Stanley J. Robboy, MD

January 2012

Stanley J. Robboy, MD

Center’s work reflects Hamilton legacy

A postage stamp in my collection honors pathologist Alice Hamilton, MD, a seminal figure in occupational medicine and public health.

Dr. Hamilton was a professor of pathology at the Women’s Medical School of Northwestern University in 1897, when she moved to the Jane Addams Hull House in Chicago. Her neighbors there were poor immigrants and she was troubled by pervasive evidence of workplace injury and toxicity in the local population.

In short order, Dr. Hamilton became a high-profile patient advocate within the emerging field of occupational health and safety. She earned the respect of local public health authorities, who recognized her skills in laboratory investigation and appreciated her clear documentation and exhaustive fieldwork.

I wanted to introduce this column about the CAP Pathology and Laboratory Quality Center with Dr. Hamilton because it seems to me that the center’s focus on evidence-based, collaborative initiatives to promote and protect patient safety reflects her legacy.

But first, a short history.

In 2007, the College partnered with the American Society of Clinical Oncology to create guidelines for HER2 testing in breast cancer. That first collaboration, which involved 15 oncologists and pathologists, stemmed from concern about inconsistent test results. Evidence suggested that as many as one in five HER2 test findings were inaccurate, driving unnecessary and costly therapies that had risks of their own. M. Elizabeth H. Hammond, MD, led the CAP team, and Antonio C. Wolff, MD, headed the ASCO group. (In July 2010, members of the first team participated, along with Cancer Care Ontario, in a second collaboration that produced guidelines on IHC ER/PgR testing.)

Responses to those first CAP/ASCO guidelines were so positive that Jared N. Schwartz, MD, who was then CAP president and had served on the HER2 and ER/PgR panels, announced at CAP ’08 that the College would launch the center to develop evidence-based guidelines (or, when evidence was not as compelling, consensus statements) to identify best practices in all disciplines of pathology. Collaborative teams of cooperating specialists would develop the guidelines; patient advocacy groups and other stakeholders would be invited to join advisory panels when appropriate. The center subcommittee of the Transformation Program Office Steering Committee was appointed to oversee guidelines development. Formation of the center signaled a forward-looking posture for the College and an understanding that the future of medicine would rest on more collaboration than in the past.

Dr. Hammond has explained that two broad criteria govern the eligibility of topics proposed for guideline development. First, there must be a serious need tied to patient safety or test accuracy. Second, there must be good evidence that points to the right approach.

Evidence-based guidelines enable transformational pathologists to take ownership of their role as members of the patient care treatment team, Dr. Hammond says, and will enable us to do our jobs in a way that is clearer and more useful to the many physicians with whom we collaborate.

The HER2 and ER/PgR guidelines preceded the center. The first consensus statement from the center was published in the Archives of Pathology & Laboratory Medicine via early online release in October; it is scheduled for the February print edition. Titled “Effective Communication of Urgent Diagnoses and Significant Unexpected Diagnoses in Surgical Pathology and Cytopathology,” the consensus statement was developed in partnership with the Association of Directors of Anatomic and Surgical Pathology.

John Olsen, MD, CAP senior director and acting vice president, transformation, observes that while the majority of guideline topics proposed by practicing pathologists relate to clinical variance, many address the need to standardize the way we report results. Variation in syntax, verbiage, and terminology cause confusion, and while not everyone likes synoptic reports, they do remove variance, which is where risk is often introduced. If variance is removed, Dr. Olsen says, a physician in Wyoming will clearly understand what the pathologist who wrote that report in Los Angeles meant.

Another 10 guidelines are in various stages of process. Eight medical specialty group partners are participating and three patient advocacy groups sit on advisory panels. Every member of the College is encouraged to suggest topics for guidelines or volunteer on a guidelines work group. If nothing else, please do respond to guidelines posted for public comment. Your input is important.

I introduced this column with Dr. Hamilton in part because she showed the power of persistence and evidence-based thinking. Her story also highlights what we as a society have overcome.

In 1919, when Dr. Hamilton became the first woman appointed to a professorship at Harvard Medical School, she was asked to accept preconditions that sound bizarre and humorous today: 1) she could not enter the Faculty Club (“for men only” at that time); 2) she could not participate as faculty at graduation ceremonies; and 3) she could not ask for tickets to football games. Dr. Hamilton responded by continuing diligently in her work and earning a national reputation. Among many accolades, the most impressive came posthumously in 1987, when the National Institute for Occupational Safety and Health chose to dedicate its new research facility in her name.

More than 100 years ago, a pathologist unearthed and documented evidence of health threats in the workplace and devised measures to eliminate them. Today, guidelines disseminated by the center will eliminate variance in laboratory testing and establish consistency in the reporting of test results. Today’s center teams follow Dr. Hamilton’s example, demonstrating without drama but with persistence the value of a pathologist at the center of the patient care team.