October 2010

Stephen N. Bauer, MD

Our challenge to communicate clearly

On Sept. 22, the online magazine Slate ran a piece by one of its business writers titled, “Death of the Salesman. Of Lots of Them, Actually.”

James Ledbetter was referring to the iconic 1949 Arthur Miller play, Death of a Salesman, which reflected on the troubles of one cog in the wheel of a consumer culture. New sales jobs, he says, were once reliably available; their rate of growth peaked at 54 percent in the 1980s. By 2007, however, sales jobs were not only no longer growing, they were shrinking.

Those of us who buy books, electronics, airline tickets, and even stocks online may miss the knowledgeable corner bookseller, the travel agent who knew the best packages, the investment advisor who could explain arcane facts about market mathematics. Still, we continue to do more and more online and to rely on our own online research.

“Disintermediation” is an Internet-era term that refers to what happens when a new tool reshuffles the deck in ways that can eliminate some roles. Once disintermediation occurs, the experts say, those who have been eliminated are not likely to return. The day of the small bookstore has passed.

Louis Wright Jr., MD, who chairs the CAP Council on Government and Professional Affairs and co-chairs several of our technology-related committees, likes to say that disintermediation is a critical factor driving transformation, especially for those of us playing an intelligent defense.

If you think of the treating physician as the quarterback on the medical team, Dr. Wright says, then the pathologist should be the team tactician, tracking rapidly changing science and technology in the field and advising on how new tools are best employed. With the advent of accountable care organizations, he adds, the pathologist will potentially become the go-to resource on molecular diagnostics, genetics, and other innovations that will come to be available in the outpatient environment.

We need to communicate our interest in making that happen.

Much of transformation is about enhancing our visibility, becoming known as a valuable resource, providing knowledge and services more ably and accessibly than anyone else. When your contributions as a physician are evident, it’s far less likely that someone will decide to replace you with a computer.

Communicating our interest in contributing in new and perhaps unexpected ways can be hard work and there’s no end to it. As George Bernard Shaw said, the problem with communication is the illusion that it has been accomplished. If we are to take our rightful place on the medical team, we have to remember that.

Events this summer drew my attention to the importance of ensuring that our communication is effective, consistent, positive, and clear.

The first concerning event was a July 19 New York Times article, “Earliest Steps to Find Breast Cancer are Prone to Error,” that described the experiences of several women who had received a misdiagnosis of ductal carcinoma in situ (DCIS). Some comments in the article reflected negatively on our specialty and could have undermined patient confidence in the accuracy of their testing and diagnoses.

As pathologists, we understand that diagnosing early-stage breast cancer can be difficult in some cases. We also understand, as did many of those who wrote to the New York Times online in response to the story, that the solution to overtreatment is not undertreatment.

Just a year ago, the National Institutes of Health hosted a state-of-the-science consensus conference on diagnosis and management of DCIS and the paper that resulted discussed the thicket that is DCIS diagnosis. A multidisciplinary team of physicians, scientists, biostatisticians, and preventive medicine professionals called for research to identify validated risk-stratification methods that would inform therapeutic choices for subgroups of patients diagnosed with DCIS. The consensus group acknowledged that we know too little about the fundamental natural history of untreated disease, and its members suggested that consideration be given to reviewing the diagnostic terms used for this lesion. They have identified a legitimate issue, in my view, and I have asked the physicians who head up the CAP Pathology and Laboratory Quality Center to consider adding DCIS diagnosis and nomenclature to their topics for possible examination. Certainly, pathologists will continue to play an important role in future investigations.

Reading patient comments in response to the article reminded me, again, of the importance of clear communication about the risks and benefits of treatment options when a breast cancer diagnosis is made. Because our interaction with patients is brief and episodic, it is doubly important that they—and their treating physicians—know we welcome the opportunity to sit down and talk with them. We can do this by accompanying our colleagues on rounds and by calling the treating physician when sending a complicated diagnostic report. We can also include a link to MyBiopsy.org in relevant pathology reports.

The New York Times article also included statements about the CAP educational program in breast pathology that reflected a number of misunderstandings. One was that those wishing to participate in the breast program would be required to meet a prerequisite number of annual breast cases. While the breast program is still in development, there are no plans for a numerical minimum. The baseline for entry into the CAP advanced practical pathology programs is American Board of Pathology certification; any additional prerequisites will be identified by experts who are developing that course, and will be evidence-based.

The article also suggested that the CAP had started the advanced practice programs out of concern about the quality of diagnoses, which is nothing if not upside down. We started the advanced practice programs because our members asked for focused learning structured in a way that would enable practicing pathologists who had examined thousands of specimens in the course of a career to demonstrate that their expertise was at least equal to that of someone just out of fellowship. The advanced practice programs were initiated at the request of our members for that purpose—to facilitate focused continuing education and demonstration of empirical knowledge.

There has also been concern about the name of the advanced practice learning opportunities. We had been referring to these learning opportunities as “certificate programs” because a certificate would be awarded at the end. This seemed straightforward to us, but it caused such widespread and persistent confusion in the marketplace, where callers believed these certificates could be confused with board certification, that we decided to change the name. While the expert teams that develop these programs discuss a new name, we will refer to the breast program to be released in the spring, and those advanced practice programs already in place, as “advanced practical pathology programs.”

This column has been all about communications challenges; I would like to close with something easier to talk about: the encouraging preliminary results of our all-member survey this summer. Returns are still coming in, but raw data show CAP members taking solid and intentional steps toward transformation—collaborating with other physicians, learning molecular diagnostics, counseling patients.

Our members are stepping up, doing the kinds of things that prevent disintermediation. More of us need to do more of the same, more visibly.

More on that later.