July 13, 2023

Interviewer: Professor Masayuki Amagai, President of JDA

We are truly fortunate to be joined by Prof. Terry Cronin for our first ever in-person JDA Leadership Dialogue. We will jump into the questions shortly, but could you first please introduce yourself to the JDA audience?

My name is Terry Cronin, and I am serving as the President of the American Academy of Dermatology (AAD) from 2023 to 2024. It is an honor and privilege to be here and be the first in-person interviewee of the Leadership Dialogue series. Following the World Congress in Singapore, I have had the opportunity to travel around Japan and meet fellow dermatologists from Kyoto University and Osaka University over the past week. It has been a fantastic experience and I have been treated very well.

In terms of my background, I actually followed the footsteps of my father, who was a dermatologist. I entered medical school and considered the various disciplines with an open mind, but I found myself drawn to dermatology because I am a visual learner. As a child, I loved reading comic books and watching movies and learning about the intricacies of visual detail. So, when I discovered the idea of looking at skin and making diagnoses to help patients, I became interested in dermatology. I was fortunate to train at the University of Miami, where the chair of the Department of Dermatology was Dr. Bill Eaglstein. He was like a father figure to his residents. And now, I have a private practice in Melbourne, Florida together with my father, and my niece who is also a dermatologist. It is a family legacy.

I think that dermatology must have been imprinted in your genes, in a way. My father was actually a dermato-urologist. The early roots of dermatology in Japan were linked to treating syphilis, and thus aligned with urology. So, for the first several decades of modern Japanese medical history, we called it dermato-urology, and that is what my father studied. My parents instilled in me a desire to become a doctor, but dermatology and urology were the only specialties I considered.

Your father was a good role model to you. In the U.S., we used to call our specialty "dermatology and syphilology," but we moved on from that term. Urology in America is mostly a surgical specialty, but dermatologists still treat many sexually transmitted diseases. It is interesting that urologists and dermatologists would be so closely aligned in Japan.

The first dermatologist in Japan also had to learn and teach about urethral-related sexually transmitted diseases, which is part of the reason for the combination of specialties. I believe in the early '60s at my university, the urology and dermatology departments separated.

In the U.S., there was a transformation in the '60s and '70s, where dermatologists became more surgery-oriented, whereas previously they were strictly departments of medicine. We bridge medicine and surgery in a unique way.

What kind of surgery do you do?

I myself focus mostly on skin cancer surgery, such as Mohs surgery for skin cancer and melanoma. I do a lot of surveillance and skin cancer operations. I am not a cosmetic-oriented dermatologist, but some of my colleagues do incredible work in that sphere, including many interesting approaches to try to fight the effects of aging.

Can you tell us more about Mohs surgery? This is a surgery that is not available in Japan.

Dr. Mohs was a surgeon who practiced in Wisconsin and revolutionized cancer treatment by using zinc chloride paste to fix the cancer and then remove it in stages, analyzing complete margins. Unlike the typical way of taking out a specimen and cutting it like a bread loaf, his method was instead like peeling the specimen margin like an orange peel, before looking at it under a microscope. This changed pathology assessment. Then, in the '70s, Dr. Tromovitch and Dr. Stegman began doing surgery on frozen sections rather than using zinc chloride paste, drastically reducing procedure time and the number of needed visits. The dermatologist works as the surgeon and the pathologist during Mohs surgery. They look at it under the microscope while the patient is waiting, and when the cancer has been completely removed, the dermatologist repairs the wound.

There are many ways that people do Mohs surgery, but typically it is more cost effective for the same one doctor to handle both the surgery and pathology for a patient. Usually, there is a lab adjacent to the operation room, so we present the specimen to the histotechnologist, and they cut the sections to prepare the slide for us to examine.

I was impressed when I first saw Mohs surgery, but when I talked about setting it up in Japan, there are many difficulties. First of all, in the U.S., there are dermatopathologists, but in Japan, the pathologists are in charge of everything. When we have a skin biopsy, all the specimens are sent to the pathology department, who makes the blocks and sections and makes a report that gets sent back to us. But then we have to reevaluate the pathological slide. In Japan, there are some dermatopathologists, but they charge off the insurance system, so it is complex.

