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Dermatology Practical & Conceptual

ISSN 2160-9381

April 2013 | Volume 3, No. 2

Ackerman AB. A Philosophy of Practice of surgical Pathology: Dermatopathology as Model. New York: Ardor Scribendi, Ltd., 1999

Mark A. Hurt, M.D.

Citation: Ackerman AB. A Philosophy of Practice of surgical Pathology: Dermatopathology as Model. New York: Ardor Scribendi, Ltd., 1999. Dermatol Pract Conc. 2013;3(2):15. http://dx.doi.org/10.5826/dpc.0302a15.

Copyright: ©2013 Hurt. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Corresponding Author: Mark A. Hurt, M.D., 2326 Millpark Dr., Maryland Heights, MO 63043, USA. Tel. 314.991.4470. Email: **

The cover

Figure 1. Ackerman AB. A Philosophy of Practice of surgical Pathology: Dermatopathology as Model. New York: Ardor Scribendi, Ltd., 1999. 470 pp with index. ISBN-10: 1893357023. ISBN-13: 978-1893357020.

Review by Mark A. Hurt, MD

It has been just over 4 years, at this writing, since Bernie Ackerman died on December 5, 2008, in New York City. On that day, I lectured at the University of Missouri-Columbia, my alma mater, on why I disagreed with the concept of the dysplastic nevus. My lecture was titled: “Dysplastic Nevus: Fact or Fiction?” Bernie was a big influence on what I discussed in that lecture, and it generated a number of questions from the audience, most of whom were residents in pathology who knew little about him or his ideas.

As I was driving home to St. Louis, my wife telephoned me about Bernie’s passing. It was a long and quiet drive home. It was a moment of reflection about him, having spoken with him only a few days earlier, which could come only at such a time. The world changed for me that day.

In the years since his passing, I have thought of him often, of his long career, of the controversies he caused-and clarified-and of the quality of ideological engagement he encouraged. It was invigorating, infuriating, challenging, sometimes baffling, but never dull.

A few weeks ago, I decided to learn whether his book, A Philosophy of Practice of surgical Pathology: Dermatopathology as Model, was ever reviewed. It was. Michael B. Morgan, MD, reviewed it in The American Journal of Dermatopathology 2001; 26:554-555. Bernie responded to the review, as was his custom. Edward Nikicicz provided very brief tribute to the the book in 2002 on the Amazon.com website. To my knowledge, there are no others.

This is the kind of book that, in my opinion, deserves an additional review, now some 12 years after the first review and 14 years after the book was published. So, here it is, and I hope that Bernie would have wanted to respond to it, but, unfortunately, he cannot.

— • • • —

Physically, this book looks more like a novel, and a well-anticipated one, it printed on 80# Simpson Teton, with pages bearing deckle edges, set in Centaur, Metro Light, and Trajan. The boards are in green cloth with a sewn-in bookmark. This book is composed of 44 chapters. There are 470 pages with a foreword, afterword, and an index.

The dedication is to Arkadi M. Rywlin, MD, and Alberta Szalita, MD, two of his teachers-the first in pathology and the second in psychoanalysis.

In the foreword, Bernie lays out the purpose for his book in these words:

What follows is his treatise.

These 44 chapters are a collection of vignettes about the practice of medicine and pathology, reflections on thought, and insights into a life well lived. If any reader of this review has read this book and knew the man, he or she will grasp immediately that these vignettes are classic Bernie Ackerman. I recall fondly his struggle to find just the right word to turn a phrase in just the right way, and the words in this book are the result of his struggle.

A philosophy of life and a philosophy of practice are difficult to grasp and even more difficult to record in a coherent manner. Bernie begins each chapter by laying out his thesis followed by excerpts from his own articles, or from other writers, with associated commentary.

Because readers of this review probably do not own a copy of this book, I think it should be of benefit to enumerate a list of the chapters with their titles to provide a global sense of it. Afterward, I will concentrate on the issues I found most interesting.

