August 2009

Jared N. Schwartz, MD, PhD

We may have had good practical reasons for ­coming here: the new ideas, the stuff to learn, the gizmos to try.... But in the end, I came to think there was also something more vital and, in a ­certain way, poignant, drawing us in.... You were, you felt, among your tribe.

Atul Gawande, MD, on his first national medical convention, from
Complications: A Surgeon’s Notes on an Imperfect Science

There’s a lot of travel in this job. It’s important to know where people are coming from, and pathologists come from a lot of places. All of medicine is knee-deep in a transformational environment driven by promising technologies and political realities. For pathology in particular, there is great potential but also many unknowns. In this context, listening before you speak is more than good manners—it is a valuable survival skill. Keeping an ear to the ground means covering a lot of ground, so when I weigh benefit against bother, get-up-and-go wins hands-down every time.

Pathologists across the country are doing wonderful work that is inventive and bold and useful and smart. At the UCLA David Geffen School of Medicine, pathologists and radiologists are collaborating to integrate interventional radiology with high-end pathology diagnostics. This time next year, a hybrid clinical service will be up and running, saving a great deal of administrative fuss and, more important, giving anxious patients their results much quicker.

Jonathan Braun, MD, PhD, chair of pathology and laboratory medicine, describes it this way: After initial imaging, patients needing an interventional diagnosis are immediately identified by the radiologist for biopsy at the same visit. Integrated into the interventional service, the pathologist and laboratory staff ensure adequacy and immediately direct specimens for specialized immunological or molecular tests. The examining pathologist and radiologist write up their findings concurrently and an integrated bimodality diagnostic report is sent to the referring physician within a few days. The patient is saved multiple radiology visits, and the clinician gets a single concordant diagnostic report for medical decisionmaking.

At Massachusetts General Hospital, pathologists-as-systems-engineers have saved the hospital hundreds of thousands of dollars. Their team has written practice standards to limit unnecessary routine and esoteric testing, for example, and they have constructed a gatekeeper system under which physicians must justify orders for certain expensive blood components. It’s a healthy culture: There seems to be an implicit appreciation for the fact that hospitals are systems requiring systems-based solutions, and pathologists are the physicians best positioned to identify and implement those solutions. As Kent Lewan­drow­ski, MD, associate chief and director of clinical services for the MGH Pathology Service, puts it, we know who’s ordering what tests, how often, and at what cost. We know where the volume is and how to identify what might be limited safely. And we are physicians who know what is responsible and what is not. I remember just how he said it: “People with a reasonable computer system can do some reconnaissance.”

Last month, we launched our first certificate program in ultrasound-guided fine-needle aspiration, or UGFNA. The pilot was conducted at the CAP. It was terrific to see pathologists clustered around ultrasound machines for hands-on practice and hear top experts in pathology-focused UGFNA lecture and demonstrate technique. I was reminded of a description in Complications, the book quoted at the top of this page, describing the learning curve in surgical training. Gawande makes a compelling case for abundant hands-on experience with mentors, which is exactly what the CAP certificate program provides.

There will be more information about upcoming certificate programs at CAP ’09, to be held Oct. 11–14 in Washington, DC. The faculty includes more than 100 of the most respected experts in our field, and the curriculum covers the landscape of transformational pathology (including an 11-course breast curriculum and a 10-course series in gynecological pathology). Lectures in anatomic and clinical pathology are complemented by practice management workshops and brain-bending special-topic sessions on everything from ethical issues in molecular diagnostics to telepathology.

CAP ’09 is about education in our specialty, no doubt about it. The opportunity to dig deep into cutting-edge science while also sharpening skills in traditional areas is unequaled. But it is every bit as much about learning from and connecting with other pathologists. Visiting pathology programs across the United States has given me an appreciation for the extraordinarily inventive and energetic nature of our membership. Pathology has, as they say in baseball, a very deep bench. Transformational change is happening in practices across the country, and pathologists from those practices will be at CAP ’09. Come for the academic motherlode and leave with new ideas based on firsthand experience in managing the welcome challenges that will frame a promising future for our specialty.

Some pathologists who appreciate their pivotal responsibilities in the transition to a new health care system are not sure where to start. Our roles are not as clear to some colleagues and administrators as they are to us. We have to educate. Some barriers are real and others perceived, but both types will evaporate if we go after them with a full head of steam. Each practice will encounter challenges en route, but you will meet pathologists at CAP ’09 who have been there and know how to get around them.

CAP ’09 is about science and medicine, but it is also about the transformational power of collective optimism. If you’ve read this far and it still seems that a trip to Washington in October would cost too much, take too much time, or be too much trouble, perhaps you’re overthinking it (a/k/a analysis paralysis). Transformational behavior, on the other hand, is a lot about seizing opportunities and going with your gut.

With any luck, your gut will tell you to spend some time with your tribe.