When you are learning dermatology in America, we spend a lot of time looking at slides, is it the same in Japan?

That is the same, like in our university, we ask the pathological department to make extra slides, which get sent to us. We look at it and make our own report without any charge. It is for educational reasons and for increasing the diagnostic level. The pathologists are good at cancer, but not at many different types of skin inflammation.

The government may change their policy if you can show how often you change the diagnosis or improve the diagnosis by looking at it as a dermatologist. In the U.S., that would be a consulting fee to have another specialist look at it, and having the dermatologist providing this service brings additional value to the patients.

Japan has a national insurance system, and the total budget is much less than that in the U.S. In the '90s, Hillary Clinton visited Japan to learn about the hospital system, because the Japanese system was able to provide a high level of care at very low cost. When she was leaving at the airport, in an interview she said this could not be reproduced in the U.S., because Japanese doctors are like priests; they do not demand more money and medical care is fixed fees.

Actually, in the U.S. we also have the same fixed amount system, whether it is the best surgeon or a brand-new surgeon. However, there are people, particularly in the cosmetic dermatology realm, who leave the system and have very wealthy clientele who come to them to look younger and fight the ravages of aging. It is not really medicine but is a part of the dermatology field. In Japan, can dermatologists go into a private practice and perform cosmetic procedures?

It is possible, but for cosmetic procedures, they are not covered by the national insurance system and therefore it becomes a free market.

If a doctor is doing cosmetic dermatology and harms a patient, is there a medical board that revokes their license to practice, like in the U.S.? With some extreme procedures, there can even be loss of life.

Yes, it works similarly. How does the AAD balance the two fields?

One of our pillars at AAD is unity, since we are a small specialty. There are many types of practice and specialties that are made up in dermatology in the U.S.: academic vs. private practice; medical vs. surgical; cosmetic vs. medical. To have any power as a dermatology specialty and to advocate for our patients, we advocate that we are much stronger together. We cannot make everyone happy, but we try to focus on those things we can agree.

What concrete strategies do you have to unify across divisions?

About 25 years ago, we had a president, Dr. Boni Elewski. She was a visionary when it came to unifying, and she brought people into the same room, to talk and hash out their differences. Spending time with one another, people become friends and realize they have a lot in common. I became concerned during the COVID-19 pandemic that we were losing some of our humanity in Zoom calls. You miss a lot on the Zoom screen, so meeting in person is important.

Also, in America, typically we have our training program then send the doctors elsewhere. If you stay within academia, you go to another university and cross-pollinate. Dr. Kenji Kabashima was telling me about the Japanese situation, where usually the doctors you train stay within your hospital system.

That is a unique Japanese tradition. The majority of people stay within a single institute, like Kenji at Kyoto University or me at Keio University. This a big contrast with the German system, where you can never become a staff at the university you graduated from. I think that is great to cross-pollinate. I think it is starting to change gradually now, though. For example, Dr. Manabu Fujimoto is from the University of Tokyo, but he is at Osaka University now.

here seems to be cross-pollination between the dermatology departments at different universities, how is that achieved?

If someone is interested in research, we can easily send our fellows to learn special techniques somewhere else, but for the medical professions it is not easy. For example, in the last decade, 61 to 68% of new residents are female—they often have families and cannot easily move around or go train elsewhere. In the U.S., how do doctors manage to move around to different institutes with such considerations?

In the U.S. too, dermatology has become female-dominated, but this is not only within dermatology. Young men in America tend not to go to college or medical school as often. However, there are many excellent and brilliant young women becoming dermatologists.

What is common is that people train and may stay at their university if they go into academia, or other opportunities will take them elsewhere. Many trainees go to well-populated and metropolitan cities like New York City or Atlanta. But we are underrepresented in rural areas. Many areas with farmers facing skin cancer issues have no dermatologists nearby. This is an issue we are trying to face in medicine in general. If you train people at Keio University, they stay there, right?

