January 2009
Feature Story

Jared N. Schwartz, MD, PhD

Winning recipe: minds over matter

When it comes to kitchens, size and equipment don’t count nearly as much as devotion, passion, common sense and, of course, experience.

“So your kitchen is tiny, so what?”
Mark Bittman, New York Times, Dec. 14, 2008

My wife is a chef and it is in my enlightened self-interest to encourage her. So it was with Diane in mind that I scanned the New York Times food section and found the quote that opens this column. I had been thinking more along the lines of Leo Tolstoy for this month (“All happy families resemble one another…”) but the food writer said it better.

Good pathology programs resemble one another. They don’t just adapt to change, they generate it. Their leadership consciously encourages risk taking. They recognize that medical excellence doesn’t require shiny equipment any more than great bread requires an electric dough hook, but it does call for the right attitude. At programs where expectations are high, willingness to collaborate, to do things differently, to risk failure when the gamble looks good, enables innovators and integrators to elicit what is needed from the resources at hand. And not always close at hand either.

Pathologists in remote locations do appear to have advantages. There are fewer naysayers nearby to tell them what they cannot do, for one thing. And creative approaches that might encounter political barriers in other settings are more readily adopted where health care access is a real problem.

For example, when Ronald S. Weinstein, MD, came to the University of Arizona College of Medicine at Tucson to chair its Department of Pathology 18 years ago, the university’s physicians were traveling thousands of miles a year to provide health care services to Native Americans on reservations hundreds of miles out. Subspecialty medical care was hard to get for other rural populations, including inmates of Arizona’s decentralized state prisons. Dr. Weinstein is the father of telepathology, having invented robotic telepathology and introduced the word into the English language while he was department chair at Rush Medical College in Chicago. So, in 1996 when Arizona state legislators approached the University of Arizona with funding to establish a multispecialty regional telemedicine project, he knew it could be done and how to do it. Today, he is director of the Arizona Telemedicine Program, a large umbrella organization for 55 independent health care organizations in 71 communities at 171 sites throughout Arizona and beyond. The program has given more than 500,000 patients access to physicians and nurses in more than 60 subspecialties and included thousands of telepathology cases. Ron Weinstein likes to say that pathologists need to learn to think beyond pathology. I think those half-million patients prove his point.

Canada is another place where a shortage of pathologists drives innovation. At the University of Toronto Department of Laboratory Medicine and Pathobiology, where Sylvia L. Asa, MD, PhD, is pathologist-in-chief, 50 medical and scientific staff provide subspecialty telepathology services to 17 hospitals in the province of Ontario. The University Health Network (UHN) began to move in this direction about five years ago, when one of its pathologists, Andrew Evans, MD, PhD, became interested in reports of the use of remote robotic microscopy in Norway. UHN had experience with a robotic microscopy service for the university’s three teaching hospitals in Toronto when pathologists from a remote hospital with staffing shortages approached them for help. Today, UHN provides fully digitized whole-slide imaging (telepathology) serving hospitals 400 miles away.

Pathologists at the University of Pittsburgh are doing remarkable work in personalized medicine and in educating pathologists and other health professionals about biomedical informatics. A lot of the credit for that goes to their chair, George Michaelopoulos, MD, who will try just about anything that encourages his people to spread their wings. It has been nearly 20 years since Michael J. Becich, MD, PhD, now vice chair of pathology informatics under Dr. Michaelopoulos, started talking about what he called the “70/70”—the fact that about 70 percent of all health care decisions affecting a patient’s life involve pathology and 70 percent of information that physicians rely upon in the health care record is laboratory-directed. More recently, he has been talking about “70/70/70” to call attention to the fact that 70 percent of the work pathologists do relates to cancer. Dr. Becich was among the first to understand that pathologists—anatomic, clinical, and all subspecialists—need to come together so that the diagnostic, prognostic, and therapeutic advice we provide is accessible and coherent. He advocates convincingly for one laboratory report that presents all findings and recommendations in a single, easily understood document. Years ago, Mike Becich was trying to get people to see that accessing, integrating, and putting relevant facts in context would be a critical aspect of patient care in the information age. Now we’re in the information age and people are finally beginning to listen.

More of us are listening and more of us are talking to other physicians, trying unlikely solutions, and learning from our mistakes. Whatever the tools at hand, pathologists have the right combination of knowledge, skills, and attitudes to make the most of them. It’s a matter of collaborating with our clinical colleagues and sharing what we know.

There’s a Brothers Grimm story that involves travelers who come to a poor village carrying an empty pot. They stop in the town square, fill the pot with water, and drop in a stone they’ve brought in a velvet bag. Curious villagers who wander by are told that they are making “stone soup,” which is always wonderful but still needs a little something. One by one, neighbors come forward, one with a carrot, another with beans, parsley, a potato, salt. They talk while it simmers and the broth grows richer; before long they share supper.

The transformational pathologist will be much like those travelers, enabling clinical colleagues and patients to realize the promise of personalized medicine, where the aggregate impact is far more than the sum of its parts. Our task will be fundamentally translational: to share what we learn as science moves forward, stir the pot as required when colleagues hesitate, and see that the benefits of new discoveries are properly tended and thoughtfully shared.