Aleksandra: [00:00:00] Have you heard the stereotype of a pathologist as a doctor’s doctor hiding behind the microscope? Forget about it. Today’s guest is nothing like that.
As a specialized cytopathology, she is patient facing by the nature of her specialty. She emphasizes the patient centricity of pathology work not just for the greater good of medicine, but for herself to connect meaning to her work. She co-authored a book, the Healing Art of pathology and decided that helping one patient at a time as a pathologist is not enough, and this needs to be amplified.
And she amplifies it by being leaders of various organizations, including the Digital Pathology Association and Florida Society of Pathology.
Welcome my digital pathology trailblazers. Today my guest is Dr. Marilyn Bui. We met briefly with Dr. Bui at the Pathology Vision Conference in 2019 when she was the president of [00:01:00] the Digital Pathology Association.
Currently, she is the president of the Florida Society of Pathologists. Welcome to the podcast Marilyn. How are you today?
Marilyn: Wonderful? So, thank you for this opportunity. It’s really nice chatting with you.
Aleksandra: Marilyn. I’m gonna let you introduce yourself and give us a little bit of your background because there is a lot of leadership and let’s just listen to it from you.
Marilyn: I’m a practicing pathologist at Moffitt cancer center in Tampa, Florida. This is the only NCI NIH Designated Cancer Center. So, I started working at Moffitt 18 years ago when I graduated from University of Florida with pathology, residency fellowship training, and also graduate school there in molecular pathology and immunology.
But before UF, I went to medical school in Beijing, China, and after I graduated, I came to UF. So, you can see I spent almost 20 years in [00:02:00] training. I did medical school, I did some research, I get into graduate school, I did some research, and then I get into my current job.
At the Moffitt I do own self tissue pathology, cytopathology and also digital pathology at the same time when you are in a cancer center, in addition to taking care of patients, will be do teaching to train the next generation pathologist and I with a PhD background, I also do research. Some are translational research, collaborating with PhDs.
When they discover things in the bench side, I help them to translate that into the biopsy can help patient. I also collaborate with the clinicians like a medical oncologist surgeon, radiation oncologist, and if they discover some magic treatment for the cancer patients as a pathologist, I will be able to evaluate how those therapy working on a patient, they are effective or not.
So [00:03:00] once I’m doing all this as a patient-centered pathologist and I realize with all this work taking care of patient’s research, education, I can only help one patient at a time. But if you are involved in organize the medicine to volunteer in the pathology societies to involved in advocacy, involved in promote pathology and the laboratory medicine, we become more influential and impactful because pathology and the laboratory medicine is such important discipline.
We’re like the central nervous system in the whole healthcare system. So, we need to protect what pathologist does and augment what pathologists do. So, in order to deliver the best quality of patient care. So, in a nutshell, I’m a patient-centered pathologist. Everything you see me doing is to serve the purpose of improving the quality of patient care as a pathologist.
Aleksandra: And this very much comes across in your book, but [00:04:00] we’re gonna get to your book later.
Marilyn: I know.
Aleksandra: I wanna dive into the digital pathology aspect of your work. So, in 2019, you were the president of the DPA. How did your journey with digital pathology even start before you became the president?
Marilyn: I started doing quantitative image analysis of breast cancer biomarkers, the receptor, progesterone receptor, and heart too in the 1990s at the University of Florida. And that’s my very first digital pathology journey, and I kept up with a biomarker testing component. And then when I started my job at the Moffitt Cancer Center 18 years ago, the analytic mic cross before, which is the core lab of the cancer center, because Cancer Center has, the patient care of part, has the research part, everybody shares.
Analytic microscopic course. So, they need a scientific director. Somebody is a PhD, has the scientific [00:05:00] background, and also a pathologist having the digital pathology, quantitative image analysis experience. So, I fit the bill. So as a junior faculty, I was giving that wonderful opportunity. So, when I started, I asked myself I’m a trained pathologist and also a scientist.
But nobody ever trained me in digital pathology. I have working experience, but that’s a totally different science, so I want to learn about it. So, I start to look for associations that is doing that, and digital pathology association is perfect for that. At the same time, there are other like Association of pathology, informatics, so I became a member.
