The Solo Pathologist

Dr. Edward Gutmann:
I'm Dr. Edward Eddie Gutmann, and I'm speaking today with Dr. Dean Joelson. Good afternoon, Dr. Joelson.

Dr. Dean Joelson:
Hello, Dr. Gutmann.

Dr. Edward Gutmann:
So I want to give a little introduction or set the stage for our discussion by describing how we met. So my former colleague, Eric Lu introduced us at a coffee break during the recent annual CAP meeting in Orlando, as I presume you recall. CAP, as you know, is the acronym for the College of American Pathologists, which is one of the largest associations of pathologists in the world. And CAP advocates for patients by advocating for pathologists. It has a significant pathology education arm and also conducts a laboratory inspection program to ensure the quality of pathology laboratories. So that the diagnoses that you and I make are accurate and meaningful and help patients. Now, I'm mentioning that obviously you know what CAP is and I know you're on committee, you've been on committees of CAP as am I, but in case some lay people were listening to this podcast, which would be great, I thought I'd explain the acronym.

When Dr. Lu introduced us, I don't have a record of the conversation verbatim, but I presume I said something to the effect that I was a cytopathologist at Dartmouth-Hitchcock, which as you may know, is a tertiary care academic medical center affiliated with Dartmouth's Medical School. And again, I don't know exactly what you said, but you said something to the effect that you were a solo practitioner of pathology in Georgia. And that sort of stopped me in my tracks or I gulped on the coffee during the coffee break because I didn't recall, and frankly, I don't recall ever meeting a solo pathologist, someone who was practicing by him or herself. And so today I want to ask you what it's like to practice solo. I want to begin by asking you about your education background, just the facts.

Dr. Dean Joelson:
Sure. So graduated from Yale University in 1997, did medical school at Emory, finished that in 2001, did my residency in anatomic and clinical pathology at UCSF with a surgical pathology fellowship, finished that in 2006, and came originally from Atlanta and came back to Atlanta at Piedmont Healthcare in 2006 where I've been ever since. However, I was originally with a much larger group before I decided to go solo.

Dr. Edward Gutmann:
You mentioned your undergraduate school?

Dr. Dean Joelson:
Yes, Yale. And perhaps now would be a good time, Eddie, to note the outcome of a certain football game that took place yesterday. We're recording this on November 23rd. And yes, Yale beat Harvard. In fact, we didn't just beat them Eddie. We can talk about this for the next 20 minutes if you'd like.

Dr. Edward Gutmann:
Yeah. Yeah. I was going to ask you about that. And given that I'm a professor at an Ivy League College, Dartmouth, I did think that it would be appropriate to congratulate you on the outcome of the game. I did look online and I did notice that Dartmouth actually beat Yale. And again, I don't want to get off to a start where there's competition.

Dr. Dean Joelson:
Of course you went there. Of course you did.

Dr. Edward Gutmann:
And by one point, which must have been quite painful, but-

Dr. Dean Joelson:
On a 51 yard field goal, yes, it was dramatic.

Dr. Edward Gutmann:
Okay. So asking you about your background was a little bit of a setup to talk about the game, which was held yesterday.

Dr. Dean Joelson:
Thank you.

Dr. Edward Gutmann:
But it also was to communicate that you have a pretty distinguished, I don't know if I should use the word elite educational background. And that suggests to me, or I'm able to infer that you could have readily gotten a job in academia or with a group. In fact, you started out with a group and it's not like you failed the boards, and you were not an attractive candidate for other types of jobs.

Dr. Dean Joelson:
In medical school, when our dean asked what my career plans were and I said, "Well, I want to work in private practice pathology." And he said, "No, no, no, no, no, no, no, no. You're going to get bored doing that, " which I thought was an interesting thing to say, but I have certainly never been bored in my job. Okay.

Dr. Edward Gutmann:
I want to focus on your current work as a solo pathologist, but as you already mentioned, you apparently worked for a non-solo group practice previously. And while I want to focus on your current job, the solo work, can you briefly describe the prior practice in the group?

