December 2009

Stephen N. Bauer, MD

No margin, no mission

I always have a few random conversations at CAP meetings that sink in only later to give me pause. This year’s annual meeting was no exception. I doubt many of you would guess that my favorite involves Plato’s cave allegory.

Emily Volk, MD, vice chief of laboratory services at William Beaumont Hospital, asked if I had thought about transformational pathology in terms of the cave myth. I was at a certain disadvantage because my California public school education didn’t exactly emphasize the ancient Greek philosophers. But once she explained, I saw her point.

Plato described a group of people imprisoned in a cave from birth. The prisoners are bound in such a way that they can see only a wall that they are compelled to face at all times. Acoustics are poor. To pass the time, the prisoners debate theories about the meaning of shadows periodically cast on the wall by light behind them.

Seeing only shadows and hearing only echoes, the prisoners are effectively cut off from the real world. Then, unexpectedly, one of them is given a brief reprieve. Seeing daylight for the first time, he is stunned by the realization that the shadows are only reflections of the real world. Sharing that insight, Plato says, is his ethical duty.

Dr. Volk suggested that pathologists are in a similar position. We have opportunities to work with new technologies that enable us to witness the dawn of a new era. We can perceive the underlying molecular activity creating the morphology that made up our former reality. And we, too, are called to share these insights. That brief conversation made me realize that we don’t often talk about our ethical duty to take responsibility for appropriate use of emerging diagnostic tools. It may not be long before new technologies relegate many morphologically based diagnoses to the realm of those ancient shadows. However, powerful new agents are vulnerable to misuse, which makes it all the more important that pathologists shepherd their implementation.

Sophisticated diagnostics only complement the physician’s intellectual assessment; they cannot replace it. Ensuring respect for that principle is part of our job. In fact, the risks inherent in rapid-fire development provided part of the rationale that drove the establishment of the CAP Pathology and Laboratory Quality Center. Best practices guidelines from the Center will enable us to clearly communicate what we learn about new tests. Equally important, they will create a structure and context for collaboration with other specialists on emerging applications. Through the Center, the College will engage all interested parties—primary care physicians, other specialists, patients, government and private-sector policymakers, administrators, educators, and researchers. Each will need to appreciate the potential power and unknown limitations of diagnostic and therapeutic agents.

Those of us who work in not-for-profit institutions are familiar with the maxim “no margin, no mission,” which relates to another ethical duty: the responsibility to remain solvent in order to meet our commitments. As a not-for-profit entity, the CAP identifies closely with that reality, which drives a certain urgency around our search for revenue that will enable reinvestment to meet the needs of our members. Funding long-term transformation is a challenge, but we’re responding.

Genuine transformation is incremental and multifaceted. Just as a wise investor diversifies his or her portfolio, today’s pathologist must look to diversify his or her professional competencies. For many, that will mean coursework to build skills with new technologies, which is why the College is creating dramatically enhanced educational opportunities through the CAP Institute for the Advancement of the Pathology Specialty.

The College has no interest in generating more revenue than is required to honor our mission, but we recognize that today’s pathologist looks to the College for more products and services than ever before. These are expensive undertakings and long-term commitments; transformation is a generational endeavor. The Center and the Institute will become exponentially more valuable to our patients and our members with each passing year. So, like our members, we are looking to diversify the portfolio of enterprises that feed our revenue stream.

Fortunately, our reputation precedes us: Both government and private industry have awarded grants that underscore respect for the preeminent expertise available through the College. To give just two examples, we are well into the second year of a National Institutes of Health-funded collaboration of CAP SNOMED Terminology Solutions and the University of South Florida Data Management Coordinating Center to design systems that will collect, store, and analyze data for the NIH Rare Diseases Clinical Research Network. And 2009 is the seventh year of a grant project for the Centers for Disease Control and Prevention to standardize surgical pathology reporting in oncology.

The current technological tsunami alone would mandate the transformation of pathology, and the superimposition of health care reform may create something of a perfect storm. There is chaos, yes, and a need for creative programming to support our members’ evolution. But pathology today is ascendant. The cultural change that drives our required investment should be welcomed. The attendant investment is steep but also necessary and prudent.

Of course, we cannot and will not step back from energetic pursuit of our traditional advocacy goals. We must ensure a place at the table as health care reform works its way through Congress. Our advocacy team remains trained on today’s agenda in Washington, which is less about futuristic tools than longstanding systemic inequities in physician reimbursement. These needs are no less urgent than they were before so many disruptive technologies appeared on the horizon. Rest assured that our core advocacy goals will not be neglected and will remain a critical element in our agenda.