And then DPA was really open their arms. They say we really welcoming academic pathologists because most members are vendor right now. But we envision to have old pathologists coming in so we can work as partners to advance the science of digital pathology. I was like, this is perfect, because the [00:06:00] pathologist will be the end user of this.
So we need to be involved in design digital pathology at the very beginning so we can make sure that products coming out actually serve the better patient care purpose. So, then they said, you’ll be perfect to be involved in the education committee and help us organize the national meeting. I take on that challenge, so I rise from the member of the committee chair, that committee.
And then later on just promoted into executive committee and then eventually the president. So, I was trying to find the partners to travel this digital pathology learning together and just being involved and then contribute, and then you get recognized and then you get into that leadership position.
Aleksandra: And so, I recently learned that this journey to the leadership position, it’s like a five-year long journey.
So, it’s not like you raise your hand and then you become president. It is a process and that there’s an official goal or like framework for [00:07:00] each presidency. What was yours and how did you achieve it?
Marilyn: So basically, Three goals. One is to engage and empower the membership because this is a member-oriented organization.
So the work is done through the membership and the leadership. So engage in power membership, that’s number one. Second is to enrich our educational content. So, we have this flag ship educational meeting called pathology missions that were. We also have a lot of other revenues now, for example, podcast, white papers, blogs and regional meetings, and we support our society, provide educational content for them, so that’s enriched educational content.
The last one is to augment our advocacy effort in clear the regulatory pathway in standardize for example, Introduce the [00:08:00] standardization. So, all the vendors in digital pathology can share a common format. Right now, everybody recognize Dicom is the one. So, this way digital pathology will be standardized, and people can really work together to advance the size in this area.
So, the way to reach all those 3 goals the most importantly is engaging, empower the board members. We have very talented, passionate, engaged board members, and the one approach I’m taking is to point the key person from the board to be in charge of a certain committees. For example, membership committee is very important one, so we put in a very talented executive into that position.
Sure enough for the past years. Every year we reach the membership engagement goal, and then we pretty much blew out all the bar we’re setting to ourselves. So now [00:09:00] the digital pathology has more than 2,600 members in the DPA, so that’s a big improvement.
Aleksandra: That’s a thousand more people than I just reviewed an article you wrote for the 10th anniversary, which is when you were president and it was, the number was 1,600 and you’re now.
Marilyn: It’s like a 1000 more.
Aleksandra: Congratulations.
Marilyn: Yeah, this is just wonderful. So, when you have everything, you build that framework, you put the right person into the right position, and everybody work together. Today’s Digital Pathology Association, it’s much more mature, it’s the leader in digital pathology and ai. So, I’m very grateful to be involved in this organization.
Helped me with my professional development in digital pathology, and also help a lot of other people at the same time. We offer so many opportunities for the next generation, pathologists and scientists. They want to be involved. For example, [00:10:00] when I finish being the president of the DPA, there’s sometimes the president will be active for a couple of years and then they disappear in the background.
But I know I still have so much to give. So, in addition to what we talk about, I ask myself, what is the legacy? What is the gift we’re gonna give to our next generation pathologist? So, I advocated the DAPA, that’s a digital anatomical pathology academy. I collaborated with Dr. Raj Singh, who is the creator and of the path presenter.
Aleksandra: And he was a guest on this podcast as well.
I’m gonna link to the, to this episode in the show notes.
Marilyn: Very good. So DPA was very supportive and invested in this. Now you can go to the DPA website to check. We have DAPA is very active, additional component. Now we have a brand new DAPA grant round. Dr. Singh invited those famous pathologists in the world to give lectures [00:11:00] using whole slide images.
We even have DAPA fellows now every year we recruit 2 to 3 fellows to help us post case of the month. And because my connection with the Chinese American Pathology Association, I connect these 2 organizations together. Now DAPA has access to all the wonderful weekly Zoom teaching from Chinese American Pathologists Association has added educational material to our trainees.
So basically, can you imagine if you are a pathologist, even outside you as, you have no access to wholesale image. You have no access to those high calibers of systemic teaching in pathology. If you become either DPA member or the CAPA member, you have access to all those. This is such a wonderful gift of education to all the pathology trainings and the practicing pathologist.
