Richard C. Friedberg, MD, PhD
December 2016—I gave a talk for the CAP16 House of Delegates in September that opened with a three-minute video showing how perspective can change along a continuum of distance (www.bit.ly/friedberg-cap16). The clip depicts a logarithmic journey across space from a grassy field in downtown Chicago to the farthest reaches of outer space, then retraces and extends its path to the deepest interior (“inner space”?) of human cells. That would be mesmerizing even without the stirring—almost danceable—orchestral accompaniment. The overall effect is visually stunning and intellectually provocative. I have watched the video a number of times. It never fails to remind me that where we stand and how we focus our attention really do shape what we see and how we see it.
Richard C. Friedberg, MD, PhD
All of this was fresh in my mind when we departed on a CAP trip to Asia a few weeks later, perhaps prompting me to think more about how my personal perspective framed my take on “foreign” experiences. I sought to sustain this awareness during our travels, which enabled me to appreciate just how quickly that sense of the foreign dispersed when we entered a laboratory. Whatever the local environment, no CAP-accredited laboratory can feel entirely unfamiliar. Reconnecting with members from a laboratory in West China that I had inspected six years earlier, and seeing their progress, was thoroughly gratifying.
Laboratory accreditation is a core element of our collective identity. More than a half-century ago, visionary pathologists saw the need for standards of laboratory practice that would grow with the science. To a significant degree, our CAP has been the home for the largely voluntary pursuit of standard-based laboratory improvement methods. So I am always pleased, but not surprised, when colleagues like those we met in Seoul, Shanghai, Chengdu, and Beijing make it abundantly clear that they hold our program in the highest regard.
The first Laboratory Accreditation Program tool would have to be the iconic back-of-the-envelope checklist penned in 1964 by former CAP president Dennis B. Dorsey, MD. Since then, our practices and activities have continually evolved yet the fundamental peer inspection model remains intact. New tools enable us to aggregate and share data in real time, but they cannot supplant the one-to-one mentoring that anchors and preserves the value of the accreditation program. The model is in many ways analogous to digital imaging: a revolutionary addition to our diagnostic toolbox that can no more replace on-site consults than chat rooms can replace tumor boards or CTs can replace autopsy. Providing health care remains a hands-on endeavor with a fundamental human component. LAP inspections connect us with our peers while expanding and improving the application of knowledge across the globe.
A few years ago, we were deeply engaged in the question of whether pathologists needed a personal transformation in order to remain relevant in a rapidly changing medical marketplace. This endeavor was a good use of our time; we learned plenty. Perhaps the most valuable outcome was a confirmation of the value and validity of our role in the House of Medicine. In the end, we found no conflict between the knowledge, perspective, and skill we contribute and the new tools that can make us more efficient.
This purposeful inquiry prompted many of us to think about what we do and what directions we seek. It reaffirmed our sense of place on the medical team. We were (and still are) medicine’s diagnosticians. We were (and still are) those who introduce a scientific perspective that exponentially deepens the rigor and muscularity of resources available to our clinicians. And we were (and still are) physicians with a unique, ever-growing role in healing. Our knowledge and ability to apply science in the clinical setting is irreplaceable, as is the insight that grows from the challenges we are glad to embrace. We are who we are and what we do is fundamentally important. We will be there, as always, for our patients and colleagues. And that is good.
We returned home from China in time to watch election returns that upended many perceived realities. A few days later, almost every informal discussion at the AMA Interim Meeting in Orlando circled back to uncertainties. What’s next for medicine? Patients? Pathology? Would new leadership be appointed to direct the CMS? NIH? FDA? CDC? If so, who? And where would that lead? It was, and still is, too soon to frame a collective response.
One way to think about this is that we have more fluidity than anticipated just a few months ago. More than that, we just don’t know yet. This is the time to be thoughtful and cognizant, to lift our gaze and be open to what is on the horizon. As change inevitably comes to our medical neighborhoods, we should seek a reasonable, evidence-based understanding of exactly what is changing and why, of where we fit in, and of how we can protect our patients from untoward outcomes of any disruption.
We will manage uncertainty by focusing our gaze on the big picture, helping to create a lexicon for discussion, and insisting that our laboratory teams set aside any anxieties to ensure that the quality of care our patients receive doesn’t suffer. We know who we are and that is good.
Just before the election, the poet and musician Leonard Cohen died. Obituaries that began to appear a few days later featured some of his better-known poems and lyrics, reflecting his introspective nature. Reading between the lines, I think Cohen wanted to say that we ride a continuum from birth unto death, that nothing is nor should be perfect, and even the most airtight argument may not be the last word. His thoughts were clearly in favor of the long view.
“There is a crack in everything,” he famously wrote. “That’s how the light gets in.” And that, too, is good.
Dr. Friedberg welcomes communication from CAP members. Write to him at president@cap.org.