Dr. Dean Joelson:
Sure. Yeah. So starting, like I said, in 2006, as people came and left, we varied the number of pathologists, but on average about eight pathologists. We covered three hospitals in Atlanta and then in suburban cities around Atlanta. I would describe it as a tertiary care, almost an academic center with a level of complexity that we had. And it was a good place to start my career coming from academics and just sliding right into that type of environment. It was also very good to have seven other very experienced colleagues to work with at the beginning of my career. Right. So I'll just back up a second. Group practice has its pluses and minuses, and we don't have to go into all of the details, but several years ago, it was 2023, I decided that it was time for a change, and this opportunity presented itself.
It's Piedmont Cartersville Hospital outside of Atlanta. It's a town of maybe 20, 25,000 people. I would say it's a semi-rural, but it's still part of the same system that I worked at before. The pathology department there is the pathologists are not employed. So when I started there, I had to form an LLC and then the LLC, me, negotiated a contract with a hospital, so I'm a contracted employer there. As many suburban or rural hospitals are, there's much less complexity than I saw in the downtown hospital. It's a lot of bread and butter type pathology, breasts, cytologies, prostate, colon, but we don't do many of the more complex surgeries like pancreatical biliary, whipples, thoracotomies, that kind of thing.

Dr. Edward Gutmann:
So what is a typical day like for you practicing solo? And specifically, in my laboratory, this tertiary quaternary care medical center, we have anatomic and clinical pathologists. We have a cytopathology unit, surgical pathology, blood bank with blood transfusions, obviously chemistry. We have a molecular lab. Although you've said that the cases may be less complex than in a large group or an academic center, are you covering all these different areas of pathology by yourself? Which again, getting back to when we met in Orlando was just hard for me to imagine, to be honest.

Dr. Dean Joelson:
Yeah. So I think the language here is important. So I would say the cases are less complex, but the job is no less challenging. And to your point, yes. So I am the clinical chemist. I'm the medical microbiologist. I'm the blood banker, and that takes up a significant portion of my time dealing with issues in the clinical lab. So what's an average day like? I get there in the morning and my slides hopefully are ready for me. I look at my slides. If I get tired, look at my slides, I get up and do some grossing.

I check emails, I answer phone calls. I think that the nice thing about my prior job is that I showed up in the morning, I got a stack of 10, 15 flats, and that was my job, just get through them. Now there's so much more variety, but it's also a lot more fragmented. So that's a challenge is there's not necessarily protected time to four hours just to look at cases. You have to be prepared to stop in the middle of a case and answer a blood bank question or chemistry question or call a critical value or whatever it is.

Dr. Edward Gutmann:
So how did you ... I mean, I do strictly cytopathology, so I probably looked at, I don't know how many tens of thousands of pap smears. So I'm quite experienced with that. How did you develop sufficient expertise in all these different areas to handle them? Or getting back to your training at UCSF, are you relying on your prior formal training and that previous practice? And that gets, I suppose, to the question of, can someone out of fellowship or out of residency do what you're doing and survive?

Dr. Dean Joelson:
Yeah, that's a great question. I think it probably depends on the person, but if you were asking me for advice, I would not recommend it coming directly out of residency. For me, a key part of my professional development was practicing in a group where I had somebody next door that I could showcases to. The hardest thing about being a solo practitioner, you've still got help, right? I mean, they're academic centers. It's in a lot of cases to Emory, Cleveland Clinic. I'm sorry, Dr. Gutmann, I haven't sent anything to Dartmouth, but we have help. There is help out there, and I rely, especially at first, fairly heavily on that outside help. And that would be my advice about how to handle it, because yes, for instance, bone marrows. I looked at bone marrows throughout my career, but now I average about a bone marrow a day.

And I think you have to have a growth mentality. You have to say, "Okay, I'm not the greatest at this, but I can get better. I can do this. I got to try. I'll write down what I think it is, create a report, don't sign it out, send it off to a consultant and then compare and see how well I did." And over time, believe it or not, you do get better, you do learn. And that's the important thing that I think that kind of mentality you have to adopt is that I don't know everything, but I can get better.