So I am very grateful for DPA [00:12:00] listen to what we have to propose and put money, manpower, and the support behind it. So, we’re hoping more people will take advantage of that opportunity. So, this is just a gift with open heart, with open mind, and please learn. And so, you can enjoy pathology and then you can help your patient better.
So, if you get me started talking about, we’re gonna take the entire whole hour. Yeah.
Aleksandra: So, this is fantastic, and I hope this episode is gonna help with spreading the word about it to those who don’t know about it yet. Because the only like hurdle is that you don’t know about it. Once you know about it, it’s a no-brainer.
And if you wanna learn, this is the place to go. But Marilyn, I wanna ask about something that didn’t go so well about a failure or big hurdle that you have to overcome in this digital pathology trailblazing journey of yours and tell me about it and if there was a valuable lesson that you learned from it. [[00:13:00]
Marilyn: So, I recognize the digital pathology’s benefit in teaching. So, at the very beginning, I started born south tissue teaching site in digital pathology. So, I used the scanner, I archived it at analytic microscopic for or because I got a grant to support it, but I didn’t think it’s through.
First those cases are not really linked to the path report then you have to physically enter that information, that’s one. Second is, how do I share this information? I can only share people who have access to my own, like a scanner, so I cannot really get offsite, my firewall, so I was like, oh, I hit the wall.
Then I met Dr. Raj Singh in one of the digital pathology meetings and he has path presenter. I was like, oh my gosh, there is somebody smarter. We taught through everything, so we made this perfect match. So, we [00:14:00] immediately made that connection because our goal is to promote pathology education using digital pathology.
So I introduced him to DPA, so we work on DAPA together and then I introduced Path Presenter to a lot of the educational activities that I’m involved. You probably realize that there is a platform I’m heavily involved with called the her2know.com.
So, her 2 h e r 2, so that’s the biomarker for breast cancer. Know is know.com. So, this is a sponsored ban, non-branded educational platform. We’re teaching pathologists to help them to be able to read and interpret her2 results much better. Because for pathologists in the era of precision medicine, we are not only making diagnosis, but we also report on the biomarker information to provide [00:15:00] prognostic and predictive information.
Her tool is a big one because breast cancer is the number one in women it also caused death for the longest time, we understand her tool as positive or negative. If her tool is positive, there is targeted therapy treating, it if it’s negative, this target therapy doesn’t work, but there’s only 15% of the breast cancer patients are considered positive.
Just in the recent couple of years, there is this landmark study realized even for the 85, HER2 negative patients, there is a great majority, 65% showing low level of HER2 expression called HER2-low. And there is target therapy for it, FDA approved. So, the medical oncologist looks to pathologists said, can you help us to identify those patients, so we know who to treat?
So, the company that developed the drug collaborate with pathologists and said, we need to work with the pathologist to do this job better. What [00:16:00] kind of educational help do you think we should do? So, we proposed website with dietetic lectures, they’re recorded with cases.
Aleksandra: I’m gonna link to everything you’re mentioning in the show notes as well.
Marilyn: Yeah. Oh, very good.
Aleksandra: Yeah, feel free. Do you know throw resources at me? All of this is gonna be later in the show notes for anyone who wants to actually look at this.
Marilyn: Wonderful. So that would be a link so more people would know about, and then I was like, oh my gosh. Every time while I show I just, image is only one, but in our practice, we look at a whole slide.
So, I introduced the path presenter to them, now there are whole slide libraries on the size people can actually review and then we went further. We said we did all those lectures. But we really need to tell people why this is important. So, they created this animated film. If you watch it, it’s only a few minutes, but every time when I watch it, it just gives me this visceral goosebump.
[00:17:00] It’s showing patients they got this breast cancer diagnosis, they feel frustrated, especially when they told her two negatives. They know there’s not much treatment going on there. And then what they realized. Maybe now there’s a HER2-Low now, maybe there’s a hope now. So, we give people hope and that little video just really touched me in at so many levels.
And then we were like, then why don’t we do a documentary film on the history of HER2 and emphasized the collaboration to medical and the pathologist. I would love to show the life of pathologists. How do we help the patient and that people said, okay, that’s great. We’re gonna make a documentary film and you are going to be the pathologist.
