An Infectious Commitment to Medical Education
James Troy, MD, 2024 DF Clark W. Finnerud Award Recipient
June 2024
James Troy, MD, is the recipient of the 2024 DF Clark W. Finnerud Award. This Dermatology Foundation award recognizes his devotion over the course of a long career to voluntarily teach and mentor residents while running a thriving dermatopathology private practice. Dr. Troy is Clinical Professor of Dermatology at the Medical College of Wisconsin in Milwaukee.
The Clark W. Finnerud Award: What it Takes
The Clark W. Finnerud Award honors dermatologists who are part-time clinicians and part-time teachers. Established in 1971, the award bears the name of the late Dr. Clark W. Finnerud, a dedicated teacher and clinician who served the Rush Medical School for 47 years. This award honors not only part-time teachers but also Dr. Finnerud for his achievements, foresight, and generosity.
Becoming a dermatopathologist
Dr. Troy was in the second year of an internal medicine residency at Columbia-Presbyterian Medical Center when his future wife, Kristin Thorsen, MD, suggested he consider dermatology. He was frustrated as an internist at waiting for lab results, then having to make difficult decisions for acutely ill patients. He accepted an offered position in the Columbia dermatology residency. His wife also played an instrumental role in his choice to be a dermatopathologist.
“I needed to do something during the year in New York when she was finishing her residency,” Dr. Troy said. “We planned to go back to Milwaukee, and the dermatology program there needed someone to teach dermpath to residents. Never anticipating a career in dermatopathology, I applied for a fellowship with Dr. Bernard Ackerman at NYU.”
During this time, he worked diligently with Dr. Ackerman to write a diagnostic textbook of dermatopathology. Over lunch, they would review numerous previously collected cases. At night, Dr. Troy would write up their notes that Dr. Ackerman would then edit. They completed 40 of the 45 chapters of the book this way, and the textbook was published a few years after Dr. Troy completed his fellowship (Ackerman et al. 1988).
Teaching, mentorship, and the art of public speaking
After starting in 1981 on the full-time faculty, in 1983 Dr. Troy became a part-time and eventually volunteer faculty member at the Medical College of Wisconsin (MCW). He became Clinical Professor of Dermatology in 2001, continuing to teach dermatology residents until he retired in 2023. He saw clinical patients on campus and in the private setting until 2008, when he devoted all his efforts to dermatopathology. For decades, he welcomed residents on their dermatopathology rotation who drove to his private practice. He also traveled to the campus to lead innumerable unknown sessions.
For decades, he welcomed residents on their dermatopathology rotation who drove to his private practice. He also traveled to the campus to lead innumerable unknown sessions.
“He coached residents on accurate and crisp communication in clinic presentations, Grand Rounds morphologic descriptions, and lectures,” according to an enthusiastic letter of recommendation submitted for this award that was signed by 98 alumni and three past directors of the residency program at MCW. “Dr. Troy was the faculty mentor that practiced countless Wisconsin Dermatological Society presentations with the residents.”
He taught a remarkable 147 residents, including Dr. Beth Drolet, now the Chair in the Department of Dermatology at the School of Medicine and Public Health, University of Wisconsin-Madison. Every fall, the department hosted the Wisconsin Dermatological Society meeting at which residents were expected to present case studies. Dr. Troy helped them perfect their presentations in the evenings, critiquing slides and methods of delivery. He felt residents weren’t being taught these routine skills that would be important in their future careers.
Dr. Troy helped [residents] perfect their presentations in the evenings, critiquing slides and methods of delivery. He felt residents weren’t being taught these routine skills that would be important in their future careers.
“His commitment to excellence was infectious,” Dr. Drolet wrote in her personal letter of recommendation. “He had an authentic and extraordinary commitment to medical education; you knew it mattered to him, so it mattered to you. Each year he would spend several evening hours helping residents prepare for their 5-minute Wisconsin Dermatology presentation. It was during these sessions that I learned the art of public speaking.”
The Troy Rules
Dr. Troy generously bought a 15-headed microscope for his lab to better teach large groups of visiting residents. During their time together looking at slides in this microscope, he shared aphorisms that came to be known as the Troy Rules, many of which can be quoted by alumni of his department.
The clinician is always right—usually.
“The correct diagnosis is in the hands of the clinician, who has the advantage of examining the patient, obtaining an accurate history, and understanding how representative the sample taken is of the disease process. The path report is only an interpretation of a tiny bit of tissue at a single point in time, subject to many variables, including the experience and attitudes of the pathologist.”
