advice you have received and from whom?
A. Dr Bernie Ackerman told his students to present themselves in their written work and lectures knowing that their audience, whether pathologists or dermatologists, were visually oriented people. This meant one of the first slides needed to be an image and that you should never show too many text slides in a row. It also meant that your images had to be in focus, the color had to be vibrant, the background white, and the subject properly framed.
On a more profound level, Dr Wallace Clark was fond of saying that “a diagnosis is an intellectual catastrophe.” This still resonates with me. Once you pigeonhole something, you stop thinking about it. There are pragmatic reasons for reductive diagnoses, but it is important to realize that not all patients have a condition that fits neatly into a diagnosis and not all conditions fit neatly into our current paradigms.
Q. What is the greatest political danger in the field of dermatology?
A. Commoditization. Not just dermatologists and dermatopathologists, but any physician in the United States has to be concerned that their craft is being reduced to interchangeable “units of service.” In the past, this was true for billing purposes, but the logical conclusion seems to be that these units can be packaged, bought, and sold (or at least the people who generate them can). One manifestation of this is venture capital-backed dermatology groups. I well understand the impetus that dermatologists have to group together to be able to push back against payors. The problem comes in the trade-off; in return for realizing the equity in a practice, a dermatologist obligates themselves to refer to a certain dermatologic surgeon or dermatopathologist. Sometimes, great; sometimes “good enough.” When the group is controlled by investors, the impetus to find the best people for these roles can be blunted. As with most human organizations, there are well-run group practices that continually contribute to advancing the field and there are poorly run ones. The incentives can be badly aligned. When the music stops, and the venture capitalists sell, my guess is that the value placed by their successors on superb clinical dermatology and dermatopathology will be very, very low.
Q. Which medical figure in history would you want to have a drink with and why?
A. It would be interesting to see how Dr Howard Temin’s mind worked. He steadfastly maintained positions contrary to most of the virologists of his time, which proved to be right, and was an activist outside of the laboratory.
Q. What part of your work gives you the most pleasure?
A. The most pleasurable parts of my work are twofold. One is watching someone I’ve trained do something that I never could have done and realizing that I played a small part in it. Some of our dermatopathology fellows and visiting fellows have made huge contributions in molecular diagnostics, the understanding of melanoma, or even in the clinical treatment of melanoma and lymphoma. Listening to them and recognizing something you taught them many years before is a kick.
Another is in finding something new. If you alighted in the world of dermatopathology in the mid-20th century, you could have been the first to describe poroma, Grover’s disease, deep penetrating nevus, pigmented spindle cell nevus, linear IgA disease—all things we take for granted now. It’s increasingly hard to find a new inflammatory skin disease or tumor, but they are out there, just as it’s difficult to claim a first ascent of a new peak. I have a few of these that I’m working on.
Q. Are an understanding and appreciation of the humanities important in dermatology and why?
A. An appreciation of history, of literature, and of art can definitely make one a better dermatologist. This has in part been the case as it has been difficult to quantify many aspects of dermatologic disease, so there are advantages to being a “dermatophilosopher.” One of my mentors, Dr Ackerman, was a sort of dermatophilosopher-king. Sadly, many of his most elaborately reasoned positions turned out to be entirely misguided!
A knowledge of history is profoundly important to being the best dermatologist or dermatopathologist one can be. If you read the first descriptions of many conditions, such as Darier’s disease (which Dr Ackerman thought was an infection due to “psorosperms”) or Spitz nevus (termed melanoma of childhood by Dr Sophie Spitz, who thought that the only microscopic feature that distinguished the condition from adult melanoma was the presence of giant cells), you realize that the best and brightest among us have ideas that are reasonable by the standards of our times, but these ideas will appear ridiculous to future generations. Perhaps as our literature becomes more scientific and less literary, this will change, but I doubt it. In 20 years, the robots (who will be the dermatologists of the future) will bust rivets laughing at some of the things even our molecular studies claim to show.
A knowledge of literature is greatly advantageous in dermatology. Because so much about dermatology is opinion (to wit, is pityriasis lichenoides related to lymphomatoid papulosis?), the ability to present ideas clearly is valuable. Just as the best novelists flesh out minor characters (giving them a backstory, putting texture into describing them), a good clinical or microscopic description finds nuance in the variegated hues of a lesion or in the shape of mounds of parakeratosis. Additionally, so much medical writing is woeful. If you can write with the least degree of sophistication, your colleagues will think that you’re Proust!
Lastly, an appreciation of art can make one a better dermatologist or dermatopathologist. Finding details in a painting, in a clinical lesion, or in a slide is the same skin. Recognizing that a painting you’ve not seen before is by the same artist as another piece is similar to seeing a patient or a slide with a different presentation of the same disease. It’s no accident that so many dermatologists and dermatopathologists have some background in art or have artists in their lineage. My father was an artist, as was Dr Lorenzo Cerroni’s grandfather, and Dr Steve Billings’s daughter.
Q. What is your greatest regret?
A. My greatest regrets are personal, not specifically professional. They are profound, and I’ll leave it at that. But in terms of my professional life, one of my greatest regrets is not coming to terms with my optimism bias sooner. Not learning how to say “no” and, as a result, engaging in too many projects has resulted in getting very little done and disappointed many people. Another regret is that I did not spend more time with some people who have passed from the field; Dr Richard Winkelmann, Dr Richard Reed, Dr Wallace Clark, Dr Wally Burgdorf, and Dr Terry Headington were all very different dermatopathologists, who I knew socially from meetings. I never actually got a chance to see them at work. You can learn a lot from watching someone approach a difficult case, talk to a clinician, or to a patient. One of my most gratifying memories is spending Dr Neil Smith’s last day in the cutaneous lymphoma clinic with him. Dr Smith was a dermatologist-dermatopathologist at St. John’s in London, England. He was about to go in for an operation on his mitral valve, but he did not survive the hospitalization. There was a tiny fan at the end of the hallway, and it was a sweltering day. The compassion and attention to detail that he brought to his patients, despite the physical toll, was a standard I think about decades later. n
Q. Who was your hero/mentor and why?
A. There are no perfect people, but flawed people can do exemplary things, and I’m happy to name some.
Dr N. Scott McNutt, who mentored me during the second half of my dermpath fellowship, set an example for taking an interest in a trainee’s development. He showed a good deal more faith in my abilities than I probably deserved at the time. Many people give lip service to the importance of trainees in their life, but Scott walked the walk.
Dr Ackerman, who was justifiably dismissive of my abilities during the first half of my fellowship (but later helped me in countless ways) exemplified complete devotion to his métier. On the one hand, he realized that dermatopathology is a flea-speck in the cosmos of human activity, but on the other, he viewed the importance of giving one’s all as supremely significant. He was an extraordinarily complicated person: meticulously perceptive, fantastically interested in others, and supremely narcissistic.
The late Dr Burgdorf stands out for his candor. Wally had great respect for people who disagreed with him, but was happy to call out, in the most public way, people who were faking it. He had encyclopedic knowledge of dermatology and dermatopathology, but no chip on his shoulder. If you pointed out a flaw in his thinking, he seemed happy to hear about it.