So, there is documentary film now and the spotlighted pathologists collaborate with medical oncologists. Now I recruited my colleagues in pathology to be in this film, and my cancer center was highlighted. [00:18:00] They were very supportive. Our marketing person competed us for 3 full days and to take us shots. So, I was like, this is fantastic because I always knew I want to be a doctor, a physician, but it took me a long time to realize being a pathologist, it’s where I fit the best.
And in this position, I was able to do all I was described before, I was able to, I’m able to talk to somebody like you and I’m able to play in a documentary film.
Aleksandra: This, you wrote the book, so you are like, totally not the stereotype of a pathologist. Stereotype of a pathologist is, and you know what? Many people fit the stereotype and I’m probably personally being one of them.
Somebody who decided to do medicine, but they didn’t really wanna interact with patients. So, I actually I’m a veterinary pathologist and I did practice veterinary [00:19:00] medicine for around 3 years. And then my decision to go into pathology was I didn’t wanna deal with patients, you’re like the opposite of that.
And this is what comes across in all your actions and the way you structured your career and the book. Let’s talk about the book, the Healing Art of Pathology. Where Dr. Marilyn Bui is the co-author and let me just give you my first impression, I bought this book and it is not a pathology book, it’s an art book.
Tell me more about this book.
Marilyn: Yes. Before we get into the book the general conception of pathologist. So, for the people who apply to pathology, if you go to interview, you go to tell the people, interview you. The reason I want to do pathology because I don’t wanna deal with patients.
Aleksandra: Don’t say that, right?
Marilyn: That’s gonna be a red flag, you want to be a pathology because you care about patient. I guarantee you every single pathologist care about the patient because the report we write down [00:20:00] have such a huge impact. But I have to agree that many of the pathologists probably prefer to let our clinical teams be the patient facing and we stay behind to be their doctors, so then we can have a more normal regular schedule.
So, we have a little better control of our schedule. So, I agree, but all pathologists care about that patient and there are a lot of pathologists also have patient encounter experience. For example, I’m a board certified in set of pathology. I perform familial aspiration.
So, I interact with patients I enjoy those moments, I sometimes even ask my patient, do you want to see the tissue we got from you? And if they’re open to it, I will actually show them what we see behind the scenes. Because this was inspired by my patient Ray Paul. And he gives me permission to mention his name because his story is really inspirational.
He makes me realize [00:21:00] that being a pathologist, every case come to our desk is not just a case it’s actually a patient that deserve our best effort. So, when he first coming to me, he was diagnosed with a very bad sarcoma, it’s the third time already. I read all his 3 cases, but I only met him when his cancer already metastatic being metastatic, so that’s not very good.
So he said, Dr. Bui, please show me what’s my tumor look like, I want to stare the devils in the eyes. I want to find this devil, but I need to see what they look like. So that’s one thing that make me feel like maybe some of the patients need to know that. So that will give them courage to fight the back, the second thing is he said, I participated the tatretic cells therapy that’s immunotherapy. I was told that this therapy will wake up my immune system generate lymphocyte to [00:22:00] fight back the cancer. Can you show me where’s my dendritic cells are by lymphocyte fighting back. So, I was able to find the dendritic looking cells and show it to him and showing his renewal reaction and all that.
So, this connection makes me realize when patients are educated about their disease, they become the driver in their cancer fighting journey. So, in this case, REPA connected with me. He called me his pathologist, that’s such a badge of honor. He connected with his surgeon, his radiation oncologist, he’s medical oncologist, the wonderful team at the Moffitt Cancer Center.
He connected with himself, he looked with him, what’s my purpose in life? He is a scientist, he’s an artist, and he’s a significant other, and he’s a son, he’s a relative, he’s a friend to many. So, he did the soul searching and he decide to fight back, and he get in [00:23:00] touch with his faith. So, he now is in remission, and he became a much better scientist, much better partner, a much better person.
That’s his own work. I become a much better pathologist because now I connected with my patients, everybody behind each case in a much deeper level, it’s such a humbling experience, I always thought, oh, we are a doctor, we make decision. No, we are part of the equation in the circle of life. Today we may be the doctor tomorrow, we may be the patient at the receiving end.