Dr. Edward Gutmann:
Yeah. I mean, just to contrast it with my own practice, we have five board certified cytopathologists here, and I think we just hired a sixth. So if I have a question about a difficult case, I can consult. Ironically, I'm sort of a generalist pathologist, even as I'm a cytopathologist, because I get needle biopsies from kidney, from lung, from pancreas, from stomach, and I can't be expert in all those organ systems. We're totally subspecialized here. And so if I have a difficult gastrointestinal case, I can go to one of the GI pathologists. So it seems that you are able to handle many of the cases, and then I guess you just send some of them out.

Dr. Dean Joelson:
The note, and one of the nice things about practicing pathology in 2025 is if you have a camera attached to your scope, then you can do a Zoom consult with anybody. So I have some colleagues throughout the state that I'll text or call and say, "Hey, do you have time for a case?" And over Zoom, we'll show each other slides, and you don't have to be a solo practitioner take advantage of that technology.

Dr. Edward Gutmann:
Yeah. Well, I think that's a powerful point. So there's a saying that pathologists are the doctor's doctor. Have you seen that expression before?

Dr. Dean Joelson:
So I've seen it. I understand it, but I happen to disagree with it.

Dr. Edward Gutmann:
Well, I happen to disagree with it strongly as well, so we can see how strongly we disagree. What's your problem with that? Because I do have a follow-up question about it.

Dr. Dean Joelson:
Right. I mean, my problem with it is I'm the patient's doctor, not the doctor's doctor.

Dr. Edward Gutmann:
Okay. My problem with it is that it's very rare for other physicians and other specialties to consult with me and ask for my opinion on what tests should be done. I know that happens. And maybe in the old days, maybe in the old days, I think in fact, when I was in college actually, and I volunteered at a pathology department and first developed my interest in pathology, I actually worked with Dr. Ansel Bloustein. You may recognize the name since his textbook still lives on. I do vaguely recall physician, other clinicians consulting with him, but I think those days are gone. Your point about being the patient's doctor is of course interesting and valid as well, but people use that phrase to sort of justify our profession. And there's problems with the public image of our profession, which I'm very interested in and have written some papers on.

And I think people employ that phrase to sort of aggrandize us knowing that we don't have that much of a public profile. But let's just say it's not a large academic medical center such as the one that I'm at. So notwithstanding our issues with the doctor's doctor, do some of those physicians consult with you perhaps because they're not super specialized in that semi-rural suburban area? I'm just asking.

Dr. Dean Joelson:
So they do. And I'm glad you brought this point up, Dr. Gutmann, because I think it's important for our listeners, and it's important for me. We know, I don't think anybody would doubt that if there's a question about how to process a tissue biopsy specimen, that the pathologist is the expert. And I get questions a lot of time, very often this informally should submit it fresh, and those are easy questions for us to handle, but we are also the experts in the clinical lab. There is nobody else in medicine that understands the clinical lab as well as we do. 

We had a case, a patient with an elevated PTT that the oncologist, the neurosurgeon, and I spent a lot of time talking about together. And maybe I've got an inflated sense of ego here, but I felt like I was an integral part of those discussions and I think we came up with a course of action for the patient that was better than any one of us could have achieved by him or herself. So I wish I actually got more questions about how to utilize laboratory tests, but again, I think that's relationships, you build the trust, people understand that you know what you're talking about and you start to get more of those types of consultations. So you

Dr. Edward Gutmann:
Mentioned the clinical lab, and I presume by that, you're mostly referring to clinical, the branch of pathology that we call clinical pathology with chemistry, blood tests, your sodium, what your potassium is, what your white blood cell count is. Again, I'm mentioning these terms for lay people. Is that fair to say?

Dr. Dean Joelson:
That's correct. And you actually asked a question a little bit earlier about my practice setting. So no, I do not own my own lab. I work in a hospital lab and that is the lab that I oversee.

Dr. Edward Gutmann:
Well, that's interesting that you say that, so to speak, you're more of a doctor's doctor, or at least help other physicians in clinical laboratory, in the clinical lab, the clinical realm. And I said that I essentially am never really queried from other clinicians. Now, I do strictly anatomic pathology and strictly cytopathology. So you give a different perspective and it shows sort of a little bit, I want to say how narrow minded I am, but I don't know what goes on as much in the clinical laboratory, so you make an interesting point with that, about that.

