August 2010

Stephen N. Bauer, MD

Stepping up will mean standing out

I sometimes hear from members who are concerned about the campaign for transformation. Seventeen thousand pathologists cannot be expected to stay on the same page all the time. This month, I would like to look at some of these comments and respond as best I can.

Some members have the impression that the transformation campaign is a call for immediate and revolutionary change. It is prudent to plan for developments that could require unusually rapid change, and we are now conducting an in-depth analysis to identify situations that might be disruptive in the near term. Nonetheless, transformation will probably be a natural and more gradual evolution. Pathologists will be increasingly expected to take on new skills and roles, but for most these will be additive, not affecting core work in the near term. Most pathologists will probably shift their day-to-day activities over the next 10 years in ways that will affect a substantial segment of the services they provide. For many, that will involve molecular diagnostics or clinical genomic interpretation. For others, it may mean taking a more active role in medical staff committees or taking a leadership role in cost or quality management within an accountable care organization, or ACO. Each of us will determine where we can best contribute. However, the pace of change is increasing and the competition is intense. If we do not prepare ourselves now, we may miss some of the most important opportunities.

Pathologists who take a leadership role in personalized medicine can effectively bridge technology-centered and patient-centered care. New technologies are a critical aspect of our future, and each of us needs a working knowledge of their effects on current and future practice. This is why the College established the CAP Institute for the Advancement of the Pathology Specialty (The Institute), an educational hub with programming focused on transformational skills.

The Institute sponsors certificate programs, self-assessment modules, and interactive digital pathology courses, as well as Webinars developed by the CAP Personalized Health Care Committee. In a July Webinar, Jennifer Hunt, MD, MEd, addresses molecular diagnostics and the use of biomarkers to evaluate treatment alternatives. At one point, she lists high monthly costs of some targeted therapies, and explains how molecular diagnostics enable the pathologist to identify those patients for whom a given therapy will be effective. She also illustrates the impact of expensive therapies, quoting a study in Health Affairs showing that it is a catastrophic illness that causes three in four bankruptcies. Given these costs, we need pathologists who can make sure expensive molecular therapies are used appropriately and we get the appropriate value from them. (Webinars can be downloaded via the Institute tab on the CAP Transformation Web page for later viewing, perhaps with a group over lunch.)

Originally we thought the drivers for transformation were tied to technological advancements and shifts in the market. Today, changes expected under health care reform, such as implementation of the medical home model and ACOs, are equally important and can be expected to create further demand for transformational pathologists on the medical team. As Dr. Hunt points out in her presentation, genomics has captured the public imagination. Stories about direct-to-consumer whole-genome sequencing point to a need for qualified pathologists who can provide interpretive services, protect patient privacy, and ensure quality.

Some members are concerned about the emphasis on direct patient care in transformational pathology. Pathology has always been direct patient care. Whether performing a fine-needle aspiration, overseeing the blood bank, talking with a treating physician about targeted therapies, or volunteering on a medical staff committee to improve infection control, the pathologist is very much involved in direct patient care. I don’t envision pathologists becoming primary care physicians, but I do expect the opportunities for direct care activities to increase.

Advocacy is one member benefit that is crucial for the agenda for now and for the future. We know that some services that a transformational pathologist will provide are not compensated adequately, and a group within the Transformation Program Office is focused on that. Everything you associate with the CAP—standard-setting, accreditation, educational programs, mentoring, and participation in the greater medical community—continues apace.

As I reported in the May column, we surveyed members last spring to measure attitudes about transformational pathology. We are on the right track: 70 percent of our members strongly support transformation, 69 percent of our members are satisfied with the level of emphasis we are giving to transformation, and 17 percent feel we should emphasize it more.

With this support, we have moved forward to build a fact-based case for change predicated on clear direction from the membership regarding priorities. A second survey, on the opportunities and barriers to transformation, was sent recently to the entire CAP membership. The questions focus on the nature of your relationships with patients, other clinicians, and institutions; the nature of services you provide today; opportunities for new services in the future; and barriers to providing those services. Your responses, which we will explore together at the transformation plenary session at CAP ’10, are essential to a meaningful, fact-based case for change. Please do participate in the survey.

Transformation is as much about being open to new roles and willing to collaborate as it is about learning molecular diagnostics and fine-needle aspiration. Small changes in behavior, such as picking up the telephone to share an interesting test finding with a treating physician, tell colleagues we see ourselves as their partners. Every pathologist who seeks to participate more fully and directly as a member of the medical team has an ownership stake in our collective transformation. Those who choose to step up will be those who stand out.