July 2009

Jared N. Schwartz, MD, PhD

What the best may have, above all,
is a capacity to learn and change—and
to do so faster than everyone else.

—Atul Gawande,
Better: A Surgeon’s Notes on Performance

It is important to remember that transformation is about more than just us. As Louis Wright, MD, chair of the CAP Personalized Health Committee and vice chair of the Council on Government and Professional Affairs, puts it, the confluence of emerging technologies that will take us to the most narrowly focused, precise diagnostic tools ever seen will also take us away from what medicine has traditionally been: trial and error. If health care reform is to succeed, it must cut the trial and error out of medicine. That is our piece, and it is a piece that will link to transformative change for many other specialists.

In Washington, the metaphor of the moment is the medical home. The goal is to organize patient care by structuring access around a primary care physician; success will require accelerated behavioral change across the board. All of this threatens the status quo in a serious way, which is not all bad. But it does make everybody nervous, and it will be part of our job to keep everyone calm and focused on the task.

There are some things to be nervous about. Without abundant physician engagement, a lot could go wrong on the road to reform. The quote at the top of this page from Atul Gawande’s wonderful book is squarely on point. A collaborating pathologist brings much-needed capabilities to the table, but we must quickly adapt to the new medical model. A lot of people, even those we see every day, don’t realize how much we can contribute. Everyone has blind spots. Even if the architects of reform don’t know it just yet, our specific expertise is much needed. We cannot wait for an invitation. For the sake of our patients, we must step up, and quickly.

All the talk about securing our place in the post-reform health care system reminds me of that story about the blind men who asked a local wise man to resolve an argument about an elephant. One had stood in front of the elephant and felt the tusk; he was sure it was a plow. One found himself in front of a foot and insisted it was a pillar. The fellow who reached out to touch the tail said it was a brush. The wise man ruled that each of them had a piece of the truth, and so they did.

Health care reform is an effort to reduce costs and improve quality by way of a collaborative, coordinated model. Given that pathology could be described as the original systems approach to medicine, pathologists should be comfortable with that. At the same time, we have to realize that pathology has far more facets than your average elephant and most people, like the blind men, will hold tightly to what they have observed. So it is that colleagues on the medical staff may see us as diagnosticians while regular patients in the blood bank think of us as primary care physicians. Both are correct, so far as they go, but they don’t go nearly far enough.

The best way to broaden the scope of what people see us doing is to do more. For example, Richard Callery, MD, is chief medical examiner and forensic sciences laboratory director for the state of Delaware. Dr. Callery engages a variety of constituencies in the course of a day, comforting the bereaved, testifying in court, examining specimens, conducting autopsies. He moves with great agility, embracing many roles. The opportunity to meet with families and help them understand what has happened, he says, may be the best part of his job. Sometimes our presence is demanded, Dr. Callery says; it’s ludicrous to abdicate responsibility for that which we are better suited than anyone else.

At Johns Hopkins, engagement is the rule. Residents rotating through transfusion medicine, for example, complete histories and physicals, write clinic notes and orders, and set up procedures. Attending pathologists routinely confer with other physicians around treatment planning, take a leading role in multidisciplinary clinics, and collaborate with individual physicians on disease management. According to J. Brooks Jackson, MD, MBA, who is director of the Department of Pathology, one collaboration leads to another.

We can make some assumptions. Diagnostic testing will continue along the current trajectory—greater capability, complexity, and cost. More people with access to care will translate to greater demand. Pathologists will contain costs and protect patients from the side effects of inappropriate therapies by ensuring they get the right tests at the right time. The College will advocate for changes in compensation policy so that pathologists who initiate consultations with other physicians on test selection and therapy can bill for those activities. We will also continue to advocate for funds to modernize laboratory information systems because updated systems that talk to one another will enable economies and efficiencies via care coordination with clinicians inside and outside the hospital.

You might say pathologists are destined to be the systems engineers for the architecture of the nascent medical home movement. I like that job description because I think it captures the pivotal role we will play, but it’s what we do, not what we’re called, that matters. I’ll always answer to Doctor; the rest is detail. The focus should be on thinking strategically about how we can be most useful in our particular environments.

As a friend’s dad used to say when we were kids, “Call me whatever you want; just don’t call me late for supper.” So now we gather our tools, muster our team, and get to the table.