Embracing Career Excellence Through Specialized Skills – An Interview With Dr. Jonathan I. Epstein

Dr. Jonathan I. Epstein is a leader in urological pathology who holds the prestigious Reinhard Chair at Johns Hopkins. With a rich career including contributions to hundreds of publications and over twenty books, Dr. Epstein is considered a pillar in the medical community. His surgical pathology consulting service, one of the largest in the United States, is steeped in unparalleled skill and dedication. Dr. Jonathan I. Epstein graduated from Boston University School of Medicine in 1981, and he completed his fellowship in pathology at Memorial Sloan Kettering Cancer Center. He is a global lecturer and committed to teaching other pathologists in the field.

What brought you to the field of pathology?

In medical school, I excelled in many subjects and was encouraged by my instructors to consider a number of fields, among them internal medicine and pediatrics. When I took the course in Pathology, I immediately knew that this was what I wanted to do as a career. Whereas other medical students could look at the microscopes for only a limited time before getting headaches or losing interest, I could stare at various tissues under the scope for hours on end. 

What qualities do you possess that make you an expert in surgical pathology?

I have always been more of a visual person than, for example, someone who learns auditorial. During medical school, I would get much more from the course material by reading it as opposed to hearing a lecture on the subject. Being an expert in surgical pathology is based on knowledge of the field, but also an intangible art of seeing subtle patterns that others may miss. 

I have trained very smart individuals who can eventually, with extensive training, become competent pathologists. However, to become an exceptional pathologist requires an innate visual skill that not everyone has. This visual skill that I possess dovetails with my interest in photography. 

How did you initially become involved in the field of prostate pathology?

When I was still in training at Johns Hopkins Hospital, the urologist, Dr. Patrick Walsh, developed a surgical procedure for taking out prostate cancer with the potential of maintaining potency and continence. As a result, men from all over the world came to Johns Hopkins for radical prostatectomy for their prostate cancer. At the time, there was no one interested in prostate cancer pathology at Hopkins. When Dr. Walsh asked the Director of Surgical Pathology if there was anyone who could help analyze the prostate cancer specimens, the director recommended me. 

What about prostate pathology interested you?

Shortly after I became involved with the prostate cancer program, I was asked to join the staff at John Hopkins Hospital. I was then examining the pathology of more radical prostatectomy specimens and their biopsies than any other pathologist in the world. What I found fascinating with prostate cancer was that there was such a wide range of histological patterns and degrees of aggressiveness (i.e. grade). Also, prostate cancer was much more difficult and subtle to diagnose than tumors in organs. The other factor that interested me was that the pathological diagnosis of prostate cancer and its grade had such a major impact on subsequent treatment and prognosis. 

What are the most influential discoveries thus far in your career?

The first would be coming up with specific histological criteria for the diagnosis of prostate cancer. Before doing so, I was taught that you can recognize prostate cancer because “it looks like cancer.” I was the first pathologist to develop specific histological criteria to diagnose prostate cancer. These same criteria are used today by pathologists world-wide to reliably diagnose prostate cancer under the microscope. 

I was the first along with clinical colleagues at Hopkins to develop criteria combining pathological findings on the biopsy with clinical parameters to determine who would be optimal candidates for active surveillance for prostate cancer. At the time, everyone with prostate cancer was being treated and it was heresy to suggest that some men with indolent prostate cancer could instead be followed closely. The criteria that we developed are still being used today. 

I led several consensus conferences on grading prostate cancer which have revolutionized how pathologists practice. The Gleason grading system that is used for prostate cancer was developed from 1967-1973. Since that time, many things have changed in prostate cancer pathology and in clinical practice. Consequently, how we grade prostate cancer had to evolve as well. 

Top Takeaways

• Pathology is a field requiring inherent visual skills which allow professionals to identify subtle patterns and details others may overlook. 

• Embrace the opportunities and collaborations afforded through education and post-education training as it can significantly shape career opportunities and influence areas of specialization.

• In pathology, accurate diagnosis and grading of diseases is key to treatment strategies and outcomes for patients.