Dr. Dean Joelson:
Yeah. And Dr. Gutmann, you're being too hard on yourself. So when I was in a bigger practice, I didn't have a lot of interaction with a lot of these parts of the clinical lab myself. We were specialized within our practice. So it's really something that I've had to do. And I've enjoyed it. I don't want to say like it's a burden, but it's something I've had to become better at as I've, when I went solo.

Dr. Edward Gutmann:
Yeah. Okay. So I noticed something on your webpage when I was trying to contact you to ask you if you'd be willing to do this podcast and I'm going to read it. You don't have an elaborate webpage?

Dr. Dean Joelson:
No, it's a one pager.

Dr. Edward Gutmann:
It's basically sort of boilerplate, but I'm going to read something that you wrote. "I welcome calls from all patients, physicians, the general public, but please be respectful. Also, I do not give out pathology results over the phone to patients or family members. I am, however, happy to discuss one of my reports once you have received a signed out copy from your physician or MyChart, which I presume is your means of communicating with patients
Finally, electronically, finally, please note that I'm a diagnostician. I diagnose things. I do not treat patients, nor do I offer opinions on medical care, prognosis, et cetera. I can discuss pathology reports, but patients need to consult their other physicians if they have additional medical questions. As you may or may not know, I've been very interested and I've written several papers about pathologists speaking to patients. It's been an ongoing and interest of mine for a couple of decades, and I want to know why you wrote that line and what it means to you. You already told me that you're not the doctor's doctor, you're the patient's doctor, so maybe that ties into that, but I want to know why you have that line on your website and what it's led to and what it means to you.

Dr. Dean Joelson:
Right. So you hit the old nail on the head there. So, correct. I'm a patient's doctor, and to me, that's why I'm doing this is for the patients. And I know from, and I'm sure you do too, lots of patients talk to us about reports, not necessarily that we've signed out, but about other pathologist reports. And there's a lot of ... We use terminology that is unclear to them. They oftentimes look at our reports and come away confused and scared. And I thought," Why shouldn't we be willing to talk to patients and help explain to them exactly how we came to the diagnosis? "To me, it's one of the greater services that I can provide is making my report accessible to the people who are impacted by what I say. And there's some practical ... I mean, I'll give you an example. So I had a patient call about a report of mine, and she said that she had asked her oncologists about something in the microscopic description, and the oncologist said," I don't know what that is. I don't know what that means.

"Which was, of course, disappointing, right? That we're writing reports for our clinical colleagues, and we use terminology that doesn't help them, but it was something about a lymphoid aggregate and a benign lymphoid aggregate. We find them all over the place in all kind of organ systems, but she had no idea what it meant and she was scared. She was really, really scared about what this lymphoid aggregate meant. And it was tremendously satisfying to be able to tell her," No, I just mentioned it that it's there, but it's a normal variant and it essentially doesn't mean anything. "And that kind of thing is ... I mean, I think that she went away feeling much better. I went away feeling much better. If I can help people by just being willing to talk about my report, then why wouldn't I do it? I guess the answer to that is I wouldn't want to do it because it takes time and I'll get paid for it, but to me, that's not a very good reason.

Dr. Edward Gutmann:
Take it from speaking to you that it's been satisfying to work as a solo pathologist. I never asked you about the weekends and the nights and who covers for you and how you get coverage. So I guess the broader question, you can answer the coverage question, but although you've clearly communicated that it's been satisfying for you, is this a viable job to be a solo pathologist? 

Dr. Dean Joelson:
So it is tremendously rewarding and fulfilling. However, I would say that it's not for everybody. So there are stresses involved with being a solo practitioner that I think sometimes for me build up to the point where I wonder if the anxiety is worth it. I'm doing a bad job of selling it here. For example, the call thing, you mentioned the call thing. So I'm on call all the time. I mean, I have always got my cell phone with me and that can wear on you. It can wear on you in a big way. If I want to take some time off, I have to find somebody to replace me and I am entirely dependent on what the locums market will provide. So if I want to see my family over Christmas, if I can't find a locums to do that, then I'm working on Christmas.

