Perinatal Pathologist Spotlight Feature
Name:Dr. Ray Redline, University Hospitals Cleveland Medical Center
Interviewed by: Dr. Sanjita Ravishankar, Case Western Reserve University
What is your practice setting? (e.g. academic children’s hospital, academic adult and children’s hospital, predominantly research based, etc.)
My practice setting is ideally suited to my interests, a pathology department in an academic medical center with full service children’s hospital (Rainbow Babies and Children’s) and women’s hospital (MacDonald Hospital for Women) situated next to a research university with a medical school (Case Western Reserve). This facilitates collaborations with neonatologists, Ob-Gyns, medical geneticists, and both clinical and basic scientists.
How did you get interested in and decide to go into the field of perinatal pathology?
I decided that Reproductive Biology was my major scientific field of interest in the late third year of medical school so I decided to apply for an Ob-Gyn residency. As part of my fourth year I rotated with Kurt Benirschke and did research with Judy Vaitukaitis (reproductive endocrinology). I loved my first year of Ob-Gyn residency, but longed to have more time to understand the underlying biology. My father was a pathologist and both Kurt and Judy recommended Pathology so I switched programs. Once in pathology, Beverly Dahms and Carlos Abramowsky ignited my interest in perinatal pathology. I was conflicted between Pediatric and Gynecologic pathology as a subspecialty, so I did a fellowship that covered both at Brigham and Women’s Hospital. I obtained the fundamentals for everything I know about perinatal pathology from Shirley Driscoll who deserves most of the credit for whatever I have been able to do in this field. This includes her persuading me to go into the lab and do basic Reproductive Immunology research for three years at Harvard Medical School under the mentorship of Chris Lu. I also gained additional research experience in vascular biology with Tucker Collins before leaving the Brigham for Cleveland in 1990. At that point I was off and running as a card carrying perinatal pathologist.
What are some of the day to day activities that your job entails?
I have actually covered a number of specialties in addition to Perinatal over my time in Cleveland including Pediatric, Gynecologic, Breast, and Gyn Cytology. Focusing just on the Perinatal pathology subspecialty service, which was established in 2015, we are responsible for evaluating all in house delivered placentas submitted to pathology (about 50/week), all products of conception (about 20/week), and half of the Gyn biopsies (about 30-40 week). Placentas and POCs from our outside affiliate hospitals and perinatal autopsies are part of our Pediatric subspecialty rotation. I have taken the, perhaps debatable, position that placentas and POC are amongst the most urgent specimens we receive in Pathology. My rationale is that immediate management decisions can follow from diagnoses such as acute chorioamnionitis, TORCH infection, features suggestive of metabolic disease, and absence of villi on curettage and that delayed diagnosis can lead to findings that require later management decisions such as gestational trophoblastic disease, accreta, and placental lesions with recurrence risks such as maternal floor infarction “falling between the cracks”. To this end, we pay residents to come in and gross placentas on Sunday and try to sign out all placentas within 1-2 days of receipt. Time will tell whether this is a practical and cost effective strategy, but we hope to create some data to justify this approach. So my day usually entails collecting complete clinical histories, looking at a lot of placentas often with residents, and staying in contact with clinicians through pages, phone calls, texts, emails, and rapid signouts. In the down time I work on various projects to enhance the perinatal service, collaborate with basic scientists and clinicians, and help develop the knowledge base for our field. I have also over the years prioritized writing papers, chapters, and books, editing and reviewing for journals, presenting at national and international conferences, and teaching at CME courses as methods to try to spread and deepen Shirley Driscoll’s conception of a dedicated subspecialty of perinatal pathology.
What are your favorite and least favorite aspects of being a perinatal pathologist?
Favorite aspect: Under explored, virgin area of pathology with opportunities to learn and discover new knowledge.
Least favorite aspect: The sometimes overwhelming challenge of having to justify our approach to skeptical residents, clinicians, and basic scientists.
What do you think is/are the biggest challenge(s) facing the field of perinatal pathology?
Skepticism from pathologists who lack interest in or knowledge of perinatal medicine. Optimizing submission criteria and improving turn-around time for reporting. Establishing management guidelines and care paths for women with specific placental findings. Showing that placental pathology is beneficial to and cost effective for the health care system.
Where do you think perinatal pathology is headed in the future?
We need to better explain our system of analysis to and engage basic scientists interested in developmental biology, genetics, and clinical perinatal research. We need to better explain our system of analysis to and engage the clinicians who manage pregnant women and children We need to prioritize research studies aimed at finding genetic variants, biomarkers and imaging techniques that predict (and explain) placental pathology before conception, during the first trimester, and early in the second half of pregnancy. We need to standardize and elevate the quality of perinatal pathology practice outside of our academic medical centers.
What advice would you give to someone who is considering training and a career in perinatal pathology?
Find competent mentors; during Path or OB residency, in the research lab, and in Peds path or Gyn path fellowship. Don’t be in a rush to get out and start your career. Obtain as broad an experience as possible in related fields such as developmental biology, immunology, genetics, vascular biology, high risk OB, reproductive endocrinology, biostatistics, and microbiology. Read everything as soon as it comes out regarding perinatal diseases. Look at lots and lots of cases with good clinical history and follow up. Develop collaborations that you believe in and have some control over. Reject all others. Once you are in a place where you will see lots of cases, start a database and think about some questions you might address.
How has the Society for Pediatric Pathology played a role in the development of your career?
First chance to present platform presentations as a resident. Established a welcoming environment (especially during the Fall interim meetings) to meet with other fellows and young faculty members. Facilitated interactions with like-minded pathologists culminating in the establishment of the Perinatal section. Provided the opportunity to gain experience in a variety of important academic tasks including committee work, collaborative projects, symposium development, journal reviewing, and editing, and judging research proposals and abstracts.
Dr. Sanjita Ravishankar
Department of Pathology
Case Western Reserve University