In this episode, we talk to pathologist Hoda Zeinab M. Amer who discusses her work with non-profits, along with her book detailing the behind-the-scenes lives of pathologists. We also open the proverbial black box of pathology and she explores the traits interested students should have if they pursue the field.

Hoda Zeinab M. Amer is a pathologist and author of Animals of Undetermined Significance.

She shares her story and discusses her KevinMD article, “Scenes from a pathology resident’s day.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Hoda Amer. She is a pathologist, and she’s the author of the book Animals of Undetermined Significance. Hoda, welcome to the show.

Hoda Zeinab M. Amer: Hi, Kevin, thank you for having me.

Kevin Pho: So we’ll get into your book in a little bit, but first off, share your story and journey to where you are today.

Hoda Zeinab M. Amer: Absolutely. So I consider myself a person of many hats, or in this case, many scarves or hats, because I do actually collect hats. But in general, I am a pathologist. I did my training in New Jersey, at UMDNJ. I also did pediatric pathology at Nationwide Children’s in Columbus, Ohio, which is where I’m based, as well as, more recently, cytopathology training at the Ohio State University.

More importantly, I think, on the personal side, I’m Egyptian American. I’m also a Muslim American. And I grew up in many different international communities, where really every person I met through those years added to who I am today.

I also have a passion for nonprofit work. I’ve worked with a number of nonprofits. I’m also the co-founder of a nonprofit called the American Board Certified Doctors for Egypt, and that nonprofit started just after, in the wake of, the Egyptian Revolution in 2011, when a lot of us who are based in the U.S. really wanted to share, or to feel that we could give back to our mother country, or the country of our origin. What we do is mainly education and training. We also have a grant or loan system for young Egyptian physicians who are applying to residency or the match process here and just need a little financial incentive. We usually begin collection in summer.

And on a personal note, my areas of passion would mainly be HPV and vaccinations, as well as the fight against FGM, which is ongoing and can span from Columbus all the way to Cairo. So that’s pretty much me altogether.

Kevin Pho: So I’m interested in your involvement with nonprofit work, because I think a lot of physicians would want to get involved with something like that. So for clinicians listening to this show who are interested in becoming involved or even starting a nonprofit, how does one go about doing that?

Hoda Zeinab M. Amer: So in starting a nonprofit, the first and main thing, honestly, is that you really need that passion and that drive. There’s a lot of legal background that you have to get through, a lot of legal jargon, and you also need to have a definite pathway of what you’re going to be doing and what you want to provide.

So our goal has been, from the start, to provide education and training with our partners. We consider them partners. Egypt in particular is an interesting country, because it’s considered a middle-income country, which has a wide range. You have, way up there, great care, and then you have, way down there, very limited care for the underprivileged. So we work with our partners there. We see what their needs are in their hospitals, and if they need some kind of training.

So, for example, one of our most successful programs was with neonatology in a hospital called Sheikh Zayed. We provided them with nine months: Every month, we would send a physician there. They would provide training to the residents, and they would follow a curriculum-based path that would be built on by the next physician who went to visit. And we would give feedback to the head of the department on the areas of weakness.

More recently, we started a grant program for the young physicians who are applying for residency here in the U.S. It can be incredibly, incredibly expensive. You’re talking about travel, where the ticket by itself is over $1,000, interviews, the USMLE exams, and so on and so forth. And so this has been very successful. Every year we provide five applicants with about $3,000, $3,000 to $5,000 depending on how much we get each year. And they use that money to pay for whatever expenses they need to get themselves over the finish line. We’re really proud of the last group, because four out of the five matched. And it’s actually a grant, so they pay it back to us after five years. So those are the two main programs.

For me, on my side, my area of expertise, what I like to focus on, is HPV, human papillomavirus. And that’s because the majority of poor and middle-income countries do not have access to the vaccine. So there’s a massive gap between the haves and have-nots globally. You have places like the U.S. or Europe, where it’s going to be almost zero in about 10 years, while, on the other hand, you have continents like Africa, where it’s going to be over 90 percent of cervical cancer caused by the HPV virus.

In particular, countries like Egypt face a challenge, because you have groups like the Global Alliance who provide the HPV vaccine to lower-income countries, and Egypt would not qualify, as a middle-income country. And so for a country like Egypt, it’s much more about prioritizing through the nongovernmental sectors or through the governmental sectors. So we were very happy to do an awareness campaign a couple of years ago. We went and visited a few hospitals. We did some lectures, myself and my colleague, Dr. Kawsar Talaat, a vaccine expert from Johns Hopkins. And we got a lot of very good feedback. Then, of course, COVID hit about a year after that, and we’ve been kind of back and forth.