So in medical school, in residency, nobody really tells us how to be a business owner. So if you want to be a solo practitioner, especially one that contracts out to a hospital, I mean, I suppose there are probably some solo practices where you're employed physician of the hospital, but in my case, I'm not. So I had to get real cozy real quick with contract law. I had to hire a practice manager to help me set up the business, hire an attorney. And I'm still, I'd like to say that I'm better at running a business, but I'm still not great at it.

It's foreign. So there's managing business, there's call, there's the not having people to ask questions to next door. Like I said, there's some technology solutions to that. You can always send cases out, but oh, billing, right? I have to find a billing company. You really shouldn't negotiate with the insurance companies by yourself. That would be a strong piece of advice. Don't try to do that. So you have to go out and find people who can help you do what you want to do. Another downside is, for instance, the practice manager company that I employed, they had almost no experience with pathology. So we're not even radiology, we're internal medicine. It's a completely different field for many in medicine. And how do I negotiate a medical director fee? There are not many people out there that can help you do that. So all of that takes a little bit of work, not just a little bit.

It takes a lot of work. But again, I don't regret it. It's been challenging. The call thing is a pain, but it's also so rewarding. I get to practice pathology the way that I want to practice. I get to put on my website, I'll talk to patients. It has been remarkably fulfilling.

Dr. Edward Gutmann:
I'm grateful to CAP, the College of American Pathologists for letting us have this chat. I enjoyed it. What is your relationship to CAP? And as a solo practitioner, is there any particular relevance of the College of American Pathologists to you as opposed to when you're in the group or imagining if you were in academia?

Dr. Dean Joelson:
So good question. The College of American Pathologists is my professional home. Although, I should say that also my other professional homes are the Georgia Association of Pathology. So I've got two professional homes. I'm allowed to have two homes, right? Is that okay? I'm a pathologist. Of course, I'm allowed to have two homes, but it's my community. And when I was in a group practice, my practice was my community and now, and I was a member of the CAP too, but I've become even more involved in the CAP over the past couple of years. Let's see, it was 2024, last year. Last year I ran for House of Delegates steering committee and was elected there. So I'm a member of the body that helps set the priorities for the CAP House of Delegates, which hopefully our listeners know is 600 plus pathologists representing all the states of the union territories. We may have some Canadian folks too, but that's really the voice of the membership and being part of the steering committee has been a great privilege and a lot of fun over the past year plus. And as part of that, I'm on some CAP committees and the organization is my professional home.

Dr. Edward Gutmann:
All right. So we've come full circle, I suppose, in that you and I met at a CAP meeting and we're ending by talking about what CAP means to you and how it's been useful to you.

Dr. Dean Joelson:
And let me just say also that I've talked about CAP being my professional home. That sounds too professional. It's also a personal home. I have going to committee meetings and annual meetings and you meet people that sure, they're your colleagues, but they also become your friends and you're going to have those friendships across the country for the rest of your life. And that is the value ... I mean, what's membership? $400 a year, whatever it is, I'd pay thousands of dollars for some of the friendships I have. For you, Eddie, maybe $5,000 a year.

Dr. Edward Gutmann:
No, I enjoyed meeting you. And it's just interesting that we really did meet by serendipity over the coffee break. And I probably interrupted you and Eric when you were talking and Eric was nice enough to introduce us. So that's gets to the point of these in- person meetings. I mean, ironically, we're talking on a podcast now, but something can be said for actually meeting new people in person, serendipity. And I agree with you about forming friendships. And I agree with your point that ultimately we're trying to serve patients. Even though patients don't see us and some don't know that we exist, then it's sort of a black box. We're working pretty hard on their behalf and we need to support each other in those endeavors on behalf of patients.

Dr. Dean Joelson:
Awesome. Totally agree.

Dr. Edward Gutmann:
Well, I enjoyed talking to you and thanks for sharing your insights. I'm again, grateful to our mutual friend and my former colleague, Eric Lou for having introduced us at-

Dr. Dean Joelson:
Fantastic chat, Eric is.

Dr. Edward Gutmann:
Yeah. And so I look forward to maybe seeing you at next year's annual meeting or perhaps some joint committee meetings in the future.

Dr. Dean Joelson:
Absolutely. Look forward to it.