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March 2009
Feature Story

Jared N. Schwartz, MD, PhD

So find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. See if you can keep the conversation going.
—Atul Gawande, MD
Better: A Surgeon’s Notes on Performance

“MythBusters,” a program on the Discovery Channel, features two special-effects experts who conduct elaborate experiments to test urban legends and the like. Someone might write in to ask whether a tongue piercing increases the chance of being struck by lightning. Someone else may want to know whether tooth fillings can transmit radio waves. People are infinitely curious; they won’t run out of material anytime soon.

The two don’t lecture. They debate the method, run the test, study the data, tweak the trial, and run it again until they can pronounce the myth ­either busted, plausible, or confirmed. It’s basic engineering with a bit of showbiz.

The guys on “MythBusters” are in the entertainment business, so any resemblance to physicians and public health workers relates to method, not motive. Still, they know their science. It’s not too much of a stretch to describe the remarkable physicians that Atul Gawande, MD, writes about in his fine book, Better: A Surgeon’s Notes on Performance, as myth busters in their own right.

Dr. Gawande presents case studies of enormous challenges faced in medicine and public health, then describes ingenious solutions devised by original thinkers who are relentlessly diligent and intent upon a noble cause. These are people who refuse to believe that they cannot find a way to eradicate polio in India, eliminate MRSA infection in a Pittsburgh hospital, or extend the lifespan of patients with cystic fibrosis. They refuse to accept the conventional wisdom—to buy in to the myth of what cannot be done. And against all odds, they succeed.

In my travels as your president, I have been meeting pathology’s myth busters left and right. At Massachusetts General Hospital, for example, where David C. Wilbur, MD, is director of cytopathology, they’ve discarded the notion that HPV testing and Pap test analysis should be entirely separate. The two tests are now conducted in the cytopathology laboratory. Dr. Wilbur, who chairs the CAP Cytopathology Committee, explains that a single report to the clinicians makes the impact of the findings immediately clear. The transition from traditional two-laboratory, two-report tests, he says, was not difficult. Clinicians are pleased, patient safety is better served, AP and CP are collaborating more closely, and cytotechnologists are learning new skills. The key, Dr. Wilbur says, is that their leaders operate on the premise that anything is possible. The only choice not on the table is contentment with the status quo.

Because the laboratory has so central a role in hospital life, we need not always initiate a policy or procedural change to be among those who take the lead on making it work. Transformative pathologists are choosing this role. The scientific method is there to test new ideas, and as the expression goes, success is often about knowing what you can change, accepting what you cannot, and having the wisdom to know the difference.

Not long ago, Massachusetts General Hospital began to post patient records on an open Web portal. Traditional thinking, that information should always be communicated by the medical staff, has its merits, but MGH administration opted for the benefits of systemwide transparency. W. Stephen Black-Schaffer, MD, associate chief of the Department of Pathology and director of the pathology training program, has an open mind. Everything in the record is informed by all the other pieces, he says. Greater transparency empowers the patient, ensures a clear record for emergencies, and raises the visibility of the clinical services the laboratory provides. He is willing to accept the consensus that those benefits will trump any concerns about who knows what first.

Dr. Black-Schaffer, who also chairs the Association of Pathology Chairs-Program Directors Section (APC-PRODS), is similarly sanguine about changes in medical school curricula related to pathology. For better or worse, he observes, the stand-alone sophomore pathology course has faded away, replaced by a set of courses built around diseases and organ systems, integrated across the traditional medical specialties. With some regret for what has been lost, his insight relates to the benefits: Changing how we teach, he says, will ultimately change how we practice, and further integration of pathology into clinical practice is surely good medicine.

Earlier this month, I had the opportunity to visit three phenomenal medical centers in California—Cedars-Sinai, the University of Southern California in Los Angeles, and UCLA. Just as at MGH, I came away enormously energized. Our vision for pathology, of what we should be doing for our patients and which areas we should be moving into, is taking hold. Again, I found significant support from our chairs, our program directors, and our faculty, and enormous enthusiasm among our residents. Transformation is becoming a reality.

I like the way Mahul B. Amin, MD, chairman of both the Department of Pathology and Laboratory Medicine at Cedars-Sinai and the CAP Cancer Committee, sums it up. In the molecular era, he says, we diagnose, we prognosticate, we predict, and soon we will participate in prevention. All that is needed is for pathologists to decide to change, to make a serious commitment to continuing education, and to take ownership of the relevant information technology.

Given the pace of change in our field, the continuing medical education piece is urgent. Our annual myth-busters convention, a.k.a. the CAP Foundation Futurescape of Pathology meeting to be held June 12–14 this year in Rosemont, Ill., is a fine place to begin.

In hospitals and training programs large and small, pathologists are leading our transformation one step at a time. They are smart, they are curious, and they are doing wonderful work.

And that negative myth, the one about the pathologist whose evidence-based thinking makes him or her reluctant to change?

Busted.
Dr. Schwartz welcomes communication from CAP members.
Write to him at president@cap.org.