But in the meantime, I did some volunteer work with a group called My Project USA here in the U.S. And that would be my other area, which is the problem of female genital mutilation. Unfortunately, this continues to happen, and Columbus, Ohio, has among the higher rates of FGM. It is not an exact rate. It’s based on population demographics. So, for example, we have a large Somali population. So therefore, there’s a large presumed number of FGM, but there really isn’t an FGM clinic they can go to, and so on.

And then the connection between Cairo and Columbus is very interesting, because they call it vacation cutting. People from Egypt or any other country, if they really want this to be done to their daughters, would actually go during summertime and have it done in the villages, wherever it is done in Egypt. And so it’s actually very much correlated. So the laws in Egypt became more strict this year. Again, we don’t have data, but it’s presumed that that will reflect on at least that particular area. So My Project USA is a group that provides for an underprivileged area here in Columbus, which is mainly of Somali origin. But obviously, their work and my work, when we were working together, overlapped in many areas.

So, to your question about how people could get involved: Definitely, absolutely, we always welcome anyone joining us through the ABCDE. And again, I totally encourage all physicians. There are a lot of ways you can give back from your background. You have very unique positions in your communities, and just looking around you to see what that need is, making a group, and really pushing for that to make the change is something that, in this day and age, is not only rare, but it’s very much needed.

Kevin Pho: All right. Let’s move on to your book. It’s titled Animals of Undetermined Significance. Now, what are some of the main points and takeaways that you want readers to come away with after reading it?

Hoda Zeinab M. Amer: So Animals of Undetermined Significance has been a long time in the making. Through my years, I’ve been faced with many different situations where I was like, “You know, I really wish more people knew about this.”

I’d say the first one is the diversity. I don’t think people realize the extent of diversity and background among the pathologists who make up the pathology world, you know? And so this particular book is about five residents, and they’re going through their daily lives in the pathology department. Each one is very different from the other. So you have Neil, for example, who is from a Hindu American background. You have Pixie, whose ethnicity you don’t really know, but you know that she’s kind of tough and rough, kind of the classic witch you see in some places. But then you kind of find out what kind of vulnerable background she came from that she’s compensating for. You have Senna, who is British Sudanese Muslim. And then you have Jane, who is of Chinese origin. And so you have a lot of different people, and then also their attendings as well. And so it’s a hugely diverse cast, not only from an ethnic point, but also just from personalities and how all of it kind of clashes together. So that would be the first thing, just how diverse everything is.

The second point is the challenges that are faced by new moms. So the first part of the book really focuses on Marla and her first day back. Her name is Marla, M-A-R-L-A, and she’s going back to work after six weeks of maternity leave. These are things that I’ve seen myself, or my friends have gone through. Of course, I’m extrapolating a bit in the book to make it a little more interesting.

But Marla goes, and her first problem is that she can’t find a place to pump. So where do new mothers go to keep up their breast milk if there are no pumping rooms? Back when I was a resident, which would have been about 10 years ago, there were no pumping rooms at all. When I was a fellow just three years ago, there were pumping rooms, but nobody knew where they were. So it’s an ongoing challenge. OK, well, what do you do? And so finally she ends up pumping in this really nasty storage room and tries to make it fit for her. But that’s very classic, if you hear the stories of where women have gone to pump and keep up their milk.

The other thing is just the bullying. There was a lot of passive aggressiveness toward moms. I’m not saying all environments are like this. Definitely, there has been a lot of progress, but it still remains that there’s a lot of this passive aggressiveness, whether it’s comments about her body or comments about her response to situations, which would be interpreted as hysteria rather than just a genuine concern or a natural response for her.

And then just how difficult it can be. So, for example, there’s this one part where she’s walking around with her shirt open, with her nursing bra underneath, and she’s totally forgotten. And does this happen? Yeah. And instead of finding support, it’s more like she has to prove herself worthy of the position of resident, or chief resident, with her new role as mom. So I would say that would be the second main point.

The third main point is really: What does a pathologist do? So this book is a really great way to show people just what the day-to-day life of a pathology resident is, what the different kinds are. People think that pathologists have absolutely nothing to do with patients, that we’re like these mutants who kind of hide in little corners somewhere. And that’s not actually true. So we get to actually follow Marla as she goes to a fine needle aspiration, which is a very hands-on experience, right? We get to see her as she does a medical autopsy, and how she connects to that individual, when she has to find the reason for their death, for example. And then also just the various different cases that we see, the different things that we, and the way each of us as a pathologist can.