So, we want to train the next generation pathologist. So, when I become the patient, the person read my slide will be somebody like me, gave her heart and soul to help that particular patient. So, then I thought, wow, I’m gonna take those digital pictures, give it to Ray. [00:24:00] So Ray starts making artwork using his pathology images.
On the canvas as the background, so this whole process make him energized, so he created a whole series called My Sarcoma, it was exhibited in the cancer center. I partnered with him. And we went our show at the Roach when they were doing the art exhibit, they invited Ray to displace his artwork. We went there, attended the opening ceremony, and we team up together and give a talk to the Roach Ventana team as an inspirational talk to show that we are all connected.
We are all doing a part to help people like Ray. Then I thought, wow, this is so inspirational in order for pathologists to do our job better, we need to connect to our patients. We also need to connect to our clinical teams and [00:25:00] the general public so they know the critical work of pathology and the pathologists do.
By creating this artwork is showing a wonderful window, spouse lighting, who pathologists are their talents, their passion. So, you have read this book, this contributed by pathologists, their families, their friends, and patients, right? There are a lot of really wonderful pieces to show. The talents behind the people are writing those pathology reports contributing to patient care.
So this whole book making process just make me a better pathologist, now this book is in the waiting room of the patients. The book has been giving to people who are working with pathologists and this book whenever I go, when I go out of council meetings, I donate that to their public library. And also there’s a little royalty coming from the [00:26:00] CAP publications, but both the coeditor and I, we donate that to the CAP Foundation.
We want that money to help other people and also spread the message that pathology is such a rewarding and important profession for us professionally. We want everybody to be able to practice pathology, be proud of what we do, and also, spread goodwill, good vibes to the whole society.
Aleksandra: So, it took me, I had to go through half of this book, to gain this shift in perspective that you just mentioned.
That, oh, there’s the doctor that makes the decision and it was like I had some kind of inner resistance that. That’s why doctors become doctors to tell you what to do and to treat you, and basically transformed my thinking. In addition to that, around the time where I read the book and they got inspired by your other podcast [00:27:00] episode at the podcast People of Pathology.
So I knew about the book. I got it, and when I was reading it, I learned about friends who were either veterinary surgeon or if surgeons or pathologists being diagnosed with cancer as well.
Marilyn: Yes.
Aleksandra: Like this whole thing and this book like helped me gain a different perspective, understand it in a different way as this hub where medicine, pathology, like other parts of medicine, patient experience and journey come together.
So, it impacted me in a very specific way.
Marilyn: Yeah. So, I’m glad you went deeper and made a connection with this book because we’re we, by making this book, we learned a lot about ourselves and our profession and it’s such a adjustment for me because that’s right before the society recognized there’s a huge burnout among the physicians.
Pathologist is also [00:28:00] one of the groups, but because I realigned with, why I’m doing it? How I’m doing it? And I don’t consider myself, it’s on this is how to give this, I consider myself as part of this circle this ecosystem. Keep open minded, keep openhearted, and the learning from the patients, learning from the cases, learning from my colleagues and continue to contribute.
It’s such a good practice, I feel like I’m almost burnout resistant just from making this book, going through this thinking process and be able to tie everything I do with a greater purpose than myself. And also, you also recognize the commonality between art and the medicine because they are all created for us to unburden the burden [00:29:00] that usually human have.
Because when we live alive, and we always have all kind of burdens and in front of us. But art and the medicine is to release us from that, uplifting us from that and give us hope. So that book also serving that purpose too, giving us hope, especially we need to look deep into ourselves to realize.
We’re part of this equation and being open-minded, open-hearted, we can get a lot more from our work than just doing it in the old-fashioned way.
Aleksandra: I didn’t know this conversation’s gonna go that way, I should have expected this judging by your, your career path. But this is so true. Like when you connect often, if you don’t make this personal connection and this book, working on this book was this transformation path for you.
Then all these things like better patient care, better faster diagnosis, better collaboration, faster drug to market, [00:30:00] I happen to work in the drug development work. These are just slogan, and you know you should use them, you see them in marketing materials, unless you actually connect it to what you are looking at on the slide and that there is somebody on the other end and you uniquely with cytopathology you actually get in touch with patients.
