June 2008
On extinguishing the bystander effect

Jared N. Schwartz, MD, PhD

When I was about eight years old, my dad bought a small grocery store. My brother and I would help out after school and on weekends. One day, my dad mentioned he was thinking about adding watermelon. We didn’t have a lot of space and I didn’t like the idea. “Dad,” I said, “why in the world would you want to add watermelon? I’m here every day after school and hardly anybody asks for watermelon.”

My dad looked at me for a moment; he had that “listen-up” look. “Jared,” he said, “just because people stop asking for watermelon doesn’t mean they don’t want it anymore. It just means they’ve decided that it’s something we don’t offer. If we say no, they’re going to go someplace else for the watermelon, and most likely they’ll pick up their milk and bread there, too. When we say no, we’re not just saying no to watermelon.”

People respond differently to change. Some pathologists prefer to decline when someone calls for a consultation; they are likely to say no when someone asks if they are planning to introduce digital microscopy or molecular diagnostics. Trained to be precise, quality focused, risk averse, and error free, many pathologists prefer familiar roles, well-tested tools, and proven methods. Although this is safe, it is not always in our enlightened self-interest.

I have asked leaders of other specialties how they manage to add new technologies to their armamentarium so soon after those tools are introduced. Colleagues have explained, and I have observed, that when a new approach appears viable, other specialties quickly bring together their professional societies, training directors, academic chairs, and certifying boards to make appropriate changes in training curricula and examinations. A collegial group effort ensures that innovative methods are rapidly introduced into residency programs, expectations are set, and appropriate questions are placed on the examinations within a relatively short period. This presses the programs to introduce the training and pushes the residents to learn the skills.

Observing this in other specialties while hearing the chorus of frustration of those who advocate for accelerated change in pathology, I have become convinced that we need to effect a cultural shift within our specialty, to foster an environment that favors much closer working relationships among our many constituencies. The truth is, other specialties have found ways to enable their training directors, academic chairs, boards, and members to partner closely and work together to ensure that their disciplines remain relevant and viable. We have not, and we must figure out a way to do the same.

A few years ago, I read a remarkable little book, The Tipping Point, which examines how social change occurs. Author Malcolm Gladwell writes about what he calls the power of context, how certain environments accommodate change and certain factors can work against it. The latter, he says, include what psychologists have called “the bystander problem.”

Gladwell’s best example of the bystander problem is a famous murder that occurred in the courtyard of a New York City apartment building 44 years ago. A young woman named Kitty Genovese was attacked three times over 30 minutes; her murder took place in full view of 38 neighbors, yet nobody called the police. Contrary to first reports, psychologists eventually determined that she had died not because nobody cared, but because there were too many witnesses, each of whom assumed that someone else would call. The lesson, Gladwell says, is that when we are in a situation that calls for action and are aware of others who may step forward, most of us will step back. If we are to ensure the future of our specialty, this can no longer be acceptable.

One who consistently stepped forward was Randy Pausch, a young, brilliant, and charismatic professor of computer science at Carnegie Mellon University in Pittsburgh, who is dying of pancreatic cancer. Shortly after his diagnosis last fall, Pausch gave a powerful talk (The Last Lecture), now available in paperback and posted on YouTube. He talked about a lot of things, including the importance of mentors. “You get people to help you,” he said, “by telling the truth.”

The truths we need to talk about include the real and perceived barriers we encounter when we try to change the way we do things. At every training program, I ask my hosts what the CAP can do for them to help ensure a bright future for our specialty. Time and again, residents, faculty, and chairs tell me they are looking to the College to help institutionalize the rapid and effective adoption of new technologies and capabilities. Time and again, faculty and chairs tell me they need help to ensure that residents understand the need to lift their sights beyond one examination to be taken at the end of their training and learn to think in terms of preparing for the practice of pathology in the new era. They will not know what they can do until they try.

Professor Pausch encouraged his students to interpret barriers as opportunities. When you feel there is a brick wall between you and your dreams, he said, look for a ladder. “The brick walls are there to stop the people who don’t want it badly enough,” he said. “They’re there to stop the other people.”

We need to think creatively about how to overcome perceived barriers to change. The many constituencies within pathology represent abundant talent and intellectual horsepower, but the work to be done is collaborative. With a team approach, some of us can think about what that wall is made of, some of us can think about how to get around it, and some of us can hold the ladder.

To foster this vision, we need to do some of the kind of informal brainstorming that takes place when like-minded people come together outside the pressures of the workplace. While this is not about a single event, we have a singular event on the fall calendar that fits the bill: CAP ’08, San Diego, Sept. 25. Consider the 12-course curriculum on GI pathology. Spend a day learning molecular diagnostics. Come to the town meeting and tell us what you expect of your leaders. Be one of those who enables an environment that accommodates healthy change.

Rapid technological advances that fall clearly within our scope of practice are emerging in a market-driven environment. We are the specialists best qualified to shepherd their safe and effective use, but we need to step up. We need to talk, to speculate, to imagine. We need to act like members of the specialty at the center of the future of medicine. Bystanders need not apply.