So, depending on the person they will have their own path, such as going into academia, private practice, going abroad, and so on. But even if they forge their own path, if they return to Japan later on, they often come to the same university.

Japanese students make the decision to go to medical school when they are in high school, right?

Yes, that is true.

I think there is an advantage in that system. The four years of college are a great opportunity to study the liberal arts and become well-rounded, but it is a very long road to become a doctor in America. After exceling at college, you study four more years at medical school, then do a year-long internship, and finally three years of dermatology. Then there are even more fellowships and degrees that people pursue. Obviously, there are also fantastic doctors and dermatologists in Japan, but do you feel like you have missed out from not having four years of college?

I think it goes both ways. Students here have to choose their specialty at the age of 18. Preparing for the entrance examination is a huge amount of work, but personally I think this robs time from young teenagers. Making any mistakes will keep you from a top university, but people learn from making mistakes. Society should be more forgiving and generous to the young generation, and I feel this is being lost. As a basic scientist to have one success, you need a thousand failures.

I think you are not alone in that view; we think about this in America as well. High-achieving students in America take entrance exams to go to college, then to go to medical school, then to get into dermatology. We should perhaps not be so reliant on tests, even though I think dermatologists are great test-takers. There is also a movement in America where people want to take a more humanistic view towards how charitable and thoughtful a potential doctor is, as those traits are highly valued by patients. It could be an interesting experiment to get some nicer people in the profession.

We really need to trust the next generation, as they will build the future world. Shifting gears here, I wanted to highlight that you are not only a talented dermatologist and surgeon, but also a novelist. Could you tell us more about this?

One thing I like to talk about is using creative writing to combat burnout. Globally, 64% of doctors are facing burnout—they are losing the joy in their work. With creative writing, you can build joy into your life. You are using a different energy than your day-to-day work. Working in the laboratory may let you use a different creative energy than seeing patients, so that may help burnout as well.

Creative writing is used by psychologists and psychiatrists as a way to help people treat depression or PTSD, and you do not have to be good at writing to use it as a tool to combat burnout. There was a writer-physician who was a survivor of the bombing of Nagasaki, and he processed the tremendous pain of losing his family through writing. I, myself write a novel series about a dermatologist detective. The first ever detective novel was Sherlock Holmes, and it was written by a physician, Arthur Conan Doyle. He based his character on a doctor named Joseph Bell, who was a surgeon and authored a book on dermatology.

When did your creative writing journey begin?

After I was about five years into my practice, I found myself seeing the same things and repeating routine tasks often. During some routine tasks I could use my creative brain, and I eventually came up with an idea for a story in my head. Eventually, I realized that I needed to get this story onto paper. My wife and kids were away for a week, so I forced myself to write 10, 15 pages or more each day until I had a draft. Then, I began showing my friends and got feedback from them.

One friend told me bluntly, "You are telling a great story here, but your writing is terrible." They advised me to get an editor, and not knowing anything about what to expect from hiring an editor, I searched on the internet and found a helpful website. I reached out to several editors, and the first response told me it would take a lot of work and cost 5,000 dollars. After looking through the first chapter they edited for me as a sample, I realized that they did not understand about what it means to be a dermatologist, so he was not the editor for me. The next day, I got an email from Stephen King's editor, who said he was intrigued by my story and offered to edit it for a fraction of the price.

Wow, that is incredible. And you were about 40 years old at the time—I think this encourages many of us to start something new.

I think there are many opportunities, be it poetry, music, creative writing, or others.

Before we close the meeting, I would like to ask a bit more about the mission and the future of AAD.

One of the missions of my being here is to build a closer connection with the JDA, and to invite you to our annual AAD meeting in San Diego in March. It will be an opportunity to connect, and I would like to do some educational cross-pollination.

JDA also has a strong desire to link with AAD, so it is our pleasure to talk with you about possible future collaborations. Finally, could you share a closing message with the JDA audience?

It is an honor and privilege to talk with you today. Prof. Amagai is well-known and highly respected among my peers. On behalf of AAD, thank you for this opportunity to speak with you today. I learned a lot through this conversation.

Thank you!