Yeah. So, I bought this book out of curiosity, and if anybody listening is at least a little bit curious, just get this book and see what it’s gonna do for you. I was surprised with, I just bought it cuz I’m like, okay, I’m in the pathology world, digital pathology world. Let me buy the book of a past DPA president and I didn’t expect what it’s gonna do to me.
I didn’t think I’m gonna go that deep.
Marilyn: Oh, thank you so much. There are so many people support this book, I can’t even list all their name that to support, for example, when the book first published, my state has society said, everybody please buy this book and to support this [00:31:00] book, pathologist in the foundation.
And I have a lot of pathologist friends, they buy multiple copies and then they put in different places in their break rooms and then, there’s one pathologist, his break room also shared by other people, like the firefighters and the police when they were in training. Then they come to this lab, share that, and you’ll see this firefighter in their own uniform open up this book, reading it.
I was like, oh, that’s such a great image and then you will see the vendors for pathologist. And then after they listened to my talk, they said, oh, we are going to purchase this book and give it to our members because their product support pathologists so need to understand what the pathologist does. There are so many people are supporting this book, including yourself, so I really do.
Aleksandra: I’m gonna link to it in the description as well. So anybody who wants to have a look.
Marilyn: I have one other background.
Aleksandra: Yeah. Show it.
Marilyn: Yeah. So for that, camera page is a pathologist and she’s a [00:32:00] breast cancer survivor herself. And then when I reach out to her, said, could you please contribute to this artwork?
And she was going to have a surgery the following day. So she wrote a very touching piece, talk about, why it’s in the spiral shape, why she’s a painting a fish because it means the transformation. So we all have to transform ourself no matter what kind of adversity is in front of ourself, we need to continue to transform ourself and then the moving forward.
So there are lot of really inspirational message and to me it’s almost like a chicken soup for the soul, but in pathology.
Aleksandra: In pathology, yeah. Before we go, what do you think is gonna be the one thing that’s gonna drive digital pathology further? What’s the next thing that’s gonna make it more ubiquitous?
Not just in the image analysis centers, but actually in all the practices. Do you have something? [[00:33:00]
Marilyn: So the short answer is, the immediate benefit of digital pathology is the connectivity because when we no longer change to the microscope, you can connect with your own colleagues, the colleagues outside your hospital, state and country, or you can connect to other profession.
The second piece is, Because of digital pathology give rise to ai, so AI can do a lot of things to augment pathologist’s ability, so those are just the tactic. But the strategy is now pathology is experiencing the third revolution. So that’s digital pathology in ai because we’re in the precision medicine era and there are so much information coming down to pathology from the H E, from the IHC, from the molecular pathology. We really need a computation pathology tool because our profession is changing, especially AP from just reading interpretation to measuring [00:34:00] quantification, pre prediction. So strategically, in order for our profession to survive in a thrive, we must embrace digital pathology and ai.
So all the other things we’re doing are main like tech. So if people can understand that, then they’re gonna realize digital pathology is today’s pathology. There are many forms of adoption, but this is going and then that’s the direction we’re going and that’s a pathologist.
When we involved in this, we can control which direction this is going. So hopefully that’s helpful and also sums up why we’re excited about the digital pathology.
Aleksandra: Thank you so much for joining us, and thank you for letting us know about your journey and about your digital pathology journey. I’m gonna link to everything that we mentioned in the show notes, and I hope you have a great day.
Marilyn: And thank you so much and thank you for everything you’re doing. I’m a fan of you and I’ve been and really appreciate this opportunity.
Aleksandra: See, [00:35:00] next time we meet I’m gonna break the book and I’m gonna have you autograph it for me.
Marilyn: I will be honored.
Aleksandra: Thank you so much.
Marilyn: Bye.
Aleksandra: Thank you for staying till the end. This was not our classical tech heavy digital pathology conversation, but digital pathology very much plays in Dr. Bui’s mission. So, if you are curious about the book that we talked so much about, go ahead check the link below and see what this book does for me. It definitely did strange things to me, and I highly recommend it, and I talk to you in the next episode.