  1. The patient is the purpose; the purpose is the patient
  2. The importance of historical perspective
  3. Comprehension of structure and function
  4. Open mind, accurate observation, profound knowledge, critical thought, reasonable interpretation
  5. Precision in language
  6. Indispensability of clinical dermatology to the mastery of dermatohistopathology
  7. Indispensability of dermatohistopathology to the mastery of clinical dermatology
  8. General pathology and dermatopathology are one pathology
  9. Lives of lesions
  10. Variable expressions of a single process
  11. Criteria for diagnosis
  12. Illusion and reality
  13. Clues to diagnosis
  14. Pattern analysis
  15. An algorithmic method for histopathologic diagnosis
  16. Histopathologic look-alikes
  17. Differential diagnosis
  18. Pitfalls in diagnosis
  19. Exceptions
  20. Mythology
  21. ClichÉs
  22. Clinical miscues as a clue to accurate histopathologic diagnosis
  23. Clinical implications of particular histopathologic findings
  24. Important or not?
  25. Unifying concepts
  26. Biopsy
  27. The best special stain
  28. Minimizing errors in diagnosis
  29. Construction of an informative pathology report
  30. Limitations of the method
  31. Advantages and disadvantages of clinical history
  32. The issues of alleged negligence and of behavior in matters medical-legal
  33. Individuality, imagination, and originality
  34. Skepticism, reflection, resistance, responsibility, and tenacity
  35. Taking the subject (not oneself) seriously
  36. “I don’t know” and “I was wrong”
  37. Ethics, etiquette, and collegiality
  38. I, myself, alone
  39. Collaboration and sharing
  40. Educare et docere
  41. A profession is not a business
  42. The master word in medicine
  43. The magic word in medicine
  44. Farewell

Bernie Ackerman was a master of the English language and of a method that he described as learning dermatopathology through “historical perspective.” I remember well when I first read his articles that employed this method. I was then a pathology resident at the University of Missouri-Columbia and fascinated with surgical pathology. His articles were unusual in that they presented case data but added a layer of cases from history, often including photographs of the original cases, that enriched the experience of reading about the disease in question. Those of you who have read his articles on mycosis fungoides [1] or melanoma in situ [2] cannot have come away unmoved by the experience. Historical perspective, precision in language, clearly established criteria for diagnosis, and excellent photography were the hallmarks of his work. Chapter 2 of this book visits this approach with a recounting of textbooks written throughout the history of the discipline.

Those of you who have read and studied his books on adnexal proliferations know well that a study of structure and function introduced the weighty subject matter of the sections of proliferations that followed. Chapter 3 details the rudiments of Ackerman’s thinking on the subject, and it is accompanied by drawings to aid his conceptual presentation.

In chapter 4, Bernie tackles one’s approach to preparing one’s mind for perception, conception, and evaluation. How many of you have read this kind of statement in the opening of a chapter of a philosophic treatise in dermatopathology?

I add only one caveat to this statement, because I know Dr. Ackerman believed it; one must bring an active mind into all matters-the mind cannot be open to everything, as it will degenerate from the lack of ability to distinguish truth from propaganda. As he states, “An open mind must be exercised, not just left open like a sieve.”

I disagree with Bernie, however, on a crucial point, which we discussed on a number of occasions. He states the following (p 83):

My point of difference with Bernie is not that there is disagreement between any two or among several observers on matters of what is observed morphologically or what it means-after all, there is an entire consultation industry in dermatopathology based on this fact. My disagreement with Bernie centers on the issue of subjectivity. Just because observers may not agree on a given set of data or a diagnosis does not mean that the process is a subjective one. In any given case, each can learn from one another until each understands precisely what the issues are, thus removing the subjective or the arbitrary from the realm of the discussion. In one sense of the meaning of subjective, however, he is right; the observer perceives the object only with his or her senses, and that process cannot be transferred. It can only be transmitted from one to another in the form of conceptual knowledge. This, then, is the meaning of Bernie’s statement that “Still, persons trained to make precise observations can do that with remarkable consistency and repeatability.” This statement is true, and it also the reason why the process is not subjective.

Precision in language (chapter 5) is one of the more important chapters, and Bernie gives examples of problems in communication in pathology: misnomers, nouns without modifiers (e.g., “nevus” without “melanocytic”), superfluous synonymy (too many names for the same pathological process), redundancies, flawed concepts, and animism and anthropomorphism. He concludes with a few examples of what he considers proper definitions.

I liked Bernie’s examples of flawed concepts, especially his examples of how the term “dysplasia” has been used in pathology. He was right then, and he is still right; it is a hopeless concept that has no coherent definition and, in my opinion, should be dropped, expunged, jettisoned from the language of pathology. The sooner this occurs, the better we all will be.

