July 2008
The power of horizontal thinking

Jared N. Schwartz, MD, PhD

Kids don’t watch [television] when they are stimulated and look away when they are bored. They watch when they understand and look away when they are confused.—Malcolm Gladwell

This morning’s New York Times had a story about wildfires on the Pacific Coast, where “flames torched massive redwoods and sent them toppling.” People were being evacuated.

A sad picture, although redwoods are incredibly resilient, often living 2,000 years despite repeated forest fires. Coastal redwoods grow very tall very fast, usually in foggy areas. The roots remain near the surface, extending out instead of down; fine-needled branches absorb moisture that condenses and drips below to feed the roots. Essentially, coastal redwoods create their own ecosystems by thinking horizontally.

Last month, I shared a story from a book by Malcolm Gladwell that examines how small insights can enable a few people to drive cultural change. This month, I would like to share another story from The Tipping Point, this one about the research that went into the launch of Sesame Street.

The creative staff at the Children’s Television Network assumed that preschool children would be drawn to stimulating scenes and bright images. They tested this by looking at how preschoolers first watched a tape of the show, then watched a version edited to remove important parts of the story but retain the more flashy, animated sequences. To their surprise, stimulation did not translate to attention. When the edited version didn’t make sense, the children turned away.

What do rainforests and children’s television have to do with us? A lot, I think.

By focusing on quality and managing so many critical functions in the hospital, pathology has essentially built its own ecosystem. Although our credibility is well established, pathology is often isolated. Instead of reaching out to clinical colleagues, we have sometimes dug down, focusing on technical concerns, reporting when we could be explaining. This has fostered a perception that pathologists are technicians rather than physicians. The explosion in high-tech medical diagnostics presents an opportunity to reverse that impression, extend our reach, and reinvent ourselves as physicians who are key members of the patient-care team.

As new technologies become more available, pathologists will have opportunities to improve diagnostic precision and monitor therapeutic efficacy. If we reach out to colleagues, recommending new tests when appropriate and clearly explaining benefits and limitations, they will feel more comfortable about ordering them. Patients will know the benefit of pathology’s quality-driven ecosystem, within which we not only do the right things right but continually raise expectations.

This has already begun to occur. For example, last month I attended Futurescape (terrific!) and visited training programs at the University of Vermont and New York University. I came home with 28 business cards, each one from a pathologist looking to volunteer for the College. I looked at those cards, actually counted them, and thought about the people who’d given them to me. Bright, energetic, talented physicians. Obvious leaders. Tall trees, every one. Something is going on; we’re hitting a nerve.

Many of us felt a shift in the wind at CAP ’06, when Elizabeth Hammond, MD, who was then chair of the CAP Education Committee, and Antonio C. Wolff, MD, of the American Society of Clinical Oncology, presented the results of a groundbreaking partnership between the CAP and ASCO to develop guidelines for HER2 positivity laboratory testing. Dr. Hammond had been the catalyst on our end; I was her co-chair. Dozens of our members contributed. Anyone who was at CAP ’06 remembers the standing-room-only crowd that showed up for Dr. Wolff’s presentation—how he was greeted with such thunderous applause that he stepped up to the microphone and joked that he “felt like a rock star.” We stood, just then, at an historic juncture. Every pathologist in that room knew it, and they have done a fine job of spreading the word.

Successful enterprise in translational research requires the leadership of pathologists like Liz Hammond and clinical partners like Antonio Wolff, and there are more physicians like them waiting in the wings, ready to take part. Only visionaries of their stature could have mustered the team that came together so quickly and proceeded so efficiently, but we do have visionaries, more every day. HER2 created a momentum that promises to persist. Dr. Hammond already has another team working with ASCO to develop guidelines for estrogen receptor/progesterone receptor positivity testing.

As we continue along this path, fellow physicians will come to see that we function extremely well outside the laboratory, thank you very much. National leadership is much engaged in this process, but communication at the local level will count the most. Day by day, we will demonstrate that pathologists should have a leadership role in progress toward personalized medicine. A few pathologists in each community who understand the power of horizontal thinking can drive cultural change.

Some physicians, including some pathologists, are inclined to believe that it will be many years before these technologies become a part of day-to-day practice; some residents, too, consider these tools to be beyond the scope of their training. This kind of thinking calls for cheerful persistence. For example, we know that digital imaging will be coming to the laboratory soon. Rather than debate the point, invite the skeptics to join you in a cook’s tour of the radiology and cardiology departments, where digitization is transforming medicine in countless and undeniable ways. Let the evidence speak for itself.

Education—and leadership—are about introducing concepts that are not yet fully formed and making them real. To do this effectively, we may need to censor the technospeak. This may not come naturally, but it will be easier if we bear in mind that when terms are unclear, confusion results, and when people are confused, they turn away.