President's Desk

November 2007
Joining in the greater conversation

Jared N. Schwartz, MD, PhD

The most important thing in communication is hearing what isn't said.
-Peter F. Drucker, 1909

Opportunity and Spirit are twin robots that landed on Mars in January 2004. Built by the National Aeronautics and Space Administration, the two exploration rovers photograph, collect, and stream information about what they find on the surface.

Opportunity and Spirit were named in a NASA-sponsored student competition. The NASA narratives that trace the rovers' journeys use nicknames (Beagle Crater, Burns Cliff, Heat Shield Rock) to describe landmarks; though they're not official, the nicknames seem to personalize the whole enterprise, bring it closer to home. And there is something oddly touching about two 5-foot-tall rovers named Opportunity and Spirit with anticipated life spans of 90 days that are still roaming Mars 31?2 years later, still sending back beautiful pictures. It was evidence gathered by Opportunity that led scientists to think that conditions on the planetary surface might once have been capable of sustaining microbial life. All in all, you can't help but root for them.

The words we use to identify things and people can create a connection, but we have to be careful about names and words, because sometimes they can also divide. For example, physicians who specialize in pathology often refer to physicians in other specialties as "clinicians." This is a mistake, because when we describe others as clinicians, we become nonclinicians, which limits our potential and even our scope of practice. It actually affects how we view ourselves. Clinicians, we know, are physicians who care for patients. That's us.

Creating distinctions between anatomic and clinical pathologists is no better. Where would Spirit be without Opportunity? There is nothing to be gained by putting ourselves in smaller boxes. It doesn't matter whether we were trained in anatomic or clinical pathology, or both. We are all physicians who practice one specialty called pathology, and that specialty needs room to grow. Anatomic and clinical practice historically were twins with varied orbits, but that is no longer true. New areas, such as molecular pathology, cross both orbits.

And while I'm on the subject, it's wonderful to enjoy your pathology subspecialty, but we are all physicians first. In times of such promise and urgency, the community of pathology must be viewed as a coherent whole. If the specialty of pathology is to survive, we must emphasize our commonalities. We need to talk about our profession (medicine) and our specialty (pathology) in terms of its exciting potential, and the talk must center on expanded scope and more connection, not greater subspecialization.

I was already preoccupied with some of this when I left for the International Liaison Committee of Presidents meeting in Dublin last month. The ILCP provides a forum for the presidents of English-speaking pathology societies (from Australia, Hong Kong, Ireland, South Africa, the United Kingdom, the United States, and the World Association of Societies of Pathology and Laboratory Medicine). The conversation flows easily at the ILCP meeting; English may be our language but pathology is our dialect and it is good to spend time together. We practice in different systems and diverse societies, yet we share the same hopes and concerns.

Several pathology society presidents from countries with a national health service said that they had already been called upon to define the value of a physician in directing laboratory services. The pathologist's added value is the experience and perspective of a physician, which enables the pathologist to understand the full potential of what goes on in the laboratory. Only a pathologist, if so focused as a physician, can fully grasp the therapeutic options and prognostic indicators attendant to a given test.

Knowing something and sharing what you know are two separate tasks, and communication between pathologists and other physicians is a huge concern across the globe. Direct patient care is the mortar of medicine and its gestalt is an important element of the greater conversation. There is a growing sense that pathologists would be so much more effective on the treatment team if our training included more hands-on patient-care experiences. This feeling is so strong in the United Kingdom that they are experimenting there with postgraduate clinical rotations in pediatrics, infectious disease, and hematology.

While lifelong learning in pathology has traditionally centered on technical skills, new trends in postgraduate education might point toward bolstering clinical experience. The government may be our ally in this, because pay for performance may move the reward system in medicine toward activities that have a direct effect on quality patient care.

College leaders will continue to look for creative ways to extend our partnerships within medicine while at the same time reinforcing our collective identity as pathologists. We have had wonderful successes already in this regard. The collaboration with the American Society of Clinical Oncology to write guidelines for HER2 testing is a great example, and plans to continue this partnership by developing estrogen receptor-progesterone receptor guidelines is another. Most recently, the College agreed to take responsibility for a comprehensive textbook of pathology for eMedicine.com, which is owned by WebMD. The eMedicine knowledge base already features physician-authored articles on 7,000 diseases and disorders, and practice guidelines in 59 medical specialties. Thomas M. Wheeler, MD, who chairs the CAP Council on Scientific Affairs, has agreed to be editor-in-chief for the project, and our College medical resource committees are ready to move.

The College is becoming an agent of transformation. We're reaching out to colleagues in other specialties and taking ownership of new tools with great promise for improved patient care. We have the expertise that our patients need and we must find ways to make ourselves—and our skills—more accessible to them.

Maybe we need to put a name to this initiative, something that identifies the spirit of the thing. Let's call it Project Opportunity.