And so part of this book is really just telling people out there. I mean, it’s always fun when people say, “What do you do?” And I’m like, “I’m a pathologist,” and then they have all these images of CSI and all this fancy stuff. And yeah, that’s me in my alternative life. I’m definitely that good-looking when I go home, right? But the fact is that nobody really knows what we do.

And even with the surgeons, I show a lot of the back and forth that you go through to try to educate them: the limitations of what we can do, and what the pathology jargon actually means. Years ago, it used to be that pathology was an offshoot of surgery. So surgeons were already adept at understanding what pathology is, and at one point in time, they even did their own. For example, my dad, who was an oncologist, used to read his own bone marrow biopsies at one point in time. But as time went on, it kind of diverged into completely different worlds. There’s an article about how pathologists are from Venus and surgeons are from Mars, or whatever. And so that’s the problem.

And then there’s also the problem with pathologists themselves. A lot of us genuinely like to keep to ourselves, and because of that, we do end up in these little basement areas without windows, and nobody sees us. The patient team doesn’t see us. They see our name on a report, and they think that we’re the ones who gave it to them: “You’re the one who gave me this disease.” Well, I didn’t exactly give it to you. And so we’d really want to change that narrative of the value of a pathologist as part of the clinicians and part of the treatment teams, and just an awareness of what we do.

Kevin Pho: Now, the people and the stories that you have in the book, are they from real-life events? Are they from stories that you’ve heard from others?

Hoda Zeinab M. Amer: So, absolutely not. This is completely fiction, but a lot of them kind of remind me of various people, and there are situations that I’ve heard of other people going through. So, for example, Marla walking around with her shirt open, OK, that’s similar to a friend of a friend who actually forgot and wore her nursing bra on the outside instead of the inside. So things like that. But I definitely do not want to say that any of this is actually true or factual on any basis or level. I’ve exaggerated to make it more humorous and more interesting. And humor is a great defensive mechanism, a great way to actually portray things that would otherwise be kind of uncomfortable or awkward for a lot of people.

Kevin Pho: Now, for those medical students who may be interested in pathology, what kind of characteristics or traits would best suit them to the profession?

Hoda Zeinab M. Amer: Honestly, I would say to any medical student who is interested in it to really go and do a rotation in pathology, and not just from the outside. Go there, be with the residents, and follow the cases from the minute they come in to the minute they are signed out. You can learn so much from that. And then, in between that, also attend surgery, and also attend, for example, heme-oncology. Attend the tumor boards. Those are great ways to really get the idea of what the role of pathology is.

I would definitely say that, believe it or not, you actually have to be pretty personable in pathology. People think that you don’t have to deal with patients, so therefore you can be a recluse. No, we’re dealing with the surgeons. We’re dealing with other clinicians. We’re dealing with the patient as a whole. So pathologists are the ones who have an idea of every single thing.

So, for example, if the patient has a GI biopsy, we’re the ones who are going to look back and see what kind of treatment they’re taking. What does that medicine look like in the esophagus, when it might be embedded? What does that surgery look like? What is the reaction to that surgery? What kind of post-radiation change would that be? So we have to know a little bit about everything to actually become a pathologist. But definitely, it is a place I totally encourage everyone to really explore, at least, and get an idea and an understanding of.

And yeah, in the book, we have an intern who kind of follows along. He’s a funny kind of little character. But it’s sort of cute to see the things that he’s joining in on and where he puts himself in the end.

Kevin Pho: And to your fellow clinicians listening to this podcast, you have a platform now. What’s the single biggest misconception about pathology that you want to clear up right now?

Hoda Zeinab M. Amer: Well, that we’re not clinicians, because we are. Our patients, yes, are sort of in slide form a lot of the time. But we genuinely are part of that treatment team. And really, like I said, there’s a lot that can be done to re-involve pathologists in the patient care outlook and in the decision-making of any hospital. And please provide us with places that have windows. We need sunlight too.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Hoda Zeinab M. Amer: Well, I’d say this is a great time when your voice can be heard. I published my book on Amazon. I did not have to go through a publisher. These are like open forums, where literally, if you have something you want to do, something you want to say, take the chance. I really do see ourselves, especially our female physicians, especially our diverse physicians, especially our physicians who have empathy and an understanding of the challenges in our communities today, really using their voices and the resources that are available in today’s age, which is really unique compared to what has ever been done before.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Hoda Zeinab M. Amer: Thank you so much. I enjoyed it.

Kevin Pho: Thank you so much.