College of American Pathologists
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  President’s Desk


CAP Today




January 2011

Stephen N. Bauer, MD

The importance of calculated risk

There was a “Far Side” cartoon posted on our bulletin board when I was first in practice. The panel showed four dogs standing beside a busy four-lane highway. A fifth dog had just run the gauntlet, dashing between speeding trucks to join them. “All right!” the caption said. “Rusty’s in the Club!”

As young physicians, we were acutely aware that every choice we made had associated risks and benefits. In residency, we had learned to recognize what some call the art of medicine: the ability to understand and balance the two. But now we had to put it into practice.

Some of the most interesting thinking we’ve been doing around transformation centers on how we confer that understanding in training new generations of pathologists. What will it mean to be a practitioner of this art 15 years from now? How do we ensure that today’s residents are ready for practice at graduation, prepared to function independently in a practice environment that presses forward in so many directions at once?

We’ll take a big step forward next July 1 when revisions to the Accreditation Council on Graduate Medical Education (ACGME) Common Program Requirements for all residencies take effect, providing a template and taxonomy for graduated responsibility in training. Program directors will have a clear framework within which to ensure that residents have appropriate opportunities to take responsibility for diagnostic decisions with progressively less oversight.

It was training program directors in surgery and pathology who persuaded the ACGME to tackle graduated responsibility in the revised Common Program Requirements. As Stephen Black-Schaffer, MD, immediate past chair of the Program Directors Section of the Association of Pathology Chairs (APC), tells it, the surgeons were able to get graduated responsibility on the table and the pathologists proposed the solution that the ACGME would adopt. That solution, a taxonomy for supervision of residents that Dr. Black-Schaffer drafted and presented to the ACGME, envisions four levels of graduated supervision with specific criteria for each. Dr. Black-Schaffer likes to say that graduate medical educators had been “punting” that vital fourth step in training—taking bottom-line clinical responsibility—to those who hired their graduates. The newly adopted provisions, he adds, will put an end to “social promotions” under which successful completion of training meant an apparent ability—rather than a demonstrated ability—to take true diagnostic responsibility.

The opportunity to learn new tools and develop the risk calculation skills of early adopters is an important element of medical education. Given the pace of development today, some training programs are creating methods to teach technologies they do not yet have. Peter E. Jensen, MD, who is president of the APC, says our educators are already collaborating to develop and share curricula and best practices. Dr. Jensen speaks to the big picture on this topic, observing that our residents need to understand emerging tools well enough to troubleshoot, but that most will be less focused on the bench than on interpreting results for other members of the medical team. The learning goals target assimilating information for diagnosis, navigating complex databases, and communicating an assessment to referring clinicians in a clear and useful way. Managing molecular and whole-genome diagnostics, in vivo microscopy, and whole-slide imaging will be as much about getting a firm grasp of pathology informatics and acquiring excellent laboratory management skills as it will be hands-on time with the tools themselves.

Experts believe that genomic testing, whole-slide imaging, and in vivo microscopy will be widely adopted within the next 10 years, and most of us will not have the benefit of residency training in the new technologies. The core work of transformation will always be continuing medical education and we will continue to investigate and experiment with approaches best suited to practicing pathologists. Those who attended CAP ‘10 had an opportunity to take part in an experiential learning pilot designed to improve the pathologist’s competence and comfort level in patient consultation. Later this year, the CAP Institute for the Advancement of the Pathology Specialty will be rolling out a series of experiential learning opportunities that will combine didactics with workshop-style simulation.

Member volunteers who serve on targeted research modules coordinated through our Transformation Program Office are examining other workforce issues as well. For example, early data from their work suggests that the supply of pathologists may not keep up with demand within the next 10 to 15 years. We know that the patient population is growing and aging and that the insured population will grow under health care reform. We also know that 41.6 percent of our actively practicing pathologists are 55 and older and that the average planned retirement age revealed in a recent member survey was 66.5. Emerging technologies should create efficiencies, but it will also create new tasks, and that means assessing workforce demand will not be a straight head count. As pathologists age and retire, we will need to replace skills, not just bodies.

While it’s too soon to be proclaiming we face a “retirement cliff,” we should be thinking about how we will fill any workforce gaps that do occur. Members of the Transformation Program Office modules have observed that technologies like whole-slide imaging could be a solution for pathologists who would like to retire but are reluctant to abandon a short-handed practice. Whole-slide imaging may enable experienced pathologists to continue to consult and to mentor younger colleagues on a part-time basis from home. That could be a win/win solution for practices whose senior pathologists are ready to slow down but not step out just yet.

We will continue to study workforce data and brainstorm what it portends. I am confident we will never run short of creative thinkers who will enable us to see opportunities others might not—and create opportunities where none exist.

Rusty’s in the club because he took a calculated risk. We know how to do that, too.

Dr. Bauer welcomes communication from CAP members. Write to him at To contact your state pathology society, please go to the CAP home page, click on the “Advocacy” tab, and scroll down to “State Pathology Societies” under “State Advocacy.”