Clinical dermatology and dermatopathology are two different perspectives on the same object. Thus, in chapters 6 and 7, Ackerman tackles these perspectives. I urge especially the reader to study chapter 7, which addresses fundamental lesions defined and illustrated diagrammatically.

In 1984, Bernie authored an entire book with Anna Ragaz, MD, on The Lives of Lesions.[3]. What more does he add to this? In chapter 9, he reiterates the principle: “Not only do diseases have lives, but individual lesions of those diseases have lives, too, just as human beings do.” I would characterize his sentiments this way: the “life” of a lesion is its natural history. To know dermatopathology (as well as any other aspect of pathology-see his chapter 8) requires a thorough understanding of the nature of the concept of a spectrum of lesions from the beginning of their evolution through and including their devolution (see chapter 10). Moreover, it requires that one knows all of the differential diagnosis so as to understand the mimicry of the lesion in question with the natural history of other classes of lesions, however similar.

In Chapter 11, “Criteria for diagnosis,” Bernie’s introduction is a quotation by Ludwig Wittgenstein, one of the most unintelligible philosophers of the 20th century, if not of all time, second only to Immanuel Kant. This criticism aside, Bernie addresses perhaps the most critical epistemological issue facing all of diagnostic pathology: how does one identify criteria that constitute a given diagnosis? In this, I differ from Dr. Ackerman, who stated explicitly that:

I disagree profoundly with this point of view. Just because one has direct access only to one’s own consciousness and no other does not mean that the judgments he or she draws are subjective. One cannot just “make up” criteria from the thin air; rather, one induces them by observation of the facts of reality, testing the hypothetical criteria against the facts of nature, and accepting valid criteria only when they pass muster. In defense of Bernie on this issue, he is better than that which he professes explicitly. When he details the process of testing criteria in the arena of the facts of nature and rejecting them when they do not work, he gets it right. In my experience with him personally, he got it right most of the time-enough of the time to teach this student a few things!

An illusion, according to Merriam-Webster (unabridged), is:

Of course, Merriam-Webster is not precise on this matter; there are no “ambiguous qualities” in nature; all qualities in nature are specific and concrete, but to be identified, they must be discovered by one’s mind. If that does not happen, an error is the result (although errors have wider causes that simply from illusion). It is the interpretation of these qualities that is often difficult and why error is so easy to make. This is not a trivial issue, as Bernie places illusion into perception as such (chapter 12), not interpretation (conception and evaluation), of what is perceived. In my opinion, this is a critical point, because it explains why one might misinterpret the object of perception; say a melanoma, as though it were a melanocytic nevus. I regard illusion as having a basis in reality and perception but conditioned by conception. This explains why misidentification happens frequently and more commonly in those who are learning dermatopathology in the early years of their careers, but it happens to us all, eventually. Bernie’s example of reviewing slides first without history is a good practice and can help remove bias:

Bernie makes a distinction between a clue and a criterion (chapter 13), the latter being more important, as it states a fundamental: “Criteria for diagnosis are the fewest denominators that enable diagnosis to be made.” Clues, in contrast, are pointers to the criteria but are not fundamental as such. He was right about both, and he taught generations of dermatopathologists how to identify them. He proceeds in the chapter by enumerating a few clues (p 221). This approach is absolutely correct and well worth considering.

Ackerman, for practical purposes, introduced dermatopathologists to the concept of pattern analysis for the purpose of an algorithmic approach to diagnosis. Even if he did not originate the method, he made it so accessible and popular that he might as well have originated it. Chapter 14 details some of this methodology beginning with his approach to inflammatory diseases of the skin, which he introduced in his famous “gold book,” [4] to his application of the method for the diagnosis of proliferations of melanocytes and adnexal proliferations. In a succinct few pages, Bernie captures a life’s work, which newcomers to the field should note well.

Prior to understanding Bernie’s algorithmic method of diagnosis (chapter 15), I and other colleagues found ourselves in precarious positions of method. How should one make a diagnosis? What was the approach? In my residency, I was told to start low and proceed to high, but I understood nothing about pattern recognition, how to use scanning magnification, and to avoid-as much as possible-higher magnifications. Ackerman provided an approach, and he spells it out in basic concept here.