Evidence-based medicine has been misinterpreted.
“The clinician’s observation of the patient is the best evidence, and residents undervalue that. They shouldn’t trust the path report more than their in-the-room impression. The path report should be viewed as a lab test and, even if on a written piece of paper, must be integrated into the clinical setting.”
Sometimes the answer is there is no answer.
This maxim was exemplified by the experience of Dr. Olayemi Sokumbi, one of his successful mentees. Dr. Sokumbi, now at the Mayo Clinic, began her career after fellowship training as a new faculty member at MCW. She spent considerable time with Dr. Troy at his lab to study cases together. “Yemi was feeling pressured by clinicians to give them a diagnosis. I taught her that sometimes it’s OK for the pathologist to be uncertain. A descriptive report may be helpful anyway, by excluding some possibilities.”
Beware the pathology report that reads “consistent with.”
It often doesn’t mean “diagnostic of”; maybe it means “could be”. The term “consistent with” may be just a habit of a reporting pathologist, but it is also used as a hedge, meaning that the diagnosis is possible only by using thoughts or suggestions of the referring clinician to arrive at the diagnosis.
Think about the doorknob.
“As you finish an examination and are leaving the patient room (or finishing a review of a slide), with your hand on the doorknob, your last thought should be: How can I screw this up, be wrong, and injure the patient?”
Consulting on the development of a first-of-its-kind medication
Dr. Troy was invited to consult as a dermatopathologist for the team that investigated vemurafenib, a BRAF kinase inhibitor used to treat late-stage melanoma. The FDA approved the drug in 2011, the first time a cloned gene was used as an isolated target in the development of a drug. Oncologists initially were troubled by the frequent appearance of growths, diagnosed by general pathologists as squamous cell carcinoma, on the skin of patients treated with vemurafenib. (Su et al., 2012).
“This was the first time patients were given a pill and they rapidly developed allegedly malignant tumors,” said Dr. Troy. “I was asked to speak about this phenomenon at a meeting of prominent oncologists who had been involved in the preliminary administration of the drug. I had reviewed the slides of the first five tumors removed and all were classical keratoacanthomas. Once they understood the natural history, outcome after appropriate treatment, and the equivalence of path diagnoses of keratoacanthoma, SCC-KA type, and well-differentiated (cutaneous) SCC, I was invited to join the investigative team.”
As the repository of all study skin specimens, Dr. Troy’s lab reviewed and collated nearly 1000 specimens during the eight years of international clinical studies of vermurafenib.
As the repository of all study skin specimens, Dr. Troy’s lab reviewed and collated nearly 1000 specimens during the eight years of international clinical studies of vermurafenib. Dr. Troy presented findings at multiple clinical investigator meetings in Australia, Europe, and South America. Since that time, immunotherapies have superseded the routine use of vemurafenib.
His role as DF supporter
Dr. Troy, an Annenberg Circle Sustaining member, has donated to the Foundation over many years, believing that its support of investigators who are just starting out is critical to the progress of dermatology. He noted that the annual Clinical Symposium is a popular meeting for many of his senior residents and that Wisconsin has an outstanding record of involvement in the Foundation.
“Since I became active in the field in 1980, I’ve watched the Foundation grow to be a major contributor to many different researchers especially at early stages of their careers.”
“The Foundation plays such an important role in our specialty,” he said. “Since I became active in the field in 1980, I’ve watched the Foundation grow to be a major contributor to many different researchers especially at early stages of their careers. I’d like to see this financial support increase. It’s a laudable goal, and all dermatologists should understand the benefits that you get from contributing.
“My career has been all about sharing my experience and knowledge,” Dr. Troy said. “That’s what’s fun for me. Whether I’m in the patient room, in the teaching arena, or writing a pathology report, I’m thinking the same way. I share what I know and try to bring others along on the thought process. It’s a sharing issue more than anything else.”
References
Ackerman AB, Troy JL, Rosen LB, Jerasutus S, White CF, King DF. 1988. Differential Diagnosis in Dermatopathology, Volume II. Lea & Febiger.
Su F, Viros A, Milagre C, et al. RAS mutations in cutaneous squamous-cell carcinomas in patients treated with BRAF inhibitors. N Engl J Med. 2012;366(3):207–215.