June 2009

Jared N. Schwartz, MD, PhD

For us, a pivotal role in a critical time

What must underlie successful [social] epidemics ... is a bedrock belief that change is possible, that people can radically transform their behavior or beliefs in the face of the right kind of impetus.

—Malcolm Gladwell, The Tipping Point

It is likely that health care reform legislation will be on the table within the next few months. The window of opportunity for pathology is open but likely to be narrow. While we know it will be a crucible, we also know that a crucible strengthens and refines. If we manage this properly and with sufficient energy, transformational pathologists will find great satisfaction in many of the changes to come. The process of health care reform may be difficult, but it will also present opportunities that may never recur.

Many pathologists are concerned about the shape that physician payment will take; this is understandable. Yet I believe that if we approach this properly, which means recognizing that pathologists can and should have a pivotal role in shaping the outcome, there is reason to be optimistic about compensation.

The perception of value is volatile but not random, sometimes unreasonable but not unpredictable. For example, consider this story from a little book published in 1993 by renowned economist John Kenneth Galbraith, A Short History of Financial Euphoria, describing what he calls recurrent “speculative dementia.”

Galbraith traces financial catastrophes across the globe beginning with a 17^th century mania for tulips in Holland (where, in 1636, “a bulb of no previously apparent worth might be exchanged for a new carriage, two grey horses, and a complete harness.”) In this case, he relates, many became rich suddenly and ordinary people who saw evidence of sudden wealth “converted their property into cash and invested it in flowers.” Inevitably, the market crashed and those who had leveraged property for credit lost their homes and found themselves bankrupt.

Galbraith walks through similar episodes and identifies common denominators. I was most interested in the methods used to assess the value of a potential investment. Time and again, history shows, conspicuous consumption is taken to suggest financial genius. If people who invest in tulips can afford elaborate luxuries, then selling your home to invest in tulips must be a good idea. People value concrete evidence; they act when they believe they understand.

Sometimes wisely and sometimes not, people trust what they see, a truth addressed best by becoming more visible. Neither your patients nor your colleagues may be able to appreciate the effort, precision, and expertise that enable you to produce the highly technical report that arrives via e-mail. If the language is obscure, they will scan to the bottom, note the diagnosis, and move on. The pathologist who makes the effort to follow up on a technical report with a telephone call, explains results to patients, collaborates with colleagues, volunteers for multidisciplinary teams, and becomes known as an accessible and knowledgeable expert on new technologies will be valued. The pathologist who works with other physicians and scientists in designing systems approaches to complex challenges will be respected.

Having the right information is no guarantee we will be heard. For that, we must have credibility; to have credibility, we must be known. This is the grassroots piece. One hospital, one laboratory, one meeting, one bedside consult at a time, we build visibility. As our patients come to know us one on one, as their treating physicians turn to us more routinely, as we emerge as not only diagnosticians but advisors on test selection, interpretation, and therapeutic choices, our value to the health care system will become more obvious.

When compensation is to be discussed, the skilled and hard-working pathologist who is neither seen nor heard may be overlooked. This is readily addressed. Are patients and family members who call your laboratory with questions about their laboratory test results directed to their primary care physicians, nurses, or other specialists? Do the choices your colleagues make when they order from the test menu suggest they would benefit from an informal in-service on test selection? Have you considered that peer education on test selection could translate to significant savings to the hospital? These are opportunities to become more visible.

Transformational pathology is a reality. At bedsides and in blood banks, in intensive care units and in multidisciplinary conferences, pathologists are introducing new technologies, pursuing further training, offering to consult on test menu selections, and volunteering to monitor therapy. By working to ensure accurate and precise laboratory findings, by creating an institutional commitment to quality standards in all phases of the testing process, by taking on the responsibilities of knowledge integration, by contributing routinely as active members of the patient care team, pathologists can come to enjoy rewarding new dimensions of their work.

We are at the long-anticipated precipice that Malcolm Gladwell describes in his book about social epidemics as “the right kind of impetus.” We are growing in transformational ways at the grassroots and doing all the right things, but everyone is not on board. Each of us, now, must recognize that medicine is turning a corner and our health care system is about to change in fundamental ways. Each of us, now, must adopt the attitudes, behaviors, passions, and beliefs of transformational pathology.