A histopathologic look-alike (chapter 16) differs from an illusion in that a look-alike offers no histopathologic clue or criterion to come to a precise diagnosis without providing some other clinical or histopathological information to enable a narrowing of the differential diagnosis. Bernie provides 15 examples that are worth knowing (pp 262-263); there are others. In chapter 17, Ackerman expands this issue of look alikes, but now he emphasizes that most “look alikes” really are not alike at all once one knows the criteria for diagnosis. This is when a differential diagnosis is imperative, and why a deep understanding of criteria aids greatly in coming to a definitive diagnosis. Bernie provides 15 examples of classic dilemmas (pp 269-271).

Perhaps this is the biggest pitfall (chapter 18) of all:

I will add, this is true especially in medicolegal cases. When an attorney asks you to “weigh in” on a case, it is very difficult not to have some kind of prejudice just by the nature of the situation at hand.

A very important chapter (chapter 25) addresses unifying concepts in dermatopathology. Bernie offers examples about melanoma, mycosis fungoides, squamous cell carcinoma, lupus erythematosus, etc. As readers of his other books and articles know well, he had particular views about unifying concepts, and he was successful at doing it well. He was not always successful, however, at convincing his readers that he was right about his opinions of them. That, he understood, was expected.

What is the “best special stain” (chapter 27) in dermatopathology? I will leave it to the reader of this review to guess, but Ackerman believed there was only one; if you know his works, you already know what it is.

How can one minimize errors? Dr. Ackerman provided a list for how he thought best to operate (chapter 28), and he offered a single maxim: “The single most egregious act of omission is a failure to concentrate.” Amen to that!

In chapter 32, Bernie addresses issues on alleged medical negligence in medical-legal matters. His principal point is that not all errors are negligent errors.

Chapter 34 is an essay on how one’s position can change about the nature of a disease. On page 373, Bernie lists a number of diseases in which he changed his opinion about their nature. The list spans the years 1967-1994, and he admits that it is not a complete list.

Dr. Ackerman concludes his book with chapters on admitting error, ethics, the joys of individual production and collaboration with others, education, the “business” of medicine versus the practice of the profession of medicine, the master-word of medicine (work), and the magic word of medicine (joy). Finally, Bernie, in a chapter titled “Farewell,” lays out his plan for shifting his emphasis in the final phase of his career. He could not have known it, but that phase would last about 8 years, and in that time, he accomplished much of what he stated that he wanted to accomplish. It was a pleasure for me to share in some of that with him.

— • • • —

In the first decade of this century, I had the honor of spending time with Bernie, perhaps in a way that many of his fellows did not. It began with a review of his second addition of Neoplasms with Follicular Differentiation, [5] blossomed into my becoming editor of this section of Dermatopathology Practical and conceptual, and led to a friendship and a collegial relationship that was constant until his death. Reading this book on Bernie’s philosophy of practice brought back a flood of memories of the man, his ideas, and why he and they matter still and always will. It brought me back to one of the most challenging times, intellectually and emotionally, of my life.

It is important that each new generation of dermatopathologists discovers A. Bernard Ackerman, MD. Love him or hate him, each one will have to make peace with his positions on ideas in this field. This book, written and published by him at the peak of his faculties, will aid in that desideratum.

As Bernie earned it, he gets the last word:

References

1. Sanchez JL, Ackerman AB. The patch stage of mycosis fungoides. Criteria for histologic diagnosis. Am J Dermatopathol. 1979 Spring;1(1):5-26. PubMed PMID: 549480.

2. Kamino H, Ackerman AB. Malignant melanoma in situ: The evolution of malignant melanoma within the epidermis. In: Ackerman AB. Pathology of Malignant Melanoma. New York: Masson Publishing USA, Inc., 1981:59-91.

3. Ackerman AB, Ragaz A. The Lives of Lesions. Chronology in Dermatopathology. New York: Masson, 1984.

4. Ackerman AB. Histologic Diagnosis of Inflammatory Skin Diseases. A Method by Pattern Analysis. Philadelphia: Lea & Febiger, 1978.

5. Hurt MA. Review of: Neoplasms with Follicular Differentiation, 2nd ed, by Ackerman AB, Reddy VB, Soyer HP. Reviewed in Am J Dermatopathol 2002; 24(2):169-179.