October 2008
How we will get to the next level

Jared N. Schwartz, MD, PhD

Most people I know don’t have a life plan. An opportunity comes along, a mentor sees a talent, and 10 years later, there you are.

A long time ago, I came to the combined MD/PhD program at Duke expecting to work for a famous bacterial microbiologist. He suffered a heart attack shortly before my arrival and was unable to take on a new student, so he sent me to work for an immunologist who happened to be a pathologist as well. The pathologists in that department did research, but primarily they were physicians. The most prominent medical staff members at Duke held them in high regard and had great respect for their clinical judgment. None of them seemed to focus on one thing (eyes or bones or whatever); they seemed to come in every day without knowing what they would be asked to do. I liked them; they were outgoing, funny, intelligent, curious, interesting people. Looking back, it seems that I chose a few of the pieces that would shape my life’s work, but they didn’t fall into place on their own. A lot of people helped.

The doctors at Duke taught me that pathology is much more than interpreting a test and reporting results. It’s an integrative process that doesn’t end with the diagnosis. And the feedback loop is critical. How did the patient respond to treatment? Did she get better? Were there unexpected side effects? This is how the best medicine is practiced. As a physician and pathologist, you must know that what you do has an impact on the patient.

We live in an era of phenomenal opportunity for pathologists. The CAP campaign for transformational pathology is about enabling pathologists to seize that opportunity and take on new roles. The campaign has two initial vehicles, separate entities that will work hand-in-hand to take pathology to the next level.

One of those vehicles, the CAP Institute, will focus on the learning needs of individual pathologists. The other, the CAP Quality Center, will focus on guidelines and standard setting for the specialty as a whole. The Institute will offer hands-on learning, self-assessment modules, and online courses. All will target the knowledge and skill required for optimal patient care, and each will incorporate cognitive and practical assessment. The Center will be a strategic driver for transformation of the specialty. We will work with other stakeholders to develop best practices in pathology. Our work product will be available to the Institute and to other groups that develop educational content.

Lifelong learning is about transformation, learning what you enjoy most and do best as you discover new opportunities along the professional continuum. For pathologists with limited exposure to new technologies or translational medicine, learning through the Institute may reveal untapped strengths and inclinations that challenge their preconceptions about “what a pathologist does.”

As new tools in pharmacogenomics and proteomics make our specialty more precise, more molecular, and more closely tied to patient care, we will need precise guidelines for best practices in their use. The Center will develop those guidelines. The Institute will provide the instruction. The board exams, and even a postdoctoral fellowship, do not guarantee competence. They will not be enough in the future to assure our patients that we are always ready and up to date with the best medical knowledge that exists at any point in time. The patient expects competence and so should we; the learning should never end.

Pathologists have an increasingly direct and vital role in patient care, partly because we have access to a lot of information and we know how to interpret it. We understand systems. We appreciate the promise of new technologies. We respect and embrace quality assurance and quality improvement. We recognize the necessity of scientific rigor and the need for consensus standards to guide and monitor diagnosis and therapy. And because laboratory testing plays a role in the vast majority of health care decisions, we are in a position to see the big picture. We are the right physicians in the right place at the right time.

A few months ago, I wrote about Randy Pausch, a gifted and charismatic professor of computer science at Carnegie Mellon University in Pittsburgh who has since died of pancreatic cancer. Shortly after learning that he had less than six months to live, Pausch had given a powerful talk titled “The Last Lecture.”

The quote at the top of this column comes from one of his mentors, whom he had consulted in a mild panic when a group of talented undergraduates had so quickly exceeded expectations that he had run out of lesson plan. Though Pausch had been teaching for 10 years, he wasn’t sure where to go next.

“You go back into class tomorrow and you look them in the eye,” his advisor said. “And you say, ‘Guys, that was pretty good but I know you can do better.’”

“And that was exactly the right advice,” Pausch told his audience. “Because what he said was, ‘You obviously don’t know where the bar should be and you’re only going to do them a disservice by putting it anywhere.’” His students responded by surprising him again and again that semester; they never did find their limits.

While there is no denying that developing best practices through the CAP Center is setting the bar, it seems to me that the transformational pathology campaign as a whole captures what Randy Pausch was talking about. The Center will underscore the importance of scientific rigor while creating a feedback loop that will accelerate information-sharing among stakeholders whose work relates to ours. The Institute will enable individual pathologists to examine the parameters of their practices and make an intentional effort to push the outside of the envelope. The Center and the Institute will complement the required board examinations and give pathologists the tools they need to reset the bar every day. I expect we will surprise one another again and again. And I hope we never do find our limits.